The Influence of Eastern Philosophy on Elder Care by Chinese Americans

Abstract

Chinese philosophy has been a major cornerstone of Chinese culture for millennia and has bestowed on the world traditions such as Taoism, Yin and Yang, and filial piety. Although these beliefs have remained steadfast over thousands of years, their ability to survive unchanged in the future is uncertain. As the world forges ahead into the 21st century, several pertinent questions arise: Will age-old axioms, primarily those concerning elderly Chinese and their relationship with their children, survive? When ancient, traditional beliefs conflict with newer, Western ideas, which system of thought is likely to be the victor? Moreover, will elderly Chinese Americans and their perceptions concerning long-term care facilities cause problems with the traditional familial unit? This article will discuss these issues in detail.

Keywords

end-of-life care gerontology transcultural health Chinese Buddhism Confucian philosophy filial piety Taoism Yin and Yang

As the United States becomes more ethnically diverse, Asian and Pacific Islander Americans will grow into the third largest minority group in the United States. Based on a 2006 study, the Asian population was more than 13 million, which made up 4.4% of the entire U.S. population (U.S. Census Bureau, 2006). In addition, the Asian population increased 142% from 1.5 million in 1970 to 3.7 million in 1980, and the growth has continued, numbering approximately 7.3 million in 1990 and 13.1 million in 2006 (U.S. Census Bureau, 2006). Moreover, by 2050, 54% of U.S. residents will be non-White (U.S. Census Bureau, 2008). It was predicted that by the year 2030, the Asian population would reach approximately 20 million, with the Chinese growing the most (U.S. Census Bureau, 2006).

According to the Pew Research Center, Asian Americans are approximately 5% of the U.S. population, a percentage expected to increase to 9% by 2050 (Passel & Cohn, 2008). Chinese Americans are the single largest ethnic group within the umbrella of “Asian Americans,” making up to 22.4% of this growing community (U.S. Census Bureau, 2006). In addition, Chinese Americans represent 1.2% of the United States, and in 2006, the Chinese American population numbered approximately 3.6 million (U.S. Census Bureau, 2006). Like the rest of the population in general, the percentage of elderly Chinese Americans is increasing; it was predicted that between 1990 and 2030, Asians aged 65 years will increase by 643% (American Association for Retired Persons & Agency on Aging, 1996).

One third of Asian Americans are elderly Chinese (age 65 years or older; Mui, 1996). It is important to understand how their traditional values and cultural practices affect the Chinese and their perceptions of the elderly and long-term care. The Asian American population is growing faster than any other cultural group, and the problems it encounters is worthy of scholarly attention (Mui, Nguyen, Kang, & Domanski, 2006).

In Chinese culture, old age is viewed as positive and is considered a sign of wisdom (Cheung, Kwan, & Ng, 2006). Historically, the Chinese see old age as the time to sit back and enjoy the fruits derived from many years of hard labor. In addition, this is the time for elders to establish relationships with the third generation (their grandchildren). Moreover, it is a time for adult family members to seek help and advice from the elderly concerning significant life issues and decision making (Yi & Lin, 2009). Moving from one’s native country to a foreign land has the inherent potential to be quite stressful, especially when the new country has completely different values from what one is accustomed to. Comparable to other minority groups, the Chinese tend to carry their values, customs, life style, and beliefs with them where ever they go, particularly for first-generation immigrants.

Chinese Philosophy

Several major philosophies, religions, and beliefs affect Chinese. For instance, speaking of the elderly with respect has been a guiding principle in Chinese culture for thousands of years (Liu, Ng, Weatherall, & Loong, 2003). One major philosophy strongly affecting Chinese behavior and social interaction is Confucianism. Some of the primary hallmarks of Confucian philosophy centers on social interaction, for instance, behaviors such as loyalty, reciprocity, benevolence, righteousness, self-respect, self-reliance, self-control, and face-saving, that is, keeping the family name honorable are important (Fan, 2007). In terms of the relationship between the elderly and other family members, the central concept of Confucianism is filial piety (Nuyen, 2004).

