The Farewell: An Argument for Collectivism

Katya Tjahaja

Class of 2025

The Farewell, a 2019 movie directed by Lulu Wang, addresses questions of patient autonomy vs. a more collectivist model in an East Asian context. It centers around Billi, a Chinese-American immigrant who struggles to come to terms with her family’s approach to her grandmother’s, Nai Nai’s, cancer diagnosis in China. In the film, Billi grapples with the conflict between collectivism and a patient’s right to autonomy. Max Ying Hao Lim addresses this conflict in their article, “Patient autonomy in an East-Asian cultural milieu: a critique of the individualism-collectivism model.” Lim argues that a hybrid system of the two is necessary for the ‘correct’ medical decision to take place. However, the narrative framing of the film argues that Chinese cultural values and familial views should impact decision-making in a medical setting. The film shows how collectivist approach aligns with Billi’s family’s ethical and cultural values.  

In the beginning, Billi’s disapproval of her family’s approach to Nai Nai’s diagnosis is informed by Billi’s upbringing in America, and by the American medical system’s focus on patient autonomy. In principalist terms, “respect for autonomy” is one of the four principles that is the dominant framework for clinical bioethics, as described by Beachamp and Childress. Lim describes the system that Billi buys into, writing “the current standard for patient autonomy seeks to enshrine the power of the patient vis-a-vis clinicians regarding decisions over their own care—that is, patients retain the fundamental decision-making power” (1). Billi constantly questions her family members and their decision to keep Nai Nai’s diagnosis a secret from her. When Billi’s mother tells Billi, “Chinese people have a saying: when people get cancer, they die. It’s not the cancer that kills them, it’s the fear” (11:50), Billi gains insight into the Chinese cultural approach towards cancer diagnoses and begins to re-evaluate whether her previous values of patient autonomy is appropriate to her grandmother’s condition. However, Billi is not yet fully convinced and continues to be concerned as she learns that Nai Nai was kept in the dark about the diagnosis. Her disagreement stems from a lack of exposure to Chinese approaches to medicine and the belief that the American approach is correct. In keeping with Lim’s argument, “with the reasonable standard of care being predominantly developed in a Western context, problems arise as we seek to globalise standards across different cultures and societies—especially since there currently exists a worldwide variety of bioethical practices based on vastly different sociocultural contexts, value systems and moralistic assumptions” (Lim, 1). Billi tries to convince her parents that informed consent and patient autonomy should be upheld in Nai Nai’s case, but they are adamant that this approach is not suitable for how Chinese families go about caring for their sick. When Billi decides to travel to China, her family is immediately worried she will inform Nai Nai of her diagnosis, but Billi resorts to saying, “I’ve missed you” (16:00). We see her hold back tears, concealing the struggle inside her in keeping a secret from Nai Nai. Though she is still unsure regarding the best approach to the situation, she chooses to cooperate with her family’s decision out of respect for her entire family who places considerable pressure on her to conform. Therefore, their behavior is consistent with the collectivist focus.  

