Last February a referendum on the protection of traditional family was held in Slovakia. It failed to reach the required turnover threshold in order for its results to be valid but the campaign leading to it divided society. Pseudo debates in which homosexuality was labelled a disease decades after all serious medical international organisations declared the contrary, filled the airwaves. The pro-referendum camp felt supported by the willingness of one former health minister from the 90s, a psychiatrist, to cure it. Late last year another former health minister, also a doctor, supported a draft bill in Parliament to send women who undergo in-vitro fertilization to jail for a period of between 5 to 12 years. It did not, however, pass. Topics like euthanasia and stem cell research rarely make it to public-wide debate in Slovakia. Law expert Andrea Erdősová has recently published a book on the topic of individual rights and bioethics and Anca Dragu was curious who shapes the public debate in Slovakia on bioethics topics and how the legislation in this field looks like.
Andrea Erdősová: We cannot say that there is a dominant topic in Slovakia when it comes to bioethics, there are a few that appear in the public eye at various times. Last year compulsory vaccination for children was making headlines, now due to a marketing campaign with billboards, the topic of homeopathy and its efficiency in treating diseases is being widely discussed. Some of these issues are relevant for those in society who want to discuss them. Others, such as abortion or euthanasia, are pushed into the public light by politicians who want votes. They do not care if the public is ready for an open and serious debate on these topics, and usually they lose interest in them as soon as elections are over.
Anca: Dragu: Who shapes the debate in Slovakia? I have the feeling that there is no balanced debate but whoever shouts the loudest gets the pole position no matter if they have evidence-based arguments or not.
That referendum on traditional family from last year was organized by the Family Alliance, a civic platform with direct links to the Christian conservative circles with a certain position on homosexuality. Slovaks are not very used to holding referenda and if you look at the fact that only 21% attended when official statistics put the number of members of the Catholic Church at 70% percent for example, then we can say that no matter who initiates such things, people are able to express their opinion as they detected what the real issue was on the table. What worries me is what happens when the topic on the table is a very complex one. Personally, I miss high quality expert discussions which bring a topic to the public presented in a professional but accessible way. Now experts who are willing to discuss it do so in isolation, only within a certain group, and public opinion is left to fend for itself.
Let's take the topic of euthanasia. Why is it publicly discussed in the neighbouring Czech Republic and in a very multidisciplinary context from spiritual aspects to medical ones and why there is such silence in Slovakia?
Yes, it's true that in in the Czech Republic they have advanced further the debate about euthanasia. I think that here there is some confusion related to its definition. Some people still link it to what the Nazis did during WWII. The term euthanasia comes from the Greek language and means a good death. It may look like a paradox but the doctor terminates a patient life for the latter's own good. It can follow the patient's direct request or it can be indirect for example when the patient is a young baby or in a coma. It can be active when medical personnel give a lethal drug to the patient and passive when the treatment is interrupted or not even started. From a bioethics' point of view it's important to see if the doctor ends a terminally ill patient's life in order to spare her or him of suffering - which is euthanasia - or tries to deal with the suffering, and the patient dies after some time without doctor's intention to end her or his life. In this case we do not talk about euthanasia. We have such practice in Slovakia too for example when very ill patients are told that by undergoing a certain treatment they may suffer more with little or no benefit to their health. In Slovakia the topic of euthanasia has been taken over by churches and the Slovak medical community is not daring enough to engage in discussing it publicly because the law says that killing a patient is a crime. In Slovakia we do not have a tradition of respecting patients' autonomy or their will as the supreme rule governing the relationship between doctors and patients. The Slovak scientific community is silent, so various interest groups fill the entire space. It's a problem because our population is getting older and we are not ready to deal with this fact. We do not have proper complex palliative care in Slovakia.
Based on your knowledge how are future doctors and nurses trained in this respect? Do they discuss it in schools or they are simply told that in Slovakia it's forbidden. Full stop. Doctors complain that it's unfair that such a complex issue as the end of life, is left almost entirely on their shoulders and with the Penal Code hanging above their heads.
I think that laypeople are too much into this image of healthcare personnel becoming some kind of "'angels of death" - which is a simplification of a very complex issue. I think that in medical schools students have the opportunity to discuss it at least when they deal with palliative care or when they talk about their obligation to do their best to save patients' lives. But then again, in Slovakia the public discussion on this topic is not well developed, while in the Czech Republic for example the Ethics Commission issued an opinion that doctors who do not continue treatment because it brings no benefit to the patient do not practice euthanasia. It helps the healthcare personnel a lot when they have clear guidelines. Behind ethics there is also the economic question that has to be discussed.
Indeed keeping somebody on life support can be very costly. Do you think that there is enough legal knowledge in Slovak healthcare when it comes to bioethics?
I think in Slovakia we are still in the early stages when it comes to medical law. There are still not many lawyers who specialize in this very interesting and quite progressive sector but I can see that students are interested in it. Healthcare personnel also feel a knowledge deficit when it comes to medical law. It is very important that the two camps cooperate and do not discuss these issues separately- lawyers among themselves at their conferences, doctors among themselves at theirs. They should also include bioethics experts in their discussions because if this does not happen we will not have a high quality public debate based on scientific arguments. We will continue with politicians and various interest groups hijacking the topics for their own benefit not that of the society.
And because we came to politicians again, at the world level gene repair therapy is the hottest topic when it comes to bioethics, while in Slovakia MPs had to recently discuss an amendment on sending women who undergo in vitro fertilization to jail for a period of between 5 and 12 years. A former health minister voted in favour. It may give the impression this country is going backwards.
There are four Eastern European countries that have very restrictive legislation in the area of bioethics: Slovenia, Poland, Lithuania and Slovakia. In all of them it's the powerful Catholic Church that played a crucial role in drafting the legislation. I think that the draft you mentioned has been communicated in a very unfortunate way. The issue there is that during assisted reproduction more embryos are created and some are destroyed afterwards and the conservative Christian groups regard them as human beings. This is also their argument against using human embryos for stem cell research in Slovakia.
But such a piece of legislation discriminates against women and couples who can't have children in the normal way, doesn't it? On one hand Christian groups are the first to argue in favour of high natality rates and on the other hand they come up with such a draft
Yes, I think that in the 21st century you can regulate it in legislation but not criminalize it.
So in Slovakia we have a weak public debate when it comes to bioethics topics dominated by strong conservative groups and little or no input from life scientists. Under these circumstances, how satisfied are you with the quality of legislation in this field? Isn't it too conservative?
Yes, Slovakia has conservative legislation when it comes to bioethics. But churches and their influence are not the only ones to blame for this situation. In 2004 when most of the current medical legislation was passed in Slovakia, there was no strong lobby from the medical and scientific community to influence the drafts. I guess Slovak researchers prefer to go abroad and do their science there. Then you have to bear in mind that not even churches have a unified approach to some issues, for example to stem cell research using human embryos. In Judaism it is allowed because they believe that it gets a soul only after the 40th day after conception. Islam and Buddhism are divided on this issue- some say that it should be allowed if it's to the benefit of curing illness. Protestants too- the majority favour the strict Catholic approach against using them but there is a minority who think otherwise. We live in an open world and conservative legislation in a country does not mean that people do not find a way to get what they want somewhere else - be it abortion or in-vitro fertilization.
Slovakia's bioethics legislation is conservative
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