CONSEQUENCES OF DEMOGRAPHIC TRANSITIONS AND SOCIAL JUSTICE

All over the world, many countries (whether they are classified as high, middle, or low income) are grappling with a demographic transition that results in increasing numbers of older people. Indeed that rise is more rapid in middle income countries like China. Ageing is often accompanied by diminished societal status, income, social networks, physical and cognitive functions, psychological well-being, as well as loneliness. The resultant challenge to the ability to have a “good life” has stimulated various debates from an ethical perspective of citizenship and social justice that has been highlighted in a Special Report from the Hastings Center, USA [1]. These discussions highlight the adverse consequences of dependency (whether economic, healthcare, or ability to meet their daily needs) that may result in deprivation of choice or increase in various forms of abuse, and ageism. There are also debates regarding who should shoulder responsibility for care of older adults.

FILIAL PIETY AS A FEATURE OF CONFUCIAN ETHICS

For many years, Chinese societies have usually been regarded to have a solution culturally, in the entity of filial piety. The latter is regarded as a cultural and philosophical feature of Chinese society which reveres its elderly and worships its ancestors and defer to seniors. The term filial piety originates from the concept that sons have the responsibility to look after their parents. With time this devolved to daughters [2]. In International Gerontological Conferences, under the Social Section, filial piety is a recurrent theme from research in Asian, in particular Chinese cultures. This concept has influenced certain health care practices such as informed consent, truth telling [3,4], and end of life care decisions, to contravene one of the cardinal medical ethics principles of autonomy. The latter is regarded as a Western concept and may not be applicable to Asian cultures. Traditional culture of filial piety (Xiao or Zhao), has been prominent in academic discourse among Chinese philosophers as part of Confucianism, to the extent that the concept had been promoted to be a moral part of long term care for the elderly [5,6]. The essence of Confucian ethics is that the societal unit is the family, and the family is morally responsible for taking care of the older member; the concept of individual autonomy is considered alien to Chinese culture. This is in contrast to the views of contemporary liberal individualists who argue that children do not have moral obligations to take care of their elderly parents, much less an obligation for parents to live with them. Confucian principles in care of older people also highlight the difference in the concept of dignity between Eastern and Western cultures. Dignity is viewed as less individualistic, and does not emphasize humans as independent moral agents, but recognizes the central importance of the membership of humans in their families [7].

INCORPORATING FILIAL PIETY INTO ELDER CARE POLICIES AND THE PITFALLS

In 2015, a core policy of China’s 5 year plan for long term care was promotion of community social care, by encouraging family support (for example creating tax preference) and strengthening traditional cultures (filial piety). It was noted then that while there was a trend in filial piety that increased by about 2% for children, it was accompanied by a decrease in expectation among older generations. A strong emphasis in family tradition in the Asia Oceania Region was noted [8]. As a result, for many years, filial piety was touted as the Chinese answer to long term care of older people. Indeed in Singapore, there is legislation for aged parents to seek maintenance from their children, in the form of the “Maintenance of Parents” Tribunal Act, and in China the Chinese Marriage Law in China that stipulates that children have an obligation to support and assist their parents, who have a right to demand financial support from their children. In Hong Kong there are tax allowances for taking care of ageing parents [5]. However there are problems associated with such legislation since older people desire not to be a burden on their children, and few would initiate legal action. Also such legislation may result in various forms of elder abuse, where there is genuine difficulty in providing care. Unlike the situation in child abuse, where the ultimate solution is removing the child from the family, family carers of older people in such situations would only be too glad for the state to intervene and provide continuing care of the older person.

While acknowledging that all over the world socioeconomic forces are shifting the locus of long term care from family to institutions, raising moral concerns that are common to both Eastern and Western cultures, Fan argues that Confucian resources must be taken seriously as an authentic Chinese bioethics of long term care, as a basis for long term care policy for Chinese societies [6]. In reality, increasing numbers of older people live alone in both developing and developed economies while their children live and work elsewhere. This phenomenon is particularly prevalent among rural communities in China, where working age adults migrate to work in cities, leaving their parents to look after their own children in many cases. There exists a huge social problem when the elderly developed health problems and cannot look after themselves or their grandchildren. Neglect and suicides, even among children, have been reported in the media [9–11]. Furthermore with increasing life expectancy, the age of family members providing care is also increasing, and many of the care recipients have dementia, giving rise to increasing caregiver burden [12]. Such changes are accentuated by the pace of population aging in many East Asian countries.

ROLE OF FILIAL PIETY IN LONG TERM CARE OF OLDER PEOPLE

This paper argues that Confucianism is a fact of history, and what it advocates with respect to filial piety is not applicable to care of older people in modern economies. Claims of its influence in medical ethical principles in creating a different set of ethics compared with the West, particularly with reference to care of older people is not substantiated by evidence: rather the opposite is true. All cultures look after the elderly: whether the family plays a predominant role depends more on the economic status of development of a particular society. It could be argued that the Western equivalent of filial piety can be found in one of the Ten Commandments “Honour thy father and mother” [Exodus 20 v.12] [13]. Cross cultural differences in attitudes about ageing should move beyond an East West dichotomy [14,15]. Persisting advocacy of filial piety has adverse effects. It ignores the current discourse on ageing issues such as re-ablement or optimizing function, newer models of long term care, and stifles societal debate regarding challenges of aging populations. It also creates problems in end of life care scenarios, and accentuates carer stress and older persons’ perception of being a burden to family/society. For example in the area of end of life care, family tends to take precedence over the individual in informed consent and truth telling [3]. In reality recent evidence show that older people expressed views that are in line with Western cultures, in wishing to know the diagnosis and make end of life care decisions themselves rather than the family [16]. According to Confucianism, children have a moral obligation to support their aged parents, and this is “encouraged” by laws and tax incentives in Singapore, China and Hong Kong, and thus facilitate a policy of home care with support [5,7]. However in recent years there is a shifting locus of long term care from family to institutions with shifts in intergenerational relations. Confucian concepts are weakening, with increase in intergenerational tensions, and filial piety being represented in practical expression such as paying for care by others; with various options allowing for choice of care [17].

