Facing Death: The Death Care Role of Classical Confucian Ethics for Living

Abstract

As demographic shifts toward aging populations intensify globally, death-related care emerges as a critical frontier in contemporary healthcare systems. This paper examines the potential for combining classical Confucian ethics for living with modern death care practices, thereby establishing a paradigm of palliative care based on Confucian ethics. Through synthesizing classical Confucian ethics for living with palliative care, this paper establishes four foundational pillars: First, applying Confucian life philosophy to alleviate anxiety surrounding death. Second, transforming Confucian death rituals into a structured palliative care plan. Third, establishing Confucian humaneness as the ethical core of palliative caregivers. Fourth, eliminating the obstacles posed by traditional filial piety to palliative care at the theoretical and practical levels. The findings affirm both the practical viability and cultural imperative of embedding classical Confucian ethics for living into death care systems, offering novel contributions to cross-cultural dialogs on Confucian ethics and palliative care.

1. Introduction

Palliative care constitutes an integrative healthcare approach that synthesizes knowledge from religion, philosophy, ethics, psychology, and medicine. This specialized death care model provides physical, emotional, and spiritual support for individuals confronting terminal illness when curative treatments prove ineffective. Its primary objectives involve mitigating bodily discomfort and mental anguish while optimizing life quality during advanced disease progression. For those approaching life’s terminus, such death care facilitates a serene acceptance of mortality. They leave this world with dignity, free of pain (Lamba and Quest 2011, p. 282). This therapeutic paradigm allows the patients to live out the last days of their lives peacefully and reduces some of the burden for their families and caregivers.

The provision of palliative care must be culturally attuned to diverse religious and philosophical traditions. Although death constitutes a universal human experience, cultural contexts profoundly influence death-related attitudes and interpretations (Long 2011). Within East Asian societies, Confucianism is the most influential cultural tradition. This tradition has a rich discourse on life and death (Fu 1994; L. Guo 2008; R. Guo 2012). Moreover, Confucianism holds that death should be dignified (Chen 2012). Li (2011) mentioned that benefiting from Confucianism, many famous Confucian scholars in the Ming Dynasty (1368–1644 AD) were able to achieve exceptional equanimity during their final life stages. This phenomenon means that despite the controversy over whether or not Confucianism is a religion (Sun 2013; Z. Zhang 2015; Q. Wang 2020), the religiousness of Confucianism can provide palliative care for those who are affected by the Confucian cultural tradition. Kim (2022) reveals that among terminally ill patients in South Korea, a country deeply influenced by Confucianism, a significant proportion believe they should avoid excessive medical treatment to prevent burdening their families. This stems from the Confucian emphasis on family. The same perspective was reflected in a pilot study conducted in eastern Taiwan. The research reported that the vast majority of elderly individuals believed decisions regarding do-not-resuscitate (DNR) directives should be discussed with family members before signing (Lee et al. 2016). This means that older adults are reluctant to make decisions alone, lest their children feel guilty for not having done everything possible to treat their parents. At the same time, it demonstrates the necessity of avoiding overtreatment and implementing palliative care in societies influenced by Confucianism.

This paper argues that classical Confucian ethics for living can serve as a religious and philosophical foundation for palliative care. First, the Confucian life philosophy can alleviate death anxiety by emphasizing the finitude of life and the transcendence of moral practice. Second, the hierarchical responsibility, mourning rituals, and emphasis on bodily sanctity and last words within Confucian death rituals can offer cultural reference to establishing a Confucian palliative care plan. Third, the Confucian concept of humaneness (ren 仁) is positioned as the ethical core of palliative caregivers, providing concrete ethical guidance for palliative care practice. Finally, it is possible to eliminate the obstacles posed by traditional filial piety to palliative care, both theoretically and practically. These interconnected dimensions collectively reveal the practical viability and cultural imperative of embedding classical Confucian ethics for living into death care systems.

