1 BIOETHICAL ASPECTS OF HUMAN RIGHTS IN EDUCATIONAL SYSTEM

2 3 CONTENT

Armen Harutyunyan Human Rights Defender of the Republic of Armenia ...... 7-8

Dendev Badarch Director of UNESCO Moscow Ofiice ...... 9-10

Vladimir Pryakhin Ambassador/ Head of the OSCE Office in Yerevan ...... 11-12

This brochure provides materials of the international conference on Elena Krasowvskaya "Bioethical aspects of human rights in educational system" held on 4-5 Executive Director of the UNESCO National Committee of the Republic of Belarus September, 2006, organized by RA Human Rights Defender's Institute in "The Protection of Human Rights and Dignity in the Context of cooperation with National Center of Bioethics and the financial support of Contemporary Bioethics" ...... 13-17 the UNESCO Moscow Office Boris Yudin Correspondent-member of the RAS, professor "The authors are responsible for the choice and the presentation of the The RAS Institute of Philosophy, Moscow, Russia facts contained in this book and for the opinions expressed therein, which "New Biomedical Technilogies and Human Rights" ...... 18-23 are not necessarily those of UNESCO and do not commit the Organization" Luminitza Drumea Expert on Science in the National Commission On UNECSO Affairs in the Republic of Moldova "Supporting the Development and Daising Awareness in the Sphere of Bioethics in the Republic of Moldova (Aspects of Human Rights)" . . . .24-26

Levan Labaury UNDP Project Assistant of the Patients' Rights Center At the Public Defender's Office of Georgia "Medical Bioethics in Georgian Health Care System and Perspectives of Cooperation with Public Defenders' Office of Georgia"...... 27-34

Yadviga Yaskevich Institute for Social and Humanitarian Education, Republic of Belarus "Philosophic Methodological Problems of Bioethics and Human Rights: the Specifics of Educational Programs in Belarus" ...... 35-44

Georgi Kutoyan Senior Adviser of the Human Right Defender of "Bioethics of Law in the Activities of Human Rights Defender of the Republic of Armenia" ...... 45-50

Tigran Khachatryan Member of the Council of ”Bioethics Development Society", Republic of Armenia Director of the 2nd Medical Union. "Medical Insurance as Bioethical Norm for the Regulation of Interrelation in Health care System in Armenia"...... 51- 54

4 5 Karen Kazaryan Armen Harutyunyan President of ”Bioethics Development Society" NGO, Yerevan, Republic of Armenia Human Rights Defender of the Republic of Armenia "Bioethics Role in the General System of Human Rights"...... 55-58 PhD in Law Karen Avagyan Dear Friends, Colleagues, Ladies and Gentlemen! Vice-president of ”Bioethics Development Society" NGO, Yerevan, Republic of Armenia I am very glad to greet you at our conference today, the urgency of which is "Human Rights in the Sphere of Bioethics - Right to Health, Social Rights" 59-64 dictated by the impetuous growth of biological sciences, the technical progress Liana Yukhanyan and achievements in the sphere of health care. Bioethics has put Union of Non-Governmental Organizations of Shirak marz, Republic of Armenia forward new tasks before us in the sphere of human rights, the solution of "Medical Ethics, Human Rights and Induced Abortion" ...... 65-69 which is impossible without consolidation of efforts of scientists, lawyers, pub- lic representatives and without implementation of a corresponding comprehen- Karen Nazaryan sive programme in the sphere of education and raising public Director of the Fund "Armenian Interchurch Charitable Round-Table", Republic of awareness. Armenia "Some Aspects of the Interrelation between Bioethics and Christianity" . .70-75 Ethical problems, raised by the rapid scientific progress, must be considered within the context of respecting human dignity and protecting Susanna Davtyan human rights and basic human liberties. The biomedical practice is a sphere Member of the Council of ”Bioethics Development Society", of realization of the most fundamental and basic human rights, in particular, Head of the Department of Philosophical Sciences, Yerevan State right to life, right to respect for human dignity, health protection and, finally, Medical University, Republic of Armenia "The Quality of Bioethical Education in Medical Institutes of right to death. Higher Education. Realias, Perspectives" ...... 76-78 The creation of new medical technologies, that expand the possibilities for effective impact on the deepest structures of human organism, human psyche Igor Madoyan and genetics, causes numerous problems, that require a solution in the legal Director of National Center of Bioethics, Republic of Armenia sphere as well as in the sphere of ethics, for example, the issues of "Problems and Perspective of Bioethics Development in Armenia" ...... 80-83 transplantation, human cloning, which are of high importance in the Karen Badishyan contemporary society. Program Coordinator Euthanasia belongs not to the least place in bioethics. It is the point of Union of Non-Governmental Organizations of Shirak marz of the Republic of Armenia collapse of humane relations with the human being and the "Life Ethics and Alternative" ...... 84-93 religious-philosophical viewpoint, which proclaims that every human being Final Document on the Results of the International Conference on "Bioethical should bear his or her cross until the end of his or her destiny. Whose Aspects of Human Rights in Educational System", viewpoint is more correct? Doesn’t the negation of euthanasia violate the September 4-5, 2006, Yerevan, Armenia ...... 94-96 human right to dignified departure from the life? Naturally, the solution of these problems is impossible without informing the society, without scientific approaches, the development of interdisciplinary science and, of course, without including of bioethics into educational system. The main resources in the sphere of development of bioethics are as follows: – teaching bioethics as a discipline (either in compulsory or optional courses) in medical educational establishments, as well as in philosophical departments; – reforming the legislation of health care system taking into account the

6 7 problems of bioethics; Dendev Badarch – discussing bioethical problems in mass media; Director of UNESCO Moscow Office – publication of corresponding literature including manuals; Dear participants, Organizers, Ladies and Gentlemen!

– stirring up the internet resources; Feeling very honoured and pleased, on behalf of the UNESCO Moscow Office – holding international and local workshops on this problem. I would like to welcome the guests and participants of the conference on "Bioethical Aspects of Human Rights in Education System", organised by the It would be impossible to carry out the above-mentioned activities without Human Rights Defender's Institute of the Republic of Armenia in cooperation common efforts of all clusters of the society, as well as without involvement of with the National Centre of Bioethics of the Republic of Armenia. representatives of governmental and non-governmental organizations. We have already been in a rather long cooperation with the Human Rights I think that this concerns other countries as well as those that participate in this Defender's Institute of the Republic of Armenia. In May 2005, together with the conference today. Human Rights Defender’s Insitute, we organized an international conference I would like to note that it is the second time that an international conference on "Tolerance, fight against discrimination in the context of fighting against on the issues of bioethics is being held in Armenia under the auspices of the international terrorism (Caucasian Dimension)". The Conference that has UNESCO Moscow Office, which spells out our special attention to the called together human rights experts from the Caucasian region, underlined significance of this problem in the sphere of human rights protection. the most important role of the national human rights institutions in supporting The detection of the problems in the sphere of bioethics, connected with the states to determine and develop active measures aimed at providing such human rights, the possible ways of their solution, exchange of experience, level of safety that would enable to fight against threat of terrorism without and, finally, the suggestions, that support efficient realization of that sphere of breaking fundamental human rights. This current meeting is called to support science, are the primary plans of our agenda for these two days. The the development of a systemized and overwhelming comprehensive objective of the conference is to involve the civil society into participation and approach to integrate the principles of ethics and human rights and the discussion process on the issue through the engagement of NGOs, UNESCO strategy into educational policy and training programmes. governmental and international organizations, as well as raising awareness of As you know within the framework of the international mandate of the the society through mass media. UNESCO's competence and along with issues of education, science and The Institute of the Human Rights Defender of the RA is ready to provide all culture, the following humanitarian and social issues are also included: human kind of assistance to reveal the gaps that exist in current legislation, and rights, ethics in science, human safety, social restructure. Within the eliminate them in cooperation with NGOs. It is ready to collaborate with all framework of its programme on "Ethics of Science and Technology" UNESCO structures, working on the integration of approaches, based on the principles supports the information-educational activities, scientific research, of human rights and ethics and introduce them into educational programmes. institutional development with a special emphasis on bioethics. UNESCO has I hope that the work in the course of these two days will be fruitful and dealt with issues of bioethics since early 1970s, when the ethical and legal regardless our tough agenda our guests would be able to visit sightseeings aspects of biology and medicine became an object of active discussions in and get acquainted with cultural values of our capital. public and scientific spheres. Following its own convictions that it is impossible to reach peace without spiritual and ethical solidarity of the whole mankind, Thank you for your attention! UNESCO views the involvement of all countries into an intercultural discussion of bioethical issues as its main goal. The UNESCO programme on bioethics was set up in 1993, and since 2002 bioethics has become one of the key priorities of the Organization.

In October last year at the 33rd General Conference of UNESCO, the Common Declaration on "Bioethics and Human Rights" was adopted, the implementation of which as a legal document on a global level connects the

8 9 ethical issues concerning medicine, science on life and use of technologies in Vladimir Pryakhin respect of human beings. The above-mentioned document is suggested as an Ambassador/ Head of the OSCE Office in Yerevan instrument to support states in the process of reforming and improving the PhD in political sciences legislations and policies, to provide a set of principles for regulating the routine life of citizens, social groups and institutions in the sphere of bioethics and Distinguished participants of the conference, dedicated to the bioethical issues supporting public dialogue. of human rights in educational system!

The adoption of this declaration highlighted the importance of bioethics, since I am very happy to greet you on behalf of the Yerevan Office of the this document is the first international legal paper in this sphere, adopted Organization for Security and Cooperation in Europe. by states. The significance and urgency of the topic of this conference is doubtless. The The Common Declaration on "Bioethics and Human Rights" is called to unprecedented qualitative progress in the development of science and support the strengthening of the role of ethical committees and making their technologies has brought forth in the agenda a number of issues on human participation active in decision making process. According to the Article 19 of rights and sometimes the issue of existence of a human being as a biological the Declaration, institutions, like independent ethical committees, are called to species. In this respect the initiative of the Human Rights Defender of Armenia bring an essential contribution in the implementation of the principles of the with the support of the UNESCO Moscow Office and the National Center of new declaration. We have great expectations from these committees in Bioethics is worth high appraisal and comprehensive support to discuss these connection with the expansion of their mandate involving not only the ethical questions at a special conference. aspects of medicine, science and life, but also the ethical sides of science, technology as a whole as well as supporting the realization of the principle of In the evaluation of the humanitarian aspects of the scientific technical social partnership. I would like to call your attention also to one aspect which progress the OSCE is guided first of all by the interests of protecting human arises from the plan of the Common Declaration "On Bioethics and Human rights. The human rights and basic liberties are directions based on which the Rights", an aspect that concerns the necessity for raising public awareness OSCE has worked out trends to achieve unification through tolerance, mutual in their rights and the ability to protect these rights. respect, consensus and cooperation in the course of decades. The elaboration of bioethical milestones, connected with the achievements of science and Following the UNESCO strategy, the sector of social and humanitarian technologies, especially in the sphere of medicine, is significant for such a sciences of the UNESCO Moscow Office has defined comprehensive consensus. support to national initiatives aimed at developing educational programs on ethics as well as creating and supporting activities of existing OSCE considers many of the issues on the agenda of the current conference committees on ethics and bioethics, as a priority direction of its in a wider sense of strengthening the security of member-states as well as the activities in 2006-2007. During the recent two years due to the support of the international community in the whole. According to the document, adopted by UNESCO Moscow Office there have been established national committees on the member-states, " The OSCE strategies in respect of the threat to security bioethics in the Republic of Belorussia and in the Russian Federation as well and stability in the XXI century", "the technological changes […] suggest new as a number of educational projects in the sphere of bioethics and human possibilities of trade, growth and development, but do not bring equal benefits rights in the Republic of Belorussia and in the Republic of Moldova. There is a to all participating countries, in some cases enhancing economic difference sincere hope that our cooperation in the cluster countries will develop and both between and inside the countries." become stronger and the list of joint projects will continue to expand. This assessment concerns first of all the sphere of science on life, At the end I would like to thank the organizers of this conference and express biotechnologies, genetic engineering, applied and fundamental medicine, as my gratitude to the National Commission on UNESCO Affairs in the Republic well as nana-technologies. The scientists' success in these spheres of of Armenia for their active support in the organization of this event. I wish research promises the human beings new qualitative benefits, miracles of fruitful work to all participants of our current meeting and sincerely hope that replacement therapy and salvation from diseases that have always been the recommendations of the conference will play their specific role in the considered as fatal. But they bring also serious negative ramifications in case solution of those problems which the current conference is devoted to. of their irrational use. Unfortunately, we cannot also exclude the possibility of

10 11 deliberate ill-purpose use of these achievements for the interests of separate THE PROTECTION Of HUMAN RIGHTS AND DIGNITY IN individuals and groups which is prone with serious negative results for the THE CONTEXT OF CONTEMPORARY BIOETHICS security of states and nations.

By the initiative of our Office a complex of problems connected with the Elena Krasowvskaya evaluation of different aspects of science and technology are discussed in Executive Director of the UNESCO National Committee Yerevan at periodically held international conferences on "New Challenges of the Republic of Belarus and Threats at the Beginning of the XXI Century". The Republic of Belarus pursues the norms of international law in the sphere In the course of fruitful discussion with the participation of Armenian and of health care. The main principles of biomedical ethics, that are international scientists on these issues, in particular the intriguing and delicate recommended by the World Health Organization, are fixed in the new laws of issue of contemporary biology and bioethics about the possibility of the the Republic of Belarus "On Health care" (1993, with additions and artificial prolongation of the human life, as well as the negative results of that amendments of 1998-2000) [2,290], the law "On Psychiatric Assistance and phenomenon on the currently existing and future generations were raised. As Guarantees of Human Rights in the Course of its Delivery" 1999, [3,421] and it has been said in the reports, made at the conference, as a result of the new concept of health care development, worked out in 1995 in the accelerating convergence of the most advanced technologies, it becomes Republic of Belarus" [4]. The Government has worked out and approved the more and more possible that in the course of the next 3-4 decades the human national strategy for sustainable social-economic development of the Republic of Belarus for the period till 2020 [5, 76-79; 107-138]. This concept is scientific and technological developments will bring to significant currently a good basis for the adoption of legal enactments as well as for achievements not only in increasing the longevity of human life, but also to the common governmental and interdepartmental programs, where concrete possibility of actual healthy lifetime of indefinite duration. measures and resources for providing sustainable developments in Belarus The positive aspects of these kinds of discoveries are evident. But at the same are determined, and decisions are made on ethical-legal support in the time we cannot close eyes to a whole range of serious social, economic and preservation of the biological diversity. first of all ethical problems, connected with this kind of progress in science. In 1999 in correspondence with the decree of the Ministry of Health care of the Unfortunately, today we are to state that the society is very little informed about Republic of Belarus "On the adoption of the rules of the medical means the existing current bioethical issues and is not ready to ultimate challenges of clinical testing", the Republican Center for Expertise and Testing in Medical the sphere. In this respect, the current conference is exclusively important and Sphere was established within the Ministry, which worked out methodical interesting. recommendations "on the rules of organizing and operating of committees on ethics in the Republic of Belarus". In April 2006 the National Committee on I wish to the participants of the conference to hold creative discussions and Bioethics was set up within the Ministry of Health care of the Republic of interesting findings. Taking advantage of the event, I want to assure the Belarus with the support of the National Commission of the Republic of organizers of the conference in the readiness of the OSCE Office in Yerevan Belarus on the UNESCO Affairs. to cooperate in the sphere of bioethical issues. According to the Guidance ¹1 on "The Establishment of Committees on Bioethics, the National Committee "is a committee established by a state body, in the majority of cases either by the parliament, or the corresponding ministry (health care, science or jurisdiction)… Usually these kinds of committees have full authority, since they are set up as a result of political decision on the establishment of a national committee in the given country". In June 2006 an international seminar on "The National Committee on Bioethics in the Republic of Belarus and the Activities of the Local Committees on Bioethics: Experience of the Central and Eastern Europe" was held with the participation and support of the UNESCO Moscow Office, the National Commission of the Republic of Belarus on the UNESCO Affairs, the Ministry of

12 13 Health care of the Republic of Belarus. bioethical system. The health of the human being is the main indicator of the complex co-evolutional development of the natural-human system. In that In the laws of the Republic of Belarus, concerning health care, medical respect one can speak about the coincidence of the goals of bioethics and assistance to citizens, close attention is paid to the bioethical aspects of ecological ethic in the context of providing ecological safety and health of the human rights. Thus, analyzing the law "On psychiatric Assistance and population in conditions of the pollution of the environment and misbalance of Guarantees of Citizens in the Course of Delivery of such Assistance", one the ecological system "Human being-Nature". should mention that the given law announces the basis of state regulation in the psychiatric assistance, human rights and guarantees, fundamental In the contemporary Republic of Belarus, due to the critical level of balance in principles of psychiatric assistance: (the principle of voluntarism, awareness, the system "Nature-Society", the status of bioethical parameters has a special consent to treatment and the ability to refuse it, as well as its provision in the significance. The data of biomedical research witness about the direct and "less restricted form"). The involuntary hospitalization and treatment of a apparent threat to the health of population and the protection of the genofund, person is possible only by the court order, which in case of disagreement can due to the complex radiological-chemical pollution of the territory of Belarus. A be applied against by the patient, his/her representative, or a remedial unique negative role in that process belongs to the Chernobyl catastrophe organization. The ethical-legal normative of psychiatric assistance is enhanced (April 1986), as the greatest technogenic tragedy, that did the most harm to the by such concepts as moral autonomy of a psychiatrically sick person over the Republic of Belarus. It has shown that the catastrophes have no boundaries whole range of his/her interrelations with the psychiatric services, and that the whole world is in mutual ecological interrelation, reminding V. reasonability of the treatment, etc. Vernadski's ideas with being of high importance about not only planetary but also ecumenical integrity. Along with the provision of the legal status of bioethics, its social-ethical grounds are worked out also through its interaction with the Christian morality. The biomedical and ecological control over the protection of human health, of Thus, promoting bioethical education of the population a clerical-public the population living on the polluted territories of Belarus speaks in favor of the council on medical ethics [6] already acts in Russia, within the Moscow threatening dynamic of diseases among adults and especially among children, Patriarchate and in Belarus, within the Minsk Patriarchate, and one is still and of the complex pollution of the environment by not only radionuclide but planned to be set up. On a range of bioethical issues the Christian church also chemical substances. It is also accompanied by long-term post- holds rather a tough position: like the cloning of human being and his/her catastrophic emotional-psychological stresses among people, mass feeling of organs (especially heart), euthanasia, artificial insemination and abortion, danger and alarm that starts and resists among the population inhabiting not which is considered as an encroachment on the future of the human only on the polluted territories but also in the whole Republic. Only 18% of individual. At the same time, the cloning of separate cells and tissues of the children that were born in the course of the sixteen years after the Chernobyl living organisms , the genetic therapy, the transplantation of separate organs, catastrophe have normal physical parameters. The most widespread are such research and implementation of a number of contemporary molecular-genetic malfunctions as the diseases of the thyroid glands (thyroid cancer), methods of treatment are considered acceptable and permissible. The respiratory channels, intestinal tract, cardio-vascular system. To our greatest woman, who is forced to stop pregnancy in case of direct threat to her regret the clinical studies have shown that the thyroid cancer among children physical and spiritual health, is not ostracized from the church but must is more aggressively expressed than among adults. The children that have accomplish penitential praying rituals, that are determined by the priest after undergone operation for amputation of the glands, in the majority of cases lag confession. Within the Minsk Diocese of Belarusian Exarchate there is enough in mental and physical development as compared with their peers. On this experience on the dissemination of the ideas of bioethics by the orthodox background the number of cases of ARD and grippe has grown drastically in brethren of doctors, and within the All Holly Man parish in Minsk the House of preschool educational establishments, the index of children of school age falls Mercywas organized. Spiritual and medical-psychological support was shown down. to hopelessly sick children in the Belarus Children Hospice within the Oncology Centre of Borovlyany. The lack of medical equipment for treatment, the incomplete set of physical training and recreational equipment bring to the wide-spread phenomenon of One of the priority directions of bioethics is the analysis of ethical norms of longer duration of sickness among children [1]. In this respect high priority human health protection taking into account his/her social essence and the should be given to the complex of preventive, recreational measures in the main principles of organization and functioning of the human being as a preschool and policlinic institutions. Urgent biomedical interference is needed

