Articles

INTRODUCTION TO READING[1]-

With the collapse of the Soviet Union, the ethical commitment reflected in the Soviet Oath no longer seemed appropriate. The changes in health care and health care ethics were rapid and dramatic. The Russians adopted a new ethic patterned closely after the Hippocratic Oath. The realities of Russian life have, however, become complex and the ethical positions adopted are similarly complex.

Two of the most important leaders in medical ethics in Russia both before and after the end of the Union are Pavel Tishchenko and Boris Yudin, both of the Institute of Philosophy, Russian Academy of Science. In this reading they describe the changes in the health care system and outline contemporary Russian positions on key issues in bioethics. The post script was prepared in 1999 especially for this volume.

In the last 7 years, Russia has seen deep changes in all spheres of political and economic life. Some new realities have appeared in Russian medicine as well. This paper tells the story of how these changes came about, what kind of unusual situations were created, and how these situations are recognized in professional and public debates.

Modern Features of the Russian Healthcare System

At the beginning of the 1980s, the need for substantial changes in the health­care system was widely recognized in the Soviet Union. The question of how a new system should be structured was opened to political and professional debates by Communist authorities. At first these debates were heavily influenced by Marxist-Leninist ideology, and all changes were directed toward modernization in an old-fashioned manner, i.e., to make direct State and Party control more effective.

The epoch of Gorbachev's "perestroika" gave birth to a fresh idea оf pluralism in medical practice. Now we can see the combination of State, cooperative, and private medical institutions. Some central hospitals in Moscow an St. Petersburg have incorporated this kind of pluralism in their general structures. For example, there are maternity hospitals where in one department service is free of charge and in another department, where conditions and services are much better, it is necessary to pay. As of January 1992, the payment for 4 days at the hospital is about 4,000 rubles (equal to the 4-month salary of a researcher in the Institute of Philosophy, half that of Gorbachev, and the same as a bus driver). Several private hospitals are now run by religious institu­tions. The professional squabble between advocates of free-market economy (minority) and advocates of socialization (majority) has little influence on everyday politics. Medical practitioners prefer to make their choices not on the grounds of ideological preferences but in a utilitarian manner, looking for indi­vidual or corporate benefits. Another feature of the modern Russian healthcare system is the gradual increase in the influence of the independent mass media. Today, healthcare providers are much more interested in having a good image expressed by newspapers and television programs.

On 28 June 1991 in the Russian Supreme Soviet, a law was passed that included regulations for a new insurance model in Russian medicine. The law will go into effect in 1993 and requires two kinds of medical insurance—oblig­atory (all citizens) and voluntary (individual or collective). The obligatory insurance is to cover the necessary minimum of medical services and the volun­tary covers all other expenses. State, private, and other kinds of medical insur­ance companies will have equal opportunities. The main goal of this legal initiative was to make patients interested in preserving their health and physi­cians interested in the high quality of their work. Unfortunately, this law to some extent is only a kind of declaration of intentions of the new democratic authorities. A large number of necessary preliminary steps have not yet been performed. The old guard of the medical establishment preserved their power, and very often they only imitate reformist activity. Even the leaders of Soviet psychiatry who are personally responsible for the collaboration with the KGB are not yet retired.

Still, the process of change in the Russian healthcare system has started and, in combination with such new (for our country) phenomena as charity funds, independent organizations of patients (diabetic societies, clubs of asth­matic people, etc.), and invalids, is producing some of the necessary precondi­tions for the existence of bioethics.

1. Healthcare political decision making, previously monopolized by State medical power, now is distributed among State committees, medical professional corporations, private capital, independent charitable funds and organizations, and the mass media.

2. The multiplicity of independent actors in our healthcare system is correlated with legitimate multiplicity of moral values that those actors are ready to use in decision making.

a. A new role of the active patient is emerging.

b. Medical professionals are becoming more liberated from their usual dependency on the State.

c. Gradually, public discussions become the necessary social mechanism of justification for each kind of policy in the healthcare delivery system. Ethics in general and bioethics in particular can exist only when people meet conflicts of moral values in their practice, when such differences are legitimized, and when people can and are ready to solve these conflicts by peaceful public moral discussion, looking for mutual benefits. These preconditions of bioethics are incorporated into a healthcare system that is now in state of chaos and misery.

