Introduction

Death is something each of us has to face, especially the elderly and the dying. Due to improvements in medical technology, life expectancy has been greatly extended and many people who suffer from serious diseases can survive. However, an increasing number of people are suffering from chronic diseases, such as Alzheimer’s disease or Parkinson’s disease, and many who are dying are living on life-sustaining machines in a state of chronic pain or unconsciousness. Therefore, in an age of highly developed medical technologies, the protection of the elderly with serious diseases and the dying has become an important and urgent issue.

In debate on these issues, human dignity is a widely invoked concept. Scholars from different philosophical traditions appeal to the concept of human dignity to defend their own opinions on issues of death. There are various and even conflicting views on how to protect dying people when applying the human dignity principle and the types of protection this principle can provide. For instance, who should be responsible for the dignity of people facing death? Do the moral demands of human dignity point to the responsibility of individuals, their families, or society? What constitutes the key elements of death with dignity: self-determination, a lack of pain, or something else?

In discussing the question of whether a person can choose the time and means of one’s own death, both parties, pro and con, resort to human dignity. Some scholars believe that people have the right to make decisions on their own death, and that only in this way, can they die in a manner that can be called a death with dignity. As a result, an increasing number of people tend to make living wills in which they decide beforehand whether to accept medical treatment and ensure that their wishes are followed in case they lose the capacity to make decisions. At the same time, other scholars hold that the most basic requirement of human dignity is to preserve and protect human life, and that insofar as human dignity is paramount, life must be sustained at all costs. Therefore, the demand to sustain life surpasses a dying person’s will, such that when a conflict arises over a life-sustaining intervention, the patient’s will is expected to give way.

What accounts for the above situation is that there is not a clear concept of human dignity. Therefore, the key to overcoming the difficulties in understanding the dignity of death is to clarify the concept of human dignity.

Confucian ethics is a system of virtue ethics that has had a far-reaching influence in contemporary Chinese culture. Although the term “human dignity” does not appear in Confucian classics, there are many discussions related to it in those classics. Reconstructing the statements on human dignity and death with dignity in Confucian ethics will provide a Chinese perspective on the ethical studies on death and a way to understand and resolve the various practical problems related to death with dignity. Moreover, an analysis of the Confucian theory of human dignity and the dignity of death can aid in the understanding of the problems that exist in China’s current end-of-life care system, which is deeply influenced by the Confucian culture.

The Confucian concept of human dignity

Just like many Western ethical theories, Confucian thought, which is based on a humanistic philosophy, emphasizes an innate personal worth. In The Book of Filial Piety (Xiaojing), Confucius says, “Among all the creatures in the world, the human being is the most precious” [1, p. 248]. In The Book of Rites (Liji), he proposes that, “The human being is the heart of heaven and earth” [2, p. 147]. In Liezi, Confucius affirms the idea that “of all things produced by Heaven and Earth, man is the noblest” [3, pp. 16–17].

Why is a human being more precious than anything else? Confucians believe that human beings differ from non-human beings in their nature. Human nature makes a human being human and most precious. In The Book of Rites, Confucius claims that human beings can understand ritual propriety and righteousness. This ability is the core element that makes a human being human [1, p. 205]. Mencius goes further and identifies the four basic qualities of the human heart (sympathy, shame, deference, judgment) as not only the distinguishing characteristics of human beings but also the “sprouts” of the four cardinal virtues (co-humanity, rightness, propriety, wisdom). He writes that “all human beings have a heart that sympathizes, a heart aware of shame, a heart that defers to others, and a heart that approves and condemns” [4, p. 245]. He goes on:

Without a heart that sympathizes, one is not human; without a heart aware of shame, one is not human; without a heart that defers to others, one is not human; and without a heart that approves and condemns, one is not human…. A heart that sympathizes is the sprout of co-humanity; a heart that is aware of shame is the sprout of rightness; a heart that defers to others is the sprout of ritual propriety; a heart for the sense of right and wrong is the sprout of wisdom. [4, p. 69]

Xunzi thinks that what constitutes the human essence is the possibility of living with righteousness. He writes, “water and fire have essences, but no life; herbs and trees have life, but no knowledge; birds and beasts have knowledge, but no sense of righteousness. Man has an essence, life, knowledge, and in addition, a sense of righteousness, thus he is the noblest on earth” [5, pp. 90–91].

These Confucian ethicists answered the question of why humans have innate personal worth differently. However, all the answers share a common idea, namely, that humans have a moral potential that enables them to live a moral life. This moral potential is believed to be an intrinsic attribute of human beings, who are understood to be the noblest creatures on earth precisely because of that potential, or ability, to live a moral life. In this sense, all members of the human race are entitled to equal dignity, which can thus be called universal dignity.

Besides universal dignity, human dignity in Confucianism has another commonly recognized meaning: personal dignity. The inborn moral potential grants universal dignity to every human being. However, different people develop that potential to different degrees. In some people, the potential falls into oblivion, while in others it grows full-fledged into virtues. Confucian ethicists believe that everyone should preserve one’s moral potential, and try one’s best to cultivate the virtues. Mencius notes that “when a human being with these four basic qualities of the heart says he cannot develop them, he is to give up himself and do harm to himself” [4, p. 69]. The extent to which one earns his personal dignity depends on how much his moral potential has been developed into virtues. Those who have developed perfect virtues get the ideal personality of Confucianism and achieve the highest rank of personal dignity. In early Confucianism, a Xiaoren (vile character) referred to those who were morally bad while Junzi (gentleman) was a respectful title for those with high moral status, and Shengren (sage) was the title for those with the highest moral status.

