IX. RUSSIA

The history and state of medical ethics in Russia in the twentieth century has been defined by the influence of the communist regime. Communism, its evolution, and its deterioration, exercised and will exercise for a long time to come, a pervasive influence on the most diverse spheres of social life, including the area of medicine and health care.

Prerevolutionary Period

The ascendancy of the Bolsheviks in 1917 sharply interrupted the stormy development of Russian healthcare, whose beginnings coincided with the great reforms of 1861, which eliminated serfdom for a peasant population that comprised the overwhelming majority of the country. Prior to those reforms, peasants could turn only to the village folk doctor (practitioner of popular medicine) or, in certain cases, healers from among the Russian Orthodox monks. For the most part, the healthcare of serfs had been the responsibility of their owners.

One of the most important of the mid-nineteenth-century reforms was the creation of elected local self-governments: the zemstvos, which received some autonomy from the central authority. The organs of local self-government levied taxes that were used for general needs, including building and equipping hospitals, ambulances, homes for orphans and for the elderly, and other needs. Zemstvos also hired and paid doctors, doctors' assistants, nurses, and other medical personnel.

In 1864, 530 medical centers were opened in Russia. Each center served an average area of 4,860 square versts (one versta equals two-thirds of a mile) and a population of about 100,000 people. After fifty years, in 1914, there were 2,800 such centers, each of which served an area of 880 square versts and 27,000 people. Expenditures for zemstvos healthcare grew from 2.5 million rubles in 1870 to 57.7 million rubles in 1912. Before 1861, the country had 519 hospitals; by 1914, it had 1,715 (Solov'ev). The local doctor's ideals formed the ethos of Russian medicine. The ordinary zemsky (hired and paid by the zemstvos) physician had a modest social standing and a very modest income. He earned about as much as a factory worker. Zemsky physicians represented one of the largest groups within the Russian intelligentsia, along with zemsky teachers. Service to the people (i.e., the peasants) was a defining characteristic of the intelligentsia. The ignorance and poverty of the peasants, whose work fed the whole country, evoked among the intelligentsia that considered itself dependent on the peasant class not only sympathy, but a guilt that moved them to active work on behalf of the peasants. Many of the intelligentsia, neglecting their own material well-being, saw as the highest meaning of their lives the unselfish service to the people. Thus was born the movement called the narodniki, that is, representatives of the intelligentsia who saw that their responsibility was to "go to the people," to work selflessly in the most far-away places in Russia. "Every comfort of life I have," wrote one of the most committed leaders of the narodniki movement, the philosopher and sociologist Petr Lavrov, "… is purchased with the blood, sufferings, and work of the millions.… I will discharge my responsibility for the cost in blood of my development, if I use my development to lessen evil now and in the future" (Solov'ev, p. 43).

Along with the more radically disposed social-democratic intelligentsia, the mass of zemsky physicians were very dissatisfied with the actual state of affairs, but they preferred the path of reform and the laborious work of education to the revolutionary path of violence. The first obstacles of the path of reform were the deep prejudices and lack of confidence of the peasants, their resistance to change from traditional lifestyles, including acceptance of medical aid or elementary hygienic recommendations.

The zemstvos system permitted physicians to achieve an unprecedented degree of professional autonomy; the government, however, constantly strove to curtail this autonomy. During these years, periodic meetings of local physicians were held to discuss current problems within the profession. In the zemstvos, physicians, together with representatives of the administration, participated in the formulation of local policies for healthcare. In 1883, the newly formed Society of Russian Doctors to the Memory of N. E. Pirogov assembled physicians of all specialties. The society, named in honor of the outstanding Russian surgeon Nikolai Pirogov (1810–1881), was the first independent organization of physicians. The Pirogov Society significantly influenced the formulation of ideas and policies about healthcare. It fought actively for improvements in the working conditions of peasants and factory workers, and mostly because of its efforts, in 1903 a law was adopted regarding the liability of owners for accidents in the workplace. The society strove to improve the health education of the people and battled for increases in budgets for medicine and healthcare. In 1910, the society blocked efforts of the authorities to unify the healthcare system and impose upon it strict government control. The society monitored physicians with regard to the norms of medical ethics, and fostered discussions about medical practice that touched on moral and ethical problems.

