“The 24 paragons of filial piety” is a collection of short tales, dating back to the Yuan dynasty. The 13th tale tells the story of a poor man called Guo Ju, living with a wife, infant son, and his old mother. Food is scarce, and Guo Ju takes the difficult decision to bury his son in order to save his frail moth-er. The wife weeps in sorrow, but she is a filial daughter herself and understands the importance of their duty. “We can have more children,” Guo Ju reassures her, “but there is only one mother”. However, upon starting to dig his son’s grave, Guo Ju strikes upon a chest full of silver and gold, worth a king’s ransom – a gift from heaven to the filial son.
Filial piety is the moral principle of taking care of one’s elderly parents. The children are forever indebted to their parents for raising them. A small way in which they can repay that debt is to reciprocate when the parents grow old. It is a powerful obligation, as seen in the extremity of the tale above – a filial son would sacrifice his child rather than let his mother die.
However, filial piety and the hierarchical familial structure face challenges in modern China. The country has the fastest ageing population observed in human history. By 2050, it is estimated that over 40% of China’s population will be above 60 years old. The advances in Chinese infrastructure and medical care have made this possible – it does mean, however, that more people reach old age, and the elderly are living longer.
The financial burden of the family duty became apparent when China implemented the One Child Policy in 1980. The economic cost of caring for 2 parents and 4 grandparents fell upon the single child in the family. The mounting pressure is further exacerbated when the child grows and decides to create a family of its own.
Additionally, urbanization has shifted working class adults’ interest towards living in cities in search of a better life. Modern living quarters are smaller, and the rents higher. It discourages the idea of three generations living under the same roof. Furthermore, for the elderly, relocating from the life they knew to a new, urban home is a vast challenge. Often, the ageing parents remain in the countryside. The young, living in cities, provide financial support through sending money back home. However, those of advanced age often have a considerably harder time getting on with their daily lives without someone physically helping them.
China was caught unprepared for the staggering increase of its elderly population, resulting in problems regarding pension schemes and geriatrics. Only 55% of Chinese receive a pension, making it difficult to afford health care. Geriatrics was not deemed a respectable profession in the past. The lack of qualified medical personnel in this field has led to ex-cessive demand for a scarce and much needed service.
Filial piety is indisputably tested by the dynamic social transformation resulting from China’s development. In an increasingly globalized world, Western influence has led to the emer-gence of care homes in China. Whilst 4-8% of elderly people in Western nations reside in care facilities, it is worth noting in China, the number is as low as 1.5-2%. Such services are still relatively unpopular, but demand rises annually and new facilities are con-stantly being created. The traditional Chinese family model is gradually lost. In a 1930 Chinese home, nearly 50% of families were three generation-al. In 2010, this was reduced to 20%.
The Chinese government has reacted swiftly. At national level, their goal is to achieve a 9-7-3 equilibrium – 90% of elderly to be home or with their children, 7% in government elderly care and 3% in private elderly care. This equilibrium has multiple benefits including the cost-effectiveness of the healthcare system, the increased autonomy of the elderly with-out removing them from the comfort of their homes, and the preservation of traditional cultural values. Several changes have taken place in order to ensure the success of this ambitious ratio.
Addressing the lack of qualified personnel, a 2011 plan has established the goal of expanding training pro-grams to be able to provide 3 million eldercare nurses by 2020. Although it means a higher availability of nurses, it does not cover for the costs of elderly service – a major problem. In rural areas, 65% of elderly are still living be-low the poverty line. This means that availability of healthcare to seniors is limited to those who can pay for it.
In response to the lack of financial resources to cover the expanding medical services, the National Healthcare Security Administration announced a new insurance program in 2018. Available to 57 million elderly, it is aimed at those struggling to cope with daily tasks on their own. In the first, pilot half of 2018, the insurance covered an average of 70% of nursing expenses for its subscribers. The One Child Policy was also relaxed in 2015, allowing families to have 2 children, allowing them to share the economic burden of medical bills.
China’s investment in the elderly pays off through the increase of its working force. Previously, the lack of geriatric nurses (and the lack of money to pay for them) meant women stayed at home to take care of sick elderly relatives. Nowadays, with the increased number of medical personnel and financial help available, this burden is alleviated. Freed from their role of unofficial nurses, women can contribute to the country’s workforce, making them a valuable economic asset.
It may appear easy to dismiss the government’s policies as only being economically beneficial, which they undoubtedly are. Yet the 9-7-3 equilibrium also appears to strive for a reminder for the responsibility of filial piety. The children are indebted to their parents for raising them, and should not forget their obligation to care for them in return. In fact, the refusal to abide by filial piety is now punishable by law. A 2016 Shanghai legislation enables elderly to sue their children for lack of financial and emo-tional support. Those recognized as guilty by court have their credit score numbers lowered. But in a country where public image is greatly valued, even the implied shame of being sued for being an unsupportive child is punishment enough.
As Atul Gawande writes in his book “Being Mortal” – “it is not death the very old tell me they fear. It is what happens short of death – losing (…) their best friends, their way of life.” China’s goal ratio ensures 90% of elderly live out their last years in their own intimate setting, surround-ed by family.
Specialized facilities may extend the life of elderly suffering from chronic diseases by a few years – but is life worth living in a new, clinical setting, isolated from all you have grown used to and love dearly? The majority of elderly do not think so. At a certain point, the quality of years remaining become more important than the quantity. Filial piety may not be as deeply ingrained in other cultures as it is in China. However, being a presence and support for elderly family members, is an example we can all learn from.