Bioethics Forum Essay
Oncology, Bioethics, and War
Like many other Ukrainians, I woke up on February 24 at about 5 am from the sounds of explosions. I live in the city of Dnipro in eastern Ukraine, not far from the airport, which was hit by rockets. The internet was filled with reports of such strikes throughout Ukraine and the rapid movement of Russian troops into our country in the north, south and east. The first day, horror gripped my city. In a panic, everyone who could lined up in traffic jams that were many kilometers long on the highways towards the western part of the country. Those who remained tried to buy food, which quickly ran out. Just as quickly, gas stations ran out of gas, and shops and all other public places were immediately closed. In a matter of days, the city was empty and resembled something from a post-apocalyptic film. The remaining citizens mostly stayed in their apartments and watched the news to learn about the situation in the country.
I had some difficult decisions to make. I treat cancer patients. My wife, also a physician, works in a military hospital. We both decided that continuing our duties would be the best way to help our country. When, after a couple of days, we learned that our army was heroically fighting the aggressors, saboteurs were being destroyed in the capital, and the government refused to evacuate, we were filled with a sense of pride in the Ukrainian people and we realized that we had made the right decision.
For my cancer patients, the situation was particularly difficult, as they were already under stress from the threat of a deadly disease. The war added greater uncertainty about the future, the likelihood of losing loved ones, housing, work, even being killed. The war has increased the vulnerability of cancer patients, their susceptibility to manipulation and helplessness. There were new problems with logistics, the provision of medicines and equipment, and the migration of patients within and out of the country. In the first weeks of the war, the health care system was paralyzed, reorganizing as much as possible for the needs of the army without attention to the needs of other citizens. There were no special directives or action plans for medical workers and hospitals.
Urgently, it was necessary for me to make decisions independently. Thanks to my bioethics training through a fellowship program of Loyola University Chicago and the Ukrainian Catholic University, funded by the National Institutes of Health Fogarty International Center, I have some principles on which to base my decisions, rather than simply intuition. Initially, I joined the program to study more deeply the bioethical aspects of clinical research. I saw that many rules are violated when conducting research in Ukraine and I wanted to participate in the development of ethical research in our country. Bioethics has now become an integral part of my work and everyday life. When the chaos of war arose around me, I turned to bioethics and its principles to organize needed actions.
The importance of the principle of respect for patient autonomy is indisputable. In the first weeks of military aggression, I observed the extreme helplessness of cancer patients. They were mostly passive and inclined to follow the doctor’s recommendations. Many hardly participated in the decision-making process and some even refused treatment. I had to think carefully about my communication with patients to prevent involuntary manipulations and actions contrary to their actual wishes. First, it was necessary to calm patients, which often required medication. Even more so than usual, I took care to avoid unnecessary fear and panic about missile strikes, death, and suffering of Ukrainians and other manifestations of a military invasion, and the uncertainty of the future or sometimes imminent death due to the progression of cancer. Creating a calm and trusting environment helped patients to participate more actively in their treatment. By focusing on immediate small goals, I was able to help my patients make decisions that aligned with their values, priorities, and worldview.
The principle of beneficence helped me make decisions regarding very practical matters. Caring for patients was complicated by disruptions to the supply of medicines and consumables. We also had to deal with the constant migration of patients (from our frontline zone to the rear, from the war zone to our zone), an increase in very ill patients due to the impossibility of their evacuation, and progressive deterioration the financial condition of both the population and the health care system. We had to adjust oncological care accordingly. This included:
1. Creating and maintaining, from all possible sources, a three-month supply of medicines.
2. Identifying new sources of obtaining and paying for medicines. This required expanding our number and geographical scope of contacts. We now work with many new suppliers and manufacturers, receive deliveries from all over Ukraine and from other countries, and obtain assistance from charitable and humanitarian organizations.
3. Identifying alternatives to scarce medicines and chemotherapy regimens, and continuously monitoring their availability.
4. Using telemedicine whenever possible to limit patients’ need to come to the clinic. (The power supply and internet have not been affected by the war.)
5. Introducing medical support for patients evacuating to safer regions. Contacts have been established with their new treating doctors; local patient communities have been organized for mutual assistance on evacuation issues and treatment options in different countries and different clinics.
6. Introducing free advisory assistance for refugees and other especially vulnerable persons newly arriving in our region from zones of active war.
Considering the principle of justice has helped me avoid unconscious discrimination of patients. While in general, refugees are usually more in need of support due to lack of work, housing, and financial savings, in the conditions of war, all cancer patients have suffered to varying degrees, often no less than displaced persons. Under these conditions, it seemed very important not to formally identify categories of patients, but instead to identify their needs in relation to our local capabilities to provide oncological and other assistance. In the overwhelming majority of cases, the way out in the face of the impossibility of assistance at the local level was medical and consulting assistance in evacuation, primarily to European Union countries, for continued treatment there. Those patients who, due to the severity of their condition, could not be evacuated and at the same time did not have the opportunity to receive the necessary oncological care, received special attention and priority for additional sources of financial and medical support.
Thus, in the conditions of the beginning of military aggression, general collapse and chaos, the use of the principles of bioethics helped me to structure interactions with patients and solve problems as they arose. Since February 24, consultations at our clinic have increased by 110%, and chemotherapy courses have increased by 60%. But the most important thing in the work, of course, is not the numbers, but the health of patients and years of their lives saved. I am grateful for the opportunity to study bioethics and implement its lessons in my daily practice.
Maksym Basarab, MD, was an oncologist in Dnipro, Ukraine, and fellow in the Loyola University Chicago-Ukrainian Catholic University Bioethics Fellowship Program, funded by the National Institutes of Health Fogarty International Center. He died of a stroke last month.
After finishing this essay, he expressed thanks to Emily E. Anderson, PhD, MPH, program director, and all the faculty at LUC and UCU.