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Medical ethics in the Soviet Union.

Medical Ethics in the Soviet Union

It is now widely recognized that there are alternative medical ethics, including those of religious traditions, of secular philosophical systems, and those of other cultures. While our knowledge of these varied approaches is increasing, we still know almost nothing about medical ethics in the Soviet Union. We do know that what the Soviets call medical deontology has been discussed in Soviet medical schools for many years and that in 1971 an Oath for Soviet Physicians was adopted by the Presidium of the Supreme Soviet.

To begin increasing communication between Americans and Soviets in medical ethics, I, along with five other American philosophers specializing in medical ethics, recently visited the Soviet Union for nine days.(1) The explicit focus was on ethical problems of death and dying, but many other concerns in medical ethics arose during our stay. The trip was arranged by IREX (International Research and Exchanges Board, a creation of the American Council of Learned Societies and the Social Science Research Council) and the Institute of Philosophy of the Soviet Academy of Sciences. We spent most of our time in Moscow meeting with philosophers, physicians, and others interested in these issues. We also traveled to Tbilisi, the capital of the Georgian Soviet Socialist Republic, where we met with Georgian philosophers, clinicians, and researchers at the Institute of Experimental and Clinical Therapy of the Ministry of Health. All told, we met with some fifty professionals working on issues relevant to our field.

Our conversations were extremely cordial, open, frank, and collegial. as expected, discussion often referred to the key figures of dialectical materialism, especially Lenin, but in keeping with the current themes of glasnost (openness) and perestroika (restructuring)--themes that were omnipresent in our discussions--other philosophical categories emerged frequently. Even religious and quasi-religious language--references to the soul, spirituality, and immortality--surfaced from time to time without any embarrassment.

It would be a serious mistake to attempt a definitive report on Soviet medical ethics on the basis of such a brief visit. However, the developments in the Soviet Union in this area are so important and so little known to those of us in the West that a brief report offering a tentative summary of major themes is in order.

We never discussed with our Soviet colleagues the question of reporting impressions, so to respect comments that may have been offered in confidence, I will not attribute any of my observations to specific individuals. Suffice to say that some themes appeared to be so clear--in both Moscow and Tbilisi--that they must represent significant, if not unanimously held positions. Since our focus was on issues of death and dying, those concerns predominate in this report. Some topics, such as informed consent, truthtelling, and resource allocation arose frequently, while others--confidentiality and genetic engineering, for example--were hardly discussed.

Ethics and Medical Ethics

Medical ethics in the Soviet Union has not developed as an interdisciplinary specialty to the extent it has in the United States. The philosophers with whom we met were specialists in ethics, but not normally in medical ethics. They examined broad cultural themes: the problem of man; history, society, and the individual; scientific and technical progress; and the concept of health. They were much more in conversation with the continental philosophical tradition than Anglo-American analytical philosophy. With one or two exceptions, the Soviet philosophers were not in close communication with medical institutions. Indeed, Soviet clinicians were surprised that American medical ethicists were on the faculty of medical schools, understood medical terms, and could talk the language of physicians.

In what might surprise a Western medical ethicist, it was clear that the primary normative reference point for Soviet medical ethics remains the Hippocratic Oath. While Western medical ethics has begun to criticize the shortcomings of the Hippocratic tradition--its paternalism, its individualism, and its focus on benefits and harms to the exclusion of duties and rights--these limitations did not concern the Soviets. Although the Hippocratic Oath was superseded by the Soviet Oath for physicians adopted by the Presidium in 1971 and has no official recognition in Soviet medicine, there was no sense of tension between the Hippocratic tradition's commitment to the individual patient and physicians' explicit commitment to the state mandated in the 1971 oath. Yet, though the Soviet Oath speaks of the high responsibility of the physician to "my people and the Soviet government," there was not a single spontaneous reference to the oath in our conversations; appeals to the more individualist Hippocratic tradition occurred regularly.

Perhaps this orientation to the Hippocratic tradition reflects self-selection of Soviet philosophers into the sphere of professional ethics. One of the most astute Soviet observers noted that, contrary to developments in the last generation in the United States, the field in the Soviet Union has attracted mainly defenders of physicians rather than of patients.

The Definition of Death

The first topic explored formally during our meetings was the definition of death. Following a report on the current American debate, the Soviet participants responded not so much with an explicit rejection of brain-oriented criteria as a sense that the issue was not critical. Transplantation is not an important phenomenon in the Soviet Union and there is even, as we shall see, considerable support for maintaining permanently comatose patients. One participant emphasized that the dialectical approach of Marxism rejects subjectivization of life and death, apparently implying that defining death in psychosocial terms was unacceptable. Another participant observed that "death is the complete and final cessation of all function of life." It was suggested that those interested in medical ethics, both Americans and Soviets, should pay more attention to easing the suffering of dying persons than to trying to define death.


