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Perm J. 2009 Summer; 13(3): 55–60.
PMCID: PMC2911815

East Asian Attitudes toward Death— A Search for the Ways to Help East Asian Elderly Dying in Contemporary America

Sok K Lee, MD, MA

Abstract

The art of dying well has been a quintessential subject of ethicoreligious matters among the people in the West and the East. Most of us wish to die at home; however, about 50% of Americans die in acute care hospitals. Furthermore, immigrants from East Asian cultures feel more uncomfortable near death, because their physicians are not familiar with their traditions.

This article is written to help American physicians understand the unique aspects of East Asian Confucian Ethics for the better care of the dying elderly. Western attitudes toward death are briefly reviewed and the six East Asian concepts related to death are elaborated from Confucian Chinese philosophy. To widen the horizon of bioethics and to embrace the Confucian wisdom of dying well, three pearls of wisdom from classical Confucianism are proposed: the relational autonomy of family, Confucian creative self-transformation, and the unity of transcendence and the human being.

We will have to give up the notion that death is catastrophe, or avoidable, or even strange.

— Death in the Open, Lewis Thomas

Introduction

Modern Americans die hard. We live longer thanks to new advances in modern medicine, but we die with less equanimity than our grandparents did. We meet our own death with fear and despair because of anticipated pain and the helpless depression of hopelessness of any afterlife. According to Phillipe Aries, French historian, death has gradually become forbidden and unnamable1 since the second half of the 19th century. In her work on Death and Dying,2 well-known Swiss psychiatrist Elisabeth Kübler-Ross laments that in this post-modern a-religious and secular society, a few of us die in what she calls the fifth stage of acceptance. During the 1950s and 1960s, advances of medical technology in the US transformed the healing arts into scientific medicine. As evidenced by the summer 2008 issue of The Journal of Clinical Ethics (Volume 19; Issue No. 2), which focused on end-of-life issues, recently there are efforts to recreate a modern version of the medieval ars morendi, or art of dying, which includes hospice care, palliative medicine, and advance directives. Nonetheless, approximately 50% of elderly Americans still die in acute hospitals, even though most wish to die in their homes.3,4 These patients also die in more pain than not, unnecessarily. With an added cultural barrier, dying East Asian immigrants in the US die in religiocultural distress because of the unfamiliar American attitudes toward death and dying. They wish to die in their homeland.3,4 Ethics committees from around the country do not value their unique way of ending life as their own family would prefer, because the bioethical norms of the committee members are inculcated by the principlism proposed by Beauchamp and Childress.5

I will briefly review Western attitudes on dying, drawn from the studies of Phillipe Aries,1 Elisabeth Kuebler-Ross2 and Sandra Gilbert.6 I will then argue that unique features of East Asian ethics can contribute to American bioethics, highlighting three aspects of Confucian philosophy of death and dying: 1) the relational autonomy of family, 2) Confucian creative self-transformation to sagehood, and 3) the unity of transcendence and human being. These three pearls of dying wisdom are drawn from six Confucian attitudes toward death along with NeoConfucianism of Chu Hsi7 up to that of a New Confucian, aTu Wei-Ming.8

Beginning in the 1950s, people died away from home at primarily in hospitals, receiving intensive medical care.

Western Attitudes Toward Death

“In the 1850s, Western society had witnessed a brutal revolution. Death, so omnipresent in the past that was familiar, would be effaced. It would become shameful and forbidden,” wrote the French historian, Phillipe Aries.1p85 Beginning in the 1950s, people died away from home primarily in hospitals, receiving intensive medical care. Physicians, the masters of death,1p89 sanitized dying, and made it more “acceptable” to the survivors of the deceased. The dying person is separated from family and home, and is seldom aware of his/her rights on how and where to die. Physicians do not know when to pronounce death for comatose patients unless they rely on electroencephalography and its interpretation by a neurologist for brain death. The survivors are then expected to recover from grieving as quickly as possible, and any prolonged grief becomes a suspicious sign of depression. Death is forbidden and avoided as much as pornography, according to Geoffrey Gorer.9 This trend is more pronounced in European countries than in the US.10 Phillipe Aries marvels at the American funeral traditions, which seem more traditional and euphoric than its European counterparts.1 In Europe, there are more cremations and visiting gravesites is rare. Aries longs for the renewal of the medieval understanding of tamed death or one's own death. This, then, evolved into thy death, which JudeoChristians embrace in their belief that God gives us a convincing reason to accept death through an embrace of religion. Aries asks if “our technological culture could ever regain the naïve confidence in Destiny which had for so long been shown by simple men dying.”1 His lamentation is augmented by another view illuminated by Kübler-Ross in her research in 1969 on the stages of dying and her book, On Death and Dying.2

