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Physicians in Pursuit of a Moral Life

In Current Issue, Student Spotlight on October 29, 2009 at 11:20 pm

Morals and Medicine in Modern China

Bianca Verma ‘09, Contributing Writer

Socialist ideology is pervasive in Chinese life, and thus digs deep into the moral core of individuals within the society. Arthur Kleinman defines a moral life is as “one that embodies our own moral commitments” (Kleinman 2). He goes further to note that those “who seek to live a moral life may develop an awareness that their moral environment, in the first sense, is wrong” (Kleinman 3). While businessmen and politicians may already operate in accordance with socialist-capitalist ideals, and thus embody their “moral environment” in that they are profit-driven and competitively seek to achieve their own ends, physicians are posed with a dilemma. While we hold American physicians to an ethical code that stresses the greater good of humanity and puts the patient before self, the temptation for individualistic motivations are thrust upon physicians in reform era China. In Priscilla Song’s article, “Cutting Edge Tactics: Practicing Health Care with Chinese Characteristics,” the nation clearly does not provide adequate financial or institutional support to physicians (only stringent laws and censorship), making it very difficult for physicians to survive without incorporating more selfish actions. However, while these actions may appear to be profiteering and self-interested, in reality, their moral frames have only modified to accommodate for the state’s external pressures, while still ideologically working for the greater good of the nation. In “The Honest Doctor” by Philip Pan, we find that even despite political secrecy and immorality, the unique morality of the physician can indeed shine through. Thus, we cannot necessarily proclaim that physician morality has degraded in reform era China, but rather altered under political and economic pressure.

The government’s attitude towards medicine in reform era China is best characterized by a quote in “The Honest Doctor” highlighting the government’s response to SARS: “When is the best time for the party to break bad news to the public? Never” (Pan 203). On many levels of intervention, the socialist-capitalist government of China deceptively appears to act for the greater good but underlying these actions are greed and pride, especially with regards to public health. During the SARS epidemic and in the Chinese hospital setting (which we see in Song’s article), it is clear that socialist politics has exerted a kind of biopower which impacts the survival of the citizens within Chinese society. Biopower is defined as “an explosion of numerous and diverse techniques for achieving the subjugations of bodies and the control of populations” (Foucault 140), and functions as the Chinese government’s ability to control the life and death of their citizens by regulating the flow of health information to the public. During SARS, they went so far as to issue a “feel-good statement about a mysterious disease they knew to be highly contagious and frequently lethal” (Pan 207). This statement is very clearly manipulated to present SARS as a simple problem that is under State control, in order to avoid careful scrutiny by Chinese reporters and the world stage.

However, a number of physicians felt quite uneasy about the SARS cover-up, one of them being the surgeon Jiang Yanyong. While many physicians were “accepting bribes from patients or prescribing unnecessary drugs to boost profits” (Pan 208) and buying into the State’s ideology, Yanyong felt the immorality of covering up a dangerous public health crisis. He felt all physicians should share in the sense of outrage towards the Chinese government. A doctor, he thought, should know better” (Pan 212). To Yanyong, his moral obligation as a physician to provide for the greater good of his people trumped the fear he felt from repercussions by the State.

As we can see with Yanyong, physicians have to reaffirm and adjust their moral codes within this new system of biopower in which the citizens (including the physicians themselves) are told to keep silent and compliant. Yanyong’s contact with the external world, and insistence on taking note of the SARS outbreak, destabilized the government’s authority in the eyes of the press, the World Health Organization, and the people of Beijing (Pan 216). He forced the world to note the immoral (economic and political) motivations of the State, while acting morally on his own sense of what’s right for the greater good, risking his job and his life to live the “moral life” he imagined.

In Song’s article, we see a similar oppression on the medical field, in that the government has conflicting state policies in regards to medicine. For example, there was a significant reduction in public funding of the urban medical sector while at the same time, enforcing below-cost charges on routine medical services (Song 3). The socialist-capitalist Chinese government was attempting to push a majority of medical service expenses onto private businesses and individuals, which elicited a strong reactionary response from both hospitals and physicians, forcing them to readjust their priorities in this adverse political and economic environment.

