Reconstructing the boundary of family involvement in shared decision-making: a confucian benevolence model for the Chinese context

BACKGROUND: Shared decision-making (SDM) in mainland Chinese clinical contexts is characterized by a persistent ethical tension between Confucian familism, which prioritizes collective family interests, and the Western principle of patient autonomy, which emphasizes individual rights. This tension has led to widespread clinical challenges, including family-driven protective information concealment and ambiguous boundaries between supportive and intrusive family involvement. Current literature lacks an integrated, culturally responsive framework to reconcile these tensions. This study therefore develops a Confucian ren-based model that harmonizes patient autonomy with familial values within Chinese healthcare settings. METHODS: We employed a dual methodology of theoretical reconstruction and clinical case analysis. First, we elucidated the conceptual structure, strengths, and limitations of Confucian benevolence ethics (e.g., familism, filial piety, graded love) in medical decision-making. Second, illustrative clinical cases were examined to assess the consequences of excessive family intervention on autonomy and outcomes. Finally, a cross-culturally informed model was developed through critical engagement with the Whānau Ora approach (New Zealand) and Hong Kong's "moderate familism" practice. Two illustrative clinical cases from mainland Chinese practice are analyzed to demonstrate how the proposed model addresses real-world ethical dilemmas. RESULTS: We propose a tiered collaborative decision‑making model centered on patient autonomy, with moderated family involvement serving as a flexible boundary. Ethical prioritization varies by context. (1) For routine treatment decisions, family‑led decision‑making, supported by structured family meeting documentation, is applied when patients delegate authority or lack capacity, thereby ensuring cultural alignment and efficiency. (2) In high‑risk interventions, mandatory tripartite shared decision‑making (clinician-patient-family) is initiated, utilizing decision aids to integrate clinical evidence, patient values, and familial concerns. (3) For end‑of‑life care, advance directives take precedence, with multidisciplinary ethics committees mediating disagreements. CONCLUSION: This framework repositions Confucian relational ethics as a resource for reinforcing patient subjectivity, establishing a "moderate familism" model that harmonizes patient, family, and clinician roles. It not only addresses institutional contradictions between legal individualism and cultural collectivism in Chinese medical practice but also offers a multicultural-sensitive paradigm for global bioethics.