VIII. CENTRAL AND EASTERN EUROPE

This entry covers Poland, the Baltic states, Hungary, Romania, the Czech and Slovak republics, the former Yugoslavia, Bulgaria, Albania, and Cyprus. In these nations to the east and southeast of the Elbe River, the doctor–patient relationship and biomedicine itself have been characterized by the paternalism and dominance of a powerful elite within the medical establishment. Furthermore, a number of factors have profoundly influenced the status of healthcare as well as bioethics in this region. Among the most important are: (1) a relatively small percentage (around 5 percent) of the gross national product spent on healthcare, biomedical research, and environmental protection; (2) Prussian-like feudalistic attitudes (e.g., a rigid hierarchical system with a small and arrogant elite at the top and a large number of disempowered people below) preserved within universities and medical colleges. For physicians the idea of being the "captain of the ship" is still self-evident, and many believe that the behavior of older doctors provides the right ethical model for future ones.

In Hungary, Poland, Romania, the former Yugoslavia and Czechoslovakia, the Baltic republics, Bulgaria, and Albania, another determining factor that shaped medicine, healthcare, and bioethics was the form of Marxism that became the official ideology after the end of World War II. The hard ideology of Stalinist Marxism prevailed in Albania much longer than anywhere else in eastern and central Europe. These ideologies instructed morals and morality, so that only behaviors that brought people closer to communism were considered morally correct. Only infallible and omniscient party leaders knew exactly what these behaviors were.

Before World War II

In central and eastern Europe a feudal-capitalistic system existed prior to World War II. Agriculture was so dominant that in most of these countries the peasantry, unskilled agricultural toilers employed by owners of huge tracts of land, made up more than half of the population. These peasant workers were not able to rise from serfdom to free citizenry. This situation existed in large part because there had never been any genuine democracy in this region. The high degree of illiteracy, and the struggle for survival within the context of wars and ethnic strife, had a great impact on the people's health as well as on medical ethics.

A significant majority of people (normally peasants and poor urban dwellers) had no health insurance, and thus no access to professional care. Infant mortality, tuberculosis, and high overall death rates due to lack of treatment were very common. It was quite natural, for example, to view patients, usually those who were unable to pay, as teaching objects in university clinics and teaching hospitals. Healthcare was basically private, a profit-oriented endeavor that brought high earnings and social prestige to physicians—who carefully controlled their own numbers, especially the number of specialists. There existed a unified medical profession and a system of professional and ethical control. Within the profession certain basic norms concerning referrals, regulation of payments (neither overcharging nor undercharging), and advertisements were generally honored, and violators were punished.

Some dedicated individuals in these countries, usually physicians, kept the Hippocratic ethics alive by writing books and articles that, for generations, exerted a strong influence over the practice of doctors: for example, in Hungary, Jozsef Imre's Orvosi Ethika (Physicians' ethics), 1925; in Poland, Wiadislav Bieganski's Mysli i aforyzmy o etyce lekarskiej (Thoughts and aphorisms on medical ethics),1899. These authors concentrated almost as much on the duties of the patient as on those of the physician. In addition to the Hippocratic works as a source of ethical standards, Polish physicians relied heavily on Catholic moral theology in the development of bioethics, especially concerning such issues as abortion, birth control, genetics, and euthanasia.

After World War II

As a result of the Yalta agreement dividing Europe into spheres of interest, a large part of central and eastern Europe came under the dominance of the Soviet Union. The communist leaders launched a massive industrialization program in most countries of the region. This resulted in an unprecedented mobilization of people that contributed to significant changes in class structures (e.g., millions of peasants became industrial workers), disintegration of large family units, and increased migration to urban areas. All these changes occurred just after World War II.

These countries became monolithic states soon after the war. Moral pluralism existed only underground. Marxism shaped by Soviet communism or distorted forms of materialistic socialism provided the basis for the dominant philosophy and ethics. Moral rules were dictated by party leaders who claimed infallibility and ruled coercively, resulting in a monopolistic moral climate. Behind these rules there stood an irrefutable state power and an excessive bureaucratization of power, with extreme centralization of decision making. Political theoreticians presented a future-oriented ethics in which every desirable human goal was placed in the future state of communism. At the same time they denied the right of existence to any autonomous professional ethics, believing that their form of Marxist ethics was adequate to answer all questions raised in any area of human endeavor. Ironically, the principal slogan in all these states was "The highest value in socialism is the human being."

