This editorial can be found in The American Journal of Bioethics’ October 2022 issue.

On February 24, 2022, Russia invaded its neighboring nation, Ukraine, in what is widely regarded in the West as a grave breach of international law. Since that time, the Russian military has been implicated in a systematic campaign of war crimes including torture, rape and murder in occupied Ukrainian territories. In response, a coalition of democratic nations led by the United States, Great Britain and the European Union has placed sanctions upon a wide range of Russian individuals and institutions. While sanctions on political and military leaders have proven relatively uncontroversial in the West, restrictions upon Russian athletes, artists, scientists and biomedical researchers have generated far more disagreement. In the sciences, some partners severed ties rapidly. Notably, the Massachusetts Institute of Technology terminated its research affiliation with Russia’s Skoltech and the European Space Agency ceased cooperation on the Luna moon-landing program. However, efforts to target individual Russian scientists directly have been more limited, although the European Society of Cardiology did exclude physicians from Russian and Belarus from ESC activities. Among major journals, only the Journal of Molecular Structure has announced that it will no longer review papers submitted by Russian investigators, while others including Science and Nature have publicly committed to continued review of such submissions. It must be noted that many Russian scientists, such as biologist Mikhail Gelfand, have been outspoken in their criticism of their government’s conduct.

While the specifics of debates over targeting Russian scientists are nuanced and complex, the underlying issues are not novel and unfortunately are likely to recur. That affords the scientific community an opportunity to use this international tragedy to rethink current attitudes toward engagement with nations linked to human rights abuses.

Western scientific and medical institutions have a longstanding history of cooperation with biomedical entities, often state controlled, in nations implicated in severe human rights violations, denials of fundamental liberties and even breaches of the Genocide Convention of 1948. For example, Western engagement with the People’s Republic of China has been largely uninterrupted by that nation’s widespread use of torture in Tibet and the ongoing cultural genocide against the Uyghur people of Xinjiang. The United States has expanded its scientific cooperation with Saudi Arabia despite the latter’s track record of torturing dissidents and consistent ranking among the world’s most brutal authoritarian regimes. Collaboration between scientists in the United States and Cuba has increased notwithstanding that nation’s worsening domestic repression. In the 21st century, with the exception of a few hermetic pariah states, such as North Korea and Eritrea, the western scientific and medical communities have largely been willing to work with institutions located in authoritarian nations engaged in the worst forms of abuse. Such interactions are frequently justified on the grounds that science is apolitical and that these interactions build bridges between the West and the people inside these repressive countries. Yet just because science itself is apolitical does not mean that the choice to collaborate with entities in regimes that engage in egregious human rights violations is also apolitical. Rather, such collaborations are a political choice that, in some circumstances, can lend legitimacy to such institutions or even whitewash such abuses under the veil of outside approval. Analogous to “greenwashing” (distracting from environmental abuses with misleading advertising) or “pinkwashing” (distracting from human rights abuses with gay-friendly policies), the process of “whitecoat washing” lends legitimacy to human rights abusers through biomedical cooperation.

That is not to say that such collaboration cannot be justified in some circumstances. For instance, zoonosis surveillance in such nations may be necessary to protect the world from pandemics; public health measures may prove justified by the number of innocent lives that they save. What is needed is a systematic way for Western institutions to evaluate and interrogate the impact of potential foreign collaborations in a manner that overtly weighs the effect of such partnerships on human rights in repressive states. Such a system is woefully lacking at present.

Medical neutrality has been a core aspect of international law since the 19th century. It is also widely accepted as an ethical norm in Western clinical practice. Physicians are expected to treat the patients in front of them—regardless of nationalities, political affiliations or creeds. (It is important to emphasize that this principle does not oblige hospitals to facilitate treatment for visiting dictators, nor does it oblige physicians to travel abroad to treat human rights abusers.) From this standard often arises the misguided corollary belief that doctors are obliged to remain politically neutral (at least on the public stage) to ensure that all patients feel welcome and that the profession is perceived to stand above the political fray. At the same time, the Enlightenment belief in the objective nature of medical discovery remains a bedrock of Western medical values. In fact, the scientific community has historically labored to prevent the field from being misused to the advantage of partisan political ends. Unfortunately, the combined legacies of medical neutrality and scientific objectivity further the misleading belief that medicine is, or can ever be, genuinely apolitical. In reality, turning a blind eye to human rights abuses is as much a political act as challenging them.