14 15 with the purpose of inspection of people residing in the ecologically biomedical research and technologies grow in the contemporary mechanism unfavorable situations, permissible either with the voluntarily aware consent of of the functioning of scientific knowledge, and the study of living systems. the adult individuals, or with the parents' consent (foster parents), if this Currently the dialogue and mutual enrichment of natural scientific and concerns children younger than 16. The assumed biomedical scientific study humanitarian discourse is being actualized, the interdisciplinary synthesis and with the interference into the psychophysical condition of people (blood test, enhancement of the world outlooks of the society takes place. ultrasonic diagnostics. etc.) must have a scientific-practical justification and evaluation of the potential risk and use. People that have undergone The contemporary model of bioethics and the development of programs of biomedical inspection must be guaranteed confidentiality of the collected biomedical research in the Republic of Belarus is adapted to the scientific, information. The contemporary interdisciplinary studies of the environment socio-cultural and spiritual traditions, its system of health care and it demands must include specialists on the environment from different branches of its own further development. science, biology, medicine, ecology, sociology, demographics, ethics and philosophy. Bibliography

Bioethics, in this respect, can bring an essential contribution in the evaluation 1. The main indicators of the population health, the activities of the of the environment. Permanently organized biomedical and ecological control sanitary-epidemiologic services and the sate of the environment: Col.// over the state of human health, residing the polluted territory of the Republic Ministry of Health of the RA, Republican Centre of hygiene and of Belarus and their transmigration to the "clean" territories, undoubtedly gives epidemiology; Edited by L.A. Savchenko - Mn.: PolitBig , 1999. positive results. 2. The Law of the Republic of Belarus "On Healthcare"// Vedomosty Verkhovnogo Soveta of RB.-1993.-N.24.- page 290 Thus, bioethics, as a socio-cultural phenomenon, to a great extent determines 3. Law of the Republic of Belarus "On psychiatric assistance and the cooperation and mutual enrichment of the legal and moral awareness in guarantees of citizens in the course of its delivery"//Vedomosty of the our society. It gives directions for the biomedical practice and for making National Assembly of the RB. - 1999.-N.25.- page 421 regulatory decisions, providing the moral climate in the scientific society, 4. Development of the Healthcare in the Republic of Belarus - 1995 medical collectives, adequate moral choice of specialists in medicine, biology, 5. National strategy of the stable social-economic development of the biotechnologies, their interference in the sphere of life, the social and legal Republic of Belarus within the period till 2020, Mn., 2004. responsibility before the society for the result of scientific practical research. 6. The Basics of the Social Concept of Russian Orthodox Church./Accepted by the Holy Archbishop cathedral 2000 of the Russian Orthodox Church.- The counterinfluence of the moral and scientific discourse in the science in N.n.: Minsk diocese of Belorussian Exarchate, 2000.-19page. general and in bioethics in particular is rather restricted for our local model of 7. Jennings B/ Bioethics and Democracy//Centennial Rev.-1990.-Vol. XXX bioethics. Its central problem is mainly the development of moral norms and IV, N.2.- P.207-225. principles that regulate the human behavior in the science on life, human being, nature (bios). The formation of the legal status of bioethics is still at the stage of development. And although at the beginning of the XX century A.Puancare said that any legal interference into the issues of scientific research would be irrelevant and pathetic, at the end of the XX century many scientists started to call to the scientific tribunal for the regulation of arguable scientific questions, and suggested creating a legislation for scientific research [7, 207-225].

Bioethical knowledge successfully fulfills different functions in the process of its functioning, such as changing the world view, gnoseologicall function, methodological one, axiological and educational. Thus, they promote to the development of the system of values, goals and ideals in the evaluation of life and perspectives of its development, ethical-legal norms. Its status in

16 17 NEW BIOMEDICAL TECHNILOGIES AND HUMAN RIGHTS the last two rights the first group of rights will not simply be acclaimed. In more concrete terms, we speak here about a wider than ever before and Boris Yudin principally about a new policy of protecting patient's rights, such as right to Correspondent-member of the RAS, professor respect the anatomy of the human individual, right receive information on the The RAS Institute of Philosophy, Moscow, Russia diagnosis and forecast of his/her own physical condition, right to participate in making decisions on the process of treatment, up to the refusal of the treatment in general, etc. Many of these vital rights are, as the philosophers One of the most important impulses for the emergence and development of would say, of social character. In other words, they assume and at the same bioethics is the desire to protect human rights, in particular in such spheres as time make the fact of private choice and the corresponding decision in the routine practice of health care and biomedical research. situations necessary when the matter concerns individual values: preservation The natural historical predecessor of biomedicine is the traditional medical of physical and psychological integrity and individual's life. ethics that has a multi-centennial history. The contemporary situation, Another important difference of contemporary bioethics from the traditional however, still more often forces to stand back from traditions and to look for medical ethics is in the fact that the latter in general has been namely new unprecedented solutions. Among the chief causes one should indicate the professional ethics, or moreover, corporative. It used to focus attention to the wide range implementation of new biomedical technologies in the routine doctor's rights and obligations in respect of the patient, as well as to the legal practice. A number of complex issues of moral-ethical and legal character regulation of interrelations inside the medical profession. The interference of emerge along with the development of the methods of artificial insemination, non-professionals was not allowed at all or was restricted to the minimum in surrogate motherhood, prenatal and pre-implantation genetic diagnostics. Not such cases. It was indirectly assumed that the doctor fully possesses not only less acute problems emerge along with the new methods of transplantation of social, technical but also ethical rights and competences. The rapid organs and tissues (determining the moment of death of the potential donor, development of bioethics speaks about the fact that the current situation is the choice of the recipient from among the long list of needy patients, the radically and irrevocably changed and the ethical issues of biomedicine are practice of commercial use of organs and tissues, etc.). And along with the solved not at the corporate level, but much wider basis and with full rightful development of the contemporary means of intensive therapy and life participation of patients themselves, as in those cases when patients as well supporting treatment one has to make decisions, for example, on how long it as those who represent their rights, are not competent. is sensible to continue such treatments, if the patient has hopelessly lost consciousness and is in a so-called stable vegetative condition which can last The rights in the sphere of bioethics are as follows: patient's right to first hand for many months and even years. information on his/her health condition, right to access confidential information that concerns his/her health and biological characteristics, right to dignified life The second most important cause for the formation of the contemporary and even right to dignified death. bioethics in many countries is the enhancement of the world understanding of the character of the interrelations between doctor and patient. Strong public One more factor that has had huge impact on the formation and development movements place human rights at the top of human problems that are of bioethics should be mentioned. The problems connected with the ethical connected with medicine and health care. and legal regulation of scientific research play an important role among bioethical rights. Here we speak mainly about the biomedical experiments In this respect without undermining the political and social-economic done on people. The scale that has been acquired by this research and significance of human rights I would like to state that these rights are not the testing, demands today a solution of such urgent issues as the domain of their only source of energy for people. Indeed, there are still rights of social- regulation, which would provide minimum risk for those that are being tested economic character, such as right to labor, right to dignified compensation for and would protect their rights to health, dignity and would exclude the overdue labor, right to education, etc. And further there are rights that one could name sufferings and pain. as vital. These are right to life, right to health (or, as it is rather often preferred to say, right to health protection), right of an individual to personal integrity, Among the fundamental human rights in the contemporary world the most right to protect one's individual dignity, etc. I think that without due provision of important one is the right to health protection. It has acquired its juridical

18 19 justification in numerous international legal enactments and declarations, over the interests of society and science". (Art. 2). It is necessary to constitutions and legislations of many countries of the world. highlight that this principle is put into many other ethical and juridical documents that regulate the practice of health care as well as the One should indicate that in a wide scale the public awareness on the right to accomplishment of biomedical research and the implementation of new health protection is very often understood as a universal right to acquire free biomedical technologies. medical treatment. However, in the course of centuries this assistance was perceived as the privilege of the wealthier layers of the world's population 2. The medical interferences (including the interference for research rather than a universally accepted right. Only in the second half of the last purposes) could be accomplished only with the consent of those people century some ideas gradually developed on the right to health protection as in respect of who they have been done, and this consent must be the part of other absolute rights of people, regardless of their proprietary voluntary and informed, i.e. it must exclude any form of pressure with the statuses, civic positions, ethnic or confessional characteristics. purpose of receiving it and it must be based on the deep knowledge of goals, tasks consequences and risks, connected with such an If a person has money, he or she can buy an automobile. If a person does not interference. (Art. 5). At the same time the rights and interests of have money, he or she can travel on foot or without an automobile. Although it individuals that are unable to give their consent independently must be makes his or her life somewhat difficult, as such, it is not an infringement or protected as well. (Art. 6-9). encroachment on his or her civil liberties and rights. However, the inability to receive a qualified medical treatment because of the lack of material means in 3. It is necessary to pursue the principle of immunity of private life as well as the contemporary world is interpreted as a serious violation of human rights to pursue the individual's right to know or not to know about the state of and a fundamental problem of not only medical ethics but also the state his or her health. (Art. 10). policy. 4. Any type of discrimination on the basis of information on the genetic One of the specifics of bioethics is the fact that many of its principles and ideas characteristics of the human being is prohibited (Art 11). The testing that acquire their own expression in international documents. will make it possible to acquire information on whether this or that person has any type of genetically transferred diseases, as well as whether he or A characteristic example is the "Convention on the Protection of Human Rights she has predisposition to different genetically transferred diseases, must and Dignity in connection with the implementation of biology and medicine. be done exclusively for therapeutic purposes and only for these The "Convention on Human Rights and Biomedicine" that was adopted by the purposes the information on the results of such a testing can be used. (Art Council of Europe in 1997 is very often called "Convention on Bioethics. 12). The interference into the genome of a human being is prohibited for the change of the genome of his/her descendants (Art. 13). The choice of The principles of the "Convention" touch upon the realization of biomedical the gender of the future child is forbidden with the exception of cases research as well as the utilization of the results of such a research in the when the matter concerns the necessity of avoiding a serious disease, medical practice and the convention itself is not only an ethically but also a connected with gender. (Art. 14). juridically significant document. In its text there are obligations, signed by the parties, on "the necessity to make all required steps for the improvement of the 5. It is necessary to respect the right of scientists to do a scientific research, national legislations so that it would reflect the principles of the present however, the latter must be done in accordance with the principles of the Convention" (Art. 1). "Convention" and other legal enactments directed towards the protection of rights, dignity and interests of each individual. (Art. 15). It is forbidden The content of the "Convention" in short can be expressed in the form of the to create human embryos for research purposes. (Art. 18). following principles: 6. The collection of organs and tissues of live donors with the purpose of 1. The main and common principle of the approach to the solution of the further transplantation can be accomplished only with his/her consent and problems connected with biomedical research and the use of exclusively for therapeutic purposes. (Art. 19). The human body as well achievements of the contemporary medical science are concluded in the as its separate parts must not be regarded and used for the purpose of principle that "the interests and welfare of an individual should prevail financial benefit. (Art. 21).

20 21 Another very important international document in the sphere of bioethics was irrelevant, since many of us have become accustomed to the fact that politics adopted in October 2005 by UNESCO as "Universal Declaration on Bioethics is what the state politicians do. At the same time regardless of how deep we and Human Rights". Special attention there is paid to the problems of social comprehend it, such a policy exists and that is a fact. But, unfortunately, the justice and solidarity in providing access to high quality medical treatment as opinions of average citizens on how they perceive the policy of the government well as to the distribution of the load of risk and hardships connected with in the sphere of health care, what they consider as important and just, what, in those that are tested in biomedical research as well as those benefits that the their opinion, right in the contemporary institutions of health care is, are new biomedical technologies give to people. systematically not expressed. Those, who in reality determine this policy, do not even think about the serious study of this opinion and these perceptions Generally speaking the UNESCO Declaration is far not the first international and do not use them as a target in their activities. document, in which the principles and norms of bioethics are narrated. As compared with all previous declarations it, however, possesses a whole range Generally speaking, social justice in providing health care to citizens is one of of new characteristic and specific peculiarities. These peculiarities are to a the most discussed topics in the contemporary bioethics. great extent preconditioned by the fact that this document has been worked out by a wide range of experts that represent all regions of the planet, the A rather wide sphere of discussions becomes the provision of a fair access to whole global community. The UNESCO Declaration on a considerably wider the newest biomedical technologies. Many of them raise strong possibility in scale than in other existing international documents on bioethics uncovers the what concerns the rehabilitation and strengthening of health, however, the problems and interests of developing nations. As it has currently become distribution of these possibilities is very often not fare. clear, there is a shift of interests in the sphere of bioethics. This shift is Very alarming is especially the fact that there is no decrease and moreover connected with the fact that the problems of bioethics attract more and more there is a rapid increase of gap between those who have access to these attention of those, who live in the countries of the third world. Correspondingly innovative achievements and the main mass of population. It starts to acquire there is a certain change of accentuations in the interpretation of the main threatening sizes, and it is perceived by the global community as one of the principles of bioethics. key problems. In this respect they speak about the ratio 90:10 meaning that The standpoint of the problems of social justice in the context of bioethics and the 90 % of means that are spent today in the world for biomedical studies, are human rights actually requires some clarifications. In this respect there is directed at the creation of means to fight against those diseases, which sense in discussing two questions. concern the 10 % of the world's population. And only the 10 % of means used for research go to cover the diseases that are prone to the 90 % of the In the first place, why is the topic of social justice in health care discussed planet's population. beyond the boundaries of medical profession?

Secondly, what is the sense of including also the topic of the human rights into the discussion of social justice and bioethics?

Let's try to answer these questions. And let's start from the fact that the problem of fair access to medical assistance concerns the whole complex of services connected with health protection, including the problems that concern not only all medics but also all citizens of the whole society in general. That is why it is rather expedient that in the course of their discussion and decision making process there must also be the participation of those voices that are the subjects of measures undertaken and planned in this sphere. It seems necessary that the citizens did not only have information but would also participate in the formation of the policy in the sphere of health care.

The discussion on politics in the sphere of health care might seem to be

22 23 SUPPORTING THE DEVELOPMENT AND RAISING The project was realized in two phases. The first phase included: AWARENESS IN THE SPHERE OF BIOETHICS IN THE z the analysis of the RM state affairs on the issues of bioethics in scientific, educational and practical aspects (the identification of REPUBLIC OF MOLDOVA organizations, human resources and age contingent); (ASPECTS OF HUMAN RIGHTS) z the development of strategy and action plan on distribution and development of bioethical knowledge in the RM. Luminitza Drumea PhD in Philosophy, The second phase was devoted to the realization of measures in three main Expert on Science in the National Commission directions in the dissemination of bioethical awareness in the Republic of On UNECSO Affairs in the Republic of Moldova Moldova. z The development of the educational process in the given sphere; Bioethics is another important phase in the sphere of philosophical knowledge, z The organization of scientific-practical events (workshops, lectures, conditioned by the development of human civilization. Its formation is conferences, consultations, developing and improvement of legal connected with the process of transformation of traditional ethics in general enactments and norms, participation in the process of law creation and and medical ethics in particular. The development of bioethical ideas is adoption, etc.); stipulated, first of all, by the increased attention to human rights and the z The realization of scientific activities. emergence of new medical technologies, which, in their turn, bring forward a The following actions were accomplished in the framework of the project: number of the most complicated problems demanding both legal and moral z the establishment of the National Centre of Bioethics of the Republic of regulation. Moldova; z the republican exhibition-competition on the best poster "Bioethics: a The level of awareness of the Republic of Moldova on the issues Bridge to Future", which was widely publicized on the territory of the connected with the ethics of science and technologies that require special Republic (educational institutions, libraries, colleges, state organizations, attention from the bioethical point of view cannot be assessed as satisfactory. etc.); The Activities of the Chair of Philosophy and Bioethics of the State University z the publication and dissemination of the educational manual on of Medicine and Pharmacology of the Republic of Moldova after Testemitsianu, "Elements of Bioethics" (in Romanian language) for students of the specialists of which lecture bioethics as a discipline in the higher universities, where issues on the correlation of bioethics, ecology, educational establishments of the Republic as well as hold annual republican medical and juridical aspect of bioethics and others are discussed. The conferences and workshops on the above-mentioned problems, are not educational manual consists of two parts: "Theoretical Principles of enough to avoid the lacunae that exist in the sphere of developing and Bioethics" and "The Practical Application of Bioethics". In the second part disseminating bioethical knowledge in our country. of the educational manual two parts are devoted to the issues of human Taking into account the urgency of the given problem, the National rights. In the part "Bioethics, Legislation and Patient's Rights" issues Commission on the UNESCO Affairs in the Republic of Moldova set up in 2004 connected with social and individual rights, conflicts between individual the project on "Supporting the Development and Dissemination of Bioethical rights and public requirements, bioethical aspects of medical and sanitary Knowledge in the Republic of Moldova". The Project was supported by the care are discussed. Special attention is paid to the discussion of such UNESCO Secretariat (Paris) and the Moscow Bureau on Azerbaijan, Armenia, perspectives of the implementation of bioethical principles and Belarus, Republic of Moldova and Russian Federation. The partners in the legalization of the patient' rights in the system of public health care of the realization of this Project were the Academy of Science of Moldova, the Republic of Moldova as the accession to international treaties Ministry of Health Care, the Ministry of Education, the State University of ("Convention on Human Rights and Biomedicine" (1997), "Declaration of Medicine and Pharmacology after Testemitsianu, the State University of Patient's Rights in Europe" (1994), "Ljubljanian Charter" (1996) the Republic of Moldova, the Institute of Pedagogical Sciences, the Chair of development and adoption of national legislation ("On the Patient's Rights Philosophy and Bioethics of the SUMPH after Testemitsianu, the Center on and Obligations", "On the Accomplishment of the Doctor's Function"). In "Intercultural Dialogue", the Association of Bioethics of the RM and mass the part "Rights and Obligations in the Sphere of Medical Activities: media. Social-bioethical Aspects" the responsibilities of medical activity in the

24 25 historical aspect and in modern world (European system), the principle of MEDICAL BIOETHICS IN GEORGIAN HEALTH CARE doctor's compensation and behavior in conditions of medical law are SYSTEM AND PERSPECTIVES OF discussed; COOPERATION WITH PUBLIC DEFENDERS' OFFICE OF z the translation of the UNESCO documents on bioethial issues into Romanian language, the publication and dissemination the digest of GEORGIA corresponding materials on "Bioethics, UNESCO Documents" on the territory of the Republic; Levan Labaury z the organization of a whole series of forums including the Republican UNDP Project Assistant of the Patients' Rights Center conference "Introduction to Bioethics" with the presentation of the At the Public Defender's Office of Georgia educational manual on "Elements of Bioethics" (10.11.2005), the Republican conference, devoted to the opening of the National Centre on PART I Bioethics in the RM (12.04.2005), the Republican scientific-practical workshop on "Bioethics in the Republic of Moldova: Achievements and Medical ethics is the discipline of evaluating the merits, risks, and social Perspectives" (11.11.2005); concerns of activities in the field of medicine. Medical ethics shares many z the organization of lectures and consultations; principles with other branches of health care ethics, such as nursing ethics. z the creation of the web-site (http://bioethics.smtp.ru) that introduces the Ethical thinkers have suggested many methods helping evaluate the ethics of actions accomplished in the framework of the project to the public. a situation. These methods provide principles that doctors should consider The results of this work are publicized in media, national radio and television. while making a decision.