According to Confucianism, then, the concept of “human dignity” has two dimensions. Firstly, “dignity” is inherent. It is rooted in the intrinsic nobility of a human being and is something we recognize as a definition of being “human.” Secondly, “dignity” can be acquired and cultivated as a noble characteristic through individual effort. The former is a universal dignity while the latter is a personal dignity. Universal dignity is a universal value possessed by every human being. In contrast, personal dignity is a respectable quality gained through moral behaviors. The moral demand of universal dignity is to respect every human being, including oneself. Personal dignity demands that one fulfill one’s own moral duty. One’s duty is generally pointed to others, so personal dignity depends on interpersonal relationships; it is based on the way we treat each other. The pursuit of personal dignity can provide good protection for universal dignity. If one does not respect others’ universal dignity, one injures his own personal dignity as well.

Universal dignity is based on the intrinsic value of the human being, while personal dignity shows a higher value of the human being. In Confucianism, accomplishing ideal moral personality is the ultimate aim of life as well as the meaning of life, so the value of personal dignity is reasonably taken to be higher than the value of universal dignity in certain contexts. When the moral demand of universal dignity conflicts with that of personal dignity, one should give priority to one’s personal dignity. Though safeguarding one’s life is at the core of preserving one’s universal dignity, under certain circumstances, one should sacrifice one’s life to preserve one’s personal dignity.

For example, as Confucius says, “people with lofty ideals and men of virtue will not seek to live at the expense of their virtues. They will even sacrifice their lives to preserve their virtue complete” [6, p. 235]. Mencius similarly contends that “when right moral principles prevail throughout the kingdom, one must comply with the principle all his life. When right moral principles disappear from the kingdom, one must sacrifice his biological life to defend the principles” [4, pp. 313–314]. Mencius also notes,

Life is what I desire, and so is righteousness. If I cannot have them both, I would choose the latter and forsake the former. To be sure, life is desirable, but I will not stick to it discreditably if something more precious is to be desired. I hate death, but I will not shun it when there is something more abhorrent than it. To make life one’s greatest desire, what would one not resort to if only he could preserve it? To make death one’s greatest abhorrence, what would one not do if only he could avert it? Hence, there is something not to be resorted to even for the preservation of life and something not to be done even for the evasion of death. Therefore, that one would prefer righteousness to life and abhor iniquity more than death is not only the case with sages, but is also true of everybody. [4, p. 252]

According to Mencius, to live in a moral way is more important than one’s biological life. For every individual, the personal dignity is more precious than life. Biological life is bound to draw to an end, but the ideal personality is immortal. The accomplishment of ideal personality can grant personal dignity to a person even after death.

Every individual’s universal dignity is a moral concept that is relevant to others. On the issue of supporting patients at the end of life, universal dignity indicates that the family, the medical professional, and even the entire society as a whole should all bear proper responsibility for taking care of the patient. Everyone’s personal dignity is, however, a moral concept that is relevant to one’s own decision and wish for oneself. The personal dignity, in this sense, refers to the idea and wish of the individual concerning how one should best go through the last stage of one’s life. The dignity in the phrase “death with dignity” refers to personal dignity rather than universal dignity in this context. Therefore, distinguishing the different meanings of dignity provides an important method for elucidating various theoretical arguments and resolving practical puzzles.

Compared to Western understandings of human dignity, the Confucian understanding is distinctive. According to Daniel Sulmasy, there are three historical uses of the word “dignity” in Western philosophy: attributed dignity, intrinsic dignity and inflorescent dignity. Attributed dignity is “that worth or value that human beings confer upon others by acts of attribution”; intrinsic dignity is “that worth or value that people have simply because they are human, not by virtue of any social standing, ability to evoke admiration, or any particular set of talents, skills, or power”; inflorescent dignity is “the value of a state of affairs by which an individual expresses human excellence” [7, p. 473]. The intrinsic meaning of dignity is similar to the Confucian universal dignity; the attributed and inflorescent dignity are like the Confucian personal dignity. But in Confucianism, its two senses of dignity are united in one theory, while the three meanings in the West were pointed out by different authors: “the Hobbesian notion of dignity is attributed” [7, p. 473], “Kant’s notion of dignity is intrinsic” [7, p.473], and “the Stoic use of the word, while it sometimes borders on an attributed sense, is generally an inflorescent sense of dignity” [7, p. 474].

To further understand the two meanings of dignity in Confucianism and their significance for death, we next put them into specific contexts and talk about death with dignity case by case.

The biological life of human beings and the dignity of death

There are different opinions on the relationship between biological life and human dignity in the West. Some people hold that to sustain life is an absolute demand of human dignity. Some theologians, for example, endorse the view that euthanasia is an insult to the sanctity of human life and to God, usurping his authority [8, p. 265]. Kant supported the intrinsic value of human life. He put forward the principle of treating no one as a mere means but always as an end in him or herself. Thus, human beings have the obligation to save their own life even when experiencing an obviously low quality of life. Killing oneself means not treating oneself as a subject with absolute value but as a means to an end. Ronald Munson also holds that ending a life violates human dignity. He argues, “Our dignity comes from seeking our ends. When one of our goals is survival, and actions are taken that eliminate that goal, then our natural dignity suffers” [9, p. 705].

