Been catching up on old emails this weekend and among those was one from a reader attaching a New York Times article, From China, With Pragmatism: Are the Chinese outdoing Americans at their own philosophical game?  The article is written by Stephen T. Asma a professor of philosophy and fellow of the Research Group in Mind, Science and Culture at Columbia College Chicago. It deals with how ethics in China are viewed from a different perspective in China than in the United States. Different, not worse.  This is a very crude summary of the article and I urge everyone actually read it.

The reader who sent me the email was dismissive of the article, saying only that:  “He [Professor Asma] should repel out of his Ivory Tower : ).”

I, on the other hand, LOVED the article because it does such a good job of showing how different our two cultures view the same thing: giving a red envelope (with cash in it) to a doctor before the surgery of a child. I will let that portion of the article speak for itself:

Chinese people regularly give red envelopes, or hongbao, filled with money as gifts for weddings, births, New Year celebrations and so on. The red color is thought to be good luck. 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.

Wow.  Again, read the article.

  • Rick in China

    It’s an interesting phenomenon and I can understand why it seems like bribery, confusing as to the logic for giving it beforehand (as opposed to say, tipping accordingly at the end of a meal or cab ride), and the general weirdness that when posed with the prospect of giving a red envelope in specific situations in China from a western perspective..

    Personally, I never felt that weird about giving a red envelope of cash as gifts for birthdays, celebrations (like children reaching X days), or weddings.. even though I always brought up the concept I’m familiar with which is to give a gift that garnered some thought to make it personal, and that cash was viewed typically as a distasteful cop-out in my corner of the world. I was recently posed with the red-envelope-to-doctor request, though.. when my wife and I had our baby at a Chinese hospital. She told me to arrange a few K and her aunt brought an envelope big enough to contain it, and at first I was apprehensive – like “what do we actually expect to be different by giving this cash to the doc..) etc. I was told that the doctor would help arrange some of the costs that would not otherwise be covered by insurance, to be covered by insurance. At the end of the day, I think it was a poor investment, but I think there is a sort of social norm where people just *believe* they’ll get some sort of special care, I can tell you — after having to serve my wife as what we in the west would call a nurse (ie. all the dirty stuff you don’t think of for the days following birth), even in the VIP ward, we did not get any ‘basic’ treatment we’d expect in the western world.. regardless of the envelope or VIP ward room, which amounted to essentially a crappy hotel room, but at least it was private.

    I’ve no idea how this can change, but I don’t think there is any benefit to society on whole.. if people truly do get worse service by not providing tax-free bribes, I don’t see why the government wouldn’t step in and prevent it either. It seems their main motivation would be to have money changing hands for service as taxable – and the gov’t taking their envelopes are already illegal and still happen in various ways, so they could still continue with their corrupt practice whilst getting it out of citizen’s routine lives.

    • Markus Peg

      With the practice so common, doctors expect it, giving the hongbao won’t do anything special in most cases. However, unfortunately, not giving the hongbao…. well that could become a problem…

      I hate this practice as it goes everything I believe in, but, would I not give a hongbao knowing that everyone else does it and if were my wife and child?
      It is a big dilemma, normally I would make a stand, not because of the money but the implications and ethics, but, I would only stand up to such things if it were only affecting myself… So in the case of my wife or child I would sadly follow the flock of sheep in the giving of hongbao to the doctor.

      Interesting post and story Rick thanks for sharing that with us.

  • Tim

    This is a classic example of a foreigner buying into the ruse of, ‘because it’s China’ when this is nothing more than a clever rationalization of a system where corruption is systemic, used to ward off foreign criticism. As one of the commenters so succinctly put it: “a private response to a flawed system ends up entrenching the flaws in the system.”

    It is very unfortunate that Chinese have to compete for competent services provided by their hospitals; and I can tell you that I see more and more Chinese in the waiting rooms of the international hospitals because quality of care is impacted by the morals of the caregivers.

    This benevolent system of ‘gifting’ a doctor before surgery has the unfortunate side effect of increased violence in hospitals by those who believe that they were swindled when operations do not go their way and is at the heart of the ethical dilemma US medical companies face to operate here and that this blog has discussed many time before.

  • ollumi

    I think one word in the article is very key to understanding the concept: Reciprocity. When Chinese people give red envelops, it’s an implicit understanding that either immediately down the future or somewhere down the road the favor is returned, so it’s not so much paying someone for a favor as further cementing a bilateral relationship. For example, those invited to the massive scaled Chinese weddings are each expected to hand in a red envelope full of waddles of cash. But these envelopes are inevitably returned – either at the attendee’s wedding, at some sort of going away party, maybe paying for an expensive dinner, or something of the sort.

    You wouldn’t exactly call that paying for a favor from the bride or groom’s family. There is a fine line between using the hongbao to denote respect/recognition of someone’s status or skill or relationship and using a hongbao because otherwise that other person is going to be a nuisance/obstruction/or you won’t get some benefit, and that fine line is often where people who are used to dealing with a more structured – whether legal or otherwise – boundaries get confused.

  • China Medical News

    This article is based on the questionable assumption that it is a common and accepted practice for hongbao to be given to surgeons by strangers (and that they will get preferential treatment in return). It does happen, but often it doesn’t, and there are other more nuanced factors at work. Guanxi are a more important factor in getting access to a good surgeon. A hospital doctor friend of mine laughed when asked about hongbao, saying they were often offered. but not worth the trouble – the management would want their cut. Surgeons make more income from commissions on drugs and devices.

    • Markus Peg

      Commission on drugs is one of the most horrific things, it pushes doctors to sell things to people that don’t need it in order to make more money. In my opinion healthcare is a human right and should not be a business that focuses purely on making money. Of course the industry needs money to exist, but, the practice of commission is highly unethical. Personally, I am a strong believer in that money coming from Tax payers.

  • idle chatter

    There’s a difference between a) what’s necessary for an individual to “get by” in a flawed system and b) the broader question of whether that’s system’s good or bad in the first place.

    As an individual, I know that the Chinese medical system is deeply flawed (as do its doctors, and as do its patients), and I want to get by. I’ve given gifts.

    But the societal setup is far from ideal — it smacks of the same desperately selfish free-for-all that’s the dark underbelly to China’s emergent society, and a fear of actions that don’t result in an immediate tangible benefit to one’s self.

    Despite my words, I like China very much. And despite what the NYT article says, this issue could be separated from morals or philosophy into societal pragmatism (vs. individual pragmatism, which China has been stuck in, ironically enough): It’s clear that as a society, China (like every nation in some way) has practices that impair its progress. The red envelope medical system is one of them.

    We all have to take short-term workarounds sometimes, but a system reliant on them can’t achieve its full potential.

  • Robert Walsh

    I always give little kids Burmese money in their Spring Festival hongbao. They are thrilled with notes that say “5000” and “10,000”. Until they take them to buy toys, that is.

  • r_s_g

    The author of the NYT post is a total China newb. He fell for a post-hoc rationalization of a dirty system, presented by the elite who benefit most from it. The precise mentality described in the article, wherein small networks of mutual backscratching hold sway over any sort of larger concern for civil society, is exactly what leads to melamine in milk and the like. The flipside of guanxi is an unrelenting disregard for anyone/anything not within the immediate guanxi network and anyone/anything with nothing to offer in terms of financial/political gain.