Chinese Studies
2013. Vol.2, No.3, 139-143
Published Online August 2013 in SciRes (
Copyright © 2013 SciRe s . 139
Structural Dilemma in Health System Reform in the Chinese
Mainland and Emerging of Structure-Based Bioethics Paradigm
Liu Jitong, Zhang Dongqi
Department of Health Policy and Management, School of Public Health, Peking University, Beijing, China
Received April 7th, 2013; revised May 23rd, 2013; accepted June 13th, 2013
Copyright © 2013 Liu Jitong, Zhang Dongqi. This is an open access article distributed under the Creative
Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work is properly cited.
After reviewing the historical development of ethics and individual-based bioethics in Western countries,
and comparing that in China, this paper starts from the extreme Beijing Tongren Case and the dilemma in
the reform of health system in the Chinese mainland, and puts forward the topics of bioethics and medical
professionalism under the circumstances of globalization, global health, and global health system reform.
It compares the individual-based bioethics in Western countries and the structure-based bioethics in the
Chinese mainland, and discusses the lessons of structure-based bioethics for other countries. The histori-
cal experience of health system reform in the Chinese mainland indicates that the health care system is
welfare in nature, which is crucial; that the welfare health care system is the systematic foundation of
medical professionalism; that there should not be direct economic interest generated in doctor-patient re-
lationship since the marketization of health financing may lead to not only the structure intension of doc-
tor-patient relationship, but also a total collapse of the medical professionalism. Therefore the Health Fi-
nance rather than Health Economics should be the material foundation of medical professionalism. The
paper also points out that the main determinants of medical professionalism are not individual medical
professionals, but the outcome of interaction between socio-cultural institutions and individual profes-
sionals, in which the sociality and structure are the most important components.
Keywords: Health System Reform in the Chinese Mainland; Bioethics; Individual-Based Bioethics;
Structure-Based Bioethics; Medical Professionalism
Extreme Case in Tongren Hospital and the
Structural Dilemma in Health System Reform in
the Chinese Mainland
Beijing Tongren Hospital 同仁医院, the best known eye
hospital in the Chinese mainland, witnessed an intensified doc-
tor-patient relationship in September, 2011, when a chief phy-
sician was hacked more than a dozen times by one of her pa-
tients (China Youth Daily, 2011). This tragedy aroused heated
discussion throughout the country, particularly loud cries from
doctors for the safeguard of their life during work. It is not an
accident but a typical case that reflects a serious social problem.
Such seriously disordered work environment is related to the
bioethical dilemma in health system reform on a systematic and
structural level.
There are no regular statistical data in this regard in the Chi-
nese mainland, but according to some statistics in 2002 and
2003 from medical agencies at all levels of China Hospital
Management Association 中国医院管理协会, medical mal-
practices occurred in 98.43% hospitals, and the case number in
each hospital kept increasing. When dealing with the medical
malpractices, 73.5% patients or their families intensified the
conflicts rather than resorted to the law. In addition, hospital
violators (“Yinao 医闹” in Chinese) have become a new group
of people who take benefit from the help they offer to patients
to initiate legal proceedings or to take radical actions to violate
hospital regulations. Nearly half of the hospitals were vandal-
ized by patients or their families, which resulted in 34.64%
cases of injury of medical workers. In Guangdong Province,
more than half medical workers experienced violence twice or
more in one year. From 86% to 96% hospitals claimed cases
where patients complained about the hospital, refused to dis-
charge from hospital or pay medical expenses. As for the
amount of compensation claimed by patients, it is positively
related to the levels of hospital. For example, 5% of the three-
level hospitals bear ¥500,000 to 1,000,000 compensation while
the percentage for the two-level and one-level hospitals are
1.1% and 0% respectively; 75% of the three-level hospitals
offer less than ¥100,000, while the compensation from 92.5%
of the two-level hospitals fall in this range (China Hospital
Management Association, 2003).
