What Really Matters: Endurance, Meaning, and the Moral Life of the Person(1)

An Interview (2015) with Harvard Anthropology and Psychiatry Professor Arthur Kleinman(Esther and Sidney Rabb Professor of Anthropology; Professor of Medical Anthropology in Global Health and Social Medicine; Professor of Psychiatry, Harvard Medical School)

Justin M. Thomas (Zheng Tao), Haiqin Yu & Mingzhu He

Interviewee profile　Arthur Kleinman (born March 11, 1941) is a physician and anthropologist. A graduate of Stanford University and Stanford Medical School, with a master’s degree in social anthropology from Harvard and trained in psychiatry at the Massachusetts General Hospital. Kleinman is a leading figure in several fields, including medical anthropology, cultural psychiatry, global health, social medicine, and medical humanities. He has conducted research in China since 1969. Kleinman is professor of medical anthropology in the Department of Global Health and Social Medicine and professor of psychiatry at Harvard Medical School. He is the Esther and Sidney Rabb professor of anthropology in the Department of Anthropology in the Faculty of Arts and Sciences (FAS), and was the Victor and William Fung director of Harvard University’s Asia Center 2008-2016. He is a member of the National Academy of Medicine and the American Academy of Arts and Sciences.

Arthur Kleinman has published seven single authored books including Patients and Healers in the Context of Culture; Social Origins of Distress and Disease: Depression, Neurasthenia and Pain in Modern China; Rethinking Psychiatry; The Illness Narratives; Writing at the Margin; What Really Matters; and The Soul of Care. His four co-authored books include Reimagining Global Health; A Passion for Society: How We Think about Human Suffering; and Deep China: The Moral Life of the Person. He has also co-edited books on culture and depression; SARS in China; world mental health; suicide; placebos; AIDS in China; and the relationship of anthropology to philosophy (The Ground between: Anthropologists Engage Philosophy). His current collaborative projects include a comparative study of eldercare for dementia in six Asian settings; an ethnographic study of trust in the doctor-patient relationship in China; and social technologies for aging and eldercare in China.

Interviewers’note　While we were studying at Harvard—one as a visiting scholar and two as master’s students—we were fortunate to be able to take some of Professor Kleinman’s classes, and to receive his guidance on our research and on planning of our course of study. After learning that our interview topic was on China’s current moral situation and on how China’s elderly could live a meaningful life, Professor Kleinman, who has shown great concern for China for many decades now, gladly agreed to accept our interview. In the interview, he incorporates a keen understanding of traditional Chinese moral sentiment in discussing China’s moral issues past and present. He argues that today’s China is not actually facing a “moral crisis” as many say, and that many American publications are overly critical of China, even sometimes engaging in “China-bashing”. Taking into account the characteristics of this globalized era, he analyzes human beings as “divided selves”, and reminds us of the need to come to a deeper understanding of Chinese and cross-cultural issues. Against the background of the dominant neoliberal political economy in today’s world, he expounds on the correctness of the traditional Chinese idea of endurance (chiku,吃苦), as well as on the tendency of Chinese people to buy famous brand-name products in order to prove their reputation or “face”. In light of the uncertainties and vulnerabilities inherent in human life, Kleinman observes that a prominent strain of Chinese thought has long concerned itself with our human limits, and that this particular Chinese worldview can help lead us to a morally fulfilling life. He believes that China’s current efforts to enrich the lives of the elderly have been very effective, and proposes that China delay the mandatory retirement age and further enhance caregiving for this population.

It is important to bear in mind that much has changed since this interview took place in 2015. The interested reader is therefore encouraged to seek out more recent publications and interviews of Professor Kleinman, including his latest book, The Soul of Care.(2) When we offered Professor Kleinman the opportunity to update his thinking, he kindly agreed to be interviewed again, in February 2023. The second interview appears following this one. It reflects important changes in the world in general and his attention on aging.

I. Moral Changes, Not a “Moral Crisis”

Interviewers　In 2006, you published What Really Matters: Living a Moral Life amidst Uncertainty and Danger.(3) In the nine years that have passed since publication, have there been any significant new developments which have bearing on our common struggle to live a moral life?

