Taoism, bioethics, and the COVID-19 pandemic.

The stress that the COVID-19 pandemic has placed on health systems internationally has forced difficult decisions concerning the rationing of medical care and has put the bioethical structures that inform those choices under scrutiny. Often, ethical approaches to pandemic circumstances center around utilitarianism, dehumanizing the treatment process and ignoring the plurality of other philosophical doctrines that inform non-Western bioethics, which could be of use in addressing the pandemic. This paper focuses on philosophical Taoism, as developed in the Tao Te Ching and Zhuangzi, in order to suggest an alternative approach to medical care when medical capacity is limited, grounded in the concept of wu-wei, or inaction. Copyright:

INTRODUCTION

COVID-19 and bioethics

The genesis of the SARS-CoV-2 coronavirus and the advent of its corresponding pandemic have had significant impacts around the globe. As medical resources have been stretched, administrators and practitioners have been faced with those most difficult questions: To whom can care be provided, and who is too far gone to benefit? How does one decide between patients with competing interests under conditions of scarcity? There are no simple solutions to these issues, but the medical and bioethical communities writ large have coalesced around certain standards. The typical approaches have been broadly utilitarian, focusing on preserving life-years across the whole set of patients; they explicitly reject autonomy-based or egalitarian moral schemata [1]. Even though multiprinciple, more nuanced approaches to medical rationing have been suggested, the general consensus has been to focus explicitly on the relative value that limited resources can generate through the selective application of care. This is borne out in the algorithms being presented in journals and developed at hospitals [23].

As the pandemic has made the reliance on utilitarian calculations more clearly evident, the theory's flaws have also come to the fore. First, rote adherence to utilitarianism fails to address cultural differences in approach to ethical issues. The most authoritative corners of the literature are silent on the validity or utility of non-Western philosophical and cultural approaches [45]. This presents an issue because the COVID pandemic is not solely a Western problem – it is a global phenomenon, and different cultures manage bioethical quandaries in dramatically divergent ways. COVID, which originated in China, impacted Asia first; each Asian country it infected responded differently, in part due to cultural variations [6]. However, the inescapable fact of the COVID pandemic has been death: For many, the definition of a “good death” is contingent upon their society and upbringing. As Hsin and Macer's research comparing Taiwan and New Zealand shows, Eastern and Western people have different goals and perspectives on the ends of their lives [7]. Furthermore, differences in approach to health care often lead to cultural conflict, which can impact care and force ethical conundrums. For instance, Bowman and Hui write, “In traditional Chinese culture, greater social and moral meaning rests in the interdependence of family and community, which overrides self-determination” [8]. Making life-or-death decisions without thoughtful reflection on other cultures’ bioethical understandings runs the risk of damaging the doctor–patient relationship, even if unintentionally; poor relationships between given sociocultural groups and the medical establishment can lead to concrete harms like lower vaccination rates [9].

Then, there are more philosophical concerns. Frustratingly, health systems often adopt utilitarianism at the expense of other foundational bioethical principles. Savalescu et al. write, “There are no egalitarians in a pandemic. The scale of the challenge for health systems and public policy means that there is an ineluctable need to prioritize the needs of the many. It is impossible to treat all citizens equally… While people may argue other things matter (autonomy, privacy, dignity), everyone can agree that well-being matters” [1]. As Tai points out, this is a fundamental revision of the value of justice in medical care [10]. While the utilitarians are correct that resource-scarce circumstances require difficult choices, the devaluation of patient and provider autonomy seems an overreach, especially for those societies that explicitly hone in on these principles as bedrocks of their bioethics. In addition, Strong notes that a utilitarian approach can “imply that if obtaining consent causes disutility, then consent should not be obtained,” further chipping away at the bioethical edifice that we have constructed since the mid-twentieth century [11]. Furthermore, Bellazzi and Boyneburgk observe that this same utilitarian spirit pushes people to overvalue individual liberties, at the expense of rejecting restrictions on personal actions in defense of their community [12]. This is beyond the harm incurred by providers, which has led to a parallel epidemic as a result of the pandemic, of provider moral and emotional distress [1314]. All told, embracing utilitarian bioethics can engender significant harms, for both patients and practitioners [15].

