This issue focuses on bioethics in Eastern Europe and Russia, supplementing the existing publications from these regions, with each paper addressing a specific bioethical issue or case. Taken together, the contributions help to reveal trends in the development of bioethical discussions in the territories of states that historically, during the Cold War, were parts of the socialist world with a particular model of healthcare. Our goal was, to some extent, to consider how the historical features of the development and formation of medicine and health policy in those countries affected bioethics - the arguments and structure of debates, education in bioethics, and the reception of bioethics in Eastern Europe and Russia.

A significant amount of research on bioethics in these countries is devoted to the historical stages and socio-cultural features of socio-political development in “transitional countries” (Baker, McCullough 2009, Jennings 2011, Kubar and Yudin 2015, Nezhmetdinova and Guryleva 2018, Tishchenko 2005). Between 1989 and 1991, as R. Nicholson pointed out, “there were immense changes throughout the region as authoritarian communist regimes gave way to mainly democratic societies” (Nicholson 1992). Much of the work was done with a support of the Hastings Center’s Eastern European program in early 1990s that aimed to help post-communist societies to accept the American concept of bioethics (Yudin 1992). In the case of the former Soviet Union, the first workshop happened in 1989 in the Institute of Philosophy of Russian Academy of Sciences after which Soviet philosophers identified bioethics as a “form of humanism practice” (Winkler D., Kaplan A., Veatch R., et al. 1989). Eastern European and Russian bioethics was also influenced not only by American but also different European traditions. There are some articles that show that European models of bioethics are often contrasted to American autonomy-based approaches. D. Dickenson identified three ‘different voices’ within European bioethics: the deontological codes of southern Europe (and Ireland), the liberal, rights-based models of Western Europe, and the social welfarist models of the Nordic countries (Dickenson 1999). In 2011 Bruce Jennings suggested that Central European bioethics as a “‘Third Way’ discursive space for social ethics and communism” due to the “contradiction of Central European bioethics toward neoliberal values and free market society” that can offer some lessons for Western countries (Jennings 2011). As Bulgarian scholar V. Prodanov noted in 2001, bioethics research in Eastern Europe needs to provide “a perspective of that development, including its struggle with a totalitarian legacy, as well as to offer some comments as to how current cultural gaps between East and West, and especially between the Western and Orthodox Christian worlds, might be bridged” (Prodanov 2001). Moreover, recently some additional approaches have emerged. Some work focuses on the neglected European intellectual heritage and brings to the table new understandings of the historical dynamics of the development of bioethics in Eastern European countries (Steger, Joerden, Schochow 2014). According to some European authors, these approaches to bioethics “have been established at the intersection of Potter’s and Jahr’s bioethics.” (Muzur et al. 2019) They hold that without knowing the work of Fritz Jahr and his basic ideas, it is impossible to identify the way for further development of bioethics in European countries (Jahr 1928). These trends somehow overlapped and contrasted with each other. However, there is still not enough material available from each country in Eastern Europe and Russia to provide a comprehensive picture of their approaches to bioethics across topics.

An important common factor for all countries was the fact that they had to adapt bioethics models that existed and had developed in countries with different models of healthcare organization and different cultures of medical communication. Despite the emergence of bioethics in post-socialist countries, the process of its real integration was stretched out and the medical community did not support it initially. Some physicians tried to preserve their autonomy and authority of decision-making in the ethically complex situations, others were simply overwhelmed with the extreme challenges they faced during the period of economic and political reforms, including a lack of funding. All these factors meant that the ground was not fertile for bioethics in post-socialist and post-communist countries.

Dr. Silviya Aleksandrova-Yankulovska, a founder of the Bulgarian Association of Bioethics and Clinical Ethics (BABCE), focused her attention on clinical ethics support (CES) in Bulgaria. She piloted and collected data from two bottom-up models – METAP (Modular, Ethical, Treatment, Allocation of resources, Process) and MCD (Moral Case Deliberation). Prof. Aleksandrova-Yankulovska adapted both models that were developed in other European countries for Bulgaria. She aligned it to the Bulgarian legal framework and ethical values expressed in Bulgarian professional codes of conduct. According to the author, both models are applicable in Bulgarian because they offer the possibility of using them in contexts in which there is insufficient ethics expertise. While addressing the Bulgarian progress in bioethics, she also highlights that many Bulgarian physicians do not recognize the possibility of bioethics to help to resolve problems of modern medicine - such as those of everyday clinical decisions, resource allocation or the introduction of new technologies.

