Population aging is an increasingly urgent issue for societies in Asia and globally. The speed of China’s aging population is extremely fast. Since 2000, China has become an aging society according the United Nation’s definition (i.e. more than 10 % of the population being 60-year old and over). In China today, there are more than 200 million people over the age of 60, nearly 15 % of the total Chinese population and equivalent to the population of the world’s fifth or sixth most populous countries, i.e., Brazil or Pakistan. By 2025, this figure is projected to rise to over 300 million. Unless there is a substantial and immediate jump in fertility rates, by 2050 one out of every three people in urban China will be elderly (Wang and Mason 2007; Qu and Li 2005; Li 2009; Wu 2013).

Eldercare constitutes a pressing and daunting challenge for the Chinese state and Chinese society in the present and coming decades. This paper presents a socio-ethical inquiry into population aging and eldercare in China. Methodologically, it is attempted to integrate normative (ethical and social policy) inquiry with empirical (sociological and anthropological) investigation. Most ethical discussions on the moral issues involved in eldercare have focused upon those arising from clinical encounters and interpersonal or individual level (e.g. The US President’s Council on Bioethics 2005). Meanwhile, most studies on population aging in China have been dedicated solely to empirical demographic and epidemiological data and economic aspects, with few addressing normative dimensions inherent to the subject.

This paper offers a socio-ethical critique of the official Chinese approach to eldercare, which characterizes eldercare as mostly an economic issue and a matter of charity and downplays the duties of the state or government owned to the elderly. But eldercare is a social as well as moral undertaking; it is a matter of social justice, human dignity and human rights to which old people are entitled. Drawing on primary and secondary information from fieldwork, official documents, and demographical data, it highlights a few key features of population aging in China in the context of the one-child policy. Based on statistics of the Chinese governmental expenditure on healthcare and social welfare in comparison with global average, it identifies the failed responsibilities of the Chinese state or government to the elderly. Moreover, to spell out some practical implications of the socio-ethical inquiry, some legal and social policy recommendations for developing adequate care for all old Chinese people will be made.

A Pressing Challenge with Chinese Characteristics

The One-Child Policy and its Consequences

China’s birth control program—widely known as the “one-child policy” and officially (and euphemistically) rendered in English as “family planning”--constitute a unique factor associated with population aging in China. Paradoxically coinciding with a decline in the planned economy and relaxed state control over society, the Chinese Government has thrown considerable resources into promoting state-planned reproduction since the late 1970s and early 1980s. The most ambitious and intrusive population program ever undertaken in human history is a quintessential example of modern social engineering. The extraordinary decline in fertility evident over the last three decades has been achieved at extraordinary human and social cost, a Pyrrhic victory even if it can be called a demographic victory. The greatest irony involved is that, while designed to improve living standards and help relieve poverty and underdevelopment, China’s state-sponsored birth control program and the application of the authoritarian model to fertility control have inflicted enormous suffering on the Chinese people, especially women, through the application of state-sanctioned violence including chiefly coerced abortions on a massive scale (Nie 2005, 2010a, 2014). While the policy may have achieved the stated demographic goals of preventing of an estimated 200 million or more births (the official claim is 400 million), it produced many unintended and far-reaching negative consequences; these include a deficit of 40 million female babies mostly as a direct consequence of illegal sex-selective abortions (not merely the result of the one-child policy) (Nie 2010b, 2011b) and a population with an artificially large elderly demographic.

From the beginning, Chinese policymakers acknowledged the challenges of population aging and eldercare that the one-child policy might bring about. Yet the general tone of official pronouncements on these issues has been optimistic to say the least. One of the earliest formal announcements of the one-child policy was made in 1980 in the form of an “Open Letter of the Central Committee of the Communist Party of China to the Party and Youth League Members on the Problem of Controlling Population Growth”. Written in straightforward, persuasive and reassuring language, the document addressed a number of concerns the public might have about the impact of the policy, including an unbalanced gender ratio, a possible shortage of labor, and problems regarding eldercare. However, the seriousness of these potential problems has been consistently downplayed. On the subject of population aging, the Open Letter argued that, even at the “fastest” rate, significant effects “will not occur” before the end of the century or even up until 40 years later (i.e. after 2020). It further reassured the public that “we [the Chinese government and society] will take measures in good time to prevent it [unbalanced population aging] from occurring.” (Peng 1997, 16) As for a situation arising where there would be too few caregivers available for the elderly, the Open Letter asserted that “When in the future production develops and living standards improve, social welfare and social security support will be enhanced and improved accordingly. In this way, provision will gradually be made for the elderly to be cared for and be given the necessary means of subsistence.” (Ibid, 17)