2. Applying Confucian Life Philosophy to Alleviate Anxiety Surrounding Death

Contemporary palliative care practice in China reveals widespread apprehension toward death among terminal patients and their families. This manifests, for instance, in relatives deliberately concealing clinical discussions from the patient. The patients’ families also instruct palliative social workers to avoid references to terminal illness or death during patient interactions (Liu and Feng 2023, p. 870). These behaviors originate in China’s profound sociocultural taboos regarding death discourse. Death-related topics are systematically avoided in daily life (Lee et al. 2016). There are nearly 500 euphemisms for death in Mandarin (Chi 2018, p. 66), all to avoid direct references to the word “death” (si 死) as much as possible. Collectively, the mention of death is perceived as an ill omen, and this has led to the dread and anxiety surrounding death in Chinese society.

Paradoxically, Confucianism, which has had the most profound influence on Chinese culture, manifests no inherent dread of death. This is actually because avoiding death in daily life and overcoming the fear of death at the end of life are not truly opposed. Guided by Confucianism, the avoidance of death in daily life aims to maximize the realization of one’s life value while alive. Fearlessness in the face of death is the natural psychological state that follows the discovery of life’s meaning. The avoidance of death and the fearless acceptance of death are distinct stages of life; the two are not mutually exclusive. Confucianism’s fearlessness in the face of death is reflected in its life philosophy.

Firstly, the Confucian life philosophy believes that individuals should focus on moral cultivation and societal contributions rather than worrying about death. Its founder, Confucius, asserted that the morally devoted individual would “despise the thought of ending their days without having established a name” (ji mo shi er ming bu cheng yan 疾沒世而名不稱焉) (Ames and Rosemont 1998, p. 188). Posthumous reputation, Confucianism maintains, hinges solely on lifetime moral and vocational accomplishments. The tradition recognizes three immortal legacies: supreme is “to establish virtue” (lide 立德), followed by “to establish achievements” (ligong 立功), and finally is “to establish words” (liyan 立言) (Durrant et al. 2016, p. 1125). “To establish virtue” means to be able to cultivate one’s good virtues and to become a model for future generations. “To establish achievements” requires solving real problems for society or the state. “To establish words” means leaving some wise sayings worth learning for future generations. If a person can do one of the three, it is enough to gain an immortal reputation. In the Confucian view, attaining an immortal reputation enables one’s spirit to live forever, sufficient to resolve death anxiety.

Secondly, the Confucian life philosophy acknowledges human death as an objective reality. Confucianism, Buddhism, and Taoism, which have profoundly influenced Chinese culture, have all explored the issue of life and death (Yu 2004; Song 2007; M. Zhang 2017). Yet their doctrinal divergence yields distinct views. Taoism asserts that people can achieve physical immortality in this world through cultivation (W. Guo 1994; Y. Wang 2019). However, this defies common sense. Without real-life success cases, this argument is hardly convincing. Therefore, Taoist theories have a limited role in the spiritual care of terminally ill patients. Buddhism considers death to be part of reincarnation (lunhui 輪迴). Death is not the end but a new beginning. A person can eventually be freed from the cycle of life and death through constant reincarnation and cultivation. However, Hui and Coleman (2012) found that Buddhists were not relieved of their death anxiety because death means that the cultivation of this life is a failure. Confucianism rejects both as implausible. Confucius said, “Death has been with us from ancient times” (zigu jieyou si 自古皆有死) (Ames and Rosemont 1998, p. 155). Regardless of wealth and status, no one can live forever. Therefore, people should accept their natural death. Natural death is when life comes to an end according to its natural course without medical intervention or life-prolonging technology. This type of death underscores the inherent inevitability and natural character of death itself. In Confucian ethics for living, natural death is a way of dying that conforms to “heaven” (tian 天) and “destiny” (ming 命) and reflects respect for the natural order of life. Death is a part of life, and people should face it with equanimity. Zixia 子夏, a disciple of Confucius, once said, “Life and death are a matter of one’s lot; wealth and honor lie with tian” (si sheng you ming, fu gui zai tian 死生有命，富貴在天) (Ames and Rosemont 1998, p. 154). This means that a person’s life, death, wealth, and poverty are all determined by “heaven” and “destiny.” Therefore, human beings should accept their finiteness and revere “heaven” and “destiny.” The reverence for “heaven” and “destiny” manifests religious feelings. In the face of death, people need this reverence to transcend the finiteness of life and find inner peace.