Thus, the realization of the given project supported the dissemination and The main 6 principles are as follows: deepening the awareness in the sphere of bioethics among the population of 1. Beneficence - the practitioner should act in the patient's best interests the Republic of Moldova taking into account the national and international (Salus aegroti suprema lex.) experience. The project has involved the whole adult population of the country, including scientists, faculty of educational establishments, employees 2. Non-maleficence - "first, do no harm" (primum non nocere). of state organizations, doctors, lawyers, ecologists, students, NGOs, mass media. The corresponding aspects of bioethics were integrated into 3. Autonomy - the patient has right to refuse or choose his/her treatment. specialized educational programs on the level of universities. However, in (Voluntas aegroti suprema lex.) order to inculcate the ideas of bioethics into people's minds the introduction to the basis of this knowledge should start in early childhood and at school. That 4. Justice - concerns the distribution of scarce health resources and the is why the organic continuation of the activity in the given sphere is the decision on who gets what treatment. involvement of bioethical elements in the educational process in the first stages of education (school, college) of the Republic of Moldova. For the 5. Dignity - the patient (and the person treating the patient) has right to realization of this actual task the guides on "Elements of bioethics at school" dignity. (1-4, 5-9 and 10-12 grades) in Romanian and Russian languages are directed 6. Truthfulness and honesty - the patient should not be lied to and for school children. deserves to know the whole truth about his/her illness and treatment.

These kinds of principles do not give answers to such a question as how to handle a particular situation, but guide doctors on what principles they ought to apply to under actual circumstances. The principles sometimes contradict each other leading to ethical dilemmas. For example, the principles of autonomy and beneficence clash when patients refuse life-saving blood transfusion, and truthfulness may not always be upheld regarding the

26 27 use of placebos in some instances. Even the professional liability is defined in this law, taking into consideration The obligation of the application of ethical principles in health care systems is the ethical aspects (Article 73): "The professional liability of the Independent differently prescribed in the legislations of various countries. Subject of Medical Activity is defined in the Georgian legislation. In case of As for the Georgian Law "On Health Care" (Article 4, section F), it is written breaking medical standards and ethical normes that are linked to the patients' that "One of the principles of the Health Care Policy in the country is the examination, care and treatment the physicians assume full liability for that. implementation of the universally recognized norms of medical ethics". In the Chapter V of the same law (Article 30) the following is prescribed: "While From the further articles of the Georgian Law on Medical Activity it is executing medical activities, medical people should be guided with ethical considered that the issues of professional liability are to be discussed by the values: recognition of human dignity and integrity, justice, principles of State Certificate Granting Council to the Medical and Pharmaceutical People. abtaining sympathy, as well as below-listed ethical principles: The Chairman of the mentioned council is the Georgian Minister of Health, z to act only according to the patients' best interests; Labor and Social Affairs. Hereinafter it is defined that the Minister confirms the z do not use his/her professional knowledge and experience against the statutes and all regulatory norms of the council. Thus, the Minister of Health, principles of humanism; Labor and Social Affairs and his subordinated body (council) discuss and z to be free and independent, do not act mercenarily while making make decisions on the ethical behavior of physicians and related issues. professional decisions concerning the patients' interests; If we take into consideration the above-presented samples, we can see that z to take care for the promotion of the prestige of medical profession, to there is an illogical approach in the legislation, particularly: if the medical treat colleagues and authorities with respect. profession is independent why the minister (state) is the only decision making The Article 34 declares that "Medical profession in its nature is a free and judging person on professional ethical issues. There are more evident profession. In any case, no representative of state authorities or physical samples to confirm our proposal. According to the order of the Minister of people is allowed to demand from the physician to act against above-listed Health, Labor and Social Affairs No. 276/n from December 25, 2002, the principles and ethical norms, despite his/her post and public position. Any kind statutes and personal composition of the National Bioethical Council has been of action that can harm the realization of professional responsibilities by confirmed. In the explanatory part of the mentioned order, the Minister states medical personnel shall be instituted to legal proceeding". In addition, the that the establishment of the National Bioethical Council is predicted by the Article 62 of the law constitutes: "In order to provide the protection of patients' existing "Law on Health Care" (Article 4, section b and f, Article 30). We have rights and ethical norms in medical institutions, medical ethics committees already presented the above-mentioned articles and there is no obligation shall be established. The background for the creation of such bodies is defined there to create state-controlled regulatory body in this field. On the other hand, by the Georgian Legislation". there is a big difference between the definitions of Medical Ethics and Thus, Georgian Legislation fully recognizes the principles and international Bioethics. Bioethics concerns the ethical questions that arise in the understanding of ethical values. relationships between biology, medicine, cybernetics, politics, law, philosophy, and theology. In this situation it is also unclear why the Health care Ministry The preamble of the Georgian Law on Medical Activities states (Chapter I, monopolizes the activities of the council that should deal with the issues other Article 1) that "One of the aims of the current law is to provide high quality of than only those of health and social aspects? We think this is a wrong medical services to the country's population by the implementation of the approach and lacks the understanding of the issue. recognized ethical standards in medical practice". Despite, it is unclear from the law who should set or recognize ethical standards in the country. According The statutes of the Bioethical Council declare that the main purpose of the to the international practice the medical profession is independent and council is to present and make decisions on the ethical aspects concerning the self-regulatory and it has the right to set the standarts thereafter. provision of health care services to the population and bio-medical research. This is another proof of our understanding that the name of the regulatory body According to the Article 38 of the Georgian Law on Medical Activities the has been defined incorrectly! The council is created within the Ministry of Independent Subject of the Medical Activity shall accurately fulfill the Health, Labor and Social Affairs and represents the consultative body to the physician's oath while executing professional responsibilities". And the Article Minister. The Activities of the council are defined as "State Competency 57 of the same law obligates physicians to act ethically with his/her colleagues. Activities". The Chapter III of the statutes says that the personal and

28 29 quantitative composition of the council are to be confirmed by the Minister; the The priority on the medical ethics issues in the country should be given to the council is accountable only to the Minister; the office for the council (working Georgian Medical Association (GeMA). The GeMA had been established facilities, communications, technical issues, technical personnel, per diems before the country gained independence from the USSR. It was officially etc.) is to be supported by the budget of the Ministry; the decision on the registered by the Ministry of Justice in 1989 and considered as the first NGO upgrade of the personal composition of the council is again up to the / professional union in the country. It unites a big number of Georgian ministerial will. We have got an impression that the council actually represents Physicians, individual members, about 50 medical professional (field) the integral structural addition to the Ministry of Health and accordingly it is associations as well as collective members. The GeMA is the member of the strongly controlled and regulated only by the Minister. European Forum of the Medical Associations, the World Health Organization and The World Medical Association. The above-mentioned Ministerial Order on the establishment of the council has a very dramatic development. Up to day, 3 former ministers have made As we can see from the presented material in Georgia the state does not only amendments and changes in this order (and statutes of the council) several pass laws, obligatory to all citizens, but also deals with professional ethical times. According to the Ministerial Order No. 326/n (2002) the personnel of the issues in the health care field. We think the presented fact is unacceptable, council has increased from 21 to 29 members; in addition, the validity of the because it may be considered as a limitation of professional independence office term was defined with 2 years. According to the Ministerial Order No. and autonomy of physicians. Only the recommendations and solutions in this 336/n (August 29, 2005) the Minister dissolved the council and confirmed the situation that come form the medical profession are to make immediate new members. After the next ammendment in the order, according to the amendments in the relevant laws and follow the internationally recognized Ministerial Order No. 11/n (January 16, 2006) the Minister was vested with the principles according to which the professional independence, self-regulation right to confirm directly the chairman and vice-chairman of the council. and autonomy of the medical profession should be guaranteed. According to the above-mentioned development the Minister excluded the representatives of the Georgian Medical Association from the council; next to PART II this, the only professor in Georgia in the field of Medical Bioethics from Tbilisi The relations of the Public Defender's Office (hereafter the PDO) with other Medical University was also excluded from the council. On the other hand, institutions in the bioethical field become more and more intensive. The there are several people in the council whose personal merits and dedication mentioned need is stipulated by the Georgian Legislation. The Medical to the Georgian Health Care system (especially ethics) are unclear and Legislation of Georgia consists of the Constitution of Georgia, International doubtfull. Agreements and Conventions, ratified by the Georgian Parliament, and about 15 laws. They are as follows: During the recent years, the Ministry of Health, Labor and Social Affairs has 1. Georgian Law on Health Care had an intention to propose and recognize so-called "The Code of the 2. Georgian Law on Medical Activities Georgian Physician". It was unclear who ellaborated the mentioned code and 3. Georgian Law on Patient's Rights what was the origin of it. Fortunatelly, Georgian Medical Community did not 4. Georgian Law on Psychiatric Assistance recognize or accept the mentioned document and today only a few people 5. Georgian Law on Blood Donors and Blood Components know about this. In 2004, Mr. Jon Sneadel, the head of the Ethical Unit of the 6. Georgian Law on HIV/AIDS prophylaxis World Medical Association expressed his dissatisfaction about these events. It 7. Georgian Law on Medicines and Pharmaceutical Activity is utmost important to emphasize that the World Medical Association has 8. Georgian Law on Organ Transplantation recently published the new edition of the manual on "Medical Ethics". This 9. Georgian Law on Promotion and Protection of Children's Natural handbook should be considered as a leading manual worldwide. On the other Feeding and Application of the Artificial Nutrition hand, the Ethical Codes are considered as an activity of the Professional 10. Georgian Law on Narcotics, Psychotropics, Precursors and Unions, Associations, Chambers or other kinds of organizations and it cannot Narcological Assistance be a nation wide titled code! In Georgia, there is the Ethical Code of the 11. Georgian Law on Tobacco Control Georgian Medical Association as well. There is the permanent task force in 12. Georgian Law on Prophylaxis of the Diseases predicted by the Iodine Association who works on the essential standards of medical ethics in the and other Micro Elements and Vitamins Deficiency frame of the professional organisation. 13. Georgian Law on Medical-Social Expertise

30 31 14. Georgian Law on the Quality of Grocery analyze the situation about the patients' rights in Georgia; to promote to the 15. Georgian Sanitary Code awareness raising on the patients' rights among the health care professionals, as well as among a wide range of the population; to analyze the existing legislative trends in Georgia and to elaborate and submit the Council of Europe: Convention on the Protection of Human recommendations on patients' rights to the Public Defender of Georgia, with Rights and Dignity with regard to the Application of Biology the aim of further implementation. 164 and Medicine: Convention on Human Rights and Biomedicine Patients' rights vary in different countries and in different jurisdictions, often depending upon the prevailing cultural and social norms. The Universal signed: ratified: Entry into force: Declaration on Human Rights has been instrumental in enshrining the 11/5/2000 22/11/2000 1/3/2001 notion of human dignity in international law, providing a legal and moral ground for improved standards of care on the basis of general responsibilities towards each other as members of the "human family", and giving important guidance on critical social, legal and ethical issues. But a Council of Europe: Additional Protocol to the Convention on the great deal of work still remains to be done to clarify the relationship between Protection of Human Rights and Dignity with regard to the human rights and right to health, including patients' rights. The Center for Patients' Rights is very actively involved in the monitoring and discussions 68 Application of Biology and Medicine, on the Prohibition of the of general health care issues, including the bioethical direction. Human Cloning The center works for the protection of the citizens' rights in the health care signed: ratified: Entry into force: sphere with respect of his/her dignity and integrity. For this purpose the center has set up the following tasks: 11/5/2000 22/11/2000 1/3/2001 z by the coordinating work with the PDO, the center is responsible for particular cases of violation of patient's rights. The center is especially active in risk zones, such as penitentiary system, army, shelters, health Council of Europe: Additional Protocol to the Convention on care institutions, local authorities, etc. The representatives of the Human Rights and Biomedicine concerning center participate in the work of response groups; they investigate cases and prepare the follow up recommendations; 186 Transplantation of Organs and Tissues of Human Origin z the center participates in the legislative activities, giving recommendations to the Public Defender. The center has set up a signed: ratified: permanent task force on elaborating the amendments and additions to the Georgian Law on Patients' Rights. The center consults with 25/3/2002 18/12/2002 different representatives of the society: medical professionals, legal persons, media representatives in the main cities and major regions of the country. The center participates in the preparation of the From the beginning of February, 2006, a center for the protection of Parliamentary Reports of the Public Defender (Right to Health). The Patients' Rights has been established in the structure of the Public center has established a very close link with the Health Care and Defender's Office of Georgia. The center provides activities in the frames of Social Affairs Committee of the Parliament of Georgia. Recently, the the UNDP Project on "Capacity Building of Public Defender's Office in center has accepted the draft project of the law on "Biomedical Georgia". The primary objective of the center is to assist in developing the Research involving Human Subject" for discussions and suggestions; Georgian Public Defender's capacity to operate as a functional, z the center expands introduction of international experience in the independent national institution, working for the protection and promotion of Patients' Rights field, with further implementation of the received Patients' Rights (as a separate direction). The scope of the center is to knowledge in the national system. The center translates the

32 33 international declarations and any other documents concerning the PHILOSOPHIC METHODOLOGICAL PROBLEMS OF patients' rights and responsibilities. In this respect the center actively BIOETHICS AND HUMAN RIGHTS: THE SPECIFICS OF cooperates with the PDO Legal Center (established also by UNDP in the frames of the same project). The representatives of the center EDUCATIONAL PROGRAMS IN BELARUS participate in various national and international trainings and seminars for raising the qualification and perfection of working skills; Yadviga Yaskevich z the center carries out educational activities to increase public PhD in Phisophy, Professor, awareness in the field of patients' rights and that of "right to health". Institute for Social and Humanitarian Education, For this purpose the center prepares and organizes training courses Republic of Belarus for medical practitioners and various representatives of the community. Up today, the center has carried out the following trainings: Bioethics, as an interdisciplinary scientific branch, an academic discipline and patients' rights, the quality of medical care, patients' autonomy, a social institute, is defined in the context of general stylistics that is patients' empowerment, patients' safety, transgressions in the health characteristic of post neoclassical science of the second half of the XX care field, forensic medicine, rights of people with HIV/AIDS, century. In that period of time the canvas of the science included ideals of the independence level of physicians in the country, physicians working in benefits for human being and the mankind, which were unusual for the risk zones, medical evidence of the torture and other degrading actions classical science, new concepts of ethics and virtue, duty and responsibility for and ill treatments, etc. The mentioned trainings took place in Tbilisi, the results acquired in the process of scientific research of human dimension Kutaisi, Batumi and Zugdidi. The representatives of the center entities. regularly communicate with media (TV and Radio interview, newspaper publications etc.). The center prepares and publishes educational The practical emergence of new medical technologies (methods of artificial materials: leaflets, flyers, brochures, books, manuals etc. insemination, surrogate motherhood, prenatal diagnosis), the actualization of the issues of transplantation, euthanasia, biomedical experiments done on As it follows from the described list of activities, the PDO takes a very active people and animals, the necessity of moral-ethical and legal regulation of the part in the discussions and actions in the health care field including collisions, which raised in the process of biomedical research, have served as bioethical issues. The PDO established official relations with medical and a unique social order for the creation and development of bioethics. non-medical, local and international, governmental and non-governmental institutions. The relations between the Georgian Medical Association and The beginning of the XXI century is characterized by the formation of united other 50 professional medical associations in the country should also be civilization with a new scale of universal spiritual values that can be named as mentioned. The PDO has signed a memorandum on cooperation with the eco-society or ecologic-information society. An important place in this civiliza- Ministry of Health, Labor and Social Affairs. The memorandum especially tion belongs to human rights, philosophy, science, neo-spherology, such inter- emphasized the issues of the monitoring of mental hospitals. The PDO has disciplinary branches of science as bioethics which through the signed a memorandum with the Georgian Law and Bioethics Society. Thus, system of education and justification of new priorities is called to provide a new the perspectives of the relations are more evident and real. We look forward basis for the ecologization and humanization of the society, the development to increasing our links and establishing new contacts with any organizations of mechanisms directed at the protection of human rights in bioethical in order to "work together for health". research. What is the role of philosophical-methodological reflection over the basis of science in this process, in which of its spheres the new approaches that change the face of the contemporary culture and providing the merger of natural scientific and humanitarian knowledge are formed? How is this knowledge used in the system of education with the purpose of inculcation of certain mechanism of human rights development into bioethical research, the development of principles of education in the sphere of human rights?

34 35 In the Republic of Belarus traditionally significant work is done towards the intensively seen in the science of the second half of the XX century. This formation of the national system of education in the sphere of human rights process is accomplished through the development of the neo-sphere concept, and bioethical research. The system of education in the sphere of human the ideas of the non-linear, strongly unbalanced thermodynamics (the school rights in the Republic started to develop in 1995, when the educational of I. Prigojhin), synergology, contemporary cosmology, the development of establishments started to teach a special course titled "Human Rights". Since systemic and cybernetic approaches, the ideas of the global evolutionism, 1998 human rights are taught in all educational institutions of the country. so-called "anthropic cosmologic principles", the development of Special standards, curricula and training manuals for this discipline have been interdisciplinary branches, the emergence of biomedical research with the worked out and prepared, in particular the manual on "Human Rights" with the participation of the human being. specification "Recommended by the Ministry of Education of the Republic of Belarus as a Training Manual for Students of Higher Educational The emergence of "human centered" arguments is clearly seen, first of all, in Establishments", comprised and edited by professors A.D.Gusev and Y.S. V.I. Vernadski's neo-sphere concept, based on the idea of integrity of human Yaskevich. (Mn., 2002). In this training manual the essence of fundamental being and the cosmos. The task of the scientific construction of the world, from human rights as a phenomenon of world culture, the ideological roots of the Vernadski's point of view, in self denial and trying to find some kind of contemporary concept of human rights, the globalisation and universality of understanding of the world independent from the nature of human being, is far human rights, the international protection of human rights and liberties are beyond his powers, it is an illusion. The observer himself, the subject himself, revealed. is included into the nature itself, into the reality, the picture of which is being studied. The neo-sphere is just a new qualitative state of biosphere in which A serious impetus to the establishment of the educational system in the sphere the mind of the human being is called to play a decisive role. of human rights in Belarus was the adoption of the Resolution 44/184 of the At present different scenarios of self-organization are considered in a wide UN General Assembly in December 1994, which declared the years range of diverse physical, chemical, biological and social systems: in physics 1995-2004 as "A decade of Education in the Sphere of Human Rights". The (hydrodynamics, lasers, non-linear fluctuations); in electrotechnics and resolution contains a call to all states to highlight their efforts with the purpose electronics; in chemistry (the reaction of Belousova Jabotinski); in biology of "directing education towards the full development of human personality and (morphogenesis, dynamics of populations, evolution of new species, enhancing respect towards human rights and basic freedoms". In November, immunity system); in the general theory of calculating systems, in economics, 2004, in Minsk with my participation and support, an International Conference ecology, sociology, medicine (synergetic approaches in psychiatry ,etc.), in on "Decade of Education in the Sphere of Human Rights of the UNO: the medicine (in the course of interpretation, of diagnosis and treatment, etc.). Belarusian and International Experience" took place, the minutes of which were published afterwards (Minsk, 2005). At the same time in Belarus a great The most important characteristics of self organizing systems is their deal of work was going on in the development of bioethical education, non-linearity (abruptness), the existence of a big number of subsystems, humanitarian parameters of the contemporary science. openness, inevitability (uniqueness). "The array of possibilities" is also characteristic of the system development at the points of bifurcation, when the The author has worked out a special training course on "Humanitarian system loses stability and is capable to develop in the direction of multi- Parameters of the Contemporary Science" for the students of philosophical optional functioning regimes. departments and social sciences of the Belarusian State University, as well as for the faculty in the system of skill improvement, including medical The evaluation analysis of the emerging questions and possible solutions of universities. It revealed the role of education in the sphere of human rights and the answers are assumed as well. "What will happen if…; what will be the price the functions of the contemporary science and bioethical knowledge in the of regaining order from chaos, what consequences will be brought by so-called culture of the XXI century. In particular, in a series of lectures it was shown that weak "influence" on the system, if…?“. These kinds of questions witness the in the development of the post-neoclassical (contemporary) science (the last necessity of withdrawing from the position of unquestioning "manipulation" and quarter of the XX century) a whole series of concepts and approaches are the severe control over the studied systems, especially in the sphere of highlighted, with the help of which one can fix the mechanisms of formation of biomedical research with the participation of human being that needs ideals and norms of scientific knowledge that fill the structure of scientific protection of rights and dignities. research with value targets and humanitarian parameters. The mechanisms that transform the ideals of the contemporary scientific knowledge are more The withdrawal from the severe means of justification of the scientific

