Mark Pufpaff
ABSTRACT
China’s population is ageing. The ratio of retirees to workers is increasing at the same time as the size of the average family is decreasing, thus putting strains on China’s working populations, many of whom are responsible for taking care of their retired family members. In China, the tradition of parent/child reciprocity is called filial piety. However, with changing dynamics and demographics, how it is or ought to be practised in the 21st century prompts fresh reflection. This paper presents the ethical challenges and opportunities facing the practice of filial piety and explores mutually beneficial options for both children and parents.
THE STATE OF FILIAL PIETY IN THE 21ST CENTURY
“If my children ever put me in a nursing home, I would feel like I was being abandoned.” - Huang Liangbao, 83
Huang, an aging parent and grandparent in Shanghai, is not alone (Fan, 2017). Many in China, where elderly housing services like nursing homes and assisted living facilities are still viewed unfavourably and as generally undesirable, still prefer to be cared for by their children as they age. Such a practice of reciprocity, where parents provide for their children when they are young with the expectation that their children will care for them once they are old, is part of the historical tradition of filial piety (孝, xiào). However, there are a number of emerging trends posing challenges to the practicality and feasibility of this tradition, at least in its current form.
China has a growing elderly population. In 2014 there were 212 million people above age 60; by 2050, that number is estimated to rise to 480 million, or more than double (Xinhua, 2015). Researchers from the United Nations (UN) found that in 2005 there were 16 retirees for every 100 workers in China; they project that by 2025 this ratio will rise to 64 retirees for every 100 workers (Griffiths, 2014). Wang Jianjun, standing deputy director of the National Working Committee on Aging, stated that China’s population is on a trajectory of accelerated aging, the effects of which will have a significant impact on public policy, for example, regulating the provision of State-funded nursing homes and related accommodations (Xinhua, 2015).
A driving factor in this trend is China’s now reformed one-child policy, originally introduced in 1979, which for over 35 years effectively prohibited the majority of Chinese families from having more than one child. This led to what is now known as the “4:2:1” problem, that is, where in a given family there are four grandparents, two parents, but only one child. While not the situation for all families, it is a situation facing many, thus making filial piety and the cross-generational housing model1 it so often represented, difficult (Green, 2014); there are three reasons why. First, there is a trend of rural-to-urban relocation among students and young professionals. In increasing numbers children of rural families are studying and working in cities (and overseas), while parents and grandparents often remain in their hometowns. Second, even when these children do stay in close geographical proximity to their parents and grandparents, the ability to house and serve them adequately – being for all intents and purposes perpetually “on-call” –is becoming increasingly untenable. This is due to the disproportionate number of elderly members compared to working age member sin such families (Green, 2014). Third, the costs for one child (or even multiple children, in some cases) to support the healthcare needs of their parents and grandparents can be over whelming. For example, Fan Yan, the daughter of HuangLiangbao, reported that “having professional staff to take care of my mother would really relieve me and my brothers from worrying all the time”(Fan, 2017).
