By Connor Fairfield, CSEEES Autumn 2022 Intern
In Part 1 of Connor Fairfield’s interview with Dr. Nataliya Shok, they discussed Dr. Shok’s path to becoming a bioethicist and her experiences in the U.S. and Russia. Please read on for a continuation of their discussion about the current state of public health and bioethics in Russia.

How have health politics and research methods changed within Russia since the rise and fall of the Soviet Union? 

This question is very complex, it could be the topic of a whole scientific article! Moreover, it is important to clarify which area of medical science or clinical practice we are discussing.

Innovations in science, technology, digitalization, and the rapid development of biotechnology have significantly changed research methods in Russia, like in other countries. This is a characteristic of science in general. Moreover, in 2010 Russia initiated a large program of global scientific cooperation, known as the Mega Grant Program, to stimulate the development of Russian science and international cooperation. Over the past decade, many leading scientists, including those from the United States, have received these grants. They created teams with Russian scientists and transferred the world's best practices in various areas of cutting-edge scientific research.

As for health policy, the situation, of course, is somewhat more complicated. Again, it depends a lot on the medical field. I must say that the development of private clinics has changed a lot. During the Soviet Union there were only state-funded hospitals, but now there are many hospitals where patients can get high quality medical care under additional health insurance programs (for example, at the expense of the employer), as well as for cash.

Additionally, compared to the Soviet period, medical tourism is developing rapidly. It is one of the priorities of the Ministry of Health of Russia. Russia has many well-equipped medical centers, qualified doctors, and the price of medical care for foreigners is more affordable than in Western Europe or the United States.

How has the current political landscape of Russia impacted the realm of both bioethics and public health policy? 

At this point it is difficult to make assessments. In general, national public health and global public health policies have common goals and constantly interact, especially when it comes to public health data sharing, which is an important part of global health security. Currently Russian medicine and public health have become dependent on a set of sanction policies, growing geopolitical tension and war. It is not easy for the Russian academic and medical community, which has participated in international programs over the last years. Historically and traditionally, we must remember that peace and international cooperation are core values of the medical profession. Therefore, public health and medical science need their independent peacemaking voice amidst geopolitical rivalry and brutal political debates.

Unsurprisingly, in all areas of Russian domestic policy—including public health—there is a growing trend towards self-sufficiency and sovereignty, as Russian political leaders like to mention. But what does that mean? In general, it means more isolated health, science, and medicine which is not in the strategic interest of the international community. Therefore, it is important to sustain what connectivity remains, which is not an easy task today.

What has been the biggest impact that the Russian Orthodox Church has had on bioethics within the country of Russia? 

One of the first scholars who actively developed bioethics in Russia was Grigory Yudin, a Soviet philosopher. He did much to familiarize the Russian academic community with the methodology of bioethics. He began this work with the support of his American colleagues in the late 1980s. In one of his interviews, he later noted: "In 1992, I went to the Hastings Center, a round table on bioethics that was organized with support of the peer-review scientific journal Questions of Philosophy. And when I spoke there, I said that in other countries the church pays a lot of attention to this, but in our country, it is somehow not visible here...I continued to emphasize then and now: the only institution in Russia that has a clear position on bioethical issues is the Russian Orthodox Church (ROC). However, the ROC sees itself more as self-sufficient in bioethics. I have almost no contact with the Church." I think this is an important observation related to this question.

The Russian Orthodox Church first outlined its approaches to bioethics in one of its key documents, "The Fundamentals of the Social Concept of the Russian Orthodox Church," in 2000. This document addressed key points regarding church-state relations and several contemporary social issues. The document also reflected the Moscow Patriarch's official position on relations with the state and secular society. Despite the high level of attention to this document in many countries and among researchers, the Russian Orthodox Church’s position on bioethics has not received the attention it deserves. It took several years for it to become institutionalized and increasingly discussed at different levels.

Evidently, in the last five years the Russian Orthodox Church has become increasingly vocal in bioethical public debates, primarily on reproductive health issues and, to a lesser degree, death and dying. Today, the Synodal Commission on Bioethics, established in 2021, is a unique platform bringing together experts from various fields of science and Orthodox priests to engage in dialogue on the key moral and ethical challenges of modern medicine and biotechnology. In fact, the ROC created this Commission to get its Orthodox-driven bioethics expertise and dialogue in with the academic community. Today, the Russian Orthodox Church plays a huge role in the debate over abortion, IVF, and surrogacy in the Russian media. In 2020, I devoted a special issue of the journal State, Religion, Church in Russia and Abroad (in Russian), to the examination of the role of the ROC, the Orthodox tradition, and Russian history in the development of Russian bioethics.

Has the COVID-19 pandemic impacted bioethics within Russia? If yes, how so? 

It is difficult to assess the real impact of the pandemic on bioethics in Russia. There is no question that the pandemic has had an impact on the practice of medicine and public health in Russia as well as in other parts of the world. However, it would be a significant exaggeration to say that bioethics is as advanced in Russia as it is in the U.S. So, we should be careful when comparing. Even though the study of bioethics in Russia has a more than 30-year history, no bioethics degree programs (MA or PhD) have been launched, and no research centers, such as The Hastings Center, have been established. The list of things not done goes on and on. The main idea is that institutionalized bioethics has not yet been fully implemented in Russia and there is no professional community of bioethicists, such as the U.S. ASBH. Nevertheless, the situation is slowly changing. In other words, I can speak here not about bioethics in general, but about my own understanding of how the pandemic has shaped bioethics in Russia. It is related strongly to the Russian history and culture. This was discussed back in April 2020 in an article I co-authored in Kennedy Ethics Journal devoted to a culture of non-disclosure that impacted Russian healthcare and bioethics before and once the pandemic hit.

What population within specifically Russia has been impacted by COVID-19 the most and how has bioethics played a role in this? 

As in many other countries, the elderly were hit hardest—they were most at risk—as well as people with chronic illnesses. Doctors, who took the first blow of the pandemic, were also at risk due to a lack of personal protective equipment. In many ways the discussions among doctors were consonant with the themes of European and American physicians: triage, lack of health care resources, medications for COVID-19 patients, etc. However, it is difficult to assess the role of bioethics specifically in the context of the Russian COVID-19 response. This type of debate did not really exist in Russia, since the healthcare system and the medical community reacted to the crisis using well-developed models of pandemic control from the Soviet past supplemented with new digital and biological technologies.

Looking back, at that time the most controversial (but little described) bioethical case that the pandemic activated was the use of a digital surveillance mechanism over sick people in quarantine (particularly in Moscow). Authorities forced the ill (and all family members living with them) to install an app for digital COVID-19 monitoring. The aim was not to monitor the patient’s health; the goal was to see if the patient and their family members remained at home. The app gave a random call and no matter the time the patient had to send a picture of their face confirming they were at home. There were a lot of questions about this practice and growing discontent among the population. Many scandals and lawsuits appeared between patients, medical institutions, and state authorities because many people received fines for violating quarantine due to imperfect systems and glitches in the health monitoring app (sometimes you were unable to send a picture). It is likely that if Russia had provided a more active platform for bioethical discussions and truly respected patients' and citizens' rights to privacy when the pandemic began, there would not have been such a case. However, there is still not enough material available from Russia to provide a comprehensive picture of its approaches to bioethics across topics. What is clear is that Russian society and the academic community still need help in developing stronger competence in bioethics education underlined by international cooperation.

If you find the topics discussed in this interview interesting, you can learn more about CSEEES’ dual degree in Slavic, East European and Eurasian Studies and Bioethics here.