Medical ethics in Russia evolved, for the most part, in the light of European traditions, even though the specifics of Russian medicine left a noticeable mark. General practitioner and hygienist Matvei Mudrov (1776–1831), one of the first in Russia to concern himself with problems of medical ethics, believed that the Hippocratic Oath could be the foundation of a code of conduct for Russian physicians. Nikolai Pirogov, whose ideas attracted particular attention to the problem of medical mistakes, and Vjacheslav Manassein (1841–1901), general practitioner and organizer of state and local medicine as well as editor of the journal Vrach (Physician; 1880–1901), which devoted significant attention to discussions of medical ethics, developed their ideas along the same lines. Among the characteristics of Russian medical ethics of the prerevolutionary period, the marked paternalism connected with the long-standing tradition of subjugation of the personality to the state or to the peasant community stands out. Typical patients were illiterate and ignorant peasants who were considered unable to make reasonable decisions in their own best interests and, therefore, required direction from others.

The other significant characteristic was the peculiar understanding of social justice, which generated a feeling of eternal indebtedness to the most impoverished and unfortunate people in society. Not by accident, a physician of German origin, Fyodor Gaaz (1780–1853), who settled in Moscow and devoted himself to the medical care of prisoners in jails and their children, enjoyed great moral authority both during and after his life. Unselfish and self-sacrificing service was demanded of physicians who understood their duty, including the willingness to work at any time of the day or night, to venture into any weather at the first call to reach the bedside of a sick person as quickly as possible, and to spend as much time at his or her bedside as necessary. To appreciate this high idealism, one should bear in mind the vast expanses of Russia, which were (and are) far from being fully connected by roads.

These ideals were also reflected in the literary works of doctors who became famous writers: Anton Chekhov (1860–1904), Vikentii Veresa'ev (1867–1945), and Mikhail Bulgakov (1891–1940). Writers in Russia were traditionally leaders of public opinion and exerted great moral influence, so the works of Chekhov and Veresa'ev that were dedicated to zemsky physicians deeply influenced the education of the intelligentsia. In his Physician's Notes (first published in 1901), Veresa'ev sharply criticized violations of ethics in medical practice and research. For many years this book was at the center of significant discussions in Russian as well as western European literature. The ideal of the zemsky doctor was so deeply ingrained that it even survived the Bolshevik regime.

Communist Period

The communist regime came to power on the crest of a world war that was especially terrible and destructive for Russia. Immediately, the new government had to confront serious problems inherited from previous governments. Social collapse, hunger, and poor sanitary conditions caused huge epidemics of cholera, typhoid, and smallpox, so that the new government mounted a fierce fight against contagion (mass vaccinations, disinfections, isolation of infected, sanitary measures, and so on). Measures were taken to coordinate healthcare activities, resulting in extreme centralization. In July 1918, the Peoples' Commissariat for Health Care in the Russian Republic was founded.

This commissariat was the first national ministry for healthcare in the world, created a year before the British Ministry (Kazer). Under the leadership of the first Soviet People's Health Care Commissar, Nicholas Semashko (1874–1949), a doctor close to Lenin, all the departments of the government having anything to do with medical services were united under one ministry (Knaus). In subsequent years, however, organizations that were autonomous from this commissariat gradually appeared, though healthcare services for the railroads, the army, and other kinds of special services remained centralized. Healthcare services were supported financially by the state and were free to the people. These measures of the new authorities provoked severe criticism from members of the Pirogov Society who complained that the introduction by Soviet authorities of free healthcare would deprive physicians of their independence and initiative, both of which had been fought for during the earlier reforms. The regime, however, was not inclined to compromise with critics, especially with any type of organized opposition. The all-Russian Federation of Medical Workers (Medsantrud) was created in opposition to the Pirogov Society. The Pirogov Society was liquidated by 1922.

Medsantrud attempted to conserve the remains of democratic self-management of the ranks of medical workers, and this brought upon it the wrath of the authorities. For example, one of the principal organizers of Soviet healthcare, the People's Deputy Commissar for Health Care, Zinovii Solov'ev (1876–1928), wrote in 1923: "What is this 'public' and what in general can 'public' mean in the conditions of the Soviet government? Two different answers to these questions are not possible. Our public is to work on all aspects of Soviet life on the basis of the independent revolutionary class, the bearer of the proletarian dictatorship, the proletariat and its ally, the impoverished and the middle peasant class" (p. 54).

