Filial Duty as the Moral Foundation of Caring for the Elderly: Its Possibility and Limitations

Abstract

Humans are “social animals”: one is born into the human relationship, nurtured with the support of other human beings, and has a chance to live life in its fullest sense only when he/she remains in this relationship. The family is at the core of this relationship. There is little doubt about the importance of family in one’s life. In Asian countries, where family ties are strong, the younger generation regards it as their moral duty to care for their elderly parents in return for the grace they receive in the early days of their lives. This sense of responsibility and thankfulness to one’s parents also extends to one’s ancestors.

These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

1 Introduction

Humans are “social animals”: one is born into the human relationship, nurtured with the support of other human beings, and has a chance to live life in its fullest sense only when he/she remains in this relationship. The family is at the core of this relationship. There is little doubt about the importance of family in one’s life. In Asian countries, where family ties are strong, the younger generation regards it as their moral duty to care for their elderly parents in return for the grace they receive in the early days of their lives. This sense of responsibility and thankfulness to one’s parents also extends to one’s ancestors.

This concept is expressed especially well in the Confucian social order. Confucianism has influenced Korean society in every aspect of life. It has served as the backbone of social relationships, as well as political and socio-cultural standards. Among its values, filial duty (孝) guides children in the care of their parents. Filial duty was once regarded as a natural representation of the loving and caring relation between parents and children on which the whole social relationship was built. However, due to rapid and inevitable social changes this basic value seems obsolete and even oppressive (especially against women), because current culture put emphasis on personal autonomy and independence. Making the situation worse, filial duty has been (mis)understood as an unconditional, unlimited commitment and sacrifice, meaning children should do what, in the opinion of “others,” is best for their parents, not what the parents prefer. It seems in this case children have little chance of demonstrating obedience, which is the proper understanding of filial duty. They also seem to have little chance for a discussion with their parents about the treatment they prefer, or what the parent would want. If we are to preserve the family as the core of Korean social life and address the undesirable tendencies mentioned above, we must renew society’s understanding of filial duty and its implications.

The idea of filial duty represented in the Xiao Jing’s Book of Filial Duty (孝經) explores what it means to care for elderly patients . The concept of “filial duty(孝)¹” can serve as moral justification for children’s obligation to care for their parents and provides good reason to involve family members in end-of-life care decision-making . However, as family members are included as principal decision makers, there is a need to support the patient actually receiving end-of-life care. It should be remembered that family members as decision makers are another form of substitute decision making and it is better to set limits on their authority. This issue will arise when we consider how elderly parents are cared for in Korea, especially when they become critically ill.

2 The Concept of Filial Duty in the Confucian Literature

2.1 Historical Background: The Confucian Chosun (朝鮮) Dynasty

Confucianism worked as a governing ideology from the point of its introduction to Korea. The Chosun (朝鮮) Dynasty (AD 1392–1897) was the period when Confucianism, especially Neo Confucianism (性理學) dominated every aspect of life, from politics to the conventions of the lay public. The strong influence of Neo Confucianism in Korea can be explained by several factors. First, politicians recognized that Confucianism would be the best way to achieve an ideal political system and, consequently, during the fourteenth–sixteenth centuries codes of law were actively enacted in an attempt to establish a Confucian political structure in Korea. Second, political leaders and Confucian scholars vigorously encouraged the spread of Confucian conventions in Korean society generally. People’s lives were framed according to the Confucian conventions of a coming-of-age ceremony, a wedding ceremony, the mourning of one’s parents, and ancestral rites (冠-婚-喪-祭) and all were educated about these rules. These efforts resulted in the establishment of a Neo-Confucian Korea beginning in the seventeenth century. Even though a foreign power took control of the Korean peninsula during the first half of twentieth century with an apparent discontinuation of the Confucian tradition as a result, Confucianism survived the rapid modernization that took place in twentieth century. The weight of this tradition is due to the “long and thorough” cultural traditions. Consequently, the Confucian tradition is still the working ideology in Korea. The rites of passage are still Confucian in their content and procedures, and personal character is still valued when evaluating one’s suitability for a public position. Moreover, everyday personal relationships are still deeply ruled by Confucian notions, including making distinctions according to age and gender and taking a hierarchical approach to organizations. The ancestral rite is a very important mechanism for justifying and preserving these Confucian conventions. People are reminded of the identity and continuity of family ties and those distinctions made according to age and/or gender, which fortify the resulting patriarchy by tending to ceremony (Cheong 2007, pp. 193–207).

Consequently, because end-of-life decision making is related to life and death, family relations, and public policy, it is important to understand contemporary Confucianism among Koreans.