Thirdly, the Confucian life philosophy emphasizes transcending the boundaries of life and death through moral cultivation. From ancient times to the present, many scholars allege that Confucianism favors talking about life and seldom talks about death or that Confucianism is relatively unconcerned with the issue of death (Ven 2005, p. 9; Yih 2022, p. 7). But in the Analects (Lunyu 論語), the word “death” (si 死) appears 38 times, exceeding the word “life” (sheng 生), which is mentioned 22 times (Ven 2005, pp. 17–18). This quantitative disparity alone undermines claims of Confucian disinterest in death. Confucius’ disciple Jilu 季路 once inquired about “death,” Confucius responded, “Not yet understanding life, how could you understand death?” (wei zhi sheng, yan zhi si 未知生，焉知死) (Ames and Rosemont 1998, p. 144). This statement by Confucius is often understood simply as an evasion of the question of death. For example, Chen Qun 陳群, a scholar of the Cao Wei Dynasty (220–266 AD), commented on this sentence as follows: “It is difficult to understand death, and it is useless to talk about it, so Confucius did not answer it.” (sishi nanming, yu zhi wuyi, gu buda 死事難明，語之無益，故不答) (He and Xing 1999, p. 146). Xing Bing 邢昺, a Confucian scholar of the Northern Song Dynasty (960–1127 AD), also interpreted this sentence as “Confucius did not say anything that would not be beneficial” (kongzi budao wuyi zhi yu 孔子不道無益之語) (He and Xing 1999, p. 146). This is a misconception. It is not that Confucius considered death to be irrelevant. Confucius intended to teach people not to be troubled by matters of life and death (Chen 2012). What Confucius means by this statement is that if one cannot understand the significance and purpose of life, it is impossible to understand death. According to Confucianism, the purpose of life is to become a moral person. One should know why one lives and dies, and fulfill the value of life in moral cultivation. Confucianism regards various ethical norms as a whole and names this whole “morality.” It believes that the pursuit of morality is the core path to becoming a true human being. This emphasis on morality is fundamentally aimed at addressing the question of how humans can transcend finite existence and realize eternal value. Confucius said, “If at dawn you learn of and tread the way (dao 道), you can face death at dusk.” (zhao wen dao, xi si ke yi 朝聞道，夕死可矣) (Ames and Rosemont 1998, p. 91). The core of the “way” (dao 道) is morality, and the noblest morality is called “humaneness” (ren 仁) by Confucius. To achieve the state of “humaneness”, Confucius believed that people “might well give up their lives in order to achieve it” (sha shen yi cheng ren 殺身以成仁) (Ames and Rosemont 1998, p. 186). Du (2000) pointed out that this means “humaneness” is an ultimate value transcending life and death. Therefore, the Confucian moral cultivation requires “their way ends only in death” (si er hou yi 死而後已) (Ames and Rosemont 1998, p. 122). Moreover, Confucius once declared that “from fifty I realized the propensities of tian (tianming 天命)” (wushi er zhi tianming 五十而知天命) (Ames and Rosemont 1998, p. 77). The “propensities of tian” here does not refer to fatalism, but rather to the mission and moral responsibility bestowed upon humanity by heaven (tian 天). To practice morality within the bounds of finite life is to respond to the “propensities of tian.” On the other hand, the subsumption of morality under “heaven” also implies its eternal and transcendent nature. Recognizing this ethical tenet can provide spiritual care to terminally ill patients who adhere to Confucian morality. People who believe in Confucianism engage in moral practices throughout their lives. When they are faced with death, by understanding the eternity and transcendence of morality, they can realize the essence and meaning of life, thus alleviating their death-related anxiety and fear.

Mencius, a pivotal early Confucian figure, referred to the life of dying in pursuit of the “way” as achieving “proper destiny” (zhengming 正命) (Bloom 2009, p. 144). The “proper destiny” emphasizes properly ending one’s life following morality and the laws of nature. For example, when Confucius was gravely ill, he still insisted on following Confucian rites (li 禮), believing that not following Confucian rites in funerals was fooling heaven (qi tian 欺天) (Ames and Rosemont 1998, p. 129). Similarly, Zengzi 曾子, a disciple of Confucius, also emphasized on his deathbed that what he sought was “a death with the rites” (de zheng er bi 得正而斃) (Luo 2017, p. 25), asking his disciples to replace his bedding that did not conform to Confucian rites. These cases mean that for those who believe in Confucianism, death cannot change their adherence to morality. If a person morally lives his life, then when death comes, he will feel that it was worthwhile and his life is in a state of fulfillment. Within palliative contexts, the Confucian life philosophy thus offers spiritual comfort to terminally ill patients who believe in Confucianism and mitigates death-related dread and anxiety.

