Can an AI-carebot be filial? Reflections from Confucian ethics

Abstract

This article discusses the application of artificially intelligent robots within eldercare and explores a series of ethical considerations, including the challenges that AI (Artificial Intelligence) technology poses to traditional Chinese Confucian filial piety. From the perspective of Confucian ethics, the paper argues that robots cannot adequately fulfill duties of care. Due to their detachment from personal relationships and interactions, the “emotions” of AI robots are merely performative reactions in different situations, rather than actual emotional abilities. No matter how “humanized” robots become, it is difficult to establish genuine empathy and a meaningful relationship with them for this reason. Even so, we acknowledge that AI robots are a significant tool in managing the demands of elder care and the growth of care poverty, and as such, we attempt to outline some parameters within which care robotics could be acceptable within a Confucian ethical system. Finally, the paper discusses the social impact and ethical considerations brought on by the interaction between humans and machines. It is observed that the relationship between humans and technology has always had both utopian and dystopian aspects, and robotic elder care is no exception. AI caregiver robots will likely become a part of elder care, and the transformation of these robots from “service providers” to “companions” seems inevitable. In light of this, the application of AI-augmented robotic elder care will also eventually change our understanding of interpersonal relationships and traditional requirements of filial piety.

Keywords

AI bioethics carebots Confucianism elder care filial piety

Introduction

Where life expectancy was once much shorter, and generations within the family tended to be closer together, modern families have taken on a different structure, often depicted as an inverted pyramid. These global demographic changes are leading to a proliferation of proposed technological solutions to address the contemporary and future challenges faced by aging societies. One such challenge concerns the increasing demand for care by older adults and the need to address a growing “care poverty” internationally.¹

These new social pressures have made the “outsourcing” of care increasingly attractive, and arguably necessary. Already today, in a low-tech way, younger generations have outsourced the duties of care towards their elders to live-in nurses, maids, and other caregivers.² This is especially true in many parts of Asia, where fertility rates have dropped precipitously and life spans are among the highest. Thus, while elder care is not itself new, it has increased in scale, duration, complexity, and demandingness. Recent developments in information technologies, robotics, and artificial intelligence (AI) have begun to offer wide-ranging “technological fixes” to this increasing set of caregiving challenges, and it is expected that these approaches will proliferate even further in the coming years. Thus, there is a need to anticipate and manage the ethical challenges that are involved in the increasing application of technologies in caregiving roles. In this paper, we explore the phenomenon of technologized care from an under-explored angle, applying the lens of Confucian values. Specifically, we examine: (1) the moral permissibility of “outsourcing” caregiving to AI-enhanced carebots (“AI-carebots”), and (2) an AI-carebot’s (in)ability to participate in a Confucian moral system. We hope that this paper will initiate an important cross-cultural exchange within the ethics of technology in caregiving globally.

Technology in care: The ethical landscape

Developments in information technologies, robotics and AI have begun to offer wide-ranging “technological fixes” to this increasing set of caregiving challenges, and it is expected that these approaches will only proliferate further. Varied assistive technologies (AT) are now fully integrated into the organization and practice of care for older adults within institutional and home-based settings, provided within the public, charitable or family sectors. AT ranges from the use of fall detectors, CCTV, and other video and remote monitoring devices, the use of robotic animals as companions, to care robots. The latter form of AT, the carebot,¹ is held up as a potentially revolutionary solution to the growing problem of unmet care needs.

Carebots present a new frontier in the pre-existing trend of care outsourcing, especially if combined with AI. At the most basic end of the scale, a carebot can replicate some basic tasks of caregiving that are critical to supporting an older person’s basic functioning or their activities of daily living (ADL), for example, helping a person to get out of a chair or bed, prepare meals, or use the bathroom. More recent advances in robotics and the use of machine learning (ML) to program AI-carebots could spur a proliferation in the capabilities of such technologies. It will soon be possible, if it is not already, for an AI-carebot to offer emotional support alongside supporting older people’s physical and functional capacities. Improvements in ML and the adoption of large language models (LLMs) in care robotics also render it theoretically possible for each AI-carebot to be trained on a personalized dataset, unique to the individual elder.