The reform and opening up policy since the late 1970s has
promoted the Chinese mainland to the second largest economic
entity around the world, but the development has also brought
problems and resultant disputes over politics, laws, economics,
society, culture and ethics. The society has become high-risk
and filled with social contradictions. The medical field has be-
come one of the industries with most serious problems. The
medical and philosophical foundation, medical professionalism
and bioethics are in structural dilemma, becoming the most
urgent social topics (Xu Zhiwei, 2006). At a time when nation-
wide efforts are being made to “establish a harmonious society
focusing on improving people’s livelihood”, and, especially, in
the social context where physical and mental health needs have
become the most important social needs (Liu Jitong, 2004a),
people expect more from doctors, which is widening the gap
between doctors’ behavior and the social expectation. More
specifically, because of the “poor access and high fee”, struc-
tu ral te nsion in doctor-patient relationship has intensified. Occur-
ences of hurt ing, abusing, an d even killing docto rs further compli-
cate the structural dilemma of bioethics (Sun Shuyin, 2011).
Why does the health system reform in the Chinese mainland
lead to the structural tension in doctor-patient relationship?
What is the reason behind the hurting, abusing and killing doc-
tors in the Chinese mainland? Is it due to the decreasing profes-
sionalism of Chinese doctors or the common challenge faced by
doctors around the world? How to build harmonious doctor-
patient relationship, and re-establish the medical professional-
ism? If individual-based professional ethics does not adequately
explain such dilemma in the hea lth sy ste m re fo rm , wh at is to b e
blamed and how to solve the problem? And what lessons can
other countries and global medical community draw from this?
The above questions are to be discussed in this paper.
Western Culture, Tradition and the Paradigm of
Individual-Based Bioethics
Reform in health system prevails in the world. Many coun-
tries are looking for new ways to maximize the benefits for the
patients and take care of the doctors’ rights at the same time.
However, the situation in the Chinese mainland shows insuffi-
cient protection for doctors. Western countries focus more on
individualism, which is also manifested in medical field. Their
practices cannot be cited to explain, still less to solve, the prob-
lems in the Chinese mainland, a region where different even
opposite situations exist at the same time; therefore a structural
change should be done.
The historical development of Western ethical mode includes
natural ethics, sanctification discipline, individualism, diversi-
fication, and so on, which clearl y describes the transitional lo cus
from virtue of the rulers to the individual-based bioethics, with
individuals eventually being the leading subject in both modes
(Macintyre, 1967; Engelhardt, 1996). The paradigm of individ-
ual-based bioethics just reflects the structural features in West-
ern society, and results from the interaction among society,
politics, economics, culture and individual in the West, which
could hardly serve as an explanation of the situations in China.
The long history of traditional virtues and moral philosophy
in pre-modern China cultivated multiple ethical modes, like
Confucian ethics in Spring and Autumn 春秋 Period (770-476
BC), Buddhist Ethics as of the Eastern Han 东汉 Dynasty
(25-220 AD), Daoist Ethics after the Three Kingdom 三国
Period (220-280 AD), social ethics focusing on Christian Ethics
after the first Opium War in 1840, professional ethics focusing
on business ethics, and revolutionary ethics centering on Marx-
ism and socialism in modern era. Generally speaking, different
moral philosophies and codes of conduct share the common
ground of “group ethics” except for the pursuit of self devel-
opment and self perfection. Therefore there exist wide differ-
ences and sharp contrasts between China’s ethics and the indi-
vidual-based bioethics in Western society.
Structure-Based Bioethics and Its Differences
with Individual-Based Bioethics
Structuralism, as one of the important social theories in 20th
century, relates with multiple subjects including sociology, lin-
guistics, anthropology, developmental psychology and biology.
Structure-based bioethics tries to explain people’s moral ideas
and codes of conduct from the perspective of social structure. It
is, rather than a brand new theoretical innovation, an inevitable
product of the bioethical dilemma of the health system reform
in the Chinese mainland.
The word “structure” means diversification, systematicness,
comprehensiveness, and institutionalization. It can be observed
in many circumstance, contents, approaches, and cause-effect
relations in human life.
Generally speaking, there are six major components in the
system of structure-based bioethics, reflecting its structural and
systematic feature from different aspects.