Finally, Confucianism can engage in cross-cultural dialog with Lars Tornstam’s gerotranscendence theory. Gerotranscendence theory posits that as individuals age, they gain more time for self-reflection, reshaping their understanding of life across cosmic, social, and personal dimensions, ultimately progressing toward a stage of maturity and wisdom. However, gerotranscendence does not occur automatically; its realization has been shown to be closely related to the depth of one’s religious faith (Jeong et al. 2020; Abreu et al. 2023). This forms the basis for dialog between Confucian moral religion and gerotranscendence theory. An empirical study on Chinese older adults demonstrates that those more deeply influenced by Confucianism achieve a higher degree of gerotranscendence (Wang et al. 2015). This is because such an ideal spiritual realm proposed by the gerotranscendence theory is similar to the spiritual realm described by Confucius, as “from seventy I could give my heart-and-mind free rein without overstepping the boundaries” (qishi er cong xin suo yu bu yu ju 七十而從心所欲不逾矩) (Ames and Rosemont 1998, p. 77). Both are pursuits of self-realization and an understanding of life’s essence, ultimately leading to the fulfillment of one’s life.

3. Transforming Confucian Death Rituals into a Structured Palliative Care Plan

Confucianism accords profound significance to rituals (liyi 禮儀). Zengzi 曾子, one of Confucius’s disciples, once said, “Be circumspect in funerary services and continue sacrifices to the distant ancestors, and the virtue (de 德) of the common people will thrive.” (shenzhong zhuiyuan, minde guihou yi 慎終追遠，民德歸厚矣) (Ames and Rosemont 1998, p. 73). This reflects the importance Confucianism attaches to funeral rituals and has led to the development of a unique system of ritualized death governance within the Confucian tradition. Zengzi’s emphasis on the importance of Confucian death rituals reflects a profound appreciation for the rituals’ dual function: honoring the deceased with reverence and providing emotional solace to the living. Simultaneously, this underscores that Confucian death rituals contain a wealth of cultural resources that can serve as a reference for establishing Confucian palliative care.

Confucianism serves as the philosophical foundation for collectivism in East Asian societies (Wang and Liu 2010). Confucianism recognizes that the value of the individual is expressed in group relations with the family, society, and the state. Consequently, individuals shaped by Confucian culture will be more dependent on the care and attention of others. Among the Confucian regulations on funeral rituals, the “five degrees of mourning” (wufu 五服) is an important principle. The term “five degrees of mourning” refers to five different types of mourning clothes, and the type of mourning worn by a relative to a funeral depends on the closeness of their blood relationship to the deceased. This constitutes the structure of the differential order of mourners in the Confucian funeral rituals. The sense of hierarchical responsibility within this differential order structure can provide a cultural reference for establishing a modern palliative care community. According to the closeness of the relationship with terminally ill patients, a palliative care staffing structure can be formed consisting of immediate family members, in-laws, friends, healthcare professionals, and community volunteers. As a result, a palliative care community has been established. The establishment of such a structured palliative care community serves a vital purpose: it delivers collective psychological solace to terminally ill patients deeply influenced by Confucian culture.