Over the last decade, ethicists with interests in care practices have become increasingly interested in the practical ethical challenges associated with the roll out of AT in caregiving settings for older adults. This has given rise to a new body of literature within which three strands of ethical analysis can be identified. In the first, basic practical ethical considerations have been scrutinized, like the requirements to obtain valid consent, manage confidentiality and privacy, and protect personal data.^3,4 In this strand of work, specific ethical and legal safeguards to modify precisely how these technologies are implemented into practical caregiving arrangements have been proposed.⁵

The second strand of ethical interest has examined broader questions of gender, social, and global justice provoked by the increased role that AI-carebots could be given. On the global stage, the increasing use of carebots is viewed as an important means of tackling the injustices that result from the transnational flow of (usually female) caregivers from low- or middle-income countries to high-income countries for the purposes of working as in professional support worker roles, or as foreign domestic workers within families.⁶ It is claimed that justice is realized here by reversing existing unjust patterns of labor movements, thus helping to prevent the home country’s care workforce from being hollowed out, without any detriment to the host country.

The final strand of ethical interest has taken a more explicitly philosophical path, scrutinizing the concepts of care, empathy, and compassion, as well as how these character traits are enacted in interpersonal relationships. The focus of this work has been to determine whether non-human agents like AI-carebots can provide authentic care in a way that is comparable to that provided by a human being.^7–10

Thus far, the consensus seems to be that carebots for older adults are a positive development which, if carefully designed and introduced as an adjunct to a human caregiver, can be ethically defended on welfare- and justice-based grounds. Strikingly, however, with a small number of notable exceptions,^11,12 previous analyses have been acontextual in character. This is surprising given that the socio-cultural contexts in which carebots are being deployed vary in important ways.

In East and South-East Asia, for example, prevailing ethical obligations associated with Confucianism shape caregiving policy and practice explicitly. The Civil Code of China stipulates that if adult children, who are not fulfilling their obligation to support their parents, have parents who lack the ability to work or are facing difficult living conditions, the parents have the right to request their adult children to provide financial support.¹³ The Law of the People’s Republic of China on the Protection of the Rights and Interests of the Elderly states: “Caregivers shall fulfill their obligations to provide for the economic support, attend to daily life, and offer spiritual consolation to the elderly, taking care of their special needs.”¹⁴ And also specifies: “If caregivers fail to fulfill their support obligations, the elderly have the right to demand support payments from their caregivers, among other rights.” Likewise in Singapore, the “Maintenance of Parents Act,” provides parents over 60 with a legal means to demand financial support from their adult children who are capable of supporting them but are not doing so.¹⁵

Confucian-based philosophical analyses of caregiving in aging societies have claimed that the resources of this tradition should be renewed to meet gaps in care provision.^16,17 At the same time, important concerns have been raised about how traditional interpretations of Confucian obligations might negatively impact families and the realization of social justice.¹⁸ The extension of Confucian analysis to the development of new care technologies has been much more limited in scope, however, for example, exploring how a carebot could fulfill a depersonalized “moral policing” role that challenges wrongdoing by older persons,¹⁹ or exploring the ways in which remote monitoring devices for care at a distance might enable the fulfillment of filial duties.²⁰

Whilst these recent papers have shone some important light on the nuanced relationship between Confucian ethical duties and care technologies, overarching ethical questions remain. In what follows, we seek to explore a related set of challenges regarding technologized caregiving in societies where Confucian ethical values hold sway. In our discussion, we draw upon Confucian ethical resources to propose a relational, role-based, and harmony-oriented ethical framework regarding the application of AI and robotics in caregiving spaces.

Can an AI-carebot be filial?

Confucianism’s five central virtues are: benevolence (ren, 仁), righteousness (yi, 义), propriety (li, 理), wisdom (zhi, 智), and integrity/trustworthiness (xin, 信). In Confucian philosophy, “filial piety” (孝; xiào) is a virtue of respect for one’s parents and ancestors and also extends to respect for the hierarchies within society, for example, father-son, elder-junior and male-female. The Confucian Classic of Filial Piety (Xiaojing) was thought to be written during the Qin or Han dynasty, and is taken as the authoritative source on the subject.²¹ Together, these ethical principles regulated society in ancient China, with longstanding repercussions.

According to Ames and Rosemont, “Confucian normativity is defined by living one’s family roles to maximum effect.”²² At the heart of Confucian role ethics is “a specific vision of human beings as relational persons constituted by the roles they live rather than as individual selves.”²³ Filial behavior and reverence for the special duties of any social role, is thus essential to Confucian ethics.

