Nataliya Shok & Nadezhda Beliakova
[This is an advance copy of an article that will appear in print in September 2020 as part of the KIEJ’s special double issue on Ethics, Pandemics, and COVID-19.]
ABSTRACT. The COVID-19 pandemic required strong state responsibility for the health of its citizens and the effective allocation of healthcare resources. In Russia, extreme circumstances reveal hidden Soviet patterns of public health. This article illuminates how Russia has implemented some changes within its health insurance structures but also has maintained the paternalistic style of state governing within public health practices. The authors examine key neo-Soviet trends in Russian society revealed during the pandemic: the ethics of silence, a culture of non-disclosure, and doublethinking. Additionally, we argue that both modern Russian medicine and healthcare demonstrate gaps in implementing robust bioethical frameworks compared with the United States. Using a robust analysis of healthcare and state practice during the COVID-19 pandemic within the framework of global bioethics, this article aims to respond to Russian history and culture in order to advance the development of bioethics.
The global COVID-19 pandemic has quickly and radically changed the world. The healthcare system in Russia, as in other countries, is under incredible pressure, and Russian society likewise is tested by “social distancing” practices. The unceasing adaptation and mobilization of resources has become part of our everyday lives. The struggle against the epidemic continues to emphasize the priority of global social health. Accordingly, we must address questions recently raised by The Hastings Center in “What Values Should Guide Us?”. What will be the new ethical norm after the pandemic? What compromises will be in place between civil liberties and public health? Will such biomedical ethical themes concerning the priority of the patient’s interests, the principal of minimizing harm, the disclosure of medical errors, and balance of equality and justice receive new recognition? Should we equally weigh the basic ethical principles, and are they universal? The global context of the pandemic allowed us to see that the practice of applying bioethical principles varies greatly, and the development of these principles depends on the history and culture of each respective country.
The differences in fundamental ethical commitments and historical forces that shape cultures result in different priorities, goals, and understandings of appropriate restrictions on behavior. These gaps can be difficult to bridge in the context of international guideline development, and they pose special concerns where lack of coordination threatens public health or undermines the ability to pursue collaborative research to advance health interests. One of the greatest barriers to developing globally shared guidelines is a lack of understanding and appreciation of local history and culture. In reviewing global responses to the COVID-19 pandemic, we understand the importance of dialogue and information exchange between countries in extreme circumstances. Responses can drastically differ between countries, as evidenced in both European Union countries (Hirsch 2020) and China (Lei and Qiu 2020), even though the scientific conclusions and state measures may share some overlap. Russia is no exception. The struggle against the pandemic exposed the deep rift between the global bioethical discourse and Russia’s response to the pandemic. In the development of public health guidelines, we cannot simply replicate the experiences and responses of foreign countries.
Russia imposed “the regime of self-isolation,” which limited citizens’ mobility rights, as the main pandemic countermeasure (Stanovaya 2020a; 2020b); however, there is no such applicable legal term in Russian law. The Russian President called this “a days off regime,” meaning a vacation from work obligations. He did not declare a state of emergency or impose quarantine restrictions. Instead, the bulk of the responsibility for anti-pandemic countermeasures was placed on the regional governments. In our opinion, such decisions and shifting of responsibility can be ethically justified only if the measures are proportional to the severity of the epidemic, taken with no violation of individual freedom and rights, and transparent to the public. These requirements were not met: the state refused to offer financial aid to businesses or to the vulnerable population. Instead of supporting its citizens, the state imposed a series of administrative measures (i.e. penalties) that were aimed at punishing the healthy population for going out of their homes without a special digital code during the non-imposed quarantine. For those who were diagnosed with COVID-19 and their families, they were forced to use a social monitoring app that required sending selfies five times per day, even at night. These penalties increased social anxiety and mistrust.
While many have studied the collapse of the Soviet Union, few realize that Soviet policy and practice in healthcare is alive and has significant implications in Russia. Although the democratic state assumed the monopoly in the fight against the COVID-19 pandemic, it quickly returned to the patterns of Soviet policy in implementing public health strategies. In the mid-1990s The New York Times used the term ‘neo-soviet style of state governing’ to describe a pattern of returning to the Soviet Kremlin medical treatment practice and assumptions for responsibility within state leadership (Stanley 1995). The budget of this health bureaucracy, then and now, is secret. The current pandemic has brought about the return of several negative trends from the Soviet past such as ethics of silence, double thinking, state paternalism, and a culture of non-disclosure.
We will begin by sharing the meaning of these four key features of the Soviet legacy that influence medicine and healthcare. We then will highlight the implications of these commitments for medicine and bioethics within the context of the COVID-19 pandemic. We consider the history of Russian medicine and explore Soviet commandeering within health systems. We argue that by identifying pathways that respond to our history and culture, we can advance the development of bioethics in Russia by using robust analyses of healthcare and state practice during the COVID-19 pandemic.