First of all, the orientations of moral philosophy of structure-
based bioethics: by that we refer to people’s moral ideas that
result from the integration of objective reality and subjective
reality. Secondly, the structure-based bioethics is characterized
by its realism, collectivism, high integration of human nature
and institutional construction. Thirdly, the research objective of
structure-based bioethics is not just to identify what people
should do, but more importantly, to understand the social real-
ity that functions as a context for people’s moral ideas and
codes of ethics. This is the foundation to understand the codes
of conduct (Sidgwick, 1901). Fourthly, the research scope of
structure-based bioethics is rather extensive. It includes not
only macro social environment and history, cultural tradition
and moral philosophy, but the social environment, institutional
arrangement and policy framework, and service system for
personal development, particularly the interaction between the
individual and the social environment (Smart & Bernard, 1983).
In other words, the structure-based bioethics explores the moral
philosophy and code of ethics from the perspective of macro
society and social structure. Fifthly, the research perspectives of
structure-based bioethics are not limited to philosophical analy-
sis. It features an interdisciplinary perspective from which the
universal law of the development of moral philosophy will be
examined. Sixthly, the major function of structure-based bio-
ethics is oriented more towards an objective to change the wor ld
rather than one to explain it. So it is meant to contribute to es-
tablishing a harmonious society and harmonious interpersonal
relationship, doctor-patient relationship in particular, through
system building (Zhao, 2005).
The individual-based bioethics is at once a direct and indirect
antithesis to the structure-based bioethics. The systematic and
structural features of structure-based bioethics—as distinct
from individual-based bioethics—are the focus of this paper.
The structure-based bioethics has a wide research scope that
covers people’s social life and individual code of ethics, espe-
cially the interaction between code of ethics and individual
behavioral mode at specific time and under specific circum-
stances. It aims to explore the social determinants that influence
people’s moral philosophy, moral ideas and code of ethics, and
to develop a new system of moral philosophy theory (Li Qi,
1994). The following aspects show the differences between the
two based on an “ideal model”, which may ignore artificial
exaggeration or minimization.
First of all, the most fundamental and prominent characteris-
tic of structure-based bioethics is “sociality or socialization”,
but not “individuality or individualization”. The basic unit of
the subject engaged in moral activities is socialized individual.
In a socialized individual or one person’s morality, one may
Copyright © 2013 SciRe s .
Copyright © 2013 SciRe s . 141
catch a glimpse of the whole society or the overall social situa-
tion, because individual moral ideas and code of ethics is capa-
ble of reflecting the general social situation at certain circum-
stances. The “individual morality” is “social morality” in es-
sence, so it is not something “personal”. For instance, hurting
or abusing doctors is not an isolated act of any individual.
Rather it is a socialized phenomenon generated and caught in
the web of social meanings and social relations. Therefore more
focus should be put on the social meanings behind individual
code of ethics and behavioral pattern, and the social environ-
ment one is in.
Secondly, the most fundamental and prominent characteristic
of structure-based bioethics is “social structure”, but not purely
individualized life. It is widely known that moral ideas, code of
ethics and moral judgment are fundamentally formulated, en-
acted, or delivered on individual basis, but this does not mean
individuals are merely independent units in this regard. It
should be noted that individual behaviors are not pure personal.
On the contrary, they are behaviors of social actors of macro
situation and micro relations. And in that capacity, they are the
typical manifestations of structuralized interaction of society. A
perspective of social structure emphasizes the interrelation a c r oss
the systems and the parts therein. For example, the distrust
between patients and doctors has become a patterned thinking
in Chinese society, which is the result of structuralized interac-
tion of society and accumulation of social influences.
Thirdly, two other important characteristics of structure-based
bioethics are its diversity of origin and coexistence of various
moral believes and practices. For instance, the traditions of
ethics in contemporary China are manifold, including ancient
Chinese moral philosophy, modern western Christian ethics,
modern business ethics of capitalism, Marxism and revolution-
ary ethics, socialist ethics from former Soviet Union, modern
social and moral philosophy, post-modern social and ethics,
and other ethics from other nations and countries (Sun Muyi,
2007). However the historical development of Western social
moral philosophy and individual-based bioethics indicates a sin-
gular line of individual moral philosophy in Western countries.
