Family members' informed consent to medical treatment for competent patients in China.
Article Type: Report
Subject: Informed consent (Medical law) (Laws, regulations and rules)
Informed consent (Medical law) (Management)
Medical ethics (Social aspects)
Physician and patient (Management)
Domestic relations (Management)
Author: Ding, Chunyan
Pub Date: 03/01/2010
Publication: Name: China: An International Journal Publisher: East Asian Institute, National University of Singapore Audience: Academic Format: Magazine/Journal Subject: Social sciences Copyright: COPYRIGHT 2010 East Asian Institute, National University of Singapore ISSN: 0219-7472
Issue: Date: March, 2010 Source Volume: 8 Source Issue: 1
Topic: Event Code: 930 Government regulation; 940 Government regulation (cont); 980 Legal issues & crime; 200 Management dynamics; 290 Public affairs Advertising Code: 94 Legal/Government Regulation Computer Subject: Government regulation; Company business management
Geographic: Geographic Scope: China Geographic Code: 9CHIN China
Accession Number: 226162642
Full Text: Introduction

Informed consent to medical treatment is premised upon the ethical principle of personal autonomy. (1) Although the notion of informed consent originated from Western liberal culture, it has gradually become a popular doctrine adopted by many countries of the world, and China is no exception. (2) Chinese law not only established the rule of consent to medical treatment as early as 1982, but has also widely incorporated the rule of informed consent since the new century. (3) However, as the notion of informed consent was imported from the West into China, three questions are worthy of consideration. First, is there any difference between the Chinese rules of informed consent to medical treatment and its dominant theory accepted in Western society? Second, what is the rationale for the difference? Third, can the difference be justified given the value of informed consent in promoting patient autonomy?

According to the prevailing theory and practice of informed consent in Western jurisdictions, a competent patient has an absolute right to make his own medical decisions and his family members have no right to interfere. However, the most prominent difference between Chinese laws of informed consent and Western ones is that although a patient is fully competent to make medical decisions, his family members have the right to make medical decisions on his behalf under Chinese law. It is even widely agreed in practice that family members' informed consent to medical treatment on behalf of a competent patient is more important than the patient's own. (4)

This article opens with a review of the development of the Chinese regulations relevant to the family members' consent since the early 1980s. The next sections briefly describe the current practice regarding family members' consent and analyse the three main arguments of the proponents for the requirement of family members' consent. Part Four explores the real reasons underlying such a requirement and Part Five discusses its negative impact on patient rights. The conclusion provides a proposal for abandoning the requirement of family members' informed consent to medical treatment for competent patients, thus promoting full patient autonomy.

Regulations Regarding Family Members' Consent

The first piece of the national enactments pertinent to consent to medical treatment is Yiyuan gongzuo zhidu (the Working System of Hospitals) made by the Ministry of Health in 1982. (5) According to Rule 6 of the collateral rules titled Shixing shoushu de jixiang guize (the Rules of Performing Operation) set forth in Section 40 of the Working System of Hospitals, written consent with the signature of a family member or danwei (6) (work unit) of the patient, either competent or incompetent, is a prerequisite for surgery.

12 years later, the State Council promulgated Yiliao jigou guanli tiaoli (Regulations on Administration of Health Care Institutions) in 1994. Its Section 33 introduces the rule of "dual consent", namely, both the patient and his family member (7) or Guanxiren (the Related Party) (8) shall grant written consent with signature prior to medical intervention. When it is impossible to obtain the patient's decision, his family member or the related party's written consent with signature will be sufficient.

In 1998, the Standing Committee of National People's Congress released Zhiyeyishi fa (the Practising Physicians Law), introducing the rule of "optional consent" under Section 26. It provides that physicians shall honestly disclose to a patient or his family member all the information about the disease unless the disclosure may have a negative influence upon the patient's health. In addition, experimental clinical treatment shall be performed only with the approval of the hospital and the consent of patients or their family members. It is worth noting that the Practicing Physicians Law expressly applies the requirement of optional consent to experimental clinical treatment, and keeps silent about whether this requirement is also applicable to non-experimental medical treatment.

Pursuant to the rules of informed consent to medical treatment prevailing in Western jurisdictions, every adult of a sound mind has an absolute right to determine what shall be done with his own body. (9) In contrast, current Chinese law provides that consent of a competent patient and/or a family member shall be obtained prior to medical treatment.