Elisabeth Kübler-Ross expounded on what the dying have to teach doctors, nurses, clergy, and their own family.2 She identified five stages of dying: denial, anger, bargaining, depression, and acceptance and advocated for healing professionals to recognize them. She argued that we are fearful of an imagined agony at death. We demand that medical professionals delay dying as long as possible and believe that death signifies defeat of the physician. The sustaining virtue for the patient to reach the final stage is identified as hope, likened to a metaphoric thread running through the five beads of the stages of dying. Ironically, Kübler-Ross blames fearful death on recent advances of medical technology—the source of the blessing of longer life. Along with books such as Callahan and Kelley's Final Gifts,10 Kübler-Ross's On Death and Dying has been instrumental in improving the American hospice system. Ms Callahan and Ms Kelley, hospice nurses, share insightful stories of their experiences of awareness in those who are nearing death. There is much to be gained from listening to the experiences of those in direct care of the dying.

How are we coping as a modern society in the 21st century? In Death's Door,6 Sandra Gilbert explores modern dying grieving. She invites her readers to death's door and asks us to peek through, to taste and to feel the reality of death via her poetic imagination. We die lonely and isolated. The survivors' grief is concealed and silenced. As an elegist, poet, and retired English professor, Gilbert offers four remedies of better dying for modern Americans. She advises us to listen to and for the dying persons, to look at them as we accompany the dying toward death's door, to remember the lives of those who pass through the door, and to imagine a resurrection of the dying as a transfiguration back into this world. Death's door is the door of life and it is always open to sneak a peek, and to step in and out. It invites all who are curious.

As seen by the four principles of bioethics studied by Beauchamp and Childress,5 American bioethics for end-of-life care proclaims and upholds the rights and autonomy of the dying to make decisions. As shown in legal cases such as Bouvia v Superior Court (1986)11 and Cruzan v Director, Missouri Department of Health (1990),12 justice and beneficence are pushed behind. The right to die was legally recognized in these cases, and after some European countries made some similar legal judgments, the Death with Dignity law (ORS 127.800-995) was passed in Oregon in 1994.

The main reason Oregonians resorted to physician-assisted suicide was to ensure that the dying person would not lose control of his/her own dying process. Evidently, the fear of death would be “overcome and controlled” by the option of suicide. We modern Americans have been offered a way out of the sanitized and grim Western death experience through Kübler-Ross's hospice care and Gilbert's remedy of poetic imagination. Is there another healthy way to approach dying, another modern ars moriendi, investigated “out of the box” of our Western thoughts?

East Asian Attitudes toward Death

Chinese philosophy is likened to a concerto with three movements.13 The first movement is the ancient wisdom systemized by Confucius (551-479 BC), who had collected and promulgated wisdom to bring social order in Spring Autumn warring period. The second movement can be described as the medieval period, which predominated during the first millennium, while Taoism and Buddhism were adjusted to and adopted as the “Three Teachings of China.” The last movement, lasting for the next millennium, began with Confucian logical systemization by Chu Hsi (1130-1200 AD) and continued with Neo-Confucianism, which is hallmarked by a revival led by Wang Yang-Ming (1472-1529 AD). Presently, we observe a recent new renaissance to rejuvenate An external file that holds a picture, illustration, etc.
Object name is prjl.13.3.055ine1.jpg Confucian creative self-transformation proposed by Tu Wei-Ming.8

The main thematic assertion throughout the three movements is that man can self-transform creatively to become a superior man (An external file that holds a picture, illustration, etc.
Object name is prjl.13.3.055ine2.jpg) and a sage, while he abides perseveringly in two prime virtues; jen (humaneness, An external file that holds a picture, illustration, etc.
Object name is prjl.13.3.055ine3.jpg and li (ritual, An external file that holds a picture, illustration, etc.
Object name is prjl.13.3.055ine4.jpg) with chung (sincerity, An external file that holds a picture, illustration, etc.
Object name is prjl.13.3.055ine5.jpg). I draw from A Source Book in Chinese Philosophy by Wing-Tsit Chan7 to survey Chinese philosophy with Chinese characters so that those familiar with them will have a greater understanding of the subtleties.