Ethics of Silence, or Why Does Russia Not have Bioethics?
It is well-known that bioethics—as a research field—originated as part of the academic and social discourse in the United States. Although there are some research groups, independent researchers, and journalists working to study and implement bioethics in Russia, the country has not seen widespread academic development or widespread public discourse. Why does Russia lack organizations similar to the American Society of Bioethics and Humanities, The Hastings Center, the Kennedy Institute of Ethics, etc.? The answer is quite complicated (Stepanova 2019).
Until the late 1980s, bioethics was not represented in the Soviet academic discourse. This was, in many ways, due to the fact that it was a product of American academic culture (Callahan 1993). As the medical sociologists Fox and Swazey stated in their mid-1980s study, we should not suppose “that bioethics is a sufficiently neutral and universalistic term for it to be applied to medical morality in China or, for that matter, to medical ethical concern in whatever society or form it may now occur” (1984, 336–37). This perspective was critical of Professor Engelhardt’s material, published after the delegation of the US Kennedy Institute of Ethics returned from China (Engelhardt 1980). Sociologists described Professor Engelhardt’s approach as “cultural myopia”; according to them, Professor Engelhardt did not adequately appreciate the deep Western and American cultural influences on bioethics. These sociologists argued that he inappropriately considered bioethics as neutral and universal (Fox and Swazey 1984, 337). Sociologists emphasized that the term ‘bioethics’ was a neologism, which appeared primarily in American culture. In other cultures, its philosophical bases can be perceived as “acultural or transcultural,” which “can significantly limit its application in practice, allowing for the use of other terms” (337–38). In many ways, this is true for both Soviet and post-Soviet Russian development of medical ethics.
Perspectives within bioethical Soviet studies in the fields of Communist morality, medical ethics, and deontology differed radically from those that emerged within the United States (De George 1969; Tsaregorodtsev 1966; Petrovsky 1988). These differences are deeply intertwined within history and culture; differences are especially evident when we examine the issue of freedom. Soviet philosophy largely encompasses a determinist doctrine, which means that a person’s choice is an illusion, as it was determined by the interests of society (De George 1969, 35-38). Another important difference concerning Soviet ethics was noted by the Professor Graham in his Nature essay. He noted numerous attempts by Soviet philosophers to transfer the solution of complex problems to a future society, which would presumably be more just (Graham 1991). He agreed that this position allowed for neutrality in the struggle of conflicting concepts, but such abstracts proved to be of no use for those who were bound to make decisions in current society. In other words, this ethical model was not applicable. The problem was made more complex by a rather special understanding of the basic ethical categories. For example, freedom was not individual, but collective, which in turn complicated the perception of such categories as responsibility, wellbeing, duty, and consciousness—which were directly dependent on the understanding of freedom (De George 1969). Thus, the individual value of a human being was bound to the needs of society, and morality was an instrument of social control that guaranteed social stability. In the public discourse there was an “embryological perspective” of a person and the inner life of a human being, which were seen as “underdeveloped” and in the need of being “raised.”
The desire of the enlightened government to educate the “ignorant” people has deep historic roots, starting from the reign of Peter the Great. At that time, numerous disciplinary and oppressive campaigns were conducted under the guise of “enlightenment.” In the Soviet period, society was evaluated on an evolutionary scale, spanning from the primitive to the communist forms, which meant that there was no need to give a detailed analysis of its contemporary state. The ideas of constructing a new society, educating the new human being for the common socialist happiness, manifested its limitations as early as the 1950s, since this ideology could boast a purely humanitarian ideal for the future, but only offer limited guidance on how this would allow contemporary problems to be solved.
Relatedly, developments concerning a culture of silence share this intertwined history. The ethics of silence was shaped by the expansion of the “classified” zones and non-disclosure demands. In the Soviet Union, the term “state secret” received a maximally-broad interpretation, especially the context of the non-stop mobilization campaigns, carried out under pretense of war. Safeguarding “state secrets and showing discretion was the duty of every Soviet citizen” (Zelenov 2012, 147). Record keeping in Soviet institutions was also aimed at secrecy; indeed, entire departments were kept secret. In more open institutions, so-called “first departments” monitored the storage of state secrets.