An opposing view also has been developed. John Hardwig suggests that if the life of a person places unbearable burdens on others, their interests in continuing to live might not outweigh the interests of those who are negatively affected by their continued existence, in which case they would have a duty to die [10, p. 35]. Hilde Lindemann Nelson once noted that when one’s persistence provides nothing but hardship for others, to continue to live would be to treat these others as a mere means to one’s own end, which is immoral even by Kant’s concept of dignity [11, p. 219].

Opinions based on human dignity that are against the ending of life usually rest on the inner value of each individual, whereas opinions based on human dignity that support the ending of life mostly rely on the value of interpersonal relationships. The Confucian concept of dignity respects the inner values of human life, but at the same time, it also pays great attention to interpersonal relationships. These two values are reflected in the distinction between universal and personal dignity. Universal dignity is based on the innate value of human life, while personal dignity is based on the way we treat each other. In regards to the relationship between biological life and dignity, Confucians agree that the moral demand of human dignity is to preserve life, and propose that under certain circumstances, to abandon life can better meet the moral requirements of human dignity.

Although life is cherished in Confucianism, death is not evaded. Confucian ethics advocates accepting death calmly, which, to a large extent, can be seen as obeying the laws of nature. Confucian ethics treats the laws of nature with reverence and holds that a moral person should follow them. Indeed, the laws of nature are the prototype of many Confucian ethical principles. For example, because giving birth to all things on earth is one of the most prominent characteristics of nature, Confucian ethics regards benevolence as its central principle. Likewise, death, as one of the laws of nature, is to be accepted calmly. According to Confucius, “the gentleman stands in awe of three things: the mandate of Heaven, great men, and the teachings of the sages” [6, p. 256]. The first thing is the mandate of Heaven. A man of high principle should revere the law of heaven. Confucius puts it this way: “at fifty, I understood Heaven’s Mandate; at sixty, my ear was an obedient organ for the reception of truth; and at seventy, I could follow my heart’s desires without overstepping the bounds of propriety” [6, pp. 13–14]. Once an individual realizes that the law of heaven is inevitable and irresistible, they can accept everything in their lives calmly, including death. Deference to the laws of nature and the calm acceptance of death are praised in Confucian ethics because they have moral value. On the issue of death and dying, Confucian ethics does not encourage people to lengthen their life deliberately through various modern medical techniques, which would be to oppose the laws of nature and would not be used by people with high moral principles.

In addition to the belief that artificially prolonging dying contradicts dignity, in some cases, Confucian ethics explicitly supports life-ending acts aimed at maintaining human dignity. For example, when an individual has to suffer humiliation as long as she lives and her dignity can only be kept by ending her life, death is righteous and worthy of pursuit. Similar cases include dying to achieve virtue or sacrificing one’s life for justice. When a subject cannot live with dignity, ending one’s own life can be defended by the Confucian principle of dignity. Similar views also exist in contemporary Western thought. For instance, David Velleman argues that if a person cannot live in a dignified way, his death is acceptable. “When a person cannot sustain both life and dignity, his death may indeed be morally justified…. The moral obligation to bury or burn a corpse, for example, is an obligation not to let it become an affront to what it once was” [12, p. 617].

In Confucian ethics, the consummation of morality is a life-long pursuit and represents the highest meaning and value of an individual’s life. In many cases, human life itself only serves as a means of achieving moral consummation. Confucian thought is not concerned primarily with biological life but with how a natural life can transcend into a moral life [13, p. 66]. When the extension of life contradicts morality, one can preserve one’s dignity by ending one’s own life for the sake of moral principles. Death in this situation is seen as a step to obtaining the meaning of life through moral cultivation, and thus, as part of living. In relation to the supreme moral values, biological life serves only as a means of realizing moral cultivation: “To die when death is not deserved is to belittle life, is unfilial; not to die when death is deserved is to attach too much weight on death, is disloyal” [14, pp. 1370–1371].

The criteria for judging whether death is deserved come from a moral perspective. Personal dignity, with moral values as its core, is more highly valued than life. The highest meaning of life lies in the unceasing pursuit of morality. Easily abandoning one’s own life hurts one’s dignity, for it means abandoning one’s responsibility for others as well as society. A life that can continue to seek moral perfection should not surrender its moral responsibility, even though it has to suffer various mental or physical pains. The individual ought to conquer these pains and maintain moral practices. In contrast, the life that is unable to pursue a moral life or contradicts morality is not worth living. A lower-level value can be abandoned to keep a higher value. In Confucianism, there is a doctrine of the sanctity of moral values, but not a doctrine of the absolute sanctity of human life [15, p. 55].

The Confucian view that the value of personal dignity is higher than that of universal dignity is different from Kantian ethics. Kant holds that human dignity has an absolute and unconditional intrinsic value. The human capacity for rational behavior is the basis for human dignity. To end life is morally wrong because this act indicates that people do not respect this value. However, there is a paradox in Kant’s opinion. According to Kant’s theory, every human being has human dignity because she is a rational being capable of making rational choices for her behavior. But on certain occasions, people need to sacrifice their life to practice an autonomous moral judgment. Therefore, human life does not always represent an absolute and unconditional value.