2.2 Filial Duty in Confucianism

2.2.1 Loyalty (義理) and Propriety (禮) as Fundamental Interpersonal Virtues

Loyalty is the fundamental virtue of Confucianism. Loyalty is based on a sense of human (and emotional) relationship to others, and a loyal person is one who shows the utmost commitment to this relationship. However, according to differences in the strength of a relationship, loyalty is distinguishable between persons. Propriety means expressing a degree of loyalty proper to the relationship. Propriety is relative to the timing, place, and person (時宜). In Confucianism, one is right only when one makes a right action according to his place (名分) within relations, more specifically, the social order. In particular, according to filial piety, children have a duty to their parents because of their relation to them and this duty is to express their gratitude and love in a proper manner.

2.2.2 Filial Duty in the Book of Filial Duty (孝經)

In The Analects (論語), filial duty is mentioned as the foundation of all human relationships: “filial piety and fraternal submission! Are they not the root of all benevolent actions?” (Confucius Analects, Chap. 2).² We can briefly examine the Confucian teachings of filial duty in the Xiao Jing’s Book of Filial Duty (孝經).³

2.2.2.1 Filial Duty Begins with One’s Own Body

The scope of the Confucian notion of filial duty can be understood by reading the Book of Filial Duty. The first chapter of the Book teaches that filial duty begins with revering one’s own body: “Our bodies—to every hair and bit of skin—are received by us from our parents, and we must not presume to injure or wound them. This is the beginning of filial piety” (Confucius Xiao Jing, Bk. I).⁴ This natural and even basic duty expands throughout the chapter to encompass the duty of public service, which includes serving the King and gaining societal recognition, the final goal of the duty.⁵ It begins with service to one’s parents; it proceeds to service of the ruler; and it is completed by the establishment of character (Confucius Xiao Jing, Bk. I). In the eighth book, the duty is understood as a natural responses to one’s parent’s love, therefore, it is unimaginable for a man to be loyal to others but not his own parents. Only when a man has been a loyal child does he deserve other social roles in government or society.⁶

The relationship between a father and a son and its attendant duties thus belong to the Heaven-conferred nature; they contain in them the principle of righteousness between ruler and subject. The son derives his life from his parents, and no greater gift could possibly be bestowed upon him. As ruler and parent, the father deals with him accordingly, and no generosity could be greater than this. Hence, he who does not love his parents, but loves other men, is called a rebel against virtue, and he who does not revere his parents, but reveres other men, is called a rebel against propriety (Confucius Xiao Jing, Bk. 8).

2.2.2.2 The Practices of Filial Duty

In the tenth chapter of the Xiao Jing, the five practices that fulfill children’s duties are provided.⁷ The services a filial son performs for his parents are as follows:

In his general conduct to them, he manifests the utmost reverence. In his nourishing of them, his endeavor is to give them the utmost pleasure. When they are ill, he feels the greatest anxiety. In mourning for them (dead), he exhibits every demonstration of grief. In sacrificing to them, he displays the utmost solemnity (Xiao Jing Book 10. Trans. Legge).

Practicing this duty then includes reverence(敬), nourishing(養), caring when ill(病), mourning(喪) and sacrificing(祭)⁸. These practices are natural but it is their performance as a response to love received that is important. In familial relations reciprocity is stressed. Theoretically parents will not be abusive to their children, because it is natural to love children (it is basic human nature). Likewise, children must do their utmost with their filial duty toward the parents. Are there any limits to the requirement of filial duty? It seems that, from the Book, one possible limit is when obeying parents will lead to the disgrace of the parents. In fact the Book does set limits on the practice of the duty: A child must argue against, rather than obey, the will of his parents if it does not fulfill the requirement of righteousness.⁹ “Hence, since remonstrance is required in the case of unrighteous conduct, how can (simple) obedience to the orders of a father be accounted filial piety" (Confucius Xiao Jing, Bk. 15)? Accordingly, while fulfilling one’s duty to one’s parents, reason and rationality are still to be pursued.

2.2.2.3 The Adoption of Filial Duty in Korean Society

Filial duty expands beyond familial relationships to include society. It is understood as a cornerstone of the ideal Confucian nation. The virtuous relationship between father and son(孝) can be applied to the virtuous king-servant relationship(忠). Due to the implications for society of filial piety, the Korean government published materials containing exemplar cases of filial duty (孝行) for laypeople who could not read Chinese characters.¹⁰ Combined with an emphasis on family ties, filial duty was always the top priority for ordinary people. Younger generations lived with and cared for their elderly parents, providing them with nourishment and respect. If one was regarded as disloyal to his/her parents he/she would not live in the same community. The obligation of filial duty therefore extends in proportion to how much the family means to the individual.