These assurances notwithstanding, China experienced accelerated rates of aging in both absolute numbers and the proportions of old population almost two decades earlier than the policymakers had either anticipated or wanted people to believe. In early 2014 the one-child policy was significantly relaxed, meaning that in situations where either parent is a single child, the couple is permitted to have a second child. In the end of 2015, the government has formally terminated the one-child policy. Still, people are allowed to have two children only and cannot have as many as they want. Yet, such a termination will have no significant immediate impact on the coming crisis in elderly care. Even if the government were to completely abolish the population control policy and impose no limitation upon the number of children people may have, it is unlikely that most couples would have more than two children because of the changed belief on the family size, increasingly competitive job opportunities, retrenchment of welfare, and the rising costs of living especially raising and educating children.

Of course, the premature greying of China cannot be attributed to the one-child policy alone. According to official pronouncements, it is the national birth planning program that has brought “excessive” population growth under “effective control”. But there is a general question on how effective the one-child policy, its coercive component in particular, has been (Nie 2014). Fertility rates have been in steady decline in China since the late 1960s, long before the draconian one-child policy was introduced. More importantly, it is a commonly observed phenomenon worldwide that fertility rates decline whenever and wherever the market economy is booming and women’s education and employment opportunities are improved. As the saying goes, “development is the most effective contraceptive.”

Nevertheless, it is out of question that the sharp fertility decline associated with the national birth control program has radically altered the structure of the population and significantly accelerated the advent of an aging society. The policy has certainly contributed to a pattern of population aging with unique “Chinese characteristics” and made existing problems with eldercare much harder to address. As a consequence of the one-child policy, in 2014 China has more than 200 million single children. What has been called the “4-2-1” family structure (four grandparents, two parents and one child) has become the norm. A generation of single children whose parents are no longer able to bear a second child has come of age. For these families, the recent relaxation of the policy has come too late. For most urban families, the phenomenon of two single children supporting and caring for four parents is a harsh reality.

Eldercare is an arduous challenge not only for these single-child families, but for the entire country. The Chinese state and Chinese society are far from ready to face up to the consequences of rapid population aging and the other large-scale negative social impacts caused or exacerbated by the One-child policy.

The Anxieties of an Upper-Middle-Class Woman

Chinese people’s worries about eldercare are widespread and deep as the following case study of an upper-middle-class woman indicates. In early 2014, I interviewed Dr. LiFootnote 1 as a part of an extensive fieldwork on China’s birth control program. While the interview was not ostensibly about aging and eldercare, a significant part of our conversation turned out to be on this very subject—initiated by her, rather than following from my questions.

Dr. Li is in her fifties and has lived and worked in Shenzhen for more than 20 years with her husband and only son. Situated on the northern boundaries of Hong Kong, Shenzhen ideally illustrates the massive social and economic transformation China has experienced over the past three or four decades. The city also exhibits the great creative potential of Chinese people that has been unleashed wherever official restrictions have been eased. In the space of only three decades, a fishing village has been transformed into a cosmopolitan city that in many respects is able to compete with Hong Kong. The citizens of Shenzhen enjoy much better living standards, incomes and social security cover than most Chinese in other parts of the country. Dr. Li has spent a good part of her career as a family planning physician providing medical services in conjunction with the state’s family planning program.