Because both Kantian ethics and Confucian ethics have endowed life with a lofty inner value, life is precious. However, it is hard for Kantian ethics to defend the dignity of death because it absolutizes this value, and if this Kantian idea is carried through to its logical end, there is a paradox. Confucian ethics can defend death with dignity because it holds that the value of personal dignity is higher than that of universal dignity. For Confucianism, although life is precious, ending a life meets the requirement of maintaining human dignity if the existence of a life damages the inner value of a human being in certain situations. People have intrinsic value because they have moral potential, and people achieve personal dignity because they have carried out moral behaviors. Ending one’s life because of a moral pursuit is not a violation of human dignity.

Suffering and the dignity of death

Even if maintaining biological life does not conflict directly with morality, when the natural extension of an individual’s life is plagued with enormous physiological or mental suffering, is euthanasia a viable choice in Confucian ethics? (“Euthanasia” here refers to voluntary euthanasia.)

Like many Western ethical theories, Confucian ethics distinguishes between a dignified and undignified quality of life. Some within both Western and Confucian ethics share the view that death can be chosen when the quality of life is lowered to an unacceptable degree. In many Western theories, suffering is a major factor that harms the quality of life. For instance, euthanasia is commonly understood to be applicable when a patient is suffering from unbearable pain with no possibility of recovery. Many Western scholars believe that suffering violates human dignity by interfering with one’s ability to live authentically in many cases, and that suffering per se can be a factor violating human dignity. Daryl Pullman writes that “inasmuch as unmitigated pain and suffering are often thought to rob human beings of their dignity, physicians and other care providers incur a special duty to relieve pain and suffering when they encounter it” [16, p. 75]. As proposed in the Code of Medical Ethics of the American Medical Association, “Physicians have an obligation to relieve pain and suffering and to promote the dignity and autonomy of the dying patients in their care” [17].

In contrast, Confucian ethics holds that suffering per se cannot violate human dignity. The Confucian concept of quality of life is equal to the quality of a moral life. The low quality of a physiological life does not justify ending life in Confucian ethics. In Confucian ethics, morality enjoys priority over the physical body. The physical body is seen only as a means of seeking morality. It is wrong to give up life as long as its moral value can be achieved, even though the individual has to bear a huge amount of suffering.

For example, after being convicted of cheating and slandering the majesty, Qian Sima (the famous author of The Records of the Grand Historian) was sentenced to death. But he was given the option to save his life by redeeming himself through castration. Despite the tremendous physical and mental pain and suffering it would cause, Sima chose to be castrated to save his life. He shouldered this large physical and mental pain and kept himself alive in order to write The Records of the Grand Historian (Shi Ji), a mission he had to complete. Immediately after being castrated, Sima wrote to one of his friends: “There is no misfortune worse than greed and selfishness, no sadness worse than desperation, no disgracing worse than insulting ancestors, and no humiliation worse than castration. A man getting life by accepting the punishment of castration has no grace to compare to other persons” [18, pp. 217–218]. It was obvious to Sima that castration was a punishment more humiliating than death. For him, “If I prefer to die, my death will be as if nine cattle lost one hair; my death will be no different than an ant’s death” [18, p. 218]. Sima suffered tremendous physical and mental pain, but throughout history, he has been admired because he chose to remain alive to finish his mission. Sima’s case shows that if a huge amount of suffering cannot prevent a human being from one’s responsibilities, Confucian ethics does not support death for the sake of eliminating suffering; instead, it encourages people to continue to live to fulfill their responsibilities. Moreover, mental suffering cannot be a reason for death because mental suffering is something that Confucians argue should be overcome and conquered. Attitudes such as staying calm in adverse situations and remaining unruffled when facing the vicissitudes of life are of moral value and supported by Confucian ethics. Indeed, if an individual chooses death due to mental suffering, he will lose his dignity.

On this issue, Confucian views are different from some Western opinions. Many supporters of euthanasia hold that when the quality of life reaches an unacceptable level, life is not worth living. If the concept of a low quality of life includes unacceptable mental suffering, a person has every reason to choose euthanasia to end that mental suffering. Take a case of euthanasia in Holland in 1991 as an example. Mrs. Bosscher was physically healthy but demanded euthanasia due to large mental shocks. She divorced her husband due to abuse, one of her two sons committed suicide when he turned 20, and the other died of lung cancer at age 20. Dr. Chabot carried out her euthanasia. The supporters of Dr. Chabot believed that mental torture could become unbearable in a manner similar to physical pain [19, pp. 148–149]. If euthanasia that aims to end unbearable physical suffering is ethical, then euthanasia to terminate unbearable mental suffering can also be defended. In Confucian ethics, Mrs. Bosscher’s action would be regarded as cowardly. Confucians are against the medicalization of mental health. Traditional Chinese medicine does not include psychiatry or psychology and does not advocate solving mental problems with medical interference. Disciplining the mind is an important part of one’s moral life.