In this way the regime essentially redefined the social role of the physician. The physician was now considered a representative of the hostile bourgeois class, tolerated only as a specialist and permitted to work only under the strict control of the proletariat. In essence, however, that control was exercised by government and Party bureaucrats.

Meanwhile, the 1917 revolution and the ensuing civil war led to a serious decrease in the number of physicians in the country. In the first years after the revolution, about eight thousand physicians left Russia. Many doctors died from hunger and disease. Between November 1917 and August 1920, 46 percent of all physicians in Petrograd died (Knaus). In response, the authorities attempted the rapid training of new physicians. People were admitted into medical schools without even a secondary education and, at times, without even being able to read or write; final exams were eliminated. A system of "brigade education" was introduced whereby the knowledge of the group of students was evaluated on the basis of an oral exam of one of the students, on the grounds that the better prepared students would help the unprepared students in their training. There was, then, a rapid increase in the number of physicians, although, of course, at the cost of serious decline in professional standards.

Such reliance on collectivism was anything but accidental. Medicine, like everything else, was viewed from the class perspective. Individualistic bourgeois medicine was countered by collectivist proletarian medicine. The aim of the new medicine became the following: "The conservation of the life forces of the proletariat and the building of socialism in and of itself, of course, must be for us the main compass with respect to which a question regarding the tasks of our contemporary medical practice will be posed" (Solov'ev, p.187). Consequently, the entire area of medical practice had to be reconsidered: "Characteristic of today's clinics is the fact that they were formed and exist today as the products of a discipline that is strictly individualistic. Contemporary capitalist society leaves its mark on medicine in the area of theory as well as particularly in the area of practice. The individualistic demand for care of a single person and not of a human collective creates corresponding methods of thought and practice" (p. 175). Key to the problem of shaping the approach and content of medical practice, according to Solov'ev, was the answer to the question of how "it is possible to strengthen the health of the human collective and restore [its] health once it has been destroyed" (p. 171).

These words affirmed the traditional approach of Russia regarding the importance of prevention in healthcare. This approach was implemented by making the work conditions and living conditions of people healthier, as well as by considering the social and ecological causes of many illnesses. At the same time, these comments by one of the leaders of Soviet medicine in its formative stages show clearly Bolshevism's negation of the self-worth of the individual, the reduction of human individuals to the role of cogs in a system of production, and the subjection of the individual to social expediency.

In the view of the Bolsheviks, considerations of class expediency defined the areas of morals and ethics. For example,

The much celebrated theoretician of petty bourgeois morals, Immanuel Kant, advanced in his time a moral demand: "Never look on another person as a means to an end but always as an end in itself.…" Can you imagine how far the proletariat would have advanced in its revolution if it had allowed itself to be guided by such a demand and not by the completely contrary demand of class interests.… The highest wisdom of the proletarian struggle consists not in that everyone claims his own rights, but in that everyone must selflessly, almost spontaneously, without phrases of superfluous gestures, without demanding anything for himself, pour all of his energy and enthusiasm into the common stream, and work for the goal, with the entire class, perhaps be the first to fall on the road. (Preobrazhenskii, 1923, pp. 72–73)

A systematic elaboration of medical ethics that could have corresponded to the ideological purposes of the new regime and the new system of healthcare was, with rare exceptions, not attempted. To the extent that the physician was considered as only an auxiliary, rather than as an independent professional, the idea of posing questions of specific medical ethics was deemed superfluous. Even though some problems had a distinctly moral-ethical content and as such were quite controversial (for example, abortion, confidentiality, and medical mistakes), they were not viewed as problems specific to medical ethics. In general, medical ethics or, as it was usually referred to, "physicians' ethics" was understood as the affirmation of a corporate morality opposed to the class interest of the proletariat. The viewpoint was rather widespread that Soviet people, regardless of their sex and profession, should be guided solely by the norms of communist morality, and that any specific norms of professional morality would only limit the scope of and adherence to the general norms.