Thus, a purely utilitarian approach to pandemic bioethics produces easy results but is both callously dismissive of individual patients and is culturally insensitive. The need for a system that is both caring and decisive is evident, particularly for members of non-Western groups. I propose that a superior approach to pandemic bioethics could be a “utilitarian-plus,” synthetic approach: the utilitarian method may be used to guide decisions, but it should be combined with another ethical approach in order to ameliorate its blind spots [16]. One such alternative theory is virtue ethics, which aims for “the full realization of every individual human life” [12]. A worthy goal, and Aristotle even directly associates virtue ethics and medical practice: “agents themselves must in each case consider what is appropriate to the occasion, as happens also in the art of medicine or of navigation [17]. However, I propose that we use an Eastern virtue ethic in order to make our bioethical discourse more accessible to non-Western communities. Michael Cheng-Tek Tai nods specifically toward the value of this choice, especially for people who reside in Asia. He argues that various approaches from Asian thought better support fundamental bioethical values, as well as better attending to these people's cultural backgrounds [18]. He describes Taoism, Confucianism and Mohism; I will continue this project by further elucidating a Taoist bioethic. Beyond cultural compatibility, I am choosing to focus on Taoism specifically for a number of reasons.

First, Tai's account of Taoist decision-making points in the correct direction but lacks concrete applicability; there is a need for additional theorizing. He suggests three steps to Taoist bioethical decision-making: describing the problem, listing solutions, and selecting the most natural one [Figure 1] [18]. However, the physician in the time of COVID may not know the most natural solution, or they may be so overwhelmed with patients that such a process is too arduous to be feasible, or there may be competing moral claims on the physician. Thus, I will seek to clarify an actionable method grounded in Tai's work. Additionally, Taoism is particularly well-suited to adapting utilitarianism, as it is an anticonventional, antistrictural philosophy. The Tao Te Ching states: “Begin to make order, and names arise. Names lead to more names – And to knowing when to stop. Know when to stop: Avoid danger” [19]. Eschewing rules and artificial order is deeply Taoist, so amalgamating two approaches would not be taboo. Conversely, Confucianism and Mohism are explicitly deontological and would conflict with utilitarianism on a theoretical level, causing more issues to arise where we seek to resolve them. Finally, Taoism is widely applicable, many older Chinese identify as Taoist, and many Taiwanese also ascribe to the tradition [20]. Its global reach gives this approach value across the borders of nationality and society. For its adherents, Taoism deeply influences their outlook of end-of-life care, making the school particularly relevant to the COVID pandemic [21].

Figure 1

A Taoist approach to ethical decision-making, adapted from Tai, “An Examination of Decision-making: The Classical Models, Checklists and Asian Approaches”

DEVELOPING A TAOIST BIOETHIC: THE VALUE OF INACTION

However, in order to embark on this project, we should first set some foundations. In this paper, I shall focus on Taoist approaches to bioethics as constructed in the Tao Te Ching and Zhuangzi. A few quick definitions are in order, too. These derive from the glossary provided by Addiss and Lombardo in this translation of the Tao Te Ching. Te is “Virtue, integrity, energy, force, moral power.” Tao is “Way, road spiritual path,” though the authors stress that the Tao of the text is metaphysical and supersedes mundane explication. Tien is, roughly, heaven. Tao Te Ching thus approximately means The Virtuous Way of Quiet [19]. As a result of deriving from the Tao Te Ching and Zhuangzi, this paper is concerned with philosophical, rather than religious, Taoism. These two schools have distinctly different (and at times antagonistic) outlooks [8]. Creel comments that philosophical Taoism is identified by its embrace of wu-wei, of inaction; it derives specifically from these two texts. Religious Taoism, on the other hand, centers on the practice of Taoism: Intentionally practicing virtue and striving to achieve hsien, (roughly) immortality [22]. Furthermore, the extant Taoist bioethical literature derives from philosophical Taoism.