Filial piety refers to the notion that younger family members are obligated to administer care for elderly family members. Thus, adult children must provide adequate caregiving for elderly parents otherwise their behavior is considered shameful (Nuyen, 2004). Filial piety has been described as respect, loyalty, and devotion to parents and is considered the virtue of all virtues and the soul of Chinese culture (Hwang, 1999), and thus, a child that sends his/her parents to a nursing home might be seen as bringing shame on the family. When this occurs, the adult child is often shunned by family and friends.

It is noticeable that filial piety and values associated with it have greatly influenced the parent–child relationship (Chaves, 2002). In fact, in Chinese culture, filial piety is a social norm stating parents should love their children, while children, in turn, should respect and care for their parents once they are old (Nuyen, 2004). The significance of filial piety is a crucial element of Confucianism and the backbone in the Chinese conception of family (Hwang, 1999). In essence, the single most important duty is the one each person has toward his/her parents. While there are many duties one should discharge, the fulfillment of one’s duty toward his/her parents is the most basic (Hamilton, 1996). Sung (1998) states that “respect toward parents is the basic feeling of filial piety.” Citing Confucius, Sung wrote, “Filial piety today is taken to mean providing nourishment for parents, but even dogs and horses are provided with nourishment. If it is not does with reverence for parents, what is the difference between men and animals?” (p. 3). Mere material support without spiritual devotion could not be called filial piety; rather, one must be imbued with respect and warmth (p.3).

A Chinese child is taught that caring for parents is to be done with gratitude, recognizing the balance in reciprocating for the care parents provided in childhood (Lai, 1995). Hwang (1999) explained why the Chinese emphasize filial piety,

In Confucianism, the core of moral behavior lies in being filial to one’s parents. Filial piety includes several obligations that the child owes his/her parents. For example, the child must obey and respect his or her parents, and support them in old age. The child’s duties to his/her parents are conditional because he/she owes his/her birth (which is the basis for one’s entire being) to his/her parents. Hence, theoretically speaking, the adult child is obligated to provide his/her elderly parents with financial and emotional support at any cost.

Any individual not heeding Confucian philosophy (i.e., filial piety) by placing his/her parent into a nursing home, even if the parent is stricken with a debilitating disease such as Alzheimer’s, is apt to find out that he/she has contravened millennia-old tradition (Chang & Schneider, 2010).

Another significant concept of Confucianism is family orientation (Sung, 1998). A person must be able to keep his or her obligation to one’s family and should place the family’s wants and needs above his or her own. Each individual meets this obligation by protecting and supporting the entire family (Yue, 2002), and to have one’s parent placed in a nursing home indicates a lack of respect and is “shameful” conduct. Furthermore, the Chinese family has been described as a close-knit social unit. For instance, the traditional Chinese family tends to have several generations living under the same roof, providing its members with support, security, and meeting other needs (Zhai & Qiu, 2007). Again, the emphasis is on the family taking care of its own, that is, family members treat the elderly with respect, and sending an aged parent to a nursing home, regardless of the physical and/or mental condition of the parent, is considered reprehensible (Fan, 2007).

In traditional Chinese society, it is normal for the family to be viewed as more important than the individual. Thus, personal mistakes reflect badly on the entire family and cause shame or loss of face. Caring for parents must be done with sincere appreciation of what they have done for their children, while personal fulfillment and happiness should result when children begin taking care of their parents. By sending one’s parent to a nursing home, the adult child is disregarding his/her debt to an aged parent and, hence, may be avoided by his/her community. In terms of seeking help, there is a strong expectation that all help would be provided from within the family and there would be resistance to obligating oneself to an outside provider of help such as a nursing home (Braun & Browne, 1998).