With respect to medical education, systematic courses in medical ethics did not exist in prerevolutionary Russia nor were they created by the new regime. After the revolution, in fact, the initiation of new physicians by means of a professional oath, a revision of the Hippocratic oath, was eliminated, even though that practice had been obligatory since the beginning of the twentieth century. The social humanitarian preparation of medical students was limited to a course in Marxism-Leninism.

Against this background of ethical relativism and nihilism characteristic of the Bolshevik scorn for traditional moral values and principles, the earlier traditions of medical ethics could still be found. Among those who received medical education, many were inspired by the ideals of disinterested and self-sacrificing service that had characterized the ethos of zemstvos healthcare. The medical profession attracted intellectuals drawn to that sphere because it was not under the sway of particularly severe ideological control. The norms and values of medical ethics were transmitted under these conditions by means of informal communication and daily contact between professors and students and between experienced physicians and new colleagues.

STABILIZATION OF THE REGIME. From the end of the 1920s to the beginning of the 1930s, the communist regime consolidated itself; its radical revolutionary policies were gradually transformed into pragmatism. This pragmatism, of course, was specifically Soviet, oriented to the resolution of problems of building a communist state. All aspects of civil life began to be affected by organs of administrative and bureaucratic planning and management. Healthcare also fell under the planning system: The number of physicians in various specialties and the number of hospital beds, hospitals, and polyclinics in cities and villages, the direction and topics of medical research, the development of facilities in sanitoriums and health resorts—all were centrally planned.

Planning presupposes qualitative evaluations and measurements, and from this perspective Soviet medicine obtained impressive results. The number of doctors had long since passed one million (about 1.2 million in 1983), and a single doctor had about half as many patients as his or her counterpart in the United States. Many infectious diseases were practically eliminated, the frequency of infant mortality was significantly lowered, and the average life expectancy was increased. By these and certain other indicators the country approached the level of more developed countries or became equal to them. The results of the Soviet organization of healthcare attracted much attention outside the Soviet Union, particularly among Third World countries.

Policy in the area of healthcare, however, was always viewed as subordinate to policy in the economic sphere. Thus, when the Communist Party began to emphasize the industrialization of the country in 1929, the central task of the healthcare system was designated as the improvement of medical services to workers in the industrial centers, especially in the mining and metallurgic centers.

The system of healthcare that developed and remained relatively stable for many years was quite original in several respects. The physician became a civil servant, a kind of clerk, whose activities, regulated by numerous bureaucratic rules, consisted largely of writing reports that reflected his or her implementation of these rules. Any appearance of personal initiative was dangerous, especially because the physician's mistake could easily be interpreted as intentional, the act of a class enemy.

In relations with patients, the physician was a representative of state authority rather than an autonomous actor. Lack of autonomy, in its turn, made less urgent the problems of personal choice and responsibility. Low salaries of ordinary physicians as well as their low social prestige were among the reasons for the large number of female physicians in the country (about 80 percent). It was thought that physician's work was not so difficult, did not demand essential physical force, and therefore was well suited for women.

The social interaction of the physician and the patient was paradoxically characterized by two mutually exclusive elements. On the one hand, the long-reigning paternalism became even more entrenched, to the point where the individual regarded his or her health as a kind of state property—and therefore no one's—which could be squandered. On the other hand, health was viewed as the highest and ideal value, so high in fact that it was simply indecent to measure it by any sort of material equivalent, such as money. So, it was presupposed that self-sacrifice and unselfishness on the part of a physician was a kind of moral norm. The combination of these alternative, conflicting attitudes permitted the rather modest financing of medicine and healthcare, at a level that would ensure only the replacement of the labor force. Another characteristic of Soviet medicine was that patients were not permitted to choose their physicians.

Medical Deontology

In 1939, the famous surgeon and oncologist Nikolai Petrov (1876–1964) published an article, "Questions of Surgical Deontology," in the Bulletin of Surgery. In 1945, he published a small book by the same title. These publications were the first steps in the rehabilitation of medical ethics. Petrov justified the use of the term "medical deontology" by arguing that the concept of "physicians' ethics" had a narrower meaning. The latter, Petrov maintained, referred only to a corporate morality, reflecting the scientific and professional career interests of doctors (Petrov). This may have been a subterfuge designed to circumvent the ideological taboo on the problems of medical ethics. It is noteworthy that such an attempt was made by a doctor who received his training and education before the 1917 revolution.

