A Confucian Perspective on Public Health Ethics

ABSTRACT

Debates in public health ethics have been dominated by the assumptions of Western liberalism: a priority given to liberty and autonomy over other values, an individualistic view of social ontology, a focus on personal responsibility, a minimal set of obligations (only created through consent), and a marginalization of social, cultural, and religious context. Examining issues in public health ethics from the perspective of a different moral tradition reveals that such assumptions are not timeless truths, but rather choices that require justification. In this paper, we briefly outline a view of Confucianism and explore how this approach can be used to articulate a critical approach to much contemporary public health ethics. Confucianism suggests a radically different perspective toward obligations, agency, and responsibility, as well as a more relational conception of social ontology and a shared notion of well‐being. Of course, some discussion in public health ethics, within the constraints of Western traditions, has pushed in this direction before. In offering a Confucian perspective on public health ethics, we are not suggesting that Confucianism is the one true approach to ethics and that everyone should become a Confucian. We are, however, seeing our discussion as a source of epistemic critique of Western liberalism, exposing the need for more active defense of assumptions at its core, as well as providing an opportunity to broaden the set of values that inform justifiable public health policy.

1. Introduction

It will aid the discussion to have an example in mind. Think of policy in relation to smoking. The Western liberal sees this as an easy case. Government legislation is justified if motivated by a concern for the health of third parties (harm to others), but not if motivated by concern about the health of smokers themselves (harm to self). Once sufficiently credible evidence of harm to third parties from smoking is available, banning smoking in enclosed public spaces (bars, restaurants, workplaces etc.) is justified. A ban on smoking in private spaces (one's own home) or in open public spaces (in parks or on a beach) is seen as unjustifiable or at least much more contentious. Such an approach to smoking policy has the advantage of simplicity, but it is shaped by a set of assumptions that can be contested [1]. Is it possible to coherently and clearly separate harm to self from harm to others? Is one's own home clearly a private space? Others may be negatively impacted by another household member's smoking. In apartment blocks, neighbors may be impacted. The average earlier deaths of smokers will harm other family members, as they will no longer contribute to family life and household income. Why should we think that the social visibility of smoking does not impact future choices [2]? We know that the children of smokers are more likely to be smokers themselves. Why should we prioritize the value of liberty to smoke over the impact of smoking on social justice [3]? Smokers are more likely to be from lower socio‐economic groups in society. Addressing smoking behavior is an excellent way to address significant health inequalities in many populations. Leaving smoking to the “choice” of individuals, and assuming it is up to individuals to choose what will contribute to their well‐being, has significant costs to others. The Western liberal approach can provide answers to whether specific policy proposals may be justified. Too often in public health ethics, the focus is upon how we can simply apply the harm to self/others distinction as a means of generating the “answer” to any specific policy issue. ¹

In this paper, we outline some core features of Confucianism and then use them to show how a very different set of policy priorities and justifications may emerge when discussing issues in public health ethics, such as smoking policy. Confucianism suggests a radically different perspective from that of Western liberalism, which is so dominant in bioethics in general and much public health ethics in particular. For example, Confucianism outlines a distinctive view of obligations, agency, and responsibility, as well as a more relational conception of social ontology and a shared notion of well‐being. Of course, some discussion in public health ethics, within the constraints of Western traditions, has pushed in this direction before [4, 5, 6]. In addition, there have also been discussions of Confucianism in relation to bioethics in general (e.g., Ruiping Fan [7, 8, 9, 10, 11] and Tsai [12, 13]). In outlining a Confucian perspective on public health ethics, we are not suggesting that Confucianism is the one true approach to ethics and that everyone should become a Confucian. We are, however, seeing our discussion as a source of epistemic critique of Western liberalism, exposing the need for more active defense of assumptions at its core, as well as providing an opportunity to broaden the set of values that inform justifiable public health policy.