The non-disclosure culture was enforced through institutions, whose employees internalized the non-disclosure norms, as well as through censorship and the state’s monopoly on mass media. As a result, Mikhailova describes the following:
Silence as a form of social protest behavior revealed its duplicity: under certain circumstances it allowed the individual to counter society’s oppressive machines, and to defend if not one’s life, then at least one’s honor. On the other hand, it provided the opportunity to sustain the fragile peace (even a questionable one), which was still preferable to the ‘good old fight,’ yet at the same time this very tendency aided the spread of lies, the formation of a pseudo-reality and the deepening of the anthropological crisis. (2011)
The “ethics of silence” and “non-disclosure culture” mechanisms, shaped in the Soviet Union, were supplemented by the phenomenon of duplicitous thinking. Soviet sociologist Yuri Levada actively used George Orwell’s formulation ‘doublethink’ to describe this practice (Orwell 1961). Levada also noted the following about late-Soviet society:
The doublethink dictatorship became total and unlimited: it was cemented that one must separate the sphere of social norms (to act, speak and think as you ‘were supposed to’), and the sphere of what was tolerated, which was basically dubbed as the ‘private’ life…The ‘minor’ and ‘major’ truths were locked together, struggling against one another, yet supplementing each other. (2006, 266)
In Levada’s opinion, post-Soviet society cemented the behavioral qualities of the Soviet period. In 2000, he called the post-Soviet person “sly”:
The sly person—on every level and in every essence of his or her existence – not only tolerates deceit, but is ready to be deceived, moreover—he or she has a need for self-delusion for reasons of the same (including psychological) self-preservation, for the overcoming of one’s internal split, for the justification of one’s own deceit. (2000, 20)
With the absence of strict barriers that would separate the proper and improper behavior, the dominant situation for post-Soviet society was not playing by the rules, but rather—playing with the rules.
The ideology of the totalitarian state, which routinely uses policies to impose state pressure on all spheres of life, also transformed the understanding of a doctor’s duty and medical ethics. This influence denied the essence of the physician’s mission and transformed the mission into a form of social work aimed at the benefit of the state, not individual interest. The late 1980s and early 1990s witnessed the appearance of first Western studies dedicated to the peculiar traits of the Soviet and post-Soviet healthcare systems (Rowland, and Telyukov 1991; Chazov 1992; Barr and Field 1996; Field 1995), especially medical ethics (Veatch 1989; Ryan 1990; Barr 1996).
In Soviet medicine, “medical privacy” received peculiar interpretations. The main ethical goal of the doctor was to aid in the creation of the “major” truth of the state. The strict paternalist model, the medical structure centralized on a pan-Soviet scale, and its moral obligation to ensure society’s healthcare (and not the healthcare of the individual patient) completely changed the term “medical privacy” throughout society. Policymakers did not protect the patient’s rights to confidentiality but rather strengthened the non-disclosure culture of the medical corporation. This naturally did not allow for the formation of bioethical institutions, as it was understood from a Western perspective. Still, academics were also interested in investigating the “second economy on an unofficial barter system” of healthcare (Barr 1996). This was a major part of the public consensus—underground payments to the doctors in underfinanced conditions and the low quality of the publicly free healthcare. This phenomenon is hard to understand, if one only depends on the official Marxist dogmas and Communist morality of the Soviet professions, which were supposed to be driven by the primacy of duty. For doctors, the expectation and acceptance of payment from a patient in exchange for medical services was officially considered bourgeois and unethical (Barr 1996, 38). Yet this also can be easily understood as a manifestation of the “doublethink” and the non-disclosure ethics in medicine.
Strict centralized control, the disregard for the specifics of regional healthcare, the priority of quantity over quality, the overall lack of resources, and lack of financing could not stimulate the doctors to improve their work. At this time, the average doctor’s salary equaled about 70% of the non-agricultural worker’s paycheck. These factors only led to an increase in mortality, a low life expectancy, and the public mistrust of the healthcare system (Rowland and Telyukov 1991). Further, independent professional associations of health care workers could not exist under the Soviet state. The state could not and did not evaluate the professional work of doctors. Soviet doctors, as state employees, were subject to disciplinary orders and could not fully control the field of their professional expertise, which was a necessity for their work. The social standing of doctors in USSR exhibited a “paradoxical combination of corporate powerlessness and bureaucratic power” (Field 1989).
In the post-Soviet landscape, and especially in Russia, the government—until recently —kept the Soviet organizational model for mass healthcare. The government began to gradually transfer the system into the sphere of “services” yet retained the paternalistic watch of the state over the medical institutions. It’s important to remember that by the 1980s, Soviet medicine was falling behind the healthcare levels of the developed countries. Researchers see the main reasons for this in the overbearing centralized management system of healthcare, the low levels of professional education, and insufficient funding (3.4% of USSR GDP in 1989, in comparison with the 11.4% in the United States) (Rowland and Telyukov 1991). As Dr. Rowland notes, “in theory, Soviet healthcare is a model of regional medical aid, which is based on local clinics. In reality, this system falls apart due to lack of finance, the indolence of centralized control, and lack of innovation” (Rowland and Telyukov 1991). The doctor’s clinical practice was not autonomous; the patient did not have the right to choose where and from whom he or she will receive medical aid. This, obviously, meant that there were no objective motivations for improving the quality of medical aid, and numerous services would only be available for an additional, informal payment. As The New York Times stated, “Communism may be dead…but its disparities and inefficiencies remain,” and “health care had never been one of the Soviet Union’s great successes….[D]octors were always relatively badly treated in the Soviet Union” (Erlanger 1992). The situation would not change for several years.