Wide discussion of the problems of deontology did not begin until the middle and at the end of the 1960s when writings on this topic by medical practitioners and philosophers began to appear. The 1969 First All-Union Conference on the Problems of Medical Deontology in Moscow played an important role in this development. In 1971, state authorities approved the text of a document called "The Oath of the Physician of the Soviet Union." The oath was required for all graduates of medical institutes who intended to enter into professional activities. The text of the oath demanded that physicians be governed by the norms of communist morals and spoke more of their responsibility to the people and to the Soviet government than to the patient.

At the same time, medical deontology was introduced into the curricula of the medical institutes. However, notwithstanding reports to the contrary in a number of Western sources, courses on deontology and medical ethics appeared only in the beginning of the 1990s. In most medical schools the subject of deontology appeared to be spread out in separate courses in medical specialties, and philosophers had not been drawn into its teaching.

After 1971, the stream of literature in the area of deontology increased sharply. The contents of these publications, however, were often one-dimensional, moralizing reflections: criticism of the anti-humanist Western medical system coupled with a confirmation of the indisputable moral superiority of Soviet free medicine and the disinterested Soviet doctor. Attention to concrete cases, mainly from the personal practices of the authors, was frequent. Authors, however, avoided discussion of truly difficult cases that presented moral or ethical conflicts. Apart from the fact that this literature signaled the presence of ethical problems in medicine, its real interest lay in its increasing references to the moral authority of prerevolutionary Russian medicine and its attempt to present Soviet medicine as a direct and uninterrupted continuation of the best traditions of the past.

Crisis and Breakdown of State Medicine

The government-supported awakening of interest in medical deontology coincided with the first signs of crisis in Soviet medicine. Starting in the 1970s, but primarily in the 1980s, the authorities and a small circle of specialists, and then finally the public at large, became aware of the high rates of infant mortality and the consequent reduction of life expectancy. The press began to write more often about failures in the medical field and about the callousness, greed, and low level of competence of physicians and other medical personnel. Notwithstanding the state's propaganda efforts, the people, who were losing confidence in physicians and in official medicine, turned more often to practitioners of alternative medicine.

These failures, as well as many others, revealed that the centrally planned and managed free medical system had used up all its own resources, among them the moral resource that had enabled the authorities to make do with "cheap" medicine for so long. It was clear that the communist modernization was accompanied by an erosion of traditional values, which was particularly noticeable as the medical profession became so large and more and more specialized. The turn to deontology was in some sense dictated by the efforts to mobilize the neglected moral factor in the face of growing medical crises. This attempt, to the extent that it appealed to values from the past, however glorious it might have been, could not succeed.

The attempt made during perestroika in 1987 to reform the system of healthcare without changing anything essential turned out to be unproductive. In 1991 the Russian parliament adopted a law providing for medical insurance for Russian citizens: This was an admission of the failure of state medicine. The stability during the last decades of the state system of healthcare was assured, even though the principles of free medicine and equal access to healthcare for all, in practice, deteriorated. The bribes that had to be given to physicians by patients and their families to some extent compensated for the pitiful financial circumstances surrounding healthcare. The availability of a special medical-care system for party members and other members of the nomenklatura, people given leading positions in various fields by the Communist party, made them less inclined to pursue radical reforms.

Previous stability itself made the process of thoroughgoing reform particularly painful for the people. The deeply rooted tradition of paternalism hindered the acceptance of personal responsibility for one's own health. In addition, social justice often was viewed as a pure leveling of differences. Finally, most people could not accept the idea that healthcare could be paid for, even though "free medicine" proved very inefficient.

Acute economic, ecological, sociopsychological problems during the period of reforms led to serious worsening of health of the population. For the first time since the beginning of the nineteenth century, mortality in Russia exceeded birth rate; morbidity, including infectious diseases, grew rapidly. These factors along with barely controlled commercialization of healthcare, limitation in access to medical services for most people, expense, and shortage of many crucial drugs generated on the part of many Russians a nostalgia about the free healthcare system of the past.