Fourthly, another important characteristic of structure-based
bioethics is collectivism, which consists of different smaller
groups and occupations, illustrating the socialized, structured,
and diversified social interaction. After China’s reform and
opening up policy, the social situation has turned from highly
unification to diversity. Larger gaps come into being among
residents from different geographic locations, different organi-
zations, and different occupations, which result in social ineq-
uity and social injustice (Liu Jitong, 2004b). More importantly,
compared with the classical individualism in Western countries
and the collectivism before the reform and opening up in the
Chinese mainland, the current Chinese society is producing a
very unique “structural individualism” during its social structural
transform. By that we mean the organization in which one
works, his/her position, and the resources and power relations
that decide his/her living condition. In the medical field, this
perception induces people to take a part for the whole. They
may think that all doctors are the same as some particular ones
who exhibit insufficient medical professionalism and relatively
low morality. This is definitely unfair to t he rest heal th workers.
The last characteristics of structure-based bioethics are its
historicity and cultural relativity. The former indicates the pe-
riodical features of a specific historical development, and the
latter reflects social relativity of moral philosophy and bio-
ethical practices. The Chinese mainland is undergoing a transi-
tion from a traditional to a modern society, which defines the
current phase of development. The moral philosophy and bio-
ethics are also in this transitional process. For example, the
collectivism and moral philosophy in the Chinese mainland is
passing through structural individualism, and heading to the
modern individualism typical in the West. But Chinese moral
philosophy and bioethical thoughts are significantly different
from their Western counterparts. They are mainly characterized
by situational and traditional implications, which uphold social
harmony, doctrine of the mean, the unity of heaven and human-
ity, and diversity-orderly structure. All of these function to help
those in distress and aid those in peril and so on (Fletcher,
1966). Generally speaking, the historical development and cul-
tural characteristics promote the moral philosophy and bio-
ethics into structure-based bioethics.
The following Table 1 shows the differences between the
structure-based bioethics and the individual-based bioethics.
Historical Lessons and Global Implications of
Structure-Based Bioethics on Theory, Policy,
Health System Reform Practices and Medical
The structure-based bioethics is not just suitable in the situa-
tion in the Chinese mainland. It has global significance under
the circumstances of globalization, global health, and global
health syst em reform.
Two lessons we can learn from the typical and extreme case
in Tongren Hospital and the health system reform dilemma in
the Chinese mainland are: First, health care system is, after all,
welfare in nature, and second, the quality of medical profes-
sionalism depends on the quality of health care system (Liu
Jitong, Guo Yan, Chen Ningshan et al., 2007). The health sys-
tem reform in the Chinese mainland appears to be a project
engaged in mutual adaptation with the social system, where
doctors’ behaviors are deeply affected by the social structure.
The political restructuring and overall plan in the Chinese
mainland, especially health system reform scheme, influence
the moral philosophy and bioethics deeply. And the quality of
bioethics depends on the quality of health system reform (Liu
Jitong, 2010). The establishment of health system reform
Table 1.
Differences between the structure-based bioethics and the individu al-based bioethics.
Compared Items Structure-b ased Bioethics Individual-based Bioethics
Nature sociality or socialization individuality or individualization
Origin result of “social structure” pure individualized life
Category diversity and pluralism singularity
Main manifestation groups and occupations b ased individual-based
Other influences unique and high relatio n with periodical features and culture less historical and cultural influences
scheme should take into consideration multiple factors, includ-
ing doctor’s sources of revenue and the financing model in
hospitals. Payment for health care should not be directly made
from the patients’ pockets, but from the third party single-payer
The building of structure-based bioethics will contribute to
optimizing the theory and policy of the health system reform,
improving health system reform practices, and promoting medi-
cal professionalism.