However, as soon as a little freedom of speech was allowed beginning in the 1980s, it became obvious that the morals of socialism were in ruins, as was the socialist economy. Despite claims that the socialist healthcare system was of high quality, free, and accessible to everyone, it became evident that this was not so. Sociological surveys in these countries showed a very poor general state of health in the populations, high mortality rates, and severely reduced life expectancies. For example, in 1994 Hungary had one of the highest cardiovascular mortality rates in Europe for people below age sixty-five, and for all ages it placed fourth, after Romania, Bulgaria, and the former Soviet Union. This situation has not changed much into the twenty-first century. The percent of women in Hungary dying from cervical cancer is twice as high as the regional average; the suicide rate is the highest in Europe and about three times the regional average; the mortality rate from malignant neoplasm is also the highest in Europe, accounting for 21 percent of all deaths. Hungary and the former Czechoslovakia have the highest mortality rates for ischemic heart disease among countries in the region. There is a difference of almost five years in life expectancy between central/eastern and western Europe.

In addition, the crime, divorce, and suicide rates in the region rank among the highest in the world. Central and eastern European countries have placed a low priority on the prevention of accidents and illnesses and to occupational diseases. They have justified their notorious environmental pollution and destruction through the repeated use of slogans regarding the need to subdue nature for the sake of human progress.

The Soviet type of healthcare system was introduced in all these central and eastern European countries. Some of the features of the Soviet system, besides those already mentioned, included: little if any freedom for patients to choose their doctors; bribes and corruption, manifested mainly in the practice of patients' tipping physicians for services; injustices in distributing limited resources; prejudice against the elderly; mechanistic patient care; and a clash between heavy demand and very limited resources. There was also, incidentally, a predominance of women in the medical profession.

For decades the problems in Soviet-style healthcare could be hidden because fact-finding studies were regarded as "top secret" and revealing them was a serious political offense. Writers on the sociology or ethics of medicine were mostly either Communist party hacks or individuals afraid of writing the truth lest they lose their jobs. Consequently, it is little wonder that people in Western countries did not understand the decay and injustice that characterized the socialist healthcare systems of the region. Only after the political and economic collapse of these once-praised systems did they come under fierce criticism. The health laws of these countries seldom mentioned patient rights, and nothing at all was said about such principles as patient autonomy. In practice, physicians and healthcare institutions had no freedom in choosing patients, nor had patients any freedom in choosing doctors. Nevertheless, people could have access to healthcare that was theoretically free and officially had a high quality level. There is no doubt that many millions of people who, before World War II, might have died due to an inability to pay for medical care, could get essential treatments under the socialist system. This, in itself, was a great achievement.

Since state and party officials accepted no professional ethics beyond an exclusive Marxist version, teaching ethics meant teaching Marxist ethics. Its main features were the unrelenting struggle against the enemies of the working class and the constant urging of people to work and produce more. Ethics was taught in colleges and universities only by the departments (or institutes) of Marxism-Leninism. These institutes occasionally smuggled issues pertaining to medical ethics into medical universities, alongside the officially allowed themes of the Hippocratic Oath and the moral ills of private medical practice. Noticing the great interest of students in ethical issues in medicine, some teachers began to deal with euthanasia, transplantation, and confidentiality. But nowhere in these countries was the teaching of medical ethics/bioethics formally established or officially supported during the Marxist-Leninist era.

The pioneers who introduced a more contemporary medical ethics in health colleges and medical universities were quite often physicians. In Hungary, the first textbook on the subject was written by psychiatrist Janos Szilard in 1972; the second comprehensive textbook, written by Bela Blasszauer, a medical ethicist with a background in law and philosophy, appeared eighteen years later in 1990. In Poland, a popular collection of essays written by doctors was recommended for teaching medical ethics at medical universities (Kielanowski). These broadly based works on bioethics contained a number of previously undiscussed issues, including patient rights, informed consent, reproductive medicine, and refusal of treatment.