2. Confucianism & Virtue Ethics

Confucianism is one of the dominant strands of ancient Chinese philosophical thought (along with Buddhism and Daoism), developed over many centuries, shaped by prominent figures like Confucius (551–479 BCE) and Mencius (who lived approximately between 372 and 289 BCE). Confucianism, in Western academic parlance, is often framed as a version of virtue ethics. This is too simplistic but has some justification as Confucianism can be seen to be centered on the moral agent's self‐cultivation and the importance of establishing appropriate education within society to acquire and practice the “four ² innate virtues,” described by Mencius as “humaneness or benevolence (ren), ritual propriety (li), (moral) righteousness (yi), and wisdom or perspicuity (zhi)” [14]. The goal of a moral education in these Confucian virtues was to enable the pupil to become a junzi—an ethically cultivated “gentleman”, a moral agent able to see and do the right thing. These traits can be seen as virtues, and not merely properties of certain kinds of actions, because they are grounded within elements of character to be developed and refined by any individual person within a social tradition.

Perhaps the most important virtue within the tradition is benevolence (ren 仁). The Chinese word, ren (仁), is sometimes translated as humaneness or goodness, in addition to benevolence. Contained in this concept is more than merely an attitude of goodwill toward others. Instead, this virtue demands moral excellence in a more holistic sense—a duty to develop personal moral self‐cultivation, altruism, and respectful observation of all of one's social obligations [14]. The other virtues, yi (義) and zhi (智), complement ren by guiding the moral agent in discerning the appropriate action in particular contexts. In this way, Confucian ethics is not reducible to a system of rules; rather, these virtues together describe a set of habits or dispositions of character, which act as tools or skills to navigate moral questions as they present themselves. This is similar (though not identical) to what would be called practical wisdom (phronesis) in the Aristotelian tradition.

Another important concept to introduce for the present discussion is that of he (和)—translated into English as “harmony.” Harmony is not like the personal virtues listed above, but rather a property of the community where virtuous people exist. In this way, harmony can be understood as both a social ideal and a moral goal within Confucian ethics. A society of junzi cultivates the four virtues, not just for the sake of personal excellence, but to contribute to broader communal flourishing. Chenyang Li [15, 16] notes that Confucian harmony has been misunderstood in the West, and is often conflated with “sameness” and thus as an oppressive concept that stifles dissent. Li [16] explains that, contrary to this conception, the Confucian ideal of harmony is not a state of static agreement, but a productive and creative state of mutual benefit through negotiation. Harmony, therefore, serves as not just a means but also an end within the Confucian understanding of ethics. It is both the product of virtue and a vital contribution to the social conditions that support the cultivation of individual and collective virtue.

In turn, such obligations are supported by other virtues such as ritual propriety (li) and filial piety (xiao). These virtues are, perhaps, more difficult to understand within a Western perspective. For instance, the notion of ritual propriety is often misunderstood as mere etiquette, but it is better understood as a socially embedded set of practices that allow for the cultivation of the other virtues. Within the ritually appropriate setting, one learns to express benevolence, justice, wisdom, along with other virtues like filial piety. It is the structure provided by li that gives shape to the expression of these other moral dispositions. Li can be linked to another key facet of Confucian ethics in that it is explicitly relational in character. Indeed, each of the five primary relationships (father and son; husband and wife; ruler and subject; older to younger sibling; and friend to friend) carries specific duties of care and obedience. For example, subjects must obey rulers, and rulers must extend care toward subjects. Sons must be filial to their fathers, and fathers must care for and guide their sons, etc. A value like filial piety can seem odd to Western eyes. Of course, most people, no matter their culture of origin, love their parents and wish the best for them. But the idea of substantive obligations toward one's parents can be seen as unreasonably burdensome in a Western context, whereas in countries with strong Confucian influence (like China, Singapore, or South Korea), it is a widely accepted norm [17, 18, 19, 20, 21]. Similarly, while xiao is not one of the “four virtues” highlighted in Mencius’ taxonomy, it is deeply intertwined with the other essential virtues practiced by the junzi. The parent‐child relationship is the primary context in which people begin to learn the emotional habits and relational expectations that underpin broader social morality. Thus, filial piety represents a foundational piece of the Confucian understanding of moral self‐cultivation.

At this point, one might naturally wonder how these personal virtues interact with or generate the social duties or obligations that are at issue in public health ethics. The answer, from a Confucian point of view, is that there is no strong distinction between moral self‐cultivation and social obligation. This is because the Confucian virtues themselves are inherently relational and thus, the virtuous Confucian life, and indeed what it means to be a fully developed person or junzi, is defined by living one's social roles to maximum effect [22]. This point will be picked up again and developed more fully in the next section, which addresses social ontology in more depth.

