UDC 179.7 (470+571)
© Saperov V.N., 2012
Received on 16.07.2012
EUTHANASIA: PROBLEM STATE IN RUSSIA
I.N.Ulyanov Chuvash state university, Cheboxary
The article is devoted to the history of euthanasia and the problem state in Russia. Lack of legal clarity of passive euthanasia in the country is emphasized. The diagnostic criteria of brain death, after which it is possible to stop resuscitation, are discussed.
Key words: euthanasia, active euthanasia, passive euthanasia, brain death
The problem of euthanasia has arisen as far back as high antiquity. Even at that time, people thought of how to accelerate coming of death of an incurable patient for the purpose of termination of his/her sufferings, whose close end was obvious. Euthanasia was used in medieval wars, when in the field of battle without medical aid there were critically wounded soldiers and they were killed “out of pity and compassion” by special short swords with the handle in the form of a cross . These tools of murder were called precisely “Madonna of Mercy” (mercy).
The term “euthanasia”, or “orthothanasia” (from Greek “euthanasia”, eu – good, thanatos – death), has been used by English philosopher F.Bacon (1561-1626) for designation of easy, painless, “noble” death. In “the Encyclopaedic dictionary of medical terms” (1984) there is such a definition: “Euthanasia is an intended acceleration of death or killing of an incurable patient, who is in the terminal state, for the purpose of ceasing his/her sufferings”.
Passive and active euthanasia are distinguished.
Passive euthanasia is interruption of rendering medical aid, which was directed to prolongation of life, to serious, death-marked patient (for example, switching-off the respiratory apparatus), that promotes coming of death.
At active euthanasia, medicinal (for example, big doses of narcotics) or other agents causing fast and painless coming of death are injected to a remediless patient experiencing incredible physical suffering. Such actions of a doctor, when he/she helps an incurable patient to commit suicide, belong to variants of active euthanasia.
All forms of euthanasia are legislatively forbidden in the Russian Federation (Russia). Article 45 of the Federal law “On the fundamentals of health protection of citizens of the Russian Federation”  (hereinafter referred to as the Law “On the fundamentals of health protection”) says: “Exercising of euthanasia, that is acceleration at will of a patient of his death by any actions (inactivity) or agents, including termination of artificial actions for maintenance of life of a patient, is forbidden to medical workers”.
In the Criminal code of the Russian Federation euthanasia is treated as a premeditated murder. Interdiction for euthanasia is approved by the public opinion of the Russian citizens. At questioning, 80% of the pollees have declared that a law on euthanasia is necessary, but in our country it is still early to adopt it . Prohibition of euthanasia, including in the form of passive euthanasia, is also included into the “Ethical code of the Russian doctor” (1994), and the International code of medical ethics .
Interdiction for euthanasia in Russia and in the majority of other countries does not remove this challenge from the agenda. Discussions on this theme, with the participation of not only doctors, but also lawyers, writers, philosophers, churchmen, were carried out in many countries, including the Russian Federation. Such discussion was held in 1990s on pages of the “Medizinskaya gazeta”. Thus, some authors [7, 11] supported permission of euthanasia, others [15, 18] were against; along with it there was an intermediate position rejecting active euthanasia, but permitting passive euthanasia regarding fatal cases, having terminal diseases .
The main objection against euthanasia consists of the fact that it contradicts the humane principle of medicine and the basic precept of a doctor – to struggle to the last gasp for the life of a patient. After all, a doctor is obliged to follow the Hippocratic oath, in which, in particular, it is told: “I will not give anybody requesting a lethal agent from me and I will not show a way for a similar plan: in the same way I will not hand over an abortive pessary to any woman”. Proceeding from it, a doctor should never promote termination of life and acceleration of death. Conducting euthanasia by doctors can lead to distortion of the sense of his/her professional duty: a doctor can be looked on as the one, who is ready not only to treat and struggle for life, but also to kill, what will shatter confidence of patients in medicine . It is not surprising that among doctors there are 3.5 times less supporters of euthanasia (12.5%), than in population, as many doctors regard euthanasia as attempt to shift on a doctor moral, legal and religious problems connected with termination of life at own will of a patient .