Since the end of the 1980s, and continuing into the twenty-first century, in Poland and Hungary more than six thousand hours are devoted to the six-year medical curriculum, and only thirty or less of these are assigned to the teaching of medical ethics. In certain medical schools there are no seminars, only lectures, depriving students of moral debates, discussions, and analysis of cases. In several countries seminar hours consist of surveying standard medical codes and existing health laws. Even in the early twenty-first century, a distinction was hardly ever made between laws and morals, laws and ethics. In Hungary, almost all the issues of bioethics were incorporated in the curriculum, especially such topics as informed consent, euthanasia, human experimentation, and patient rights.

Only a few countries at the turn of the twenty-first century, some years after the radical political changes throughout central and eastern Europe, encourage the teaching of bioethics, allowing bioethics to begin achieving a prominent place in the medical school curriculum. Whereas all Hungarian medical universities and health colleges teach thirty hours of bioethics, usually in the third year, in the Czech and Slovak republics bioethics is taught in ten medical schools; in Slovenia thirty hours of bioethics are given to medical students and fifteen hours to dental students. In Romania bioethics is on the medical school curriculum in Bucharest and Temesvar; in Estonia, one priority is to train bioethicists and to begin teaching in this area.

The war in the former Yugoslavia gave Croatia an impetus for developing medical ethics. Until the war, medical ethics was not taught as a separate subject in medical faculties but was a part of the history of medicine, social medicine, or forensic medicine. The same was true in Bulgaria and other Balkan countries. Since 1982, Croatia's capital Zagreb has been the seat of the Croatian Center for Medical Ethics and Quality of Life. In 1992, the medical faculty of Rijeka introduced medical ethics as an independent subject. It is the ambition of the Department of Social Studies at Rijeka to establish an international center of medical ethics for the neighboring countries.

Main Areas of Ethical Concern

Several issues are of universal and particular interest and are widely discussed in the media and are in the forefront of medical ethics education.

TIPPING. Sometimes referred to as parasolventia, gratuity, or even bribery, tipping was one of the most hotly debated medical ethics issues in many of these countries in the later years of the twentieth century (see, for example, Adam, 1986; Page; Szawarski, 1987; and Bologa). Outside of the healthcare system, tipping has long been a common practice in many of these societies. Where there is a real or artificially created scarcity, and a tradition of some occupations with obligatory tips (e.g., waiters, barbers, concierges), the spreading of the practice to medicine may not be so surprising. The practice of slipping envelopes containing money into physicians' pockets for the treatment that was provided was not only unlawful but a violation of the basic idea of free healthcare, an idea that was supposed to make socialism superior to capitalism. In Hungary from the 1950s until the 1980s, the Communist party and the government waged a campaign against tipping. It was doomed to failure at the very beginning. So far every such attempt to eliminate or at least curb tipping has been absolutely ineffective.

Still, in the few articles on medical ethics or medical deontology that did appear in these countries, only the most courageous or the most trusted authors dared to write about tipping. Generally, they would have been prosecuted for damaging the reputation of the socialist healthcare system. Moreover, though it was (and is) a well-known phenomenon, it is very difficult to prove who took such money, how much, when, and why. In Hungary, the irony is that tipping is illegal, but nevertheless it is taxed. In Poland, since tipping makes healthcare unregulated and uncontrolled, the Code of Medical Ethics forbids accepting tips (Extraordinary Congress of Physicians). The Hungarian Code of Medical Ethics, on the other hand, only forbids accepting tips if they are given before treatment or given by colleagues working in the healthcare system (MOK).

In undergraduate medical education, ethics classes were devoted to this phenomenon. Ethics teachers were expected to educate future doctors to uphold socialist morality, which condemns taking money or any other form of bribe or gift from patients. Tipping has penetrated the whole system of medical care and hinders radical reforms in the system. Whether the cause is low professional salary, lack of public resources, the patient's feeling of gratitude, or simply a general moral decay, widespread tipping has morally eroded the system of healthcare. Some experts believe that the system would collapse without this extra income, which in some cases is many times greater than the state-paid salary. Other experts claim that no reform can be successful as long as the practice of tipping exists.