The exemplar cases put forth were not the stories or ordinary, everyday people. They contained foolish filial duty(愚孝), foolish loyalty(愚忠) and foolish virtuous women(愚烈). The exemplars required individuals to sacrifice themselves in extreme duty with no aim and no limits. Filial duty implies reciprocity and rationality in theory, but in reality it eroded to a brute justification of a vertical hierarchy where being of a higher caste requires obedience, sacrifice and commitment from those who are younger and of a lower social position.

This distorted understanding of filial duty in combination with loyalty (忠) has survived through the current day. During the Japanese occupation period (1910–1945) and the Japanese dictatorship (1945–1992), filial duty was confused with loyalty and obligation to dictators. In Korea, the concept and practice of filial duty still plays a crucial role in social life. However, we can imagine that the practice of filial piety is also often misled by factors outside of its original meaning. As such, it is necessary to compare people’s conventional understandings with the original meaning of filial duty. It is also necessary to consider whether the responsibility of care can be justified by the Confucian notion of filial duty and how this value can be saved. This discussion leads us also to consider policy implications for the aging population whose burden of care often falls on younger generations, usually their children.

3 Future Research for Applying Filial Duty in Medicine

Filial duty , with its virtues and vices, is still a guiding principle for assisting family members in making decisions about end-of-life care. It locates the individual within those relationships that give him aims and meaning in life. Filial duty provides a good moral foundation for surrogate decision making for elderly patients because it requires children to care for their parents while also considering the genuine will of their parents. Children who are willing to care for their elderly parents and are very attentive to their will, can be reliable surrogates. However, there are still some issues to be resolved in the interest of a better decision making process.

First, we need more empirical information about the actual surrogate decision making process: What factors affect the decision? How is consensus reached? How are the children involved in advance care planning?

Second, contextual barriers to soliciting and fulfilling the patient’s care preferences need to be identified.

Third, medical professionals need to be made aware that inviting the whole family to participate in advance care planning can result in better outcomes. At present, they typically abandon one of the stakeholders, either the patient herself or the family. Consequently, the medical care setting needs to be changed; more palliative/hospice care facilities should be made available, service charges for advance care planning should be reimbursed, and professional ethics consultations for end-of-life care should be provided.

These issues come into play in the following situation in Korea.

4 Filial Duty in the Twenty First Century in Korea

4.1 How are Dying Patients Cared for in Korea?

Life in Korea, especially when one becomes ill, centers on the family relationship. One is provided social resources (education and support) by his/her family and in response, as a member of the family, one adopts the duty of family. It includes participating in important rites (e.g., wedding, mourning, and ancestral sacrificing), and taking care of his/her old and ill parents. Elderly parents typically abide by the decisions their children make. The younger generation recognizes the care of their elderly parents as a moral obligation ; meanwhile they find it quite burdensome (Cho 2006). In a national survey, over seventy percent of respondents answered that caring for one’s elderly parents is a family obligation in 2002, but in 2008 this number dropped to thirty-seven percent (Statistics Korea 2011).¹¹ Recent cases of “lone death” (孤獨死, 無緣死) in Korea confirms the concerns of society. There was also the tragic story of an abandoned elderly couple that chose to commit suicide because there was no one to turn to (Huh 2012). The traditional obligation of filial duty is losing its grasp on the younger generation of today: they find the obligation more suitable for the state (Statistics Korea 2011).

However, in matters of healthcare, the moral obligation of caring still abides in the younger generation. When a parent becomes sick and cannot care for oneself, the common understanding among Koreans is that caring for one’s elderly parents is a very natural obligation (Kim and Song 2012). In one study about end-of-life expenditures, almost 80 % of the out-of-pocket fees are covered by the children of the patient, with 15 % from the spouse, and 8 % from the patient (Lee 2012).

4.2 Family Members as Surrogate Decision Makers

As children bear the burden of care for their parents, they also play the role of surrogate decision-maker for determining end-of-life care. Only a small percentage of patients document their treatment preferences in advance directives or living wills, leaving the family members or physician to make the decisions. Although there have been campaigns to increase the public awareness of such documents (Cho 2012), it may take a long time to include patients in end-of-life decision making. For example, in a palliative care hospital, only 0.7 % of patients had of advance directives . Similar results have been reported several times (Park unpublished; Heo 2009). At this point one may ask, “does it matter if patients entrust their welfare to their children and that children do their best for the good of their parents?” The problem is that end-of-care decisions are often too personal to entrust even to the patient’s own children. They are often overwhelmed by the possible loss of their loved one or exhausted from the long, burdensome care that is required. Confusion, a lack of pertinent medical knowledge, and the unavailability of legal and ethical counseling can lead to tragic decisions. Family members of dying patients are often in need of help and the moral justification for the authority of one’s children needs to be explored. For now we have to trust that their children have the best intentions, and filial duty is often referenced in this regard.

