Defensive Medicine or Economically Motivated Corruption? A Confucian Reflection on Physician Care in China Today

Abstract

In contemporary China, physicians tend to require more diagnostic work-ups and prescribe more expensive medications than are clearly medically indicated. These practices have been interpreted as defensive medicine in response to a rising threat of potential medical malpractice lawsuits. After outlining recent changes in Chinese malpractice law, this essay contends that the overuse of expensive diagnostic and therapeutic interventions cannot be attributed to malpractice concerns alone. These practice patterns are due as well, if not primarily, to the corruption of medical decision-making by physicians being motivated to earn supplementary income, given the constraints of an ill-structured governmental policy by the over-use of expensive diagnostic and therapeutic interventions. To respond to these difficulties of Chinese health care policy, China will need not only to reform the particular policies that encourage these behaviors, but also to nurture a moral understanding that can place the pursuit of profit within the pursuit of virtue. This can be done by drawing on Confucian moral resources that integrate the pursuit of profit within an appreciation of benevolence. It is this Confucian moral account that can formulate a medical care policy suitable to China's contemporary market economy.

Keywords:

• Confucian virtues
• defensive medicine
• market
• medical corruption
• profit

I. INTRODUCTION

China is passing through a period of dramatic economic and cultural change. It is moving from being an underdeveloped country to being a global economic powerhouse, with many health care institutions now equal in quality to the best in North America and Western Europe. However, regional differences in quality and the availability of health care are significant.

China also faces the challenge of moving from a dominant ideological and cultural understanding that was antithetical to the market and profit, to one that supports the market and profit. This change will require an ideological and cultural understanding that

1. can support the transformation of China through a market economy that can significantly raise the standard of living for all its citizens, while

2. preserving the structures of trust and virtue.

As with all periods of cultural transition, there are conflicting moral messages derived from the non-market culture of the recent past and the emerging ethos that is now defining China's transition. This essay examines one of these conflicts that engender inappropriate economic incentives for physicians due to lingering inappropriate structures from the recent past.

The focus is on a widespread medical-ethical problem in China, namely, that there is a tendency to over-use high-cost diagnostic and therapeutic interventions. In China this phenomenon is often explained in terms of a rise in defensive medicine due to an increased concern with malpractice risks. While not discounting the significance of concerns regarding malpractice suits in contemporary China, this essay lays equal, if not greater, blame on a policy regarding the payment of physicians that encourages physicians to over-use expensive diagnostic and therapeutic interventions.

The circumstance is as follows:

1. physician remuneration is set at a low level;

2. physicians may not adequately charge for providing better basic care; and

3. physicians can nevertheless receive significant payments for high-cost diagnostic and therapeutic interventions.

This article examines how this complex of misguiding moral and legal structure engendered from China's pre-market ideology seriously distorts medical judgment in a cultural and legal context that has turned to market development.

The following section exposes the major types of non-medical influences on medical decision-making in the contemporary Chinese health care context. It is followed by section III, which examines current Chinese practice patterns involving the over-use of expensive diagnostic and therapeutic interventions so as to determine the extent to which they can be adequately explained as a response to malpractice considerations.

It is argued that features of Chinese medical malpractice law that are often criticized and held to be the sole cause of the over-use of expensive diagnostic and therapeutic interventions cannot be the only or perhaps even the main factor generating these practice patterns. Rather, significant blame should be placed at the feet of misdirected governmental policy regarding hospital budgets and physician income.

In section IV, the resources of the Confucian moral tradition are explored as a basis for a perspective that can combat these corrupt practices by integrating the pursuit of profit within a Confucian account of the pursuit of virtue that can maintain the focus on the best interests of the patient. The article thus ends with a proposed treatment for these distortions of medical professionalism drawn from the resources of Chinese culture.

II. TYPES OF NON-MEDICAL INFLUENCES ON MEDICAL DECISION-MAKING

The corruption of medical judgment is a phenomenon obviously not unique to China, though the Chinese context gives it a special local character. The professional judgment of physicians across the world tends to be distorted by considerations of defensive medicine, as well as by possibilities for payment.

For example, where there is a considerable malpractice threat, the medical decision-making of physicians tends to be corrupted, in that physicians are encouraged to engage in diagnostic procedures not in order medically to benefit the patient, but in order to protect the physician against the costs of litigation. So for example, if a child has fallen from a low tree limb and physical examination shows no broken bones, x-rays are often ordered primarily in order to document the correctness of the physician's diagnosis.