Tai's work develops an account that invokes concepts such as yin/yang, the Five Elements, and Tien and Tao, all of which are part of this discourse. However, his theorizing primarily addresses end-of-life care. From this discussion, he comes to the primary conclusion that heroic, life-extending measures run counter to Taoist thought, to which I acquiesce [23]. But there is a space to investigate other ways that Taoism can form a bioethical system. Bowman and Hui briefly allude to another component of Taoist ethical thought:

Philosophical Taoism… is reflected in the phrase, “Man comes into life and goes out to death.” For this reason, one should view death with equanimity. In the face of death, acceptance is the only appropriate response. Any artificial or heroic measures contradict the course of natural events and should not be undertaken (emph.mine) [8].

This equanimity with death and refusal of heroic intervention is consistent with Tai's system, but also points toward another major avenue to developing a Taoist bioethics: That of wu-wei, or inaction. Furthermore, having differentiated between philosophical and religious Taoism, I shall henceforth refer simply to Taoism, with the qualifier “philosophical” understood as being implicit.

The Tao Te Ching states: “Is and Isn’t produce each other… Therefore the Sage is devoted to non-action… When no credit is taken, Accomplishment endures” [19]. Taoism puts a significant emphasis on noninterference, imbuing the decision not to act with moral quality. As a result, Taoism seems like a virtue ethic, with wu-wei as its chief virtue. But it is clearly distinct from the Western, Aristotelian formulation. Aristotle develops his virtues as concepts that one should strive toward in order to live well [16]. The Taoist ethic, however, emphasizes aiming to be like the Sage. The Sage, in the Tao Te Ching, is derived from traditional Chinese histories, where great rulers were “paragons of virtue and wisdom” [19]. Unlike Western approaches to ethics, with proofs and strictures and abstractions – think of rule consequentialism or Kant's categorical imperative, or even Aristotle's list of virtues – the Zhuangzi and Tao Te Ching do not offer particularly concrete answers as to what qualifies as virtuous living; wu-wei is held up as a virtuous standard, but to reduce the theory to just the virtue does Taoist thought a disservice. Instead, Taosim enriches its theoretical system by offering cases where the Sage acts in accordance with Tao, or where some hapless person fails to do so: Taoism is analogical. In this way, Taoism is able to differentiate itself from other philosophical schools and develop a system without delineating rules – “The torch of chaos and doubt – this is what the Sage steers by” [19]. And the Sage, in these texts, acts in accordance with wu-wei. Virtuous living is through acting as the Sage would, inactively, in accordance with Tao. Of course, the striving built into a virtue ethic seems contradictory to wu-wei. But striving toward inaction is in keeping with the Taoist spirit of intentional absurdity and antirationalism; inaction “is not a forced quietude,” but rather a perspective from which to approach the world [24].

HOW DO WE CULTIVATE

As Tai's work has shown, Taoist cultivation can come in many forms. However, even though we are focusing on wu-wei here, the practice of inaction has multiple approaches, reflected in the varied ways that a person may act in accordance with Tao. The Tao Te Ching highlights some of these: “I have three treasures To maintain and conserve: The first is compassion. The second is frugality. The third is not presuming To be first under heaven” [19]. These three – compassion, frugality and humility – combine with Tai's equanimity with death and a focus on authentic connection to form five key applications of wu-wei that provide the practical approach to Taoist virtuous living [Table 1].

Table 1

The five components of wu-wei in a Taoist bioethical system, and relevant associations

Component	Association
Compassion	Care for all
Frugality	Avoidance of unnecessary interventions
Nonpresumption	Moral luck
Equanimity with death	Personal obligation
Authentic personal connection	Value of expertise and relationship

The first application is found in compassion. To be virtuous, the Taoist must be universally compassionate: “The Sage has no set heart… People who are good I treat well. People who are not good I also treat well” [19]. This assumption is in stark contrast with certain strands of Western thought, which cast human nature as a nasty, brutish war. Instead, the Taoist presumes the world and its people to be acting compassionately even in the state of nature; acting with heartlessness violates wu-wei, and is thus wrong. There are clear connections to biomedical practice, too. The Tao Te Ching is quite explicit about what it expects of providers: Universal care. “In this way the Sage Always helps people And rejects none”; in fact, this exhortation is repeated multiple times throughout the text [19]. This may cause some amount of consternation: After all, medical rationing in pandemics necessitates deciding who may receive treatment and who may not. But treatment is not always medical intervention – sometimes, the most appropriate treatment is simply easing the process of dying.