In the United States, the recent trend has been to acknowledge the political nature of medical engagement at the domestic level. On a range of issues from racial disparities to reproductive rights, physicians have taken the lead in advocating for social justice. These efforts reflect a parallel evolution in the historiography of medicine that acknowledges the significant social impact of medical choice. They are reflected in the admonition by Asch and Armstrong that medicine should not be defined by “tired conventions about what doctors do” but “should instead be defined by what patients and communities need”. Yet the double standard between domestic and foreign matters is striking. For example, Columbia University recently suspended its chairman of psychiatry for sending out an allegedly “racist” message on Twitter. At the same time, Columbia operated a Global Center in Beijing that has continued to function while the Chinese government methodically killed minority citizens in Xinjiang.

Physicians do engage in international human rights advocacy through organizations such as Physicians for Human Rights. In rare cases, such as the academic boycott of South Africa’s apartheid regime, some medical institutions have formally disengaged with the scientific communities in human rights abusing nations, although even those efforts have generally proven limited. On the whole, statements on the importance of human rights are rarely followed with systematic review of engagement with transgressors.

What is needed is a process for formally appraising international biomedical cooperation vis-à-vis its impact on human rights. Such collaboration is already scrutinized systematically in other regards, such as to ensure that research results relevant to national security are not disclosed to foreign powers. A system might easily be adopted, mirrored upon Institutional Review Boards (IRBs), which are used in the United States to monitor the safety of human subject research. Collaborators, both clinicians and researchers, would be responsible for submitting for review relevant information on the human rights conditions in the nation where they seek to engage and the impact of this cooperation. These would-be collaborators should be specifically called upon to address the benefits of such partnerships against their optical downsides and potential “whitecoat washing,” taking steps to prevent the latter in advance when possible. A committee composed of both intramural and external experts, a Human Rights Review Board (HRRB), would then consider the proposals, determining whether the benefits significantly outweigh the downsides with regard to fundamental liberties. Such review might add some bureaucratic complexity to cooperation—much as IRBs sometimes delay or complicate research. At the same time, both are justified to prevent greater evils. While defining human rights may prove challenging in cases where genuine disagreement exists, these complexities should not distract from the protection of widely held Western values such as opposition to torture and support for free expression.

The primary goal of such review would be to force institutions, scientists and clinicians to reflect directly upon the impact of their professional choices upon international human rights. HRRBs would not focus only or even primarily on whether the collaboration itself engaged in human rights abuses, which would clearly be unethical, but also upon whether the project so entangled itself with compromised parties, institutions or nations as to implicate itself indirectly in the whitecoat washing of those entities. Whether or not HRRBs had legal authority or relied solely upon moral authority (like hospital ethics committees), either approach would bring the impact of such collaborations to the fore. Among the questions an HRRB might ask in rendering a verdict on cooperative endeavor are:

1. How severe and pervasive are the human rights violations of which the partner nation is accused?

2. To what degree does that nation control, support or otherwise maintain a direct relationship with a partnering institution?

3. What potential impact does the cooperation have on the public image of the partnering nation and is there a likelihood that the cooperation will distract, either directly or indirectly, from that nation’s human rights violations?

4. What are the attitudes of victims and survivors of these human rights abuses toward scientific and biomedical cooperation?

5. Are there humanitarian justifications for engagement, such as a clear and significant social benefit from the cooperation, that meaningfully outweighs any optical harms from the partnership?

This list is not exhaustive. Its purpose is to force western institutions to confront the calculus involved in cooperating with human rights transgressors.

All engagement with nations in which human rights violations occur is not inherently unethical. In some cases, partnerships may even prove desirable. But what is needed is systematic review and reflection of such engagement on the ground level. Much as physicians and scientists today look back upon the abuses of the past century, such as the Tuskegee Syphilis Study, with shock that few objected to such grave violations of ethical norms, future generations may ask why nations that allegedly championed freedom and human rights allowed their leading universities and hospitals to partner with institutions in regimes linked to the torture, mass murder and the suppression of basis liberties. Human Rights Review Boards offer an innovative mechanism for compelling western institutions, clinicians and researchers to justify such cooperation to the public and to history.