To a much smaller degree, health professionals other than physicians supplement their wages with occasional tips. A common feature of central and eastern European state healthcare systems is the very low salaries of doctors and other health workers. Still, some of these professions remain attractive because financial rewards can be hoped for as long as the system of gratuities persists. One can expect that debates will continue to probe the causes of this practice that has been causing major problems in the physician–patient relationship and also greatly distorts the relationship between physicians and nurses, as well as nurses and patients.

EUTHANASIA OF ADULTS AND INFANTS. Although discussion of euthanasia was long considered taboo in central and eastern Europe, it surfaced from time to time and aroused tremendous public interest. While laws in these countries forbid both active and passive euthanasia regardless of the status and prognosis of the patient (thus making no distinction between the active and the passive forms)—the latter is widely accepted and practiced. In Poland, euthanasia debates have been rare because the Auschwitz, Birkenau, Stuthof, Gross-Rosen, Treblinka, and Majdanek concentration camps were the sites of Nazi doctors' criminal practices and experiments. The memories of crimes against humanity and the moral teachings of the Catholic Church have made the Polish people very hostile to any argument favoring either form of euthanasia (Szawarski, 1987, 1988). In Romania, even under the communist dictatorship of Nicolae Ceausescu, there were scholars who openly advocated passive euthanasia: Erno Kiraly and Karoly Daniel introduced and endorsed the use of the living will in that country in the 1980s. In Romania it was not even possible to talk about bioethics until 1989; now there are hospital ethics committees for special care issues. In Czechoslovakia, physician Pavel Lukl advanced the idea of passive euthanasia in 1970. In Slovenia the practice of passive euthanasia is openly accepted, while active euthanasia, as everywhere else, is rejected (Straziscar and Milcinskij).

The Hungarian euthanasia debate dates back to the early 1920s, when a crusade to legalize active euthanasia, led by Karl Binding and Alfred Hoche (a German lawyer and physician, respectively), was rejected. In the 1970s the debate was renewed, and several articles and a book appeared (Boldizsar; Blasszauer, 1984; Czeizel, 1982). Those sympathetic to euthanasia were accused of deviating from the socialist norms and advocating discrimination among people on the basis of social worth (Horvath; Monory). The former Hungarian Health Act of 1972 states, without mentioning the word "euthanasia," that the physician's duty is to do the utmost until the very end for all patients, even those who suffer from incurable conditions. There is no mention of consulting the patient about his or her wishes. Nor is there discussion of what is to be done when legally mandated heroic efforts require respirators, dialysis machines, or other lifesaving devices that are in short supply.

In the case of seriously ill newborns, those who argued for the need to select infants to receive life-sustaining treatment were harshly condemned and even accused of behaving like the notorious Nazi doctor of Auschwitz, Josef Mengele (Mestyan). Because of Hungary's low birthrate, obstetricians were rewarded with promotions or premiums for infants who survived at least to the age of one. Therefore, up to the age of one the statistics are closely monitored, while beyond that age there is no incentive to provide high-quality healthcare. The decision to extend treatment to seriously ill infants belongs exclusively to physicians; in most cases the parents are not consulted. At the turn of the twenty-first century, however, some universities and county hospitals established infant-care ethics committees.

Only after the radical political changes of the late 1980s and early 1990s could such topics be discussed openly without accusations and reprisal. In Hungary a survey asked physicians, "Do you believe, in all circumstances, every possible effort should be made to sustain life?" Seventy-nine percent of responding physicians who worked in neonatal intensive-care units answered no (Schultz).