After 1991, Russia started developing the private medical care sector, which was more flexible but also expensive for population-based health needs. The last healthcare reform in Russia, which took place during 2015-2017, was driven by the logic of “optimizing” costs and raising the “economic efficiency” of the system. In Russia, the main direction of reform concerns the reduction and merger of clinics, the partial privatization of insurance, and in some cases, privatization of the actual delivery of services. In contrast, in the United States, the most important part of healthcare reform lies in the field of insurance, not in the actual delivery of healthcare services (Filatova and Schultz 2016). Russian policy changes have led to the bureaucratization of the system, a decrease in number of hospitals and hospitals’ enlargement and specialization, with a marked and forced decrease in numbers of doctors and nurses (Nurik 2015). Nurik notes the following figures from between 2005 and 2013:
The number of health facilities in rural areas fell by 75 percent from 8,249 to 2,085. That number includes a 95 percent drop in the number of district hospitals, from 2,631 to only 124, and a 65 percent decline in the number of local health clinics, from 7,404 to 2,561. (2015)
In 2014, a broad public campaign against the collapse of the Russian healthcare system was launched by the Deystvie Union, the Russian Confederation of Labour, the Pirogov doctors’ movement, the “Together for Decent Medicine” protest group, and other civil society organizations. This did not yield the desired results. Instead, with Russia’s huge territories and disproportionate population spread, the reduction or merger of hospitals partially led to the rise in inequality of people’s access to healthcare.
On one side, as Kleinert and Horton state in their editorial, “the health system itself is marred by an insufficient skill level of its too many doctors who are still underpaid and demotivated” (2017). On another, the Russian Constitution guarantees the right to health and free medicine in state hospitals for every citizen. But the scope of guarantees is not defined by law. The budgets for medical care are scattered: they are partly paid by the federal budget and partly by regional budgets. A citizen does not know who pays, when they pay, or for what. The population does not participate in financing public health care. Health resources are disintegrated, and their allocation cannot be considered equitable. Availability of health care depends on one’s location within the country and social status. As Sheiman and Shishkin (2010) noticed, an important part of the reforms should be raising the level of legal education in the field of healthcare. It is necessary to create conditions to facilitate patients’ choice of medical organizations on the basis of accessible and transparent information and ratings of clinics. This information might also include the results of assessing the quality of medical care based on patient’s opinions. It is necessary to specify what it means for the state to guarantee free medical care, to strengthen regulation of paid medical services, to make a serious revision of medical education on all levels.
The consequences of this healthcare reform became clear in light of the pandemic, which shed light on the most vulnerable groups and re-activated the ethics of silence. Professor V. Vlasov calls this “the continued misuse of health care for political purposes” (Vlasov 2017). For many years, the government used healthcare programs to solve demographic problems (e.g., suppressing access to abortions, increasing funding for in-vitro fertilization). Healthcare was a tool, aimed at the increase of manpower, instead of being an instrument focused on aiding sick people (Vlassov 2017).
L. Roshal, the chief physician in the National Institute of Emergency Children’s Surgery, recently confirmed that Russian healthcare was not ready for emergencies like COVID-19. According to him, a meeting took place almost a year ago on the preparedness of Russian healthcare to offer aid in various emergency situations. It was hosted by the All-Russian People’s Front, a civil initiative, with the participation of representatives from the Ministry of Defense, Ministry of Emergencies, the “Defense” Movement (Zaschita), the Ministry of Healthcare, the managers of the ambulance doctors’ union, and chief physicians of various clinics. The conclusion was extremely depressing: “We are not ready to provide aid to the country’s population.” Due to a combination of numerous state initiatives to “optimize” health are and decreases in total healthcare workers, Russia was primed to experience difficulties throughout a pandemic.
Moreover, this commentary also demonstrates another example of the non-disclosure culture: no one wants to bring healthcare reform failure to the public’s attention. The regime of “secrecy” (which demands silence) reemerged in Russian everyday life with the threat of COVID-19. Public discourse on responses to the pandemic focused on the high level of social mobilization and heroism, typical for the Soviet past and in tune with communist morality. Russians’ realities were penetrated by something that is directly connected with the ethics of silence and non-disclosure culture: “The crash of Communism instilled hope that science would transform Soviet health care in the interests of humanity, but still, it serves mostly the ideology of the Russian State” (Vlasov 2017). The culture of non-disclosure persists in the neo-Soviet era.
