Jing-Bao Nie

Patient-physician mistrust and violence against physicians in Guangdong Province, China: a qualitative study

Objective To better understand the origins, manifestations and current policy responses to patient–physician mistrust in China. Design Qualitative study using in-depth interviews focused on personal experiences of patient–physician mistrust and trust. Setting Guangdong Province, China. Participants One hundred and sixty patients, patient family members, physicians, nurses and hospital administrators at seven hospitals varying in type, geography and stages of achieving goals of health reform. These interviews included purposive selection of individuals who had experienced both trustful and mistrustful patient–physician relationships. Results One of the most prominent forces driving patient–physician mistrust was a patient perception of injustice within the medical sphere, related to profit mongering, knowledge imbalances and physician conflicts of interest. Individual physicians, departments and hospitals were explicitly incentivised to generate revenue without evaluation of caregiving. Physicians did not receive training in negotiating medical disputes or humanistic principles that underpin caregiving. Patient–physician mistrust precipitated medical disputes leading to the following outcomes: non-resolution with patient resentment towards physicians; violent resolution such as physical and verbal attacks against physicians; and non-violent resolution such as hospital-mediated dispute resolution. Policy responses to violence included increased hospital security forces, which inadvertently fuelled mistrust. Instead of encouraging communication that facilitated resolution, medical disputes sometimes ignited a vicious cycle leading to mob violence. However, patient–physician interactions at one hospital that has implemented a primary care model embodying health reform goals showed improved patient–physician trust. Conclusions The blind pursuit of financial profits at a systems level has eroded patient–physician trust in China. Restructuring incentives, reforming medical education and promoting caregiving are pathways towards restoring trust. Assessing and valuing the quality of caregiving is essential for transitioning away from entrenched profit-focused models. Moral, in addition to regulatory and legal, responses are urgently needed to restore trust.

The Plurality of Chinese and American Medical Moralities: Toward an Interpretive Cross-Cultural Bioethics

Since the late 1970s, American appraisals of Chinese medical ethics and Chinese responses to American bioethics range from frank criticism to warm appreciation, from refutation to acceptance. Yet in the United States as well as in China, American bioethics and Chinese medical ethics have been seen, respectively, as individualistic and communitarian. In this widely-accepted general comparison, the great variation in the two medical moralities, especially the diversity of Chinese experiences, has been unfortunately minimized, if not totally ignored. Neither American bioethics nor Chinese medical ethics is a field with only one dominant way of thinking. Medical moralities in America and China--traditional and modern--have always been plural and diverse. For example, American and Chinese cultures and medical moralities both exhibit individualistic and communitarian traditions. For this reason, bioethics in general and cross-cultural bioethics in particular must be fundamentally interpretive. Interpretive cross-cultural bioethics appreciates the plurality of medical morality within any culture. It can serve as a vital means of social and cultural criticism through engaged interpretations.

The United States Cover-up of Japanese Wartime Medical Atrocities: Complicity Committed in the National Interest and Two Proposals for Contemporary Action

To monopolize the scientific data gained by Japanese physicians and researchers from vivisections and other barbarous experiments performed on living humans in biological warfare programs such as Unit 731, immediately after the war the United States (US) government secretly granted those involved immunity from war crimes prosecution, withdrew vital information from the International Military Tribunal for the Far East, and publicly denounced otherwise irrefutable evidence from other sources such as the Russian Khabarovsk trial. Acting in “the national interest” and for the security of the US, authorities in the US tramped justice and morality, and engaged in what the English common law tradition clearly defines as “complicity after the fact.” To repair this historical injustice, the US government should issue an official apology and offer appropriate compensation for having covered up Japanese medical war crimes for six decades. To help prevent similar acts of aiding principal offender(s) in the future, international declarations or codes of human rights and medical ethics should include a clause banning any kind of complicity in any unethical medicine—whether before or after the fact—by any state or group for whatever reasons.