Professor Arthur Kleinman　After What Really Matters, I edited a volume with my former students who are now professors in China, called Deep China.(4) And in Deep China, we tried to use the ideas from What Really Matters to understand changes in China today. So, we first of all looked at moral changes in China today. We decided that this needed greater balance than is usually presented. Many people say that China is having a moral crisis, but I think you have to be very balanced about how you think about this moral crisis. What’s usually used as an example of a moral crisis is like, a child is walking along a street, and no one is paying attention to the child, because the child’s mother is not there, or the child’s family is not there. The question is, shouldn’t someone be helping the child? Or, the so-called “good Samaritan scam”, which is when an elderly woman gets off a bus, falls to the ground, a young man picks her up, and then she accuses him of having pushed her or something, and being responsible for her, and demands some money to go to the clinic, or whatever. You know, these things you can find in the old China, before 1949! Part of it is a reflection on the structure of moral sentiments in Chinese culture, which are often very particularistic, within the social network and the family. So, if you fall outside the family, outside the network, you’re not necessarily going to be dealt with in terms of universal principles of helping strangers. That is an issue traditionally in Chinese society; there’s nothing new about that. So you can’t accuse China today of having a crisis that’s any different than it had in the past on this particular set of ethics.

What’s more to the point is the feeling amongst many Chinese today that it’s become so materialistic in China. At a time in which both Communism and Confucianism have been undermined as ideas and living practical philosophies for how to live your life, people are questing for other moral and spiritual knowledge or models of how to live a life. And I think that’s very true in China, but that’s also true all over the world. I think it’s happening in every country. So, I think that there’s definitely moral change in China, but I don’t think China is necessarily in a moral crisis.

In fact, if you look at Chinese society, the problem is that most American publications, in my view, tend to be overly critical of China, and to do a little China-bashing. And so I’ve tried in my own work to go to the other side of things. Just think about China today: the most unprecedented improvement in people’s lives ever, with the economy so much better today than it was in the past; with the number of poor people going down;the middle class going way up. This is a great accomplishment. It’s an enormous accomplishment. At no time earlier in Chinese society was there an accomplishment like this. And if you look worldwide, no other society in the world has so quickly had such an effect. So, there are a lot of good things in China.

That said, there also are problems, as there are in America, or Europe, or everywhere, there are problems. I think one problem is that the connected world of the internet today and global culture produces some problems that are found everywhere. One of them is an enormous emphasis on the individual as an isolated individual. And this is not true in Chinese society, or in America. In very few places are individuals actually isolated. It’s the hyper-individualism of the media that emphasizes this. You know, China uses the term guanxi (relationship) or guanxiwang (social network)as if it were just Chinese society. It’s not just Chinese society, but America as well. Guanxiwang is very important to America, but we don’t have a term for it. Well, we call it “networks”, in some way, but we don’t give it enough significance. But it’s very important here. It’s not just in China that this idea is important.

II. The Quest for Meaning and Understanding the Divided Self

Interviewers　In your book What Really Matters, you write of your usage of the term“moral” in its broader sense: “This meaning of moral is not synonymous with good in an ethical sense”.(5) Further, “We shall see that moral life is closely connected to the idea of ethics, by which we mean we aspire to values that transcend the local and that can guide us in living a life”.(6) In this era of globalization, how can each of us lead a good moral life?

Professor Arthur Kleinman　I would say that all over the world, people are searching for meaning in an age that is very different than the past. It’s a globalized age; it’s a highly materialistic age; it’s an age of the power of institutions like bureaucracies;it’s an age of the power of corporations. We’re all affected by large institutional structures around us. This university is a large institutional structure, where we’re spending our time. It’s the same in Hunan University. So, it’s our coming to terms with the modern structuring of social life: highly connected, highly institutionalized, very strongly affected by cultural values, because of the way the internet, and our cell phones, and our awareness of what’s happening in the world, and the huge amount of propaganda—we call it advertising—of commercial enterprises influences our lives. I think that it’s in response to this that we see an intensification of what I would call an age-old cross-cultural quest for wisdom. The wisdom being: How do you live in the world? How do you live in a world like the world we’re living in? But these quests are not new. These are very old and affect many societies. It’s just that, I think that the growth of the Chinese middle class has made these quests much more easily intellectualized and much more visible. So in terms of where things have gone, it seems to me that all over the world, there’s an interest in these moral issues.