Social Disparity and Culture of Non-Disclosure in COVID-19 Russia
The regime of “secrecy” came back into Russian reality with the threat of COVID-19, as part of the public discourse of mobilization that was a well-known part of Soviet morality accompanied with “the culture of non-disclosure.” According to the Blavatnik School of Government at Oxford University, the measures taken by the Russian government were among the strictest in the world, according to the global scale of state countermeasures to the coronavirus (2020).
The Russian National COVID Response Team was created on January 29, 2020. On January 31, Russia closed its border with China. Following that measure, self-isolation regimes and electronic passes were introduced. The government took unprecedented measures, initially stating that its care for its citizens was the prerogative. At the first stage, Russian society responsibly accepted the social isolation guidelines in spite of their numerous drawbacks. Yet the federal government refused to impose nationwide quarantine measures or even impose them on the large metropolitan areas. Responsibility for such measures was instead routed to the regional governments. Additionally, the state refused to offer financial aid to businesses or to vulnerable groups of the population. In the aftermath, the state continued to pursue the disciplinary-oppressive course, which was represented as an “educational” measure aimed at “irresponsible” citizens. Instead of supporting its citizens, the state imposed a series of administrative measures that were aimed at punishing the population for violating the non-imposed quarantine measures and for the spread of unverified information. The state also created a special procedure for registering and selling medicine, while maintaining limitations in trade and businesses.
The legal system has imposed strict measures in response to COVID-19. One of the specific measures was the Russian Supreme Court’s decision that forbade the discussion and spread of any coronavirus information under threat of criminal charges. Article 207.1 (“Public dissemination of knowingly false information about circumstances posing a threat to the life and safety of citizens”) was introduced into the Criminal Code on April 1, 2020. It focuses on filtering coronavirus distribution data. Accordingly, information concerning the pandemic that does not originate from official state channels is presupposed to be aimed at political and social destabilization.
Digital passes, isolation, and fines have also been imposed in Moscow vigorously. Regional authorities try to follow the capital’s example as best as they can. All of this was accompanied by the strengthening of social inequality—state officials of all levels, members of security services, journalists, and jurists were exempt from the restriction measures. The elder generation of Russian citizens characterized this situation as the imposition of “martial law.” Society’s perception of this time-period as a “time of war” allows us to analyze these events from the point of view of the history of Russian collective mentality . This approach allows us to see the “content plane” that lies beyond the “expression plane” of the social mindset (Ariès 1981, XIII–XVII). With the original cooperation of the population (who agreed to social distance and limit their movement), the level of the state’s communication with vulnerable people facing economic instability deteriorated to its usual forms—fines, bans, threats, and pressure. Under the conditions of the epidemic, the mental predisposition of almost all state officials becomes quite clear: the Russian president calls for social isolation, and thus it is unacceptable to say anything against social control. Following this idea, President Vladimir Putin signed the new federal law No. 123 on April 24, 2020:
On conducting an experiment to establish special regulation in order to create the necessary conditions for the development and implementation of artificial intelligence technologies in the subject of the Russian Federation—the city of federal significance Moscow.
This law amended Article 6 and 10 of the Federal Law “On Personal Data.” As a result, Russian citizens are facing a new ethical challenge to their rights to privacy; this is partially why the state’s actions are aimed at further enforcement of isolation. Nevertheless, the measures taken by the authorities in their fight against the coronavirus vary from region to region, as does the level of the pandemic’s spread (Volkov 2020).
In order to properly evaluate perception of the imposed restrictions, we must understand which measures will be repealed once the quarantine ends and which will remain permanently. For now, we can only say that only a minor percentage of the Russian population considers the state’s anti-COVID measures extreme. Here, we should examine Russians’ attitude towards similar restrictions: the law allowing security services to monitor private correspondence, the blocking of several foreign websites (including some universities), and punishment for “extremist” social media posts. These previous initiatives were actually met with support by a bulk of the population; however, public opinion on the matter was dominated by representatives of older generations and residents of rural regions. Both groups tend to traditionally see the state as the institution responsible for the safety and morality of the people. Younger, more educated, and socially active Russians and residents of major cities, on the contrary, were highly unhappy with these laws. They had a better understanding of the restrictions’ essence and “extrapolated” on themselves the possible punishments.