A parallel driver has been an increase in life-expectancy among Chinese citizens due to improvements in health care. While in 1970 the average life expectancy was 59 years, by 2016 it had risen to over 76 years (World Bank, 2018). With China’s elderly living longer into their retirement years, paired with the lingering effects of its one-child policy, a rethinking of the country’s public policy agenda may be in order. Luo Shanzhen, director of CHJ-Care Lezhi, a Beijing-based senior living service provider, indicated as much when she stated:
Over the next 15 years, as the first generation of parents affected by the [one-child] policy enters their 70s and 80s, they will need more professional care and attention…residential compounds for the elderly — especially the upscale ones — will be in greater demand. (Fan, 2017)
It may very well be that the luxury market grows first, or fastest. Luo is seeing a change in attitude among the wealthier and more highly educated in Beijing, many of whom see in upscale retirement compounds a fulfilling life. This is partially due to the services and the quality of life offered there, but also because they will not receive the same treatment staying with their children or grandchildren. According to Luo,
A coming demographic shift will quickly grow demand for [luxury homes for the elderly] in the years to come. China’s one-child policy was introduced in 1979, which means more and more Chinese who need regular elderly care don’t have the traditionally large families to cater to this need. (Fan 2017)
To accommodate their higher-end lifestyle demands, Luo outlines the value proposition of luxury residences:
At some luxury apartments in Beijing, older people are lining up to live there. Lower-tier cities have started to develop the upscale market as well. Such institutions provide daily care, entertainment, exercise, trips, and classes such as English, calligraphy, and knitting –all tailored to the elderly. (Fan, 2017)
If the prospects for the luxury nursing and retirement home market in China look good, what about the low-mid range of the market? The government has indicated that providing for such people is an important priority. Li Jianguo, vice chairman and general secretary of the Standing Committee of the National People’s Congress, stated as far back as 2011 that there needed to be a serious increase in the number of government-funded nursing home beds available for the elderly going forward. His desire did not go unheeded. In 2012 there were approximately 4 million beds available; by 2015 that number had risen to 6.7 million and is only set to continue rising (Nelson, 2012). Much of this increase was directed toward those at the lower end of the economic spectrum, where the government perceives the greatest need.
However, the need is not just to provide quality facilities for the less wealthy, but also to change perceptions. Fan, speaking on behalf of her mother Huang, stated: “[My] mother is reluctant, because she thinks of all nursing homes as the sparsely adorned rooms and run-down facilities of many state-run institutions” (Fan, 2017).
With the development of luxurious facilities, outfitted with attractive dining and recreational amenities, paired with the fact that an increasing number of elderly, regardless of financial status, are choosing to reside in nursing homes, such negative perceptions may diminish over time. One reason is social. Living alone is a more unfavourable prospect than living in a senior facility. Confirming this, Gao Lanzhi, a 75-year old now living at the Happiness Senior Citizens Care Center in Beijing, said that living by herself, even with an in-home nurse whom she had hired after knee surgery, was unbearable. After moving to the care centre, she found being in the company of the 200 other residents deeply fulfilling: “The nursing home provides me a quiet and reliable place to do what I like and to meet more peers” (Xinhua, 2015).
Despite the social attractions there are limits to the current capacity of nursing homes. According to Xinhua (2015), “the aged care service industry in China faces the awkward situation of lacking qualified professionals.” China’s Ministry of Civil Affairs sets the national professional standard for aged care staff; however, of the over one million industry workers, less than 40,000 of them meet the requisite standard. Many prospective residents like Gao are having to do a substantial amount of shopping before committing to a care centre or nursing home, with the patience, knowledge and attentiveness of the staff being a deciding factor. Hu Tongwei, director of the Happiness Senior Citizens Care Center, stated that of the 24 staff working there, “most of them [are] without professional aged care training.” But as the industry grows, and demands for such professional qualifications increase, the disparity between qualified and unqualified workers is projected to decrease. As Gao mentioned, “it’s high time for governments to increase the training of nursing home workers.” (Xinhua, 2015)
THE ETHICS OF FILIAL PIETY IN 21ST CENTURY CHINA
What do these developments within the elderly care industry mean for the tradition of filial piety? Filial piety represents the first of the Confucian relationships, parent/child, and expresses the Confucian value of reciprocity. The Chinese character for filial piety, xiào (孝), is a combination of two characters; the top character derives from lao (老), meaning “old”, and the bottom character is zi (子), meaning “son”. This symbolically presents the parent being supported by the child, which in practice is descriptive of the way children should act toward their parents (Teon, 2018). However, the reason why the child should act in this way is due to the upbringing they were given by their parents and the sacrifices they made for their child’s benefit (providing a home, healthy food, an education and emotional support). Thus, when children give back to their parents what was originally given to them they are embodying the value of reciprocity and continuing the tradition of filial piety.