Moreover, the concept of filial piety may have adverse consequences, in that societal expectations of obligation to care for senior members within the family can lead to a distinct type of care burden termed ‘worry about performance, especially among daughters who are caregivers [18,19].

RESPECT FOR OLDER PEOPLE AND AGEISM

If Confucian principles are still part of Chinese societies, then one would expect lower age discrimination or ageism and a more positive image of ageing. In fact the reverse is true, as evidenced by constant media portrayal of ageing being a burden, of older people as those living in old age homes, for the past two decades. Examples can be found in the South China Morning Post [20–23]. Initiatives to build community care centres or old age homes for older people are still being met with protests from people in the neighbourhood. This pervasive negative image of ageing and knowledge gap among the general public and healthcare professionals is supported by empirical evidence from surveys of understanding of elderly issues and healthcare prioritization. A survey of 2694 people comprising of 580 people aged 65 years and over, 348 people aged 50–64, 1564 people aged 18–49, and 275 healthcare professionals was carried out in Hong Kong, where respondents were asked to agree with certain statements. 50% to 70% of respondents agree with the statements that most elderly people are unhappy, and most drop out of society, with higher percentage in the older age groups. Remarkably 70–95% of people agreed with the statement that most elderly people’s teeth would fall out. The survey revealed significant knowledge gaps and misconceptions relating to ageing among the Chinese community in Hong Kong, with respect to negative perceptions, poor health literacy, dependence on others for health matters, lack of knowledge regarding home aids, unrealistic expectations of prolongation of life, and lack of knowledge about legal matters such as enduring power of attorney [24]. A study of healthcare prioritization was carried out among 1512 Chinese people aged 18 years and older and compared with a similar one carried out in the United Kingdom [25], where 12 health services were ranked. Both populations ranked services for children as first; long stay hospital care for elderly people was ranked 8 and 10 for HK and UK respectively, treatment for people aged >75 was ranked 9 and 12 respectively, and special care and pain relief for people who are dying 10 and 2 respectively [26]. With respect to choice of end of life care, individual choice appear to take lower precedent over that of family or society, although this pattern is slowly changing with various community initiatives in promoting the individual as central to the choice of quality of life at the end of life period.

There is also low awareness, even among healthcare professionals, of international concepts relating to ageing and health and the need to adapt service models to be fit for purpose [27]. The WHO concept of the Third Age, which consists of a message that this could possibly be the best stage in life, instead of the worse in terms of being dominated by diseases and disabilities, has received little awareness in Hong Kong and China. Public health is still structured towards the prevention and treatment of individual chronic diseases, with the group of geriatric syndromes such as cognitive impairment, frailty, sarcopenia, end of life care, largely ignored. Interestingly among Western cultures there is a negative reaction to the entity of frailty, a term developed by geriatricians to represent a phenotype that required multi-domain comprehensive assessments, to draw attention to the importance of early detection in the community followed by intervention. The term is considered stigmatizing [28]. Yet experience from community living Chinese people in Hong Kong find that in fact prevention of frailty proved to be a very strong motivator for change to a healthier lifestyle in terms of diet and exercise, such that the latter programs became integrated into the regular activities even though they are self-financing. Focus groups evaluating such screening and intervention programs did not find any comments about the stigmatizing nature of the term “frailty”, as the term is equated with poor health with no stigmatizing connotations [29].

A world-wide cross cultural study of modern attitudes towards older adults in the aging world examined 37 papers from 23 countries and 21,093 participants from Eastern and Western cultures, posing the research question whether Eastern cultures hold older adults in higher esteem due to stronger collectivist traditions of filial piety. The findings show that more negative attitudes were observed in Eastern cultures, although there was high heterogeneity. The strongest levels of senior derogation was observed in East Asia, compared with South and Southeast Asia; in non-Anglophone Europe, compared with North American and Anglophone Western Europe. At a country level, recent rises in population ageing predict negative attitudes; while cultural individualism predicts positive attitudes [30].

CONCLUSION AND IMPLICATIONS

The perceived East West dichotomy in attitude to ageing is superficial. The underlying mechanisms behind cultural differences in aging attitudes are likely to be due to higher levels of industrialization and economic progress, rapid population ageing, as well as intergenerational conflict with rising numbers of older people exerting a negative impact, rather than the collectivist tradition of filial piety. The attitude of filial piety is currently not supported by empirical evidence of behavior, so that forceful promotion of filial piety through legislation may not be effective in elder care policies. Efforts to promote care of older people may be targeted towards community as a whole, in tandem with development for supportive services.

CONFLICTS OF INTEREST

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

How to Cite This Article

Woo J. The Myth of Filial Piety as a Pillar for Care of Older Adults among Chinese Populations. Adv Geriatr Med Res. 2020;2(2):e200012. https://doi.org/10.20900/agmr20200012