These contemporary state measures reinforce isolation measures. The lack of bioethics and a professional community of specialists, capable of articulating society’s interests who seek to balance individual freedom with social interests, has led to the restoration of the “ethics of silence.” This is verified by public opinion surveys. For example, Lev Gudkov, the director of the Levada Center notes that “over 60% of the population is neutral in their assessment of the President” (2020). Gudkov calls this the “base construction,” where this population concludes that “there is nothing we can do, so I will not say anything good or bad” (2020). In the post-Soviet period, Russian society went through a radical transformation and assumed a highly unstable structure. Post-Soviet Russia experienced several crises—e.g., 1998, 2000, 2014—with each one deepening the social and economic divide, creating new vulnerable groups in Russian society. Yet the problem of poverty, questions of inequality, or a search for solidarity did not become subjects of public discourse. Russian society exhibits a far greater level of income inequality than European and the majority of post-Socialist countries. The “middle class” is absent, as are the conditions that would allow for its formation, while the population is subject to a high mortality rate.
Meanwhile, individuals living in poverty were further marginalized. Poverty remained adamantly overlooked by Russian society. In 2014, sociologists marked the stigmatization of the poor; society would bestow them with highly negative characteristics (Mareeva and Tikhonova 2016). The concept of a two-level social inequality in modern Russia is applicable to healthcare access. Inequalities in health are not limited to inequalities in access to health services, however. The difference in the social status of patients creates different attitudes regarding health, reinforcing inequalities in maintaining the health of Russians. A high social status allows the patient to establish equal relations with the doctor and affects the degree of satisfaction they experience in contact with the doctor and treatment. Low social status limits the patient’s choice: they usually use the state medicine, not only because the low costs, but also because of prejudices in private medical services. The COVID-19 pandemic—aside from emphasizing the divide of the population of the large metropolitan areas with large and small towns and rural areas, intertwined with demographic factors such as age, education, and income—also brought into the open the crisis of public trust towards official medical institutions and doctors (the lack of transparency in medical statistics, malfunctioning tests, the cancellation of any medical treatment aside from COVID-19). The lack of professional associations and the political subjectivity of regional authorities leads to little legal accountability . With this in mind, it is noteworthy that the Moscow City Administration is actively promoting the values of transhumanism, that is, the improvement of a human being with digital technology and AI, through measures such as the “Smart City 2030” program and the new digital pass system testing that has been ongoing throughout the COVID-19 epidemic.
In addition, there is a lack of accountability for the social, immunological, and psychological consequences for isolated people. Using their own clinical observations, several doctors have recently discussed the risks of prolonged isolation that directly challenge the currently imposed measures (Jalsevac 2020). However, information questioning the state’s responses will often be met with hostility on social media. The military mobilization of the health services allowed the state to go back to the comfortable and familiar forms of communication with society—a format of strength, stemming from paternalism and police control.
Healthcare Professionals During the COVID-19 Pandemic
During the epidemic, American medics have noted the moral suffering of doctors who are forced to make daily decisions on whom to help in the state of deficit. The United States’ medical community is troubled by the underestimation of psychological consequences of the doctors’ work during the COVID-19 pandemic. The current epidemic unexpectedly and radically destroyed our perceptions of the norms within medical practice, actualizing the need for transparency. The bioethics community agreed. They are certain that under the epidemic conditions, the main dilemma is the struggle between public healthcare ethics, oriented towards the just distribution of organic resources and social security, and the model of clinical ethics, oriented towards the individual patient’s wellbeing and interests. Are such statements equally applicable for all countries? What are the peculiar traits of the situation in Russia?
Russians have dedicated great attention to scrutinizing health professionals’ behaviors throughout the pandemic. On April 22, 2020, during the online conference “Ethical Dilemmas: Does the Crisis Write Everything Off?” the chief physician of one of Moscow’s largest hospitals—Alexei Svet—characterized the current situation as a “time of elastic morals.” Answering a question on what is to come after the pandemic, he stated, “Of course they will find those ‘responsible’ for the situation, who did not do enough to counter the epidemic…and it will be health workers.…They did their job poorly and did not do enough to protect us.” In other words, he expects medical professionals to be made into scapegoats for the shortcomings in the system, regardless of the state’s role in its weakening.
The main measure that impacted health professionals employed through the public health services was the re-orientation or closure of the state hospitals. From the moment the epidemic broke out in Russia and self-isolation was imposed, hospitals were directed to treat COVID-19 patients; these regional hospitals were charged with responsibility for monitoring COVID-19. Major state clinics focusing on other specialties or clinical practices were closed. Doctors were forbidden to have multiple practices (in two or more clinics); meanwhile, methods of calculating the mortality and infection rates were constantly being updated. For example, in Moscow hospital No. 57 with a specific department dedicated to treatment of pulmonology and cystic fibrosis for adults (the only one for the whole country) was closed. Patients were discharged without any support. During April–May 2020, in 11 regions (out of 85 Russian Federal units), their regional health ministers resigned or were dismissed. These measures raise many ethical issues.