Confucius (551-479 BC) was able to elaborate the possibility of human perfectibility and an idea of subjective anthropocentrism. For the next 2500 years, his teaching of jen (An external file that holds a picture, illustration, etc.
Object name is prjl.13.3.055ine6.jpg and li (An external file that holds a picture, illustration, etc.
Object name is prjl.13.3.055ine7.jpg) and his philosophy have spread widely to influence profoundly China, Korea, Japan, and Vietnam. Mencius (371-289 BC), an idealistic Confucian sage, refined and internalized Confucian teachings by emphasizing the inner ability of the mind to do good by cultivating the original seeds of the beginnings of four virtues: humaneness (An external file that holds a picture, illustration, etc.
Object name is prjl.13.3.055ine8.jpg, righteousness (An external file that holds a picture, illustration, etc.
Object name is prjl.13.3.055ine9.jpg), propriety (An external file that holds a picture, illustration, etc.
Object name is prjl.13.3.055ine10.jpg) and wisdom (An external file that holds a picture, illustration, etc.
Object name is prjl.13.3.055ine11.jpg). Presented here are the teachings of both Confucius and Mencius relevant from the Chinese classics, Analects,7p18–48 Mencius,7p49–83 The Great Learning7p89–94 and the Doctrine of the Mean.7p95–114

a) The Mandate of Heaven (An external file that holds a picture, illustration, etc.
Object name is prjl.13.3.055ine12.jpg): Heaven is the first component of the Chinese “trinity” which is followed by the two other components, Earth and Man. Whereas the concept of earth consisted of natural phenomena such as the four seasons and wind and rain, the idea of Heaven was transformed from the idea of the omnipotent devilish spirits with angry demands in prehistoric China (up to 800 BC) to the concept of the benign ancestral supporters. By the time of the Spring and Autumn era (500 BC), the importance of the brutal powerful mandate became minimized, as the Confucian humaneness of virtue was considered more important. Heaven's will became a kind of principle (An external file that holds a picture, illustration, etc.
Object name is prjl.13.3.055ine13.jpg), moral destiny and natural endowment in about 1100 AD, when Chu Hsi—the Chinese Thomas Aquinas—systemized the Confucian philosophy with Taoism and Buddhism.

When Confucius was very ill in his old age and a prayer was offered by a student, he responded that “What counts is the life that one leads.”7 Human beings are self-perfectible as long as they are trying sincerely to be god-like. This unceasing effort of man is limited and only perfectible through hope. Confucius taught a concept of fate and destiny, in which one is to be neither in despair, nor to be presumptive about death and life.

b) Confucian idea of fate and destiny: Wing-Tsit Chan7 upholds the Confucian theory of “waiting for destiny” as the best prevailing theory over other theories about destiny or the mandate of Heaven. According to this theory, man should exert his utmost in moral endeavor and leave whatever is beyond our control to fate. Life and death are the decree of Heaven. The superior man does not complain against Heaven above or blame man below.7 Confucius knew the Mandate of Heaven at the age of 50.7 Still he strived to be at ease with whatever he heard and could follow his heart's desire without transgressing moral principles.

c) Funeral Reaction by lamentation, emotional crying, singing, and beating on an earthen bowl: The aforementioned Confucius' lamentation to Heaven is contrasted with Chuang Tzu's (An external file that holds a picture, illustration, etc.
Object name is prjl.13.3.055ine14.jpg) singing at the death of his wife. Univocal logic is only good in mathematical problem-solving. The mystical way of Chuang Tzu (399-295 BC, Taoist philosopher) who has expanded Lao Tzu's Taoism, needed a dialectical poetic voice to make a sense of the absurdity of dying (Chaung Tzu, the equality of life and death). In response to remonstrations for his mourning, Chuang Tzu said, “… I realized that originally she had no life; and not only no life, she had no form; not only no form, she had no material force… for me to go about weeping and wailing would be to show my ignorance of destiny.”7

This fundamental difference in perception of existence as deeply embedded in family as opposed to individualist existence is extremely important for understanding the way that East Asian people cope with grief in death and dying.