Historically, Western versions of public health ethics, as outlined above, have tended to be dominated by versions of liberalism or lists of values or principles, structured after the Four Principles. The latter lists, despite their putative commitment to some form of pluralism, in reality, often promote liberty above any other value [4]. However, inspiration is sometimes sought from other traditions. Horner [23] was an early advocate for integrating virtue ethics into public health ethics, and this idea has recently been taken up and expanded by a number of authors [24, 25]. Much of this work has been developed in the Aristotelian tradition, and debate continues about which particular virtues are important, how these virtues relate to moral education and character development, and the degree to which virtues might be held to be social and/or collective in nature. This latter point relates to the objection that virtue ethics can only be of marginal benefit to public health because virtues (and vices) are properties of the characters of individuals. The response has been to argue that, on the contrary, at least some virtues can be related to the aims and practice of certain social institutions such as public health [26]. Individuals will flourish within the domain of a society that has a commitment to a substantive idea of a flourishing life. Such an approach can agree to leave many choices to the individual, thereby respecting freedom and a certain degree of personal responsibility. However, it remains the case that whilst we can allow individuals to choose what to do, they cannot, in many cases, choose what will make their lives go well. Such features relate to the nature of what it is to be a human being, that is a creature with a certain kind of biological and social make up. Public health often focuses on features of society that contribute to such flourishing, such as providing clean water and air, adequate sanitation, protection from threats from disease, or risks to our health. Such features of an Aristotelian approach to virtue ethics related to public health can be seen to be parallel to much in the Confucian tradition.

3. Confucianism & Social Ontology

Just as we can see parallels between Aristotelian and Confucian approaches to ethics, and differences between what they share and Western liberalism, we can also see these commonalities and differences within approaches to social ontology. Western liberalism focuses on the individual self, but the Confucian self is not an isolated and separate individual but is instantiated through that individual's relationships with others and the concomitant duties that attach to those roles. This ontological difference has, in large part, fueled the stereotypical impression of the difference in attitudes between “East” and “West” regarding individual autonomy. But the true difference is not as simple as saying that the West prioritizes individual interests, and the East subjugates the individual for the interests of the group. Jana Rošker [27] has argued that the Confucian model of relational ethics encourages sensitivity and empathy for the other, which in theory may provide a basis for a more cooperative social response to public health concerns. She cites contemporary Chinese philosopher Li Zhehou, who emphasizes that “traditional Chinese societies were structured as networks of relations that bonded together individuals who were not constituted as isolated and independent entities” [27]. This can be related to concerns about social atomism in the West, as Henry Rosemont [28] argues in his book, Against Individualism: A Confucian Rethinking of the Foundations of Morality, Politics, Family and Religion. This Western tradition was set in motion by thinkers like John Locke (1632–1704 CE) and Immanuel Kant (1724–1804 CE), and it has shaped Western moral philosophy since. This view sees the self as rational, calculative, self‐interested, and most importantly, autonomous.

There is more than one way of construing individualism, however, and the Confucian response to individualism will differ depending on which notion of individualism is at issue. In one sense of the term, individualism is the prescriptive claim that individual interests should take precedence over those of the group when or if they conflict. In another sense, individualism is simply the claim that the individual is free to choose from a wide range of options as to how to live. In a third and final sense of the term, individualism might be meant in the sense of following one's own moral compass or living in accord with one's own values regardless of how others see it. Confucianism indeed rejects individualism in the first two senses, but not for the reasons that one might assume. Rather than simply subjugating the interests of the individual to the group, Confucianism sees all interests as being governed by the higher value of harmony (he, 和), as mentioned above. Harmony, in this sense, requires compromise and balance, and neither individual nor group interests are automatically prioritized. As to the second sense of individualism, regarding lifestyle choices, Confucianism, by contrast, is more perfectionist in orientation and articulates a substantive account of the good life. From the Confucian perspective, there is only one right way to live the best human life and achieve moral excellence. However, at the same time, Confucianism is explicitly against using coercive methods to get people to follow this path: the junzi will know what to do and will do what is required. Just as in the tradition of Aristotelian ethics, to be a truly ethical person, it is not enough to merely perform the right action (through coercion) but it must be performed consciously and endorsed. For this reason, Confucianism can be seen to be more accommodating of individualism in the third sense as moral self‐cultivation is central to its teachings and following one's conscience, once developed, is not only accepted but encouraged. Having said this, it is important to note that the education and development of the Confucian self will always occur within a cultural and community context, not in opposition to it. We note, once again, the extensive overlap with the Aristotelian tradition of virtue ethics.