Financially, Dr. Li’s family is much better off than most families even in Shenzhen, belonging to the upper-middle class or even the upper class in today’s China. Her husband is a very successful businessman, and their son is studying computer science at a prestigious British university. Despite all these advantages, she is seriously concerned that she and her husband will not be able to receive adequate care when they retire. She feels that it is unrealistic to expect her son (and future daughter-in-law) to provide everyday care for her and her husband, even if they are willing to do so. At the same time, she questions whether such institutions like the eldercare facilities or yanglaoyuan can offer adequate care. If it was still possible, she would want to have at least one more child. She told me that many of her peers share these feelings.

While deeply personal, Dr. Li’s anxieties have a much wider societal dimension. If eldercare is such a serious concern for even the best-off families in China, the outlook for ordinary and especially disadvantaged individuals and families are much grimmer.

Shidu: Parents who Lose their Only Child

In my interview with her, Dr. Li made frequent use of the expressions shidu (失独), shidu fumu, shidu laoren and shidu jiating. These newly minted Chinese phrases refer to parents, elderly people or families who lose their only child, and thus their chief source of support. In 2010, there were over one million such families in China, a figure which is set to increase by at least 76,000 per year (Xinhua News Agency 2013). Although some of these couples had only one child simply because they had no other choice, many of them probably did so because they willingly accepted the official policy. With only limited social support available to them, they are forced to bear the painful consequences of losing their only child. According to an official survey conducted by the National Political Consultative Committee, 50 % of parents in this situation suffer from chronic illness such as hypertension and heart disease; 15 % have serious conditions like cancer and paralysis; and 60 % suffer from depression, with over half showing suicidal tendencies. In addition, 50 % have economic difficulties, with monthly incomes below ¥1200 (less than $200); and 20 % are solely dependent on the low social insurance pay-outs provided by the state (Xinhua News Agency 2013).

The Dramatic Growth of the Oldest Population Strata

As a consequence of increased life expectancy, more and more societies are experiencing dramatic growth in the oldest strata of their population. In China, while the proportion of those aged 65+ will increase from 6.8 % in 2000 to 23.6 % in 2050, the proportion of those in the 80+ age group will grow even more dramatically, from 0.9 to 7.2 % over the same period. To put it another way, the proportion of those over 80 is expected to increase from 13 to 30 % of the elderly population (defined as 65+) between 2000 and 2050 (Chen and Liu 2009, 161). While this broad demographic trend is not unique to China, the radically altered population structure associated with the one-child policy will produce a much higher proportion of very old people compared with other countries.

The seriousness of the challenges posed by these demographic trends for adequate eldercare is obvious for China and other aging societies. The proportion of people suffering from dementia and other physical and mental conditions—both chronic and acute— increases dramatically with age. For instance, almost half those in the 85+ age group suffer from Alzheimer’s disease; this holds true all over the world. The provision of adequate care for the oldest elderly with dementia and other serious physical and mental disabilities requires greatly increased levels of physical and psychological support from family members and caregivers, increased financial and medical resources, and raises numerous ethical dilemmas for caregivers as a result of the diminished mental competency of those in care.

The Epidemic of Elder Suicide, Especially in Rural Areas

The most alarming issue for eldercare in China is the rapidly rising incidence of suicide among the elderly. Globally, suicide has long been a major public health issue; in China, suicides constitute the fifth leading cause of death. As documented in a number of pioneering Chinese studies (e.g. Xu et al. 2000), suicide rates among the elderly have shown a marked increase since the 1990s, with a higher incidence in rural areas compared to the cities. One recent nationwide study of suicide in China for the years 2002–2011 shows that, while in general suicide rates have been declining over the past two decades or so, self-inflicted deaths among the elderly, especially the rural elderly, have been increasing rapidly. It found that suicide rates increased along with age and peaked in the oldest group (see Fig. 1); victims aged 65 and over accounted for 44 % of all suicides (Wang et al. 2014). These results are in marked contrast with suicide patterns in other parts of the world such as the United States and Canada, which are often portrayed as “a paradise for youth and hell for the elderly” in both the official mass media and its popular counterparts in China. In North America, as in most parts of the world, suicide rates peak in midlife and thereafter show a slow decline; in the United States, the over-65 age group accounts for 18 % of all suicides, in contrast to 44 % or 2.5 times higher in China (ibid).