Regarding how to accompany the terminally ill, Confucian funeral rituals offer some references. Firstly, when accompanying the sick, Confucianism requires that “the stringed musical instruments should be removed” (qu qinse 去琴瑟) (Luo 2017, p. 224). This ensures that the patient is in a relatively quiet environment and emphasizes moderation in sensory entertainment. Focusing attention on the patient by removing recreational items ensures that relatives and friends are focused on the patient’s company. Secondly, Confucianism requires that “When one’s illness is serious, the house inside and outside should be swept and cleaned.” (jibing wai, nei jie sao 疾病，外內皆埽) (Luo 2017, p. 224). Decontamination of the physical space where the patient is located is achieved through whole-house cleaning so that the patient and their companion are in a relatively comfortable environment. This is beneficial for soothing the mood of the patient, their relatives, and friends. Thirdly, Confucianism has also laid down provisions on the sounds of mourning, the most important of which is the rituals of weeping. The wailing in Confucian funeral rites is not an unrestrained outpouring of grief, but rather a means for relatives and friends to express sorrow appropriately while maintaining the order of ritual propriety. (Guo and Shen 2024). Music therapy in modern palliative care can draw inspiration from this. In this therapy, music is not about entertainment but about enhancing the quality of life for the terminally ill. This does not conflict with the Confucian proposition of abstaining from sensual entertainment mentioned above. Empirical research indicates that music therapy can positively affect the mood of patients and their families (Hilliard 2005; Gallagher et al. 2017; Wu et al. 2025). Therefore, the structured weeping mourning within Confucian tradition might be adaptively transformed, under music therapy guidance, into participatory musical farewells during palliative care. Patients can plan their repertoire and perform with family and friends. This approach both upholds the Confucian tradition of measured mourning and alleviates anxiety for patients and their companions, thereby enhancing the quality of life for those at the end of life.

In palliative care, the care of the patient’s body is critical, which aligns with the Confucian concept of valuing the body. Confucianism believes that, based on filial piety (xiao 孝) to parents, everyone should not actively harm their bodies. At the time of death, people should also ensure that their bodies are intact (Jones and Nie 2018). Moreover, the deceased’s body should be washed and kept clean (Chen 2012). This emphasizes the sacredness of the individual body. This emphasis extends posthumously, as seen in funeral rituals prioritizing bodily dignity. For example, when a person has just died, someone “uses a spoon of horn to open his mouth, and a stool to fix the deceased feet” (xie chi yong jiaosi, chuo zu yong yanji 楔齒用角柶，綴足用燕几) (Luo 2017, p. 228). These two measures are designed to ensure the body’s proper posture and preserve the deceased’s dignity after death. Therefore, in Confucian palliative care, the emphasis on the body should be reflected in respect for the integrity and dignity of the dying person’s body. For example, caregivers must treat the patient’s body reverently in daily ministrations, prioritizing cleanliness, comfort, and the avoidance of undue pain or injury. In addition, valuing the body should provide ethical guidance for medical decision-making in palliative care. When confronted with medical decision-making for the terminally ill, this notion reminds us that medical decision-making must consider not only the technical possibilities of prolonging life but also the respect for the patient’s body and the preservation of life quality. For example, when deciding whether or not to engage in invasive treatments, the harm that the therapy will cause to the patient’s body needs to be weighed against the potential benefits to avoid over-treatment and consequent physical and psychological suffering.

Finally, the Confucian emphasis on the last words can also provide a cultural reference for palliative care. The last words are the final teaching and expression of the last wishes of a dying person to their family, friends, and disciples in the last stage of life. Through their last words, the dying person can impart moral knowledge and life wisdom to descendants, friends, and disciples, and arrange funeral rituals. Zengzi said, “felicitous (shan 善) are the words of a dying person” (ren zhi jiang si, qi yan ye shan 人之將死，其言也善) (Ames and Rosemont 1998, p. 121). In the Confucian view, everyone’s last words are felicitous. Therefore, the relatives and friends of the dying person should fully respect their wishes in the last stage of life. As the dying person approaches death, their companions should gather around the bed and listen to their final teachings and wishes. Such ritualized accompaniment embodies profound respect and compassion. Integrating the Confucian ritual of listening to last words into palliative care can be implemented as follows: With the assistance of the palliative care team, gather family members to listen to the patient’s recollections, expectations for loved ones, and arrangements for funeral matters. Simultaneously, guide family members to express gratitude and affection to the patient. This ritualized communication alleviates the dying person’s fear and anxiety about death while reducing the family’s sense of guilt after the patient’s passing.

In short, Confucian palliative care, evolved from Confucian death rituals, offers spiritual solace to the dying. Moreover, just as Confucian death rituals provide the living with an education about death (Chen 2012), Confucian palliative care inherits this function from the cultural tradition.