36 37 knowledge, the considerations of different impacts on the system parameters The ethical and axiological arguments are inevitably "striking through" other and the use of the concepts of random, the probable processes are medical disciplines as well. Such a medical biological science as tanatology demonstrated at the contemporary stage as well as in many medical that studies the causes, symptoms and mechanisms of death with a specific disciplines. The crisis of the soviet clinical psychiatry, as indicated by some acuteness raises the problem of "ethical argumentation" in respect of researchers, is mostly explained by the "attachment" to the linear principle. transplantation of organs. The question how to avoid ethical bias comes According to this principle, each (psychic) disease must include united forward: before the donor's "alive" organ is taken away, the donor should be causes, expressions, course, consequences and anatomic changes (i.e. one already "dead". The same collision occurs while deciding about the cause has the same effect). Such "toughness" in the wording of the thesis (the prolongation of the sick individual's life with the help of specific equipment: statement of the clinical diagnosis), as witnessed by the contemporary which arguments will be ethically sound while deciding whether to switch off medicine, is not justified. One cannot but take into consideration the fact that the equipment or not, i.e, as a matter of fact "killing" the sick individual. In the the physical and spiritual characteristics of separate individuals are unique as course of deciding in favor of prolonging the life of people who are incurably well as the individual expression and the course of the disease of individuals. sick we again solve the dilemma, to what extent the ideals of bioethics and ethics are ethical that call to struggle "till the end" if the sick person prefers an The argumentation on the basis of the "infallible", "objective", "unprejudiced" "easy death", etc. clinical method, narration without "personal comments" is baseless not only from the logical point of view. At the same time inadequacy of the pretences of The cognition of such complex objects as nuclear energy, objects of ecology, the clinical method to the inductive inference of rules is demonstrated. In this gene engineering, microbiology by a human being, when the process of case, as N.A. Zorin indicates, the system of statement of the clinical diagnosis cognition includes the human being, the wide use of robotics and computers is nothing else but a discourse on analogy, or inductive proof, when on the in the industry and in the most different spheres of human and social life, the basis of repetition of the symptoms and syndromes the concept of rule is functioning of life at the contemporary stage as a socially integrated stated (nosologic form). It is important that such an approach is inconsistent in technological expertise in a number of spheres, the use of new medical the ethical-psychological aspect, as long as the treatment is targeted not at the technologies, cause doubts in respect of the "ethical neutrality" of the science individual, as it is declared by the clinical psychiatry, but towards the disease, (B. Yudin). i.e. the "disease is being treated, not the sick person". It becomes clear that the contemporary natural sciences are much closer by The withdrawal from the single linearity and toughness, the appeal to the the strategy of research to the humanitarian sciences than in the previous theories of random processes, dissipative structures will bring, as some specialists believe, to the innovation of psychiatry. The concept of disease will period of historical development and insert into it the categories of duty, be probable and its emergence in a number of cases will become principally morale, etc, that are unusual for the traditional natural science. (V.S.Stepanin) unpredictable. In psychiatry freedom of will will appear in its thermodynamic [1]. The arguments that are used for the comprehension of unique evolutional expression. This will cause a change both in the judgment on "the norm" and systems cannot be ethically indifferent. The position, targeted only at the the disease, and in the washing out of the "boundary" between the norm and acquisition of new real knowledge, is too narrow and sometimes dangerous. the disease with a wide spectrum of adaptive reactions. The discourse on the There comes the necessity for the emergence of new approaches that "normal" will change together with the society and depending on the model of establish control over the process of cognition of truth as such. In the medicine. hierarchy of values, among which there is undoubtedly scientific truth, along with it in the contemporary science there are such values as the benefit of a The comprehension of the utmost complexity and integrity of the object of human being and the mankind in their unity and interaction, the good and research has put the contemporary psychiatry before the necessity of ethics. The search of the scientific truth "is elucidated" by axiological including into its argumentation system the descriptions of different levels imperatives: whether the new knowledge will increase the risk for existence (biochemical, behavioral, social), like the subsidiary principle of N.Bore. The and survival of human beings, whether it will serve to the benefit of the flexibility and multi-optionality in the description of the disease diagnosis the mankind's interests. orientation towards a concrete individual provides the incorporation of the fundamental principle of medicine that is " to treat not the sickness but the sick The incorrectness of elimination of axiological, ethical, legal and humanistic person" and avoid ethical biases (hyper diagnosis and vice versa, the values from the system of scientific cognition has specifically exposed itself in presumption of disease, etc.). the sphere of biomedical research. This critical period was preceded by the

38 39 re-comprehension of the paradigm of values of the neutrality of scientific essence, the human being sometimes becomes more dependent on the knowledge, the technocratic way of thinking that is characteristic of the contemporary technical means and only in the organic integrity of the human classical science and technical-engineering model of interrelations between being and the cosmos, in inside creation, in ethical self-improvement the doctor and patient, within the framework of which the human being is human being approaches the creative freedom (freedom for oneself). The considered as an object of experimentation and manipulation (R.Vitch). The value status of freedom in the process of deepening our knowledge about the activity of the subject, free will, uniqueness, the specific peculiarities were not live substance in biomedical research, dealing with unique singular objects taken into consideration in the given model of interrelations between doctor (human gene, social natural systems), assumes the necessity of self- and patient. The emergence of such a new interdisciplinary model of research restriction on behalf of the research, formation of the concept of collective as bioethics, supported the actuality of a more adequate model of responsibility of the scientific research and the unanimity of the mankind. The interrelations between doctor and patient, based on the democratic values of concept of responsibility transforms from the individual dimension into the solidarity, compassion, communicative interests (B.Jennigns). collective responsibility for the harm done to the human being and the nature.

The new model of interrelations between doctor and patient, the following Within the framework of bioethical discourse morality appears traditionally in powerful public movements for human rights in the reception of correct the supreme meaning. It touches upon the relations between personalities information of the diagnosis and the prognosis of one's own medical condition, (doctor - patient, researcher- the tested) in existential marginal situations at the the independence in making decision about the choice of the methods of edge of life and death, health and disease. Due to that, the philosophical treatment, etc., have pushed forward the development and systematization of recognition of the categories of justice, duty, humanism is received. It becomes the main principles of bioethics in the 70's of the XX century, among which clear that the humanistic paradigm in bioethics can be realized not only along there were included not only the principles of "not harming", "making good" but with ethical principles but also with the strong pursue of legal norms. The also the principle of freedom, justice, duty and benefit, humanism. concept of justice assumes a social component and correspondingly an equal access to public benefits, biomedical services, availability of pharmacological The development of bioethics into an academic discipline and a social institute means, necessary for health care. has been preceded by axiological and ethical turning points emerging within the contemporary scientific interdisciplinary studies, the moral problems of the The categories of duty and benefit, traditional for bioethics that are envisaged biomedicine, connected with the necessity of protecting patient's dignity and in the Hypocrite's formulae of "do not harm", i.e, use in the medicine those rights [2, 45]. Bioethics unites the biological knowledge and human values and means, that will not harm the patient, are expanded in contemporary bioethics is a "systemic study of human behavior in the sphere of science on life and up to "not only do not harm but also do benefit". Let's notice that the health care in as much as the behavior is considered in the light of ethical interpretation of the concept "benefit" is not unambiguous especially when values and principles" [3, 102]. The thirty year period of existence of bioethics discussing the questions of supporting life in vegetative condition, cloning as an interdisciplinary direction and a social institute has been connected with living beings and even human beings, etc. the dynamics of bioethical problems of empiric description of the medical moral in respect of philosophical reflections of morality in the sphere of Thus, the contemporary paradigm of bioethics is characterized by a radical biomedical research. Starting from the second half of 80's in bioethics along turn around from the means of empiric description of medical morality to the with the development of biomedical technologies a rather powerful layer of strained philosophical reflection over the basis of morality in biomedical philosophical knowledge is accumulated that transforms the conceptual basis studies, its own statements on moral values, expansion of the problem field of of the traditional model of bioethics of western type. From a new viewpoint bioethics with the inclusion into it not only morality but also philosophic and issues of rights and freedoms, typical of bioethics, are being actualized as well legal components. as the expanded interpretation of freedom, including the acknowledgement of the personal autonomy, is being formatted. The development of mainly ethical norms and principles that regulate the practical actions of people in the process of studying the nature and the human The philosophical reflections, along with the deepening of our knowledge being, the moral criteria on social activity for changing the environment, the about the live substance, concern also the category of freedom in the direction assessment of the role and place of human being in the framework of from the consumer freedom "freedom from" to the creative freedom "freedom biological realities, the theoretical foundation of the concept of co-evolution of for". The contemporary level of biomedical studies permits the human being to the society and the nature, the status of categories of life and death, are the possess a certain level of "freedom from". However, flying out from the natural scale of the Belarusian model of bioethics, based on a rather expansive

40 41 interpretation of the problem field and subject. [5, 352-354]. Doubtlessly esed to support the deeper understanding of bioethical problems and dilemmas, the bioethical elucidation of people concerned. A fundamental organizational scientific and educational activity on the development of bioethics takes place in the Republic of Belarus: the With the efforts of scientists, managerial structures and public organizations, a scientific conference on "Biomedical Ethics: problems and perspectives" basis for the establishment of the National Committee on Bioethics in the (Minsk, 2000) has been translated into Belarusian, the materials of which were Republic of Belarus was prepared, like those that exist today in different published in May, 2005. On the basis of the Belarusian State Medical countries of the world. University the republican students' scientific-practical conference took place with the further publication of materials. In June 2006 an International While setting up the National Committee on Bioethics, first of all, its status and workshop took place on "The National Committee on Bioethics in Belarussia structure, legal basis, functions and capacities were determined, as well as the and the Activities of Local Committees on Bioethics: the Experience of Central field of activities as compared with the local bioethical committees that act and Eastern Europe". today in the Republic of Belorussia, so that the special-functional definition of the subject of ethical regulation was stable and real. The state of affairs was In 2002 at the Minsk State Economic University after A.D. Sakharov for the studied, concerning the international expert structures on the issues of first time in the CIS out educational programs on biomedical ethics were bioethics and in this respect the work experience of different countries. worked and the course on "Principles of Biomedical Ethics" (20 hours) started for the students of bio-medical specialties. In 2000 the training manual on The creation of the committee on bioethics in the Republic of Belarus was "Biomedical Ethics" was published under the edition of T.V. Mishatkina, S.D. preceded by fundamental organizational, scientific and educational work in the Denisova, Y.S. Yaskevich for the students of biomedical specialties (300 context of national, socio-cultural and historical-political traditions and the pages), (republished in 2004). In the Republican Institute of higher education inclusion of the world experience. Like the Council of Denmark on Ethics, the out a program on biomedical ethics was worked for the system of skill Ethical Committee of the Ministry of Health Care of the Check Republic, the improvement and together with the Belarusian State Medical University and National Committee on Bioethics is set up within the Ministry of Health Care in Belarusian Medical Academy courses are organized for post-graduate the Republic of Belarus with the support of National Commission of Belarus on education on "Basis of Biomedical Ethics" (72 hours) for the faculty of medical the UNESCO affairs. educational establishments and doctors, clinicians and researchers. International scientific and methodical cooperation goes on with colleagues Taking into account the tasks, goals and functions of the National Committee from other countries, with the Ukrainian State Medical University after on Bioethics of the Republic of Belarus, we can conclude that it must play the Bogomolets, with the Ukrainian Association on bioethics, with the Institute of role of a unifying, coordinating and consulting nody in the sphere of public Human Being and the Institute of Philosophy of the Russian Academy of control over the protection of human rights in the sphere of biomedical Sciences, etc. The results of scientific and educational-methodical work on research and in respect of the activities of local committees, working out a bioethics that goes on in the Republic have been introduced in the course of justified policy of doing research in the sphere of health care, organizing the recent 5 years at international conferences and in publications of different forums for discussions on the issues of bioethics on the national level and kind. The foundation of the fundamental research of the National Academy of influencing the development of legislative policies, education and public Sciences of Belarus has approved the project of international cooperation of training or raising public awareness in the sphere of bioethics. Belarusian scientists with the Institute of Philosophy of the Russian Academy of Sciences. The Forum of the Committees on Ethics of the CIS member BIBLOGRAPHY states plays a big role in the maturation of the bioethical way of thinking in the 1. Þäèí Á.Ã. Ìåòîäîëîãèÿ íàóêè. Ñèñòåìíîñòü. Äåÿòåëüíîñòü. Ì., 1997; Republic of Belarus, the development of bioethics, the solution of the Ñòåïèí Â.Ñ. Òåîðåòè÷åñêîå çíàíèå. Ñòðóêòóðà, èñòîðè÷åñêàÿ ýâîëþöèÿ. questions that emerge along with the progress in the sphere of health care, Ì.: «Ïðîãðåññ-Òðàäèöèÿ», 2000. biology, biomedical sciences and biotechnology (Chairman Kubar O.I.). The 2. Áèîýòèêà. Âîïðîñû è îòâåòû. Ñîñò. è îòâ. ðåä. Þäèí Á.Ã., Òèùåíêî Ï.Ä. workshops, organized in the framework of the Forum, the reports of the Ì., 2000. leading specialists and experts of international level (F.P. Crawley, J-P. 3. Encyclopedia of Bioethics//Ed. By W.Th. Reich. N.-Y.-L., 1995- Vol.I: Tassignon, J. Karbwang, K. Bragman, M.Lin, L. Rudze, A. Tikk, B.G. Yudin, O.I. Basic Writing on the Key Ethical Questions That Surround the Major Kubar, Y.I. Kundiev, N.A. Chashchin, P Vitte, E.Malishev, P.D.Tishchenko, etc.) Modern Biological Possibilities and Problems. P. 102

42 43 4. Encyclopedia of Association/Ed. Katherine Gruberg-Detroit: GaleResearch BIOETHICS OF LAW IN THE ACTIVITIES OF HUMAN Co., 1986. 905p.; Leavitt F.J. An Israeli approach to cross-cultural Ethics: RIGHTS DEFENDER OF THE REPUBLIC OF ARMENIA corrections and elucidation//Eubios Ethics Inst. Newsletter. 1993. Vol.3 P.3-7; Vermeersch E. Environment, Ethics, and Cultures//Brussels C.E.J.: Biosphere and Economy. 1995. N7. P.1-40. Georgi Kutoyan 5. Áèîýòèêà: ïðèíöèïû, ïðàâèëà, ïðîáëåìû: Ñá. ñò./Ðîñ.àêàä.íàóê. Candidate of Legal Sciences Ðîñ.íàö. êîìèòåò ïî áèîýòèêå, Èíñòèòóò ÷åëîâåêà; Îòâ.ðåä. è ñîñò. Á.Ã. Senior Adviser of the Human Rights Defender of Republic of Armenia Þäèí. Ì., Ýäèòîðèàë ÓÐÑÑ, 1998. ñ.352-354. Ðóêîâîäñòâî ¹1 ïî ñîçäàíèþ êîìèòåòîâ ïî áèîýòèêå. ÞÍÅÑÊÎ, 2005.- The issues of bioethics of law are not often in the limelight of the Armenian law researchers and in this respect this concept is rarely mentioned in the ñ.13, 19-20. national juridical literature.

It is well known, that for the first time the term "bioethics" has been used by the American biologist Potter. In 1969 his book "Bioethics: a Bridge to Future" was published. The author describes bioethics as a science that combines biology and ethics. Literally, this is a science that serves as a bridge between biology and ethics.

Since then problems characterized as bioethical, have been widely discussed in public in the West. However, the most actively discussed problems are those of euthanasia, abortion, new technologies of conception and child bearing (surrogate motherhood), transplantations, etc. The discussion of these problems is connected with the new approaches to the concept of life and death of a human being accordingly.

This means that in reality bioethics deals with ethical problems in medicine tha arem connected with life and death.

The specificity of this branch that actually predetermined its separation into an individual discipline is the equal importance to ethical, medical and legal aspects of the problem.

Thus, bioethics as an independent science is in the junction of sciences such as ethics, medicine and law. Bioethics of law is an independent direction in the contemporary jurisprudence. It reveals existing problems in jurisprudence and tries to eliminate them as much as possible, rather than opposes itself to other branches. The representatives of the school of bioethics of law are interested in the following problems: 1. the problem of the correlation of biological essence and legal entity of the human being; 2. the problem of the regulation of the right to vital beginning, the correlation of somatic components while making decisions on legal aspects; 3. the problem of "scientific legitimacy".

44 45 First of all, specialists of bioethics think that it is necessary to clarify which of consent of the patient, especially in written form. the concrete aspects of the legal entity are the reflections of our biological characteristics. In this respect a historical analysis is done on how It would be impossible to overcome the paternalistic type of correlations the development of medicine and biology has influenced the status of the between doctor and patient. We have not accepted yet the relations by an subject of law. agreement between doctor and patient of the purchase-sales type or even making the joint decision with patient about the latter's treatment plan after Studying the problem of regulating the right to vital beginning, the detailed discussion of the essence of the disease. Very complicated is the correlation of the somatic components in the course of making decisions on question of the medical secret. On the one hand, the dissemination of the the legal issues of bioethics, based on the cases that cannot be solved by the patient information by the treating doctor is unacceptable. On the other hand, norms of the existing law, they make decisions on the necessity of it is also unacceptable to hide the information about the dangerously infectious supplementing it with corresponding concepts and institutions. The cases of disease of the patient from the competent regulating bodies, like in case of bioethics highlight the problems existing in the contemporary law. HIV/AIDS, etc.

The third main problem, as it has been already said, is the problem of Taking into account the accumulated experience, as well as the experience of "scientific legitimacy". Evidently, the unregulated scientific research can bear other countries, it is expedient to solve a number of organizational issues certain level of danger for many individuals and even for the whole mankind. connected with both formation and activities of ethical committees. We should determine what boundaries of research should be set up by the legal regulation so that to save people from becoming incidental or deliberate Let us illustrate the above-stated problems in the framework of the named victims of uncontrollable scientific research. directions of the Human Rights Defender's activities, for example, the right to information, which is declared in many documents and is narrated in the Article Although the problems of bioethics are discussed in a number of 7 of the RA law "On medical assistance and population theoretical works, authored by our co-patriot scientists and researchers, one services". The patient's information includes result of inspection, diagnosis, should state that, as applied to the activities of the Human Rights Defender forecast, methods of treatment, risk, connected with the method of treatment, these problems as a matter of fact have never been analyzed. At the same consequences of the disease and other information. time, in our opinion the observations in this sphere are of high importance from the point of view of the fact that in the present Armenian state the Institute of As a result of the study of medical cards in one of the hospitals of Yerevan we the Human Rights Defender is responsible for a range of serious tasks in can state that in overwhelming majority of medical cards there has been no providing services to the citizens of the country for the realization of their indication on the patient's awareness of his/her disease, methods of fundamental rights. diagnosis, treatment risk and its justification, possible complications and consequences. And in all cases there has been no entry about the patient's In the current report I have tried to analyze the problems of the refusal to receive information. contemporary bioethical law in the context of the two most important branches of activities of the Human Rights Defender of the Republic of More often in any doctor's practice there can be conditions, when the Armenia, namely the analysis of the legal practice in the sphere of civil and doctor is to receive a voluntary informet consent of the patient to medical human rights and the development of suggestions on analyzing and improving interference (article 8 of the Law). Currently this important preliminary the legislation of the Republic of Armenia in the sphere of civil and human condition of any interference either is not defined by law or the law does not rights, recommendations on improving the legislation. specify what kind of interference is meant. Regardless that the diagnosis and treatment of nearly each of the patients were accompanied by a certain kind of Furthermore, I want to state that the problems that have been interference into the patient's organism, in some of the indicated in the result of the analysis touch upon the above-mentioned two medical cards there was no reflection even of that. The consent is necessary directions of activities of the Human Rights Defender. because in this or that way any interference can harm the patient and that, in Currently we should indicate several main problems that need solution. accordance with law, causes juridical responsibility. If the patient is informed and aware and has given consent to such an interference, this fact excludes Our society apparently is not ready yet to fully accept the rules of the informed the guilt of the medical worker in case of absence of delinquency.