From the perspective of biomedical ethics, the responsibility of filial duty has a double edge. Patients can make their wishes known through their husbands and wives or their daughters and sons, who take the wellbeing of their loved-one to be a top priority. Patients become a member of the community through a strong bond and the common goal of regaining health. They are located in a network of caring people. This network is composed of people with mutual understandings of each other so that decisions can be made on the basis of their deep communications. Patients can influence decisions by stating their treatment preferences. The principle of filial duty in end-of-life care holds for children. They are to consider both the physical welfare and the wishes of the patient. This considerate approach is compatible with other principles in biomedical ethics.

However, there are many obstacles to deal with. In Korea, patients are often times not provided with basic information about their disease and instead, family members, most often the eldest son, make medical decisions for them and are responsible for those hospital charges not covered by insurance (approximately 50 % of net expenses). Koreans consider care for the elderly to be the responsibility of one’s children, which is understood as filial duty (孝ko, hyo or xiāo). Worldwide, it is quite natural for children to love and care for their aging parents, but in Korea it is considered the most fundamental duty of a human being.¹² In fact, people are evaluated by how they regard their parents because filial loyalty is fundamental to all Confucian ethics. Ignoring this duty is tantamount to committing a serious sin worthy of social blame and scrutiny. The old saying goes: “Serve your parents with everything: it will be of no use to mourn them after they have passed.” This cultural belief supports the idea that a good child would be willing to cut off one’s own finger so that their dying parent might be revived by the vitality of the blood and their sacrifice.

As such, children feel that it is their duty to keep a parent “alive” and to provide every possible means of curative care, regardless of the likelihood of recovery. Even in cases where parents explicitly refuse aggressive medical care, children feel (or are expected to feel) guilty if they cease to request every possible medical treatment. In contemporary Korea, children will sacrifice their jobs, houses, and savings to pay the necessary hospital expenses in order for their parents to remain in the hospital longer. Understandably, because children seek every treatment measure available, the economic burden is unimaginable.

In the meantime, the Korean family structure is changing: most Koreans now live separately from their parents, resulting in the loosening of family ties. Children seek to escape the burdensome duty of caring for their elderly, disconnected parents. When there remains little emotional bond to one’s parents, it is difficult to fulfill one’s filial duty. In addition, there is another problem related to this change of family structure. As a consequence, children are becoming less reliable sources of their parent’s preferences for treatment. Filial duty requires a child to think from the perspective of the welfare and happiness of one’s parent, but it does not provide an objective or quantitative standard for one to apply during deliberation. Because there is no proper standard to rely on, decisions are usually made in a cautious manner, i.e., the parent remains connected to a ventilator for as long as possible. Children do not want to risk any blame or scrutiny for “killing” their parent, especially not from their acquaintances. Consequently, a patient’s living will is ignored and the decision is made without consulting the patient.

5 Policy Implications

Fulfilling one’s filial duty is a step toward personal integrity and the perfection of self. To admit of an obligation to one’s parents is to recognize one’s personal position within society, especially with relation to one’s family, ancestors and descendants. Consequently, policy initiatives should be undertaken to encourage a more rational and patient-centered model of surrogate decision making , however, not in the conventional or medicalized sense¹³.

First, palliative care for dying patients should be more accessible in terms of quality and expense. Children should be informed of alternative treatments and their attending costs and benefits: aggressive life-sustaining treatment can be critical in the care of patients. However, sometimes it is useless or even harmful for the patient. Children should understand that palliative care is not abandonment of the patient and should not be seen as a failure of filial duty; in fact, it is often times a true act of beneficence.

Second, the patient should be included in the shared decision-making process. Conventionally, the patient is excluded from information sharing and discussions of the treatment options. These practices are undesirable from the perspective of patient autonomy, however, from the perspective of filial duty it is seeking the parent’s wishes and letting them conform to the will of heaven.

It is difficult for clinicians, as well as family members, to break bad news. Policy initiatives to promote advance care planning and documentation through advance directives should be undertaken. The newly revised Cancer Control Act (2011)¹⁴ mandates disclosing the patient’s diagnosis as well as the goals of palliative care to the patient. During intake sessions, physicians have the chance to ask for the living wills of patients. A patient’s participation in care planning can improve compliance and assist the patient and family in preparing for what’s to come.

6 Conclusion

Filial duty is representative of the natural relation between parents and children. It can serve as a guiding principle for biomedical decision making. Consequently, we don’t need to abandon our tradition to be ethical. However, we do need to amend our view of filial duty such that it encompasses rational deliberation rather than just an unconditional, unlimited commitment. In addition, there are further policy issues that must be addressed before asking people to change their views on one’s duty to care for terminal elderly patients .