So, where might AI assistive technologies fit into this picture? In a simplistic sense, of course, an AI-carebot cannot be filial—it has no parents or familial connections. Yet, there is another sense of the question posed in the title of our paper that comes into the view when we consider the potential of enhancements offered by AI to care robotics. Can a carebot programed to be “human-like” in the enhancements made to it through AI technology be viewed as possessing the qualities that are commonly associated with enacting the ethical duties of filial piety? This is an important and practically relevant question to address because, in other areas of health and care, value sensitive (or value flexible) design has been embraced as an approach to programming AI models that can address concerns that the replacement of, say, doctors’ judgments with AI decision-making tools will strip the practice of healthcare of its appropriate ethical content.^24,25 Indeed, the possibility of programming AI-carebots with Confucian values has been considered.^26,19,27 Liu (2018) has gone so far as to suggest that the four essential virtues of Confucianism could essentially be “implanted” into robots to enable them to act as moral agents (and presumably, therefore, to also be held to Confucian standards of moral responsibility).²⁶

So, let us imagine that the AI-carebot has been programmed with a functional ethical framework of duties calibrated to those within the Confucian tradition. Let us also imagine that, through carefully calibrated machine learning algorithms, this AI-carebot could effectively respond to the full emotional, spiritual, and functional needs of the care recipient. Could this machine be said to be acting filially?

Whilst Confucians would likely draw attention to an immediate, insurmountable ontological difference between a robot and a human, there were of course no robotic caregivers (AI enhanced or otherwise) in the early days of Confucianism. Thus, there are no direct references to the ethical question of human-robot relations in the primary texts of the Confucian tradition. However, we can find insight into the questions that we need by examining what the classic texts have to say about the distinction between humans and animals. These texts can not only help us understand the proper relationship between humans and machines but also provide insights into the scope of the responsibilities that Confucianism places on caregiving roles.

The Confucian tradition acknowledges that there is a fairly minimal difference between humans and beasts. As Mencius is known to have said, “The reason why humans differ from beasts is indeed slight.” This observation serves as a warning for people to strive to uphold the achievements of human civilization, as otherwise, they could easily regress to a beastly state. When discussing filial piety, Confucius said,

“Today, those who practice filial piety are all said to be able to provide for their parents. But even dogs and horses can be provided for. Without respect, how can it be distinguished?”²⁸

Scholars have interpreted this passage in various ways, but one point is common among them: what distinguishes the care provided for horses and dogs from filial care is the presence of respect. The emphasis, therefore, is not on the actions of filial piety, but on the quality, or the character, of the agent fulfilling its duties. It is evident that filial piety is not simply a matter of materially providing for parents. Rather, it is defined by a character trait unique to humans—the Qing (情) of reverence and respect. Qing is a concept translated variously as “emotion,” “feeling,” “sentiment,” or “passion.” Qing entails the concept of ren (仁) which is itself variously translated as “humaneness” or sometimes “co-humanity.” Ren describes a way of life that involves ethical relationships and a higher state of existence compared to the lives of animals which are thought to be primarily characterized by pursuing survival.

The Confucian tradition, therefore, necessitates a strict distinction to be placed between carebots and human caregivers because of the inability for the AI-carebot to be genuinely ethically responsive. The ontological differences between humans and machines matter precisely because the ethical responsibilities of humans derive from the character of human agents that cannot be replicated by machines, and the difference between human emotion and the mimicry of emotion by machines is taken to be essential in the construction of an ethical human-machine community that honors human nature, in the Confucian sense. So, as to the question of whether a carebot enhanced by AI algorithms to mimic the enactment of Confucian ethical duties can be filial, the answer is a firm no. Filial care requires a genuine and responsive partner, imbued with character traits possessed only by humans, and capable of real relational reciprocity and a commitment to co-humanity (ren).

That said, there are further questions worth examining concerning the role of technology in care and its relationship to filial piety, specifically, if we imagine placing that technology in an explicitly adjunctive role. These questions shift the focus of our analysis, as we ask whether it is morally permissible for a human caregiver to express their filial duties through the medium of this kind of technology, and if so, within what parameters?

Can Confucians permissibly use AI-carebots as adjuncts in caregiving?

Given our arguments in the previous section, what then—if anything—is an authentic Confucian response to the use of these novel technologies in meeting the growing demands of elder care? The answer, we will argue, depends largely on the extent and the manner in which such technology is employed.

