What does bioethics have to say about the events in Ukraine? Is it within our remit of responsibility to weigh in on the war and the human tragedy that is unfolding? If war is the ultimate public health crisis, then surely bioethics—and bioethicists—should have something to say about the tragedy in Ukraine.
This all seemed obvious to me, but in discussions with colleagues, some have pushed back. What expertise do we have in world affairs? Would anybody care about what we as a scholarly community had to say? And then, the most frequent objection, if we comment on this, what about other things that pull on our moral heartstrings from the oppressions of the Uyghurs in China to the suppression of voting rights in the United States? All good points from people whom I respect and challenging questions as I personally oppose the repression of the Chinese regime of the Uyghurs (and Tibetans) and feel that voting rights suppression undermines American democracy in a fundamental way. But if we cannot speak out against everything does that mean we cannot speak out against anything? That seems morally untenable and illogical.
Especially because the war in Ukraine is fundamentally different than these other worthy concerns. The scope of the horror—and what a Russian victory would mean for the democratic institutions that shelter all the subsidiary rights we seek to defend—calls on us as an academic (and moral) community to speak up. Not only are we compelled to do so, we are also positioned by our own history to bring a special kind of expertise to the conversation, knowledge that other academic domains may not possess in quite the same way.
Let us start with history and an image seen around the world in mid-March. It is of a pregnant woman on a gurney being carried away from a maternity ward in Mariupol after the Russians brutally bombed a women and children’s hospital. She lies on her side, her hip detached because her pelvis was crushed when she was wounded. Her hand covers her wound. The brightly colored hospital in the background is now charred with the windows blown out. The Ukrainian soldiers and aid workers are walking through rubble, a battlefield, not a hospital courtyard. As physicians tried to save her life and she learned her baby was going to die, she told them, “Kill me now!” The baby was stillborn, and the mother could not be resuscitated.Footnote 1 By early April, the WHO estimated that 72 hospitals had been shelled by Russian forces and that 71 healthcare workers and patients had been killed. As critically, with the destruction of these facilities, the public health infrastructure of countless communities was also imperiled.Footnote 2
With healthcare ethics a central feature of bioethics, we need to recall that the Geneva Convention, the bedrock of international humanitarian law, speaks to the sanctity of healthcare and the vulnerability of the wounded, and specifically pregnant woman, mothers, and children. In the first Geneva Convention of 1864, Article 6 provides that, “Wounded or sick combatants, to whatever nation they may belong, shall be … cared for.”Footnote 3 Article 14 of the Fourth Geneva Convention of 1949 speaks to the provision of “hospital and safety zones and localities so organized as to protect from the effects of war, wounded, sick and aged persons, children under 15, expectant mothers, and mothers of children under 7.”Footnote 4
The historic centrality of healthcare in international humanitarian law clearly privileges those of us who speak to ethical issues in healthcare. If we date the origins of modern bioethics to the Nuremberg Code, our field was born in the shadows of World War II, a conflict which the War in Ukraine increasingly resembles. More recently, the rise of democratic movements in Eastern Europe was closely tied to bioethics.
I do not know whether this story has been written, but in the late 1980s, the Hastings Center hosted scholars from Eastern Bloc countries and the former Soviet Union. They were there as bioethics scholars, but, in fact, they were there as dissidents and champions for democracy and civil liberties in their countries. The theory was if patients could get rights in the hospital with the recognition of their autonomy and self-determination, citizens could get rights in the streets and in civil society. In Eastern Europe and the former Soviet Union, bioethics was a crypto-democratic movement. It was much more than making choices about a ventilator at the end of life—it was about making choices about how one wanted to live one’s life.
The relationship with these scholars and the Hastings Center ran deep. Friendships evolved with colleagues like Daniel Callahan, the President of the Hastings Center, ultimately being named an Honorary Professor at the Charles University Medical School in Prague in 1996. Rumor had it that George Soros, who would later found the Open Society Institute and who is himself a refugee from Hungary, was funding these academic exchanges in order to foster the civil society that would transform autocracies into democracies.