4. Establishing Confucian Humaneness as the Ethical Core of Palliative Caregivers

Within palliative care, healthcare professionals fulfill a fundamental role. They not only provide medical care but also pay attention to the psychological and social needs of the patients and help the terminally ill and their families face the end of life (Ling et al. 2023). These caregivers serve not merely as healers but also as essential companions and supporters throughout this journey.

Confucianism can provide ethical guidance for healthcare professionals. This is because the idea of “humaneness” (ren 仁) in Confucianism and humanistic care in medicine are similar. Confucius identified “humaneness” as the supreme moral virtue. “Humaneness” means to love and sympathize with others. Within medicine, this virtue manifests as the care and compassion that healthcare professionals provide to their patients. Thus, in East Asian cultures shaped by Confucianism, medicine is an art that embodies “humaneness” (Lee 2023). Healthcare professionals should cultivate the virtue of “humaneness” in their medical practice (Li and Wen 2010). Specifically in palliative care, this means that healthcare professionals should not see caring for the terminally ill as a simple task but rather as the practice of the virtue of “humaneness.” In modern palliative care services, this practice translates into compassionate care for every patient: For instance, using knowledge of death studies from Confucianism to patiently alleviate a patient’s fear of death, or mediating disagreements among family members regarding how to care for a terminally ill patient. These practices are rooted in “humaneness,” the highest moral standard of Confucianism—that is, empathy for the dying rather than mere pity. In the context of palliative care, “empathy” and “mere pity” exhibit an essential difference: “Empathy” is based on equality, achieved through active emotional immersion, striving to understand the complex inner experiences of the dying—their fear of death, their attachment to life—from their perspective. “Mere pity” represents a passive sentiment of regret toward the unfortunate circumstance of “end-of-life” from an observer’s perspective. It implies a condescending, unequal relationship, focusing on “the suffering itself” rather than the individual experiencing it. This emotion risks reducing the actions of palliative caregivers to mere formal consolation. The comparison highlights the ethical significance of integrating Confucian “humaneness” into palliative care.

Rooted in classical Confucian ethics for living, healthcare professionals should treat the sick like relatives. Mencius said, “Treating the elders in one’s own family as elders should be treated and extending this to the elders of other families” (lao wu lao, yiji ren zhi lao 老吾老，以及人之老) (Bloom 2009, p. 9). In the Confucian view, everyone would treat strangers like family members. On this basis, Sun Simiao 孫思邈, a physician of the Tang Dynasty (618–907 AD), believed that doctors should treat their patients “equally, all like family members” (pu tong yideng, jie ru zhiqin zhi xiang 普通一等，皆如至親之想) (Xu et al. 1998, p. 217). This principle remains vitally relevant, offering an essential ethic for modern healthcare professions, such as palliative care, and constituting a source of crucial emotional sustenance for individuals facing terminal illness.

Finally, in East Asian societies, which are influenced by Confucianism, it is also necessary to educate healthcare professionals in Confucianism. Medical education curricula across all institutions should facilitate a deeper professional comprehension of death and foster the development of an appropriate perspective on death. Concurrently, such education ought to sensitize students to the significant influence religious beliefs exert on societal understandings of death. Therefore, it is necessary to have an introductory course on reading Confucian classics, which will help medical students understand the core ideas of Confucianism. By studying Confucianism, medical students can better understand the connotation of the virtue of “humaneness” advocated by Confucianism and enhance their medical ethics. In addition, courses on the relationship between Confucianism and medical ethics can be set up. It is beneficial for students to apply Confucianism flexibly to doctor-patient communication and humanistic care throughout the medical process. Through this integrated approach, students can achieve a profound understanding of Confucianism alongside their medical specialization, consciously integrating Confucian ethics into their medical practice. To realize this educational objective, it is also necessary to strengthen the faculty resources, and it is essential to train a group of teachers who understand both Confucianism and medicine. Simultaneously, curriculum materials and teaching resources should be improved, and Confucian teaching materials suitable for medical colleges should be prepared. Collectively, these educational reforms provide a robust foundation for effectively practicing palliative care within the framework of Confucian cultural values.

