Schools of medicine began. There were 7 schools of medicine in the two periods spanning between 770 and 221 B.C. There were popular doctors with numerous disciples. These schools and groups developed into non-governmental medical organizations which resulted in the development of medical ethics.

The Six Taboos

One popular doctor, Bian Que set forth the earliest code of medical ethics in China, The 6 Taboos.

"Medicine should not be offered in six circumstances… to:

1. People who had unreasonable arrogance and indulgence,
2. People who appreciated riches more than life,
3. People who couldn't even keep body and soul together,
4. People who were suffering from interlocking Yin and Yang,
5. People who were too weak to take medicines, and
6. People who didn't believe in medicine but in sorcery."

Ethics as Protection for Physicians

The main reasoning behind these taboos was to take into account the complexity and severity of the patient's disease, the likelihood of the patient sabatoging the doctor's efforts, and the limitations of the doctors' therapies.

In ancient China, physicians were rather independent. They were wanderers without formal training, licensing, or officiating bodies. This meant that there were not only righteous and excellent doctors, but also quacks and incompetents. The consequences of poor care were often severe for the doctors. Failing to cure an Emperor could lead to execution.

To protect themselves, doctors emphasized both prognosis and codes of conduct. Knowing the future course of a disease (prognosis) helped physicians choose which cases to treat and which ones to refuse. Following a good code of ethics meant that, in cases of failure, the doctor had done all he should and was beyond reproach.

The Influence of Confucianism on Chinese Medical Ethics

From the Han Dynasty on, Confucianism took over Chinese values. This influence put more emphasis on the value of caring for patients. Physicians were expected to cultivate themselves.

Benevolence, or loving people, is the core of Confucian ethics. Confucianists believed that medicine, whose purpose was to save lives, was the ultimate expression of saving people via love. The great Zhong Zhang Jin (writer of the Shang Han Lun, the earliest systematic herbal text) said that Confucians could realize their goal of loving people if they only grasped medical theories and treated people attentively. This is the origin of the saying "Medicine is the Art of Humanity"

Benevolence requires the veneration of human life. Nothing was more valuable. The great physician Sun Simiao said that people's lives were worth more than gold. Confucians were rigorous and painstaking in their diagnosis so that they would avoid doing harm. Thus, Mencius said, "In medicine, benevolence means causing no harm to patients."

Benevolence also called for respecting patients. It would be improper for the doctor to act as if he'd done his patients a favor; care was his duty, the ultimate expression of humanity. Requiring money or sex for care was out of the question.

Confucianism also dictated a universality of care. No patient should be given better or worse care on the basis of status, money, appearance, age, race, or mental ability. Tianchen Li, a Ming Dynasty physician, suggested "We should treat the patients as our mothers." This is in accord with the Confucian golden rule.

Confucius believed everyone had a conscience, an inborn sense of right and wrong. In physicians, this would lead to another 4 senses:

The way that Confucian physicians practiced self-cultivation was through self-examination, self-criticism, and self-restriction. Confucius proposed that instead of trying to set up a universal code of behavioral guidelines, each person should subject themselves to self-examination. This is one major reason for the lack of codified medical ethics in Chinese Medicine.

Other Influences on Chinese Medical Ethics

Ancient China was not highly organized. It was an agricultural economy, and the main social unit was the family. Consequently, medicine was passed down familial lines. The education was not standardized. There was little or no competition between professionals. There was not the same great need for universal ethical guidelines that comes in more socially interactive cultures.

Taoism and Buddhism also influenced Chinese Medical Ethics. Taoism's greatest value and goal was immortality. Among the ways to achieve this were taking miraculous herbs and practicing good deeds upon others. The latter idea fit with Buddhism's emphasis on cultivating "good karma" by right action toward others.