Fig. 1
figure 1

Age-, gender-, and region-specific suicide rates, China, 2009–2011 (Wang et al. 2014, p.935)

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Even more disturbing, suicide rates among the rural elderly, males in particular, are much higher than for their urban counterparts and the national average—three to five times as high, or even more (see also Li et al. 2009). As Fig. 1 shows, compared to the nationwide suicide rates among the middle-aged people, suicides of rural male elderly of age 80–84 are more than ten times higher and those of rural male elderly of age 85 and above nearly twenty times higher. Although in large cities like Beijing and Shanghai the incidence of suicide among the elderly is lower than the national average, rates still increase along with age as in the rural areas. To describe this phenomenon, especially as it affects older people in rural areas, Chinese scholars and even the official mass media have employed phrases such as pingjing yu canlie (quiet but miserable) and chumu jingxin (shocking to the eyes and disturbing to the heart).

Partly because of the positive image, which portrays China as a place where family values and filial piety predominate, far from sufficient systematic and in-depth research has been conducted on the actual living condition of the elderly, especially negligence and abuse and domestic violence against old people. Pioneering research indicates that elder mistreatment is not at all uncommon in China and that old residents who experienced mistreatment are at much higher risk of suicidal ideation (e.g.Wu et al. 2013).

It is wrong to blame the one-child policy alone for the elderly suicides. In fact, as a result of popular resistance, the one-child policy has never been strictly implemented in rural areas so that most rural couples have more than one child especially when their firstborn is a female. Another major demographic factor for rural eldercare is the massive outflow of young people from the countryside to urban areas. More than 200 million young rural migrants are now working and living in China’s cities; and the number may reach 400 million by 2025 (Hays 2015). Because a significant proportion of young women from country areas work as baomu (housemaids) whose duties include caring for the elderly and young children of urban families, this has significantly alleviated the burden of eldercare in the cities, but has greatly exacerbated the problem in rural areas. As in the cities, more and more rural old people live alone or with only their spouse to accompany them.

A Soicio-Ethical Critique of the Offical Approach

The harsh plight of an enormous number of the elderly in China, especially their extremely high suicide rates, signposts an absolutely unacceptable failure in eldercare. Obviously, the whole Chinese society should be accountable for this large-scale erosion of eldercare. In this section, taking a socio-ethical standpoint, the particular emphasis will be given to the failed responsibilities of the central government and the inadequacy of the dominant official approach to eldercare.

The Official Approach

Partly in order to defend the one-child policy in face of international as well as domestic criticism, in the 1980s and 1990s the official Chinese discourse often downplayed the issue of population aging and was overoptimistic about the challenges posed by eldercare. As the issue has become increasingly pressing in recent years, the Party-Government has finally begun to acknowledge the seriousness of the problem and has taken a series of measures aimed at enhancing eldercare. Although not highlighted in the official discourse, the subject of elder suicide is not totally invisible but covered by the state-controlled mass media as cited above.

On the one hand, the official state-oriented approach and stressed the authority of the government. At the same time, the official position on eldercare minimizes the responsibilities of the government and the state. From the beginning, the Chinese Party-Government placed the primary responsibility of eldercare upon individuals and families. The 1980 Open Letter asserted that “respecting the elderly, caring for the elderly and providing for the elderly so that they can enjoy their later years constitutes a duty that should be borne by the children. This is also a fine tradition honoured by our society … The people of our country must carry forward this excellent social practice. Those who do not provide for the elderly or who neglect or even abuse their parents should be criticized and punished if they have violated the relevant laws.” (Peng 1997, 17)

Recent documents continue this official standpoint. They include “The Law on the Protection of the Rights and Interests of the Elderly” (promulgated in 1996, and revised in 2009 and 2013) and a general circular issued by the State Council in 2013, “Options for Accelerating the Development of the Eldercare Service Industry”. Despite some worthy sentiments in these major legal and policy documents (see next section for more discussion), the main responsibility for the care of elderly people still falls on families and individuals. For instance, the 2013 revised version of the law includes a new clause which stipulates that individuals not living together with their parents and grandparents “must frequently visit or give regards to the elderly”, an addition that brought much criticism from the legal scholars and the public because of the ambiguity of the requirement. While the responsibilities of the state are mentioned in official documents, in practice they are often devolved to local governments.

