Tishchenko P. D. Corruption: the Russian Experience
Is corruption a necessary part of today's health care system in Russia? That is one of the questions raised in the first paper in the September 1996 Review. The second item is also intended to provoke discussion, being a draft Bill to permit physician assisted suicide. It was drafted by the Voluntary Euthanasia Society who would welcome comments on it. The section ends with summaries of empirical studies.
The transition of Russian health care from
the Communist to post Communist state took place within an economic and political environment usually labelled as 'corrupt'. Such a judgement is backed by sound empirical evidence. But before applying such a normative notion and jumping to conclusions which are unpleasant for Russian health care professionals it is prudent to first make clear what is meant by ‘corrupt’. In political and moral reasoning it often means some deviation from a moral and/or legal ‘standard’ of professional service. The Webster’s Collegiate Dictionary gives a group of similar interpretations of this word – ‘impairment of integrity, virtue or moral principle’; ‘inducement to wrong by improper or unlawful means (as bribery)’; ‘a departure from the original or from what is pure and correct’.
All these meanings are often attributed to both Soviet and modern Russian medicine. It departs from the ‘pure and correct’ original of the socialist ideal of universal health care that is still officially preserved. Improper means such as ‘bribes’ are not rare in Russian healthcare. From the Soviet as well as Russian moral perspective this constitutes an ‘impairment’ of medical professional integrity and moral standards.
At the same time, I share concerns expressed by some researchers of Russian health care about the significant confusion that could result (and often does) if this term is used without critical reservations.‚  Corruption was one of the most powerful causes of the collapse of Communism. That is why there are scholars in political science and politicians in Russia who would like to emphasise the progressive role of corruption as an important mechanism of ongoing transformation of an ‘utopian’ society into a ‘normal’/capitalist one. Corruption is treated from this point of view as a ‘moral’ resistance of the population (including medical professionals) to unrealistic Communist standards imposed on their professional activity.
I would like to discuss the possibility that there is ‘a moral right to corruption’ for Soviet and Russian physicians in the same sense as Englehardt has proposed ‘a right to the black market’. Is it correct to justify corruption with the accepted right to resist totalitarian domination?
As soon as corruption constitutes a deviation from a moral standard it is necessary to initially consider some principle features of the Soviet normative ideal of good medical practice and its relation to reality.
Socialist ideal of health care
As Mark Field eloquently wrote ‘the blueprint of the Soviet socialised medicine held the promise of universal (though not necessarily equal) health security to the population, at the expense of society (or the polity) from birth to death...’. 
The medical profession was entitled to fulfill this blueprint, not as a sovereign social group, but as a representative of the state. Even in modern medical legislation the medical profession is not recognised as an independent partner of the state in health care, as a social group that has something of its ‘own’ (that doesn't belong to the state), including its own economic interests. Most of the articles of Soviet and modern Russian medical laws sound like state guarantees – ‘The state guarantees a provision of health care to all pregnant women’ or ‘cancer patients’, or ‘children’. In such conditions poorly paid physicians had an official image of beneficent unselfish state protectors of public and individual health who provided their services for free to all people.
This official image was internalised by medical professionals and replicated in the normative teaching of the socialist organisation of health care. At the same time this image was absorbed into public consciousness during 70 years of Communist propaganda as the standard of good medical practice in general.
From my personal experience (which complies with the observations of independent researchers) this standard should be treated more as a political myth, than something that had or has a sound normative power inside Russian medical professional activity. ‚  It was and is ‘for all’ only in official declarations and for an extraordinarily low standard of ‘medical’ services. In many rural districts there were no physicians at all. A significant number of medical institutions (hospitals) had (and have) virtually no modern medical equipment and a limited supply of simple medical instruments and medicine, no plumbing or sewerage.
‘At the time of the Soviet collapse, supplies of sterile needles, syringes, gloves, intravenous tubing, dressing supplies, surgical instruments and basic medications were sufficient to meet only 10% to 20% of need’. If considering that this 10% to 20% was distributed to the level of ‘socialist' justice – 50% of resources went to less than 1% of the population and 50% to 99% of the population, it is easy to imagine the real Soviet meaning of the attractive principle ‘for all’.
As I make clear in the following paragraphs, the health care that existed and exists deviates from the blueprint of socialist medicine in the sense that it was and is ‘for free’ to a very limited extent of usually low quality ‘average’ services.