Practically, this all means that the provider must accept all who need care, but be willing to move patients into palliative treatment; though some published approaches (particularly those that originate from Asian countries) generate similar exhortations – such as Krishna et al., who suggest early discussions of palliation – the Taoist threshold for withdrawal of intervention and initiation of palliative treatment is even lower [3]. Moving to palliative care both fulfills the caring criteria, and can be compassionate: Rather than living out a short amount of time in immense suffering, patients in palliative care can approach the ends of their lives in relative comfort, with the opportunity to focus on natural quality of their demise [25]. Taoist medical practice also recognizes that people and their lives are incredibly finite: “Heaven and Earth are not kind: The ten thousand things are straw dogs to them. Sages are not kind: People are straw dogs to them” [19]. But even though the ideal provider recognizes that there are limits to what can be done for a patient, they always act with compassion: “Mind opening leads to compassion, Compassion to nobility, Nobility to heavenliness, Heavenliness to TAO” [19]. In this way, providers may maintain their accordance with wu-wei, and thus Tao.

The second application is centered around frugality. And I suggest that this is frugality not just in terms of money or some other mundane quantity, but rather a frugality in approach to life – and medical care. As already stated by Tai, Bowman and Hui, artificial or heroic medical interventions are not morally right, as they diverge from the natural Way. This is precisely because “The Sage rules… Practices non-action and the natural order is not disrupted” [19]. The natural order of life is to proceed to death; thus, noninterference in the process of mortality is correct. However, this is with the understanding that Taoist inaction does not require us to be wholly dormant in the world:

Woodworker Qing carved a piece of wood and made a bell stand, and when it was finished, everyone who saw it marveled… Qing replied, “I am only a craftsman”… When I am going to make a bell stand, I never let it wear out my energy… when I have fasted for seven days, I am so still that I forget I have four limbs and a form and a body… After that, I go into the mountain forest and examine the Heavenly nature of the trees. If I find one of superlative form, and I can see a bell stand there, I put my hand to the job of carving; if not, I let it go [24].

The story of Woodworker Qing emphasizes that action is possible in the world, but it must be in the sight of wu-wei and Tao. The virtuous person is not actionless; rather, they are inactive by appreciating their place in the grand tapestry of the universe and not trying to supersede it.

The correlate to the precept of noninterference with mortality is that unnecessary medical intervention is also harmful, as illustrated by the Death of Hundun story. In short: In an effort to repay Hundun's kindness, Shu and Hu decide to bore holes into him, to give him the seven human openings; this leads to Hundun's demise, as the formation of artificial holes was directly deleterious [24]. By operating where there was no need, Shu and Hu directly caused physical damage; as this did not follow the Way of inaction, this action also caused ethical harm. This is a fairly concrete application of the wu-wei virtue, as overly zealous interventions are the antithesis of medical frugality.

The third application is found in non-presumption. I propose that not presuming to be first under heaven has two senses. First, as we will see, there is a personal obligation to accept one's death. The correlate to this moral duty is that one should not presume one's life is more valuable or more deserving of care than another’s. But non-presumption, I believe, also implies a sense of moral luck built into Taoist bioethics: I should not presume to know the plans and machinations of Tien. The Tao Te Ching explicitly comments, “Bad fortune rests upon good fortune. Good luck hides within bad luck. Who knows how it will end?” [19]. Luck determines which patients fall ill and need care:

When Gongwen Xuan saw the Commander of the Right, he was startled and said, “What kind of man is this? How did he come to lose his foot? Was it Heaven? Or was it man?”