Economic distortions of physicians' judgments also occur worldwide. Physicians tend to engage in activities that pay well and avoid those that lower their income. Where the primary consideration in the physicians' choice is not the patients' best medical interests, but instead the physicians' concerns regarding malpractice and/or profit, medical decision-making is distorted or corrupted.

It is not easy to explore the complex interaction of concerns about malpractice and economic rewards shaping contemporary medical practice worldwide. This is because medical decision-making often occurs in a grey zone where one can highlight different clinical circumstances in order to justify particular diagnostic and therapeutic interventions. In this grey zone, physicians can often justify diagnostic and therapeutic interventions out of malpractice and economic concerns by accenting the risks that would justify those interventions which give malpractice protection or generate profit, although those interventions do not serve the interests of the patient.

Since risks express a probability of a mal-event occurring, and since risks usually range over a spectrum and are determined by the particular health condition of the patient, there is a considerable plausible leeway in medical decision-making, depending on how one weights different factors.

This is further complicated by the question of how to weight the significance of morbidity and mortality risks (e.g., how bad is a possibility of suffering or death at a particular time). Medical decision-making requires comparing less than certain possibilities of suffering and death.

So, for example, in a retrospective reimbursement system in which the patient has full indemnity insurance, the physician will generally be motivated to engage all diagnostic and therapeutic interventions that on balance convey a reduction of morbidity and mortality risks, irrespective of the costs. After all, the patient has paid for insurance to support such all-encompassing work-ups.

In the case of a patient with persistent headaches, the use of an MRI to evaluate his complaints has primarily economic costs, while having the benefit of conveying psychological reassurance regarding the absence of a possible brain tumor and, in some rare cases, actually leading to a life-saving surgical intervention. In such cases, where the patient's interests have been secured, although economic costs have increased, the physician's decision has been influenced, but not corrupted by economic interests. The focus has secured the patient's best medical interests. It is just that in this case the physician's economic interests are consistent with the patient's medical interests.

On the other hand, in a prospective-reimbursement, resource-constrained system, where a physician's remuneration may decrease if expensive and therapeutic interventions are engaged, physicians often rely on “evidence-based medicine” in order to justify denying access to expensive interventions until the intervention's benefit is well established, even when in the judgment of the physician those interventions would, in general, promise more morbidity- and mortality-risk protection than medical harms.

The economic concern to reduce expenses and maximize the effective use of resources sets a burden of proof against expensive interventions, so that clinical judgment is distorted and the patient's best medical interests may not be secured. If the patient is not informed about these considerations, then the physician's decision is not just influenced, but corrupted.

As to defensive medicine, it is a commonplace that physicians engage in diagnostic and therapeutic interventions to protect themselves against malpractice. Such interventions usually involve a corruption of medical decision-making (e.g., the ordering of diagnostic tests that confirm a physician's clinical judgment for malpractice considerations without advantaging the patient's medical interest, albeit usually only involving a minor medical risk to the patient). The more the risk to the patient, the greater is the significance of the corruption.

Again, it is often difficult to show that the physician's decision has been corrupted, when the factors tipping the physician's choice to engage in the behaviors of defensive medicine cannot clearly be shown to harm the patient, but when there is nevertheless some plausibility of the intervention providing a medical benefit. In this gray zone, the fear of malpractice litigation can move physicians to engage in diagnostic and therapeutic interventions to protect themselves and therefore not to act primarily to benefit their patients.

This phenomenon takes different shapes in different countries, and Chinese medicine is no exception (Liang, Zheng, & He, 2004). In contemporary China, because the contradictions between physicians and patients are increasing, the relationship between physicians and patients is tense and medical dissension is on the rise (e.g., H. Zhou, 2004). As a consequence, China has witnessed a pervasive phenomenon of physicians taking precautions against potential malpractice risks involved in diagnosis and treatment (Cheng, Cheng, Cai, Liu, & Wang, 2003; Liu, 2003).

Four types of special medical behavior mark contemporary Chinese medicine. First, there is a practice of requiring more and more expensive diagnostic work-ups than are clearly medically indicated. Physicians tend to use a wide range of expensive high-technology examinations, such as CT scans and MRI examinations, to establish a diagnosis when less-expensive diagnostic procedures would have been sufficient.

The second type involves the prescription of more expensive forms of medication or other therapeutic interventions than are clearly indicated for treatment, with the excuse that one must provide all that may benefit the patient.