The part of Russia's GNP destined for medical needs is negligible. This problem is highlighted during strikes of healthcare professionals. Shortages of every kind of resource are dramatic. On February 4, 1992, a preliminary strike of the staff of Moscow Institute of Emergency Aid (Sklifosofsky Institute) took place. Among the slogans were "Hungry physicians are useless for patients". In 1992, the Russian Ministry of Healthcare has absolutely no funds to support the approximately 100 scientific research institutes that are at its disposal. According to some estimates the number of beds in Russian hospitals this year will be reduced 50% because of decreases in the real healthcare budget. The inability of the State to provide the necessary minimum healthcare for people stimulates further increases in commercialization of Russian medicine and provokes legal methods in the healthcare providers' struggle for survival.

Distributive Justice

The fair distribution of extremely limited resources and facilities is among the most important medical ethical issues facing post-Communist Russia. The new understanding of distributive justice can be explained by a single illustration. When Gorbachev, as President of the USSR, met the problem of distribution of Western humanitarian help during the winter season of 1990-91, he had subordinated the distributive mechanism to the KGB. However, in this winter, new democratic authorities decided to organize Regional Committees, which include statesmen, representatives of the Church and the political opposition, publicly recognized respectable persons, media people, etc. This change means an evident shift of decision making from the absolute monopoly of the State as the distributor of goods to some kind of equilibrium of State and public forces. Of course, a KGB officer could meet moral problems in his practice as distrib­utor, but he had no need for public moral justification of his decisions. The practice of Regional Committees is based to a great extent on evaluation of principles of just distribution through moral public discussion and consensus. A new practice of public moral discourse has originated, which is a sign of hope for bioethics in our country.

Another change concerns the tactics of justification of inequality of distri­bution of social benefits, including access to healthcare. The principle of socialism "from each according to his (her) abilities, to each according to his (her) work" had been used to justify the existing inequality: a high-ranking Party boss had greater access to healthcare because his work had greater social value. New democratic authorities inherited such privileges with the presup­posed model for justification.

In addition to this old sense of justice, a new one has emerged. Now thereare a lot of advocates of the idea that inequality produced by fair competition in a market economy is also just. Those who produce more social goods should have the right to greater access to social benefits, including medical services. The beneficent and charitable practices of "newly rich" men are actively adver­tised. Increasing public justification of inequality becomes a very important moral balance to traditionally influential egalitarian feelings among Russian people.

Definition of Death and Transplantation of Organs

There is no ethical debate in Russia on the problem of the definition of death. Brain-oriented criteria did not cause any publicly articulated objections. The concept was legalized by temporary instructions of the Soviet Healthcare Ministry in 1985. In 1987, the permanent instruction was adopted. In this instruction, death is diagnosed by the irreversible cessation of brain stem func­tion, or "brain death." The diagnostic tests do not differ from those used in other countries. In special applications, there was a complete enumeration of medical institutions (very limited) where the practical usage of this definition was permitted. The majority of hospitals and clinics had no necessary equip­ment for diagnostic tests or well-trained neurologists. The worst aspect of the situation is that diagnosis of brain death is usually made by doctors who are in close relationship with scientific teams responsible for organ transplantations. Inadmissibility of this situation is well recognized by all involved parties. In December 1990, The Centre of Surgery of the USSR Academy of Medical Sciences organized a special meeting where ethical and legal problems of transplantology were discussed. Progress was made during a 3-day interna­tional meeting on Bioethics and Social Consequences of Biomedical Research organized on the initiative of UNESCO by the USSR Academy of Sciences' National Center for Human Science, the Institute of Philosophy, and The Centre of Surgery USSR Academy of Medical Sciences in May 1991. The special Declaration of Soviet Participants in the UNESCO international meet­ing was issued in view of the development of clinical transplantology. This Declaration calls upon:

1. the State and public organizations working for charity and beneficence to form an independent association for the development of clinical transplantology whose main task would be the implementation of economic, legal, and ethical decisions without which the development of clinical transplantology in our country is impossible;

2. the scientific academies, societies, and organizations that finance scientific research and clinical practices to organize independent committees to perform legal, ethical, and economic assessment of the projects to be financed;

3. the Committee for Public Education to include in school, college, and university curricula courses in bioethics that would prepare the future generations to meet extraordinary situations that will be created by new biomedical technologies.

