Modern societies are predominantly focused on inclusive education that ensures equal access to quality education for all students and takes into account the diversity of their special educational needs (SEN). Inclusive education in Russia is formally secured by the Federal Law On Education in the Russian Federation [1] and a number of ratified international conventions, primarily the Convention on the Rights of Persons with Disabilities [2].

Traditionally, the issues of education of students with SEN were considered from the point of view of pedagogics, psychology and special medicine. However, inclusive education is fundamentally grounded in ethics and human rights. The goal of this article is to demonstrate that inclusive higher education is a direct ethical imperative arising from the fundamental principles of bioethics, and that the medical community, built on these principles, is obliged to play an active role in its approval. Objectives:

1. to analyze the paradigm shift from the medical to the socio-ethical model of disability;
2. to look at inclusion through the lens of autonomy, beneficence, non-maleficence, and justice;
3. to detect essential ethical dilemmas while inclusion is implemented;
4. to determine the ethically justified role of a health worker (pediatrician, neurologist, psychiatrist, rehabilitation therapist) in the inclusive process.

FROM THE MEDICAL MODEL TO THE BIOETHICAL PARADIGM: CHANGING CONCEPTUAL FOUNDATIONS

The medical (or rehabilitation) model of disability describes a historically widespread approach to disability. According to it, a problem exists within the person. It views disabilities as abnormalities that need to be cured, corrected or isolated in specialized institutions [3]. The model-based educational system is associated with segregation at specialized schools where they focus not on social integration but on how to compensate a defect. The model is problematic from an ethical point of view because it makes a diagnosis, limits autonomy, and results in stigmatization and social isolation.

Starting from the 2^nd half of the XX century, a social model of disability is developed alongside with the development of bioethics [4]. Its core message states that physical dysfunctions occur not due to disturbed health but because of inadaptability of the physical and social environment (architectural, information, communication, attitude barriers). Thus, the “problem” is shifted from the individual to the society. The task of the latter is to eliminate the barriers.

The system of bioethical principles (Beauchamp TL and Childress JF) offers a solid foundation for a social model. The discourse is shifted from a purely medical plane to the plane of rights, dignity and social justice. According to this logics, inclusive education is not a “service” for the “patient” but the right and condition for treating any society member with dignity.

PRINCIPLES OF BIOETHICS AS THE FOUNDATION FOR INCLUSIVE EDUCATION

1. Respect for autonomy (principle of self-determination). The principle means that an individual has a right for their own choice, opinion and participation in life-related decisions [5]. For a child with SEN, it is about shifting from the paternalistic approach (when a doctor/teacher knows better what you need) to the partnership model. Autonomy is implemented through:

• the individual educational program (IEP) developed based on the opinion and potential of the child and the child’s family;
• assistance in taking decisions about the form and place of education;
• recognizing the right for the voice. Even a non-verbal child has some preferences that have to be understood and respected.

Violation of this principle results in a forced enrollment in specialized schools, ignoring the family’s opinion, and treating the child as a passive object for intervention.

2. Beneficence and non-maleficence. The traditional segregation system was often justified to be selected for the “benefit” of the child and for the purpose of placing such a child in a “safe” and “comfortable” environment. From the bioethical point of view, however, the assumption could be disputed.

Beneficence in inclusion means an active creation of conditions for the best development of social, academic and personal competencies. The research shows that in case of an adequate support, inclusion leads to better academic and social results for children with SEN, and to empathy and tolerance in their neurotypical peers [6]. Non-maleficence is an obligation that prevents from creating conditions leading to isolation, low self-esteem, or learned helplessness. Even if the conditions are good, isolated education does harm by depriving the child from the social experience and attaching the label of “someone who is different from others” [6]. Thus, refusal from inclusive conditions can be taken as an ethical violation of the “non-harm” principle.

3. The principle of justice is the core inclusion principle. Justice is rather taken not as something that makes everyone equal but as redistributive justice (distribution of resources according to needs) [7]. In education, the principle requires to ensure equal possibilities but not similar conditions. This means that a child in a wheelchair needs a ramp, and a child with dyslexia (impaired ability to read and understand a written text) needs a text typed in a special font. It is a “reasonable accommodation”, a significant term of the Convention on the Rights of Persons with Disabilities. Health discrimination should be avoided. Financing, personnel, and methodological support should be distributed to exclude privileges or discrimination because of developmental challenges.