Confucian ethics supports choosing death to end unbearable suffering in only one situation: when the suffering is physical instead of mental. Moreover, the suffering should be so great that it prevents an individual from realizing his moral value, fulfilling obligations, or caring for moral norms. Even today, although there are some very effective methods for relieving physical suffering, there are still many sufferings that cannot be controlled by Medical intervention. For example, the suffering caused by bed sores or the breathing machine cannot be relieved by medicine. Many patients with esophageal cancer do not accept gastrostomy due to various psychological reasons and suffer from starvation as a result. In all these cases, the patients’ ability to practice their duty has been impaired to a large extent. There are also other occasions in which, even though the medical interventions can effectively alleviate suffering, the patients’ ability to live a dignified life is still greatly harmed by their disease. For example, patients who are in a hepatic coma generally suffer from manic symptoms, causing patients to hurt medical staff, their family members, or themselves. Of course, a tranquilizer can stop such symptoms, but the use of a tranquilizer is not suggested in this case because it would very likely cause the death of the patient. What is more, the frequent use of painkillers can harm the brain and nervous system, which can have a direct negative effect on a person’s behavior. Living under such conditions may lead to damage to the patient’s personal dignity.

Euthanasia occurs in the medical field and requires the assistance of medical staff. Therefore, in addition to the consideration of the patient’s personal dignity, it is inevitable that an analysis of euthanasia should involve the morality of the medical staff and take into account the Confucian ethical code for physicians.

The Virtue of the Great Physician (DaYiJingCheng) by Simiao Sun (a distinguished physician in the Tang Dynasty) is an important literature on medical ethics. It teaches that

in all cases, when you treat disease as an eminent physician … you must first develop a heart full of great compassion and empathy. You must pledge your desire to rescue all sentient beings indiscriminately from their suffering.… If someone facing disease or disaster comes to you seeking relief, you must treat all of them exactly the same as if they were your closest relatives.… When seeing the suffering and grief of others, you should feel as if it were your own and open your heart deeply to their misery. You must not avoid dangerous mountains with rugged cliffs. Any time of day or night, cold of winter or hot of summer, hunger or thirst, fatigue and exhaustion, you must treat and cure the patient wholeheartedly. [20, pp. 95–105]

This statement embodies the primary moral demand of Confucian ethics for physicians: physicians should be benevolent. The affective experience of feeling other people’s pain or suffering forms the foundation of Confucian ethics. As Mencius has said: “sympathy is the starting point of benevolence” [4, p. 69].

In cases in which the patient is unable to bear the huge amount of suffering and asks to end his own life, Confucian ethics would not always favor extending the patient’s life regardless of their unbearable suffering because Confucian ethics demands that physicians be empathetic towards their patients’ suffering and try their utmost to provide relief.

Throughout history, Confucians have attempted to educate people to cultivate a quality of moral life rather than to maintain a quality of biological life. However, in the Confucian moral system, the instinct of sympathy for others also acts as a basic moral sentiment. This instinct is so important that Confucian ethics does not allow ignorance of other people’s overly low quality of biological life. Mencius’s view of benevolence is utterly reliant on sympathy, which is an instinctual sentiment. Universal sympathy is not only approved of in Confucian ethics but acts as the theoretical foundation for the basic concepts of Confucian ethics such as benevolence. As human beings, we cannot disregard other humans’ suffering, which requires that more resources be put into relieving pain, such as making hospice care more available. If death is the only way for patients to overcome suffering, it is not contradictory for doctors to assist with euthanasia and, at the same time, to be benevolent.

The autonomy of human beings and the dignity of death

Many Western theorists argue that human dignity is equal to autonomy. For example, Ruth Maklin has proposed that “dignity seems to be nothing other than respect for autonomy” [21, p. 1419]. In the case of death, they hold that the most important issue is whether a patient accepts treatment and what treatment is accepted out of her own will. This issue is the main reason why the living will is a common practice in the West. A total of 35 states in the United States have passed natural death acts. Under these acts, people who are critically ill or on their deathbed can choose whether to accept treatment and determine which treatment to accept according to their personal wishes by signing the living will. In Europe, the living will is also commonly accepted. For example, people in England and Wales can make an advance directive or designate a proxy according to the Mental Capacity Act of 2005. Bundestag is an advance medical directive act that went into effect in Germany in September 2009. This act is based on the right of self-determination. The first living will association was set up in China in June 2013. Its founder regards death with dignity as the theoretical basis of the practice of living wills.

Although the practice of autonomy is under constant development, theories of dignity completely based on autonomy contain contradictions and do not adequately explain relevant practical issues. For instance, John Harris proposes that dignity is equal to shaping one’s own life autonomously, which cannot defend the euthanasia he supports. He argues that, “Autonomy, as the ability and the freedom to make the choices that shape our lives, is quite crucial in giving to each life its own special and peculiar value” [22, p. 11]. According to Harris, because the value of life comes from our autonomy, banning voluntary euthanasia would be a profanity against human dignity. Harris argues that a life form becomes a person when it is capable of valuing its own existence. Hence, persons who want to live are wronged by being killed because they are thereby deprived of something they value; persons who do not want to live are not, on this account, wronged by having their wish to die granted [22, p. 9]. But the problem is that if a person with no serious disease or a healthy person wants to die and goes to a hospital to ask doctors to euthanize him, should doctors respect this person’s autonomy? Of course not. No doctor will assist a person without serious disease or a healthy person to die. Here, it is clear that there are values higher than autonomy.