Of course this action was only a declaration but it showed the readiness of medical authorities to collaborate with philosophers, clergy, lawyers and the public to solve their professional problems, rather than trying to do so only within the professional community.

One of the most acute problems is financial. The State has not enough money to finance transplantology. New resources were found in joint ventures with Russian and foreign medical firms (for example, providing clinical testing of new drugs or medical equipment), in charity funds, in private charity dona­tions, and in forms of cooperation with nonmedical institutions on a barter basis. The barter system is specific for modern Russia. For example, when one of the largest plants in Moscow helped one of the surgery hospitals with money and equipment, the plant workers received privileges on a "waiting list" for transplantation of kidneys. The same situation occurs with foreign patients who are ready to cover expenses in hard currency. There were some objections in the media against "illegal and amoral sale of Russian kidneys abroad." One of the influential members of the Commission on Healthcare Problems in the Moscow Soviet named this practice "The Satan business." But none of those critics made any useful recommendation for how to solve our financial prob­lems in other ways and their cries were submerged in public silence. Nevertheless, a new direction for the corruption of equal distribution in the healthcare system has been created.

Physician-Patient Relationship (Ph-PR)

Moral problems in Ph-PR have very specific historical grounds in Post-Communist Russia. There is a strong tradition of transparency of all types of social life to State control. There was no place for privacy in any kind of professional activity including medical practice. Even the Russian Orthodox Church for a long time was only a department of government in the Czarist state. Peter I abolished the sacrament of confession in the beginning of the 18^th century. Bolsheviks radically strengthened State control and made it more universal. In this political system, the social role of the physician was reduced to that of passive screw in the mechanism of state government. In the Soviet Medical Oath, the superior responsibility of the physician is to "my people and the Soviet government" and he (or she) solemnly swears "to work in a good conscience wherever it is required by society" (that means by State or Party). This "medical screw" has a very low social value. Today the salary of a physi­cian is approximately ¾ that of a charwoman in the Moscow Metro and 1/5 that of a Moscow bus driver. Now we can see a strong wave of strikes organized by medical professional unions to change the existing order of things. Not only do economic problems provoke these strikes, but there is a clearly articulated will to obtain more social value. Therefore, the starting point for moral debates on Ph-PR is not only the vulnerability of patients but also that of physicians. It is impossible to speak about privacy or confidentiality until healthcare providers are sovereign social actors. Physician autonomy and self-determination are necessary preconditions for possible trust on the side of the patient. One episode that took place in a laboratory of anonymous HIV testing gives a good example. This was a telephone conversation with client:

Hello, is this the anonymous diagnostic laboratory?

Yes, sir.

May I come today for testing?

You are welcome.

And have I to bring a passport with me?

…?!

This strange question is a result of long social training, and it will be a long time before people believe that physicians have a right not to inform State authorities against their clients and that there is strong legal protection for such rights. But such belief can be based only on respect for the power and authority of the law. In Russia, there have never been strong legal traditions. Russian people are trained to protect their interests not through hearings in courts but by looking for restoration of justice through the mercy of those who govern. Soviet patients used to send letters with complaints (actions) against physicians to the Healthcare Minister or the General Secretary of the Communist Party. It will take a long time to turn the vertical relationship of servile "brotherness" of the patients and physicians under supervision of State authority into a horizontal relationship of civil "otherness" under protection of the law.

The problem of distrust in the Ph-PR common to Western countries and Russia will be solved in different ways. In Russia it is necessary not to redistrib­ute decision-making power between patients and doctors but to recreate power in both parties and to initiate movement toward each other on the grounds of mutual respect.

Psychiatry and Behavior Control

The problem of repressive psychiatry in the Soviet Union had a very narrow political interpretation. The struggle against involuntary mental hospitalization was a part of dissident activity. The main interest was focused on collaboration of psychiatric authorities with the KGB and absence of legal protection against such abuse of human rights. In 1988, the new legal regulation for psychiatric service was adopted by the Supreme Soviet of the USSR. The Purpose of the law was to increase the autonomy of psychiatric patients and to give effective protection to their human rights. Criminal penalties were provided for malevolent involuntary mental hospitalization of evidently normal people. Mentally ill patients received the right for lawyer assistance and defense of their interests in court. However, independent organizations of psychiatrists have criticized this law because it leaves room for old-fashioned repressive interpretations. A new bill of special regulation for psychiatric service is now being discussed in Commissions of the Russian Supreme Soviet.