A third type involves undertreating patients because of the fear of lawsuits associated with the risks tied to the full, medically indicated treatment. For example, surgical interventions are at times limited out of fear of lawsuits with the reasoning that engaging in more extensive operations, although best for the long-term interests of patients, would involve a more significant immediate mortality rate (although the probability of long-term success is higher) and therefore would involve a higher malpractice risk.

In the fourth form, a corruption of proper professional behavior occurs when, against the background of a generally untrusting relationship between physicians and patients, some physicians tend to over-emphasize or even exaggerate the severity of a patient's disease in the hope that, should unexpected problems or complications occur, the patient and the family will more easily accept them.

These types of medical practice have been interpreted as forms of defensive medical behavior because they are conducted by the Chinese physician “in order to try one's best to obviate uncertain factors, to reduce the risks involved in the course of diagnosis and treatment, and not to leave any excuse for patients to sue afterwards” (Liang, Zheng, & He, 2004, p. 133).

Many Chinese scholars have attempted to account for such behaviors as a form of defensive medicine (e.g., Cheng, Cheng, & Liu, 2002; Du, Zhang, & Zhang, 2006; Zheng, 2006). This article does not dispute that the third and fourth medical practice patterns are forms of defensive medicine. However, this article argues that it is much more accurate to interpret the first and second medical behavior patterns as corruptions of medical judgment that are also, or perhaps primarily, induced by economic incentives engendered by a perverse reimbursement policy, rather than as simply the result of defensive medicine.

III. DEFENSIVE MEDICINE OR ECONOMIC CORRUPTION?

Some may argue that to attribute the overuse of expensive diagnostic and therapeutic interventions to economic motivations overlooks important changes in Chinese laws that are sufficient to account for these behaviors in terms of malpractice concerns. Even if a desire to increase physicians' income motivates the over-use of expensive diagnostic and therapeutic interventions, it is also true that these physicians may often plausibly argue that they are motivated to make these choices in order to protect themselves from possible medical lawsuits generated by the new legislation on medical practice.

With the gradual development of Chinese health care law, the popularization of legal education, and the awareness of patients regarding awards from malpractice suits, malpractice law has been strengthened day by day. When dissension occurs, patients or their families frequently want to find some fault with the physician in order to claim compensation.

This increase in litigiousness is further complicated by the circumstance that courts are often more influenced by data produced by high-technology diagnostic interventions than by claims of good medical judgment and the physician's clinical experience. These factors certainly have motivated doctors to attempt to protect themselves through a defensive medicine characterized by such strategies as the use of high-technology diagnostic interventions. One may conclude, the use of high-cost diagnostic and therapeutic interventions cannot simply be understood as corrupt practices motivated by economic interests, but must also be understood as involving a defensive medicine motivated by the new circumstances of Chinese medical malpractice law.

This conclusion is particularly plausible given the series of new laws and statutes on medical malpractice that have been issued since the 1990s. First, the “Ordinances on Medical Negligence and Malpractice” issued by the State Council have been in force since September 1, 2002. Article 2 of the Ordinances stipulates that

“medical negligence and malpractice refer to an incident in which the medical establishment and its professionals violated a health care management statute, an administrative decree, departmental rules and regulations, or diagnostic, therapeutic, and nursing norms in a medical intervention and have negligently caused physical injury to a patient.”

This stipulation extends the scope of medical negligence and malpractice to the entire “physical injury of patients.” In addition, the Ordinances further classify medical negligence into four levels, according to the degree of harm to the patient and then set a standard amount of compensation for each level.

The changes expand the meaning of a medical mal-event, further increasing the responsibility and burdens of medical organizations and physicians (Ding & Wang, 2004; Y. Zhou, 2004). These developments have made many patients think that they can successfully sue when they are unsatisfied with the physician or are suspicious of the physician's treatment methods. As a result, not only is the number of malpractice actions increasing, but the amount of the awards is as well.

Also, once a suit is filed, this becomes part of a physician's record, which can adversely affect the rest of a physician's career, even if the suit against the physician fails. The result is that, under the current malpractice climate, in order to avoid being the subject of a suit and in order to have a better defense in court, many physicians believe they have no alternative but to engage in diagnostic and therapeutic interventions for defensive purposes.