Ronald Dworkin also advocates autonomy, but he also argues that a subject’s autonomous behavior should be restricted when he does not respect his own value. Thus, a contradiction occurs. Dworkin says, “no one treats his life as having any intrinsic, objective importance unless he insists on leading that life himself” [23, p. 239]. He defines “dignity” as the right to consider and act on our answers to “the most fundamental questions about the meaning and value of [our] own lives” [23, p. 166]. At the same time, he notes that because we attribute dignity to everyone, we do not allow others to give up their dignity. Thus, treating others with dignity sometimes means protecting their inner value by mandatory interference, even if this would hinder their implementation of the answer to the most fundamental questions about the meaning and value of their own lives.

The above views on dignity hold that human dignity is dependent on being able to make autonomous decisions about one’s own life. Most Western concepts of dignity place an emphasis on autonomy. This emphasis shows that the essential core of an individual’s life is irrelevant to others. However, no one can live as an isolated being. Every person’s life is connected with others. Every person’s decision about his own life is closely related to those of others. Thus, the above theories cannot provide a clear and substantial statement on what should be done in practice according to the principle of human dignity. Due to the assumption that every person’s life is independent of others, the above theories can hardly answer what an individual’s dignity requires others to do. Consequently, an individual’s feelings about his or her life of dignity are easily confused with the universal and minimum demands of human dignity. Distinguishing between universal dignity and personal dignity will help to clarify these questions.

Confucian ethics holds that every human is born with universal dignity. As long as he is a human being, he deserves to be respected. The moral requirements of universal dignity mainly point to others. An individual’s universal dignity requires others to realize and respect it. Out of respect for the universal inner value of human beings, others should protect one’s universal dignity even in a mandatory way. In Confucian bioethics, the priority of the principle of beneficence over the principle of autonomy shows that protecting universal dignity is mandatory. However, this does not mean that Confucianism attaches no importance to autonomy. Autonomy is mainly reflected in the acquisition and maintenance of personal dignity. One achieves personal dignity by autonomously making the correct moral choice. An individual’s moral position and moral choices on death directly influence the dignity of her death. Because universal dignity is a moral concept mainly related to others, family, country, and society are all responsible for the concerns of dying persons on their deathbed. Personal dignity refers to one’s views and ideals of how to spend the last stage of one’s life. Therefore, it is concerned with the choices that a patient makes on her deathbed.

For a given individual, the value of his personal dignity is thought to be higher than the value of his universal dignity. However, when facing others, his universal dignity is what should be valued the most. The requirement to respect others’ human dignity is on us: we should not place other values above the individual’s universal dignity, which has the highest value. The differentiation between universal dignity and personal dignity explains why dignity permits others to interfere with an individual’s most basic interests while, on other issues, it encourages an individual to autonomously shape their personal dignity, which reflects every person’s particular value.

Moral autonomy is directly related to personal dignity in Confucian ethics. The individual autonomy built on individualism in the West separates an individual from others, whereas Confucian moral autonomy tightly links an individual to others, especially one’s family members. “The self derives only from the individual’s relationships with specific others, especially family members” [24, p. 29]. In such relationships, every individual bears certain responsibilities for others. Confucian ethics states in detail the moral responsibilities of an individual in various relationships and situations. It is the responsibilities and obligations of individuals to their group that shape their identity, and sticking to these particular responsibilities and obligations gives human beings their dignity. Because the readiness and act of implementing these responsibilities and obligations are equally important, an individual autonomously choosing to fulfill his moral responsibilities and obligations is more meaningful for the establishment of his personal dignity. By taking into consideration the relationship between the collective and the individual in the understanding of autonomy, Confucian bioethics deepens our understanding of autonomy.

In many Western theories, an individual belongs only to herself. In contrast, a Confucian individual belongs not only to herself but also to her family and community. Hence, an individual who makes decisions completely for her own interests is morally wrong. An individual’s value in Confucianism is mainly based on whether she has been filial to her parents and beneficent to others. An individual under the vision of Confucianism must be responsible to others rather than being irresponsible. She should live with her family members in unity and have harmonious relationships with her friends and neighbors. This type of life is believed to be guided by others. Confucian ethics strongly emphasizes relationships (particularly family relationships), and individual goals unrelated to the family are believed to be morally wrong. “Confucian familism holds that every family member shares his/her identity and life with other family members, and the family makes a unity as do individuals in Western liberal society” [24, p. 29]. From the viewpoint of the socially constructed self and the self in relationships, Confucianism believes that the honor of the family is also an embodiment of the individual’s dignity [15, p. 70].

Westerners shape their lives through autonomy, whereas Confucians pursue the Tao of sages and try to make their lives conform to an external and universal moral demand. Take suicide as an example. An individual choosing to commit suicide because of his own physical pains, lack of money, or mental burden is essentially abandoning his responsibilities for others and cutting off the possibility of pursuing morality with his biological life. Therefore, this autonomous decision does not preserve his dignity but causes him to lose his dignity. An individual who has been knocked down by hardships in life and has given up his responsibilities will lose his personal dignity and do harm to his universal dignity. Only when biological life cannot support an individual’s pursuit of morality will the ending of life be permitted. When people are dying, bearing a large amount of pain, and not likely to be cured (i.e., their biological lives are not able to sustain their ability to live a moral life), giving up treatment does not contradict the Confucian principles of dignity.