Based on centuries of Confucian thought, harmony and unity of the family are concepts keeping the family together as a single unit. Confucian philosophy suggests that each family member has his or her specific role to play within the family. Each member has his or her prescribed status, which means that the elders have more authority than the young, the parents have more authority than their children, husbands have more authority than wives, and so on (Wong & Chau, 2006). Moreover, the family is hierarchical, which takes priority over spousal relationship and friendships. However, each family member’s specific role is prescribed according to gender, age, and birth order. If each person keeps his or her role, the result will be harmony and unity within the family. For example, parents work hard to provide a good living environment for children, such as providing good education, while children obey and take care of their older parents (Fan, 2007; Hong, 1999).

Chinese Traditions

Traditional Chinese medical traditions and health beliefs are also considered important elements affecting an older individual’s view of long-term care facilities. The Chinese believe in preserving good health and believe in a balanced nutritional food intake, according to the principle of Yin and Yang (Wonsuk, 2009). Everything in the universe may be categorized according to Yin and Yang principles, including disease and foods. The Chinese feel that each individual needs both Yin and Yang if he/she hopes to live a life that is in accord with the universe. While both forces are interconnected, a number of differences exist between the two. For instance, Yin is thought to be one’s internal energy, while Yang centers on one’s physical body. In addition, Yin is construed as being a negative force, whereas yang is positive. Yin represents the female and negative productions such as darkness, emptiness, and cold. Yang represents the male and positive productions such as light, warmth, and fullness (Ng, 2008). In addition, the Chinese classify their food into Yin and Yang. Yang foods are fried and are rich or spicy, while Yin foods are usually green leafy vegetables. If there is an imbalance, illness, poor health, and disease will often follow (Braun & Browne, 1998).

Chinese life is heavily influenced by religion. Taoism and Buddhism are the two major religions in Chinese culture, and while both have differing beliefs, they possess two common strands, that is, both place great emphasis on adult children taking care of their elderly parents and both emphasize reincarnation (Overmyer, 2003). It is obvious that Chinese culture has been influenced heavily by Buddhist doctrine. Buddhists believe there are 18 levels of hell, filled with instruments of torture designed to punish those who committed evil acts when they were alive (Hsu, O’Connor, & Lee, 2009). How are these two great philosophies related to the elderly and long-term care? Their doctrines for teaching children how to treat their parents contain excellent pedagogic tools.

Many Chinese believe that if they do not treat their parent(s) in a respectful manner, they will suffer eternal damnation or will experience reincarnation as a lower form of life (snakes, roaches, spiders, etc.); consequently, many Chinese feel it is unethical and shameful to place one’s aged parents in a nursing home (Cheung et al., 2006). The simplest way to explain reincarnation is this: the manner in which you treat your elderly parents will revisit you once you are old. In other words, the great wheel of life will turn, and thus the child who treated his or her parents wrongfully will someday be treated in the same manner (Ho, 1998). We know a great deal about how traditional Chinese philosophy, values, and beliefs affect a Chinese native’s (Taiwan and China) views concerning their elderly family members and their caregiving support for them. However, since we are living in the 21st century, do the modern, native Chinese still provide the same caregiving support to their elder parents? And if not, how is it changing?

The Present

By 2010, the life expectancy for Taiwanese men had grown (75.34 years) as did that for women (81.2 years; Central Intelligence Agency [CIA] Factbook, 2010). At the same time, fertility rates declined (1.57 children per couple in 2003, as compared with 1.15 in 2010; CIA Factbook, 2010), while family caregiving issues became important topics within the aging society (Kao & Acton, 2006; Zhao & Kinfu, 2005). As population demographics changed, Taiwan also experienced rapid social and economic changes. Traditional familial household arrangements slowly changed, with the nuclear household (mother, father, and children—no grandparents) becoming more common (Tung, Chen, & Liu, 2006). This societal shift will increasingly affect the capacity of families to maintain their caregiving roles. Due to reduced fertility in the beginning of the 21st century, many elderly persons will have few or no children available for them to live with, thus severing traditional beliefs (Tung et al., 2006). In fact, reasons dictating whether or not adult Taiwanese children (Chinese, as well) provided support to their elderly parents will depend first on their financial ability and second on the ability and willingness of the young generation to provide support in the future (Wang, Laidlaw, Power, & Shen, 2010).