The imposition of listed measures was subject to severe logistical errors, caused by the instability of the decisions made, the extraordinary transfer of financial resources, the constantly changing demands of the regional governments to the hospital administrations, and the threat of legal consequences for the spread of the infections. Under these circumstances, the social inequality of the health workers became clearer than ever. Professional medical vulnerabilities were exposed, since now the entire industry was quietly “mobilized” by the state. In our essay, we feel that it is our responsibility to state that in the current political situation, we need to expand the vulnerable categories of citizens (namely, the elderly, homeless, prisoners, children, and solitary people) to add doctors to the list. The epidemic exposed new forms of conflict on several levels: between state and private medicine (financing); between the hospitals fully and partially equipped for COVID-19; and between doctors of various specializations because of financial inequality, since the payment for treating COVID-19 patients is higher. Many private clinics retain the ability of continuing their practice unrelated to COVID-19. The salary levels in private clinics are significantly higher than in state clinics. Differences in doctors’ everyday life are also clear; for example, doctors working with COVID-19 receive hotel accommodations. Meanwhile, private clinics also retain the right to receive patients with either state insurance, with further state compensation, as well as privately for market-price payment.
Disparities in protection and communication exist between state hospitals and partially-equipped clinics. State staffs of the hospitals and emergency rooms that are dealing exclusively with COVID-19 patients were informed regarding the high levels of contamination. They were insured, and the information on the doctors contracting the disease is not being hidden. But within the partially-equipped clinics, doctors did not receive adequate self-protection kits against COVID-19, and an intense conflict between doctors and the hospital administrations is on the rise. For example, in Moscow’s 23rd Hospital, COVID-19 patients entered through several channels and found themselves in various treatment departments. Despite the fact that a separate block of the hospital was being prepared for COVID-19 patients, a significant number of young doctors contracted the virus. The hospital administration pressured its staffers not to take medical leave, and this pressure in part increased the number of virus-stricken doctors. Nevertheless, the doctors were not registered as “COVID-19 workers”: the workers did not receive security guarantees or financial compensation for their risks.
Infected doctors must continue to work for two reasons: to sustain “good” statistics, as information on their illness can hurt the hospital’s chief physician due to fines or penalties, and out of fear of being fired for the spreading the information in question. Moreover, doctors of different specializations often find themselves under the conditions of growing financial inequality, and the lack of inter-department cooperation protocols further undermine stability. Payment for treatment of COVID-infected patients is higher than for the treatment of other patients facing conditions like a cold or pneumonia. Nevertheless, not all doctors working with these patients receive adequate financial compensation, and doctors in state clinics are forbidden to continue any other medical practice.
Because of the low level of public trust in Russia’s health system, we now also face an incredibly low level of trust when it comes to doctors. This is evidenced by the growing number of lawsuits against doctors who supposedly infected their patients. In Russia, COVID-19 activated a culture of non-disclosure, contrary to the perspective of bioethics that Dan Callahan, founder of The Hastings Center, defines as foundational and conversational. According to Callahan, “bioethics has to ask hard, even nasty questions.…It shouldn’t be troublesome just for the sake of being troublesome, but because the very nature of ethics requires that it ask hard questions, they always bring trouble” (1993). In Russia, we see the rise of the “ethics of silence” and the dominance of the non-disclosure culture. The main problem for the doctor is the “pressure triangle”: the hospital administration; the threat of criminal charges from the state; and displeased patients and their relatives who may threaten lawsuits. In Russia, the culture of non-disclosure and the lack of a proper structure for clinical bioethics led to doctors, as a social group, becoming even more vulnerable during this pandemic.
We argue that there are three main epidemic-aggravated barriers in modern medicine in Russia. First, medical errors are a part of criminal law and therefore never should be acknowledged. It means that keeping all medical information as a secret is a part of doctor’s corporate code of behavior, a sort of life-keeping model. Second, we do not generally withdraw ventilators because it is considered euthanasia, which is forbidden. Third, we have a different culturally-rooted meaning of the basic bioethical concepts. For example, among physicians we may find the point of view that medical ethics is aimed at avoiding patient complaints, and it is not connected to the idea of respect of patient’s autonomy. The last commitment led to the practice where clinical bioethics in the ICU is within a psychiatrist’s scope of responsibility. In the ICU, typically no one will ask a conscious patient about his agreement to use ventilators. Usually, physicians consider this treatment as a part of “life-saving” behavior. If a patient is against ventilators, according to the law, he may sign a refusal of this procedure, but the ICU team may ask a psychiatrist to check the patient. When this consultation is finished and the psychiatrist diagnoses the patient with depression, the patient will be intubated and prescribed antidepressants, using the psychiatrist’s permission. Based on the history of medicine in Russia, we believe that these barriers are rooted in the fear that physicians may be put in prison if a patient dies.