There is no in-principle objection from Confucianism regarding the use of carebots—or any new technology. Indeed, Confucians would require that carebots are capable of significantly empowering both the care providers and care recipients in many regards—allowing them more independence, facilitating their social abilities by keeping them mentally engaged and stimulated, and enriching their social experiences, Yet, the high value Confucianism places on familial bonds would advise caution regarding anything that implies fewer human connections and interactions, or that could potentially erode these essential social ties or undermine the moral cultivation of the individuals involved.

Thus, assessing the moral acceptability of what we might call “outsourcing” the filial responsibilities of care to AI-carebots will depend entirely on the specific contexts of caregiving, of which duties these carebots are performing, and what effect the outsourcing of the fulfillment of these duties has on the harmoniousness of the family relationship.

The scope of care duties

In order to assess which duties an AI-carebot may permissibly perform, however, we ought to first specify the duties that fall under filial piety in the first place. This is no simple task. As REDACTED 2020 writes,

“...the exact boundaries of care are blurry. On the positive side, this has allowed the obligations to evolve with the times. Duties to help one’s parents run the family farm or business have evolved to accommodate modern lifestyles. Thus, filial piety may cover a variety of activities and expressions today, from generally treating one’s parents with politeness and kindness to providing them with financial assistance. However, this flexibility is always tempered with reverence for tradition – meaning Confucian values still sometimes find themselves at odds with competing liberal values from the West, particularly regarding gender roles, sexuality, and individuality”¹⁸

Filial care encompasses many more duties than elder care alone. Naturally, children are expected to be filial throughout their lives, and not just when their parents are declining. In fact, filial piety in some senses extends into the afterlife, as children are expected to remember and revere their parents even after they have passed on. The potential to automate so many aspects of caregiving—up to and including conversation and companionship (as some AI models are now capable of simulating) now forces the issue of just how far the outsourcing of care can go before it breaks the filial bond.

Fleshing out an adjunctive role: Filial bonds under pressure

Even a decade ago, it was recognised that the filial bond was under pressure, as Canda (2013) observes:

[G]iven widespread major upheavals of social change, it is becoming increasingly difficult for many adult children to fulfill parental and societal expectations for providing care and support, thus resulting in distress for all involved … Even adult children who are able to provide direct personal support for aged parents might feel burdened by the care demands, loss of income and freedom of movement, and conflict with the care receivers.²⁹

In light of some of these social tensions that emerge from the struggles of elder care, some have looked optimistically at the potential of carebots to absorb or diffuse these areas of friction.^30–32 For instance, where it may be clearly morally problematic to subject human caregivers to verbal or physical abuse from cantankerous elders, or to expose vulnerable elders to neglect or cruelty, automated nurses have no feelings to hurt, and if programmed correctly, no temptation to be derelict in their duties. In particular, Lancaster (2019) has argued that there is no good reason to prefer a human caregiver to a robotic one, assuming the quality of care is the same. She argues that the appearance of emotional care is sufficient and the idea that it is “fake” or unlinked to genuine emotional states does not undermine the quality of care.³³

But there are other consequences to consider as well. As Alexis Elder^19,27 argues, Confucianism resists the mainstream framing of elder care as burdensome. Rather, for Confucians, caregiving is an important source of meaning as well as an essential form of moral self-cultivation.²⁷ It is through care that we develop the essential Confucian virtues. Even if caregiving is character building, this does not make the work light. Adult children performing caregiving often find the work frustrating and fraught with tension, especially given the awkward power dynamics involved in “parenting one’s parents.”³⁴

Elder care can be far from ideal, and the behavior of parents can become more challenging with age and cognitive decline. Plausibly, there are some tasks for which robots would be better suited than human caregivers. For instance, carebots do not need sleep, do not get tired, do not get cranky, and do not take offense. In this way, outsourcing some of the more strenuous forms of care to carebots could have a salutary effect on social relationships that are otherwise worsened or aggravated by the burdens of care.

For example, we can also imagine the case of an adult child’s spousal relationship requiring them to live far away from the aging parent. Rather than being forced to sacrifice one connection for the sake of maintaining the other, technologies like video-calling and remote monitoring can enable the elder’s care to be overseen by a family member (even at a great distance) and the bond to be maintained.²⁰ The use of technology in such a case would seem an obvious and welcome support for core Confucian values and relationships—even if it means that the adult child cannot be there in person.