Practice Regarding Family Members' Consent

As described previously, both the competent patient and his family members are entitled to exercise the right to informed consent and dual consent to medical treatment. However, it is common practice for doctors to discuss the condition of the patient with family members instead of the patients themselves, especially when the patient has a serious illness or needs hospitalisation or a major operation. (10) Whether, when, and how much information should be conveyed to the patient virtually depends on the discretion of family members. In the opinion of most doctors, consent of the family members of a competent patient seems more important. (11) A large number of doctors even insist that competent patients' decisions may be overruled by the decisions of their family members in the case of conflict. (12)

In other words, though the current law literally confers the equal right to informed consent upon competent patients and family members, in reality the consent of family members plays a more substantial role in medical decisionmaking. For example, Hunan Province conducted a survey recently, where 225 people, all between 18 and 60 years old and fully competent (both the patients receiving the operation or their family members) were randomly selected. The survey showed that 43 per cent of informed consent forms were signed by family members of competent patients, 32 per cent were signed by both of them and only 25 per cent were signed by the patients themselves. (13)

Arguments for Family Members' Consent

Three main arguments are frequently advanced to support the necessity of family members' consent as well as the opinion that the consent of family members is more significant than that of the patient. The most common argument comes from traditional Confucianism, which puts emphasis on the family rather than the individual. Doctors practising traditional Chinese medicine (TCM) used to keep information about diagnoses and treatment from the patient for the purpose of paternalistic protection. (14) This argument may be questioned from two aspects. First, what TCM doctors actually did in ancient times is unclear and controversial. For example, two scholars, Nie Jingbao and Zhao Ming'ie, have pointed out that the so-called customary practice of preventing the patient from knowing his health conditions in TCM was actually a misunderstanding, because historical records show that some famous doctors in ancient China, such as Bianque and Huatuo, did honestly inform their patients of their health conditions, even in the event of an incurable disease. (15) Second, even though we have gained a better understanding of China's ancient culture, contemporary Chinese society has become very different due to dramatic social, economic and cultural revolutions since the late 19th century. It thus seems inappropriate to blindly resort to China's ancient culture to explain a phenomenon existing in current society. For instance, typical Western notions of personal autonomy, individualism, and human rights no longer sound unacceptable to Chinese citizens nowadays. Hence, whether and to what extent traditional Confucianism and the notion of Jiabenwei (family orientation) result in the requirement of family members' consent concerning the medical treatment of competent patients deserves careful consideration. We should, at the very least, not take it for granted.

The second argument that opponents raise is that disclosure of information about health conditions to the patient does no good to the progress and outcome of the proposed medical treatment, especially when the patient has an incurable disease. (16) Though such an assertion may be true for those patients in a considerably vulnerable mental state, it is not a sufficient reason to deprive all competent patients of the right to know as well as the right to informed consent. To avail the competent patient of relevant health information does not necessarily result in a negative influence upon the effect of medical treatment. On the contrary, empirical research has shown that disclosure of necessary information is likely to benefit patients who are seriously ill. (17) Just as therapeutic privilege under common law jurisdictions is only an exception to physicians' duty of disclosure, the question of whether disclosure will do harm to a particular patient should be decided on a case-by-case basis. Therefore, the second argument is not strong enough to warrant the general replacement of consent of competent patients with that of their family members.

The third opposing argument is that a large number of elderly or uneducated patients, though competent, lack the ability to correctly understand what doctors are saying, let alone make a medical decision. Thus, the efficient alternative is to let their educated family members make decisions on their behalf. It is true that some information disclosed by doctors is very difficult and may be too technical to be understood by patients. But this phenomenon exists in every jurisdiction. Doctors should resolve this problem through providing the patient with careful explanation in a proper manner, rather than arbitrarily refusing to disclose the information to the patient at all. Therefore, it is unreasonable to conclude that consent of competent patients should be superseded by that of family members simply because they have difficulty in understanding the information.

Underlying Rationale for Family Members' Consent

There are actually two social factors that might more clearly explain why hospitals and doctors pay so much attention to consent of family members in practice: one is health insurance and the other is medical malpractice liability.