Additionally, three important factors contribute to viewing physicians as a vulnerable group in Russia: lack of personal protective equipment; violations of the labor rights of doctors (e.g., labor contracts for special working conditions are not provided and signed); and the fear of not receiving payments after dismissal. Today, the position of a doctor in Russia differs little from that of a doctor in the USSR and in Russia in the 1990s. Despite ongoing reforms, the social status of the doctor has not changed (Saks 2015). There were no conditions for the emergence of an independent union of healthcare professionals or an independent expert association of doctors able to assert their rights and focus attention on medical ethics. Additionally, these physicians face significant moral pressure. Doctors may fear the inability to help everyone, and they may feel pressure from extreme work exhaustion and lack of equipment. Lastly, they may have inadequate information and fear legal consequences at every turn; pressure also stems within the system from chief physicians, who can fire them for refusing to follow oral orders that violate the law. All of these factors force us to think about the high vulnerability level of doctors both as a professional and social group. The factors challenge us to speedily introduce clinical bioethics practices within Russian hospitals. This introduction will allow for significant relief for physicians and nurses throughout all levels of healthcare.
The impossibility of consolidating our panic-stricken society, the activation of Soviet patterns, the absence of joint collaboration between doctors, and the lack of bioethics specialists—these factors led to the current social tension and conflict during the pandemic. Undoubtedly, it would be fair to say that public health ethics is in permanent conflict with clinical ethics. However, in Russia—with its notable lack of a civil society and respect of human rights—this conflict assumes totally different forms. Although self-isolation, quarantine, and digital pass measures have been put into practice globally, these measures, in Russia, provide a unique opportunity for tightening state command. These measures resurrect patterns from the Soviet-era control and discipline but with newly equipped unique IT technologies. The easy introduction of the ethics of silence into public discourse was possible due to the “forms of secrecy” that have been gradually imposed since the mid-2000s. These forms of secrecy are now gaining in massive scale because of the pandemic. Moreover, the general “wartime” discourse has minimized the values of individual rights from the public mind, quietly bringing to life the Soviet ideals of duty and state’s monopoly on differentiating the population’s rights to access resources. In 2020, we definitively see that Western bioethics is absent in Russian practice.
Modern Russia clearly exhibits the old and well-known conflict between the healthcare system on one end, which remains largely state-controlled and paternalistic, and the professional medical community on the other. The independence of the latter is fully subsumed into the Soviet concept of medical deontology. Duty is seen as a level of socially restricting freedom of action and the base for moral responsibility in a model that is maximally-far from reality (with its ban on defending individual, personal interests). The healthcare professional received the status of state employees in wartime, without the rights to violate the orders and regulations or to oppose their superior. Just like 30 years ago, the Russian healthcare system does not account for the doctors’ independent professional practice, where a physician has the right to make his or her own decisions in various circumstances. Medicine became the “safeguard” of Soviet ethics of professional duty, professional duty having the connotation that “duty as well as the greater good is the goal,” both of which are determined by the state.
Simultaneously, the state began operating as the arbiter that enacts social control but does not dictate responsibilities; instead, it limits social interaction and communication. With the absence of bioethics, doctors found themselves in a very vulnerable position: they are forced to abide by the epidemic’s behavioral norms, imposed by the authorities. At the same time, the doctors are considered guilty for failing to fight the virus. The medical vulnerability of doctors is also evident, because of the high-infection rate among them and the lack of information on the subject (which merely proves the vulnerability of their position). The facts we examined do not give us any ground to believe that there is currently a bioethical discourse or a public dialogue aimed at social solidarity, which is seen in the United States, where bioethicists and healthcare leaders are looking for a joint solution to the problem. State officials in Russia, having taken on the external forms and terms of the WHO, filled them with Soviet instructions—leaving the doctors as the “guilty” and vulnerable group.
In Russia, people often discuss the traditions of the national medical ethics and deontology. Yet the controversies and memory wars surrounding the social history of the last century do not provide much hope for the monolithic perception of this phenomenon and its national exclusiveness. The fight against the epidemic uncovered the discourse divide in social meaning and bioethical projections between the Russian public healthcare practice within its clinics and practices globally. Currently, there is a risk that decisions will be made for expedience by separate agents, bypassing normal routes of consideration. Under these circumstances, we depend on the ties and interactions within the global bioethics community, striving for the swift development of an institution responsible for “clinical bioethics.” This will allow us to both provide the transparency in the field of medical aid and defend the interests of both doctors and patients.
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