“It was Heaven, not man,” said the commander. “When Heaven gave me life, it saw to it that I would be one-footed. Men's looks are given to them. So I know this was the work of Heaven and not of man” [24].

The Commander of the Right realizes that we are all flies caught in the web of fate; there are many things that we cannot change in our world and must accept. Moral luck, I will propose, has a role in the Taoist resolution of quandaries that arise from situations of medical scarcity. Wu-wei is actualized through non-presumption, by letting fate do with you what it will.

Fourth, choosing inaction can also occur on a personal level – through achieving equanimity with death. The Tao Te Ching states: “If people do not fear death, How can you threaten them with death?” and “The world has as source: The world's mother… Your body dies, There is no danger. Block the passage, Bolt the gate: No strain Until your life ends… Don’t cling to your body's woes. Then you can learn endurance” [19]. This makes explicit the Taoist acceptance of mortality, along with a more explicitly bioethical assertion: That the body and its diseases are ephemeral and unimportant. The Taoist holds that the person who aims to live sagaciously must take it upon themself to reach this sense of moral and spiritual ease. The Zhuangzi, in a colorful passage, shows how the Sage approaches mortality:

Zhuangzi's wife died. When Huizi went to convey his condolences, he found Zhuangzi sitting with his legs sprawled out, pounding on a tub and singing. “You lived with her, she brought up your children and grew old,” said Huizi. “It should be enough simply not to weep at her death. But pounding on a tub and singing – this is going too far, isn’t it?”

Zhuangzi said, “You’re wrong. When she first died, do you think I didn’t grieve like anyone else?…

“Now she's going to lie down peacefully in a vast room. If I were to follow after her bawling and sobbing, it would show that I don’t understand anything about fate. So I stopped” [24].

The Taoist bioethic suggests that each person has a moral duty to accept their eventual death; standing in the way of fate is not only frivolous, it is antithetical to virtue – a significant difference in comparison with Western thought. The Taoist goes a step further even, suggesting that acting like the Sage and achieving internal stillness can salve the soul: “Stillness and quiet can benefit the ailing… rest and quiet can put a stop to agitation”; this is all in keeping with the precept of inaction [24].

Fifth and finally, the Taoist maintains the centrality of authentic personal connection. Notably, Zhuangzi's craftsmen parables illustrate how wu-wei may be, in fact, active. Consider the story of Cook Ding, who describes how mastery of one's craft bestows superior insight into one's avocation. For Cook Ding, this is cutting up an ox: The master cook knows how to follow the “natural makeup” of the animal, rather than hacking blindly through its joints and other hard points. One meaning of this metaphor is that, in his daily life, Cook Ding embraces the natural Way rather than attempting to artificially constrain it; he knows his craft and thus acts virtuously. Moving from text to bedside, the Taoist bioethicist would thus assert that medical providers should have greater autonomy in making decisions about rationing care [24]. The standard approach to pandemics has been to disempower the providers who directly care for patients, instead employing triage teams or officers; this is, however, not in accordance with Tao, as it is the people, rather than the algorithms, who can actively attend to “things as they are,” and choose the least active course – as would Cook Ding [2426]. Though some Western bioethicists might contend that this introduces an uncomfortable level of subjectivity into clinical decision-making, the Zhuangzi embraces it, as subjectivity that pervades human existence. Burton Watson writes, “it seems to me that the extreme care and caution which the cook uses when he comes to a difficult place is also a part of Zhuangzi's ‘secret of caring for life’”[24] (emph. translator’s).

COMBINING TAOISM AND UTILITARIANISM

Thus, Taoist inaction involves multiple important components of the wu-wei virtue: It emphasizes universal, compassionate care; stresses frugality and repudiates invasive medical treatment; centers the value of non-presumption and moral luck; underscores the moral duty to come to terms with one's death; and enjoins authenticity, empowering providers to both take charge of medical decision-making and to compassionately care for all of their patients. But how does this apply to the resource scarcity that the COVID-19 pandemic has caused? It seems all well and good to discuss these values per se, but as we have seen with the difficulties for Western ethics, we have an intellectual duty to see how they can be maintained while parsing through a flood of patients seeking care as resources become limited. This is where we find our synthesis between Taoist bioethics and utilitarianism, combining the two to create an effective way to route patients between levels of treatment, without sacrificing individual autonomy or wu-wei.