Generally, only autonomous decisions are related to an individual’s personal dignity. The core of Kantian dignity is the capability to carry out a self-imposed moral law, which also highlights the importance of autonomous decisions in moral choices. From the modern liberal perspective, the Confucian style of living is heteronomous because “individuals” in the view of liberalism are without the bond of responsibility. However, a “self” defined by family in Confucianism is not heteronomous. People are still allowed to make their own decisions and do not feel that their dignity is being violated. For an individual in the Confucian context, human dignity is to be rooted in moral autonomy instead of individual autonomy. Moral choices are not to be made only with an individual’s own will and purpose as the starting point; instead, the decisions of one’s own life should be made from the perspective of one’s family. Self-determined acts are the premise and foundation of Confucian personal dignity.

Due to the traditional Chinese view of filial piety, many elderly people in modern medical settings cannot make their own choices with respect to their death. In traditional Chinese culture, the attitude towards one’s parents reflects one’s moral level or even one’s qualification as a person. It is the younger generation’s obligation to take full care of their old and dying parents. Confucius says, “Among all of the behaviors of a human being, being filial to his parents is the most important” [1, pp. 248–251]. Filial piety, as one of the core essences of human nature, is also the prototype of benevolence. “Therefore, children’s affection for their parents occurs when they are young and increasingly grows into veneration. This is one of the human natures, which is utilized by the sages to enlighten respect and love. Sages’ enlightenment could succeed without being deliberate, and sages’ administration of a country could be effective without being strict, for filial piety is one of the human natures” [1, pp. 248–251]. This natural sentiment serves as an important foundation for Confucian ethics. If a person is not filial to one’s parents, then one loses one’s human dignity and the qualification of being a human. Against such a background, if a parent autonomously decides to end his life on the deathbed, his children will likely lose their dignity due to his autonomous decision. This is one of the reasons why the elderly in the Chinese medical setting are currently not allowed to undergo voluntary euthanasia. Their children, in consideration of their own reputation, tend to oppose their parents’ autonomous decision to end their life.

Filial piety in Confucianism contains three senses: revering, obeying, and serving one’s parents. Revering and obeying the parents means that a child should fully respect his parents’ subjectivity and help fulfill (or at least not obstruct) his parents’ wishes. Serving their parents requires the children to try their best to save their sick parents and make every effort to keep their parents alive. Thus, which is more important: obeying or serving their parents? Which is the higher principle? Compared with serving one’s parents, revering and obeying them seem to be more important. There are cases when the parents are advised three times and do not change their mind, and the children have to follow their parents’ desire. Namely, “In the service of his parents by a son, if he has thrice remonstrated and is still not listened to, he should follow his parents’ will with loud crying and tears” [1, p. 63]. Therefore, the elderly person’s will on the issue of death should be respected. If the suffering elderly patient is fully conscious, her will for euthanasia should be obeyed by her family members. For the unconscious, if she had a living will beforehand, her family members could follow her will; if she did not have a living will, her family members should try to guess her will and follow it accordingly, especially for passive euthanasia. The parent’s autonomous choice of euthanasia, especially passive euthanasia, does not threaten the children’s dignity.

Social justice and the dignity of death

Moral standards are primarily based on considerations of the factors that can promote justice in human society. The human beings in Confucian ethics are in essence individuals in a group. The question of whether an action is beneficial to the welfare of the group is an important measurement of an individual’s moral choice and is directly related to Confucian human dignity. Hence, it is necessary to discuss the dignity of death in Confucianism from the perspective of social justice.

Whether medical materials are distributed justly has always been closely related to the ethics of death. Relevant statements can be found in Confucian ethics. Compared with universal dignity, Confucian dignity puts a priority on personal dignity. As explained above, Confucian ethicists advocate an individual dying for benevolence and righteousness. From here, it can be inferred that Confucian ethics will likewise support euthanasia for benevolence and righteousness. Confucius once scolded his old friend Yuan Rang: “In youth not humble as befits a junior, in manhood doing nothing worthy of being handed down, and living on to old age not to die can be regarded as a pest” [6, pp. 227–228]. Does this mean that in the context of Confucianism, it is regarded as morally wrong to consume public resources to sustain a dying elder’s life? Some scholars say no. Confucius had an idea called “Society of Great Harmony.” In the Society of Great Harmony, all the vulnerable people are taken care of. In The Book of Rites, Confucius said to Zi You: “When justice is prevalent in society, the society gives rights to every citizen; they choose men of talents, virtue, and ability as their leader; their words are sincere, and they build harmonious relationships with others. Thus, men did not love their parents only, nor treat only their own children as children. In such a society, the old will be well taken care of, men in the prime of life will have a chance to serve society, and the young will receive a proper education. Widows, widowers, orphans, the childless, the disabled, and the sick are to be well taken care of” [2, p. 142]. Confucians held that the best society is the Society of Great Harmony in which various vulnerable people, including the elderly, are all provided with basic living security, even when they are consuming social resources and not making any contributions to the society. Therefore, some scholars argue that the Confucian theory that life can be sacrificed for morality cannot be applied to euthanasia [25, pp. 624–641]. A good society should be one in which widows, widowers, orphans, the childless, and elders are taken care of.