INFORMED CONSENT AND TRUTH-TELLING. Until the end of the twentieth century, in harmony with the existing paternalism, patients in central and eastern Europe usually received little, if any, information about their conditions. Physicians' unwillingness to discuss diagnosis, prognosis, and intended therapy with the patient was due to their training, their limited knowledge of contemporary bioethics, and their characteristically negative judgment regarding their patients' medical knowledge and ability to make rational medical decisions. Since the physician is the "captain of the ship," it was taken for granted that the patient's duty is to follow his or her orders. Hungarian sociologist Agnes Losonczi described the situation well when she stated that a sick person does not have as many rights as someone who seeks to have a washing machine repaired.

Generally, relatives of the patient were given medical information and left to decide whether to reveal that knowledge to the patient. Disclosure is still not common in cases of incurable disease; silence is believed to be justified by fear of patient suicide. This claim is simplistic and unsupported by fact, but despite arguments against deceiving patients, the dominant principle was expressed by prominent internist Imre Magyar: "One must never tell a hopeless prognosis, instead one must always give hope" (1978, p. 2). As long as a high court judge writes that an incurably ill patient must not be informed that a planned surgical intervention will bring only temporary relief, there is little hope that lawyers will fight for patients' autonomy (Toro). Silence still remains a practice in many places, despite the fact that after the collapse of communism, new laws in most countries require health professionals to honor the principle of informed consent.

Considering the prevalence of this practice of silence in central and eastern Europe, little can be said about the principle of informed consent. Although the law requires it, in reality the principle is not always honored. The Hungarian Health Act of 1997, for example, explicitly states that informed consent must be obtained before any medical intervention. Patients have seen some progress in regard to the right to access to medical documents, and many healthcare institutions provide documents to patients on request, without court intervention. The failure to obtain the consent of the patient drives most contemporary malpractice suits.

HUMAN EXPERIMENTATION, REPRODUCTIVE MEDICINE, AND GENETIC SCREENING. Because high technology is still far from being widespread in central and eastern Europe, research is primarily related to pharmaceuticals. The Helsinki Declaration of 1975 is accepted everywhere as a guideline for ethical research using human subjects, and in some of these countries (e.g., Hungary and Romania) the guidelines have been incorporated into laws regulating biomedical research. Prisoners are excluded from any experimental or research protocol, and nontherapeutic research uses volunteers, usually students. The Polish Code of Medical Ethics (1991) makes no distinction between therapeutic and scientific research. In practice in central and eastern Europe, however, research ethical guidelines are often violated, and the region is infamous for its loose approach to honoring ethical principles.

In a few clinics and hospitals, artificial insemination, in vitro fertilization, and GIFT (gamate intra fallopian tube transfer) programs proceed under vague and inadequate legal and ethical norms.

Genetic screening is done in most central and eastern European countries, but in some of them (e.g., Hungary and Poland) it meets with opposition from the Catholic Church. In Cyprus, President Archbishop Makarios introduced compulsory screening for thalassemia, a hereditary blood disease. The screening has considerably decreased the occurrence of this disease.

CONFIDENTIALITY. Throughout this region confidentiality is highly valued. Cases of its violation, however, hardly ever come before the courts because the laws in these countries allow many exceptions (the interest of the state, divorce cases, etc.). In practice, the violation of medical confidence is very common and goes hand in hand with the frequent violation of privacy. In the Marxist-Leninist era, the state had exclusive access to all patient records—patients were not even allowed to see them. In certain countries, like Hungary, the laws overregulated confidentiality; thus everything was viewed as a secret, which led to nothing being honored as a secret.

ABORTION. In most of the former communist countries abortion was considered a hard-won right for women. Laws were lenient, allowing abortion for simple social reasons. In Hungary, for example, 4.5 million abortions were performed between 1956 and 1990. Some view this as a national tragedy, but the antiabortion movement has only been vocal since the Communist party's demise. Abortion was (and is) a major method of birth control: In the former Czechoslovakia there were ninety-four abortions for each 100 live births in 1988 (Albert).