Euthanasia is always carried out at will of a patient, more often it is connected with the presence of intolerable pains. However, nowadays in overwhelming majority of cases, it is possible to take out pains and to break the desire of a patient to die. Sometimes a doctor cannot only kill pain, but also prolong the life of a “remediless” patient and even to promote development of short-term remission. Serious objections are expressed to the address of supporters of passive euthanasia of patients, who are unconscious, too: a doctor has no right to deal with the question of termination of life of patients, who are not in the condition to express their opinion.
There are also other objections against euthanasia. Errors in the diagnosis and in definition of “hopelessness” of the patient, connected with objective difficulties and insufficient professionalism of doctors, especially in definition of terms of life and coming of lethal outcome are possible. Such cases were repeatedly highlighted in literature. Similar errors are also known to us, true, concerning these patients a question on euthanasia was not brought up, but forecasts of doctors concerning fast coming of a lethal outcome have not worked well. There is a possibility of opening by science of effective remedies for treatment of incurable diseases during the period, when medical actions directed to prolongation of his/her life are carried out to a patient, too.
According to some authors, permission of euthanasia can serve as a brake for elaboration of more effective methods of treatment of seriously ill patients, and can promote decrease of efforts of a doctor in rendering assistance to such patients.
Fears are expressed also that, under condition of absence of control, euthanasia can lead to abuse, and under the conditions of the state with an insufficient legal basis – to annihilation of people from political and other considerations masked by the purposes of “painless death”.
Severe objections against active, as well as passive euthanasia concerning the patients, who are in consciousness, are put forward by religion. Such euthanasia is always carried out at will of a patient, therefore it is identical to suicide, and suicide on religion canons is a heavy sin. Sacredness of human life is declared in Christianity and in other basic religious beliefs, therefore suicide and euthanasia at will of a patient are considered as transgressing of divine will. The church speaks about curse of suiciders on eternal punishment, they are refused burial on Christian ceremony, it is not authorised to read the burial service over them. According to church, God has given invaluable gift of life to everyone, and only God – and anybody else – can take away each of us in one’s hour.
A position offered by some authors “On incompetence of legal statement of the question on admissibility of euthanasia”  coincides with religious interdictions for euthanasia. Such arguments are advanced in this regard. Human life is an absolute value, its origin, realisation and termination occur under natural laws (laws of nature). For this reason, we speak about naturalness and inalienability of the right to life. And nature and natural laws cannot and should not be subject to legal laws.
There are also “earthy” objections against euthanasia: patients, whose illnesses have an unfavorable effect on family financial position, under these conditions can faster arrive at the idea that to die is their duty before their families. In such cases the desire to die will be not voluntary, but caused by external circumstances.
An effective alternative of euthanasia is hospice – a special hospital for severe, death-marked patients, where patients get social-psychological support and expected treatment (in particular, sedatives and antidepressants), and at the will of a patient – a pastoral care, too. It stipulates invitation of a cleric to hospice, who by prayer and sermon helps the fatal case to reach pacification . Thanks to the corresponding situation, good care and expected treatment the last period of their life becomes quite satisfactory.
Arguments of supporters of euthanasia are rather convincing, too. First of all, they assert that each man has the right to deal with the question of life termination, to finish life adequately, without troubling himself/herself and associates. They speak even about the fact, that refusal in the right to death of the patient contradicts to fundamental laws of man. After all, the right to death is the same natural right as the right to life, and euthanasia is considered as realisation of the right to worthy death, as the right of man to be master of his/her life . Further, it is underlined that it is inhumane to curse a remedilessly sick man, whose close end is inevitable, to intolerable torments. If the hope of improvement is definitively lost, a patient experiences extreme physical and moral sufferings and demands leaving from life; there is a question of euthanasia, which its defenders in these cases consider as the highest manifestation of mercy. After all, euthanasia is always carried out from compassion and without a material interest of a doctor .
And how is observance of the Hippocratic oath in these cases? Supporters of euthanasia believe that a doctor is obliged to treat patients till the last moment, but only those who wishes to live.
Immense tragedies in numerous families are also mentioned, where in care of relatives there are dying oncologic and paralyzed patients, from whom “urine and feces flow”. They beg relatives and doctors to help them to die, as they know that there are new and more terrible torments onwards.
Errors in diagnostics of diseases and definition of forecast can be reduced to the minimum and even be completely avoided, if a decision is accepted by the commission of at least from 4 specialists: an attending physician, a specialist-adviser in the given illness, a doctor-resuscitator and a representative of administration of the medical institution.