5. Reconciling Filial Piety with Palliative Care: A Critical Reconstruction

The aging population is causing the traditional Confucian ethic of filial piety to face significant challenges in East Asian societies. This deeply ingrained ethos complicates acceptance of palliative care for many individuals shaped by Confucian culture. For example, if adult children do not try to prolong the life of their parents when they are gravely ill, it will be regarded as a violation of filial obligations. This traditional mindset further influences healthcare providers, compelling them to administer often futile interventions to terminal patients. This contradicts the purpose of palliative care, which is to improve patients’ quality of life. Therefore, it is essential to reconcile filial piety with palliative care.

The Confucian doctrine of “cardinal principle” and “situational flexibility” (jing quan 經權) offers a hermeneutic framework to address tensions between filial obligations and palliative care. In Confucianism, “cardinal principle” refers to the fundamental ethical and moral norms of Confucianism that cannot be changed, such as “filial piety,” which belongs to the “cardinal principle.” “Situational flexibility” emphasizes weighing specific circumstances to adapt to current needs, allowing for flexibility within the framework of the “cardinal principle” with the ultimate goal of better realizing the “cardinal principle.” This is the dialectical thinking in Confucianism. In palliative care settings, this dialectic justifies prioritizing patients’ quality of life over strict adherence to rigid ethical dogma. Under the guidance of the concept of “situational flexibility,” filial piety should not merely manifest itself as blindly providing useless medical treatment to one’s parents. Working with hospice caregivers to improve the quality of life for parents at the end of life should be seen as an expression of filial piety. This is a feasible explanation for eliminating the obstacles to palliative care posed by traditional Confucian filial piety ethics from within Confucianism itself.

In practice, family meetings can be used to break down Confucian culture’s prejudice against palliative care. The family meeting model is a decision-making mechanism that uses the family as the decision-making unit and, under the guidance of a neutral third party, achieves equal communication and consensus among family members. In China’s palliative care practice, family meetings have been widely implemented, and a set of professional institutional norms has been established (Palliative Care Committee of Chinese Nursing Association 2023). Its core function is to integrate family opinions, resolve cognitive conflicts, and form collective decisions, adapting to the collectivist decision-making logic of Confucian society. The resistance to palliative care in Confucian societies mainly stems from cognitive biases, equating palliative care with the unfilial act of abandoning treatment. Family meetings can reshape perceptions. By incorporating the Confucian concept of “cardinal principle” and “situational flexibility”, this bias can be corrected, establishing a new understanding that accepting palliative care is equivalent to achieving a good death, which is equivalent to fulfilling one’s filial duty. In addition to family members, a neutral third-party facilitator is also necessary. They must possess two key abilities: expertise in palliative care and a deep understanding of Confucian culture. This also echoes the aforementioned proposal to train healthcare professionals who have both medical expertise and knowledge of Confucianism.

In summary, by reinterpreting filial piety within Confucianism and breaking down the Confucian cultural bias against palliative care in practical terms, it is expected that the current low frequency of palliative care service utilization in East Asian societies will change.

6. Conclusions

Confucianism can provide a unique religious and ideological resource and practical framework for modern palliative care. First, by emphasizing moral practice and spiritual immortality, the Confucian life philosophy can help terminally ill patients alleviate anxiety surrounding death. At the same time, the function of Confucian life philosophy in alleviating death anxiety can also engage in cross-cultural dialog with Lars Tornstam’s gerotranscendence theory. Second, some concepts in Confucian death rituals can also offer cultural references to the establishment of a structured palliative care plan. This includes several aspects: specific provisions for accompanying the terminally ill, the cultural reference to community support in palliative care provided by the structure of the differential order of Confucian funeral rituals, the cultural reference to the protection of the dignity of the dying provided by the Confucian notion of the sanctity of the body, and the Confucian emphasis on the last words, reflecting the respect and care for the gravely ill. Third, classical Confucian ethics for living require healthcare professionals to treat the dying with the virtue of “humaneness” and elevate their professional ethics to the level of moral practice. At the same time, it is necessary to include Confucianist courses in medical education, which can cultivate healthcare professionals with both a humanistic spirit and professional skills. Finally, through the Confucian theory of “cardinal principle” and “situational flexibility”, and the family meeting system in palliative care, the obstacles posed by traditional filial piety to palliative care can be eliminated at both the theoretical and practical levels.