The reciprocity and care by children for their parents as they age can take many forms depending on the resources, lifestyles and needs of the family. However, historically, there was a common context in which filial piety was carried out, namely, the cross-generational home. As discussed briefly above, it is a home that includes family members from different generations. For example, a household may include grandparents, parents, and children (Green, 2014). It may also be the case that the home is the same residence the parents grew up in and inherited, and then passed on to their children. This inheritance and passing on of real estate reinforces the cross-generational home model so often seen in the practice of filial piety.
Does the present-day rise in nursing home occupancy undermine the practice of filial piety? If a child invites a parent to visit a nursing or retirement home because they feel it will give them a better quality of life, is that showing a lack of reciprocity? Some, like Huang, may say yes. They may feel their child was abandoning them, and by extension neglecting their filial duties. But many others are saying no. The caveat is that many who are embracing elderly care homes are China’s so-called high-net-worth-individuals (HNWI). According to Flora (2016),
Preference [by HNWIs in China] for senior living communities has grown by 87 percent in the past year. A total of 28 percent of HNWIs have listed “medium- to high-end elderly care homes” as their personal post-retirement plan, marking a jump from 15 percent in 2015. Meanwhile, the percentage of those planning on “home retirement” has declined from 77 percent in 2015 to 57 percent in 2016.
For those HNWIs nearing retirement age, the desire not to burden their children and the necessity of having adequate healthcare services on-call are two of the driving reasons for the acceptance of life in a retirement home. But this does not mean their children are out of the picture. Flora (2016) continues:
While more wealthy aging parents may be living away from their children, they’re still getting a significant amount of support from them. For now, the cost of post-retirement healthcare and living is being taken care of by a combination of the parents’ savings (37 percent), funding from their children (30 percent) and social insurance (30 percent), with commercial insurance only funding around 2 percent.
Not only are children funding a significant portion of their parents’ post-retirement costs, they are also remaining in close touch with them through telecommunications technology: “Modern technologies, particularly social networking, has made [parents] feel closer to their children.” (Xinhua, 2015)
Gao Lanzhi, introduced above, said that she “lives her life in full without the feeling of loneliness and fear, although her daughters live abroad.” This feeling of closeness, however incomparable to being together in-person, is facilitated through smart phone applications such as WeChat. So effective has the emergence of such technology been in keeping children and parents in daily contact, that technology companies such as Tencent, which operates WeChat, and the government are supporting projects and initiatives that would embed such technology into the elderly care industry:
Seniors in China are owning more and more electronic gadgets…many of them have mastered applications on smart phones. Chinese tech companies have taken on the project of connecting the elderly with their relatives, communities, and hospitals, using big data on the internet. Data from daily life, including health index, [is] collected and uploaded through wearable devices to the cloud platform, [whereby] family members, living afar, receive updates. In 2013, the State Council asked local governments to support enterprises in applying the Internet and other new technologies to the industry. (Xinhua, 2015)
THE PRACTICE OF FILIAL PIETY IN 21ST CENTURY CHINA
If the prospects for retirement home life are positive for HNWIs in China, what about the less financially well-off? The Chinese government has indicated that the growth of the elderly care industry must accommodate those who need such housing and services the most. Wu Yushao, director of the China Research Center on Aging believes that, there should be a screening system to ensure that those most in need are admitted to nursing homes. Without the evaluation of physical and economic conditions, healthy and rich old people with lower ages [will] occupy the nursing resources…those without the ability to care for themselves, [and] who are in financial difficulty, are kept outside. (Xinhua, 2015)
Until the supply of nursing home beds, especially within state-run institutions, rises to a level whereby such discretion is unnecessary, a rationing of beds in favour of those most in need should be required. Such a policy would accommodate the desire of children, who may not be able to support their parents adequately by themselves, to care for them and thus carry out their filial responsibilities.