Specific Areas of Ethical Debate and Decisions

This section provides an overview of only those problems of medical ethics that have been treated in Russia in a rather original fashion.

ABORTION. Abortions in prerevolutionary Russia were considered criminal acts. In 1920, the Soviet government became the first in the world to legalize the artificial termination of a pregnancy at the request of the woman. Then, in 1936, in seeking means to improve the demographics, abortions were once again criminalized; in 1955, with some liberalization of the regime, they were again legalized to lessen the negative social consequences of widespread illegal abortions. The passage of legislation in 1993 permitted abortion at the request of the woman up to twelve weeks of pregnancy for any reason, and up to twenty-two weeks with consent of the woman for medical reasons. Abortion became a common means of birth control. The use of abortion for birth control may have resulted from a lack of contraceptive alternatives, as well as inadequate public knowledge and education about these matters.

Although abortions have been considered morally reprehensible, the attitude of people in concrete situations has been rather liberal. For many years the Russian Orthodox Church, the most influential confession in Russia, was prohibited from taking positions on any question of social significance. Even after the persecution of religion ceased, the church had not shown itself ready to express an opinion on most matters of biomedical ethics. One exception was the stance the church took on abortion. In 1990, the Patriarch of the Russian Orthodox Church confirmed the church's unequivocal censure of abortion; yet on a practical level priests tended to be more tolerant because of the hard economic situations of many women. In 1992, the Right to Life Society was formed to oppose abortions and was supported by the Russian Orthodox Church.

CONFIDENTIALITY. Controversial discussions occurred in the 1920s concerning the problem of physicians' secrets. The People's Commissar for Health Care, N. Semashko, announced "the abolition of physicians' secrets," which were understood as holdovers of bourgeois medicine. This position was based on the notion that an illness was not a disgrace but, rather, a misfortune. Full abolition of physicians' secrets would occur, it was thought, when that concept was accepted by the population. Until that time the necessity of maintaining physicians' secrets was linked to the fear that eliminating them would create an obstacle for people seeking doctors' advice and help.

Even though Semashko himself, no longer a people's commissar but a practitioner, spoke out in favor of physicians' secrets in 1945, his earlier viewpoint turned out to be more influential, for many healthcare workers did not understand the need for confidentiality. The requirement of confidentiality gained a legal basis only in 1970. Up to 1993, however, a patient who returned to work after illness was obliged to bring a sick-leave certificate from a physician. This certificate containing the patient's diagnosis was available to many people. New legislation changed this norm: A diagnosis would be filled in only with the consent of a patient; without consent only general reasons (disease, trauma, etc.) could be indicated.

DISCLOSURE TO PATIENTS. The subject of disclosure to patients has been marked by strong paternalistic tendencies. The overwhelming majority of those writing on the subject considered it unacceptable to inform a terminally ill patient of his or her diagnosis and prognosis. The practice of informing patients was not generally regulated, so concrete decisions were left to the discretion of the treating physician.

However, Russian laws on psychiatric treatment and on transplantation of human organs and tissues, which were adopted in 1992, contained norms of informed consent for patients and donors. Included in the legislation were norms governing the protection of the health of citizens, granting the patient the right to know his or her diagnosis and prognosis as well as the right to refuse this information.

The law also established specific rules regarding receipt and documentation of informed consent of patients undergoing biomedical experiments. The advent of glasnost (openness) in 1985 permitted public disclosure of the terrifying information about fatal biomedical experiments (such as testing of nuclear or chemical weapons, new drugs, etc.) carried out on soldiers of the Soviet Army and on prisoners under Joseph Stalin (1879–1953) and Lavrenti Pavlovich Beria (1899–1953) and even later. Some steps were undertaken for ethical control of biomedical experiments, but as of 1994 most researchers were not aware of internationally accepted norms of experimentation.

EUTHANASIA. As early as prerevolutionary times the well-known Russian jurist Anatoly Koni (1844–1927), opposing the dominant view, defended the admissibility of euthanasia under certain exceptional circumstances: (1) conscious and insistent requests of the patient; (2) the impossibility of lessening the suffering with known methods; (3) agreement by a commission of doctors on the impossibility of saving the life; and (4) preliminary notice of the decision to the prosecutors. A law permitting mercy killing of a patient was adopted in the criminal code of 1922, but in subsequent legislation it vanished. It was practically inoperative and little is known about its utilization.