Now, what distinguishes my approach, as a medical anthropologist and a psychiatrist, from the approach of many people looking at values, is that I’m interested not just in values as principles, as ideas. That’s important; social justice, the idea of equality—these are important social values. But I’m also interested in the way that we live our values. How do we live our values? And those lived values I’ve called the moral, and I’ve distinguished them from the ethical. The moral has to do with, first of all, the groups that we’re a part of. We find ourselves, as it were, thrown into a world of moral experience, in which the values are already there, in the behaviors and actions of others. But then, we have our own internal moral commitments. And there I’ve argued for a more nuanced idea of the self. Who is the person engaging moral issues? And I like the idea of a divided self: that we’re not a single thing, which is easy to stereotype. We are complex beings with divisions inside ourselves. One division is the public-private. In China, you say that explicitly: Children are taught there are certain things you can’t speak up about publicly, and that you keep private. In America, the same thing, except we’re not as explicit about this. But this is the Chinese statement: yaba chi huanglian, youku shuobuchu（哑巴吃黄连，有苦说不出）. This roughly means “a mute person eating bitter herbs, having to suffer in silence”. You know, you’re not supposed to speak out about certain things. So, this is division inside the self between what can be spoken and what can’t be spoken. We have the same thing in the U.S. You may harbor very negative views about Harvard. In the Asia Center right now, meeting with me, you’re not going to say those things. But knowing you, Justin (Zheng Tao), I know you don’t harbor such views.

So anyway, my point is that all these attempts that I’m making to answer your question are meant to make the question more complicated. What I’m against in looking at China or looking cross-culturally is coming to too simplistic answers—answers that are too flat, too uniform, easily stereotyped. Those are wrong, in my view. What we always need are deeper answers, and those deeper answers require two things: a deeper knowledge of the social context, and a deeper knowledge of our individuality. That’s why I talk about the divided self: not a simple individuality, but a more complex individuality. These moral issues can’t just be talked about in terms of grand theories, like social justice. Those are wonderful theories. But you have to put them into the local worlds and into the people to understand why we act the way we do, and why it is that these great principles often don’t seem to go anywhere with society.

III. Embracing the Traditional Chinese Concept of Endurance

Interviewers　In the introduction to your book What Really Matters, you speak of “the big lie”—that is, “our assiduous denial of existential vulnerability and limits that is extraordinary in American culture”, and which is also at the center of global culture. How would you evaluate modern Chinese people’s attitude toward existential vulnerability?

Professor Arthur Kleinman　Yes, well I think in the past, Chinese parents taught their children the importance of how to endure. How to endure.(7)

Interviewers　Chiku （吃苦）, which literally means “eating bitterness”.

Professor Arthur Kleinman　Chiku, yeah. Endurance meant that you would eat bitterness, yes, but also that you keep going in spite of the fact that times are very hard. And how do you keep going? That’s the important point. I think that in both societies (America and China), and all over the world, this is a key idea, of enduring. But in the world we live in today, it doesn’t fit with our political economy. So, the neoliberal political economy that’s dominant in the world today, in the United States and in China, needs to sell things. You don’t sell things effectively by telling people, “just endure”. You gotta tell them, “No, you shouldn’t just endure; you’ve got to endure in style.” And you have to buy things. Otherwise, no one would buy anything, or we wouldn’t buy new things. You would decide, well, I have a refrigerator, it’s 30 years old and a little slow, but it’s good enough. For enduring, I don’t need a new one.

So, the world we’re in, the emphasis is on buying things, on desiring things, on fulfilling our desires; and this is very different, I think, than in the past. There are some similarities, but there are areas of real difference. So for example, you go to Paris (someone from Paris visited my office just before you), and you go into a store, a famous store, and you see all kinds of Chinese buying the same bag. Now, that bag is very expensive—maybe a Gucci bag, or one of the other famous brands. And you say, “Why do the Chinese spend so much money buying these brands?” One reason is people want to have this because of the advertising. But another reason is actually very Chinese: that you’re not so much buying this for yourself, but to identify yourself within the social group—that you belong to the elite class. This gives you face, “mianzi”（面子）, you say in Chinese. It’s somewhat different from just buying it for your own joy, your own enjoyment. And if you actually ask Chinese about why they do buy this, they’ll often tell you: “Well, you know, in my group, if I bought something else, I would be looked down on, I would lose face. I’ve got to be at this level.”It seems to me that in that kind of setting, there is a tension between the idea of enduring, of getting through life—you must endure—and the idea of having a good time, always having a good time. I think they’re in real tension.

I think that the Chinese view, the traditional Chinese view, for me, is not only right, but very powerful. This view holds that we need to recognize the dangers around us, and see what they are. Just think of what the Chinese have come through over the last one hundred years, a little bit more than a hundred years: the fall of the Qing Dynasty, the Warlord Period, the Anti-Japanese War, the Korean War, the Cultural Revolution. All of those things demonstrate how dangerous the social world is.

Secondly, on the financial side: China could have a financial downturn. People are concerned about their money, and the like. Third, just think of the illnesses that we worry about. China has had SARS, has had H1N1 flu, we’ve just come out of the Ebola crisis in West Africa. China was concerned about that; they didn’t want Ebola to go to China, just like we are in the United States. (Of course, since the time of this interview, Covid has presented us with even more difficult challenges.)