Other debates include the problem of experiments in the field of behavioral control practiced by the KGB and the use of soldiers and prisoners as subjects in experimentation. An independent investigation, organized by the media, is being carried out.

In contrast to Western countries, there have been no ethical questions raised about the potential harms of uncontrolled psychiatry and behavioral control. Consequently, a wide variety of "therapies" have proliferated outside any controls—legal, educational, or financial. A major problem now is to address this lack of constraints and establish necessary social policies and professional guidelines.

Abortion

For a long time, one absolute value—the idea of Communism—gave exact values to all matters and problems in our lives. What was good for the construction of Communism was the absolute Good. The problem of abortion was not excluded. In 1920, the USSR was one of the first countries to legalize abortion. During the period of industrialization, acute lack of labor resources motivated State policy in this field. Party leaders wanted to quickly increase the number of workers by involving women in industrial production, and abortion became one way of liberating women from their traditional family dependency.

In 1936, prohibition of abortion was supposed to help improve the demo­graphic situation, which deteriorated during the period of collectivization of agriculture and the Great terror. Another part of this policy was restriction on the production of contraceptives. In spite of the legalization of abortion during the Khrushchev government (in 1955), the state policy in this field did not change. This policy resulted in a permanent shortage of contraceptives, an increased number of abortions, and an official and rigorously promoted attitude toward women who made such family-limiting decisions as semicriminals or moral deviants. This attitude was expressed in strict limitation of anesthesia. Pain was justified as a sort of social penalty. But it was not harmful to kill a fetus; it was harmful to damage State labor resources.

Current public debate concerning abortion practices reveals the usual opposition of interests between rights of a woman for self-determination and rights of a fetus for life. The dominant feature of this debate in Russia is theappeal to recognize women who decide to have an abortion as normal patients and to treat them with mercy and compassion. The rights of a fetus to life are advocated in an old-fashioned manner by religious organizations.

The program of studies in ethics for students of medical schools was formulated and implemented long before "perestroika" started. It does not require special theoretical studies, and elements of the theory of medical ethics are incorporated into courses of philosophy, history of medicine, and "introduction into the profession. " In general, this theory of medical ethics is heavily overloaded with communist ideology. It stresses duties of healthcare providers to the State, government, Party, and Soviet people. As is pointed out in a popular dictionary of ethics, "Man becomes a moral person when having comprehended the content and meaning of his acts, he voluntarily submits himself to moral requirements of society." If someone did not voluntarily submit himself to "moral requirements of society, " which were exclusively articulated by the Party, then that person could be submitted involuntarily by the KGB or by psychiatrists. The problems of practical application of ethical principles are supposed to be discussed during the teaching of therapy, surgery, and other medical subjects.

Of course, in the modern situation it is impossible to follow the old-fashioned program literally. The majority of teachers make changes by replacing communist ideology with the ideology of "new thinking." "New thinking" emphasizes the priority of universal human values over the values of class, nation, profession, and other groups. Yet most partisans of "new thinking" remain deaf to the rights of the individual against the interests of society.

In 1991, the first course of lectures on bioethics was formulated and imple­mented at Moscow State University at the Department of Philosophy (with about 20 students). The course requires 1 year of theoretical studies and contains all topics usually found in programs of bioethics in the United States. In 1991, the first semiannual course of lectures on the philosophy of healthcare and bioethics was implemented at the Department of Psychology of MSU for a group of clinical psychologists. The main focus of teaching was on the issues of physician-patient relationships and death and dying. In 1991, a course on bioethics was started in Samara Medical School. The specific features of bioethical courses at MSU are connected with the traditions of Russian and European philosophy.

In the Institute of Philosophy and the Center for Human Studies of the Russian Academy of Sciences, there are now several postgraduate students who are specializing in bioethics.

Bioethics and the Media

Bioethical problems are getting more and more attention in Russian newspapers and magazines. Among the items most often discussed are organ donation and transplantation, euthanasia, allocation of resources and access to healthcare services, experiments on human subjects, and tendencies in AIDS and HIV infection (this infection in Russia is developed commonly due to the malpractice of medical personnel).