Sociological studies conducted among physicians in Moscow indicated that about 40 percent of them viewed euthanasia as permissible if the patient wishes it or in exceptional cases. However, many respondents did not seem to know what the word euthanasia meant (Bykova et al.). The public's attitude toward euthanasia appeared more tolerant: According to the findings of one public opinion poll, 55 percent of the respondents approved and 19 percent opposed the mercy killing by a physician of a terminally ill patient who wishes to die.

The majority of specialists in medical ethics, including physicians, jurists, and philosophers, have with rare exceptions adopted a sharply negative opinion of active euthanasia. The prohibition of active euthanasia, understood as acceding to a patient's request to hasten his or her death by medical means, was included in a law for "the protection of the health of citizens of the Russian Federation." Nonetheless, such forms of passive euthanasia as the refusal by the patient of treatment or the withdrawal of life-sustaining treatment from a hopeless patient were considered acceptable. The public's attitude toward euthanasia remained rather tolerant.

EUGENICS AND MEDICAL GENETICS. In the first decades of the twentieth century, Russia was among the world's leaders in the development of genetics. This interest in genetics generated a rather strong eugenics movement, which flowered in the 1920s. To some extent this interest may be explained by the consonance of eugenics with the central communist ideology of the creation of a "new man" who would be free of the "birthmarks" of capitalism. One of the leaders of Russian genetics, Nikolai Kol'tsov (1892–1940), following Francis Galton, spoke of eugenics as the religion of the future that still awaited its prophets. It was the powerful ruler of nature and the creator of life that would permit the creation of a perfect type of human being (Adams). In the 1920s, when ideological control was not yet particularly strong, the possibilities for forming a new human being were suggested by psychoanalysts as well as by those in other areas of scientific research.

The paths of communist ideology and eugenics diverged rather quickly, however. The principal criticism of eugenics was that the new human being should be formed by social, and not by biological, methods. Eugenic projects in Russia, because of such criticism, were interrupted long before they had achieved any practical realization. Inasmuch as Russian eugenics at that time was a form of medical genetics, the blow to eugenics also impeded research in human genetics. This setback was only the first of many caused in the Soviet Union by the reigning ideology associated with Trofim Lysenko, who taught the thesis of inheritance of acquired characteristics, which lasted until Khrushchev fell from power in 1964. Even afterward the development of medical genetics ran up against ideological obstacles, since many associated it with the eugenics that served as a basis for the murderous racism of the German Nazis. Since the beginning of glasnost and the end of ideological censorship, some far-reaching proposals with possible eugenic interventions in the Russian population have been published, among them, killing newborns with serious defects and forced sterilization of alcoholics and drug abusers. Genetecists, however, have been rather passive in relation to public discussions of these topics. Despite the growing public concern about the genetic effects of radiation and environmental pollution and despite rather intensive research in the field of medical genetics, Russia now has only limited capacity for genetic screening and counseling except in a few large cities. In 1994, the Russian human genome project started to study possible ethical implications of recent developments in human genetics.

REPRESSIVE PSYCHIATRY. The practice of using psychiatry as a weapon in the struggle against political dissidents began under the regime of Nikita Khrushchev. The first victim was Zhores Medvedev, who was punished for wanting to publish a book on the crushing of genetics in 1948. Medvedev was diagnosed by state psychiatrists as mentally deranged and was committed for treatment. The widespread use of psychiatry in this manner did not occur until later, during the regime of Leonid Brezhnev. Hundreds of victims, without any judicial proceedings and often without even being physically present, were sentenced for indeterminate lengths of time to special psychiatric hospitals under the jurisdiction not of the Ministry of Health but of the Ministry of Internal Affairs. "Treatment" ranged from "wall therapy"—merely keeping patients inside four walls—to forcible psychotropic injections. The practice came to be used even against ordinary citizens who had conflicts with local authorities. The Soviet psychiatrist Andrei Snezhnevsky (1904–1987) worked out the basis for this method of repression, using the concept of "creeping schizophrenia" with symptoms such as the "spreading of slander," "exaggerated religiosity," and "excessive appreciation for the West." The center for expert studies and diagnoses of such afflictions was the V. Serbsky Institute for Forensic Psychiatry in Moscow.