Chinese culture recognizes Heaven, fate, and spirit, but anchors the existential perspective on family life; whereas Western culture looks to God for individual salvation. Aries1 reviewed how Christians relied on the concept of afterlife to cope with the despairing agony of the deathbed. For the modern, Gilbert invoked “an imagined resurrection in order to embrace the mystery of death.”6p433 This fundamental difference in perception of existence as deeply embedded in family as opposed to individualist existence is extremely important for understanding the way that East Asian people cope with grief in death and dying.

d) Five Relations of Mencius: Mencius advocates that the seedlike goodness inborn in man's heart can be cultivated to bear good fruits by persevering education. “Man without education becomes none but an animal.”7 The Five Relations teach that there should be a norm of human relations by moral reciprocity with a hierarchical degree of priority; “… between father and son, there should be affection (An external file that holds a picture, illustration, etc.
Object name is prjl.13.3.055ine15.jpg); between ruler and minister, there should be righteousness (An external file that holds a picture, illustration, etc.
Object name is prjl.13.3.055ine16.jpg); between husband and wife, there should be attention to their separate functions (An external file that holds a picture, illustration, etc.
Object name is prjl.13.3.055ine17.jpg); between old and young, there should be a proper order (An external file that holds a picture, illustration, etc.
Object name is prjl.13.3.055ine18.jpg); and between friends, there should be faithfulness (An external file that holds a picture, illustration, etc.
Object name is prjl.13.3.055ine19.jpg).7 Chan points out that only the first relation is biological and the rest are moral relationships. It is of note that this precept of Five Relations does not include strangers and the enemy. Out of the five, the affection between father and son trumps over the righteousness in social relationship. When a father has stolen a sheep, his son should conceal the misconduct of his father rather than bear witness against his father.7 Even a son-king should resign his kingship, when he discovered his father-king's past misconduct, he should run away with him and hide together far away, Confucius admonishes. The reason, he explains, is that the father-son affection should be protected at all cost. This prime utmost value of the family is crowned in East Asian ethics as the doctrine of relational autonomy of the East against that of individual autonomy and freedom of the West.

e) Eight steps of creative self-transformation of The Great Learning (An external file that holds a picture, illustration, etc.
Object name is prjl.13.3.055ine20.jpg): The Great Learning (An external file that holds a picture, illustration, etc.
Object name is prjl.13.3.055ine21.jpg),7 a small one-chapter classic, has exerted great influence on Chinese thought. This is a Chinese methodology to learn to be a superior man, to cultivate an affectionate family, and to promote peace in the world. These eight steps, which include the investigation of things (An external file that holds a picture, illustration, etc.
Object name is prjl.13.3.055ine22.jpg), extension of knowledge (An external file that holds a picture, illustration, etc.
Object name is prjl.13.3.055ine23.jpg) sincerity of will (An external file that holds a picture, illustration, etc.
Object name is prjl.13.3.055ine24.jpg), rectification of the name (An external file that holds a picture, illustration, etc.
Object name is prjl.13.3.055ine25.jpg), cultivation of personal life (An external file that holds a picture, illustration, etc.
Object name is prjl.13.3.055ine26.jpg) regulation of the family (An external file that holds a picture, illustration, etc.
Object name is prjl.13.3.055ine27.jpg), national order (An external file that holds a picture, illustration, etc.
Object name is prjl.13.3.055ine28.jpg), and world peace (An external file that holds a picture, illustration, etc.
Object name is prjl.13.3.055ine29.jpg), start an individual creative self-transformation by inner investigation and sincere contemplation. He then transforms the family, his society, and the world. Once skilled with this method, a student of ethics could take a journey through the Chinese dialectics of harmonization to reconcile with the fear of death.