Second, on November 6, 2001, the Supreme Court of the People's Republic of China promulgated “the Regulations on Evidence to be used in Civil Lawsuits.” Article 4.8 stipulates that, for civil lawsuits generated by the medical activities that may have probably violated the patients' rights, the relevant medical institutions are obliged to provide evidence to show that there is no causal connection between medical treatment and any harmful outcome and that there is no medical negligence or malpractice involved in the medical activities (available at http://www.allbrightlaw.com.cn/law/law164.htm). This regulation has ordinarily been called “reversed obligation to provide evidence” ( ju zheng dao zhi).

In the past, if patients and their families sued the physician, they had the obligation to provide evidence of medical negligence or malpractice. Now under the new regulations the hospital and physicians under suit have the obligation to provide evidence showing that no medical negligence or malpractice has occurred. This change in the law has motivated some physicians to treat all patients as potential plaintiffs. This in turn has led to the view that physicians must now endeavor to develop and maintain evidence that can show that everything possible that would have benefited the patient was done so that the physician subsequently cannot be successfully sued.

It is also true that malpractice cases have been significantly on the rise in recent years. For example, the medical lawsuits in Beijing have increased from 340 cases in 2001 to 778 cases in 2004 (Long, 2006).

These developments in Chinese medical malpractice law do not provide as strong a justification for explaining the over-use of expensive, high-technology diagnostic and therapeutic interventions as might initially seem to be the case. First, they do not show that physicians have been solely motivated by malpractice concerns when requiring more expensive diagnostic work-ups and prescribing more expensive drugs than are clearly indicated. In fact, the possibilities for remuneration indicate that physicians are also motivated in these actions by the allure of making significant supplementary income, not just engaging in defensive medicine.

In China, where most hospitals are government-owned, with funds both provided and regulated by the government, physicians' base salaries have been set at very low levels (for instance, a senior physician at a big-city hospital may only earn a base monthly salary of US$350).

However, at the same time, physicians are allowed to enlarge their income significantly by gaining large bonuses through certain categories of services to patients. Ironically, the fees for additional direct physician services are set at a very low level. The result is that, while physicians may not adequately and legally charge for providing better basic care, physicians can gain large bonuses through prescribing expensive diagnostic tests, as well as more drugs or more expensive drugs.

In fact, for many hospitals 50–60% of their total revenue comes from “selling” drugs prescribed by physicians. Similarly, diagnostic work-ups using high-cost technology are very beneficial for physicians' incomes. A CT scan costs the patient the equivalent of $50 and an MRI examination can cost as much as $120. As a result, such bonuses for many physicians are more than their base salaries. Given this state of affairs, many physicians are highly motivated to supplement their livelihood through the sale of drugs or through performing high-technology procedures.

The hospitals, which also profit, have little motivation to be critical of such physicians. The result is that physicians seek reasons for requiring more expensive diagnostic work-ups and for prescribing more drugs or more costly drugs, shifting the burden of proof against less expensive interventions (Fan, 2007).

There is a second ground for discounting the role played by considerations of defensive medicine. Almost all studies of recent Chinese medical malpractice cases indicate that high charges and expensive payments by patients and their families to physicians constitute one of the major motivating factors for malpractice suits (e.g., Xu & Chen, 2006). This suggests that the opposite strategy, namely, limiting costly diagnostic and therapeutic interventions, would be an appropriate strategy for reducing the risk of medical malpractice suits. But most physicians have not adopted this strategy of forgoing expensive interventions.

Further, although the new regulations of the “reversed obligation to provide evidence” involve a substantive change in who bears the burden of proof, they have not that significantly changed the actual practice in malpractice cases. Physicians have always had professional rights and duties to provide relevant evidence.

Also, since most lawyers and judges, as well as patients and their families, do not possess professional medical knowledge, the Chinese courts rely heavily on the opinions of medical experts randomly chosen by the courts out of a large pool of medical experts to assess cases of alleged malpractice. As a result, the real players in Chinese malpractice cases are not judges, but such medical experts (Ou, 2006). If physicians appropriately understand these circumstances and if they are primarily motivated to protect themselves from such lawsuits, they would have practiced medicine in accord with well-established professional standards or indications—that is, they should have required less diagnostic work-ups and prescribed fewer expensive medications. Yet, this is not the case.

Therefore, economic interests very likely have played an important role in addition to considerations of defensive medicine. Of course, many Chinese physicians may in various ways misunderstand what is involved in a fully rational response to malpractice concerns. Nevertheless, given that many physicians are aware of these circumstances and given the widespread practice of prescribing expensive diagnostic and therapeutic interventions that is to the clear financial benefit of the physicians, but not to the clear medical benefit of patients, the over-use of expensive diagnostic and therapeutic interventions is too widespread to be accounted for plausibly by defensive medicine alone.