There is even such an argument in protection of euthanasia: supporting life of dying people, for whom it is additional torments and sufferings, doctors in vain spend agents, which can be effectively used for treatment of other patients .
As an argument in favour of euthanasia, there are also statements of separate patients, too. Here is a confession of the 39-year-old patient, who was dying hard from cancer of pancreas: “A doctor is obliged to struggle for life, but not for sufferings. My torments are intolerable. It is above human forces. Nobody can help me. The biggest and the most desired is to stop my excruciations. Continuation of sufferings of a lethally sick man is malicious. After all, medicine is sympathy, empathy, compassion, and mercy. Can it put up with the cause of continuation of torments?” .
And is it not an argument in favour of permission of euthanasia in exception situations a case described in the “Medizinskaya gazeta” (1998, 18 August). A 19-year-old young man after thermal burns of the face, respiratory tracts and both arms, which had to be amputated, wounds on the face were not healing, face bones became bare, he became completely blind, there were constant strong, exhausting pains, which became intolerable, from which he periodically fainted. Anaesthetising preparations did not help, and he constantly persuaded mother looking after him, who was a doctor by profession, to help him to die. At last, mother yielded to persuasions, agreed and heard gratitude words from him. She made a will and, having made a lethal injection to her son, herself decided to commit suicide, having taken a handful of sleeping-pills. However, she was salvaged, and a criminal case for a premeditated murder was opened against her, but it was stopped because of abalienation of the accused.
The examples quoted above testify how complex the problem of euthanasia is. “The euthanasia problem today is a tangle of biologo-medical, moral-ethical, religious, and legal problems” [9, P. 29]. Despite severity of arguments of euthanasia opponents, laws were adopted on permission of active and passive euthanasia in Holland, and then in Belgium, and in the USA in the states of Oregon and Washington. Thus, the given law (the law “On worthy death”) in the states of Oregon and Washington was adopted in spite of the fact that the American medical association had forbidden its members to participate in euthanasia, having put forward the slogan: “Doctors should not be executioners” [16, P. 33]. The Constitutional court of Colombia has legalised euthanasia, too. However, a legislative permission of euthanasia in Holland, Belgium, and the USA in the states of Oregon and Washington has not led to increase of cases of abusing in this area [9, 16] that can serve as an additional argument in favour of legalization of euthanasia.
As far as passive euthanasia (termination of rendering aid to fatal case under their request) is concerned, it is permitted in Switzerland, Germany, Sweden, and Finland . Such a passive euthanasia is not considered infringement of law and is practiced also in the USA, Canada, Australia and some other countries . Possibility of passive euthanasia at will of a patient is recognized by the World medical association (WMA). In the special Declaration of WMA on euthanasia (1987) it is told about regardful attitude of a doctor to desire of a patient “not to interfere with the natural process of dying in a disease end-stage” [Cyt. in 19].
As it was noted above, Article 45 of the law “On the fundamentals of health protection” forbids carrying out both active, and passive euthanasia. One would think, it “closes” euthanasia problem in Russia completely. However, it is not so. Article 20 of the given Law says that “a necessary preliminary condition of medical interference is giving of the informed voluntary consent of the citizen or his/her legal representative for medical interference”, and Article 19 of the same Law among the rights of a patient declares his/her right on “refusal of medical interference”. The possibility of the patient fixed in the law to refuse treatment is a legal basis for realisation of passive euthanasia concerning the people, who are in consciousness . What is more, some authors (lawyers) consider that permission of euthanasia is a constitutional right of man. Therefore, if a serious, incurable patient suffering both physically, and morally, asks not to use life-supporting treatment methods, then refusal in satisfaction of his/her request can be considered as use of force, cruelty, humiliating human dignity to man . It follows from the fact that health is a property of man, and he/she has the right to ask and even to request mercy, including in the form of euthanasia .
Therefore, in the Law “On the fundamentals of health protection” there is an obvious competition of legal norms of identical validity, in other words – legal uncertainty . This is reflected in the fact that, on the one hand, it is forbidden to conduct both active, and passive euthanasia, on the other – under the request (demand) of a patient the doctor is obliged to stop life-supporting treatment, that is he actually conducts passive euthanasia. In such a case, it is necessary to consider the consent of the patient to any medical interference as the main criterion of legalness of treatment . Proceeding from this, in the Russian Federation, as well as in the majority of other countries, carrying out of passive euthanasia, i.e. termination of life-supporting treatment, is allowed, when a death-marked patient, who is in full consciousness, but suffering physically and morally, asks to stop remedial measures.