The only journal that attempts to discuss bioethical issues in a regularmanner is the bimonthly Chelovek (The Human Being). This journal began publication in 1990 and has included articles by E. Pellegrino on medical ethics in the USA and by B. Yudin about discussions on euthanasia in the Russian media (No. 2, 1990). An extensive report about discussions on prospects of bioethics in Russia ("Round-Table") was published in two issues (No. 6, 1990 and No. 1, 1991), and a round-table discussion on social and ethical problems of transplantology was published in No. 4, 1991. The journal has also published articles concerning ethical problems of biomedical research, including those arising from the Human Genome Project.

In general, the media, the public, and the politicians in Russia do not yet understand that the field of bioethics is very important in the realm of human rights.

Bioethics as a Social Institution

Bioethics as a social institution includes five distinct yet interrelated domains of activity: 1) grass-roots and media activity to help shape and reshape healthcare policy; 2) bioethical structures such as ethics committees in hospitals, research institutes, and elsewhere; 3) law making in the field of biomedicine; 4) bioethical education; and 5) bioethics as a multidisciplinary area of scientific research.

The current situation in Russia as it pertains to each of these domains can be summarized as follows.

1. Growing concern about the present and future of the healthcare system is evident in Russian society. This concern is expressed in the media, yet it remains diffuse, and different topics (such as transplantation, euthanasia, abortion, etc.) are not understood as components of the whole. As a result, most such discussions end without definite results.

2. Recently, some leading centers of biomedical research have tried to establish bioethics committees. A new Russian National Committee on bioethics under the aegis of the Russian Academy of Sciences has been formed. The first step of the Committee was the organization of the Commission on protection of animals as subjects of scientific experimentation. Another bioethical institution, The Center of Biomedical Ethics and Law, was organized in Moscow in 1990. It conducts regular interdisciplinary debates on urgent problems of Russian medicine. A proposal to establish an all-Russian Committee on biomedical research will be submitted to the President of Russia and thereby will not be controlled by medical or academic authorities. Ethical assessment and regulation will be among the principal goals of this Committee.

3. In Russian society, much work must be done in the fields of medical law and judicial regulation of healthcare practice and biomedical research. The current situation in this field is disastrous. Many people were compelled to speak about the necessity for law-making activities, for example, about the need for new legislation after facts about commercial use of organs and tissues from cadavers became public. Implementation of a healthcare insurance program makes the need for legal reforms more noticeable, and lawyers are showing some interest in medical specialization.

In November 1991, the Declaration of Rights and Liberties of Citizens was adopted by the Russian Supreme Soviet (parliament). It establishes the principle of voluntary consent regarding participation in scientific or medical experiments (article No. 8) and the right of every citizen to qualified medical aid in the state healthcare system. Non-state forms of healthcare services were also legalized. A new draft of legislation on "protection of health of citizens of Russian Federation" passed first hearings in the Healthcare Committee of the Supreme Soviet. This law will bring radically new approaches. One of the main ideas of this draft is to transform the whole system of healthcare. The Ministry of Healthcare will be only one of several elements under the control of Society and the State. According to the draft, management of biomedical research, as well as management of medical expertise (including medical statistics), must be implemented by agencies directly subordinated to the Russian president.

Previously, medical and healthcare legislation was mainly declarative and strongly laden with ideology. The new draft, which is much more concrete and definite, stresses rights of patients and their families. It includes six chapters:

I. General principles

II. Rights of citizens and of different categories of the population to healthcare and medical and social help

III. Protection of rights and legitimate interests of citizens in the sphere of health

IV. System of healthcare of Russian Federation

V. International cooperation

VI. Activities of professionals (including the rights of physicians and the obligations of physicians)

An important point in relation to this draft is that it must be, after its adoption, a "constitutional law," in that all subsequent legislation in medicine and healthcare will become a "detailization" and extension of it.

4. The first steps in bioethical education have already been taken in Moscow and Samara.

5. Fragmentary scientific research work in the field of bioethics has started in the Russian Academy of Sciences. It is possible to find publications on bioethics in medical, biological, judicial, and philosophical journals. Forgotten during the Communist government, the intelligent humanitarian traditions of prerevolutionary Russian medicine become more attractive to modern scholars.