If the practice of over-using expensive diagnostic and therapeutic interventions is best to be understood as reflecting, at least in part, a corruption of medical judgment through economic incentives, with an overlay of concerns for defensive medicine, then the moral issues at stake take on a more serious moral valence.

The damage done to medical practice and ethics is more serious in a Chinese cultural context if due to economic self-serving interests, than if undertaken for the purposes of defensive medicine. Economic concerns are considered more venal than self-defense and more likely to bring the profession of medicine into disrepute, thus constituting a more serious threat to medical professionalism. In any event, both of these practices distort the physician's clinical judgment, leading to the provision of diagnostic interventions and treatments not clearly clinically indicated.

IV. A CONFUCIAN REFLECTION: RESTORING THE INTEGRITY OF MEDICAL JUDGMENT

On what moral resources can China draw to reform this state of affairs? This is a foundational issue, much of which goes beyond the scope of this brief article. Here it can only be observed that China now faces the challenge of re-assessing the moral and cultural framework within which it must understand its major social institutions as it further develops within the twenty-first century.

On the one hand, China will need to determine what moral and cultural understandings can help restore and maintain the moral integrity of its local institutions, its professions and its citizens. On the other hand, it will need to determine what resources for this task are possessed by its own millennia-old cultural and moral heritage, so as to frame a moral and cultural understanding that can effectively support a sustainable moral framework for its health care policy. In particular, Chinese cultural-moral understandings locate the pursuit of profit within a life of virtue so as to harmonize the concern of physicians for better incomes, while maintaining the medical profession's proper focus on medical decisions that serve the best medical interests of patients.

Contemporary Chinese moral discussions, as well as health care ethics, are characterized by a competition among three different moral accounts. First, there are remnants of the moral and political ideology that directed the prior, centrally planned economy, and that excluded a role for the free market in general, and for private, for-profit health care activities in particular.

Second, there is a thin overlay of liberal social-democratic understandings of morality and health care that has recently been imported into China from Western Europe and North America. This ideology supports moral concerns drawn from the French Revolution regarding liberty, equality, and fraternity, recast in terms of more recent liberal-social theories, such as that of John Rawls (1971). Such understandings often stress an individualistic approach to medical decision-making, as well as an egalitarian view of health care as social welfare alien to the roots of Chinese culture. Third, there is a longstanding Confucian moral tradition that has survived a series of modern Chinese revolutions and that has recently been revived in an attempt to reconnect Chinese policy with Confucian values.

The previous non-market ideology, with its egalitarian emphasis, allowed physicians to receive only meager rewards for their services and did not allow even significant billing for better quality physician services. This ideology can no longer effectively guide Chinese medical practice, given the recent social and economic reforms that have placed China in a world economy structured by market forces.

Also, this ideology does not recognize that market incentives can reinforce excellence and medical professionalism. It is not an ethic that can encourage the virtue of ordinary physicians who have concerns for their own welfare and that of their families within a society increasingly framed by the market, while they also wish to pursue the good of their patients. So, too, the liberal social-democratic understanding of political and social structures fails to appreciate the significant economic challenges facing the welfare state throughout the world, as well as the special challenges to a developing country such as China.

One example of these challenges in the West is the impact of the demographic catastrophe on social welfare systems, which are now confronting the difficulty of finding enough young workers to pay for the health care needs of an increasing proportion of older, health-care-consuming citizens. The West became rich and highly developed before it became old and social-democratic. As a result, the impact on economic growth of a social-democratic ideology has been less distorting than it would be for China, as it is still on its way to becoming an economically and technologically fully developed country. This ideology, like that of the non-market ideology of the last decades, cannot direct the energies of a vigorous, developing China.

The economic distortions of medical judgment described in this article are due to a remnant of the previous ideology and the impediments grounded in this ideology that have made it difficult for physicians appropriately to seek higher compensation for providing better quality medicine. Instead, physicians, unaccustomed to professional norms for appropriate profit-seeking and unable to bill adequately for better quality care, have sought better incomes by requiring more expensive diagnostic and therapeutic interventions.