In Figure 2, I propose an algorithm that aims to do just this. Given the problem of medical resource scarcity, the provider should first discuss goals of care with the patient and their family – this actualizes patient autonomy by giving them input into their treatment. If they desire less than maximal care, they should be offered it, allowing for an early inclusion of palliation. But should they want maximal care, they are then to be assessed to determine if they medically need the use of whatever resource is scarce. This is the utilitarian move; in the context of our Taoist approach, we derive a resultant synthetic ethic from their combination [16]. However, this is not simply an effort to dispose of the less-valued. It “bear[s] in mind that every life is worthy… and deserves to be treated in the best way they can” [10]. Using consequential calculations in this manner answers questions of justice through the emphasis placed on discourse in this system, as well as the various other forms of caring involved. For instance, if the patients do not meet the utilitarian standard, they are first counseled about the virtue of acceptance of mortality. This can lead either to them desiring less than maximal care, or being evaluated with the patients who need full care with a utilitarian method – determining who is most likely to benefit from care and prolong high-quality life (rather than pure life-years).

Figure 2

A synthetic approach to ethical decision-making in periods of medical scarcity, incorporating both Taoist and utilitarian methods

If the needed intervention is invasive and unlikely to yield a high-quality life as a result, the intervention should be avoided; palliation should instead be offered. If the intervention is likely to benefit the patient without being invasive to the point of contravening wu-wei, the next question is whether the intervention is immediately necessary. In the case where this is untrue, the provider should wait until the intervention is absolutely necessary (no prophylactic ventilator placements if there is a shortage, for instance). In the necessary case where the intervention is urgent, the provider should endeavor to offer the treatment. However, if there is still a scarcity after all of this winnowing, the provider can then resort to moral luck to determine who gets care. This lottery is not a normative comment on any of the involved patients; rather, it is letting Tien decide, knowing that everything else has been attempted. Furthermore, should the conditions of scarcity resolve, the provider may be able to revert to the simpler, purely Taoist approach outlined by Tai in Figure 1 [18]. In this way, the components of wu-wei are considered and Tao followed, to as much of an extent as possible. The provider – and patients – have played active roles in the process of treatment planning, and thus have all acted in a way compatible with virtue.

CONCLUSION

Taoism in the time of COVID

This brief discussion, of course, cannot adequately survey all of the nuances of a Taoist bioethic. But I have attempted to paint a picture of what a more compassionate utilitarian calculus could look like, once melded into the Taoist's human authenticity and goal of inaction – with its many manifestations. This, then, leads to a consistent approach to medicine in conditions of scarcity, like in the COVID-19 epidemic. It is one that respects the value and autonomy of both patients and providers and does not reduce people to rote calculations or mathematical outcomes; all the while, this new, synthetic approach allows for the flourishing of all involved.

The pandemic has impacted people throughout the world, but Asian patients struggle from the dual burden of the disease itself and the difficulties of existing in sociocultural environments where the dominant value systems may be dramatically different from their own. Being able explain difficult decisions to patients and families who may come from different backgrounds in the terms of their own schemata offers an immense amount of value, as patients recognize and appreciate the effort to respect their cultural norms; even better if these are ethical systems that explicitly prioritize their values. Given Taoism's weight in China and Taiwan particularly, expanding the bioethical consensus to consider its tenets could improve the patient experience for everyone, but particularly for people of these backgrounds – saving lives while still maintaining basic bioethical principles like autonomy and wu-wei; because of our global society, our existing bioethical discourse would benefit from this addition, too. As Tai notes, all people have intrinsic dignity, even under the strain of COVID-19; by attempting to better uphold dignity, we will learn a profound lesson that will serve us well in the future [10].

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Conflicts of interest

There are no conflicts of interest.