Reduced fertility rates in Taiwan could cause elderly parents to have no working-age adult children who can provide support (Yi & Lin, 2009). In addition, the continuing decline in fertility will reduce the number of children available to share parental support obligations and increase the support burden on individual offspring. As a result, continued dependence on one’s adult children as the major form of support will leave a substantial proportion of the elderly without resources, while a large proportion of the younger generation will be financially burdened. On the other hand, for native Chinese and from an older parent’s perspective, the extended household is still the primary living arrangement. Moreover, younger adult children still maintain a strong obligation toward their elderly parents. For example, many individuals live outside their parents’ major support service (Lee, 2007). It is clear that the caregiving issue, in terms of Taiwan’s future, is not highly correlated with an adult child’s parental obligation; rather, the declining fertility rate is seen as being more important.

Despite noticeable differences in patterns regarding Chinese conceptions of the elderly in their native countries, relatively little is known about how these patterns have changed as persons of Chinese origin become integrated into the American society. As Kamo and Zhou (1994) observe, “Chinese carry the cultural pattern with them when they immigrate to other parts of the world, although the circumstances of migration and treatment in the host country obviously condition the duration and strength of its persistence” (p. 50). Current writers and researchers, however, have suggested that because of different experiences and changing values, second- or third-generation Chinese Americans may not place the same significance on caring for their elderly as their immigrant parents or even grandparents. The support from Chinese families for their elders may be changing (Ishii-Kuntz, 1997; Mui & Shibusawa, 2008).

What caused this dramatic change? Primarily, tremendous diversity in intergenerational relationship among Chinese Americans exists due to generation differences and immigration experiences. Furthermore, it may be too simple to conclude that Chinese Americans’ strong obligation toward their elderly parents has been maintained because of the traditional Chinese filial responsibility. It may also be premature to characterize elderly Chinese Americans as not needing help from outsiders because their adult children have a strong sense of obligation. In fact, the amount of an adult child’s support for his/her elderly parents may be influenced by other combinations of reasons such as financial and social resources, being influenced by the immigrants having few social and financial resources in which to depend on. These two elements could strongly affect how they take care of their elderly parents. Even an individual with strong traditional filial piety, but has few resources and is struggling to survive, may not be able to care for his or her parents as well as he or she would desire (Ishii-Kuntz, 1997; Mui & Shibusawa, 2008).

Immigration to Foreign Countries

To understand what has happened to native Chinese once they moved to Western countries, certain questions should be asked. First, can a foreign culture affect one’s native culture? The answer is an unqualified yes. Fundamental differences exist between Chinese and American cultures such as their emphasis on family. Chinese culture stresses faithfulness to one’s relatives and commitment to tradition, while downplaying the individual; on the other hand, American culture is the opposite as it stresses individual freedom, while glorifying the individual. As a result, many Chinese that immigrate to America often find it hard to adjust (Lau, Fung, & Yung, 2010; Rawl, 1992).

When an adult Chinese American (foreign-born Chinese) accepts America’s educational system, and develops similar, American social values, it is much harder for adult Chinese Americans to have the same strong filial obligations that their ancestors had. Caregiving between different generations in Chinese American families is often reciprocal, with the elderly assuming responsibility for child care (Kramer, Kwong, Lee, & Chung 2002). In a family, if the elderly parents are traditional and younger members are Westernized, conflict will likely occur (Chiang-Hansiko, 2010; Yeo, 1996). Additionally, if adult Chinese American children are married to non-Chinese, the possibility of conflict in values grows exponentially.