So, to the most extent it was and is a political myth, but a powerful myth. Two practical consequences of applications of this mythology are the most interesting for this discussion. First, this myth had determined the blueprint of the Soviet legislation on health care, and it determines the main trends of modern Russian medical legislation today. Physicians are treated in the legislation mostly as ‘unselfish benefactors’ whose duty is to provide their services ‘for free and for all’. That is why a significant number of adopted laws in this field had no practical use as judicial norms for regulation of medical practices, for coordination of economic interests of the medical profession and interests in health care of the population. They are like declarations of good minded political intentions – guarantees of the state and duties of physicians. For this reason in previous years there were very few cases in which the law was used for resolution of conflicts inside the health care system and for protection of patients or physician’s rights or interests. Accordingly, that is why the rapid development of ‘for profit’ programmes in modern Russian health care is mainly in a grey zone, out of legal regulation.
The second practical consequence of the myth of the socialist medicine is an unrealistic and illusive standard of a good medical practice as ‘unselfish’ and ‘free for all’ that dominates public opinion. The population doesn't treat medical doctors as independent individuals who have a right to ‘own’ something, particularly their own economic interests and property. This socialist ideal was imprinted on the mentality of the Russian people. Naturally each deviation from this standard, especially if connected with physicians making money, is interpreted by the public as corrupt. As soon as the whole system of Soviet and modern Russian health care doesn't match this ideal the public often thinks it is totally corrupt.
The conclusion is simple. One of the causes of corruption in Soviet and Russian health care is a result of an Utopian standard of medical practice that does not match with real life and real economic interests of medical doctors, and which was imposed on the medical profession by a totalitarian regime and internalised by the population. In order to escape a problem so typical in the post Soviet economy, some theorists and politicians offer to turn the tables – to make normative what is normal in real everyday life. That means legalising and giving moral authority to practices that are treated under a Utopian ideal as corrupt.
How does this real system work?
A neutral description of corruption
For better understanding I would like to neutralize my moral feelings for a moment and think of ‘corruption’ in a positive way. First, it is necessary to consider the very low social status and level of financial reimbursement of medical professionals in the USSR and Russia. Because of ideological considerations, salaries of medical doctors were only about 70-80% of the salaries of factory workers. UNICEF experience shows that whenever wages drop below what can be called an ‘efficiency wage’, survival considerations take precedence over contractual obligations and professional pride. Let’s just imagine the existential feelings of an ‘average’ Russian physician in July 1996 with a relatively low salary. Even this salary has not been paid during the last two to three months. In such a case ‘corruption’ – as an attempt to get some money for services that she or he under the law should provide ‘for free and for all’ will be a matter of survival for this physician and her/his family. The same principle existed in a less aggravated form in the USSR.
That is why in the USSR it had become a common practice for physicians to receive money or goods as an additional, ‘under the table’ payment for their services. The judgment about the moral value of such a practice would be different from different perspectives. From the standard Soviet point of view it is an evident case of corruption.
But with a broader perspective this could have another meaning. ‘In the United States, as in the Soviet Union and its successor states many doctors are not satisfied with what the government health plan would pay for treatment. In the former Soviet states, where most doctors are still paid a salary by the government, expecting extra payment as a condition of treatment is often equated with demanding a bribe... In the US, such practice is called good business and is supported by many medical societies’.
This ‘bribe’ was not something special for medical practice in the USSR. It was and is an important mechanism that determines how all limited resources are usually distributed. Donald Barr gives a good description of how this mechanism works: ‘In Soviet society, high quality care (by relative standards) was also a scarce commodity. As with other scarce commodities in the Soviet Union, these services were available through the ‘second economy’ on an unofficial barter system... Consider the Russian family with a plugged toilet. It could take weeks before the state plumber would get around to coming and fixing it. On the other hand, if the family happened to have an extra...bottle of vodka, the toilet would be fixed before dinner, often by the very same state plumber.’
The Soviet second economy represented (and in many areas represents) a relatively orderly economic system for the distribution of scarce goods and services. Through the effect of supply and demand, a system of prices was established, and it came to be commonly understood that payment in kind was expected. This was as true for food and clothing as it was for medical care.
Today it is already less true for food and clothing, which have become ordinary commodities on the market of the ‘first’ (normal) economy, but it is still true for so called ‘state’ health care. This observation gives us a chance to understand better the special features of the political economy of Soviet and post-Soviet health care – the real economic system in which a Russian physician was forced to make his or her moral choice.
Next I clarify a notion of ‘property’ and ‘property rights’ in such a barter system. This will help us determine the application of Engelhardt’s conception of a moral right to the black market to Soviet and Russian medical corruption.
Friends and enemies of Communism usually take for granted as characteristic of the Soviet political system a notion of the state, or people’s property, including people’s property in resources of health care. In reality this economic and political entity covers a diffused pattern of social interactions. Donald Barr has limited his explanation of the ‘second economy’ to personal relations between an individual physician (or plumber) and a client. Even at this level we can find consequences that will help us to understand what was and is hidden under the label of ‘state property’.
