Health is one of the biggest worldview disconnects between Chinese and Western cultures. Another is ethics. Putting it simplistically: To us, their stark pragmatism sounds amoral and selfish. To them, our abstract principles sound naive and heartless. It’s mutually appalling, and mutual understanding is nigh impossible. (Parenting has gotta be in the top 5.)
We’re halfway through a week in the hospital, and I thought this anti-“hongbao” signage was interesting. “Hongbao” (红包) is an ingrained aspect of Chinese culture where the patient’s family slips extra money to the surgeon in a “red envelope” to encourage better treatment. It’s illegal in Chinese countries, but that doesn’t stop it.
Front and center on the nurses’ station:
Honest medical treatment; Refuse to accept hongbao
Despite this, the translator assigned to us (she’s helpful, but her English is harder for us to understand than the doctor’s Chinese) says, “Sometimes, it still happens.”
Apparently there are a lot more ways than hongbao for doctors to earn extra ethically-suspect income. This poster is at the entrance to our floor:
To Strengthen Medical Treatment Clean Behaviour Customs, Construct “The Nine Forbiddens”
- It’s forbidden for health care personnel personal income to be connected to medication or medical examination income.
- It’s forbidden to take a commission.
- It’s forbidden to receive payment against the rules.
- It’s forbidden to illegally accept social welfare subsidies.
- It’s forbidden to participate in marketing activities or distribute medical advertising against the rules.
- It’s forbidden to fill prescriptions for business purposes.
- It’s forbidden to use illegally and selfishly procured medical products.
- It’s forbidden to accept kickbacks.
- It’s forbidden to accept patient “hongbao”.
I don’t think hongbao is good despite what the authors linked below argue. But simplistically dismissing it as a bribe without first understanding it isn’t that helpful either. Looking more closely at the reasons and dynamics of this old practice also provides a helpful window into Chinese culture and common ethics. Here’s a bit from an American hongbao apologist:
From China, With Pragmatism
It is very common for a Chinese family to give hongbao to a surgeon who is about to perform a procedure on a family member. Everyone knows to do this, and everyone does it to the extent that they are able. The Americans in our group thought this practice was unethical bribery, because it sought to bias the doctor in one’s favor. The Chinese people at the table replied, “Of course it biases the doctor. That’s why we do it.” Not only were they mystified by the censure, but the Chinese were prompted to ask if the Americans had any children — for every parent surely uses any means necessary to protect loved ones.
When one embassy officer (working his best “hearts-and-minds diplomacy”) suggested that the Chinese switch the giving of hongbao to after the successful operation, rather than before, the Chinese were struck dumb with astonishment. Of course, you have to give the hongbao beforehand because it motivates the doctor. The gift tells the doctor: (a) to take special care with our child (b) we respect your surgical skills/education and “give face” accordingly (c) we are devoted to our child, will hold you responsible and have the means to do so. The fact that not everyone can afford to influence their doctor with hongbao is not grounds for withholding it, since we’re trying to protect my child here and now. The parent, according to the Chinese, should never weigh the child’s well-being against something so arcane as an abstract principle.
And here’s another piece that spreads the blame around:
Bribery serves as life-support for Chinese hospitals
Bribery is the lubricant that helps keep China’s public hospitals running, and the health system would struggle to function without illegal payments to poorly paid doctors and administrators, say medical practitioners and industry experts.
A doctor fresh out of medical school in Beijing earns about 3,000 yuan ($490) a month including bonuses — roughly the same as a taxi driver. A doctor with 10 years experience makes around 10,000 yuan a month, according to Peter Chen, chief executive of privately run Oasis International Hospital in Beijing.
“Without the grey income, doctors would not have the incentive to practice,” said Yanzhong Huang, a senior fellow for global health at the Council on Foreign Relations in New York.
Dealing with the problem is not so easy:
Should Doctors Be Rewarded for Refusing Bribes?
hongbao is adding to the financial pressure most patients are already under, at a time when medical and health cost is very high. The public has long expressed their dissatisfaction with this accepted practice. The government has already taken a number of measures to save the deteriorating patient-doctor relationship resulting from hongbao by announcing that doctors who take bribes will be struck off the doctor roll. In some parts of China, it is announced that those who report this practice to the government can receive a reward worth thousands of yuan, while the doctors concerned will be dismissed. However, despite these kinds of measures, it seems the hongbao tradition is entrenched and likely to die a very slow death in China.
Here’s a little larger, current context for the hongbao practice:
Under the Knife — Why Chinese patients are turning against their doctors
Violence against doctors in China has become a familiar occurrence. In September, 2011, a calligrapher in Beijing, dissatisfied with his throat-cancer treatment, stabbed a doctor seventeen times. In May, 2012, a woman attacked a young nurse in Nanjing with a knife because of complications from an operation performed sixteen years earlier. In a two-week period this February, angry patients paralyzed a nurse in Nanjing, cut the throat of a doctor in Hebei, and beat a Heilongjiang doctor to death with a lead pipe. A survey by the China Hospital Management Association found that violence against medical personnel rose an average of twenty-three per cent each year between 2002 and 2012. By then, Chinese hospitals were reporting an average of twenty-seven attacks a year, per hospital.