Olga Riklikienė and Žydrūnė Luneckaitė analyze the diversity of strategies to strengthen dignity at the end of life for terminally ill patients. Their contribution highlights the legal preconditions and limitations for implementing these strategies in independent Lithuania. As a former state of the Soviet Union, Lithuania is tackling change in relation to dying with dignity through euthanasia in a country in which palliative care is underdeveloped and underfunded. Authors pointed out that Lithuanian medical professionals work in isolation, intuitively dealing with the issues of dignity for terminally ill patients in their everyday practice. Legislators see no need for a proper ethical and legal framework aimed at helping the medical community in this area. In 2007 the decree issued by the Minister of Health described the requirements for palliative care services for adult and pediatric patients. In Lithuania, a country in which Christianity is largely practiced, society sees good palliative care as connected with strong spiritual care. However, professional spiritual care in palliative health care facilities is limited to clergy staff visits under requests and provision of the sacramental grace. Olga Riklikienė and Žydrūnė Luneckaitė stressed that this should be resolved. The authors are confident that until palliative care is ensured and well-designed across all settings involved in Lithuania, the question of euthanasia should not be raised, as this violates the patient’s primary right to receive treatment and care from the beginning of the illness to the end of life, reducing pain and suffering.

Marta Makowska, Emilia Kaczmarek and Marcin Rodzinka concentrated their attention on a topic has never entered the mainstream of bioethical public debate in Poland, which is dominated by issues surrounding reproductive ethics and abortion. They conducted empirical research to understand students’ opinions about the legal regulations governing students’ future relationships with the pharmaceutical industry. Their results highlighted an ambivalent relationship between disclosure and trust, and they presented opposing views regarding the consequences of introducing different legal solutions discussed in Poland - restricting the value of gifts and introducing transparency. The authors pointed out that measures will be highly unlikely to solve all of the current problems with the diminution in trust in medicine caused by conflicts of interest. Their findings should be useful for policy makers deliberating how to optimally regulate pharmaceutical marketing and the relation of the pharmaceutical industry to doctors and medical students. The particular value of the study is that it is the first of its kind in Poland. It also contributes to international research regarding medical students’ opinions of legal regulations surrounding physicians’ cooperation with the pharmaceutical industry.

Roman Tarabrin, using the case of reproductive health, highlighted an underrepresented area of research on bioethics in Russia, the activity of the Russian Orthodox Church (ROC) in public debates on IVF. ROC entered the field in 2000 when it published ‘The Basis of the Social Concept of the Russian Orthodox Church’ one chapter of which is devoted to bioethics. The author examines a newer ROC document, ‘Ethical issues Associated with In Vitro Fertilization,’ This document was developed using the general approach that ‘The Basis of the Social Concept of the Russian Orthodox Church’ offered. However, the focus on IVF and reproductive medicine technologies led to extensive public discussions. The article offers unique insights because the author was a part of the working group in the ROC that developed the document. He noted the deep division among priests of the ROC on the matter of IVF and explored how this prevented the Orthodox community from deciding. The final document is still under consideration. In his article, the author proposes an approach helping to orient Orthodox Christians toward ethically acceptable IVF options and away from impermissible methods. The discussion within the ROC has demonstrated how significant bioethical issues are in the lives of religious people. According to the author, the ROC has chosen the path toward learning how to apply its teaching to the actual socio-cultural dynamics of society and to find a proper way of clarifying its social doctrine. However, the ROC has not been able to overcome pre-existing divisions among clergy and lay audiences.

Despite the different topics, approaches, and frameworks across countries present in this issue, several similarities, underpinned by the commonalities of a communist past even 30 years of its collapse and huge reforms, emerge in this collection of essays. First, there is a lack of cooperation between professionals in the field of bioethics in these countries. Second, there is a lack of trained ethicists, and physicians are reluctant to allow external (i.e., individual ethics consultant) involvement in their decision-making process related to ethically sensitive areas (for example, see the Bulgarian and Lithuanian papers). The articles show either intersection in terms of attention to the lack of autonomy of one group or another in clinical decision-making (Bulgaria, Lithuania). The papers also underscore the problems associated with adapting existing standards of bioethical practice in clinical settings (Bulgaria, Lithuania), medical education (Poland) and within non-medical actors that want inform and maintain bioethical approaches either in hospitals (Lithuania) or in the public space (Russia and ROC). Several papers touched on challenges that spiritual and religious institutions face in the debate about certain issues of bioethics (Lithuania, Poland, Russia).

The essays collected in this special issue reveal important factors that demonstrate the similarity of problems facing bioethics in countries that have some shared historical past as they adapt bioethical concepts and models from the United States and Western countries in the transition period. We also find in this collection similarities regarding the challenges that are characteristic of integrating bioethics and medical humanities into physician education and clinical practice. The examples provided by authors showed that the problem in Eastern European countries and Russia are not only related to the adoption of bioethical standards but also how to harmonize existing bioethical tools developed in other countries and cultures to the realities of its legal and social realms of the healthcare and public policy. Finally, these countries still need help in developing stronger competence in bioethics education. This issue could be partially resolved through empowering their ability to publish cases and research, as this journal has done here. Much can be learned by focusing on areas of medical practice or public debates in Eastern European countries and in Russia. This would potentially help to explore a wide range of topics in bioethics and address the solutions to the specific difficulties these countries face in implementing bioethics that should be related to their history and culture of medicine and society.