Let us modify Barr’s example and examine a case of barter between a physician and a plumber. Imagine that their unwritten contract concerns an exchange of the privilege of access to the limited resources of health care and plumbing services respectively. Now let us ask – whose property is in the process of exchange? Under the official written law this property belongs to the state, or to all people. But from the perspective of what modern Russian economists call unwritten or ‘customary laws’ still governing the country, this property is already privatised to the extent that a partner in such barter interactions could control the distribution of scarce resources at will.
Now let us consider that the same process of barter in principle, goes on not only at the level of individuals interactions, but on the level of medical institutions, factories, regional bodies administering health care and municipal services, medical centres, industrial corporations, different departments of the ministry of health care and other governmental bodies.
As it was shown in works of Russian liberal economists, the state property in the USSR was de facto mostly privatised already in Brezhnev's time., , ,  So the process of ‘privatisation’ happening today is to some extent a further development and legalisation of property rights already shaped by customary ‘laws’ inside communist society.
High quality medical services, and high tech medical diagnosis and treatment that were always in limited supply were ‘privatised’ for the most part. ‘Average’ services that were accessible ‘for free and for all’ stayed as ‘unwanted’ state property. The notion of ‘average’ differs in different places. What is and was ‘average’ in Moscow could be an extremely scarce resource in Chechnya, Uzbekistan or rural Russia. Only this residue of low quality medical services can be considered as health care resources that were and are free for all and under common people’s ownership.
This general speculation could help us to understand now that under the label of state property in health care lies a complex of different property rights with uncertain and unstable border lines that are shaped by unwritten customary ‘laws’. Naturally all these unwritten customary rights were never publicly discussed and recognised. People acted due to these ‘laws’, but usually did not realise this. It is and it was like a ‘collective unconscious’ into which different economic desires and interests were ‘repressed’ by the communist state ‘super-Ego’ in the form of totalitarian ideals for socialist health care.
That is why it is an emotionally painful surprise for the public to perceive the power of private property, established by customary rights, in areas where people do not expect it to exist. It is easy to predict that in trying to put their painful emotions into words they use as both a description and a normative judgement the word ‘corrupt’.
Who are owners of our cadavers and aborted fetuses?
The development of transplantation programs in the later years of the Soviet Union and in Russia today is fatally connected with a permanent scandal in the national and international media. The central, most painful problem, is the right of physicians to profitably harvest organs from cadavers. In the USSR an official practice existed of harvesting organs and tissues from cadavers without the consent of relatives, or even without their right to refuse this harvesting. The state was a kind of owner of human bodies after death, and medical doctors as the state employees were entitled to control the use of this state property for state interests. As all other social actors in the USSR, they had participated in the barter economy de facto (at any rate partially) privatising this special state ‘property’ to the limits of their factual control. The main limit was the necessity to preserve the intact appearance of the dead body displayed in funeral rites. All other manipulations which didn’t cause disfiguration of a cadaver were permitted.
That is why after ‘perestroyka’ morgues of medical hospitals started the highly profitable business of harvesting and selling organs and tissues for transplantation (e.g. cornea, bones, skin), pharmaceutical production, education and other purposes both inside the country and abroad. This became possible only because of the customary rights of medical professionals to private ownership of human bodies (or at any rate their organs and tissues) after death. Many attempts to implement new legislation regarding autopsies that will redistribute these property rights in favour of allowing people to control the fate of their bodies after death through special wills, or to recognise the ownership rights of relatives, have failed under the pressure of a powerful lobby in Parliament.
The same thing is happening with the commercial use of aborted fetuses. For the public, the mere fact of making money by using fetuses for transplantation is a case of unbelievable corruption of medical professionals.,  But, in fact, medical professionals have this right to control aborted fetuses under the Soviet legislation. In the Soviet Union aborted fetuses, along with all other ‘wastes’ of maternity and gynaecological services, belong de facto to the state and de facto to medical professionals who can use them for research, educational and other purposes.
Perestroyka opened a door for commercial use of this ‘property’. The very profitable business of harvesting organs and tissues from cadavers and aborted fetuses which has dubious legal grounds, resting mostly on customary rights, is the most upsetting example of a great number of tacit privatisations and profitable uses made of state property. From the perspective of socialist health care standards, all such cases of privatisation of what is supposed to be people’s or state property are reasonably labelled as cases of ‘corruption’.