Post Script: Seven Years After

After approximately seven years of reforms that have come since our previous observation, Russian health care is still in the process of transition heavily influenced by the unstable economic and political situation in the country The vector of the transition is rather unclear. At the moment the system combines in an eclectic manner "for free" and "for profit" programs of provision of medical services. Free provision of medical services that covers in principle all Russian population is achieved through two basic mechanisms—direct financing from the federal and regional budgets in combination with obligatory medical insurance. Obligatory medical insurance, as a federal system, is still in the process of painful development. Both systems in combination could provide ordinary patients access only to a minimal amount of medical services. As it was during the communist administration, special privileges for access to free high quality health care are available for the Russian ruling elite.

"For profit" programs combine direct payment in cash and mechanisms of voluntary medical insurance. The latter have suffered dramatically during the financial crisis in August 1998. "For profit" programs offer high quality and high technology medical services practically in all areas of modern medicine. The existing level of prices is much lower than in the USA and Western Europe, but (in spite of this) not affordable for the majority of the Russian population. Demarcation lines between "for free" and "for profit" programs are not clearly designed in legislation and institutional policies of the Russian Ministry of Health Care. That is why in a lot of cases the mere necessity to pay and the level of payment could be a matter of special negotiations between physicians and patients.

Development of Medical Legislation and New Features of Physician-Patient Relations (Ph-PR)

During this period several very important steps for legal framing of new patterns of relations among physicians and patients were taken. In 1992 the Russian Parliament had adopted legislation entitled "On Transplantation of Organs and Tissues" that legalized the concept of "brain death" and the "presumed consent" model for harvesting of organs. New legislation on the provision of psychiatric services that gave some guarantees for protection of patients rights and prevention of practices of "repressive psychiatry" existed in the USSR was adopted in the same year. In 1993 the "General Law on Health Care of Russian Federation" was adopted by the Russian Parliament. The law has legalized development of medicine in Russia as a combination of federal, municipal and private medical institutions. It was the first law that guaranteed protection of basic patients rights: informed consent for every medical intervention, protection of privacy and confidentiality, the right to terminate treatment, the right to know one's diagnosis and prognosis, the right to choose a physician and medical institution and some other rights. The law also gave protection to research subjects and framed physician-patient relations in new reproductive technologies. It also has a special article that forbids active euthanasia.

Some important legal norms for development of "for profit" programs in health care were established by the "Federal Law on Protection of Rights of Consumers" (1996). The "Federal Law on Medical Drugs" adopted in 1998 had established research ethics committees in every medical institution participating in clinical testing of new drugs. At the moment it is very difficult to say to what extent such committees exist not only in a "paper form," but in reality too. The law also prescribes organization of an ethics committee for review of programs of clinical testing in a Federal Agency controlling quality of medical drugs.

Several other bills were prepared in the Russian Parliament to modernize this legislation, but none of them was adopted. As examples we could mention bills on protection of patients rights, reproductive rights of citizens, a new medical oath, and a bill with a strange sounding name—"Federal Law On Legal Foundations of Bioethics and Its Guarantees." Legislators defined "bioethics" in this bill as a "set of traditional values in healthcare." The last legislative initiative expresses increasing influence of conservative, traditionally-oriented (including religious) groups aiming to limit abortions, forbid experimentation on aborted fetuses, limit development of new reproductive technologies (e.g. forbidding "surrogate" motherhood), introduce a model of "presumed non-consent" in harvesting of organs for transplantation, and prohibit creation of transgenic organisms that have human genes in their genome. This bill is to some extent a reaction to bills that were proposed and lobbying by some medical "interest groups" wishing to widen liberties of physicians in the provision of new high tech services, for example in the area of reproduction.

Development of new legislation in health care that is more sensitive to the ideas of patients rights and general changes in the mentality and behavioral values of the Russian population influences basic patterns of Ph-PR, making them less paternalistic, more oriented on individual choice, and more tolerant to market-oriented provision of health service. More cases of conflicts among physicians and patients are settled not through complaints to governmental authorities (which was characteristic of the situation in the USSR), but in courts. Most cases are concerned with malpractice, but some (and this group has a tendency to grow) are connected with limitation of patients rights (e.g. treatment without consent).