I remember the courage of these scholars when I came to the Hastings Center in 1989 as a Visiting Scholar. The Velvet Revolution was underway in Czechoslovakia. It was a time of great expectancy for a post–Cold War world, of which a modern and independent Ukraine is a part.
These Eastern European and Soviet bioethicists were co-creators of that new society, one which I got to see firsthand in 1992. I traveled with Hastings Center colleagues to a meeting on chronic care and aging in Czechoslovakia.Footnote 5 It was a hurried visit and nightfall when my colleague Strachan Donnelley and I needed to return to our hotel across the Vltava River. A newly restored bridge was open, but the old Charles Bridge, which was under repair and closed to traffic, was closer to our hotel. We took the shortcut only to find ourselves on the other side in a construction site with a chain-linked fence blocking our entry back into the city. We thought we would have to retrace our steps, but Strachan saw a hole under the fence for us to slip under.
We had found our own Berlin Wall to breach, both of us in trench coats looking too much like spies. However, instead of returning to modern Prague, it was as if we were in a time portal. When we got to the other side, we found ourselves in the past. By now, it was dark and foggy, and I had an eerie sense of foreboding realizing that we had emerged in the old Jewish Quarter where Franz Kafka was born. There were (metaphorical) ghosts everywhere, and I thought what a difference 50 years makes. What if this had been 1942 and not 1992? This was a place of horror and death, roundups, and genocide. It was something to remember but still a function of my imagination. And now, just 30 years later, the unimaginable is very real. The past is too present, and we must remember that history will judge our actions, or inactions.
As the world drifts again toward totalitarianism, it is incumbent on all of us who create and sustain liberal societies to defend the institutions that protect our liberties and freedoms. Yale professor, Timothy Snyder, who has eloquently told the story of the Bloodlands between Berlin and Moscow and the ravages of Hitler and Stalin’s totalitarian regimes,Footnote 6 reminds us in On Tyranny: Twenty Lessons from the 20th Century of the importance of ethics in the defense of civil society. As ethicists, we must heed lesson #5, where he writes: “Remember professional ethics. When political leaders set a negative example, professional commitments to just practice become important. It is hard to subvert a rule-of-law state without lawyers, or to hold show trials without judges. Authoritarians need obedient civil servants, and concentration camp directors seek businessmen interested in cheap labor.”Footnote 7
Our colleagues and our communities turn to us for guidance about norms and behaviors. For us, to be silent on this immoral and illegal war borders on complicity that allows for the erosion of freedoms and the rise of autocracy. As Hannah Arendt famously said in Responsibility and Judgement, “In brief, what disturbed us was the behavior not of our enemies but of our friends, who had done nothing to bring this situation about. They were not responsible for the Nazis, they were only impressed by the Nazi success and unable to pit their own judgement against the verdict of History, as they read it. Without taking into account the almost universal breakdown, not of personal responsibility, but of personal judgement in the early stages of the Nazi regime, it is impossible to understand what actually happened.”Footnote 8 If we remain silent and on the sidelines as an academic community, we will need to ask ourselves what actually happened? Why did not we say something, do something? Why did not we mobilize our considerable capabilities as a moral community to inform and educate, to seek to repair our broken world.
And for those colleagues who remind us that this is not our place, that we have no special claim or responsibility, I would end with Elie Wiesel’s preface to a volume entitled Agony in the Pulpit, a capacious and compelling anthology of sermons given by the American rabbinate from 1933 to 1945. Wiesel urges us to speak up, “I am obsessed with silence because of the silence of the world. I do not understand why the world was silent when we needed its outcry … Where were the humanists, the leaders, the liberals, the spokesmen for mankind? The victims needed them. If they had spoken up, the killers would not have killed, or would have killed less. If they had spoken up, the slaughterer would not have succeeded in his task.”Footnote 9
The atrocities of Hitler and Stalin are now joined by those of Putin in the 21st century. We now, as a bioethics community, must stand with Ukraine in her valiant struggle to defend freedom and civility.