Second, social and financial resources are important elements affecting the support quality that adult Chinese Americans give to their elderly parents (Ng, Phillips, & Lee, 2002). In fact, despite other traditional concerns (i.e., filial obligation), the more financial resources the adult child has, the more likely that he/she will provide monetary and emotional support for his/her parents (Ho, 1994; Ng, 2002). Thus, lack of resources can be devastating in terms of providing support.

Most studies showed that Chinese Americans, as a rule, still provide caregiving support to their elderly parents. However, if care is withheld, regardless of the reasons, where will the elders go if they become weak and feeble? Will they accept living in a nursing home? If not, what are the reasons or beliefs that hinder their acceptance of Western style care?

Overall, the language barrier is the most difficult task for elderly Chinese immigrants (Yoon, 2005). Many Chinese Americans are ashamed and embarrassed when they cannot speak English well enough to communicate with others. They may exhibit hesitation in asking questions or asking for help because they are afraid they will bring inconvenience to others (Fong, 1994). In addition, it is always more difficult for Chinese Americans to verbalize their negative feelings, even if there is no language barrier (Rawl, 1992; Yoon, 2005). Moreover, since the Chinese come from a close-knit society, when most immigrate to America, they tend to live in specific communities, such as Chinatown. On the other hand, this is understandable. If Chinese Americans live with other Chinese Americans, many of the problems encountered in American society disappear, that is, language and cultural barriers (Rawl, 1992). However, since English is the official language of the United States, an individual’s lack of communicative ability could definitely steer him or her away from seeking long-term care facilities, regardless of any potential benefits.

Different health practices and beliefs are other reasons causing older Chinese Americans’ hesitation in accepting nursing homes. First, Chinese medicine has been practiced over 3,000 years, becoming a medical services options for Chinese and Westerners (Rawl, 1992). As stated earlier, the Chinese believe strongly that an imbalance of Yin and Yang can cause illness. This belief can restrict the proper food intake based on Western nutritional guidelines. In addition, many elderly Chinese Americans are not comfortable eating Western-style food. Cheng (1997) wrote that when hospitalized, many would not eat the institution’s food, preferring their families to bring them meals three times a day. This practice can create further difficulties for the elderly, especially in terms of accepting long-term care and nursing facilities.

Second, self-care or self-treatment health practices are also common in Chinese society. In fact, many Chinese Americans use both Western and Chinese medical services, depending on the type of illness they have. If an individual has an acute illness, he/she tends to choose Western medicine. On the other hand, if an individual has a chronic disease, Chinese medical services are selected more frequently (Rawl, 1992). In fact, Chinese herbs have been used extensively by the Chinese in their daily lives for centuries. The Chinese believe a person should take care of his or her health each day. Moreover, they believe daily health care can prevent a person from contracting illness, which can be shown in their allegiance to taking herbs. Chinese medical lore states that Ginseng is a valid treatment for hypertension, as is garlic—both ideas have been validated by Western science (Yeh, Davis, & Phillips, 2006).

Another problem is that the Western concept of nursing homes runs counter to Chinese philosophy, values, traditional culture, and so on. Thus, many of the elderly may find the idea of long-term care facilities anathema. As demonstrated earlier, due to the myriad traditional Chinese cultural beliefs, such as Confucianism, Taoism, and so on, the Chinese elderly have difficulty in accepting nursing homes. The Chinese (along with Japanese, Koreans, etc.) tend to expect their adult children to take care of them instead of placing them in nursing homes, and if a family cannot take care of the elderly, it is viewed as shameful (Jung & Salmon, 2007).

Times are changing. Though Confucian ideals and beliefs about filial piety and respect for the aged have strongly influenced Chinese culture, it is still inevitable that the Chinese view concerning the elderly and long-term care will be affected in the 21st century. Both native Chinese and American Chinese have their own facts to face.

Because of the continuing decline in fertility rates, or as adult children become more Westernized, the conflict between filial piety and institutionalization of the elderly will be more pressing.

Footnotes

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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