4. Confucianism & Public Health

What implications might this different sense of social ontology have, in general, for public health? As established above, the Confucian self is situated within a network of relationships and duties. Because of this, the cultural logic does not provide as much ground for positioning the individual's interests in opposition to those of the group. Social relations are governed more by conjunction rather than disjunction. As outlined above, the goal is, after all, harmony. Harmony, in the Confucian sense, like many aspects of public health, can be seen to be a good that is held in common; that is, it only exists as something to be created through joint activity and is something that must be shared. The benefits of harmony can, of course, be enjoyed by all individuals, but no individual can create and enjoy them alone. This has strong parallels to a way of interpreting the goods pursued within public health as common goods [4].

This notion of harmony is not reducible to uniformity or the avoidance of conflict. It is a complex sense of negotiation and appreciation of the balance of different goods and interests. As such, it is not analogous to quantitative measures that might be used in the service of public health. It is not something that can be calculated, nor is it a threshold to be achieved. Rather, it is better thought of as a normative orientation, a means of assessing whether any given policy sustains cooperative relationships, enhances mutual trust, or promotes community wellbeing. Where difficult decisions must be made, harmony can guide deliberation through a focused attention to what would lead to balanced coexistence rather than collapsing into either/or decisions or zero‐sum scenarios. That said, our intention in this paper is not to offer any technical policy advice, but to highlight the value of this concept as an ethical resource.

Confucianism's emphasis on obligations, as mentioned above, provides a distinctive view toward public health. In Confucian thinking, matters of public health are not passed on from the individual to an overarching government, but rather everyone has an active responsibility for looking after the whole. The cultivation of benevolence naturally must express itself through the expanding concentric circles of duty and care. First, one must foster virtue within oneself, then extend care and good conduct to one's family, then to one's nation, and so on. As mentioned in our discussion of the virtues, in the Confucian system, personal virtue and social obligation are entwined. Thus, from a Confucian perspective, any obligations toward the promotion of public health are not confined merely to large‐scale institutions or governments; they are everyone's duty [29].

We can see where the liberal sense of individuality and the Confucian perspective come apart when we return to the example of smoking. As noted above, Western liberalism will frame such behaviors as a matter of personal choice, even when there is evidence that not smoking would benefit the individual's health interests or that action to cease smoking would contribute to reducing public health burdens. On this view, an individual emphatically does not owe any duty to be healthy to anyone else, or even themselves [30]. By contrast, in a Confucian ethical framework, smoking would be seen as irresponsible and a valid target for social criticism, as it undermines a person's ability to fulfill familial and societal obligations [29] and is in conflict with the virtues of humaneness and benevolence and fails to promote harmony and the common good. Again, we can see the perfectionism in Confucian thought. A society where fewer people smoke is, unequivocally, a better society. A Confucian approach allows us to see this as a common good, where children are brought up in a society where fewer people smoke, and therefore, each child is less likely to choose to smoke themselves. A further advantage of a Confucian approach is that the range of anti‐smoking policies that have been introduced into different societies over time can be offered a coherent and integrated justification. Consider the list: gradually rising tax rates on tobacco, removal of cigarette machines from public places, bans on smoking in public places, graphic representation of tobacco‐related harms on packaging, plain non‐branded packaging, controls on advertising and sponsorship, promotion of smoking cessation programs and so forth. It is hard to justify all these measures through an appeal to harm to others, and shrieks of paternalism will be heard in the background, but they can all be seen to be policy choices that can be framed in terms of Confucian perfectionism.

Of course, just because the Confucian perspective would support criticism for the poor health choices of others, it does not mean that members of contemporary societies that have been historically shaped by this tradition (like China, South Korea, or Singapore) do not continue to make poor health choices. In fact, smoking continues to be common in modern China, despite increasing awareness of its negative health effects. The fact that many Chinese people smoke should also not be taken as evidence that Confucianism embraces smoking. Though it is true that Confucianism has a strong historical influence on Chinese culture that persists in subtle forms to this day, contemporary China is not by any means an officially Confucian society. Many modern Chinese people do not explicitly or intentionally think in Confucian terms at all. That said, even in an explicitly Confucian culture (were we able to find one), individuals could still choose to smoke. Smoking can, however, be condemned as contrary to the social good, and it will certainly not be encouraged or protected by rhetoric about (mere) harm to self.