In the United States, the language of "euthanasia" has been resisted of late because of the ambiguities between active killing and withdrawal of treatment and the invocation of Nazi uses of that term. No such hesitation was displayed by our Soviet counterparts, because their views on active killing did not differ significantly from their views of what the American members called "passive euthanasia," that is, the withholding and withdrawing of treatment.

The absolute moral prohibition on euthanasia was as strong as any I have ever encountered, and recalled the physician ethics of preceding generations in the United States. I have reconstructed virtually verbatim the moral position presented by at least a dozen Soviet commentators:

Life is of intrinsic and absolute value; it is an end in itself. One moral principle that is without exception is not to kill. Even passive euthanasia is to be opposed from an ethical point of view whatever the circumstances...It is

impossible to justify a physician fulfilling a patient request to stop treatment. Any person able to think wants to live. If a person comes to a physician everything should be done. He has come for the doctor's advice; unconsciously he wants to be treated even if he requests nontreatment....The duty of the physician is to continue to the last minute. Even when it is believed that nothing can be done there may still be recovery. We should continue as long as there is a little hope. Patients believe in their immortality and should not have that betrayed. We should sustain life until there is full confirmation of death from the physiological point of view. Neither the physician nor the patient can decide when death is to come to the patient.

These perspectives were expressed by the majority of clinicians as well as philosophers. Numerous anecdotes were related about patients who had not wanted to be treated or for whom resuscitation seemed fruitless but who were nevertheless treated successfully. One patient, for example, was saved after forty resuscitation attempts. In defense of continued treatment in extreme cases even against the wishes of the patient, one clinician told of a well-known person with Parkinson's disease who over a three-year period repeatedly asked to be allowed to die. He retained "adequate mentality." The family objected to halting treatment, and his life was maintained; as a result he was able to dictate important scholarly contributions. And when Georgian physicians were asked what happens when a patient's family requests that treatment be stopped, we were told that this never occurs in Georgia.

With this firm commitment to preserving life, the analytical subtleties of the American debate over the distinction between active killing and letting die become largely irrelevant. The opposition to euthanasia was so strong that it is worth exploring its historical roots. They appeared quite readily. We heard repeated references to a past experiment with legalizing active euthanasia, an event with which we were unfamiliar. Apparently the 1922 Penal Code of the Russian Federation permitted killing a patient on grounds of mercy. We were told that the law was abused and abolished after only six months. No such provision appears in the present code. The participants observed that if active killing for mercy were ever legalized again, the act would have to be performed by some other profession because the main duty of the physician is to sustain life.

The discussion of euthanasia was also often closely associated with the Nazi past. While the Nazi analogy also enters the American debate, for the Soviets those historical events have a far more compelling immediacy. Their experience of the war with Nazi Germany was much more immediate than ours, and their remembrances of it are much more acute. We frequently saw older men on the street wearing battle ribbons on their breasts.

The period of glasnost and perestroika has also encouraged a more vivid awareness of Soviet history. Together the war and the increased awareness of abuses in Soviet history heighten the fear of abuse if the value of life is not treated as infinite. The Soviet participants frequently referred to historical periods in which the elderly, incapacitated, and dying were treated inhumanely and as expendable. The consensus was strongly in favor of doing everything to affirm respect for life.

While the Soviet medical ethic has not pursued the subtleties of distinguishing between justifiable and unjustifiable actions that have the effect of shortening life, it does give attention to what Western philosophers would label the medical ethics of virtue. Constant references were made to mercy, humaneness, empathy, and compassion, and the need to restore these qualities to health care. The rehumanizing of medicine seemed as high on the Soviet agenda as it is on that of some Americans. While in the U.S. philosophers have tended to emphasize philosophical analysis, holding that rehumanization is a broader task beyond the scope of philosophy, in the Soviet Union this task of reforming the physician-patient relation seemed more central to those philosophers with whom we spoke. Given the vivid sense of historical context, this is understandable.

The Link to Resource Allocation

This historical setting for the discussion of euthanasia perhaps also explains why the Soviet participants were so quick to link the issue of life-sustaining treatment to questions of resource allocation. When we summarized American concerns about patients' rights to make decisions to forgo life-sustaining treatment, we were immediately interpreted as supporting limits on care based solely on societal interests. That an individual might simply prefer omission of a treatment, even though that would lead to his death, appeared inconceivable to our Soviet counterparts.

One scholar immediately responded to a discussion of the right to refuse treatment by saying one cannot take into account money, power, or ethnic group, etc. in limiting care. He proposed an analogy to slavery as an instance of radical subordination of the individual to the social agenda when the American participants had in mind a case of a terminally ill elderly patient in pain insisting on nontreatment. In another conversation a Soviet physician made a strangely familiar argument: if we need more money, it should come from the space program. The combination of a strong commitment to preserving life even at the expense of suffering and the historical context in which euthanasia was understood as an outrageous social project made the American support of patients' freedom to refuse treatment incomprehensible.