Limits of state intervention in sex-selective abortion: the case of China

Sex-selective abortion is the major direct cause of the severe imbalance in the sex ratio at birth – contributing to the phenomenon of over 100 million ‘missing’ females worldwide and 40 million in China alone. Internationally as well as in China, moral condemnation and legal prohibition constitute the mainstream and official position on sex-selective abortion. This paper characterises the dominant Chinese approach to the issue as state-centred and coercion-oriented. Drawing upon case study material, the paper discusses eight major problems arising from coercive state intervention in sex-selective abortion: neglect of reproductive liberty and reproductive rights; the hidden dangers of state power; inconsistency with existing abortion policies; practical ineffectiveness; underestimating the costs and resistance involved; simplifying and misrepresenting the key issues; the lack of sufficient public discussion; and ignoring the moral and political principles established by traditional Chinese thought. To avoid a solution that is worse than the problem itself, alternative social programmes that are focused on women, community-oriented and voluntary in nature need to be developed.

Traditional, complementary, and alternative medicine approaches to mental health care and psychological wellbeing in India and China

India and China face the same challenge of having too few trained psychiatric personnel to manage effectively the substantial burden of mental illness within their population. At the same time, both countries have many practitioners of traditional, complementary, and alternative medicine who are a potential resource for delivery of mental health care. In our paper, part of The Lancet and Lancet Psychiatrys Series about the China-India Mental Health Alliance, we describe and compare types of traditional, complementary, and alternative medicine in India and China. Further, we provide a systematic overview of evidence assessing the effectiveness of these alternative approaches for mental illness and discuss challenges in research. We suggest how practitioners of traditional, complementary, and alternative medicine and mental health professionals might forge collaborative relationships to provide more accessible, affordable, and acceptable mental health care in India and China. A substantial proportion of individuals with mental illness use traditional, complementary, and alternative medicine, either exclusively or with biomedicine, for reasons ranging from faith and cultural congruence to accessibility, cost, and belief that these approaches are safe. Systematic reviews of the effectiveness of traditional, complementary, and alternative medicine find several approaches to be promising for treatment of mental illness, but most clinical trials included in these systematic reviews have methodological limitations. Contemporary methods to establish efficacy and safety-typically through randomised controlled trials-need to be complemented by other means. The community of practice built on collaborative relationships between practitioners of traditional, complementary, and alternative medicine and providers of mental health care holds promise in bridging the treatment gap in mental health care in India and China.

The Problem of Coerced Abortion in China and Related Ethical Issues

This paper critically examines the problem of coerced abortion occurring in China and the ethical issues accompanying it. It begins by confirming the existence of forced abortion in the country then argues that coercion itself is not always morally wrong. This is done through an analysis of the concept of coercion. On the other hand to demonstrate why coerced abortion is morally objectionable concepts of individual rights and traditional Confucianist and Taoist moral ideals are used. These individual concepts include the right to reproduce and the right to privacy while the moral ideals include governing by education rather than extensive use of compulsion and by letting people govern themselves. Finally turning to the conflict between the serious problem of overpopulation and the popular will of people to have two or more children this paper shows that coerced abortion may be a moral tragedy or a genuine ethical dilemma rather than a thorough moral evil as it first appears.

U.S. responses to Japanese wartime inhuman experimentation after World War II.

In 1945-46, representatives of the U.S. government made similar discoveries in both Germany and Japan, unearthing evidence of unethical experiments on human beings that could be viewed as war crimes. The outcomes in the two defeated nations, however, were strikingly different. In Germany, the United States, influenced by the Canadian physician John Thompson, played a key role in bringing Nazi physicians to trial and publicizing their misdeeds. In Japan, the United States played an equally key role in concealing information about the biological warfare experiments and in securing immunity from prosecution for the perpetrators. The greater force of appeals to national security and wartime exigency help to explain these different outcomes.