f) Chinese dialectics of harmonization and New Confucianism of Tu Wei-Ming: To overcome the impasse of Western dialectics of contrast, Chinese wisdom offers the harmonious dialectics before known as “following two courses at the same time,” which is found in a story of a monkey keeper's ingenious reconciliation with his grumpy monkeys by simply switching the feeding sequences from three-nuts-in-the-morning-four-in-the-evening to four-nuts-morning-three-evening.7 Therefore, when the sage harmonizes, the right and wrong rests in natural equalization. Chinese Doctrine of the Mean19 emphasizes a dynamic center embracing the opposites together on the middle in the ever-changing process without forgetting the ideas of two opposites. Tu Wei-Ming's creative self-transformation takes its root from Confucius' admonition to be a man of dialectical harmony:7,8p28 “. A man of humanity, wishing to establish his own character, also establishes the character of others, and wishing to be prominent himself, also helps others to be prominent.”8p132 Tu claims that persevering self-improvement could be possible only by helping others improve in the hope that we together will eventually be in peace.

What are the Pertinent Aspects of Confucius Ethics to Help Us Care for Elderly East Asians, Sick and Ill in the US?

Three concepts of East Asian ethics, once appropriately applied to the principles of American bioethics, will benefit East Asian elderly for a better process of dying.

The Relational Autonomy of Family; An Aspect of Interpersonal Relation

In contrast to the political person-hood of the West, in which a Westerner considers family as a volitional option, the familial personhood of the East stands on the foundation of a family with each individual person. “Filial piety (An external file that holds a picture, illustration, etc.
Object name is prjl.13.3.055ine30.jpg) is one of the roots of humanity, with the other brotherly love .”7 The continuity of a family connotes perpetuity of the self and is valued as a way to accomplish personal immortality in the Chinese mind. Having no children was one of the three vices against his parents according to Mencius.7 A son should respect and care for his aging parents and keep ritual sacrifices after their deaths. The individual and his or her family are closely bonded, rather than two separate entities. In contrast, the generational union of Western families is melting down, perhaps, because the individual right trumps over the familial right. According to H Tristram Engelhardt, Jr,14 Western marriage is a love-initiated, partially economic symbiotic arrangement for bicareer cohabitation. Atomized Western man is dislocated historically: once he goes off to college declaring an independent life, he is a nuclear man without family. Individual rights and freedom, as guaranteed by the US Constitution, trump those of the family. Subsequently, the euphoric freedom of the individual eventually becomes boredom. A life without purpose becomes meaningless. I lament that this is one of the untoward side effects of Kantian autonomy and Nietzschean nihilism.

To rescue The Western Fall of Man, Shui Cheun Lee,15 an East Asian ethicist, proposes a concept of relational autonomy that entails a two-dimensional decision-making process for end-of-life care. Western individualism is rejected, because it insists on, “I am, therefore you are.” Instead, “You are, therefore I am” is the core of Confucian ethics. In the Doctrine of Mean7 and the dialectics of harmonization, patient and physician invite the family as a three-member group for the purpose of agreeing on important clinical matters. When an Eastern man becomes sick, all family members are afflicted because life's value is family-centered in spiritual, ethical, and financial matters. A human being is a being-in-between, as promulgated by The Five Relations.7 For Eastern culture, discussion of diagnosis and prognosis are often not confidential matters between the patient and physician.

Confucian Creative Self-Transformation Toward Sagehood; An Aspect of Personal Self-Perfectibility by Helping Others be Perfect

According to Confucius, the Chinese concept of immortality becomes possible and conceivable through virtue-building, achievement, and perseverance.7 Anyone is perfectible by the eight steps of The Great Learning. The six stages of Confucius' life7 have been drawn to undergird the self-transformation of Tu Wei-Ming's creative improvement of character in New Confucianism. The creative tension built by internal Jen (humanism, An external file that holds a picture, illustration, etc.
Object name is prjl.13.3.055ine31.jpg) and external li (propriety, An external file that holds a picture, illustration, etc.
Object name is prjl.13.3.055ine32.jpg) has been a dynamic force for a persevering person to take a journey as a pilgrim of hope toward a process of becoming an authentic human being, which is the Confucian Heaven. In a similar vein, a pilgrim with family undergoes a reciprocal change with cultivation and transformation, as together they accomplish sagehood. In essence, the pilgrim and society become one, neither alone nor separated. Tu's two dialectical transformations are reminiscent of the double movements, the infinite resignation and the leap of faith, of Kierkegaard.16 Then, when an East Asian old man in the utmost interest of sagehood follows the path of Confucian perfectibility of personhood, he would be able to embrace his death and dying with no fear or boredom, but rather with joy and pleasant surprise. By his age of 70 years, Confucius could follow his heart's desire without transgressing the moral principles7 and Chuang Tzu was able to sing at his wife's funeral.7