A Tiny Opening to Limits on Care

Did every patient actually receive every imaginable treatment that would sustain life regardless of cost, utility, and personal preference? During the course of the conversations we began to perceive that this was not really the case. The first suggestion that there may, in fact, be limits on care arose in discussion of what was a potentially important difference among the delegations at the level of metaethics. Those who argued that it was as morally unacceptable to let die as to kill conceded that as a pragmatic matter digressions from moral rule are inevitable. They readily acknowledged that sometimes patients are not given every possible treatment. One participant commented that practitioners in the Soviet Union resort to "passive euthanasia" as do others all over the world. But when members of the American delegation pressed the question of whether these were cases of ethically justified exceptions to the rule, that formulation was unacceptable to the Soviet conferees. The issue was not that clinicians engaged in what we would call morally outrageous conduct, that they stopped ventilators for self-serving reasons. It was rather that such stoppages, no matter how necessary or understandable at the practical level, could never be termed moral. As one philosopher put it, "I can do, but I cannot justify." Even the religious metaphor applied: "I have sinned. It is impossible to justify." It was considered psychologically important for those who stop treatment to continue to feel guilty.

This difference at the theoretical level over whether a decision not to treat should be called an ethically justifiable omission or an unethical, but practically necessary act, should not minimize the important real differences in actual behavior in treating dying patients. There is little doubt that in the Soviet Union patients are being treated who would not be in the United States.

Nevertheless we also encountered what could be labelled a cautious minority view. One scholar appeared to propose a moral basis for certain justifiable omissions. He pointed out that in ancient times it was impossible to separate the biological and the social life, but that more recently the trend is to separate the two. He argued that it was conscious life that should be respected and implied that patients who are brain dead and perhaps those permanently vegetative need not be treated. He acknowledged resource limitations as one basis for omitting treatment, but implied more fundamental personal reasons as well.

We might hypothesize that the unrelenting advocacy of aggressive medical treatment (at least at the level of ethics) derives from the fact that, given the state of medical technology in the Soviet Union, such issues have not really been confronted. This hypothesis can quickly be put to rest, however. A visit to a hospital verified what clinicians reported. More than enough high technology interventions are available to provide ample opportunity for the Soviets to confront the moral issues of life-sustaining treatment. We learned of experimental cancer therapies and of numerous cases of life-support via ventilator, for example.

Disclosure to Patients

Excluding patients from decisions about life-sustaining treatment was supported by discussion of the information communicated to patients. The Soviet delegates discussed it under the rubric of "medical secrets." The justification for this exclusion seemed to follow patterns familiar in the West. Patients are not informed of a terminal diagnosis, because, it is felt, they do not have the knowledge to understand; they have no role in "medical" decisions; and they need protection from the trauma of the bad news. The doctrine of therapeutic privilege is alive and well among many Soviet physicians.

At the same time, change appears to be coming just as it has in the United States. We were told of one oncology professor who insisted that patients be told the truth, although we were assured that others held different views. One philosopher observed that increasing education has enabled lay people to process complex medical information far better now than in the past. Still, from clinicians the message was clear: disclosure of terminal illness to patients is the exception rather than the rule.

Transplantation and Psychiatry

Our conversations did touch on issues beyond those of life-sustaining treatment. In these other areas the impressions left were even more tentative and require further verification. One such area was organ transplantation. The Soviets have apparently engaged in some transplantation activity, but clearly this is not a high priority. Still, our contacts indicated that there is no moral objection in principle that limits transplanting organs from cadavers.

We also briefly discussed the ethics of psychiatry for which the Soviet members were remarkably blunt. The spirit of glasnost surely prevailed. No apologies were made for historical abuses other than to point out that they came from outside the health sphere. Psychiatric commitment was a departure from ethical norms; and perestroika is now overcoming that abuse.

Patient Participation

Perhaps the most basic issue that confronts medical ethics in both the Soviet Union and the United States is the evolving ethical foundation for increasing patient participation in medical decisionmaking. In the United States, of course, the moral categories that have predominated have been autonomy and respect for persons. These terms were not absent from the Soviet vocabulary although they clearly do not play the central role they do in some contemporary American medical ethics. One exquisite discussion of the issue described paternalism as "one of the characteristics of our professional ethics," but the Soviet participants argued that sociological changes will require greater participation by the patient. We were told that the image of the small-town, self-abnegating physician, who treats illiterate peasants and is uninterested in material reward no longer fits Soviet medicine.

Perestroika, it was indicated, will encourage active involvement by the individual and direct special attention to problems of human rights, though this emphasis has yet to have much of an effect on medical ethics. But sooner or later, we were told, the situation will change: Medical ethics will give rise to the importance of patients' rights, as part of individual rights. It sounded like a hope and American medical ethicist could share.

References 1 Other participants included Dan Brock of Brown University, Arthur L. Caplan of the University of Minnesota, Richard T. DeGeorge of the University of Kansas, Bernard Gert of Dartmouth University, and Daniel Wikler of the University of Wisconsin.
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Author:Veatch, Robert M.
Publication:The Hastings Center Report
Date:Mar 1, 1989
Previous Article:Theology and bioethics.
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