Hospitals, facing harsh regulations and government inquiry, began to act as real estate brokers for “medical entrepreneurs,” who are physicians that exploited this sudden opening of opportunities for economic success (Song 3). Hospitals were forced to think of profits and not necessarily services or quality provided, in order to maneuver the murky legal waters that made it very difficult to even remain open and operational. Even hospitals that went under because of illegal “unauthorized” departments were able to re-register with the state if they changed their name slightly, such as the Beijing City West Hill Hospital as though becoming a new reformed entity (Song 16). This reflects the definite moral corruption that categorizes the highly competitive, business-focused existence of hospitals in reform era China.

On the surface, even physicians could be viewed as having to manipulate the state political and legal systems in order to simply remain with a steady job. However, it can be argued that physicians have a different moral driver that dictates their actions than the profiteering focus of hospitals. While physicians had to “deploy a myriad of creative tactics ranging from exploiting administrative loopholes to capitalizing on technological advances in order to evade government scrutiny and attract new patients,” it is not explicit that they are seeking self-interested, personal economic gain alone (Song 2). For example, Dr. Huang had to begin using the facilities at Wanjie Hospital in Qingdao as a satellite clinic, because it “enabled him to weather the sudden loss of operating privileges at West Hill” (Song 14). However, it is also important to understand the motivations of Dr. Huang in working hard to maintain his job. This will be further explored later.

Dr. Huang also began performing smaller surgeries that could be done without a fully equipped operating room, which were much more expensive and difficult to access. For example, the procedure of treating ALS patients, while normally requiring larger procedures and producing more comprehensive results, was to now be treated with smaller procedures that could be done with local anesthesia and minor invasion. This way, Dr. Huang would still be able to treat these patients within the new facilities of Wanjie Hospital without having to work around the law. Although this option could be seen as a breach in the ethical obligations of a physician to provide the best possible care, Dr. Huang himself said his choice of treatment was “eminently a moral decision that prioritized patients’ well-being over petty bureaucratic wrangling” (Song 15). It is difficult to find argument with this explanation of Dr. Huang’s ethical decision, for it does, in its own way, conform to the new moral stance expected of physicians in China at this time – to do whatever they can in the position they are in, with what they have.

In some sense, the fact that physicians have had to struggle to assert their individual identity and moral values into an oppressive State only furthers their conviction in their own beliefs. As Kleinman has said, “radical changes in politics and the economy refashion moral life” (Song 16). Physicians and hospitals both stretch and blur the boundaries between what is moral and immoral, ethical and unethical. However, while hospitals undeniably turn to business-minded ventures, in both action and motive, physicians maintain a sense of moral integrity, even while integrating a degree of politics and economics into their practices. In reform era China, one cannot fully live a moral life as a detached, freethinking individual, especially not as a physician with external medical ethics codes placed upon them. Both Yanyong and Huang display this effort to protect what is most important to them – their nation and their patients, even in a corrupting and politically charged environment – and thus indeed live the moral life Kleinman defines. Physicians in China must constantly negotiate the line between moral drivers of government or institutions and an individual’s own moral code. This complicates our understanding of the moral changes that physicians’ experience. We cannot simply categorize these changes as moral degradation, but rather reorient our definition of what is moral and ethical back to the individual in hard times.

References

Foucault, Michel. The History of Sexuality Vol.1: The Will to Knowledge. London: Penguin, 1998.

Kleinman, Arthur. What Really Matters: Living a Moral Life Amidst Uncertainty and Danger. New York: Oxford UP, 2006.

Pan, Philip P. 2008. Out of Mao’s Shadow: The Struggle for the Soul of a New China. New York: Simon and Schuster. “The Honest Doctor.” pp. 199-234.

Song, Priscilla. “Cutting Edge Tactics: Practicing Health Care with Chinese Characteristics.” Yale University. Dissertation excerpt.

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