46 47 The Article 17 of the Law empowers the patient with the right to reject on health care, donor blood and its components are being medical interference or to terminate it at any stage. However in case of discussed. rejection of the medical interference the treating doctor must, in a clear form for the patient, explain the possible consequences, which are described in the Certainly, it would be a mistake to bring all interrelations between doctor, medical history of the patient in detail. This form must be signed by the patient patient and society forth to the legislation. However, we must not or his/her legal representative and the treating doctor (or head of department). underestimate its role as that of a social regulator. The law does not define how to state or express the consent or rejection; thus, In the Republic of Armenia throughout the history such a situation has been it is possible to do it through filling in a corresponding form. formed which is characterized by the underdevelopment of the legal regulation This concerns the legal representative of the patient including the parents, in of the national health care system. Currently the legislation does not allow to case the patient is disabled or has not reached the age of 18. regulate all aspects of health care systems in full scale and the prolonged process of reforming the health care system cannot have further development In a number of cases the law stipulates the exclusion of the mandatory without a sound legislative regulation. consent in respect of the inspection and treatment of the patient (Art. 16 of the Law). In such conditions a significant event is apparently the adoption of the draft RA Law "On health care" at the first hearing. Our data, however, show that the doctors do not always adhere to the legal injunctions in case the patient rejects the diagnostic or treating interference, as Special attention is paid to the patients' rights in the draft law. A very important it is inscribed by law. condition for the implementation of these norms, put in the basis of the draft, is the respect for human dignity, the citizens' right to In a number of cases patients have rejected medical interference. There is a awareness and information, personal inviolability of human life, preservation of corresponding entry about this fact. However, in neither case there was physical and psychic integrity. These basic human rights have been put in the competent information available about the patient, about the consequences of basis of patient's specific rights to awareness and information, that have been such a rejection or listing of possible complications. studied in the project, informed consent to medical interference as well as informed rejection. In medical cards there was no information about the introduction of the patient to his/her rights. This, in its turn will have negative impact on the The draft law touches upon such actual problems as the establishment of eth- solution of the issue connected with the violation of the patient's rights, in case ical committees. Restrictions are suggested for those medical technologies of conflict. that have not been approved by ethical committees.

Thus, the analysis of medical cards has shown that the introduced rights of the We think that the adoption of the above-mentioned law will create initial patient, due to different reasons are often neglected in practice. In conditions for citizens to assert their constitutional rights to health care and particular, the right to awareness is not reflected in the majority of medical solution of the most serious problems of the contemporary bioethical law. documents. One of the problems is the secrecy of the medical information about the In respect of the second direction of the Human Rights Defender's activities, it patient. is necessary to indicate that in the Republic of Armenia a whole range of laws were adopted, aimed at protecting the basic rights of our citizens in the sphere The draft law contains a general rule. According to it the provision of of health care. information that is the essential part of medical secrecy can be allowed only with the consent of the citizen or his/her representative. The positive point is The most important one is the above-mentioned RA law "On medical the fact that in the Draft the "medical secrecy" is defined, comprehensively assistance and services to population". listing the cases when the provision of information, which is the part of "medical secrecy", is done without such a consent. There are also other adopted laws such as: "On organ transplantation and/or human tissues" (2002), "On psychiatric assistance" (2004), etc. Currently laws The Principles fixed in the Draft are directed at the implementation of the

48 49 principles of the article 23 of the Constitution of the Republic of Armenia, MEDICAL INSURANCE AS A BIOETHICAL NORM FOR THE according to which each individual has the right to private life and personal REGULATION OF INTERRELATION IN HEALTH CARE secrecy. Medical secrecy is confidential information that cannot be under the possession of only an individual since this kind of information is revealed in the SYSTEM IN ARMENIA process of interrelation between the patient and medical worker. Tigran Khachatryan Summing up the above-mentioned I would like to underline that I have touched Member of the Council of ”Bioethics Development Society" upon only a few of the most acute problems of bioethics in Armenia. However, Director of the 2nd Medical Union, Republic of Armenia it seems to me that what was said above would be enough to make conclusions that bioethical problems should be brought into the limelight Health care must be effective from medical, economical, social and within the Institute of the Human Rights Defender in the RA. bioethical standpoint. Nevertheless, the priority must be equivalent, only in that case it will be possible to speak about real health care.

One of the institutes of equivalency provision is medical insurance, the fundamental principles of which correspond to bioethical principles, especially to principles of justice. The basic principle of medical insurance from economic standpoint is "the rich pay for the poor, the healthy for the sick", from medical standpoint - control over curing quality, from social standpoint - protection of the patient’s right .

In the nineties of the last century, after the social-economic formation change in the countries of Commonwealth of Independent States and the transfer into market economy, health care went through hard crisis, and since then the concept of medical insurance has existed, which, unfortunately, gradually became a populist slogan, whenever health care reforms were mentioned. Medical insurance is a difficult institute of medical aid provision, which has its canons and specific infrastructures of health care system. The present mechanism as a "drug" and its incorrect utilization, without creating means for its assimilation, can bring to serious consequences for medicine.

Medical insurance principles are well-known. The use of the present institute has more than 100 years experience, but it is necessary to point out that in all countries of the world this system has got different forms which are adapted to their individual conditions. For medical insurance implementation the following premises are necessary: z social order of community; z established infrastructure of health care system on market conditions; z legislative basis of medical insurance and its interaction with health care system.

In states with social orientation, where social justice is proclaimed constitutionally, one of the most important social orientations of democratic state activities is health care. The health care of each member of the community and the possibility to get adequate quantitative medical support, in case of necessity, is the most important task of the state.

50 51 Unfortunately, starting from objective and subjective reasons, the state at current sphere of economics, especially from bioethical standpoint. present is not able to implement its duties. Medical service market dictates severe conditions, and whether the state wants it or not, health care financial For the successful functioning of medical insurance, the activities of medical system in qualitative sphere is less than real prices, which were established in institutes must be strictly regulated by legislation and act in the network of the market of medical service, besides, a considerable part of it does not get licensing and accreditation when providing medical aid and medical service. financial support at all. Licensing must not be a non-permanent process but must have a continuous character with a permanent control from the side of the government. Starting from the above-mentioned, at the presence of social tenseness, the community is very much interested in creating a system of spreading means For the successful activity of medical insurance, such an infrastructure of and resources from the principles of social justice. The role of the state is in medical institutes must be created where, due to the introduction of creating conditions for the functioning of the system, that is medical methodic-economical standards and new forms of licensing and accreditation, insurance. insurance companies can provide their clients with modern and qualitative medical aid. Here it is also necessary to pay special attention to personnel The state has social public order, and this order is actual and urgent. policy of health care, where the capability of medical workers must be very strict, licensed, regulated in the implementation of qualitative medical aid, For medical insurance functioning, it is necessary to have the infrastructure depending on their experience, knowledge, etc. health care system which must correspond to the following principles: z adequate financial evaluation of medical service market and quality of Health care system must be ready for the acceptance of "drugs" of medical aid. We do not have to discover America, these are medical insurance, but along with that it is also very important to have a methodic-economical standards; method of application and dosage of the current "remedy". Medical insurance z the use of these standards, in which the scale and the means are is divided into Obligatory Medical Insurance (OMI) and Voluntary Medical actually reflected, and which are necessary for qualitative medical aid, Insurance (VMI) all over the world. starting from the nosology of illnesses and suggested medical service, will allow to evaluate the fields of real financial bases, necessary for OMI is a social type of insurance, which does not pursue profit, and it is in satisfying health care system functioning. This financial minimal basis is more correspondence with bioethical norms. OMI basic principles are the the first key to a successful introduction of medical insurance, as it allows following: to evaluate insurance risks and payments with the help of actuarial z universality; calculation with the use of statistical exponents (morbidity, population z obligation; quantity, social sections, employment, age, sex, etc.). z equal conditions for citizens; z existence of obligatory minimum of medical service according to the When providing medical aid to the clients, methodic-economical standards insurance; allow insurance companies to control the quality and capacity of medical z participation of the government and employers in the financial system; service. z governmental control; z insurer's independence; Medical insurance together with insurers are interested in the effective z free choice of a doctor and an insurer. curing of their patients from medical and economical standpoint, and methodic-economical systems allow insurance companies to demand from VMI is a commercial type insurance, which has an additional character, it is health care system structures accurate work implementation and protection of implemented at the expense of personal means, on volunteer basis, and patients from arbitrariness in some medical institutions. guarantees the presentation of usually expensive medical service which is not repulsed in the programs of OMI. The most important functioning of medical insurance is health care system surveillance and predictability. Medicine is a field of service and here the Health care is a sphere of service as well as of insurance, and without taking market laws function, though each branch has its own peculiarities, and the care of the client and his interests, medical, social and economical government role must be directed to the control of established laws in the effectiveness of the system will be insignificant.

52 53 It is very important to prepare "the patient" of health care system to take the BIOETHICS ROLE IN THE GENERAL SYSTEM OF "medicine", but it is also necessary to hurry, because the "illness", which HUMAN RIGHTS affected this sphere, can be redoubled.

In our opinion, medical insurance, being one of the institutes, which provides Karen Kazaryan qualitative medical aid, medical insurance, from bioethical standpoint, solves President of ”Bioethics Development Society" NGO, the problem of patient-doctor-medical institute-government interrelation more Yerevan, Republic of Armenia effectively. Human Rights start from the borderline of obtaining and knowing one's rights.

The development of modern democratic community is impossible without the provision of close cooperation between the system of human rights and fundamental freedom with bioethical principles and norms.

Depending on the historical period of human rights origin, realization and formulation, they can be conditionally divided into generations. Starting from the order of right origin, civil and political rights refer to the first generation. It is the "oldest" one of generation of universally recognized human rights. Social-economic rights refer to the second generation. Collective or solidarity rights refer to the third one, and an extraordinarily wide part of human rights refer to the fourth generation which is realized in the sphere of bioethics.

In modern world the tendency of modern health care development, biomedical technologies and scientific investigations is connected with the control of ethic norm and human rights observance. Bioethical issues have an expressive disciplined character. Physicians, biologists, ecologists, philosophers, jurists, religious confession representatives participate in them. Generalizing scientific, social and religious views, national peculiarities, traditions, they create integrity of national principles, norms and rules which they follow in their professional activity. More important are those that are consolidated with respective legislative acts and find reflection in international conventions, declarations, charters. In the course of time these principles, norms and rules change in accordance with the social-economical changes of social conditions, state politics, public opinion. Particularly, in the period of the formation of new relation system, democratic community development in our countries (where certain communities appear), in the conditions of health care commercialization and its inclusion into market relations, the emergence of ethic dilemma, connected with modern condition of science, medicine and industry of health with allocation and separation of health care resources and medical help, need more moral-ethic and legal regulation.

The core of human rights conception is the tendency to protect human dignity of all people. Bioethics puts the human being in the centre of attention, being based on respect for each human being's life and dignity, whose

54 55 interests must be above the interests of science and community. The norm, with the low level of legal literacy of key bearers of citizens' rights in this confirming each human being's welfare priority over the interests of science sphere. Occasionally citizens are unaware not only of separate conditions of and community, has become fundamental in all international documents today, laws concerning their rights, but also of the existence of the rights. Though, it on the basis of which ethic and legal regulation of medical practice and is important to mention, that the situation changes rapidly. experiments on human beings are implemented. The balance of personal and There is an opinion that bioethics is an appendage of rich countries with general interests is rather difficult, and its significant shift into any side can developed infrastructure in health care system. Of course, the rejection of the bring to disintegration of relations. influence of economical level of life on community morals is not right. We will Human rights are inseparable and interconnected. We can distinguish not discuss what factors define ethic level of community on the whole and its between different measurings and categories of human rights, the separate members, one thing is obvious: observance of bioethical principles in implementation of which is provided on a state level. Human's legal right (in bioethics investigations and medical practice promotes medical science and general view) is the minimal realization of human demands protected by the health care authority advancement as well as protects the rights and dignity of state, the satisfaction of which can provide him/her (consequently the all participating sides. community) survival and development. For that reason, all human rights are How to provide the observance of bioethical norms and principles in specifically formulated in the legislation. The main function of the state is the practice so that they remain only good intentions? self-protection activity on the defense of its citizens' rights. Human rights, formulated in the legislation, are not maximal and optimal but minimal In our opinion, with the aim of introducing basic norms of bioethics and standards of civilized inter-human relations. It's the capacity of human claims principles into the community it is necessary: to the state, physical and juridical persons, the realization of which gives some z legislation basis development on human rights protection in the light of guarantee to his or her survival and progress. Each human right is an bioethics norms and principles, formulation of normative, regulator and additional factor, additional possibility of his or her safety and welfare growth. educational standards with the aim of creating and improving the The orientation of the nation health protection and the provision of conditions, national system of ethic expertise in accordance with international which gives an opportunity to survive with dignity, are the indicators of moral legislative acts, declarations (Universal Declaration of UNESCO about politics of the state and one of the most important conditions of its Bioethics and Human Rights, European Convention about Human Rights preservation and development. and Biomedicine); The community on the whole and each human being in particular must be z determination of structures (for instance, ethic committees), public institutions which are appealed and obliged to realize bioethical rights; interested in the observance which should be regulated by law and be rigidly controlled. The realization of the right to health on all community levels z advancement of possession of information about different levels of presupposes possession of information from the institutions which practice the responsibility on observing bioethical principles and norms on local, progress of such human rights. The fact that citizens' possession of regional, national and international levels; information about dignity and shortcomings of national health care system and z to promote the process of getting acquainted with bioethical norms and about the responsibility each level of this system has, is as important as the creation of viable educational programs in this sphere, preparation of duty of the state in the provision of this right. Citizens' willingness to participate specialists and teachers for professional and non-professional in the determination of health care needs in the process of problem solving is community groups: physicians, biologists, scientific collaborators, jurists, a necessary condition. Either the human being uses the system, or the system teachers, members of institutes of higher education, parliamentarians, uses the human. non-governmental organizations, etc; z popularization of ideas and values of bioethics, increase of public Bioethical problems have a global character and are actual all over the world, consciousness level and legal literacy of population, expansion of including in the Republic of Armenia. Civil and political rights with all their population's access to information in the field of legislation in the sphere importance are not considered vital by the citizens of Armenia today. The of health care with the use of modern information technologies; problems, connected with social-economical rights, on the contrary, concern z development of the network of ombudsman's institutions. everyone directly and loudly, but in spite of juridical difficulties, its realization depends mostly on economical, not juridical factors. The situation worsens For the realization of bioethical norms and principles, it is necessary to

56 57 have the support and interactions with such organizations as UNESCO with its HUMAN RIGHTS IN THE SPHERE OF BIOETHICS - RIGHT international mandate in the sphere of human rights, education, the only TO HEALTH, SOCIAL RIGHTS organization in which social and humanitarian sciences are one of the spheres of its competences and such a body as the institute of human rights protection - ombudsman's institute which is called to contribute human rights affirmation Karen Avagyan in the community, to provide the rule of law in the community, as well as Vice-president of "Bioethics Development Society" guarantee their effective realization. NGO Yerevan, Republic of Armenia

In the light of the above-mentioned, in order to occupy its position in human The scientific-technical progress, as a condition of social-economical rights system, bioethics must not be and must not remain a field of involving development, as well as the modern demands of practical medicine have only specialists, experts, but also to become the subject of public attention and fundamentally changed the professional and social role of doctors in the generally accepted element of social relations. sphere of health care. Besides, mastering a high professional ground it is essential for doctors, with calculation of modern demands for developing health care, to thoroughly investigate and take into account the regularities of social development, theoretical and practical tasks of health care from the standpoint of bioethical norms and principles.

It is impossible not to agree with our colleague Boris Yudin: "Unfortunately, as in many post-soviet countries the significance of human rights is not satisfactorily realized in the sphere of bioethics. Traditionally, either social-economical or civil and political rights of human beings were in the focus of attention in our country. Not belittling their significance, I would like to point out that biomedical practice is the implementation of, perhaps, the most fundamental vital human right". Yes, our countries are like one another in many respects. Moreover, it is obvious: they were together before, which proves that the main basic principles will be practically of the same type. The significance of human rights in the sphere of bioethics is unsatisfactory in Armenia either.

Now, it is high time to remember the BME rules: z rule of Veracity. Veracity and trust are the guarantee of treatment effectiveness. Patient's right to receive right information; z rule of Confidentiality. The subject of confidentiality (diagnosis of illness, information on health condition, prognosis, non-medical information about the patient and his relatives); z rule of Information Agreement. Information on the aims of medical interference, its duration, results, risk for life, availability of alternative methods of treatment and its effectiveness.

Bioethical principles are directly connected with the understanding of life value and personal dignity, which, in its turn, suggests orientation on spiritual and moral values. Namely, this orientation is capable of providing effectiveness of state politics in the sphere of health and is the criteria for the state well-being. The modern civilized society is inconceivable without permanent political will

58 59 to the defense and justice provision, as well as to such a vital sphere for each The social-legal imperfection of health care of the native system promotes to citizen as the health care. the growth of socially significant illnesses, in connection of which cases, when the population sees pseudo-doctors, medical dealers, different kinds of One of the modern criteria for the state well-being is the social protection of the witch-doctors and healers, increase, tring to substitute their methods of human being in the sphere of health care. This assumes not only the "treatment" for official medicine only with one aim - to get money. realization of human right to medical help, but also the implementation of other rights, first, including the right to life and health safety, which has equal These crisis occurrences are redoubled with a new serious problem - the lack availability and acceptable quality of medical help. The provision of the of appropriate control over the use of new biomedical technologies by the above-mentioned rights becomes especially important in the conditions of community and state, which is capable of leading to irreversible progressive development of biomedicine and emergence of new biomedical social-cultural and demographical results. technologies. The counteraction to these dangerous occurrences and the violation of rights Simultaneously, it is important to focus rapt attention to the problem of human in the sphere of health care must be provided by the Constitution taking into life quality and value. The quality of medical service inevitably descends consideration bioethical principles developed by the international against the background of health-care commercialization as the community as well as the European Council, the UNO, the Worldwide Medical latter demands respective equipment of clinics (expensive apparatus, medical Association. technologies, specialists), which, in its turn, brings to the rise in prices of medical service. Everybody knows that high prices of medical service cannot In the wide sense of the word bioethics is understood as the body of be psychologically comfortable factors for the overwhelming majority of demanding norms directed to the provision of nation life quality and, first of all, citizens who have desire to get medical help from highly-qualified specialists, health and safety. with expensive apparatus and use of new technologies without restraining their constitutional rights. Mechanisms of social guarantees should be added When the state faces socially directed tasks, it is important to remember once by the state to solve this matter (state order, etc.). again the basic conditions. It is necessary to achieve the development of civil society institutions in the sphere of health care, formation of medical right and gradual legal formation of fundamental relations in health care. It is also necessary to establish an CONVENTION ON HUMAN RIGHTS AND DIGNITY organization which aims at defending both doctors' and patients' rights, PROTECTION IN THE SPHERE OF BIOETHICS: gradual transition from "consumer investigation" (as the basic form of the CONVENTION ON BIOMEDICINE AND HUMAN RIGHTS assertion of citizen's interests in the protection of their health legally) to the norm of conflict solving in legal community in Armenia. PART 1 The RA legislation undergoes changes according to the European GENERAL CONDITIONS standards. Hence, it follows from here that the community democratization, which tends to become a member of European family, cannot avoid the development of bioethical principles and norms in Armenia, which have been Article 1 (Goal and tasks) regulating the wholem sphere of health care in Europe for a long time. Moreover, the adoption of such norms is an obligatory condition for entering The sides, which signed the current Convention, are obliged to defend each the Euro-union. human's dignity and individuality in the sphere of biomedicine, as well as guarantee everyone without any exceptions human integrity, fundamental The universal tendencies and experience of post-soviet countries speak of the rights and respect for freedom which every human being masters. necessity of adoption of laws, at the heart of which must be "European Convention on Human Rights and Biomedicine", 1997, as well as, for instance, The sides are also obliged to undertake necessary steps for improving internal the project "Universal Declaration on Bioethics and Human Rights", Paris, legislation so that it reflects the condition of the current Convention. starting from 24.06.05.