The two most prominent features of the official and popular Chinese approach to population aging and eldercare are well captured in these two catchphrases:

  • weifu xianglao (未富先老, growing old before getting rich); and

  • guanghuai ruoshi qunti (关怀弱势群体, caring for weak groups).

The former offers a diagnosis and the latter the way to address the problem. In other words, the official approach defines the care of elderly mostly or even merely as an economic problem, places the primary responsibility on individuals and families instead of government and society, and in general treats it as a matter of public and private charity.

The Government’s Failed Responsibilities

In official policy documents, the state-controlled mass media and academic publications alike, “growing old before getting rich” is constantly upheld as embodying the most salient aspect of population aging and the most important issue involved in eldercare in China. Placing an emphasis on “growing old before getting rich” – that is, defining eldercare in economic terms – may help urge the government and society to develop low-cost social welfare services for those who cannot financially take care of themselves.

However, to overemphasize the economic dimension is seriously misleading. To present the problem in terms of a lack of financial resources merely serves to justify the inadequate levels of eldercare currently available in China. Especially, such an overemphasis excuses the failure of the government to assume its essential obligations in this area and helps to disguises the problems of misgovernance. Furthermore, it gives ammunition to those in favor of minimizing the responsibilities of government in providing basic levels of healthcare and social welfare.

It is a misrepresentation even in the economic sense. China has become the second largest economic entity in the world and has joined the global club of middle-income countries. In terms of the funds at its disposal, the Chinese government is probably the richest in the world, and has been rapidly expanding budgets for defence and public security to “maintain social stability”. As economists have pointed out, China’s remarkable economic boom since the 1980s has enormously expanded the financial capability of the state and laid the necessary foundation to better address the problems in social security (Cai and Cheng 2014).

Although total expenditure on health care and social welfare has been increasing yearly, the percentage of government spending in these areas has consistently been much lower than the averages of international figures, not just the developed welfare states (e.g. Zhao 2011). Based on World Health Statistics 2014 and World Health Statistics 2010 issued by World Health Organization (WHO), Table 1 shows how China’s per capita government expenditure on health and the portion of general government expenditure on health of total government expenditure are persistently lower than global averages.

Table 1 China’s government expenditure on health in comparison with global average
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My point here is not that China has sufficient financial resources for eldercare; no one can deny that the insufficiency or scarcity of resources is an essential condition of life in any society. Rather, my point is that China has for some time now been wealthy enough to provide much better eldercare services for all old Chinese and at least to significantly reduce the high incidence of suicide among the elderly. As I see it, there is a clear correlation between the unusually high suicide rates of older Chinese people and the persistently low government expenditure on social security and healthcare.

Although China has been a socialist country since 1949, it is still on the “Long March” to establish universal healthcare coverage and universal pension system (Lang and Langenbruner 2013; Cai and Cheng 2014; Tatlow 2015). On the one hand, the governmental expenditure on healthcare and social security is seriously inadequate. At the same time, as to be discussed below, the distribution of the expenditure is strikingly unequal, systematically discriminating rural residents and rural migrant workers in cities.

If China’s birth control program – a massive project of social engineering founded on a gross ethical error – constitutes a grave abuse of the power of the state and is fundamentally unjustifiable (Nie 2010a, 2014), in the case of eldercare these priorities have been reversed, meaning that the Chinese government ought to play a much more active role. However, an increase in the level of government intervention in eldercare should in no way be taken to imply support for the current authoritarian model of governance. It is critical that in the process of providing adequate care for the elderly, the people, not the state, should be empowered (Nie 2015). The basic duty of any government and society is to care for its people so that the aged in particular are looked after. However, the official approach thus far has been to empower the government and the state, rather than the people and society at large. The Chinese government has addressed the issue of eldercare only to the extent that it is able to achieve its ultimate goal of maintaining the status quo with regard to the political, economic, social and cultural power enjoyed by the Party-Government.