In turn, patients who could not directly pay physicians for better quality care sought to purchase better care through more expensive diagnostic and therapeutic interventions, which were not necessarily indicated. The result has been a distortion or corruption of medical decision-making. Given China's current market-oriented economic culture, neither the first nor the second ideology can help to develop norms that can effectively guide physicians in distinguishing between appropriate and inappropriate profit-seeking.

To remedy the prevailing corruption of medical judgment, the structure for the remuneration of physicians in public hospitals should be changed in order to reduce inappropriate incentives for increasing payment through the over-use of expensive diagnostic and therapeutic interventions.

Physicians' base payments should be significantly raised, physicians should be allowed to charge for better basic care and the current arrangements that support bonuses for costly diagnostic and therapeutic interventions should be abolished. It is perverse to set low levels of remuneration for physicians and then reward physicians by means of bonuses that encourage wrongly directed medical decisions. But most importantly, a moral vision must be supplied that can relativize the pursuit of profit within an encompassing commitment to professional virtue.

Confucian virtues still exert an extensive and far-reaching influence on China's economy, politics and culture, as they have for thousands of years. They should be drawn on as a foundational cultural resource so as to reform the current medical service market in China.

The cardinal Confucian understanding of virtue (de) recognizes the importance of character cultivation and proper action as realized through exercising benevolence (ren) in the tasks of everyday life, medical activities included (Fan, 2006). Confucian culture provides a moral framework especially appropriate for China's contemporary economic context by encouraging the profit and the accumulation of capital within the constraints of virtue (Cao, 2007; Ho, 2007).

The Confucian tradition affirms the market, including the enjoyment of affluence. Within Confucian thought, there is no prima facie moral suspicion of profit or wealth (Sheng, 1999). It is rather that these goals should be set within a larger, guiding moral framework.

The Confucian account of the virtuous person provides a paradigm for integrating expectations for financial reward within a life of benevolence. The important exemplars of such integration within the Confucian moral tradition allow one to affirm the goodness of profit and at the same time not to define one's life or profession by greed. It offers an integrated appreciation of the appropriateness of financial success within a life of virtue (see, e.g., Analects 6.28, 8.13, 14.1; Mencius 3B4; Xunzi 9, 10). It is this moral insight that lies at the core of the ability of Confucians to sustain a medical profession appropriate for a market economy.

Confucian thought offers an over-two-and-a-half-millennia-old moral narrative about a virtue-based way of life and spirit of professionalism that show in detail that appropriate material rewards both require and flow from the pursuit of virtue. This view is grounded in an anthropology that recognizes that people are naturally and properly directed by the profit motive and that this motive leads to the production of wealth, services, and excellence in one's profession, but that excesses must be avoided through the cultivation of virtue (Analects 5.5, 15.32).

Profit should be pursued not only honestly, but also consciously within a spirit of benevolence, the concrete content of which is defined within a particular profession. This requires the establishment and maintenance of a social order ideally realized within a fabric of mutual trust between physician and patient.

In all of this, public policy must support measures that at the same time enhance both virtue and general affluence, in that enriching people is recognized as one of the three most important governmental obligations (Analects 13.9). Because Confucianism affirms profit by locating it in the virtuous life, it is fully appropriate to hold that those who successfully engage in an important social activity such as health care should secure a high remuneration for their valued work, while being praised as virtuous (Fan, 2007).

A Confucian account of medical professionalism therefore shows its particular importance for China as it goes to meet the challenges of development at the beginning of the twenty-first century. Such a Confucian account can affirm the financial rewards integral to encouraging medical excellence, while at the same time placing the pursuit of financial reward within the side-constraint of seeking the medical best interests of patients.

In summary, a root cause of the corruption of medical decision-making that this article has explored lies in a failure to acknowledge the importance of and appropriate place for profit in medicine.

Current policy fails in not appreciating the necessity of placing the profit motive within the power of virtue. In order both to harness the power of the market in the development of China and to preserve the integrity of the medical profession, the Chinese government should draw on the Confucian cultural resources, which provide an understanding of the harmonious relation between the pursuit of profit and the pursuit of medical virtue in restructuring reimbursement policies for physicians.

The Confucian moral-cultural perspective can help direct the reform of China's policy regarding the remuneration of physicians. Direct pay to physicians should be increased. In addition, patients should be able to pay more for better basic care and physicians should be able to charge more for better basic care.

However, incentives for gaining bonuses by requiring more diagnostic work-ups or prescribing more expensive drugs must be abolished. These reforms should be pursued within a commitment to a moral vision that can nurture the synergy of profit and virtue.