60 61 Article 2 (Human Priority) 3. In exceptional cases, for the patient's sake the law can make limits on the realization of the rights mentioned in the 2nd point. Each human's interests and well-being must prevail above the community and science exceptional interests. Part 4 Public Discussion Article 3 (Equal Availability)

In the network of its jurisdiction as well as starting from the demand of Article 28 (Public Discussion) medical help and existing resources, the sides are obliged to undertake necessary measures aiming at providing equal availability of medical help for The sides, which signed the Convention, must take care of basic problems, all community members. connected with the progress in the sphere of biology and medicine (especially their social-economical, ethical and juridical aspects), to be Article 4 (Professional Standards) exposed to wide community discussion and become the subject of appropriate Any medical interference, including interference with the investigation aims, consultation. must be implemented in accordance with existing professional demands and One of the top-priority steps for setting up the legal bases of bioethics in standards. Armenia must become the rule of "Obligatory Medical Insurance". Without discussing the matter of a more useful model of OMI in Armenia, which must maximally provide the implementation of bioethical norms, it is necessary to point out the following in red print: z first of all, starting from the way health care system is built and is being Part 2 developed in Armenia and taking into consideration certain stability and Agreement positive dynamics of economical growth of the Republic, we can confidently say that adoption of the law on "Obligatory Medical Insurance" Article 5 (General Rule) in Armenia is inevitable; Any medical interference must not be implemented without voluntary z second, starting from the above-mentioned, the law gives necessary legal information agreement of the person who is subject to an examination. basis for the regulation of health care system of, first of all, such relations Preliminarily, the person must be provided with respective information on the as doctor-patient, which in its turn will become the beginning of imple- aims and nature of interference as well as on the results and risks mentation of certain bioethical norms and demands; connected with it. z third, with the introduction of a more effective OMI model in Armenia, The person who has agreed to pass a medical examination can take his/her health care system of the Republic will get an additional financial agreement back any time he or she wants. resource which, in case of being rationally used, will give an opportunity to improve the condition of health care social part. Different systems of health care exist and function in the world - from totally autonomic types to exceptionally state types. In some countries help is Part 3 provided only to those who desperately need it, in others medical health care Private Life and Right to Be Informed developed system exists, the third ones significantly moved forward in the organization of complex health protection. Different degrees of combination of Article 10 (Private Life and Right to Be Informed) private initiative and state policy in the sphere of health care generate 1. Everyone has the right to respect for private life concerning the numerous variants of systems of medical help provision. Starting from this, information on his/her own health. starting up human right systems in the sphere of bioethics in Armenia, it is 2. Everyone has the right to know any information which refers to his/her necessary to rest upon Resolution on generic medical practice (accepted health. by the 40th Assembly of Worldwide Medical Association, Vienna, Austria,

62 63 September, 1988). MEDICAL ETHICS, HUMAN RIGHTS AND INDUCED Since medical assistance is not organized in the same way in different ABORTION countries - from absolute freedom of medical practice to health care system totally controlled by the state, Liana Yukhanyan since economical and social conditions, in which health care systems exist, Union of Non-Governmental Organizations of Shirak marz reflect the difference between medical help and social mode of various public Republic of Armenia formations, since numerous forms of medical assistance provision is necessary for Medical ethics, also called bioethics or biomedical ethics, affects the adequate satisfaction of public demands, everyday lives of health professionals as well as all of us at some point in our it is decided that Worldwide Medical Association approves the conception of life's journey. A human being is a morally significant person when he/she has implementation of generic medical practice as a method of a permanent rights, and we are under moral obligation toward that individual. These issues provision of qualified medical help, adequate to the principles of medical are usually discussed. ethics. The GMC, in the current edition of Good Medical Practice states: 'If you feel that your beliefs might affect the advice or treatment you provide, you must Dear Colleagues! explain this to patients and inform them of their right to see another doctor.' Bioethics in Armenia can productively develop due to the participation of The new draft of Good Medical Practice, currently out for consultation, goes organizations realizing respective programs and at the expense of our united further. It says: 'If carrying out a particular procedure, or giving advice on it efforts. contradicts with your beliefs, you must explain this to patients and inform them We consider that the basic task of bioethics as an institute of civil society is the of their right to see another doctor. Where it is not practicable for patients to development of publicly acknowledged moral and legal limits and make such arrangements themselves, you must ensure that arrangements are conditions connected, first of all, with the receipt of available and qualifying made for another suitably qualified colleague to take over your role so that the medical assistance. patient's care does not suffer”. Starting from the above-mentioned and taking into account the worldwide tendencies in the matter of setting up of real legal principles in the community It is widely accepted that the fact of induced abortion has been a subject of on the basis of bioethical norms, ”Bioethics Development Society" considers conversation and controversy for many decades. The reason for this is that the one of its main aims the one which can be characterized with one slogan- percentage of people who accept abortion as a 'normal' procedure is nearly "Doctor's honour and patient's dignity". equal to the percentage of those who think of abortion as a crime.

The dramatic increase in abortion worldwide this century has run counter to historically accepted codes of medical ethics. The Hippocratic Oath includes the resolution 'I will not give the woman a device to produce abortion'. The Declaration of Geneva (1948) states: 'I will maintain the utmost respect for human life from the time of conception even against threat...' and the International Code of Medical Ethics (1949) affirms that 'a doctor must always bear in mind the importance of preserving human life from the time of conception until death'. In the same spirit the UN Declaration on Human Life (1948) asserts that 'everyone has the right to life' and the UN Declaration of the Children's Rights (1959) asserts that the child deserves 'legal protection before as well as after birth'.

Although abortion has been practiced at some level in most societies, legal abortion on a massive scale is a relatively recent phenomenon. Since the

64 65 Soviet Union first legalized abortion in 1920, much of the rest of the world has issued a decree allowing abortions for health reasons to be performed through followed it: Scandinavia in the 30s, Asia beginning from the 40s and Western the twenty-eighth week of pregnancy. The Government continued to extend Europe from the late 60s. By 1982 only 28% of the world's population lived in the circumstances under which legal abortions were available, and on countries where abortion was largely illegal - mostly in Muslim countries, parts December 31, 1987 it issued another decree establishing a broad range of of Africa and Latin America. There are now estimated to be 55 million legal non-medical indications for abortions performed on request through the abortions performed each year worldwide. twenty-eighth week of pregnancy.

As the abortion rate rocketed world-wide, consistency of belief and This included: practice were achieved by further amendment of ethical codes. At the 35th z the death of the husband during pregnancy; World Medical Assembly held in Venice in October 1983 the WMA changed the z the imprisonment of the pregnant woman or her husband; Declaration of Geneva as follows: the words 'from the time of conception' were z the deprivation of maternity rights; amended to 'from its beginning'. The result is that now medical professions are z the possession of many children (the number of children exceeds five); among the major facilitators of abortion. z the divorce during pregnancy; pregnancy following rape; z the disability of child in the family. The Soviet Decree of June 27, 1936 prohibited the performance of abortions except in case of a danger to life, a serious threat to health, or the Moreover, the order provided that, with the approval of a commission, an existence of a serious disease that could be inherited from parents. The abortion could be performed on any other grounds. abortion had to be performed in hospital or maternity home. Physicians, who performed abortions outside hospitals or without the presence of one of these Armenia is one of the former Soviet Union countries where currently indications, were subject to one to two years' imprisonment. If the abortion was abortion is legal. performed under unsanitary conditions or by a person with no special medical As a result, abortion practices in Armenia were similar to those throughout the education, the penalty was no less than three years' imprisonment. A person former USSR. Since independence, no changes have been made in the who induced a woman to have an abortion was subject to two years' abortion law. imprisonment. A pregnant woman who underwent an abortion was subject to a reprimand and the payment of a fine of up to 300 rubles in case of a repeat According to the regulation on the artificial interruption of pregnancy the offence. induced abortion is allowed till 12 weeks inclusive, on women's voluntary basis. In an edict of November 23, 1955 the Government of the former USSR repealed the general prohibition on abortions contained in the 1936 Decree. Information on induced abortion was collected through different surveys. Other regulations, also issued in 1955, specified that abortions could be performed freely during the first 12 weeks of pregnancy, if It is interesting to note that there is a curvilinear relationship between induced no contra-indication existed, and after that point, when the continuation of the abortion and education. Women with a primary/middle education have the pregnancy and the birth would harm the mother (interpreted to include fetal lowest percentage of pregnancies resulting in induced abortion (43 handicap). percent). Also approximately one-third of pregnancies end in abortion among women with a secondary or secondary-special education (57 percent and 59 Despite the approval of the 1955 edict and regulations, the problem of percent respectively). Among women with higher education, the percentage of illegal abortions did not entirely disappear in the former USSR. This situation pregnancies ending in abortion is virtually the same as the percentage for resulted in part from the Government's conflicted attitude towards women with primary/middle school education (46 percent). contraception. Although at times it manifested support for contraception, it did little to make contraception available and in 1974 effectively banned the There are no vivid differences between the prevalence of induced widespread use of oral contraceptives. The result was a reliance on abortion abortions and urban-rural residence. There is a curvilinear interdependence as the primary method of family planning. between the educational level and induced abortion for women inhabiting in rural as well as in urban area. It is possible that higher levels of fertility among Concerned with the high rate of illegal abortions, in 1982 the Government less educated women accounts for the low recourse to abortion (i.e., when a

66 67 woman gets pregnant, she is more likely to give birth); at the same time, it is Caucasian neighbor Georgia has a significantly higher TAR: 3.7 compared possible that women with higher education, who use more reliable methods of with 2.6 in Armenia (Serbanescu et al., 2000). It should be noted that fertility birth control, are less likely to become accidentally pregnant in the first place. levels in the two countries are the same (1.7 TFRs), but contraceptive prevalence in Georgia is significantly lower (41 percent versus 61 percent in Residence Induced abortion Armenia). Urban 53.9 100 Thus, we can conclude that Rural 56.1 100 1) Whatever decision the woman make, it is a fact that she should be aware Education of all the further consequences of medical abortion. Primary/middle 43.3 100 The practice of induced abortion can adversely affect Secondary 58.5 100 I. woman's mental and physical health, Higher 45.8 100 II. reduce her chances for further childbearing, III. contribution to maternal and perinatal mortality. The mean number of abortions per woman is 3.3. As expected, the frequency of abortions increases with age: among women 20-24 years of age According to official statistics in Armenia induced abortions account for a 14 percent have had an abortion, compared with 57 percent of women age significant proportion of maternal deaths (between 10 and 20 percent). 25-34 and 73 percent of women age 35 and older. There is also a positive 2) It is important to know the contraceptive behavior of women that lead to an interdependence between having had an induced abortion and number of induced abortion. This information is of particular interest to both family living children. Less than 1 percent of women with no living children have had planning counselors and abortion providers because the woman, who has an an abortion, compared with 25 percent of women with one child, 77 percent of abortion, either does not use a method of contraception at the time of women with two to three children and 84 percent of women with four or more conception or uses (perhaps incorrectly) a method that failed. In addition to a children. high level of contraceptive failure, it is important to note that one-third of The TAR (total abortion rate) is interpreted as the number of abortions a pregnancies resulting in induced abortion were not from women using any woman would have in her lifetime if she experienced the currently observed method of contraception to prevent the pregnancy. age-specific rates during her childbearing years. It seems clear that the access to more reliable methods of contraception and Age-specific abortion rates are lower than the fertility rates of women under the use of them would reduce the incidence of induced abortion, thus age 25 but are greater than the fertility rates for elder women. The total improving the reproductive health of women in Armenia. abortion rate is 2.6. The rural TAR is more than 60 percent higher than the Thus, in order to achieve these aims, it is very significant to raise patient's urban TAR. There are significant differences by background characteristics. awareness for making her own right decision according to her own values and Total abortion rates vary by residence: the TAR in rural areas is higher by more beliefs and to increase knowledge about the social, legal and ethical issues of than one abortion per woman than in urban areas (3.4 versus 2.1). It should abortion and unwanted pregnancy. It could be implemented through primary be noted that significantly more rural than urban married women use and secondary prevention by organization lectures, debates and conferences; withdrawal (40 percent versus 26 percent), which is one of the least reliable publishing pamphlets and leaflets; and publications on abortion and related methods of contraception. Thus, the higher rural TAR may be attributed, at issues to this. least in part, to the higher proportion of women who unsuccessfully try to control their fertility by using withdrawal. Primary, prevention, including state sexual education at schools, universities and medical facilities. The TAR in Armenia is significantly higher than any post-Soviet Central Asian country where TARs range from a low of 0.7 in Uzbekistan (IOG and MI, 1997) Secondary, popularization of contraceptive methods, family planning and etc. to 1.6 in the Kyrgyz Republic (RIOP and MI, 1998). However, Armenia's

68 69 SOME ASPECTS OF THE INTERRELATION BETWEEN problems. Why? Because in historical aspect questions of soul and body, BIOETHICS AND CHRISTIANITY human and nature interrelation the fixed level of influence on human corporal beginning, moral face of doctors were in the sphere of attention of church confessors and of many theologians significantly earlier. The conceptions that Karen Nazaryan "born in flesh is flesh, born in spirit is spirit" (Johan 3-6) were formulated in Doctor of Biological Sciences, evangelists' time, and the expression of Saint Luka "Doctor! Cure yourself" Director of the Fund "Armenian Interchurch (4:23) has been a graphic evidence of moral priority of this task since early Charitable Round-Table" Christianity. Body and soul curing was one of Jesus' missions. We read in the Republic of Armenia Gospel of Matthew: "and Jesus went through all cities and villages-healing any kind of illness and any infirmity in human beings" (9:35). In this way, it is "…and only when this life disappears, as a snowflake in a warm hand, we feel obvious that Christianity always considered healing, and moral problems permanent loss". connected with it, important. Let me dwell on some aspects of Bioethics of Christian vision and On the other hand, for a faithful Christian any scientific investigation is understanding. sintered with belief, and it is a basis for our reasoning and summarizing. Here we can remember Grigor Tatevatsi thought: "those, who want to build a As a problem and subject of investigation of the modern temple, first put and enhance the fundament and only after that they build. This understanding, bioethics was formed after the famous Thalidomide is the basis of our belief and science - God-". catastrophe in 60's of the 20th century. Such moral, theological and philosophical problems usually refer to bioethics as: In spite of the above-mentioned, in my opinion, the problems of modern z abortion; bioethics were first put forward to doctors and biologists, jurists in the process z contraception and new reproductive technologies; of practical job, and after that they were comprehended in church. For z experiments on human beings and animals; instance, before the beginning of sixties, medical community shared the point z receipt of information possession agreement and provision of patients' of view that for the sake of "humanity" welfare, separate human being's rights, development of death determination; well-being can almost always be sacrificed. As this postulate is in dramatic z suicide and euthanasia; contradiction with church dogmatics, it served as a trigger for forming integral z relationship problems with dying patient; z vaccination and AIDS; church conception on bioethics problems. z demographic politics and family planning; z genetics (including problems of genomic investigations, gene Recently churches and their AAC have actively participated in the engineering and gene-therapy); discussions of a number of bioethical questions. A bit later I will bring specific z transplantation; examples and will dwell on the results of this work. z justice in health care; z cloning of human beings, manipulations with rotting cells, etc. Of course, it is important to mention, that the main mission of church is not being the driving motive of different social or ecological problems, though they Another aspect of bioethics is Remedial Movement. Remedial Movement can may be very important. The church has another role, as it functions not in a be observed as the second most vital presupposition of bioethics global but in cosmic system. We must acknowledge that the church cannot formation. If ecological movement appears in response to the threat forward make the protection of surrounding environment or bioethics or even social physical (natural) human well-being, bioethics begins to develop rapidly in the justice its fundamental mission, and not because of the reason that we can live result of finding new threats towards moral human identity from the side of in agreement with God's word without it, but because these are deeds which technological progress in the field of biomedicine. will make us, if we want become a part of God's kingdom. That is to say, these questions implicitly form a part of the church. Through a very short interval Churches and other Christian organizations and units actively join the discussions and debates of many bioethical It's important to mention in the discussion the circle of questions here in which

70 71 the church has a significant participation: against science. We just want scientific achievements to be used either z pregnancy and status of human germ; humanly, or not be used at all". z abortion and integrity problems; z AIDS; It seems that in present Armenia which, mildly said, does not belong to the z genetic manipulations, etc. countries where modern investigations are held in the sphere of natural science, the moral and legal questions of bioethics are not very actual, According to the authoritative opinion, discussions and dialogues of priests especially if we take into consideration other numerous social problems. and theologians in this sphere are particularly useful and productive. Indeed, However, the peculiarity of modern globalization processes is such that there is practically a total unity in viewpoints between catholic and Orthodox isolationism is practically impossible. I will try to validate this situation with a Church demonstrations. And it is not by chance that one of the first modern simple example. Let us remember that computer, internet and cell-phone dialogues between AAC and ROC was devoted to bioethical questions. reached all the corners of the planet not avoiding us. Some years ago no one Unfortunately, the level of information possession of Armenian community is could anticipate in the cold and dark, broken Armenia that it would happen so rather poor. Besides, there is no understanding that the church must take care soon. We are not rich now either, but all the above-mentioned objects have of such questions. One of the reasons is the shortage of general religious general expansion. education. Many people of our country are faithfuls spontaneously and instinctively. As a whole, they perceive the church as something ancient, Besides, I think, that many bioethical problems cannot be solved only by conservative which was inherited from ancestors and which must be kept administration or propagations. That is to say, if we want to shorten the untouched. That is why one of the reasons of real communication is the number of abortions it is important and necessary to implement consistent and introduction of information of the work done in the sphere of bioethics in the active work of the church by sermons, explaining methods, but it is also Armenian church. necessary for the church to actively coordinate with social institutes of the government and non-governmental organizations. In order to validate such an That is to say, I consider real communication as an attempt to present what assertion, it is enough to compare the statistics of abortion in poor and happens in AAC in bioethical sphere, without claiming, of course, full breaking countries with the rich countries of the North. coverage. The majority of modern scientists are sure that it is impossible to confine science and scientific investigations, and that modern civilization It is obvious that health-care condition cannot be considered satisfactory in our cannot survive without science. Actually, what we would do without telephone, country today, but in spite of it, well trained and informed church acolytes can airplanes or toothpaste! I think few people would like to live in this world help the doctors. With this aim there have been organized programs for without these and many other useful things. Besides, it is impossible to deny training pastors in the field of medical, psychological and religious aspects, that scientific investigations brought humanity to a number of tasks which are consultation of patients and their relatives. It refers to such illnesses which solved with difficulty. It becomes more and more obvious that science, have social basis like AIDS and other illnesses, which pass by sexual track. It technologies, industrialization of the West have lost their magnetic strength in also refers to more global problems like consultation or pastor work with many people's opinion. people who have stayed in the condition of a long stress.

In spite of this, many people continue to insist that scientific progress There is another teaching program for theologians' seminars which is called cannot be stopped or confined either by inquisition, or KGB (State Security "Green Theology". It is a kind of attempt to conceive theological bases of Committee), or FBI, or parliaments and churches. Indeed, God created man in surrounding environment protection. Imagine that the fundamental position of his image and likeness and rewarded him with inquisitive and comprahansive Christian ethics lies on the basis of caring attitude towards Nature. There is an brains. And what is science without pure incarnation of human's will and important aspect here which I would like you to pay attention to. There is much sense? In particular, in this aspect it differs from belief. And it is interesting and Western literature on this matter, and many people, working in dangerous just in this aspect. We must always remember that in spite of its consultation field, cannot avoid the attraction of using these materials. It is not achievements, science is mistakable. and it is created by sinful people. difficult to adapt a little, translate ready materials and organize trainings on Nevertheless, it does not mean that church is against science. In this sense, their basis. Experience shows that it is not the best way to spread knowledge, theologian's saying is interesting, deacon ROC A. Kuraeva: "our fight is not it often gives opposite effect, discrediting useful and necessary concept.