It is interesting to notice that the 1982 Working System of Hospitals required written consent with the signature of a family member or danwei of the patient before performing surgery. The patient's consent seemed irrelevant. This provision can be understood by taking into consideration the health insurance system prevalent at that time, i.e., Laobao zhidu (Labour Insurance Scheme, "LIS") and Gongfeiyiliao zhidu (Government-funded Medical Insurance Scheme, "GIS"). State-owned enterprises and collectively owned enterprises, namely danwei, were required to join LIS. The LIS fund was provided by the enterprises. It provided employees, no matter employed or retired, with a full coverage of medical expenses including fees for diagnosis, treatment, surgery, hospitalisation, drugs, etc. Additionally, the dependants of employees received the same benefits from LIS except that they needed to co-pay half of the fees for surgery and routine drugs, and full fees for hospitalisation and costly drugs. (18) In the meantime, GIS was applicable to civil servants and quasi-civil servants such as staff of the Communist Youth League. The GIS fund came from the annual budget of the government qua danwei. In that circumstance, consent of the patient's danwei was of great importance to healthcare providers because it worked as an implied warranty to pay all or most medical expenses. By the same token, consent of family members of patients played a similarly important function when the patient did not enjoy benefits from either LIS or GIS because it was strong evidence for hospitals to claim medical expenses against the family of the patient.

The Chinese modern reform of health insurance system began in 1988, aimed at establishing a new chengzhen zhigong jiben yiliao baoxian zhidu (Urban Employees Basic Medical Insurance System, "UEBMIS") to substitute for the previous LIS and GIS. Under UEBMIS, both employers and employees are required to pay premiums to the citywide UEBMIS fund. However, UEBMIS has two major problems: first, too many people are not covered by the system; and second, even those who are covered find that the coverage is often inadequate. Regarding the first problem, since UEBMIS is an employment-based system, it excludes unemployed urban residents, whether retired or laid off, as well as the elderly in general, college and university students, and minors who are not dependants of someone covered. According to the third national survey of healthcare services launched by the Ministry of Health in 2003, only 30.2 per cent of urban residents were covered under UEBMIS, (19) while 8.6 per cent retained the benefits of LIS and GIS, (20) and 5.6 per cent had purchased private medical insurance; the remaining 55.6 per cent of urban residents had no medical insurance coverage and had to pay all medical expenses themselves. With respect to the elderly, healthcare expenses for senior citizens are about 2.5 times the average spending per person, and it is estimated that 80 per cent of the lifetime gross healthcare expenditures come after age 60. (21) By 2002, 73 per cent of elderly urban residents were self-insured, which indicates that they and their families must cope with a substantial financial burden in terms of healthcare costs. (22)

The second major problem with UEBMIS relates to limited coverage and high personal expenditures still required of those covered by UEBMIS. Under UEBMIS, the municipal government determines the deductible threshold as well as the maximum amount of reimbursement. The former is normally 10 per cent of the local average annual salary, (23) while the latter is about four times the local average annual salary. In other words, the participants have to pay both the deductible and all expenses that exceed the maximum reimbursable amount. Also, the participants are still required to co-pay a certain portion of the expenses between the deductible and the maximum, which is also determined by the municipal social security authorities. Given the deductible, co-payment and extra payment exceeding the maximum, UEBMIS-insured individuals still need to rely on out-of-pocket expenditures, especially in the case of catastrophic illnesses. In addition, UEBMIS restricts the scope of covered diagnoses, treatments, and prescription drugs. Patients must themselves pay for uncovered services and drugs.

On the other hand, rural residents encounter much heavier financial burdens due to the collapse of hezuoyiliao zhidu (Cooperative Medical Scheme) prevalent in Mao's time. According to the third national survey of healthcare services in 2003, 79.1 per cent of rural residents had no medical insurance coverage of any kind. Despite the expanding coverage of the New Rural Cooperative Medical System ("NRCMS") from 2003, most rural residents still have to rely on their families for financial support when they access healthcare. Pursuant to the fourth national survey of healthcare service in 2008, among rural residents covered by NRCMS, 65.5 per cent of them have had to pay all outpatient expenses by themselves, and only 34.6 per cent of inpatient expenses have been reimbursed by the NRCMS fund. (24)

As a consequence of the large number of residents uninsured and underinsured in China today, the patients' families are the actual payers in most cases. Thus, the consent of family members, no matter competent or not, becomes very significant because it acts as an implied warranty of payment for medical expenses. In other words, family members' consent indicates a contractual relationship of healthcare service between the hospital and the family.