This should be a good enough reason to tempt Confucians—to the extent that AI-carebots can enhance these social ties, they would seem to be a welcome addition. In practice then, if the use of AI-carebots enables more people to meet the demands of elder care more easily, then Confucianism ought to encourage this. These precise areas of application would naturally vary on a case-by-case basis, as some elders and some parent-child relationships are more discordant than others.

Of course, the choice before us is not as simple as using a carebot or not using a carebot. As we considered above, it is possible to design AIs and robots with Confucian values built into their programming, and this could have broader implications on the care recipient in ways that function to support filial bonds. For example, Elder^19,27 describes the possibility of robot caregivers that rebuke bad behavior in elders, for example, prompting them to refrain from abusive language. This strategy could allow an AI-carebot to serve a morally edifying role, and one that may in turn help improve the quality of the elder’s real human connections over time.

This is a hopeful picture, but there are still more hazards to note when we consider the more extended functions that AI-carebots might be given. For instance, Wheeler (2022) asks us to consider the case of a child outsourcing the performance of a parent’s funerary rights to a robot. He argues that few people would be likely to find this kind of outsourcing acceptable on the grounds that it undermines the network of relationships that is so essential to the Confucian vision of the good human life, even if the robot were able to execute the procedure flawlessly.³⁵

If we interpret the value of filial piety according to its spirit rather than by the specific actions that it is taken to require, then we have some hint at where Confucianism might draw the line as to which applications of technology are acceptable and which are not. If and when the use of AI-carebots (or similar technologies) translates into the wholesale abandonment of elders by their children, or the erosion of any of the essential social bonds, then this would clearly be impermissible. In contrast, where AI-carebots promote connection and ease the burdens of care in ways that create opportunities for filial piety to be maintained over the longer term, they would be welcome adjuncts. Nevertheless, there are still further dangers worth articulating from a broader Confucian perspective that concern the application of technology in caregiving.

Beyond filial piety: Harmony in relationships

Filial piety and ren/Qing are not the only Confucian values that are important to consider in this context. Harmony (he; 和) is the ideal that guides all human relationships. Harmony depends on coordination between all elements involved, wherein each part must (1) perform its own roles and functions, (2) relate to other elements in an appropriate way and (3) refrain from overpowering or dominating other elements.³⁶ Harmony, thus, requires balancing all components so that they complement and support each other. Indeed, harmony can be conceived as the normative standard of Confucianism. In Confucian thought, the harmony–disharmony distinction plays a role similar to other binaries, like right–wrong, good–bad, and success–failure.³⁷ Thus, in a Confucian ethics of technology, harmony “calls for a continuous negotiation and adjustment of relationships between human beings, society and technology.”² ³⁸

From this perspective, the greatest ethical concern in the use of AI-carebots for elders is their potential to create or exacerbate imbalanced (or disharmonious) relationships. The most prominent form of imbalance between machines and humans is often explored under the pretext of “deception.”³⁹ From here, we can distinguish between two types of imbalanced relationships that are relevant.

The first type of imbalance occurs when elderly individuals receiving care from machines actually find more satisfaction in this form of caregiving, leading to a diminishing satisfaction in their interpersonal relationships. Viewed only through an individualized lens, one might struggle to identify what is wrong with this picture. After all, if the user of the AI-carebot is having his or her needs met, and no one else is being harmed, what objection could be raised? If all that matters is the user’s subjective experience, then indeed, a well-designed AI-carebot is just as good as a human caregiver.

Yet, Confucians, with their understanding of selfhood as essentially social and relational, would argue that this asymmetrical relationship with a machine constitutes a serious moral threat. Moreover, the Confucian view does not set desire satisfaction or happiness as the end goal of human life. Similar to some kinds of virtue ethics, Confucianism endorses an expanded account of human flourishing. This account can (and even must) include some struggles, and some personal happiness may be permissibly sacrificed for the sake of other goods, like harmony, and humaneness, among others. Thus, even if an individual elder is made better by an AI caretaker, then, Confucians would still warn against its use.

The second type of imbalance concerns a one-way, asymmetrical emotional relationship between humans and machines. AI-carebots, capable of resembling human expressions and behaviors, can easily trigger empathy in human subjects. Humans can mistakenly believe that they can sense the emotions of the machines and establish a genuine relationship with them.