Post Soviet Russia on one hand inherited the socialist standard of good medical practice, and on the other hand unleashed a tendency in health care to privatise the people’s property. There is a historical irony in the fact that representatives of the Russian medical establishment who are profiting most from such privatisation are also the most energetic advocates of traditional values of socially oriented medicine’. As soon as the public accepts such a self description of medical professionals and tries to apply it to the real practices of Russian health care, the logical result is that this system is judged as totally corrupt.
Understanding the causes of corruption (both ideological and economic) and special customary property rights that determine the development of unacceptable (from the standard Soviet point of view) commercial practices in health care does not constitute its moral justification. I think that it will be useful to try to apply for purposes of moral interpretation of the phenomena of corruption in Russian health care a concept of H. T. Engelhardt Jr. of ‘the basic rights of persons to the black market’, and the generally accepted notion of the moral right to resist totalitarian rule.
An attempt to morally justify corruption
According to Engelhardt, the moral justification for a black market is based on the ‘principle of ownership’. ‘The principle of ownership is central to understanding the roles of public and private funding of health care, as well as rights of physicians to exempt themselves from constraints of national health services. Owning private property, insofar as such private ownership exists, will always permit patients to buy around the established system. So, too, having the right to own one’s talents will permit physicians to sell around the constraints of such a system. This can be tendentiously summarised as the basic right of persons to the black market’.
Official Soviet and post Soviet ideology does not recognise physicians’ property rights in their talents and treats them as a part of the state bureaucratic machinery. Customary ‘laws’, at any rate partially, restore physicians’ property rights and return what justly belongs to them. As soon as the rights of owners to their talents are recognised, medical doctors are given the moral justification ‘to look around’ the state system, and to sell their own property (talents) on a black market.
But Russian physicians are selling around the state system not only their talents that justly belong to them. In addition, they are selling ‘things’ that are not ‘formed’ or ‘transformed’ by their labour (the last is the condition for just ownership in Engelhardt’s conception). In many cases they are selling something that was alienated by the totalitarian regime from the people. For example, they could sell as their ‘own’ organs and tissues of cadavers, or aborted fetuses. And in all cases they sell their working time as civil servants, using technology in which they have invested nothing themselves. Facilities and medical equipment were brought with public money. In this case, as in the case of fetal and cadaver organs, physicians use the consequences of the alienation of public resources from the public that was produced by totalitarian bureaucratic power for their own profit.
The general confusion around property rights that exists in Russian health care makes it difficult to apply Engelhardt’s idea of the right to a black market in this case, even if one accepts that the idea itself is ethically correct.
On the same basis, it is difficult to use the universally respected right of people to resist a totalitarian regime that alienated their civil (including property) rights and liberties, to morally justify ‘corruption’ in Russian medicine. Physicians are ‘victims’ of the totalitarian regime, and at the same time they are entitled to represent the interests of this regime, and have customary power to use its authority for their own interests. Cadavers and aborted fetuses can be used as a kind of medical corporate property for private benefits, only on the basis of alienation of property rights from people in their bodies after death.
So, it is not a resistance to the totalitarian regime, but the use of the medicalised power of the regime for individual survival (of underpaid physicians), or enrichment – as in cases of the sale of organs. Corruption is not a resistance to totalitarian power, but its effective reinforcement and proliferation into micro and macro social relationships. Thus even the matter of survival could produce only a mitigation of moral responsibility in cases of corruption, not its justification.
Corruption of the state and the party bureaucracy was one of the main causes of the collapse of Communism. But this does not mean that it is an engine for the development of the new democratic society as some Russian politicians and economists would like to argue. From my point of view it will be an obstacle as long as it preserves the unjust totalitarian mechanism of power and property rights at the level of micro-social relations between the medical profession and society, physicians and their patients.
There is a necessity for a new social contract between the Russian medical profession and society in general (the state) that will be grounded in a democratically established agreement of a realistic and affordable meaning of ‘good medical practice’. The existing low social status of Russian physicians contradicts their real power to control vital resources of health care. This contract should guarantee legitimate rights of medical doctors as owners of their skills and talents, as well as the property rights of lay people to their bodies and all that is formed or transformed through their labour. I think that medical doctors may wish to ‘bargain’, and give some of their customary rights and privileges to patients as a condition of public re-evaluation of their social status.
(While writing this, Pavel Tichtchenko was based in the Utah Center for Human Genome Research in Salt Lake City in the United States. He has recently returned to Russia)
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 Tishchenko, P and Yudin, B. ‘Moral status of fetuses in Russia’. Bulletin of Medical Ethics (1996) 119; 13-15
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First published in Bulletin of Medical Ethics. September 1996. Number 121. pp. 13-18.