Lastly but not least importantly, defining eldercare as primarily an economic challenge overlooks the more fundamental ethical issues involved. Eldercare is first and foremost an ethical challenge, a test of communal values. Without a sound ethical vision, no society, no community can provide adequate care for its entire retired people. Economic resources are necessary but not sufficient for the development of adequate eldercare. For eldercare is not merely a matter of charity and providing the means of subsistence, but a question of human rights, human dignity and social justice.

A Matter of Justice, Dignity and Human Rights, Not Merely Charity

In a response to the increasing inequalities evident in every aspect of life in China, an officially endorsed and popular approach to social welfare known as guanghuai ruoshi qunti (caring for weak groups) has been developing in recent years. Among these “weak groups” are the elderly, families with members suffering from serious illness, rural immigrants to the cities and rural people. The merits of this “charity-oriented” approach include a show of goodwill, not denying the existence of problems out of hand, and calling society’s attention to these issues.

Despites these merits, the charity-oriented approach, especially the key term “weak groups”, is seriously misleading from the ethical perspective. It is not ethically sound because it endorses a victim-blaming ideology, effectively promotes belief in Social Darwinism, and encourages a patronizing attitude in formulating public policies and programs. Above all, it misrepresents the results of injustice and ethically unjustifiable inequality as merely misfortunes or even the fault of the victims themselves. It dismisses the responsibility owed by society and especially the state to the elderly and other so-called “weak groups”. As a result, it treats the necessary care owed to elder people as the enci (bounty or bestow) of the government. While charity is not an essential moral duty for organizations or individuals, individuals and families as well as governments and societies have a fundamental moral obligation to provide adequate care for elderly people.

A number of studies have identified the adverse life events that have led to elderly suicides, including acute and chronic illness and injuries, financial difficulties, and family conflicts (Li et al. 2009). These are important reasons for a person under stress to commit suicide. At the same time, the moral and spiritual factors involved in suicide should never be ignored. One may add that many older Chinese have taken their own lives as a last resort because, existentially, life has lost all meaning for them and because, ethically, their basic dignity as human beings has been deprived.

The high incidence of elderly suicides in rural China makes a compelling case for treating eldercare as a matter of social justice, human dignity and human rights. In order for the Party-Government to control the society tightly, a caste-like social stratification—the hukou (household registration)—was introduced following the establishment of the People’s Republic of China in 1949 and has existed as a basic social institution in China ever since (Chen and Selden 1994; Wang 2005). The system divides Chinese into two civil status groups ascribed at birth places: rural and urban. If “class”, “gender” and “ethnicity” are the essential categories of analysis for understanding social reality in the Western countries, a fourth category, “residency”, is essential to grasp the reality of life in contemporary China. The social, economic, cultural and health inequalities marking the rural–urban divide are so vast that there are effectively “two societies in one country” (Whyte 2010). Discrimination and injustice against rural people are so pervasive that the common Chinese term for rural people, nongmin (peasants), has acquired connotations of backwardness, ignorance and benightedness. The life expectancy of rural residents is several years less than that of their urban counterparts. In addition to suicide, death rates from infectious diseases, respiratory diseases, pregnancy and childbirth, injuries and accidental poisoning are much higher in rural areas (e.g. Han and Luo 2009).

China’s very high rural suicide rates have been unique in the world. In the 1980s and 1990s, suicide rates among young rural women were three to five time higher that their urban counterparts (Lee and Kleinman 2000; Nie 2011a, chapter 10). Now, older people living in the countryside, especially males, are following a similar pattern.