72 73 That is why the work in this direction is a creative, scientific search, polemics between the churches and different governmental and a comprehension of AAC rich heritage. That is the reason that diploma works non-governmental organizations. It is really a dilemma: will it be appropriate to and dissertations are written and defended on the subjects connected with consider embryo, which consists of some ten cells, a living organism. I will only bioethical questions in Gevorgyan Theologian Academy in St. Edjmiadzin. say that in our church an opinion prevails about the unacceptability of such manipulations, as it is considered that soul is put into human embryo If we return to the subject of priest and practical doctor collaboration, I would simultaneously with conception, and it is conformable with basic postulates of like to remember an interesting formula of general approach to the Christian anthropology. According to them, an individual is considered a healing process which was proposed by a Christian doctor: Chemistry+Love. puzzle, mystery which is created in God's image and likeness. Undoubtedly, He says that we are often able to give the first one but we cannot give the God created man in his image and likeness rewarding him with freedom of will, second one in an appropriate way. That is why he applies to the church and the peculiarity of bioethical discussions is in the fact that people and acolyte. Yes, love and belief are medicine which can supplement and community can understand what is acceptable and what is unacceptable from strengthen classical medicine. "Recover, your belief saved you" is said in the the viewpoint of clever and Christian man. Why the Christian man? Because, Gospel (Luka 18:42). Let us remember here what apostle Paul says in the in my opinion, modern science is the product of Christian civilization. The message to Corinthians: "If I have conception and belief, I can move solution of this task is difficult, but it is not impossible. mountains, and if I don't have love, I am nothing". He finishes his love hymn with the words: "And now belief, hope and love come out if which love is The modern condition and dynamics of genetic investigations are such that stronger". Corinth 1-13-13. while we speak and argue, the human cloning becomes a fact at present. Now the matter is, whether it will become an ordinary matter in the nearest future. In our reality bioethics touches upon, also such problems as the use of Or the humanity, starting from the norms of the Christian morality and ethics, achievements of modern medicine and the problem of their availability. Today will be strong enough to take this process under control, or this process will this question is very vital for the citizens of our country. And are the take place only by the scenario of commerce and market. Further thoughts achievements of modern medicine available to us? Unfortunately, the answer about humanity fabrics and other matters I leave for people with more is negative. In the country where social protection institutes are poorly developed fantasy. If people and government acknowledge the actual danger developed, the majority of the population does not have an opportunity to get of the phenomenon, I think they will manage to put the process under adequate medical help. A great number of people in many countries are in the adequate control. Let us remember about the existence of a more or less same situation, that is to say, it is a critical global problem. effective control on the spreading of nuclear weapons (actually, two battle nuclear explosions were necessary for that). Let us remember that the only effective anti-retrovirus curing of AIDS on account of its expensiveness is available only to the inhabitants of developed When does life begin and end? What is the dignity of life? Is cloning a new countries, and the inhabitants of many countries of Equatorial Africa, suffering powerful instrument of medicine or another mistake, crime for distorting the from epidemic, do not have an opportunity to get the treatment. A few years real essence of life? Can we really believe that cloning will make life happier? ago we could not imagine that a number of most difficult surgical operations, We often refer to the raised difficult questions only from the viewpoint of like heart operation, would become a part of our reality. But are they science or short economic profit; we separate science from ethics, national, financially available to the majority of the population? Unfortunately, only to a humanistic, Christian values. For such mistakes we have to pay later. Taking very small part, as our insurance medical system is not formulated. In this case this danger into consideration, governmental and intergovernmental structures a question arises: are these medical achievements necessary which are priori must attract the church, scientists and non-governmental organizations into available only to some rich people. the discussion of bioethical questions. The absence of such a program or formulism of political powers are fraught with great difficulties for us. Let us refer to the church position in one of the fields of the latest investigations. Practically all churches and some governments discuss the The used abbreviations: matter of introducing reproductive cloning of human being today. Everything is B - Bioethics clear with this. The matter of therapy cloning is not clear. Relatively, the AAC - Armenian Apostolic Church utilization of rotting cells for curing a number of hard diseases became ROS - Russian Orthodox Church

74 75 THE QUALITY OF BIOETHICAL EDUCATION IN MEDICAL z collective presentations; INSTITUTES OF HIGHER EDUCATION. z crossed seminars. REALIAS, PERSPECTIVES In spite of the difference in teaching methods, there are also some genera regularities: Susanna Davtyan z in the teaching obligatory program of social disciplines, priority is given to Member of the Council of "Bioethics Development Society", those subjects, which are closely concerned with modern biotechnologies Head of the Department of Philosophical Sciences, and genetics. First of all, such subjects are bioethics and culture study, Yerevan State Medical University, Republic of Armenia the rapid development of which is comparable to the development of Candidate of Philosophical Sciences, Professor biomedical science; z the specifics of the current subject and the wide specter of questions Beginning from the eighties subjects like "ethics" and "bioethics" were of great touching them demand holding interactive studies with small groups (not importance in medical institutes of higher education of developed more than 20 people) for understanding it more effectively; countries. z increasing tendency is registered in bioethics course hours.

In the institutes of higher education of many countries bioethical and In Yerevan State Medical University after Mkhitar Heratsi, deontology, ethics ethical teaching methods are different, which depends on national, social, and esthetics have traditionally been taught in the course of many decades, at cultural and religious peculiarities of the specific country. the same time bioethics teaching at social sciences chair began to be taught as an obligatory subject since 2001. International student For instance, in France ethics, esthetics and bioethics are taught in the first conferences were held by their own strength, which were devoted to bioethics courses and in capacity form 20% of all taught subjects. At the end of the year, fundamental principles and norms and Armenian culture where the majority of students pass written competitive examination. both foreigners (from 18 countries of the world) and local students began to comprehend the importance of bioethics in more detail and more profoundly. In Spain this subject teaching entered into force in 1988. At first the subject was taught among the graduates. Now it is taught not only to future doctors, At the beginning bioethics was taught only to students, citizens of Armenia, but also to nurses and hospital attendants. and since 2003 it has also been taught to foreign students. The stimulation of introducing bioethical bases into teaching process was a vital demand of In 1989 a bioethical center was founded in the Krems Academy by Peter making studying programs in accordance with international standards for Kampits in Austria. In Columbia bioethics teaching began in 1992. holding the international rating of our university. It is also important to mention that Armenia is a member of the Council of Europe, and accordingly, takes In Norway teaching of ethics to first year students was founded in Examen participation in its social-legal, economical, health-care and cultural structures. Philosophicum. Normative and practical ethics are introduced into historical and obligatory courses. At present it is expedient to implement bioethics teaching in three phases: 1st phase - general understanding about ethics. nd In medical institutes of Italy bioethics is taught together with the subject 2 phase - medical ethics and deontology. rd "Medicine History". 3 phase - the reasons of the origin of "bioethics", subject understand- ing, its principles, models. In medical school of Rome Catholic University the teaching of ethics and bioethics are held for already 40 years. For having more effective results, Lectures are given to first and second year students at all faculties. methods were formed as follows: Unfortunately, unlike the mentioned worldwide tendency, for the last three z formal presentation; years the hours of bioethics were cut from 36 hours to 18 without seminar z practical knowledge; studies. Besides, the teaching is of elective character for local students, and it z interactive seminar studies; is obligatory for foreign students.

76 77 During these years, the chair aimed at providing technical means, institutes of higher education. educational materials, and printed publications on the current thematic. During this period, some quantity of necessary educational materials and literature It seems to us that it would be more productive if the activities of ethical was obtained from the countries like Israel, Byelorussia, and Russia. The department, sciences and technologies of social and humanitarian science matter of the personnel is not solved yet which concerns increase of teachers sector of UNESCO would be satisfied not only with information provision but it of bioethics in Armenian, Russian and English. The system of preparing the would also promote regions with financial support with the aim of publishing personnel - bioethics specialists - is also lacking. bioethical books, school-books, translation of literature into native languages. The support of above-mentioned UNESCO sector is necessary in the Several publications of UNESCO (some copies of the book "Informed realization of these projects. Agreement") were given to the University Library only after my participation in 2 international conferences, organized by UNESCO in Israel on the subject "Ethics Teaching in Medical Institutes of Higher Education".

Natural necessity arose in creating school-book in Armenian. The work was edited by R.A. Hovhannisyan and M.A. Harutyunyan. The distinguishing characteristics of this school-book is: z Some subjects of the book are enriched with the results of specific sociological investigations, held together with the Institute of Philosophy, Sociology and Law of RA. z There are some ideas, statements of old Armenian philosophers, doctors (S. Anhaght, M. Gosh, M. Heratsi, Amasiatsi and others) on some bioethical themes. z Basic legislative acts on bioethics are presented in the appendix which were admitted by the international community.

What tasks do we have to implement for the future development of educational process?

¾ To provide the participation of our teachers in international scientific conferences and seminars, devoted to bioethical problems with the aim of increasing their professional level; ¾ To participate more actively in the creation of school-books on bioethics, which are to be published by UNESCO; ¾ To attract local and foreign students of our university to the spreading work of resolutions, recommendations and other normative documents in the field of bioethics of the UNESCO International Consultation Committee; ¾ To prepare and publish a school-book on bioethics for students of medical institutes of higher education in Armenian.

Speaking of the use of educational programs in accordance with the regional demands, it is necessary to point out the significance of creating specific training-programs on bioethics teaching of students of medical

78 79 PROBLEMS AND PERSPECTIVE OF BIOETHICS cannot be considered independent from ethno-cultural traditions of a specific DEVEOPLMENT IN ARMENIA nation. Armenia has the richest experience and the oldest history in the field of medical ethics. That is why when we speak about bioethics development in Armenia, we must undoubtedly consider the peculiarities of national self- Igor Madoyan consciousness and legislation, and not blindly imitate foreign experience. On Director of National Center of Bioethics the other hand, bioethics norms and principles are successfully realized in Republic of Armenia many countries of the world which have universal character. And as Armenia Bioethics is one of the most modern fields of human activity. Its history is not is also a member of the world, and in particular, the European community, it is more than 40 years old. The origin of the term "bioethics" is usually necessary to include specific corrections in its legal-creative activity, taking into connected with the name of the American scientist-doctor Potter. In the wide account international documents. sense of the word bioethics is appealed to investigate the valuable aspects of Five - ten years ago not only people who were far from health-care but also life, moral-ethic conditions, providing its worthy passing. We can point out the overwhelming majority of doctors and even philosopher-ethics in Armenia some sources of this rapidly developing sphere of knowledge formation. I will did not have the least notion about bioethics, moreover, even did not hear of concentrate on two of them, which, in my opinion, correspond to the subject of such a term. For justice, we must say that such a phenomenon was observed our conference more. First of all, it is a movement for human right and an (in some countries earlier, in some later) in the countries of Eastern Europe impetuous scientific-technological progress in bioethics and medicine. As a and the Commonwealth of Independent States. Bioethics ideas began to be social movement, bioethics calls to follow the patients' rights and probationers, spread in Armenia due to the enlightening activities of enthusiasts who were as well as to respect their dignity. As a scientific-practical discipline it tries to very few. Actually, they are not that many now either. Through personal find methods of solving moral problems, which appear or may appear in the conversations, round-tables, seminars and organized activity games, connection of bioethics achievement. It is necessary to point out that these newspapers and television, through attempts to ensure governmental officials problems refer to all sides of life both in bioethics and social meaning of the in the importance and necessity of inculcating the population to bioethics word: interrelations between doctors and patients, investigator and norms and standards, they managed to engender interest in bioethics probationer, cloning, genetic therapy, birth and death transplantation of organs development in Armenia. and use of rotting cells, AIDS, finance and resources fair distribution in health-care. It is far from being the full list of directed activities which need At the beginning of 2000, non-governmental organizations of bioethical nature bioethical comprehension. began to appear. Interrelating with one another, on the one hand, and with governmental institutions, on the other, they become closer, and, I would say, For developing ethical norms of behaviour in different situations specialists of more trustworthy. Armenia gradually activates its participation in the activities bioethics often have to not only investigate the present stances on most of bioethics structure of international organizations (Council of European, difficult moral problems, but also discover and give notice of new problems and UNESCO, Euro-commission, Forum of ethic committees of Commonwealth of make them public property. They must try to point people's attention to them Independent States, Worldwide Health care Organization and others). till they face moral difficulties of life. If you want, give the alarm. The prominent Unfortunately, because of the catastrophic shortage of professionals in the Armenian poet Paruyr Sevak has a poem which is titled "Incessant Belfry". The field of bioethics, Armenia is often presented by specialists, perhaps enough main task of bioethics, in my opinion, is to be "incessant moral belfry" in all the authoritative in the sphere of its own professional activities, but having distant way of bioethics development. conception on bioethics norms and principles. Bioethics in practice is realized through the work of so called ethics Though the interest in bioethics in Armenia obtains growing character, and few committees. The latter can function on different levels (national, regional, people suspect in its actuality (the evidence of which is the fact of holding such local), but they refer both to state and non-governmental organizations. Here a conference in Yerevan), up till now there is no distinct and total program of it is important to specify that the name "ethics committee" is used more as its development. The lack of the program, in my opinion, is the main problem generalized characteristics of different structures functioning in various of bioethics development in Armenia today. Let us ask a question: "What does countries of the world and having different names today. As the forms of bioethics development mean?" It is, in my opinion, first of all, the formation of moral-legal regulations, as it is known, have national specifics they naturally bioethics (or ethic) network of "committees" of all kinds and creation of

80 81 personal school on the preparation of national professional teachers. The Here bioethics is considered a scientific-educational system and social order of the conference and the report time itself does not allow to state movement at the same time. It is expected that as a movement it must form a personal vision of project's details of development program. That is why let us social-psychological base for making the population understand bioethics pay attention only to some points of bioethics perspectives in Armenia. norms and principles, as well as comprehending the actuality and the need of the latter in each citizen's everyday life. It is obvious that at the same time it is Let us refer to the presented scheme. necessary to use all available means of popularization, enlightenment and propaganda. In parallel, the program of founding Armenian expert-bioethics school through the system of teaching and education is realized. Two models for specialists' preparation are offered. The first one presupposes the availability of structures (faculties, sub-faculties, centers, etc.), where bioethics has the status of basic education. The second one gives the representatives of different professions an opportunity to specialize in the sphere of bioethics. Expert in bioethics, undoubtedly, will be demanded both in the system of education and in the sphere of forming bioethical world view in the population, as well as in legislative, judicial, governmental and other institutions.

As it is already mentioned above, one of the pivotal tasks, which must be solved in the process of the realization of bioethics development program in Armenia is the creation of a network of all kind of bioethical (ethical) "committees". In addition, in order to make these "committees" function effectively, joint efforts of representatives of different social groups and professions of expert-bioethics are necessary without which practical activity of such "committees" is brought to infinite debates on moral subjects at best. Hence, starting from today's realia, to speak about creating "committees" of local and regional character, in my opinion, is a bit early. We must speak only about organization of bioethical "committee" on national level. The question of creating such a structure in Armenia matured at the moment when our state entered European Council. The actuality of the question is also explained by the fact that an exigency of concordance of national and international legislative acts arose, connected with the scientific-technological achievements in biology and medicine. Besides, non-governmental organizations with the creation of national "committee" on bioethics will have an opportunity to appeal to governmental structures as far as some difficulties arise in their everyday activities while inculcating bioethical ideas into our lives. And, finally, such a governmental teaching ought to promote the organization of bioethical education in Armenia.

I am sure that there are all kinds of presuppositions and bases for providing help and support in the realization of the program of bioethics development in Armenia from the direction of UNESCO and Ombudsman's institute.

82 83 LIFE ETHICS AND ALTERNATIVE for the survival of the humanity in modern situation. Modern bioethics includes a number of closely related forms of activity. Karen Badishyan z It is a multi-disciplinary sphere of investigation of conditions and results of Candidate of Economical Sciences scientific-technical progress in biomedicine. The problems, which the Program Coordinator Union of Non-Governmental Organizations humanity faces, are investigated by doctors, biologists, philosophers, of Shirak marz of the Republic of Armenia theologians, jurists, psychologists, political scientists and representatives of other disciplines; Bioethical formation is conditioned, first of all, by all those considerable z it is a sphere of academic and educational activities. Different courses on changes which took place in the technological rearmament of modern bioethics are taught at kindergartens, schools and lyceums, universities (medical, biological, philosophical, theological and other faculties); medicine, with cardinal improvements in methodical-clinical practice, which z it is a rapidly developing social institute. It includes a complicated system were reflected in the success of gene-engineering, organ transplantation, of international, national, regional and local (in the structures of biotechnology, patient life maintenance. All these processes sharpened the investigative and practical organizations) ethical committees. Bioethics is moral problems which doctors, patient's relatives and medical personnel a part of right protection movement in the field of health-care. faced. Are there any boundaries, and which are they in the life maintenance of a fatally ill patient? Is death lethal injection permitted? At what moment does The problem of euthanasia is very important in the following tasks. The term death come? At what moment can the embryo be considered a creature? Are "euthanasia" was first used by F. Bacon in the XVII century for abortions permitted? Are abortions considered to be the killing of living defining "light death", and since the XIX century it has begun to mean "to kill creatures? These are just some of the questions which the doctor and the somebody from pity". Here the matter refers to calculated homicide with the large community face in the conditions of unseen technological equipment of aim of lightening unnecessary suffering. In that case, there is no more modern medicine in the developed countries. ambiguous word than "euthanasia".