The History of Western Medical Ethics

Western Medical ethics began with Hippocrates. He founded a medical school and required his students to take an Oath. The main ideas of the Hippocratic Oath were:

1. Honor medical instructors and their offspring.
2. Pass on medicine only to those bound by the Oath.
3. Practice medicine for the benefit of patients. Do no harm.
4. Give no deadly medicine or substance to produce abortion.
5. Abstain from mischief and corruption.
6. Doctor-patient confidentiality

In 1794, Thomas Percival (an English physician noted for his care of the poor) published a code of medical ethics that later was adopted by the AMA. The main points were the moral authority and independence of physicians, responsibility to care for the sick, and individual honor.

The AMA Code of Ethics was adopted in 1847. In the 1840's, people could call themselves medical doctors after just a 3 month course (doesn't that remind you of how MD's can now practice acupuncture after a similar length of study? Can you say "hypocritical?"). This code was so powerful that it almost tore the AMA in two 20 years later. The AMA revised their code in 1980, and then again in 2001.

Another significant development occurred after WWII. The Nuremberg trials, in response to experiments performed by the Nazis, led to The Nuremberg Code. It was meant to protect patients involved in research studies. The most important of these 10 principles are voluntary consent, the ability of the patient to end their participation at any times, and protection of the patient against harm.

The next development was the 1948 Declaration of Geneva, from the World Medical Association. It was meant to update the Hippocratic Oath, which was seen to be both outdated and not comprehensive. It also was a reaction to Nazi atrocities.

"At the time of being admitted as a member of the medical profession I solemnly pledge myself to consecrate my life to the service of humanity: I will give to my teachers the respect and gratitude which is their due; I will practice my profession with conscience and dignity; The health and life of my patient will be my first consideration; I will respect the secrets which are confided in me; I will maintain by all means in my power, the honor and the noble traditions of the medical profession; My colleagues will be my brothers: I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient; I will maintain the utmost respect for human life, from the time of its conception, even under threat, I will not use my medical knowledge contrary to the laws of humanity; I make these promises solemnly, freely and upon my honor..."
(my boldings to highlight the new ideas)

In 1964, the World Medical Association released the Declaration of Helsinki. It was also meant to protect research subjects. It contains 22 principles- too many to list here. It has been revised in 1975, 1983, 1989 and 1996 and is the basis for Good Clinical Practices used today.

Medical ethics as a field of study in the U.S. has really grown up in just the last 30 years. In the 1950s the progress of medicine was seen as something that could not end. In the 60's opinions changed; MD's had long opposed to reforms to medical care financing, which they stigmatized as "socialized medicine." People began to see MD's and the AMA as greedy, uncaring, and self-interested.

With the rise of "alternative medicine," MD's have seen patient en masse deserting their western "traditional" care. They are slowly awakening to the fact that people want physicians who care. They also are rejecting some of the limitations of western medical therapies. However, it is easier to change the former problem.

Now, many physicians feel that reform in the medical ethics realm is the MD's only hope of survival. George Lundberg, MD (former AMA president and CEO of Medscape) thinks of his own profession potentially terminal. He states that medical ethics is the most popular writing topic for submissions to the Journal of the American Medical Association.

Comparison between the Two Ethical Systems

Both cultures developed ethics as an extension of becoming 'professions.' Traditionally, the three learned (scholarly) professions are law, religion, and medicine. These are callings to which are trusted "the most private and intimate secrets of a person's mind, soul, and body" (Lundberg).

Ancient China was much less socially grouped than ancient Greece. In the Middle Ages of the West, political and social groups were very important. Doctors organized unions voluntarily. They developed apprenticeships and tried to avoid internal competition. While the West constructed social codes, China emphasized personal virtue.

The Confucian concept of benevolence is similar to the Hippocratic 'do no harm.' In fact, there are many parallels between the AMA's revised principles (which is the latest outgrowth of thousands of years of Western philosophy and medicine) and Chinese medical ethics.