In general rural people have greatly benefited from China’s remarkable economic growth since the early 1980s and their incomes have steadily grown in the past three or so decades. However, as Fig. 2 clearly shows, the gap between urban and rural nominal incomes has been rocketing up since the 1990s, especially the late 2000s (that is, in the past several years) (OECD 2015: 55)

Fig. 2
figure 2

Urban and Rural Nominal Income (CNY) Per Capita (1978–2012) . Source: National Bureau of Statistics (2013) China Statistical Yearbook 2013, China Statistics Press, Beijing. From OECD Urban Policy Reviews: China 2015, p. 55

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Up to the 1980s, the great majority of Chinese lived in rural areas and until 2010 more than half of China’s population were rural people. But, as Fig. 3 shows, the gap between health expenditure in urban and rural areas have been rapidly widening up since 2000. In 2009, health expenditure in rural areas was less than three times that in urban areas.

Fig. 3
figure 3

China Health Expenditure Trend, 1995–2010 . Source: China Health Statistics Yearbook 2010. From Lang and Langenbruner 2013, p.2

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Like healthcare, rural–urban and regional inequality constitutes the most persistent feature of the Chinese social security system (Cai and Cheng 2014). China’s multiple pension schemes structurally benefit first the civil servants and the employers of the state enterprises and institutions, and then urban residents. Pension and availability of other forms of social security for rural people are even more limited than healthcare, with even much lower coverage. Pension for a non-state employee in Beijing may be 3000 Chinese yuan or more per month; but it can be only 80 or less for a person in rural areas, nearly 40 times lower, if he or she has any pension at all (Tatlow 2015).

In early 2014, China’s new leadership finally announced plans to reform and abandon the household registration system. However, the proposed reform does not directly aim to remedy the issues of inequality and injustice, but will rather serve the state-engineered goal of nationwide urbanization. In addition, the timeline and procedures involved in the reform process are uncertain. Even with the determination and tools to undertake meaningful reform, substantial inequalities between the rural and urban sectors are likely to continue for many years.

As I see it, the primary human rights violation evident in China—and thus one of the most serious in today’s world—is not among those often voiced in the Western media, but is the structural and continuing discrimination against rural people. The main reason lies in the sheer number of people suffering from the structural discrimination. Rural people once constituted the great majority of Chinese society and still make up half of China’s nearly 1.4 billion people. This is one tenth of today’s human population. Besides persistent world poverty, hardly any other human rights issue operates on such an enormous scale. Of course, a systematic discussion on the structural social inequality and injustice against rural people in China as an issue of human rights is out of the scope of the current paper. My key point here is that using the term “weak people” to refer the rural elderly in the official approach is seriously misleading, to say the least. It serves to cover up the genuine nature of the problem as a large-scale human rights negligence and violation.

The very high suicide rates of rural old people, along with those urban elderly, are indeed “quiet but miserable” calls for social justice, solidarity and respect for the most fundamental of all human rights, the right to life.

Legal and Social Policy Recommendations

While so far this paper has highlighted the failed responsibilities of the central government in the area of eldercare, it should be mentioned that more and more efforts have been made from the state to address population aging and provide better eldercare nation-wide. The centrepiece legal and social policy document for eldercare in China today, “The Law on the Protection of the Rights and Interests of the Elderly” (promulgated in 1996, and revised in 2009 and 2013), includes some commendable provisions. As the title demonstrates, the Law has put the protection of the rights and interests of the elderly as the central goal. While placing the main responsibilities upon individuals and families, it does stipulate some essential duties for the government and state. For instance, Article 3 states:

The State and society shall take measures to improve the social security system regarding the elderly and gradually better the conditions that contribute toward their well-being, good health and participation in social development, so that they are provided for, have access to necessary medical care, have opportunities for their own pursuits and studies and enjoy themselves.

Practically, the Law promotes multiple levels of social security, “a social care-giving service system that is based on home care, supported by community care and backed up by institutional care” (Article 5). In 2013, the State Council issued a general circular, “Options for Accelerating the Development of the Eldercare Service Industry”, which outlines the strategies and measures of the state to be implemented to achieve the government’s goal of universal eldercare.

Nevertheless, more needs to be done to enhance adequate support and care for all old Chinese people, especially those most disadvantaged and deprived. While it is not possible here to elaborate a comprehensive scheme for significantly improving eldercare in China, a few legal and social policy recommendations based on the socio-ethical inquiry presented above are in place, albeit briefly.