Billi continues to question family members regarding their approach, resulting in conversations that add layers to their decision-making process. Billi asks her Aunty Ling, “what if she wants to say goodbye?” to which Aunty Ling responds, “say goodbye? That’s too painful. Why would you want her to go through that? If you tell her, you’ll ruin her good mood, right?” (34:30). Their interaction highlights how the family prioritizes the mental health and happiness of Nai Nai, seeing knowledge of the truth as destructive to her contentment. They believe that the diagnosis is more of a problem than the actual disease. They would rather have Nai Nai continue to be oblivious. For them, withholding the truth is an obligation: as Lim writes, “families may choose not to inform and involve the patient with discussions pertaining to his/her medical condition as a manifestation of their duty to fulfil familial obligations within the family unit, for example by protecting the patient from potential suffering,” (Lim, 1-2). Billi struggles to comprehend because of its contradiction to patient autonomy and informed consent. She does not continue questioning Aunty Ling out of respect, even when she is still unconvinced. However, Billi subsequently asks her Uncle Haibin whether or not Nai Nai should be informed. He responds, “there are things you must understand. You guys moved to the West long ago. You think one’s life belongs to oneself. But that’s the difference between the East and the West. In the East, a person’s life is part of a whole. Family. Society. You want to tell Nai Nai the truth because you’re afraid to take responsibility for her. Because it’s too big of a burden. If you tell her, then you don’t have to feel guilty. We’re not telling Nai Nai because it’s our duty to carry this emotional burden for her” (1:02:46). Uncle Haibin reveals that Nai Nai is a patient, but she is also a part of a family, society, and culture where autonomy is not shouldered by a singular person. His statements reflect a Chinese cultural perspective which views shouldering the diagnosis as an honorable act so the actual patient, Nai Nai, does not have to be burdened with it. Billi is deeply affected by her conversations with both Aunty Ling and Uncle Haibin as she continues to cooperate in their secrets. Billi observes how Nai Nai’s diagnosis has become a source of sadness for her family, who panic whenever Nai Nai starts to cough or feel unwell. As a result, Billi acknowledges that their actions are fueled by love and affection for Nai Nai and the belief that they are acting in Nai Nai’s best interest. The enactment of the collectivist ethos, through the relational dynamics her family expresses towards Nai Nai, becomes more salient to Billi, who goes along with her family’s decision. 

Billi’s encounter with a young Chinese doctor is also key to her acceptance of the collectivist ethos. Though the encounter is brief on the screen in comparison to the screen time dominated by Billi’s family, the conversation is key for Billi’s eventual conformity to her family’s collectivist approach. The doctor, who went to medical school in the United Kingdom, is cognizant of the difference between Western and Chinese approaches to medicine. As a Chinese doctor, however, he does not want to inform Nai Nai fully because, as Lim points out, “in a collectivistic cultural milieu, the patient-doctor relationship is much more influenced by family opinions as compared with that in the West” (Lim, 2). When Billi questions the doctor on his knowledge of Nai Nai’s condition, he responds “the cancer is quite advanced. In her situation, most families in China would choose not to tell her. When my grandmother had cancer, my family didn’t tell her.” Billi points out that they are all complicit in telling a lie. He responds, “when it’s for good, it’s not really a lie. It’s a good lie” (48:00). His actions are in keeping with Lim’s observation that “doctors acting in the best interest of patients may choose to involve family consultation within the decision-making process, disclosing information to family members without the patient’s consent, so long as this is believed to be in the spirit of ‘respect for persons’ and in the patient’s best interest” (Lim, 3). The doctor, who Billi initially perceived as having a Western view of the importance of upholding patient autonomy, surprises Billi by being cooperative in her family’s decision. Relating to a personal event in his own life, he stands by the decision of not informing Nai Nai. Instead, he chooses to revert back to Billi’s family for the decision to inform Nai Nai instead of taking on the typical doctor role Billi is accustomed to experiencing. Billi’s conversation with the doctor encourages her to embrace collectivism’s lack of informed consent as she understands how common, accepted, and even preferred this approach is in Chinese culture. 