Hence, the world is a dangerous world. It’s a dangerous world that we live in, and to be aware of that doesn’t mean that we can’t have a good time, and can’t be happy. But we’re happy because we understand what the limits are, what our limits are. It’s not just China, by the way, that has a problem in this regard. The United States has a very big problem. There are some very bizarre people in America who believe that either we will learn to live forever and get rid of death, or we will live a very long time, maybe 150 years or so. Scientifically, this is not true. But it’s more problematic than being not true scientifically. It actually distorts how people look at the world. And so you know, there’s a movement in the United States to freeze people’s brains or freeze their bodies, and then in the future someone may wake them up when we have a magic pill you can take and live forever. This is very silly, a very silly idea. The same thing with the idea of living to 150. I’ve seen many very old people. I don’t want to live to 150, because we would be so diminished, we would be at such a low level of functioning, very few people would want to have that kind of existence. So these desires seem to me to be denials of reality. People like to deny reality. Why? Because reality suggests there are limits to what we can do. And I think the Chinese in the past have been very concerned with those limits.

IV. The Chinese Worldview Can Lead Us to a More Fulfilling Life

Interviewers　After narrating Yan Zhongshu’s story in What Really Matters, you observe: “His story also shows us that coming to terms with the dangers and uncertainties of our lives, however painful and troubling it is to confront what matters, is the existential responsibility we owe our humanity to craft a moral life that is not simply the mechanical reaction of a cog in the machine but reflects the human potential for self-knowledge and collective refashioning of who we are and where we are headed. This is the ethical requirement of human experience—not easy, never fully accomplished, always caught up in the limits of politics, social life, and our own genetically and psychologically based passions, but, at the end, what moral life is for”. What influence do you think the Chinese worldviews have on the construction of the moral life of Chinese people?

Professor Arthur Kleinman　In fact, I happen to like the Chinese worldview very much. I like a particular Daoist worldview from the past. This worldview has been well worked on by my colleague Michael Puett. And this view holds that the world is full of negative energies, many negative energies; and that anything that human beings try—no matter what it is—will be eventually knocked down and destroyed by these negative energies. But our responsibility is in the face of all the negative things in the world, to still cultivate our humanity, build something in the world, even though we know it won’t last. It’s very close to a European point of view called “the tragic view of life”. I like those views. I think they are closer to the way life actually works than the more robustly positive view that you always have a good time and nothing is going to interfere with your life.

But these are very powerful global cultural influences, and they affect us all. They affect us all. And so, if you look at drug-addicted people—now many of them are predisposed because of their impoverishment in poor economic groups, or their limited abilities to be able to get jobs or build their lives. But there are plenty of people who become drug-addicted, who themselves cannot tolerate simply enduring. They need to feel happy, they need to feel that their desire is fulfilled all the time. And they do that through drugs. Again, I would see that as a cultural problem. The cultural problem is coming to terms with, “What is an adequate life? Good enough for us?”Everyone wants a greatly good life. Justin (Zheng Tao) here, would like someone to give him a million dollars, or provide him with a job that pays$500,000 dollars a year. Or give him a new car, or something like that.

Interviewers　That’d be great.

Professor Arthur Kleinman　That’d be great. But if you think about it, what’s an adequate life? It’s a much better thing to aim for, to work at, and to come to terms with. For any of us, what’s an adequate life? We need food, we need clothing, but we need more than that. We need to have certain leisure activities. You want to go to the movies, you want to go to the restaurant, you want to have a reasonably good time. We could frame things in terms of what’s an adequately good life as opposed to the idea that everyone deserves everything. Then there would be no resources left in the world; we’d destroy society. So how to come to terms with that is very, very difficult. And I think this is all part of what I’m talking about. Living a moral life is deciding, in part, “What is good enough for me, given my reality?” The world that I’m in, my own interests and desires, the amount of money I have available, the effect that what I will do will have on others or on the environment—all those things need to be balanced.

And I think this question of “What is an adequate life?” will become a great question for policymakers. They’re going to have to decide, in your country and mine, what is an adequate life. Now I had the pleasure about a month ago, or a little longer, with the Harvard president to meet your president, Xi Jinping in Beijing. I enjoyed meeting him very much. We talked about the environment, but we could have been talking about any number of things. And it’s clear that China has recognized problems with its environment, and wants to make for a better environmental policy and environmental outcomes. Again, that raises this question of what’s an adequate life for people. This is going to put some dampers on things that people do. In China, you can’t have all 1.3 billion people, or most of them, driving cars all at the same time and still want to protect the air. It’s not going to happen.