In Romania, however, abortion was forbidden; as a result of illegal abortions, at least ten thousand women died from complications during the Ceausescu era. In Poland, a heated debate accompanies the attempt, strongly urged by the Catholic Church, to reverse liberal abortion laws. The 1991 Polish Code of Medical Ethics allows abortion under two special circumstances: if the mother's life and health are at risk, or if conception was the result of rape. In Lithuania, opposition to abortion is increasing, and the law that allows abortion on demand in the first trimester is considered by the antiabortion group in that country to be a crime against humanity. The debate is especially intense and interesting in the former East Germany, where abortion laws were far more liberal than in West Germany (Breese).

TRANSPLANTATION. The policy of presumed consent for the donation of organs, tissues, or other biological material is universal in central and eastern Europe and provides an almost unlimited possibility for procurement of such materials for research, transplantation, and drug production. Lawmakers influenced by prominent members of the medical establishment were instrumental in enacting presumed-consent legislation that made organ procurement quite easy and opened the way to organ transplantation.

In these countries, transplantation has so far been largely limited to kidneys. In spite of the policy of presumed consent for donation, organs are as scarce as everywhere else and demand is high. The problem of organ procurement cannot be blamed on individuals' lack of willingness to donate their organs, but on the indifference of many health professionals. Their lack of motivation leaves many available kidneys unreported: In the early 1990s it was estimated that only 10 percent of potential donors in Hungary are made available to transplant centers. Age is one of the main criteria for transplant recipients, and in the 1980s and 1990s no "new" kidney was available for persons over the age of fifty. Heart and liver transplants have also taken place (e.g., in Hungary) and have received tremendous media coverage. Consequently, the problem of obtaining organs has drawn great public interest and has become an important ethical issue for discussion. In these countries, where the medical establishments are strong and have significant political influence, the consent by the spouse or relatives of the dead person to use organs in most places is not necessary and their refusal is seldom honored.

MALPRACTICE. Charges of malpractice are very rare in central and eastern Europe, and successful lawsuits are even rarer. The most likely reason is not the superior professional skills of physicians working in these countries but the lack of patient rights, and the very powerful medical establishment that displays a high level of solidarity at critical times. The laws are worded in such a way that carelessness, negligence, or incompetence is difficult to prove as causally connected with the patient's state of health. Despite the fervent opposition of the medical profession, however, with the process of democratization and the planned reform of healthcare, and especially with the introduction of market conditions, malpractice is finding its way slowly into the patient–physician encounter. Insurance against malpractice had appeared in several of these countries by the beginning of the twenty-first century.

Western Help: Promising Changes

In central and eastern Europe the transition from a one-party system to political pluralism has opened the way to democracy with free elections, public control, and constitutional guarantees. These countries have begun to reform healthcare, allowing free choice of doctors; encouraging health insurance; providing mechanisms to finance health provision; overseeing the constant separation and reunification of healthcare and social services; allowing the extension of private practice; and encouraging reimbursement in accordance with the type of disease and number of patients.

The changes have brought a divergence of opinions on bioethical issues to the surface. Such world organizations as the World Health Organization (WHO), United Nations Educational, Scientific, and Cultural Organization (UNESCO), and the Council of Europe promise to bring help to the region. These organizations hold meetings, work out guidelines, keep data banks on bioethical activities, and encourage such endeavors. The Hastings Center in the United States has played a key role in helping to bring together the central and eastern European bioethicists and their western counterparts. It has provided books, journals, forums, and scholarships to a number of bioethicists in this region. The Centre for Philosophy and Health Care of Swansea, Wales, joined the Hastings Center's Eastern European Program in the late 1980s. In the early 1990s it obtained support from the Nuffield Foundation, which has been quite generous in giving scholarships, libraries, and journals to many of these countries. The European Society for Philosophy of Medicine and Health Care, the European Association of Centers of Medical Ethics, the Jefferson Medical College of Philadelphia, the Inter-University Centre of Dubrovnik, the Center of Medical Ethics of Oslo, and the International Association of Bioethics have helped move bioethics out of the underground. Without such international help, bioethics in the region would be still back in Hippocratic times and would be poorer both intellectually and materially. In 1999 the Central and Eastern European Association of Bioethics was established with the participation of nineteen countries to promote dialogue among the former Soviet satellite countries and help each other to (re) humanize the healthcare systems.

bela blasszauer (1995)

revised by author

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