At solving the question on passive euthanasia, it is necessary to be guided by the will of the patient, legal and ethical reasons. Lawyers of many countries warn about danger to listen in doing so to the request of relatives of the “remediless” patient, who in some cases are ready to send “expensive and favourite man” to glory, faster to take hold of his/her property. Therefore, in a number of countries, for example, in Sweden and Finland, requests of close relatives for termination of life-supporting treatment are invalid .
The termination of life-supporting treatment, according to foreign authors, is possible only at observance of the following conditions: 1) it is admissible only concerning an adult man without mental disturbances (necessity of consultation of psychiatrist!); most often the request of the patient for termination of life-supporting treatment is caused by a depression condition, and the rational prescription of antidepressants helps to break the situation; 2) diagnosis and hopelessness of the condition should be established by a consultation of independent specialists; 3) severe physical sufferings, which are not eliminated by treatmen, should be registered by the patient; 4) the wish about termination of treatment should be repeatedly stated by the patient and confirmed by a written statement, which is usually written under dictation of the patient, is signed by him/her and the attending physician in the presence of a lawyer.
Passive euthanasia of patients, who are unconsciousness, and who cannot state their will, is forbidden in our country. The question of termination of resuscitation actions may be solved positively only at ascertaining of brain death in the patient, which along with biological death is a criterion of man’s death. Therefore, termination of resuscitation actions after brain death is not passive euthanasia, as it is carried out after ascertaining of man’s death on the basis of brain death, i.e. at the irreversible termination of all functions of hemispheres and brainstem. Brain death, as a rule, should be confirmed by the absence of electric activity of brain (straight lines on electroencephalogramme) and termination of cerebral circulation (according to angiography). Such patients are capable to acquire only nutrition and to release their wastes (vegetative condition). Cardiac activity, at continuous artificial ventilation of lungs (AVL), can be supported indefinitely long - weeks, sometimes months. Such patients stay in a steady vegetative condition (SVC).
There is a question: is it possible to consider sustentation of such vegetative condition as prolongation of life? Many foreign authors answer this question negatively. It is also determined by the unfavorable forecast at the given condition. If diagnosis of SVC was put correctly (after ascertaining of brain death), recovery is impossible. Therefore the standard legal position in the West European countries consists of the fact that termination of use of artificial agents for sustentation of life in these patients will not be illegal, where AVL, nasogastric tube, cardiopulmonary resuscitation, hemodialysis, etc. are referred . At the same time, it is necessary to provide usual methods of treatment (care, struggle against infection, etc.) to such a patient, that reducing probability of biological death from routine reasons.
Stricter approach to passive euthanasia of patients with SVC is recommended in Declaration of WMA “On persistent vegetative condition” (1989). However, here the question is of not about patients with brain death, but about any comatose patients with “severe damage of cerebral hemispheres”. It says: “With rare exception, if a patient has not regained consciousness within six months, prospects of resusciatation are very small, regardless of the nature of brain damages. Therefore, it is possible to consider as a guaranteed criterion of irreversibility of SVC 12 months of unconsciousness, and for people older 50 years recovery is almost impossible in 6 months, either”. These terms are recommended to be considered in solving the question on termination of life-supporting treatment of the patient, who is in SVC [Cyt. in 27]. At the same time, it is necessary to underline that SVC and brain death are not equivalent concepts. SVC can be observed in patients without brain death, being in the condition of deep coma, too. That is why a deep coma and SVC, without diagnostics of brain death in these patients, are not criteria of termination of life-supporting treatment .
Thus, statements of some authors that only biological death is a condition for termination of resuscitation actions in our country, do not represent the facts [20, 23]. The statement that criteria for termination of resuscitation actions concerning the patients, who are in deep coma, including in a steady vegetative condition, are not established in our country, does not represent the facts, either . Brain death is such a criterion. Paragraph 6 of Article 66 of the Law “On the fundamentals of health protection” says: “Resuscitation actions stop … at ascertaining of man’s death on the basis of brain death, including against noneffective use of a full complex of resuscitation actions directed to sustentation of life”.