Western Civilization was inherently more likely to develop a set of ethical guidelines than Chinese culture. Western civilization and its religions are highly legislative and literal. It creates guidelines which are fixed, absolute, and eternal. These guidelines are often kept in a book or document such as the Bible, the U.S. Constitution, or the AMA's Principles of Medical Ethics.

In China, Taoist natural spontaneity, Buddhist sudden enlightenment and Confucian self-cultivation combined to repel the idea of absolute standards. Of course, this is not wholly true; Christian "living in the Spirit" can be totally spontaneous, Jesus was a homeless wanderer led by God, Buddhism has 4 noble truths and an 8-fold path, Confucius wrote the Analects, and Lao Tzu wrote the Tao Te Ching (an oxymoron - the way that cannot be named can be written in a book?).

Medicine and Money

Confucianism's disgust with monetary reward left it open to socialism. In socialized medicine, doctors are not paid as well as their western counterparts. The thin line between altruism and greed is a major ethical dilemma in western medicine (this includes the western practice of chinese medicine).

I recently heard a story of a newly graduated student of Chinese medicine in Los Angeles. A patient had called to find out if they had been treated well. Details aside, the doctor was both incompetent and negligent. Not only that… he charged $140 for the first visit, and $90 for return visits. That's a high price - period… let alone for incompetency.

George Lundberg, MD suggests that students enter western medicine for 4 reasons:

1. To be of service
2. Because they're good at science
3. To have a good deal of independence
4. To make money

The first three are good reasons. The fourth is dangerous.

A Table of Comparisons between Western and Chinese Medical Ethics

References

1. Benfu Li, Medical Ethics (Beijing: Peking Union Medical College and Beijing Medical University Press, 1996), 41-42.
2. Bocong Li, On Bianque and the School of Bianque (Xian: Shanxi Science and Technology Press, 1990).
3. Declaration of Geneva. Adopted by the General Assembly of World Medical Association at Geneva Switzerland, September 1948.
4. DECLARATION OF HELSINKI: Ethical Principles for Medical Research Involving Human Subjects Adopted by the 18th WMA General Assembly Helsinki, Finland, June 1964 and amended by the 29th WMA General Assembly, Tokyo, Japan, October 1975; 35th WMA General Assembly, Venice, Italy, October 1983; 41st WMA General Assembly, Hong Kong, September 1989; 48th WMA General Assembly, Somerset West, Republic of South Africa, October 1996; and the 52nd WMA General Assembly, Edinburgh, Scotland, October 2000.
5. Lia Chen, Ancient Religions and Ethics (Life, Reading and New Knowledge, 1996), 7.
6. Lundberg, George D., MD. Severed Trust: Why American Medicine Hasn't Been Fixed. Basic Books, 2000.
7. Miraculous Pivot (Beijing: People's Health Press, 1963).
8. Nuremberg Code [from Trials of War Criminals before the Nuremberg Military Tribunals under Control Council Law No. 10. Nuremberg, October 1946-April 1949. Washington, D.C.: U.S. G.P.O, 1949-1953.]
9. Qian Sima, Records of History: Biography of Bianque and Canggong.
10. Simiao Sun, Essential Prescriptions Worth a Thousand Gold in Hua Fan's History of Late Han Dynasty: Records of Crafts (Beijing: People's Health Press, 1982), 476.
11. Shuming Liang, Essence of Chinese Culture (Shanghai: Xuelin Press, 1987), 69.
12. Unschuld P., Medical Ethics in Imperial China (University of California Press, 1979), 5-10.
13. Yimo Zhou, ed. Famous Physicians' Addresses on Medical Ethics (Changsha: Hunan Science and Technology Press, 1983), 212
14. Zhang and Cheng. Medicine is a Human Art: The Basic Principles of Professional Ethics in Chinese Medicine. Medical History Research Center, Beijing Medical University.
15. Zhongjing Zhang, A Treatise on Febrile and Miscellaneous Diseases (Beijing: People's Health Press, 1963).