The West's dismissal of the Khabarovsk trial as 'communist propaganda': ideology, evidence and international bioethics

In late 1949 the former Soviet Union conducted an open trial of eight Japanese physicians and researchers and four other military servicemen in Khabarovsk, a city in eastern Siberia. Despite its strong ideological tone and many obvious shortcomings such as the lack of international participation, the trial established beyond reasonable doubt that the Japanese army had prepared and deployed bacteriological weapons and that Japanese researchers had conducted cruel experiments on living human beings. However, the trial, together with the evidence presented to the court and its major findings — which have proved remarkably accurate — was dismissed as communist propaganda and totally ignored in the West until the 1980s.This paper reviews the 1949 Khabarovsk trial, examines the Wests dismissal of the proceedings as mere propaganda and draws some moral lessons for bioethics today. As an important historical case, set in the unique socio-political context of the Cold War, the Wests dismissal of the trial powerfully illustrates some perennial ethical issues such as the ambivalence of evidence and the power of ideology in making (or failing to make) cross-national and cross-cultural factual and moral judgments.

Reviving medicine as the art of humanity in China

1462 www.thelancet.com Vol 383 April 26, 2014 2 Ma L. Kindergarten probed over pill claims. China Daily, March 13, 2014. http://www. chinadaily.com.cn/china/2014-03/13/ content_17343004.htm (accessed March 13, 2014). 3 Luo WS. Medicine scandal shows child-care mismanagement. China Daily, March 18, 2014. http://www.chinadaily.com.cn/ china/2014-03/18/content_17354289.htm (accessed March 18, 2014). 4 Southern Medical Economy Research Institute of China Food and Drug Administration. China report of medication safety for children in 2013 (in Chinese). http://web.yyjjb.com:8080/ html/2013-06/03/content_192971.htm (accessed June 3, 2013). 5 Liu ZH. Children forced to take adult medication. China Daily, Dec 25, 2013. http://www.chinadaily. com.cn/life/2013-12/25/content_17195142. htm (accessed Dec 25, 2013). A scarcity of national adverse drug reaction surveillance systems among children and weak national drug policies are the major issues. Although CFDA has achieved a lot in improving medicine administration, it is not enough. CFDA should increase collaborations with health officials and health institutions to create a comprehensive national paediatric drug administration network. The restricted availability of paediatric drugs is another important issue. Only 5% of the pharmaceutical companies produce paediatric drugs, and 90% of medications on the market do not have a child-specifi c dosage on packages in China. Paediatricians are forced to prescribe adult drugs, which can threaten children’s safety. China should encourage paediatric drug research and production, and support safety and eff ectiveness of drugs used in children. Moreover, the tense doctor–patient relationship in China can also lead to irrational medication. Indeed, when the treatment does not work as quickly as the parents would expect, doctors are under pressure and can be threatened by parents; doctors might then favour strong and fast-acting medicines. To ensure drug safety for children in China, efforts are needed at all levels: governments, drug regulatory agencies, pharmaceutical industries, health-care professionals, and parents. Collaborative regulatory initiatives, such as the use of common warnings, can also contribute to a more rational use of medications for children.

Connecting the East and the West, the Local and the Universal: The Methodological Elements of a Transcultural Approach to Bioethics

ABSTRACT: From the outset, cross-cultural and transglobal bioethics has constituted a potent arena for a dynamic public discourse and academic debate alike. But prominent bioethical debates on such issues as the notion of common morality and a distinctive “Asian” bioethics in contrast to a “Western” one reveal some deeply rooted and still popular but seriously problematic methodological habits in approaching cultural differences, most notably, radically dichotomizing the East and the West, the local and the universal. In this paper, a “transcultural” approach to bioethics and cultural studies is proposed. It takes seriously the challenges offered by social sciences, anthropology in particular, towards the development of new methodologies for comparative and global bioethics. The key methodological elements of “transculturalism” include acknowledging the great internal plurality within every culture; highlighting the complexity of cultural differences; upholding the primacy of morality; incorporating a reflexive theory of social power; and promoting changes or progress towards shared and sometimes new moral values.