Criteria of brain death have been developed by the special commission in 1968 in Harvard (USA), and then in 1981 have been added by the Presidential commission on studying of ethical problems in medicine and biomedical and behavioural researches. In our country, man’s death is established on the basis of brain death according to paragraph 1 of Article 66 of the Federal law “On the fundamentals of health protection”: “The moment of man’s death is the moment of death of his/her brain or his/her biological death (irreversible destruction of man)”. Further, it is underlined that “Brain death comes at the full and irreversible termination of all its functions registered at working heart and artificial ventilation of lungs”. Criteria for diagnostics of brain death are stated in “the Instruction on ascertaining of man’s death on the basis of diagnosis of brain death”, approved by the order of Ministry of health of the Russian Federation No.460 of 20.12.2001 . Various approaches to establishment of duration for observation of patients are established at the primary and secondary affect of brain.
Brain death, as a result of its primary damage, develops owing to sharp rising of intracranial pressure and termination of cerebral circulation caused by it (severe closed craniocerebral trauma, intracraneal hemorrhage, infarct of brain, brain tumours, closed acute hydrocephaly, etc.), as well as owing to an open craniocerebral trauma, operative measures on brain, etc.
Secondary damage of brain develops as a result of hypoxia of various genesis, for example, at cardiac standstill and termination or sharp deterioration of the system circulation, owing to long proceeding shock, etc.
The directive, containing in the instruction, has a practical value not to envisage the diagnosis of brain death until intoxications, including medicinal, primary hypothermia, hypovolemic shock, metabolic endocrine comas, as well as use of anaesthetising agents and relaxants are excluded.
Authors of the instruction have taken into account that not in all medical institutions and resuscitation and intensive care units there is an opportunity to carry electroencephalography and angiography of the main vessels of head. Therefore, according to the instruction, the diagnosis of brain death can be accurately established on the basis of clinical tests.
The clinical criteria, which presence is compulsory for establishment of the diagnosis of brain death, are as follows:
Full and steady absence of consciousness (coma).
Atony of all muscles.
Absence of reaction to strong pain stimulations in the field of trigeminal points and any other reflexes, which are becoming isolated above cervical part of spinal medulla.
Absence of reaction of pupils on direct bright light. It should be thus known that any preparations dilating pupils, have not been applied. Eyeballs are motionless.
Absence of corneal reflexes.
Absence of oculochephalic reflexes.
Absence of oculovestibular reflexes.
Absence of pharyngeal and tracheal reflexes.
The technique of definition of the reflexes designated in paragraphs 6, 7 and 8 is given in the instruction.
Absence of spontaneous respiration.
Registration of absence of breath is not supposed by simple switching-off from the AVL apparatus. Switching-off of the patient from the AVL apparatus is made by means of specially developed apnea test - the test of apnoetic oxygenation, requiring definition of gas structure of arterial blood (apnea test is carried out after having received the results of previous tests). Its main point is that after switching-off the AVL apparatus wetted to 100% oxygen is delivered with the rate of 6 l/minute to endotracheal or tracheostomy tube. In connection with the absence of breath, there is accumulation of endogenous carbon dioxide (stimulator of the respiratory centre). If rising of CO2 strain in arterial blood reaches 60 mmHg and above (in the norm of 35-45 mmHg), and in so doing spontaneous respiratory movements are not restored, apnea test testifies to absence of the function of the respiratory centre. At occurrence of at least minimum respiratory movements, that testifies to absence of brain death, pulmonary ventilation is immediately resumed. In such cases the patient continues to receive the prescribed treatment.
However, AVL and other medical actions are resumed, when apnea test has shown absence of respiratory movements. These patients are observed dynamically. Duration of observation depends on the fact, whether the patient has a primary or secondary affect of brain.
At primary affect of brain, for establishment of the diagnosis of brain death, the duration of observation should be not less than 6 hours from the moment of primary revealing of clinical signs of brain death. Upon termination of this time, repeated registration of clinical criteria of brain death is carried out, and at their negative results the man’s death is acknowledged on the basis of brain death. The apnea test is not carried out repeatedly. The given period can be reduced, if right after the first establishment of falling out of brain functions, to conduct double panangiography of the main arteries of head by clinical criteria. If absence of cerebral circulation is thus established, the brain death is verified and the further observation is not required. Thus, angiography of the main vessels of head is carried out, according to the instruction, for reduction of necessary duration of observation. In the same way, electroencephalography is not absolutely necessary for acknowledgement of the diagnosis, either. It is necessarily carried out for verification of the diagnosis of brain death, when there are complexities in definition of oculocephalic and oculovestibular reflexes (trauma or suspicion on trauma of the cervical part of backbone, rupture of tympanic membranes).