As the film’s focus is on how the collectivist approach was justified in Nai Nai’s case, there is a lack of definite acknowledgement from Nai Nai regarding her true desire. In the postscript of the movie, Lulu Wang’s grandmother, on whom the film character Nai Nai is based upon, remained alive for several years after the movie’s events took place, seemingly justifying her family’s actions and showing that the family did the right thing. However, throughout the movie, Nai Nai keeps asking questions about her diagnosis, hinting that she wants to be informed. After Nai Nai’s sister, Lu Hong, enters the doctor’s office to discuss Nai Nai’s medical test results instead of Nai Nai herself (03:25), she is seen reacting to the discussion with the doctor. She is clearly upset, but chooses not to disclose the truth to her sister. Instead she says to Nai Nai, “you’re in full health!” (04:43). Lu Hong informs Nai Nai that she has ‘benign shadows’ instead of cancer in her lungs. This scene depicts how Chinese culture views diagnosis information, in keeping with Lim’s statement that “from an East-Asian perspective, this is judged against cultural differences centred on collectivism…where group autonomy and shared decision-making are emphasised over personal privacy” (1). Nai Nai does not question her sister and holds back her questions out of respect, even when she is curious about her test results and what the ‘benign shadows’ mean. Throughout the film, Nai Nai repeatedly praises Billi’s independence and states that “it’s also good to be independent. A woman needs to be self-sufficient.” Her acceptance and appraisal of independence leaves room for different interpretations on patient autonomy and the amount of choice one should have in life. When Billi asks Lu Hong whether Nai Nai would be mad if she knew her family was keeping a secret, and how she knows that Nai Nai prefers this approach, Lu Hong responds “she did the same thing herself! When your grandpa had cancer, Nai Nai lied to him too. When she knew he was close to the end, that’s when she told him. When your Nai Nai reaches that point, I’ll tell her too” (50:36). Lu Hong’s approach is consistent with Lim’s statement, “the principal issue is not whether bad news is delivered to the patient (depriving patients of their autonomy), but rather who is best positioned to deliver the news, how it is done and when it is most appropriate to do so” (Lim, 3). Lu Hong firmly believes that continuing to keep the secret is for the benefit of Nai Nai’s health and it is Lu Hong’s duty as a family member to shoulder the diagnosis. Billi witnesses how Lu Hong cares for Nai Nai, accompanying her to all her health clinics and medical testing, which helps Billi understand that Lu Hong prioritizes Nai Nai’s health above all else and truly believes that keeping the diagnosis a secret is in Nai Nai’s best interest. Observing Lu Hong’s approach and understanding her stance, Billi becomes more inclined to agree with that approach, though she never truly knows if Nai Nai would have supported this decision. As viewers of the film, we are in the same position. 

The film, revolving around Billi’s personal beliefs about patient autonomy, beliefs that were shaped by individualistic thought but then were swayed by the collectivistic model displayed by her family, explores how the individualistic approach to medicine is not applicable to Nai Nai’s case. When Billi’s father considers informing Nai Nai, saying that in America not telling her would be illegal, Uncle Haibin points out that “this isn’t America” (49:50), highlighting how the values and norms of America do not apply to Chinese society and, particularly, Nai Nai’s family. In Lim’s article, they provide an example of the Hong Kong approach to medicine, in which individual patient autonomy is still upheld, but familism is highly prevalent, writing, “all patients have the right to be informed of bad news. Not lying to the patient. Telling the truth to the patient eventually” (Lim, 2-3). This approach is different from that of Billi’s family, which reserves the right to inform Nai Nai without the doctor and, instead, continues to perpetuate the lie to keep Nai Nai healthy. Lim argues that “core ethical principles need not be culture-bound—indeed, their very existence mandates for them to be universal and non-derogable—but instead cultural alignment occurs in the particular implementation of these principles, insofar as they respect the general spirit of contemporary ethical standards” (Lim, 1). In the context of Billi’s family, the doctor conforms to the ethical standards and practices of Chinese medicine rather than those of his British medical education. His deviance from his training proves how culturally-rooted and respected the collectivist mindset is in China, which convinces Billi to accept her family’s approach to Nai Nai’s illness. The Chinese cultural values of collectivism, intertwined with her conversations with all of her adult family members, changes Billi’s mindset. Bearing witness to how strongly her family upheld the approach, no matter how much pain and sadness it caused them (such as Uncle Haibin crying at his son’s wedding whilst thanking Nai Nai) (1:10:35), helped Billi comprehend the weight of their decision to bear the burden of the diagnosis for Nai Nai. In the end, Billi stops Nai Nai’s maid from collecting her test results (1:22:58) in order to alter the paper and continue her family’s lie. When her family fabricates a new document and shares it with Nai Nai, Billi is relieved as Nai Nai believes that her health is not compromised by a diagnosis. Billi’s acceptance and participation in the collectivist model proves how their approach is correct for Nai Nai’s case as it is perceived as ethical and in cultural alignment with her family’s values. 

Works Cited

Lim, Max Ying Hao. “Patient autonomy in an East-Asian cultural milieu: a critique of the individualism-collectivism model.” Journal of Medical Ethics, 7 June 2022. 

Wang, Lulu. (2019) The Farewell: A24.