The seeming contradiction between the advocacy of euthanasia for society and the wish to support the elderly can be explained by the Confucian understanding of human nature. In Confucian ethics, there is no independent individual, and the most basic ethical principle originates from an individual’s obligation for others and society. Different individuals stand in different positions and play different roles, which results in a Confucian ethics that is highly contextualized. That a person who lives on to an older and older age without dying can be regarded as a “pest” is a statement that old Confucius made to his elderly friends. Hence, it represents, to a large degree, the elderly’s standpoint. From their own moral position, the elderly think that it is unnecessary to consume more resources for the maintenance of weak lives, especially when such maintenance will not prevent their death. Instead, these resources should be put into more productive matters. That all the vulnerable, including the elderly, are to be well taken care of is Confucius’s preaching to the young. This position should be taken by the young because it is a young person’s compelling duty to be filial to their parents and kind to the other elderly members in the society. In Confucian ethics, an individual’s consideration of his own dignity always involves others. There are no independent individuals, only individuals bearing various duties that are closely linked to the others. An individual’s understanding of his own personal dignity does not separate him from his specific position in society.

The young respect and care for the elderly primarily to maintain their own dignity. From the perspective of the old dying patients who choose voluntary euthanasia to avoid increasing family and societal burdens, the choice is actually about maintaining their own personal dignity. It is quite commonplace to find many contemporary Chinese scholars endorsing the idea that social interests matter more than individual interests. Consequently, in debates about whether euthanasia should be legalized in modern China, one common argument is that the legal practice of euthanasia can relieve the financial and emotional burdens of the family, save money for the country, and save medical resources for other productive purposes of the nation [15, p. 73]. Many viewpoints supporting euthanasia in current China are based on these types of theories.

There are also some scholars who think that Confucianism does not support euthanasia if the effects of the altruistic suicides it advocates are taken seriously. They argue that, although morality has a higher value than life and Confucianism in many cases encourages altruistic suicides, altruistic suicides do not apply to the situation of euthanasia because altruistic suicides in ancient China were usually intended to render a positive benefit to others. Altruistic suicides in the form of negatively removing the “burden” to one’s family and to society were not encouraged [25, pp. 624–641]. Therefore, although Confucianism supports altruistic suicides, it cannot justify euthanasia.

Scholars who oppose this interpretation of Confucianism do so for two reasons. Firstly, suicide supported by Confucianism is not always altruistic insofar as they do not necessarily benefit others. In certain circumstances, committing suicide is just a way to show one’s respect to certain moral rules. For instance, Confucian ethicists once believed that a person with high moral standards would rather commit suicide than surrender to the enemy state. Only in this way can he show his loyalty to his own country. However, no one would benefit from his suicide in this case. Secondly, in terms of euthanasia, the positive and negative effects brought about by suicides are mutually transformable, so the euthanasia carried out according to the patient’s own will can fit into the notion of altruist suicide in Confucianism. In modern medicine, various advanced technologies have resulted in an increasingly high medical consumption, but at the same time, the space in which such technologies can come into play is very limited. For instance, highly expensive life sustaining equipment cannot improve health and can only sustain a low quality of life. If the medical costs of using such treatments could be put into curable diseases or treatments that result in an obvious improvement in health, the limited medical resources could be more effectively utilized. In this way, the burden that had been weighing negatively on the family and society can be transmuted into a matter of positive interest. The resources saved by euthanizing dying patients would be turned into a positive interest for other patients. That is to say, people suffering from curable diseases could be helped.

Conclusion

In summary, there are two meanings of human dignity in Confucian thought: universal dignity and personal dignity. The foundation of universal dignity lies in the moral potential with which every human being is born, whereas personal dignity is based on an individual’s moral choices and behaviors. The moral demand of universal dignity points to the responsibilities of others to treat the individual with basic respect, such as by honoring the individual’s basic rights as guaranteed for everyone in the Constitution. The demand of personal dignity points to the individual and encourages her to accomplish her own obligations. In Confucian ethics, the accomplishment of obligations is contained in the essential stipulation of being a human and is the determining factor in whether an individual can obtain the qualification of being a human. Hence, this factor must be related to her human dignity. Every individual should try to approach the Confucian ideal personality and become a “gentleman” or a sage to obtain the highest degree of personal dignity.

In Confucian ethics, the end of biological life or bearing a large amount of suffering does not necessarily lead to a loss of dignity. According to Confucianism, the qualification of being a human originates from a person’s moral attributes. Dignity is mainly understood from the perspective of morality. Life is a process of moral cultivation. Death, as a part of life, is the last stage of moral cultivation. Hence, the ethical issues related with death should be first considered in terms of morality. In the process of death, it is the autonomous ethical decision that serves as the most important objective of Confucian moral cultivation.

Many traditional and current ethical theories emphasize that dignity cannot be lost, it has nothing to do with one’s virtues, behaviors, or achievements, and it is absolutely equal among all human beings. But in reality, we all often feel that people in some cases lose their dignity or different people have different degrees of dignity. Thus, such theories create a contradiction between theory and reality. The double structure of human dignity in Confucianism explains the relationship between the cannot-be-lost equal dignity in theory and can-be-lost and not so equal dignity in practice through observations of the differences and similarities between universal dignity and personal dignity. Distinguishing between the two meanings of dignity not only resolves the contradiction between theory and practice but also helps to end the chaos of concepts in the theoretical argument of death with dignity. People for or against the various medical practices related to death tend to emphasize one of the two meanings of dignity. Confucian ethics can offer distinct answers to death-with-dignity issues and can contribute to the resolution of confusions concerning concepts and theories in Western research on the dignity of death.