At a secondary affect of brain, for diagnostics of brain death duration of observation should be not less than 24 hours from the moment of the first establishment of clinical signs of brain death, and at suspicion of intoxication the necessary duration of observation is increased till 72 hours. After this period, repeated definition of clinical criteria of brain death is carried out, and at their negative results the brain death is verified. The observation period can be reduced, if right after establishment of clinical signs of falling out of brain functions, double panangiography of the main arteries of head, which will reveal termination of cerebral circulation, is carried out.
Unfortunately, conditions for definition of blood gases and for performance of the “classical” apnea test are available far not in all treatment-and-prophylactic establishments. There is no information in literature about possibility of using “simplified” apnea test (without definition of gases of arterial blood) that, in our opinion, is quite admissible.
The diagnosis “brain death” from the very beginning till now is exposed to criticism both on the part of professionals, and on the part of religious figures, lawyers and specialists in medical ethics. First of all, possibility to identify “brain death” and “man’s death” is called in question. Certainly, concepts of brain death and biological death are not identical. However, after brain death (full and irreversible deenergizing of functions of hemispheres and brainstem), if not to support life in “comatose body” in artificial way, inevitably in the near future there comes biological death. The following was written by aide-de-camp of Acad. V.A.Negovskii prof. A.M.Gurvich about it in 1997: “Brain death is irreversible, defined by the global destruction of brain, exception of possibility of sustentation by brain of conscious contact of an individual with the environment, its reactions to external influences, carried out by reflexes, becoming isolated through brain, and providing the basic vital functions – independent breath and sustentation of arterial pressure and homeostasis as a whole. Therefore, the organism in the condition of brain death is doomed to death in traditional understanding – to cardiac standstill – in the next few days or (seldom) 2 weeks, very rarely – during larger time”. And further: “The world’s almost 40-year-old experience testifies: 1) diagnostics of brain death, if it is executed without infringement of instructions, is absolutely reliable; 2) no patient in the world in this condition has survived more above the specified term, all such patients are doomed to cardiac standstill in the near future” [5. P. 193].
These statements of a well-known resuscitator A.M.Gurvich once again prove the statement that brain death is an equivalent of man’s death. In this connection, there is a big mistrust to published reports on how patients come to life after brain death. In these works, there are no criteria on which basis the diagnosis “brain death” has been made, therefore, diagnosis “brain death” gives rise to doubt. It is not excluded that the condition of deep coma, meanwhile coma – only one of nine clinical criteria of brain death, was accepted for brain death. However, long duration of coma is not an indicator of brain death. More likely on the contrary: it testifies to absence of brain death. So, there is information about a patient of 84 years, at whom coma proceeds more than 6 years in the absence of brain death: despite proceeding vegetative condition, he reacts, when addressed, can move with toes, and when he hears in record performance of his grandchildren on children’s holidays, his eyes are bedewed and there is a suspicion of a smile on his lips .
In summary, in our country, as well as in the overwhelming majority of other countries, active euthanasia is absolutely forbidden . At the same time, passive euthanasia of the patients being in consciousness and refusing medical interference or demanding its termination, is lawful. The question on legitimacy of termination of treatment at comatose patients with brain death (provided all criteria of its diagnostics are used) and being in a steady vegetative condition.
Unequal approach to active and passive euthanasia is connected with their basic difference. Any active euthanasia is murder, though “at will of fatal case, in coordination with him/her” (V.A.Negovskii) [10. P. 34], while passive euthanasia means as it is written in the Declaration of WMA (1987) and as it has already been mentioned by us above, “not to interfere with natural process of dying in disease end-stage”. Therefore, according to the English professor of medical ethics R.Vcatch, “since some time passive euthanasia practically ceased to be considered as euthanasia, in this connection it is more correct to name it as “refusal of action” [Cyt. in 27].
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INFORMATION ABOUT AUTHOR:
Saperov Vladimir Nikolayevich
Honoured Doctor of the Russian Federation, Doctor of Medicine, professor, head of hospital therapy chair No.1 with phthisiology course in “I.N.Ulyanov Chuvash state university”
apt. 82, 20, Dzerzhinskogo str., Cheboxary, Chuvash Republic, 428032
Tel.: +7(8352) 58-46-30