Besides acting as an implied warranty for medical expenses, the consent of family members is also regarded by healthcare providers as a weapon against the potential risk of medical malpractice. When a competent patient dies from or becomes incompetent because of a non-negligent accident, the family of the patient is likely to challenge the validity of consent made by the patient and claim liability for medical malpractice. (25) Once family members of patients have given written consent to the proposed treatment, healthcare providers have preponderant evidence and are more confident to defend against medical malpractice claims.

In short, family members' consent is obtained to secure payment of medical expenses and reduce the risk of medical malpractice liability against healthcare providers. Patient autonomy seems irrelevant for this requirement. What is worse is that it serves the above two purposes at the cost of patients' right to access healthcare, autonomy, and the right to privacy.

Negative Impacts of Family Members' Consent upon Patient Rights

The requirement of family members' consent may easily violate patients' basic civil rights as afforded by Chinese law. First of all, when family members of competent patients refuse to consent to the proposed medical treatment, doctors often give up and leave the patient untreated. Obviously, patients' right to healthcare and health will be prejudiced against. For example, in the case of a pregnant woman suffering prolonged labour during childbirth, which could lead to intrauterine asphyxia of the foetus, the doctor suggested performing a caesarean operation immediately. The husband and mother-in-law, however, insisted on postponing the operation because the lucky birth date they had chosen for the baby fell on the following day. More often, family members of patients may decide not to proceed with medical treatment because of the financial burden upon the whole family.

Second, even when family members do have the patients' best interests at heart, their decisions may not be the best choices in the opinion of the competent patients due to different personal values or religious notions. Thus, patient autonomy may be compromised in that situation. For instance, a female model had breast cancer and her doctors provided two options for treatment: either removing the galactophore tumour or a mastectomy. The husband opted for mastectomy because there would be less risk of transfer of cancer cells and a higher five-year survival rate. However, it was proven that the husband's decision was against the will of the patient, who had been kept uninformed before the operation.

Third, when consent of family members is required to perform medical treatment, the family members will inevitably find out the full details of the patient's health conditions and medical history. Thus, the privacy of competence is likely to be infringed, for example, in cases of sex-related diseases, pregnancy before marriage, or some genetically linked disease.

Conclusion

Based on the analysis above, this article proposes that family members' consent for competent patients be abandoned by Chinese law. On the one hand, this requirement does not result from cultural factors, such as medical paternalism and family orientation, which are neither critical nor unchangeable in contemporary China. It also does not promote patient autonomy. Indeed, the requirement of family members' consent actually serves as a tool to secure payment of medical expenses and to mitigate the risk of medical malpractice liability, which could be better resolved through less costly alternatives such as expanding the coverage of medical insurance and improving the medical records of informed consent made by patients. In addition, this requirement is highly likely to violate patients' basic right to health, body integrity, and privacy, all of which are recognised by Minfa tongze (the General Principles of Civil Law) as China's civil code.

It is not difficult for authorities to abandon the rule of family members' consent for competent patients. Pursuant to Section 79(1) of Lifa fa (the Legislation Law), the General Principles of Civil Law made by the National People's Congress recognise citizens' rights to body integrity, health and privacy. Therefore, the dual consent rule required by the State Council's Regulations on Administration of Health Care Institutions virtually conflicts with the General Principles of Civil Law which has more enforcement power within the legal hierarchy. In this sense, family members' consent for competent patients could and should be abandoned under current Chinese law. However, the role of the family may remain significant in medical decision-making as long as patients are willing to share personal medical information with their families or agree to authorise the latter to give consent by proxy. Ultimately, competent patients should have the final say on their own health matters.

(1) Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics (New York: Oxford University Press, 2001), p. 114.

(2) Qiu Renzong, "Yixue lunlixue (si) (fudao cailiao) (The Fourth Part of Teaching Materials on Medical Ethics)", Zhonghua huli zazhi (Chinese Journal of Nursing) 4 (1988): 115.

(3) Such as Section 14 of Renlei fuzhu shengzhi guanli banfa (Measures for Administration of Human-Assisted Reproductive Technology) made in 2001, Section 19 of Renti qiguan yizhi tiaoli (Regulations on Human Organ Transplant) made in 2007.

(4) For the sake of convenience, "family members' informed consent on behalf of a competent patient" is shortened here to "family members' consent".

(5) In the Chinese legal system, Falu (Law) is made by the National People's Congress and its Standing Committee; Xingzheng fagui (Administrative Regulations) are made by the State Council; Bumen guizheng (Departmental Rules) are made by various departments of the State Council; Sifa jieshi (Judicial Interpretations) are made by the Supreme People's Court. They are all within the scope of the national enactments, which generally govern informed consent to medical treatment.