Western liberalism, because of the focus on individualism and autonomous choice, tends to assume a strong degree of personal responsibility in relation to health. The reasoning goes something like this: because people who engage in risky or unhealthy behaviors are to blame for their own condition, others in society should not be burdened with the cost of treatment or care. There are a number of problems with such a framing [31]. For example, many diseases are multifactorial, and even assuming that moral responsibility tracks causal responsibility, it is not easy to allocate an appropriate degree of causal responsibility. For instance, some smokers may never develop lung cancer and some people with lung cancer may never have smoked, other factors (e.g., radon gas from rocks, particulates from industry and transport etc) can contribute to lung cancer risks, in indeterminate amounts, in combination with smoking. In addition, as mentioned earlier, smoking rates are influenced by socioeconomic determinants that stand outside of any individual's capacity to control [3]. ‘Choices’ to smoke are not simple personal decisions, even ignoring issues of addiction to nicotine, so attributing personal responsibility in this context can be seen as unjust. Responsibility within a Confucian approach can be seen socially, because individuals are never truly separable from the group, and similarly, benefits and harms must be seen within a cultural and social context, not as a mere aggregation of those attributed to individuals [29, 32]. Within a Confucian culture, the actions of individuals are open to criticism if they are not oriented toward the common good. Whilst on the surface this might sound inappropriate to Western ears, it is important to see that we can consider other benefits, namely, greater social solidarity and public trust. These latter features, in turn, reinforce notions of a shared and harmonious life together. The obligations governing a Confucian society emerge from the non‐individualistic social ontology described above. They do not emerge from any process of individual consent, but pre‐exist any particular individual, and bind all.

Confucian traditions can offer a valuable perspective toward supporting the legitimacy of government action and the maintenance of public trust. Confucian values emphasize moral leadership and the duty of rulers (and therefore governments) to act to create and ensure public trust through virtuous governance. The legitimacy of authority is tied integrally to the ‘moral potency’ of the ruler and the ability to act in the best interest of the people. Additionally, the Confucian approach highlights the reciprocal dynamic between ruler and subject, just as individuals have duties to their communities, governing bodies must cultivate trust by demonstrating benevolence, transparency, and accountability in their health policies. The relationship between governments and citizens is conceived differently in the liberal and Confucian traditions. Western liberalism focuses on (hypothetical) consent provided by citizens toward government. This can be withdrawn and is vulnerable to dramatic shifts as a result of contingent factors such as misinformation (such as during the recent COVID pandemic). Confucianism, on the other hand, sees society as an extension of the family dynamic, meaning that the authorities (the ruler, or ministers) are seen in quasi‐parental roles. Just as the father must provide care, and children must be filial—the ruler must be benevolent, and the people loyal.

From the perspective of Western liberalism, such a Confucian framing will be subject to the objection that it is paternalistic and thereby morally wrong. Such actions are likely to be seen as meeting the requirements for being a case of paternalism on the commonly accepted tripartite definition due to Dworkin [33]. On this view, actions are paternalistic where they interfere with the liberty of an individual, where they do so without consent, and the action is motivated by a concern for the welfare of the parties impacted. However, on a Confucian approach, the response might well be to accept that this can be labeled as a case of paternalism, but go on to reject that this means it is morally wrong. This, in turn, is because, from a Confucian perspective, the government is acting according to the relevant obligations in line with what is morally right ³ [34, 35]. The Confucian view, rooted in a different social ontology than that of Western liberalism, does not prioritize individual freedom or hold it to be inviolable. That said, this does not mean Confucianism would give states carte blanche for authoritarian policies. Rather, individual freedoms must be balanced with concern for collective wellbeing. This can mean that from the outside, a hypothetical Confucian government could certainly look more comfortable with paternalism than many Western democracies. Yet, even within Confucianism, there are limits to what would be permissible. Rulers have obligations to act benevolently, preserve the common good, and uphold righteousness, and these values are not compatible with abuses of power that arbitrarily run roughshod over the welfare and dignity of the people. Thus, Confucian paternalism is bound by the principle that authority depends on serving the people's wellbeing. Western liberalism needs a more robust justification for proclaiming wrongness here than just begging the question by stipulating that such actions are paternalistic (and thereby wrong).