The Unity of Transcendence and Human Being; An Aspect of Confucius Religiosity

Confucius said, “How abundant is the display of power of spiritual beings!”7 However, Confucianism has not been recognized as a religion in the West, because it has no doctrine of a deity and is not affiliated with an institution. Those western thinkers often quote, to disparage the lack of religiosity in Confucianism, Confucian retorting, How can we know about death, if we don't know yet about life.7 But Tu asserts that Confucianism is religious because it has faith in the ultimate goodness and all-embracing divinity of human nature, decreed by Heaven to be fully realized through the conscious and conscientious activity of the mind.8 Tu restates Confucian religiosity in terms of a twofold process: a continuous deepening of ones' subjectivity and an uninterrupted broadening of one's sensitivity.8 The concept of Heaven has been transformed for two millennia from devilish and wild spirits to guiding norms of morality and principles of nature, as illuminated in the earlier section (a). In addition, atheistic Chinese religiosity became tamed and philosophized by Neo-Confucian thinkers, accommodating Taoist's mysterious Tao and Buddhism's metaphysics. East Asian people believe that through family names and rituals they are able to keep their spirits alive symbolically. Therefore, a person is never forgotten nor dies. In contrast, Western Christianity rejects death, believing in eternal life after death. Eastern philosophy is narrative, Western is analytical. The characteristics of the former are intuitive, practical to know how, interdependent, and corelational, whereas the latter is logical, systemic to know what and independent. The Eastern process is of dialectics of harmonization and cyclical in the worldview, as the Western process is of dialectics of conflict and evolutional and linear in the worldview, according to Ames.17

Confucius said,… ‘How can we know about death, If we don't know yet about life.”7

Conclusion

There are three aspects of East Asian ethics to help the elderly from East Asia embrace their death in better moral comfort: the relational autonomy of family, new Confucian creative self-transformation to sagehood, and Confucian ethicoreligiosity. How can Western clinicians help dying patients of East Asian culture? First, encourage, invite, and involve the patient's family in the conversation about end-of-life care. Because they find the meaning of life grounded on the relational autonomy of family, East Asian elderly patients tend to be less individualistic and hope to be a part of the family. Second, East Asian cultures value a specific kind of self-improvement, which becomes perfectible with others. Asian-American patients may appear to be stoic, self-controlled, and meditative in facing pain and death; they accept Heaven's mandate as a part of natural passage. These attitudes may come from supranaturalistic Taoism or Zen Buddhism. A physician finds that the patient ends his/her life in peace as a cycle of nature. Furthermore, by helping others improve they become self-transformed. Together, they will eventually be whole and in peace. Such community solidarity under-girds the relational autonomy of family. Finally, East Asian atheistic ways should be recognized to be as religious as Western theism. East Asians believe in the benevolent spirits of ancestors, whom the living ought to keep pleased in annual rituals. Such religious thoughts provide hopeful answers to the mystery of death for the dying. Physicians could draw Confucian religious resources for East Asian elderly to ease the existential suffering of death.

The difference in the roots of these two traditions should be recognized in each unique locality if we hope to maintain peace in local and global communities. Engelhardt14 proposed to recognize moral strangeness in our global village, where the moral diversity is one of the features of the global world. By drawing wisdom from Confucian relational autonomy of family, dialectics of harmonization, and the creative self-transformation toward a peace under the religious Heaven, we could explore a new ethical theory to facilitate globalization without losing particularity.

Acknowledgements

The author expresses thanks to Professor Robin Wang for her guidance in his independent study of Chinese Ethics in 2008 and to Professor James Walter for reading this manuscript and for his encouragement. They both teach at Loyola Marymount University in Los Angeles, CA.

References

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Articles from The Permanente Journal are provided here courtesy of Kaiser Permanente