(6) Danwei (work unit) refers to one's place of official employment and social registration in urban settings under the Chinese planned economy. Danwei was responsible not only for employment but for a range of essential social services including housing, healthcare, childcare, marriage and family planning for its members. It also implemented and enforced various policies of the state and the Communist Party. Before 1980, the influence of danwei over the lives of employees was pervasive and controlling. For example, workers received healthcare coverage from danwei, but one needed danwei's permission to see a doctor. The role of danwei in Chinese society has decreased significantly with the deepening of China's economic reforms since the 1980s. Increasingly, employers, including state-owned enterprises, are retreating from the heavy responsibility of providing basic social needs to their employees, such as housing and healthcare coverage.

(7) Nevertheless, the current law has not given a definition of "the family member". It remains ambiguous whether this term can be understood as "next of kin", which is defined as "spouse, parents, children, brothers and sisters, grandparents and grandchildren" according to Section 12 of Zuigaoren-minfayuan guanyu guanche zhixing minfa tongze ruogan wenti de yijian (shixing) (Opinions of the Supreme People's Court on Problems in Implementing General Principles of Civil Law [for Trial Implementation]).

(8) The Regulations on Administration of Health Care Institutions do not give any interpretation of the term "the related party". But it may be understood as "other legal representative" in the light of the principle of legal representative set forth in Sections 14, 16 and 17 of Minfa tongze (the General Principles of Civil Law). The term "family member" is used here to cover both the family member and related party of a patient below.

(9) Schloendorff v. the Society of the New York Hospital, 105 N.E. 92 (N.Y. 1914).

(10) In reality, the competent patient's own consent may be sufficient in the case of minor medical intervention, such as dental extractions. But consent of the family member is required by healthcare providers when a competent patient either has a serious illness or needs major surgery.

(11) Zhang Yingtao and Sun Fuchuan, "Lun zhiqingtongyi de zhongguo bentuhua: Zhongguo wenhua shiye zhong de zhiqingtongyi zouxiang" (Study on Localisation of Informed Consent in China: Trend of Informed Consent in Chinese Culture), Yixue yu zhexue (Medicine and Philosophy) 25, no. 9 (2004): 13.

(12) Gao Yongping, Wang Lianhua and Yang Xuan, "Zhiqingtongyi zai linchuang shijian zhong de wenti yu duice" (Problems and Countermeasures of Informed Consent in Clinical Practice), Hebei zhigong yixueyuan xuebao (Journal of Hebei Medical College for Continuing Education) 21, no. 3 (2004): 66. Family members' signing of the informed consent form for the competent is very common, especially in the case of serious diseases. See Song Qinfen, "Yindao fenmian zhiqingtongyishu zai chanfang de yingyong ji diaocha fenxi" (Application and Investigation of Informed Consent Forms Regarding Vaginal Delivery in the Delivery Room), Zhongguo jiceng yiyao (Chinese Journal of Primary Medicine and Pharmacy) 2 (2006): 335; Wang Qing, "Guanyu bingren zhiqingtongyi de diaocha yu fenxi" (Investigation and Analysis of Patients' Informed Consent), Zhongguo gonggong weisheng (China Public Health) 1 (2003): 64. Interestingly, an investigation showed that only 21.5 per cent of the respondent patients knew that they had a right to give consent in healthcare. See Yang Jian, Liu Yin and Song Wenzhi, "Huanzhe zhiqingtongyiquan de zhishi yu taidu diaocha" (Investigation of the Patients' Knowledge and Attitude Towards Informed Consent), Zhongguo weisheng fazhi (China Health Law) 6 (2007): 24.

(13) Su Yinli, "Huanzhe zhiqingtongyiquan luoshi xianzhuang diaocha fenxi" (Investigation and Analysis in the Practice of Patients' Right to Informed Consent), Zhongguo yiyuan guanli (Chinese Hospital Management) 9 (2008): 26.

(14) David Cummisky, "Confucian Ethics: Responsibilities, Rights and Relationships", Eubios Journal of Asian and International Bioethics 16, no. 1 (2006): 19.