V. Living a Meaningful Life in Retirement

Interviewers　You have long paid particular attention to the question of care of the elderly. In 2000, China joined the ranks of the world’s aging societies, and the population continues to age at a surprising pace. How to effectively address this problem has now become a major issue with direct bearing on China’s overall development and on the welfare of hundreds of millions of Chinese people. There is a saying in Chinese: “Of all virtues, filial piety comes first.” This culture of filial piety is a precious legacy of Chinese culture; respecting, loving, nurturing, and assisting the elderly is a traditional virtue of the Chinese people. Facing accelerating aging, the Chinese government has proposed that the elderly lead lives with structure and planning oriented toward their goals and dreams, thereby actively and joyfully living out their later years. Many communities have proposed that the elderly must have things to keep them occupied, including working to help each other. Our question is, how do you suggest that this population can live a meaningful life in retirement?

Professor Arthur Kleinman　I think that’s a great question: “After retiring, what kind of life?” What kind of life? I think first of all, China has a big problem on aging because in the year 2050, somewhere between 20 and 25 percent of Chinese will be over 60 years of age. So you’re going to have a lot of elderly people, and with a one-child family, you’re going to have inadequate support from younger people. Plus the fact that—I don’t know what you feel, but most of my Chinese friends are not counting on their child necessarily to support them when they grow older as filial reverence and support of the aging loses its paramount significance, and horizontal relations, conjugal relations, get more important.

But I think that this is a story that China is working on very effectively. I see it in the “yanglao” （养老） movement. You know, “cultivating, nourishing the elderly”—it’s actually “yangsheng”（养生）—“nourishing life”. I think that all of these activities that people are engaging in—dancing, walking, doing all these things—I think this is incredibly important, staying active. Women in China are asked to retire too young. Retiring at 55 years of age is not good. You’ve got to increase the retirement age there, even for men.

Interviewers　It’s 60 now, for men?

Professor Arthur Kleinman　It’s 60 for men. Get it up to 65. And China is doing this, trying to have a better social security system, better insurance, and health insurance. All of these things are critical to being able to live an adequate life. So, I feel that this is a problem we all share, and I have a lot of concern in China for elder care. We have a big set of studies on elder care(8), (9), (10), (11). How do you take care of the elderly who are disabled, whether mentally or physically? This is going to be a huge problem today. Look at the Disability Federation in Beijing. They’re very good, but they’re thinking of blind people, people who can’t hear, people who are paralyzed. They’re not thinking of the elderly. But they’re going to have to.

Thank you for the time. Good to have the interview. Justin (Zheng Tao), best to you. OK. Goodbye! Thank you!

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(1)　This interview was carried out on May 13, 2015, at the Harvard University Asia Center, CGIS South Building, 1730 Cambridge St, Cambridge, MA 02138. It has previously been published in the Chinese language, and Haiqin Yu is the corresponding author for both the Chinese and English versions. The citation information for the Chinese version is as follows: THOMAS J M, YU H Q, HE M Z, et al. What really matters: Holding up a meaningful life—Interviewing Harvard Anthropology Professor Arthur Kleinman[J]. Journal of Guangxi University for Nationalities (Philosophy and Social Science Edition), 2018, 40(5): 134-140. (In Chinese)

(2)　KLEINMAN A. The soul of care: The moral education of a husband and a doctor[M]. London:Penguin Publishing Group, 2019.

(3)　KLEINMAN A. What really matters: Living a moral life amidst uncertainty and danger[M]. Oxford:Oxford University Press, 2006.

(4)　KLEINMAN A, YAN Y, JUN J, et al. Deep China: The moral life of the person[M]. Berkeley: University of California Press, 2011.

(5)　KLEINMAN A. What really matters: Living a moral life amidst uncertainty and danger[M]. Oxford:Oxford University Press, 2006: 2.

(6)　KLEINMAN A. What really matters: Living a moral life amidst uncertainty and danger[M]. Oxford:Oxford University Press, 2006: 3.

(7)　KLEINMAN A. How we endure[J]. Lancet, 2014, 383(9912): 119-120.

(8)　KLEINMAN A. Caregiving: Its role in medicine and society in America and China[J]. Ageing Int,2010, 35: 96-108.

(9)　KLEINMAN A. Caregiving as moral experience[J]. Lancet, 2012, 380(9853): 1550-1551.

(10)　KLEINMAN A. Care: In search of a health agenda[J]. Lancet, 2015, 386(9990): 240-241.

(11)　KLEINMAN A. The soul of care: The moral education of a husband and a doctor[M]. London:Penguin Publishing Group, 2019.