Many cases of psychiatric repression became well known in the West. This caused the breach in 1983 in relations between the World Psychiatric Association (WPA) and the Soviet All-Union Society of Psychiatrists and Narcologists. The membership of the society in the association was renewed only in 1989. That same year, the Independent Psychiatric Association, founded in the Soviet Union in 1988 and actively involved in exposing psychiatric abuses, gained unconditional membership in the WPA.

A 1989 fact-finding mission of U.S. psychiatrists to Soviet psychiatric hospitals discovered that the malice of psychiatrists or of repressive state bodies was not the only cause of the abuse of psychiatry. Other factors included the poor training of medical personnel, the absence of adequate judicial mechanisms for the protection of the rights of patients, and the low level of ethical standards for hospital personnel. The aim of a 1992 law was the improvement of psychiatric treatment. According to this law, involuntary hospitalization in a psychiatric hospital was permissible only on the basis of a court's decision. The position of supervisor, to protect the rights of patients, was to be established in every psychiatric hospital. In 1993 the Russian Society of Psychiatrists—the most influential psychiatric association—adopted the Code of Professional Ethics of the Psychiatrist.

TRANSPLANTATION. The adoption in 1992 of a "law on the transplantation of human organs and tissues" provided an example of the direction of the reforms in Russian healthcare. Before adoption of this law, questions such as the determination of brain death, the rights of donors and recipients, and the permission for the removal of organs and tissues from cadavers were decided on by internal instructions of the Ministry of Health, instructions that were unknown to the population. On the one hand, this situation impeded the practice of organ and tissue transplants and, on the other hand, facilitated abuses, such as commercial use of human organs or the too-hasty declaration of brain death. The law on transplantation at last provided a legal basis for this area of medicine, and more important, became one of the first laws relating to healthcare using principles and practices accepted in the world community.

Perspectives for Russian Bioethics

Interest in the problems of bioethics grew as Russia emerged from isolation. Such interest evolved mainly through the efforts of a small group of enthusiasts. Neither the leadership of the healthcare system nor the government bureaucracy nor the public itself grasped the critical importance of problems in bioethics. Democratic reforms, to the extent that they will continue, will change this situation. As reforms develop, healthcare will become one of the most important priorities of social legislation and public interest. The reform of medicine and healthcare will make both physicians and patients much more independent and, consequently, responsible parties in social interactions.

Foundations of Legislation of Russian Federation on the Protection of the Health of Citizens, adopted in 1993, as well as other laws filled in many gaps in healthcare and legal regulations. The law opened the door for the creation of ethical committees (commissions) at federal (similar to France), regional, and local levels as well as in hospitals and biomedical research institutes to defend human rights in healthcare areas.

In 1992 the Russian National Committee on Bioethics (RNCB) was established under the aegis of the Russian Academy of Sciences. The main activities of the RNCB include the development of ethical guidelines for scientific research, proposal of legislation in healthcare and biomedicine, promotion of bioethical training and education, preparation of textbooks and methodical materials, stimulation of discussions on bioethical issues in the mass media, and encouragement of bioethics in Russian regions as well as in countries of the Commonwealth of Independent States. The RNCB prepared documents on such acute problems as mass vaccination and protection of human rights, ethical aspects of transplantation of organs, ethical regulation of new reproductive technologies, ethical control of biomedical experiments, and so forth.

"Free medicine" has not been a social priority, and whoever leads the government can find more critical need for expenditures than healthcare. But the failure of free medicine, however painful for the population, will provide the basis to hope for a better future. Already the harsh reality has caused people to realize that the government or the Ministry of Health is not alone responsible, nor will either pay for the people's health; people themselves must do so. People are also beginning to realize that medicine and healthcare are areas in which the fundamental rights and vital interests of people are realized (or not realized) and, consequently, this area requires moral and ethical consideration as well as legal regulation.

boris yudin (1995)

translated by richard schneider

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