(15) Nie Jingbao and Zhao Ming'ie, "Zhiqingtongyi zai zhongguo bu shiyong ma: Wenhua chayilun de renzhi cuowu" (Is Informed Consent Not Applicable to China? Intellectual Flaws of the Cultural Difference Argument), Yixue yu zhexue (Medicine and Philosophy) 23, no. 6 (2002): 20.

(16) Wang Yunling, "Zhiqingtongyi: Huanzhe de quanli yu kunjing" (Informed Consent: Patients' Right and the Dilemma), Yixue yu zhexue (Medicine and Philosophy) 3 (2001): 2. In a 2007 survey, 99.5 per cent of the respondent patients with malignant diseases did not exercise the right to informed consent; 71 per cent of patients having benign diseases did not attend the pre-operation conversation with their doctors and 80 per cent did not give consent before operation. See Yang Xinfang, Liu Li, Chen Xiaolin, Lu Xiaoyan, Wei Yuhong and Li Liping, "Dui shoushu bingren zhiqingtongyiquan de diaocha fenxi" (Survey and Analysis on Informed Consent of Patients Receiving Surgery), Hull yanjiu (Nursing Research) 34 (2007): 3146.

(17) Fang Weiqing, Lin Renyu and Li Zhiyuan, "Houai huanzhe zhiqingtongyi hou qingxu zhangai yu yingdui fangshi de chubu yanjiu" (Primary Study on Dysthymic Disorder of Laryngocarcinoma Patients After Giving Informed Consent and the Countermeasures), Zhejiang linchuang yixue (Zhejiang Clinical Medical) 7, no. 4 (2005): 338; Cao Xinmei, Bi Cuiyun, Lu Zhongxia, Lu Ping, Zheng Huifang and Zhu Xueqin, "Yunyong zhiqingtongyi ganyu gaishan jingshenfenliezheng kangfuqi huanzhe de zhiliao yicongxing" (Employing Informed Consent to Improve Therapeutic Compliance of Rehabilitated Schizophrenics), Shanghai jingshen yixue (Shanghai Archives of Psychiatry) 16, no. 4 (2004): 237; Huang Zuo, Zhao Jun and Wu Zonggui, "Zhiqingtongyi qianzi dui guanzhuang dongmai zaoying huanzhe jiaolu qingxu de yingxiang" (Influence of Written Informed Consent upon Anxiety of the Coronary Arteriongraphy Patients), Zhonghua xinxueguanbing zazhi (Chinese Journal of Cardiology) 29, no. 3 (2001): 152.

(18) See Laodong baoxian tiaoli (Regulations on Labour Insurance) made in 1951 and Guanyu gaijin zhigong laobao yiliao zhidu jige wenti de tongzhi" (Notice on Problems Regarding Improvement of the Labour Insurance Health Care Scheme for Employees of Enterprises) made in 1966.

(19) That figure has increased to 44.2 per cent according to the fourth national survey of healthcare services conducted by the Ministry of Health in 2008. See Information Office of the Ministry of Health, "Ministry of Health Publishes Main Results of the Fourth National Survey of Health Care Service" at [29 Nov. 2009].

(20) Despite UEBMIS, LIS and GIS still exist in a limited scope, covering various groups such as Laohongjun (old Red Army veterans), Laoganbu (retired Communist Party cadres), senior civil servants, and employees in some special industries such as munitions factories.

(21) The medical costs for retired elderly people covered by the Xiamen URBMIS accounted for 49.7 per cent of total healthcare costs in 2001, and increased to 51.8 per cent in 2002: see He Jianfeng, "Xiamenshi chengzhen zhigong jiben yiliao baoxian jijin yunzuo qingkuang de sikao" (Thoughts on the Operation of Xiamen URBMIS Fund), Weisheng jingji yanjiu (Health Economics Research) 5 (2005): 17.

(22) "Laonianren he ruoshi qunti" (The Elderly and Vulnerable Groups), Beijing ribao (Beijing Daily), 10 Apr. 2002.

(23) The average annual wage of urban employees was RMB 13,785.8 for the year 2007, while the average annual urban living expenditures for the same year was RMB 9,997.5 (from China Data Online Database).

(24) See note 19.

(25) See note 12, Yang Jian, Liu Yin and Song Wenzhi, "Huanzhe zhiqingtongyiquan de zhishi yu taidu diaocha", p. 24.

Ding Chunyan (carrie_ding@yahoo.com) is a PhD candidate in the Law Faculty at the University of Hong Kong. Her main research interests include health law and tort law.
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