  1. 1)

    The central government should significantly and steadily increase the percentage of GDP in health care and social security. The available basic health care and social security coverage for old people, especially those oldest, is far from adequate and should be enhanced. Special considerations should be given to special needs groups, e.g. the elderly in rural areas and those who have lost their only child.

  2. 2)

    Special efforts should be directed to further develop healthcare and eldercare in rural areas. Much better health care service and especially mental health support programmes need to be established in the countryside.

  3. 3)

    Not only should the house registration system that segregated rural people from urban residents as two classes of citizens be abolished altogether, a National Committee on Social Justice and Human Rights should also be set up to review all major social policies that discriminates Chinese people due to gender, residency, age and other ethically unjustifiable reasons.

  4. 4)

    All the aforementioned measures are urgently needed. Yet, the most urgent is to set up a National Commission of Population Aging and Elderly Care. An immediate task of this Commission is to deal with the shocking high rates of elderly suicide, including the creation of social policies and social and healthcare programmes to prevent elderly suicides. Moreover, the Commission should be in charge of developing a series of long-term social policies and social and healthcare programmes for eldercare. It should also coordinate and supervise the nationwide eldercare services in the following decades.

Conclusions

This paper has documented the general erosion of eldercare in China today. The “one-child policy”—a massive project of state-driven social engineering—has significantly accelerated the advent of an aging society, radically altered the population structure, and made the problems associated with eldercare much more challenging. In addition to the rapid growth of the oldest sector of the population (“the oldest of the old”), China faces serious problems associated with the increasing numbers of families who lose their only child and, most disturbingly, the rapidly rising suicide rates among its old people, especial the rural elderly. In order to reframe the issues at stake in socio-ethical terms, this paper has defined eldercare as first of all a moral task, not merely an economic problem; stressed the duties of the government in this area, which should go well beyond individual and family responsibility; and characterized eldercare as a matter of social justice, human dignity and human rights, rather than public and private charity. In so doing, I have been at pains to present a socio-ethical critique of the official Chinese approach to population aging and some essential elements of any ethical governance with regard to eldercare.

The paper has focused upon eldercare at the societal level and as a socio-ethical undertaking. But care of the elderly is ultimately interpersonal and can hardly be achieved without caring individuals as well as supportive and nurturing communities. Due to the scope of the paper, this important dimension has to be left out.

The ethical criticism of the official Chinese approach to eldercare presented, particularly the highlight on the failed responsibilities of the central government and normative perspective of human dignity and human rights, may appear to be very “un-Chinese”. According to some popular and pervasive stereotypes, Chinese cultures, Confucianism in particular, have stressed the almost unqualified obligations and obedience of the people to their rulers and the government. However, the moral reasoning, intellectual curiosity and cultural orientation that underlie this paper are all deeply rooted in traditional Chinese social philosophy. As being discussed elsewhere (Nie 2015), the Confucian socio-ethical vision of eldercare underscores the duties of the government to the people, the rights and dignity of the elderly, and the primacy of morality. The doctrines of renzheng (humane polity or benevolent governance) and mingui (the importance and value of the people) articulated in Mengzi by Meng Zi (Mencius), one of the founders of Confucianism, demonstrate compellingly that the central theme of classical Confucian political and moral thought is the responsibility of rulers and governments to the people including the elderly, rather than the other way round. In other words, erosion of eldercare in contemporary China is absolutely unacceptable not only ethically but culturally.

It is widely acknowledged in China and the world that respecting the elderly and taking good care of them constitutes a characteristic norm of Chinese civilization. This fundamental Chinese value can be traced back to such ancient exemplary kings as King Shun and King Wen who lived more than four and three millennia ago, respectively, both in terms of their personal character, public policies and socio-political practices. It was given a key role in the classical Confucian moral and political doctrines by Kong Zi (Confucius, 551–479 BCE) and Meng Zi (372–289 BCE). If King Shun, King Wen, Kong Zi and Meng Zi were living in today’s China, they would be appalled by social suffering associated with the one-child policy, the shocking suicide rates of the elderly especially the rural elderly, and the failed responsibilities of the government in providing with adequate eldercare.