As an investigational direction of interdisciplinary character, bioethics was The term "light death" has been used by the Congregation of Dogma in the formed at the end of the sixties and at the beginning of the seventies. The term "Declaration on Euthanasia" since May 5, 1980. The text of the Declaration "bioethics" was suggested by V.R. Potter in 1969. The Interpretation of the averts any subjective defining and finally explains the meaning of euthanasia: word is rather heterogeneous. First of all, it is attempted to identify bioethics "Euthanasia means any action or, on the contrary, inaction, which per se or on with bioethical ethics, limiting its content with ethical problems of the purpose brings to death which aims at eliminating pain and suffering". That is relationship "doctor-patient". There is also a wide understanding of bioethics, nowadays, euthanasia , in its literal meaning, means an aforethought which includes some axiological problems of professional activities, a number homicide with the help of a method which provokes very little pain and of social problems connected with health care system, and finally, problems suffering, done from pity or for the purpose of avoiding life difficulties, which is referring to the attitude of a human being to animals and plants. Thereby, considered to be "inhumane" and "not worthy for a human being". Suicide or bioethics includes ethical regulators of attitude towards animals and a set of death in the result of anesthetic therapy are not included here if the death is problems which earlier referred to ecological ethics. Besides, the term not perceived directly. By the definition of the Dutch legislation, "euthanasia" is "bioethics" points out the fact that it is oriented to the investigation of living any action which is directed to put an end to this or that person's life meeting creatures regardless of the fact whether they find their application in the his or her own willing, and which is done by a disinterested person". The therapy or not. In other words, bioethics is oriented to the achievement of famous doctor Jack Kevorkian from the USA openly accepted that since 1991 modern biology on the basis or solution of moral collisions which arise in the it has helped more than 50 patients to die, and has never been instituted process of scientific investigations. criminal proceedings. Together with this euthanasia opponents consider that terminological chaos is provoked by the fact that there was a substitution of the Bioethics is a complicated cultural phenomenon which serves as a response understanding "to allow to die" and "to help die". In their opinion this confusion to the threats of moral and physical well-being of the person, and which was is not harmless; it is maintained deliberately in order to bring doctors and born with the rapid progress of biomedical science and practice. The protec- community opinion to a false dilemma: either you are humane and are tion of fundamental moral values, determining human existence, is a condition capable of sympathizing your relatives, which means that you must overstep

84 85 unlawful actions (to cause death); or you put abstract dogmas above simple murder either to himself/herself or those who are under his/her responsibility, human sympathys, which means that you will not stop to prolong these and cannot give his/her agreement in a direct or indirect way. In this way, con- meaningless sufferings which you will not bear yourself. More heated demnation refers to any kind of encroachment on human life such as both discussions are held on the matters like "Right to life and right to death" and abortion and euthanasia. From medical standpoint, to relieve the pain is "Right to live humanly". Euthanasia adherents declare that if life is not truly always possible. The development of analgesic pharmacology, the best way of humanly (life in community) then it is better to die humanly (that is to day, with perceiving the effect of analgesine and optimal conditions of using it promote the help of euthanasia). In this way, active euthanasia is justified. If there is a today's doctors' to be more informed in this sphere. The pain, "persistent to right to life, can it also include the possibility of such an understanding as "right anesthetization", often occurs in the result of the primary incorrect pain- to death"? It would be an internal contradiction of the legislation, the basic reliever and insufficient dosage. It can bring to the pain renewal before its principle of which is life protection. In any case, life is accentuated: it is disappearance. Nowadays we know that regular usage of opium and necessary to protect life not death. If one can find it right to help to put an end preparation of it by pain intensity and character can save from painful to a morally defensible life (cry for help who implores for putting an end to his depression occurrence, which increases the patient's sensitivity and sufferings), than it can be considered legal only by law which denies itself. sufferings. It is often possible to reach pain-killing effect with the maintenance There exists the right to die with dignity, humanly, without unnecessary of patient's lucidity without causing him narcotic dependence. It is possible to sufferings. Here the matter is about the respect for human dignity. Anyway, this relieve pain by pharmacological methods, but it is not enough. The drama of right is not released from law on the matter of life protection. Death is a part of patients cancerous as well as of the majority of patients in the terminal state, human reality with all its consequences and humiliations. To avoid it means is generally of psychological character: they feel abandoned not only by the you are a coward. The right to worthy death also includes right to cure with the doctor but also by their relatives. At that moment they think about euthanasia, help of human methods: they must be directed to the relieving of sufferings the request of which is the cry for help. It means that it is very important for the and despondencies, helping to die calmly, without unnecessary and infinite patient to humanly create an atmosphere of trust and attention around him in fight. which he can "die quietly". In many surgery centers organs' transplantation (kidney, heart, liver) has become an ordinary operation. In this field surgery A stronger argument in favor of euthanasia is the position of the "Declaration achievement was accompanied by the occurrence of such a serious problem on Euthanasia" on the fact that "meaningless suffering is evil". If starting from as the formation of organ can for transplantation. atheistic and materialistic perspectives or the standpoint of modern secularity, human being does not owe his life to anyone, which means 1. Ethical aspect of gratuitous provision of organs, their acquisition, that he is the owner of it and can decide the matter of his or her death. If maintenance in-vitro and usage has become an important subject in bioethics. human being's ideal is the welfare in this world, if the only meaning of his or This problem of organ acquisition from seriously injured patients and from her life is good health, beauty, strength, light future, then, indeed, life is full of patients in state of coma has arisen a number of questions connected with the difficulties, and without the hope for recovering life it becomes "empty" and not conception of death as well as the problem of getting supraliminal agreement. worthy living to the end. It means that "worthy" life leads the one who is young, There arises another ethical risk: acquisition of organs in a deceitful or even healthy, beautiful, happy, clever and necessary for community. That is the criminal way from unprotected people as well as the organization of organ reason that life exists, "having no values", and it becomes logical to annihilate trade. This section of bioethics appeared in 1970s in connection with the invalids, seriously and incurably ill people. Such was Plato's and Nazis' point development of diagnostic means of fetus state in mother's womb, definition of of view, such is the policy of leaders of the countries with totalitarian regime, aperiodicities and development defects, genetic illnesses. where the government has the right to make decisions on the liquidation of Genetic tests include both prenatal and pre-symptomatic tests (pre- "unnecessary mouths". As for the Christians' attitude towards euthanasia, they symptomatic tests are carried out with the born person and allow to discover consider it a direct violation of God's law. The commandment "do not kill" does hereditary illnesses before the development of the symptoms). With the help not have "mitigating circumstances". For Christians death is the way God of prenatal tests it is possible to discover the abnormality of fetus's sends it at the moment and the way He wants. Christian Church officially and totally condemns euthanasia. The Declaration of Dogma Congregation of 1980 chromosome, to diagnose such serious hereditary illnesses like Down's proclaims: "It is quite necessary to announce with all resolution that nothing syndrome, Hentington illness, Teya-Saksa and others. Out of these test, and nobody can kill an innocent man, whether he or she is an embryo or fetus, echography is the most harmless, acceptable and non-invasive method for child or grown-up, old, incurably ill or dying". Besides, no one can demand to mother and fetus. The amniotic increases the risk of spontaneous abortion and

86 87 fetus damage. increase the level of hidden toxins. It is difficult to ascertain something with accuracy about food value of such plants and about their influence on the As at present methods of therapy or surgery curing of fetus in mother's womb surrounding environment and wild nature. All these questions are important but are still just being developed, doctors make their task to find they still do not have answers. It is difficult to anticipate how the GE products possibilities to make fetus abortion which has development defects at the early will influence on the organism after some time as there must be held stage of its development. From here moral dilemma for parents arises as for observation on some generations using such food products. them the acceptance of such a diagnosis means accepting the conception of abortion. Biological investigations in the sphere of genetics gave successful At present genetically modified sorts of maize, potato, soy, tomato and other results. DNA structure was decoded by Watson and Krick in 1953. In 1956 a crops are being derived and already cultivated. Basic arguments in favor of correlation was founded between genetic code and chromosome. It can give this technology are the following: positive results in the sphere of prophylaxis and curing of genetic illnesses. But z the scientists suggest that in the process of the following 20 years the for the sufferers of genetic defects or for the people with genetic disposition to quantity of people on the planet will increase twice. We must think about the illnesses like, for instance, cancer of lactic iron or skin cancer, leukemia, the matter of how to feed the increasing human race now. Plants, cardiovascular illnesses, metabolism breach, it can have negative results. constructed with the help of gene engineering, can give richer harvest Employers and insurance companies will be able to really use genetic than traditional corps. They are artificially allotted with useful properties, screening when selecting people. The development of genetic screening for instance, steadiness to insect-pests. In this way, the possibility of arises a question about human right on information receipt (or non-receipt). increasing harvest is the main argument in favor of the fact that Another question arises about the prophylaxis of genetic defects or illnesses trans-gene growing is a real method of feeding the increasing population which is done now before birth diagnosis and by means of abortion of genetic of the earth; anomaly carriers. z the plants can be modified the way they have more feeding substances and vitamins. For instance, "putting" vitamin A into rice, it will be possible Genetic modification of products became widely available after gene to grow it in the regions where people suffer from shortage of this vitamin; engineering success in the field of agriculture. Gene engineering (GE) is a z the GE plants can be adopted to extreme conditions like drought or cold; branch of molecular biology connected with teleological construction of new, z the GE corps usage will allow us to cultivate fields with pesticides and non-existent combination of genes with the help of genetic and biochemical herbicides less intensively. For instance, putting earth bacteria gene methods. The GE takes genes and DNA one type parts and puts them into Bacillus thuringiensis (nature pesticides) into maize will provide the plant another cell. For the secretion of DNA segments, the GE disposes a with its own protection, and there will be no need for extra cultivation; composition of different technologies in DNA incision in voluntary or z foodstuff consisting GE ingredients can become useful for health if we put allegoristic sections. All these manipulations allow to overcome interspecific vaccine from different illnesses into them. For instance, salad-lettuce has obstacles and mix genetic information into absolutely separate types, and here already been created which cultivates vaccine from hepatitis B as well as arises another problem: to stop the process of combined gene functioning is banana which consists analgin. absolutely impossible. The plant has nothing to do in the process of the new gene, even when this permanent compulsory production of the "new" product The last decades of the XX century are famous for the rapid development of both weakens and worsens its growth and development. Besides, without any one of the most principal branches of biological science - molecular reasons, the new gene quite often functions actively only for some time and genetics. At the beginning of the seventies the scientists in laboratory then suddenly "breaks off". It is practically impossible to anticipate the gene will conditions began to get and clone recombinant DNA molecular, cultivate in behave in its new place. It is connected with the fact that functions and test-tube cells and tissues of plants and animals. A new direction of genetics characteristics of gene, which are investigated in the test-tube, reflect what it appeared - genetic engineering. On the basis of its methodology different responds to and how it behaves just right in this test-tube. It will not tell us types of biotechnology were developed, genetically changed organisms about its role and behavior in the organism from which we took it or about how (GCO) began to be created. There was a possibility of gene therapy of some it will behave itself where we are planning to put it in. human illnesses. And the last decades of the XX century were famous for another important event - a huge progress in cloning animals from somatic In this way, we can be sure that genetic modification of the plant which we use cells was achieved. The investigations of Scottish scientists from Roslin in food will not all of a sudden produce new toxins and allergens or will not University got a particularly great resonance in the world community: they

88 89 managed to receive genetically exact copy of a pregnant sheep from the cell alternative methods of diagnostics or curing (as the probationer is considered of a lactic iron. The cloning of the sheep called Dolly developed normally and to be a patient, and the investigation is directed to examine the new method of gave a birth to one at first, then three normal lambs. The developed methods diagnostics or curing), as well as about his/her right to stop his/her of animal cloning are not still perfect. In the process of experiments there is participation in the investigation any time he/she wants. At present the norm of high mortality of plants and newly-born. Many theoretical questions of animal informed agreement is used when making any medical interference which is cloning from different somatic cells are not clear. Nevertheless, the success, implemented not only for investigation but also for therapy purposes. All which was achieved in sheep and monkey cloning, showed theoretical violations of this norm (agreement of not only the patient or probationer, but possibility of creating genetic copies of human being from different cells taken also the representatives when he/she is not competent; interference without from one of his organs. Many scientists accepted the idea of human cloning agreement in emergency cases) are also regulated both ethically and with enthusiasm. Public opinion poll in the USA showed that 7% of Americans judicially. are ready to be cloned. Together with this, the majority of scientists and many politicians are against the creation of human cloning. Their objections and The current subject includes experiments of selecting the sex of a future baby, anxieties are quite defensible. artificial fertilization, experiments on rotting cells of human being, etc.

For the last 30-40 years the development of both ethical and legal regulation In 1978 Luisa Brown was born in England, the first baby who was born owing of biomedical investigations was held with the participation of human beings to the method "fertilization in-vitro", which was probated on animals. Soon after and animals. The thing is that the interests (in plurality communities also this, Amandin was born in France (1982). Today the number of values) of sides, which take part in investigations, do not coincide always and children, which were born in this way, exceeds 14.000. Fertilization in-vitro in everything. This lack of coincidence is usually conditioned not by the evil will actually made a revolution in midwifery and curing of female sterility. of the sides, but by objectively existing conflict of interests between Nevertheless, this method has got a negative side not only because of investigators and probationers: for the former it is important to receive new astonishing immoral suggestions but also because of the violation of human scientific knowledge, whereas for the latter it is important to improve or embryo in the modern phase of the development of artificial fertilization maintain their health. The relationship between the sides is far from being method. In order to make a successful fertilization, several embryos must be symmetrical: the investigator has got professional knowledge and abilities introduced into woman's uterus at the same time; the rest is kept in a frozen which the probationer usually does not have; at the same time the condition. From the number of introduced embryos in mother's womb, only one probationer has to run risks the greatness of which depends on the is developed, the others are to be aborted. seriousness of the interference into his/her organism or psyche. For The matter of experiment availability on animals is the second most probationers' protection there has been developed a mechanism of ethical difficult moral problem in the sphere of human and animal correlation which the expertise of investigation project. It is obligatory for each application of humanity tries to solve. It is obvious, that the experiment on animals is a biomedical investigation to pass such an expertise. It is held by ethical necessary source of knowledge for medicine, and humanity cannot fight committee, the status of which must guarantee the independence of the against illnesses without them. Experiments on animals, which began almost administration institute expertise in which the investigation will be 300 years ago, are very significant in the history of medicine which, because implemented by both the investigators and those who finance the investigation of them, reached considerable success in diagnostics and curing of illnesses. project. The history of experimental medicine can be divided into three phases. The The policy of the majority of biomedical journals' presenters is an addition to first phase begins with the activities of the anatomist Andreas Vezalia in the this mechanism: it does not accept articles about investigations which have not XVII century and occupies two centuries: XVII and XVIII. This period of passed ethical expertise into publication. Another mechanism which is called experiments on animals without anesthetization was opened only at the to protect probationers' health, right and dignity, is the informed beginning of the XIX century; such experiments got the name of vivisection agreement of the probationer. Any investigation can be implemented only after and differed from others for being extremely cruel. In this epoch, the the probationer gives competent, voluntary and clearly expressed agreement. community opinion about vivisection cruelties was not practically expressed, Necessary information on the purpose of investigation is given to the though separate writers and scientists expressed their indignation against probationer in a comprehensible form; he/she is informed about the possible vivisections. The second phase of development of experimental medicine is benefit and risk connected with his participation in the investigation; about the considered the XIX century when the community began criticizing experiments

90 91 from ethical standpoint. In the XIX century animal protection movement courses in medical educational institutions of all levels is very significant in the started, and new organizations were created directed to the cessation of formation of ethical self-consciousness of medical community. And, finally, the animal experiments. At the end of the XIX century, in 1878, the first law for support for the investigators of bioethical work is very important. experimental animal protection was admitted in Britain, which regulated the work with them, prescribing the usage of anesthetic preparations. The third In my opinion, bioethical development in Armenia can help our community to phase of methodic-biological experiment development is considered the XX get adapted to the new system of medicine and will allow obtaining valuable century; it is characteristic of the modern epoch that criticism of animal human orientations, which would correspond to the rights of human being, life experiment has become tougher and is held not only for morality but also for and citizens' dignity, fundamental humanitarian values of the humanity. The science. This phase distinguishes doctors' participation in the movement of development of bioethics in our country presupposes comprehension of those modification of experimental science or even abolition of experiments on living tendencies, which existed in the ethical conception of Armenia, the analysis of animals. At present, a number of centers are created for the development of their philosophical bases and those horizons, which they open in the new alternative methods substituting animals in experiments. attitude of human being to the life. Social health becomes one of the key directions. This thematic includes such problems as fair distribution of health-care resources on national and interna- tional level, provision of availability of medical preparations and elementary medical help, first of all in developing countries.

The greatest popularity received the scheme, which was suggested by the American philosopher T. Bichamp and a theologian J. Childresson. It includes four principles and a number of rules, which were validated with the help of these principles. The rules, in their turn, serve for the moral substantiation of decisions and actions in specific situations. The principles are the following: the principle of respecting patient's autonomy which is based on the conception of information possession agreement; Hypocrate's principle "do not harm" which demands minimization of detriments, which are caused to the patient during medical interference; the principle "do beneficence", which points out the doctor's duty of taking positive steps for improving patient's state; the principle of justice pointing out the necessity of both fair and equal relations with patients and fair distribution of resources (which are always confined) in health-care system.

The development of bioethics in Armenia can promote the humanization of national biomedicine and ethical self-consciousness of the professional community of doctors. Bioethical development in Armenia cannot, of course, take national health care out of crisis in which it is now. But it can help to formulate new ethical regulators for professional community of doctors, acknowledge moral collisions and dilemmas which biologists, doctors and psychologists come along in their work. There must be a legislative regulation of biomedical investigations and health-care practice in the fields like transplantation, defining the moment of death, life maintenance curing boundaries of incurably ill patients, etc. The creation of ethical committees and commissions in scientific-investigation and medical institutes must play an important role in the development of bioethics. The introduction of bioethical

92 93 FINAL DOCUMENT ON THE RESULTS OF THE national bioethical committees. Attention was paid also to the autonomy of the INTERNATIONAL CONFERENCE ON individual in the context of protecting the human individual in doctor-patient interrelations (in particular the protection of children's rights). The participants "BIOETHICAL ASPECTS OF HUMAN RIGHTS IN have made the following decisions and recommendations for working out EDUCATION SYSTEM" special means on the national level and making decisions in the framework of SEPTEMBER 4-5, 2006, YEREVAN, ARMENIA programs of international cooperation. The main principles are as follows: The global tendency of the development of research, medical technologies 1. Recommendations to the Ministry of Education: and contemporary health care is closely connected with the control over the z to include the basis of bioethics as a compulsory discipline into protection and provision of bioethical norms and human rights. Naturally, the the curriculum of medical, biological, philosophical, juridical and other solution of these problems is impossible without informing the society and humanitarian or social specialties; raising awareness about research approaches, development of z to study mechanism of training qualified specialists through master interdisciplinary sciences and, of course, without inculcating bioethics in the programs and post graduate studies; educational system. z to include into the post-graduate programs curricula of specialists courses of enhancing skills and knowledge in bioethics; The actuality of bioethical problems is conditioned by the wide range of philosophical, ethical and legal problems that arise connected with the rapid 2. Recommendations to organize workshops, trainings, round tables for development of medicine, biological science, implementation of high different target groups; technologies and progress in the sphere of health care. 3. Recommendations to consider the RA possibility of joining the Convention Based on the necessity of discussing the scientific approach to one of the most of the Council of Europe " On Human Rights and Biomedicine" (on the actual problems of the contemporary society, the Institute of the RA Human level of signing and ratifying this convention); Rights Defender in cooperation with the National Centre of Bioethics and 4. Recommendations to study the issue of opening a Chair of UNESCO on under the auspices of the UNESCO Moscow Office has organized an human rights and bioethics in the higher educational establishments taking international conference on "Bioethical Aspects of Human Rights in into consideration their specialization; Educational System". The participants of the conference were delegations from the UNESCO cluster countries, representatives of national institutions of 5. Recommendations the relevant structures to translate the international the ombudsmen and organizations from the Russian Federation, Belarus, documents on bioethics into their national languages; Georgia, Republic of Moldova and representatives of international structures 6. Recommendations the relevant structures to translate the manuals and and non governmental organizations of Armenia. training guidebooks on bioethics into national languages as well as The participants of the conference have paid special attention to the issues support the publication of special training literature into national concerning human rights in the context of bioethical problems, by language; emphasizing the necessity of including the discipline of bioethics into 7. Creation of bioethical Committees on national level; educational system with consideration of national peculiarities and traditions of the national mentalities. It was indicated that an absolute factor of success is 8. Recommendations to the Institute of Human Rights Defender of the RA to the partnership of state structures both with the society and the international add a clause on bioethics in the annual report of the Ombudsman; organizations, paying special attention to the social and ethical aspects in the 9. Recommendations to the Institute of Ombudsman of the RA, the National system of doctor-patient relations, and the necessity of creating a legislation in Assembly of the RA, to improve the legislation in the sphere of civil rights the sphere of bioethics, as well as to the philosophical religious roots of the in the Republic of Armenia and to bring it to conformity with the norms of problem. The guests of the conference exchanged experience in establishing European community and other developed in legal aspect countries in local bioethical committees in medical establishments, in including the the light of the norms and principles of bioethics: discipline of bioethics into higher educational curricula, as well as in creating z to raise the level of public awareness and legal literacy of the

94 95 population in conformity with the principles of bioethics; z to raise the information access for the population to the sphere of medical legislation; z to draw public attention to the problems connected with the progress in the sphere of medicine, technologies, especially their social, economic, ethical and legal aspects. For the achievement of these goals it is necessary: z to establish contacts and start cooperation with non-governmental organizations, that deal with problems of bioethics and the Committees on bioethics in the neighboring and distant countries; z to study the legislation of civil rights in the Republic of Armenia and analogical sciences and legislative enactments adopted in the more legally developed countries of the European Union and the Organization of United Nations; z to find out legislative gaps in existing laws, prepare corresponding adjustments and amendments as well as take part in drafting corresponding laws with the purpose of eliminating white spots in current BIOETHICAL ASPECTS legislation of the Republic of Armenia; OF HUMAN RIGHTS IN z to organize television and radio broadcasts, as well as publication of articles in the periodical media with the purpose of familiarizing EDUCATIONAL SYSTEM population with basic norms and ethical principles of bioethics; z to organize meetings, conferences and round tables involving specialists, that are dealing with bioethical problems in their professional activities; z to draw the attention of students from medical, biological, legal and social departments of higher educational establishments of Armenia to the issues of bioethics; z to create a web-site using the contemporary information technologies for popularization of the knowledge in the sphere of bioethics basing on international experience and taking into account the national priorities and peculiarities; z to strengthen and expand connections with local and foreign organizations, the activities of which are directly or indirectly connected with the protection of civil rights in the given sphere, through creating joint programs and realization of joint projects, as well as organizing corresponding events and other actions.

Published with the financial support of the UNESCO Moscow Office

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