New legislation and growing experience of Russian biomedical professionals in international scientific collaboration produce some improvement in moral standards of research on human and animal subjects. For example, written consent (not necessarily adequately informed and from this point of view not in the full sense voluntary) is now a usual procedure in recruitment of  research subjects. Some research organizations (like Russian Humane Genome Project) have developed their own moral guidelines for research and application of biomedical knowledge that correspond in most positions to Western standards. The Russian Ministry of Health Care has established its own "Ethics Committee" for review of moral conflicts in medical practice, development of new institutional policies, and improvement of education of medical ethics in medical schools.

An important feature of today in Russia is a growing number of patients groups and organizations that through mechanisms of mutual assistance (in education, provision of information and other ways) are trying to solve health problems in the existing difficult social and economic environment. Correlatively, we could see self-organization of medical professional groups aiming to make better professional and moral standards for the provision of medical services. Organizations of physicians and other medical professionals establish their own ethics committees, develop moral guidelines, etc.

Very important steps (mostly in the area of education) are taken to appropriate the new idea of nursing that has its own independence from physicians in providing health care. New role models for nurses have special importance in the field of provision of health care for patients in terminal conditions in hospices and medical institutions having programs of palliative care.

Development of Bioethical Research and Education

In 1992 Russian National Committee on Bioethics (RNCB) was established inside Russian Academy of Sciences as a nongovernmental and noncommercial research institution that today coordinates most of academic activities in this area.

RNCB (in collaboration with different scientific and medical institutions) has organized several conferences in which philosophers, lawyers, medical doctors and scientists from different regions of Russia participated: "Ethical and Legal Problems of Clinical Testing and Scientific Experimentation on Human and Animal Subjects." (1994), "Death and Dying: Interdisciplinary Interpretation" (1994), "Hospice movement: moral, philosophical and social problems" (1995), "Social Problems of Children's Oncology" (1997), and some others. In 1992 RNCB published a special report entitled "Vaccination and Human Rights" in which practices of involuntary vaccination in Russia were criticized.

Since 1995 RNCB has received grants from the Russian Scientific Program "Human Genome". These grants fund both theoretical (philosophic and moral) and empirical (sociological) studies. Several surveys of the Russian population were performed to reveal attitudes towards different polices о genetic betterment (including eugenic). For example, it was found that one-third of the Russian population is ready to support eugenic policies such as involuntary sterilization of "subnormal" persons (alcoholics, drug abusers, homosexuals etc.) and involuntary abortion of fetuses with genetic “defects”.

A growing amount of research in bioethics is now being performed universities and departments of philosophy of medical schools in Moscow, Krasnoyarsk, St. Petersburg, Saratov and Volgograd. These research projects cover most fields of modern bioethics with the exclusion of the problem of justice in health care.

Academic journal "Cheloveck" (Human being) publishes many of the bioethical papers in Russia. It had presented debates on euthanasia, definition of death, ethics of scientific research, ethics of modern genetics and so forth. Other academic and medical journals also welcome papers in bioethics. Before 1991 (the time of our first review) there were no books in Russian that could systematically present basic problems of bioethics for scholars and for the public. During the last few years several books were published in the field: A. N. Bartko, E. P Mykhaylova "Biomedical Ethics (theory, principles, problems)" part 1, 1995; part 2 1996; "Biomedical Ethics", editor VI. Pockrovsky, 1997; "Beginnings of Bioethics", editor A. N. Orlov, 1997; "Introduction to Bioethics", editor B. G. Yudin, 1998; "Bioethics: Principles, Rules and Problems", editor B. G. Yudin, 1998.

Teaching of bioethics is presented in a large number of medical schools around Russia and in some departments of philosophy in universities. Still we could say that the system of bioethical education is only in the process of development.

Literature (for more information)

Tishchenko, Pavel "Corruption: the Russian experience" in Bulletin of Medical Ethics, number 121, September 1966, pp. 13–18.

Tishchenko, Pavel "The Individual and Healthcare in the New Russia" in Cambridge Quarterly of Healthcare Ethics, vol 4, number 1, winter 1995, pp. 75–79.

Tishchenko, Pavel; Yudin, Boris, "The Moral Status of Fetuses in Russia" in Cambridge Quarterly of Healthcare Ethics, vol 6, number 1, winter 1997, pp. 31–38.