How else might the government and the elderly care industry work together to preserve the idea of filial piety? An important area to consider within China is the role of legislation in helping to support, however temporarily, the transition of filial practices from an increasingly outmoded cross-generational home model to one that includes elderly care facilities, both public and private. This transition is creating pockets of uncertainty, regarding the quality of care at such facilities and how living in them may or may not affect the filial relationship between the elderly and their children. Smart regulation can help to manage the expectations of would-be elderly care tenants, giving them reassurance that their children will be walking with them, albeit in a different context, as they age. Such regulation, properly implemented, can ensure harmony in the traditional parent/child relationship, as envisioned in Confucius’ Analects.
One proposal involves mandating the use of digital technology. Given the rate of digital technology adoption in China2 (Statista, n.d.), a law requiring that new homes be fitted with enough digital technology to allow all residents to contact their children on a regular basis would be one way forward. While HNWIs may already be able to furnish their parents with digital technology3, such a policy would be all the more relevant and necessary for homes catering to the less wealthy, many of whom may not even own a smartphone, computer, or tablet(Xinhua, 2015). The provisions of the law could, for example, require that each room be fitted with a basic smartphone and internet access and require training on the use of applications such as WeChat.
Another way is to encourage the children of residents to participate in structured activities such as cooking meals, going for walks, or taking a community class with their parents on a regular basis. This would of course be dependent upon whether the child lives in close geographic proximity to the home where their parents are residing. But insofar as they do, making it a requirement for admittance into the home would be consistent with the ethic of filial piety, and would give children an opportunity to serve their parents. For children residing far away from their parents, requiring at minimum a weekly WeChat video call – or some such equivalent – would help assuage the fear of parents like Huang that their children are abandoning them.
China is going through a transition, not only sociologically, but also in terms of how its historical values and traditions are to be understood and applied in the modern age. Filial piety is one of many such traditions in transition. How can we be sure that China’s elderly receive the care and services they so deserve? As Huang Liangbao said:
“I want to fade away with dignity.” (Fan, 2017)
1 Cross-generational housing is when family members from multiple generations live within a single housing property over the course of their lives.
2 56% of the Chinese population owned smartphones in 2017. That percentage is predicted to rise to 63.3% by 2019, without any signs of stopping
3 For example, Gao Lanzhi has two smartphones and an iPad.
Mark Pufpaff, Project Director, Case Study Research, Rothlin Ltd.
REFERENCES
Fan, Y. (2017, December 02). Shanghai’s Elderly Elite Flock to Luxury Nursing Homes. Retrieved from http://www.sixthtone.com/news/1001284/shanghais-elderly-elite-flock-to-luxury- nursing-homes
Flora, L. (2016, August 18). China’s Rich Opt for Luxury Nursing Homes Over Filial Obligations. Retrieved from https://jingdaily.com/chinas-rich-opt-for-luxury-nursing-homes-over-filial- obligations-for-aging-parents/
Green, D. (2014, July 31). Elderly care: Coping with the 4:2:1 problem. Retrieved from http:// chinaoutlook.com/elderly-care-coping-with-the-421-problem/
Griffiths, J. (2014, July 16). Here’s why so many elderly Chinese are collecting trash. Retrieved from https://www.pri.org/stories/2014-07-16/here-s-why-so-many-elderly-chinese-are-collecting- trash
Nelson, C. (2012, April 1). Senior Care in China: Challenges and Opportunities. Retrieved from https://www.chinabusinessreview.com/senior-care-in-china-challenges-and-opportunities/
Statista. (n.d.). China smartphone user penetration rate 2013-2019 | Statistic. Retrieved January 26, 2018, from https://www.statista.com/statistics/257045/smartphone-user-penetration-in-china/
Teon, A. (2018, February 04). Filial Piety (孝) in Chinese Culture. Retrieved from https://china- journal.org/2016/03/14/filial-piety-in-chinese-culture/
World Bank. (2018). Life expectancy at birth, total (years). Retrieved from https://data.worldbank. org/indicator/SP.DYN.LE00.IN?end=2016&locations=AF-CN&start=1970
Xinhua. (2015, October 8). More elderly Chinese choose to live in nursing homes. Retrieved from http://www.chinadaily.com.cn/china/2015-10/08/content_22130227.htm
Click here to view the PDF version