The moral consequence of being mistaken in this way is a serious one. This is not because the AI-carebot is untrustworthy or even because the recipient of the care in this case is necessarily unhappy with the pseudo-relationship. In fact, it is in the very potential for such imbalanced or asymmetrical relationships to be emotionally satisfying and psychologically rewarding that the threat lies. Speaking of the impact of technology on social relationships, Turkle notes:

[W]e want more from technology and less from each other. What once would have seemed like ‘friendly service’ from a sales clerk has “now become an inconvenience that keeps us from our phones⁴⁰

The ability of technology to satisfy our desires, to amuse us, to make life more convenient, can have the unanticipated consequence of crowding out opportunities for genuine connection. AI-carebots can be pre-set with facial expressions and the ability to express emotions when engaging in conversations with care recipients, and these can be tailored to individual preferences for maximum emotional effect. However, in reality, the care recipient is merely being triggered to seek empathy from an entity that cannot genuinely reciprocate, meaning the end goal of all these evolved social processes has in fact been frustrated rather than fulfilled.

More concerning is that this unidirectional and asymmetrical emotional relationship places users in a vulnerable position, making them more susceptible to exploitation and manipulation. The manufacturers of AI-carebots are highly likely (or at the very least, there is ample motivation) to utilize this emotional bond to increase user engagement and, potentially, exploit the emotional relationship to profit from those receiving care. Exploitation of elders already exists as a problem across different societies, and the new horizons made available by AI for emotional manipulation are as easy to anticipate as they are hard to manage.³

Confucianism would advise societies to avoid creating robots that could occupy such important human roles, like providing emotional support, especially when these entities do so by preying on the very emotional drives that define us as a species and set us apart from animals. This new technological frontier of AI capable of simulating human speech and other social signals in such naturalistic ways has revealed stress points in our social apparatus. If AI-carebots are allowed to proliferate in such roles, this could lead people into one-sided emotional connections that lack genuine meaningful content, or give rise to a broader risk of a deleterious effect on emotional and moral development over time, if robots replace essential social relationships.

Conclusion

Confucian ethics is pragmatic in nature. Rather than beginning with abstract principles or ideal theories, Confucianism begins with things as they are, and seeks to generate a harmonious balance. When it comes to policy setting and building ethical frameworks for new technology, this can offer greater flexibility than more top-down approaches. As such, it promotes a skeptical view about technological possibilities, while staunchly advocating for integrating technology in a manner that supports but does not seek to alter human nature.

Given the economic and demographic forces at play, it would seem that AI-carebots will become a part of elder care regardless, and the transformation in—and expansion of—the roles of these robots will be inevitable. AI-augmented robotic elder care will likely also eventually change our understanding of interpersonal relationships and the requirements of traditional notions of filial piety. We change the world with our technology, and in turn are changed by it. The Confucian tradition reminds us that we are not always benefitted by the removal of burdens; certainly examining the justification for recent developments in AI care robotics requires a careful case-by-case analysis of how human bonds, relationships, and responsibilities are impacted. From a Confucian perspective, we should not allow ourselves to be easily taken in by the appeal of labor saving devices, and to proceed with caution in order to ensure that technology-mediated caregiving does not lead to the mistaken allocation of moral agency on machines, a weakening of our social ties, or the fostering of disharmonious human relationships.

There are varied ethical and wider philosophical concerns that accompany the creation of AI-carebots for elders that remain to be explored. Many of these concerns extend well beyond the context of elder care, to any caregiving or emotionally supportive activities. It may seem at first blush, that outsourcing filial care to technology has many advantages, even advantages that serve important areas of social justice. Yet, from the perspective of Confucian ethics, we can see that the kinds of one-dimensional relationships humans might have with AI-carebots means that they cannot adequately fulfill these caregiving roles. This is not because Confucianism is a luddite or techno-phobic tradition. Rather, it is a human-centered and relationship-centered ethic. As such, it enjoins us to ask about any novel technology, will this make us more or less human?

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Chinese Social Science Foundation [grant number 19ZDA039]; the Social Science Foundation of Fujian Province [grant number FJ2022B146]; the Singapore Ministry of Health’s National Medical Research Council under its Science Health, and Policy Relevant Ethics, Singapore (SHAPES) Programme [grant number MOH-000951]; and by the National University of Singapore under its NUS Start-up Grant [grant number NUHSRO/2022/035/Startup/05].

ORCID iD

Kathryn Muyskens

Notes

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