Theoretically, the individual-based bioethics in the West is
not transplantable to the Chinese mainland, where lots of bio-
ethical misconducts of doctors should be explained by inappro-
priate social structure. The structure-based bioethics, however,
emphasizes the interaction between morality and national poli-
cies and other social ethics, so as to understand the deciding
power of macro social structure and moral philosophy structure
that shapes personal behaviors and life, and to promote the
transformation from condemning individuals to the establish-
ment of systems (Liu Jitong, 2005). What this means to health
system reform is a change from blaming the doctors to improv-
ing health system and systematic policies. It may also enrich
the theoretical system of bioethics in Western society.
In this reform, the sociality of structure-based bioethics calls
for a public understanding of bioethics, medical code of ethics,
and medical professionalism. And such understanding is to be
attained against a background of the social complexity in China
(Liu Jitong, Yan Jun, Wang Mingxu et al., 2009). It also re-
quires the understanding of bioethics, moral philosophy and the
medical professionalism from the perspectives of social system
and its structural function.
As for medical professionalism, the health industry, as part
of social service, should follow the guidelines of the profes-
sionalism in the service. Therefore the value behind the medical
services is the most important component of medical profes-
sionalism. We should abide by the Hippocratic Oath strictly,
and regain patients’ trust (Liu Jitong, Yan Jun, & Kong Lingzhi,
2010). We should strengthen the humanities education for
medical students to improve their medical professionalism.
Besides, the introduction of social workers and social welfare
system into the medical service area may also provide addi-
tional guarantee for medical professionalism and help meet the
requirement of transform of biomedical model (Liu Jitong,
The structure-based bioethics follows the inner rules of so-
ciality, which reminds us of two approaches in system building
to solve the bioethical dilemma in the health system reform in
the Chinese mainland and resolve the professionalism crisis of
doctors. One is to regain the nature of “social welfare” in medical
services; the other is to reinforce the building of the system of
public welfare finance and health finance (Liu Jitong, 2008).
Conclusion: Building Harmonious Doctor-Patient
Relationship and Reconstructing Medical
The reform in health system in the Chinese mainland is fac-
ing an unprecedented structural dilemma, of which the struc-
tural dilemma of bioethics is erroneously considered as the mai n
reason for the tension in the doctor-patient relationship and the
decreasing of doctors’ professionalism. It seems that the prob-
lem of “poor access and high fee” prevailing in the Chinese
mainland would be gone if doctors were more ethically strong.
Therefore, the bioethics becomes the best perspective to ob-
serve the dilemma of the health system reform and doctor-pa-
tient relationship in the Chinese mainland.
Having discussed the health system reform in the Chinese
mainland, compared the Western and Chinese bioethics, and
identified the common goal of health to be the enhancement of
the wellbeing of patients, the authors come up with a new theo-
retical model, namely structure-based bioethics. As a new con-
cept created by the authors, it refers to the synthesis of opinions
and principles to observe moral philosophy and code of ethics
from the perspective of social system, social structure, and s oc ia l
interaction. Its opposition is individual-based bioethics. It is
composed by such six main components as identifying its na-
ture, main focus, research scope, research methods, and major
function. In addition, the structure-based bioethics and the indi-
vidual-based bioethics are compared from several perspectives
so as to explain th e so ciality and diversity of the structur e -b ased
bioethics, and, with specific examples, illustrate its origins and
main characteristics distinctive from the individual-based bio-
To sum up, the forgoing discussions on the policy implica-
tions of structure-based bioethics and, especially, the aspects of
theoretical innovation, policy guidance, and medical profes-
sionalism have been conducted in hope of promoting the a
change from condemning individuals to establishing systems.
This requires a g eneral understanding of the bioethics an d med i-
cal professionalism against the background of social complex-
ity, and suggests building social welfare system to achieve the
common goals of healthcare. The final goal is to establish a
new health system based on a systematic and structural consid-
eration, to build a harmonious doctor-patient relationship, and
to promote the medical humanities care and medical profes-
sionalism, so that the development of the reform in health sys-
tem in the Chinese mainland can proceed in a systemized man-
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