Of course, there are some features of Confucianism that are contested, including within Confucian societies. For example, it might be seen as encouraging too much deference to authority or encouraging sexism. As other contemporary scholars have noted, Confucian society is “starkly hierarchical and gendered” [36], and the five relations of Confucian society are explicitly patriarchal. This can create problems when Confucian values are applied to contemporary issues (see Pang‐White [37] and Herr [38] for more about the Confucian tradition and its intersection with feminism). Yet, this does not mean that the tradition should be abandoned wholesale, at least no more than any other tradition (like Christianity, Islam, etc.) should. Just as Christian bioethics scholars work to interpret their tradition in ways that remain faithful to its core commitments while addressing contemporary issues that may not be explicitly covered in scripture or church teaching, so too Confucian scholars face the task of articulating how Confucian values apply to contemporary debates in bioethics. And just as Christian bioethics contains a diversity of interpretations, contemporary Confucian thought likewise can accommodate debate over what counts as an authentic Confucian stance on particular bioethical questions. It is important to engage with the Confucian perspective not just because it gives insight into the ethical system that has historically informed a large portion of the world, but also because it serves as a critical counterpoint to the often unexamined assumptions of Western liberal thought in public health ethics.

Like all traditions with deep cultural roots and long histories, Confucianism, just like Aristotelian virtue ethics, carries some baggage from the past that might be set aside. Indeed, there are a host of scholars engaged in the process of both revivifying and critiquing the Confucian tradition for contemporary issues. For example, scholars like Sor‐Hoon Tan have explored Confucian conceptions of meritocracy in Singapore [39] and Confucian approaches to democracy [40], pushing back on the simplistic notion that Confucianism is an imperial philosophy and therefore hostile to egalitarian principles. And others, like Justin Tiwald [41], have examined whether Confucianism is compatible with human rights. However, even if the critics are right, this need not invalidate Confucianism's other merits or its potential to help revitalize and enliven some of the most persistent debates in public health ethics today.

Exploring how Confucianism provides an alternative moral perspective on issues in public health, to those of Western liberalism, allows us to see that much of the literature within the discourse of public health ethics applies the insufficiently justified starting assumptions of Western liberalism. We do not argue, here, that such an approach is wrong or that a Confucian alternative is correct. This assumes that we must choose between two incommensurate moral perspectives. And we see no reason to endorse such relativism. However, taking a Confucian approach to ethics seriously, and exploring how it might apply to just one issue in public health policy, allows us to provide an epistemic check on the assumption that Western liberalism is the automatic default, a feature of natural law, or somehow counts as a neutral Archimedean point upon which the universe turns. As we have emphasized, through exploring the parallels with Aristotelian virtue ethics, there is much that is shared across cultural and moral traditions, once we begin to question Western liberalism [42].

5. Conclusion

As with any ancient tradition, it is an ongoing and evolving process to reinterpret values and explore their relevance in a new social context and in the face of new challenges. The process of deciding what to keep and what to discard from old traditions is a continual negotiation, and there are no easy or simple paths. Nevertheless, it is necessary to ensure cross‐cultural and global dialogue to meet the present and future challenges in public health ethics. It is not the intention of this paper to claim that Confucianism possesses all the answers, only that its voice is a valuable corrective to the assumptions of individualistic traditions of social ontology dominant in Western ethics. The appeal of the distinction between harm to self and harm to others is its clarity. But it is of little use if it is simplistic, rather than simple. We all stand to benefit from more cross‐cultural dialogue within the realm of public health ethics. The Confucian concept of the relational‐self and the junzi promotes a view of our obligations that does not see them as oppressive of our liberty, but rather as expressive of who we are and what we share. In addition, we are able to see public health action as, rightly, concerned with both one's own health and the health of others, and that these are not in opposition but jointly pursued, through the fostering of a population of junzi, interested in mutual care and social harmony.

Conflicts of Interest

The authors declare no conflicts of interest.