ETHICAL DILEMMAS OF INCLUSION IMPLEMENTATION

The ethical principles implemented in practice face dilemmas that require a balanced approach. First, it is a dilemma of resources and limits of “reasonable accommodation”. The principle of justice demands nothing impossible. But where is the border of the “reasonableness”? This is an ethical question. When does the environment accommodation stop being “reasonable”, start disturbing education of other children or become unbearable for the institution? The decision requires an open dialog between all parties (parents, teachers, administration of the educational institution, medical personnel) and search for creative compromises but not for an administrative prohibition.

Second, it is the conflict of interests such as the family autonomy, the child’s well-being and interests of the group. It can happen that what the family wishes (if they insist on inclusion though the child experiences constant stress because of the unprepared environment) can conflict with the current benefit of the child. Third, it is the problem of the limits of professional competence and interdisciplinarity.

A health worker’s role in inclusive education is one of the most complicated ones. On the one hand, its expertise (diagnosis, prognosis, support recommendations) is essential. On the other hand, there is a risk of medicalization of an educational process when only diagnosis determines the pedagogical route.

A doctor has an ethically suitable position when they submit objective information about educational needs based on health and when they serve as consultants in a team of psychological and pedagogical support instead of directly instructing the school (“the child can’t join a regular class”) [8].

Resolution of these conflicts should be very delicate. It requires respect for the family autonomy and fair instructions about the risks and possibilities.

THE ETHICALLY PROVEN ROLE OF THE MEDICAL SOCIETY

Taking into account bioethical principles, a health worker should move beyond just diagnosing illnesses and focus on advocating for a patient’s rights and health in a broader sense. The ethical responsibilities include as follows:

1. protection from discrimination: do not use a dialog as a sentence limiting life chances;
2. interdisciplinary partnership: work in collaboration with teachers, psychologists, and speech pathologists respecting their professional expertise;
3. enlightment and destigmatization: explain the essence of a social model and bioethical basis for inclusion to colleagues, teachers and society;
4. family support: submit information that helps the family to make a conscious choice and support it while the child’s rights are asserted.

Inclusive education is not an experimental pedagogical method but a complex social and ethical project deeply held in the system of modern bioethical values. Whenever it is implemented, the principles of respect for human dignity, autonomy and justice declared by the society are checked for validity. The principles of bioethics such as respect for autonomy, beneficence, non-maleficence, and justice give a clear regulatory direction to overcome the practical and ideological barriers on the way to inclusion. They are used to solve issues, determine the borders of responsibility and build constructive interdisciplinary interaction.

The medical community that acts as the guardian of these core ethical principles incurs special responsibility. Doctors, medical specialists, clinical psychologists, social workers, and healthcare officials are called upon to become active participants in changes rather than passive observers, translating the ethical imperatives of bioethics into the practice of building an inclusive society starting in the classroom at school. Thus, they serve as expert intermediaries who navigate patients through difficult healthcare decisions and help them find an ethically sound path. Refusal from an outdated model in favor of the bioethical inclusion paradigm means both a professional duty and contribution to the formation of a more humane and just society for everybody.

The research shows that inclusive education is not just a pedagogical trend but also an ethical imperative grounded in the fundamental principles of bioethics. However, systemic steps are required to include the ethical imperative into the daily practice. We use the analysis to offer the following recommendations to different layers of the professional community and management system.

The medical community members and health professionals should do as follows:

1. to change the format of medical reports for the PMPC (psychological, medical and pedagogical commission) and educational organizations. Instead of diagnosis (“not capable”), the report should contain a structured description of educational needs of a student (in communication, movement, information perception, activity organization) and certain recommendations on creating conditions (technical means, regime, interaction specifics);
2. to implement obligatory educational modules on the basis of bioethics, social model of disability and interdisciplinary interaction into the continuing medical education program for pediatricians, neurologists, psychiatrists and doctors of other related specialties;
3. to create positions of clinical bioethicists or ethical consultants at large medical centers who will, among other tasks, deal with problems across medicine and education, support doctors in taking non-paternalistic decisions and resolve conflicts with families.

The system of education and interdepartmental communications should perform the following tasks:

1. to capture an obligatory participation of a doctor (or a medical representative) as a full member of the academic psychology and pedagogical council at the regulatory level. His role is not to provide instructions but to submit expert information and participate in the joint development of the individual educational route;
2. to develop and introduce clear interdepartmental (Ministry of Health — Ministry of Science and Higher Education, Ministry of Education) protocols transferring information about students with SEN from the healthcare system to the system of education. The protocols should warrant confidentiality and translation of medical data to the language of pedagogical tasks;
3. to develop the system of independent ethical expertise of complex inclusion cases when conflicts of interests or disputes about the “reasonability of accommodation” arise. The commissions should include not only teachers and officials, but also bioethicists, human rights lawyers and representatives of non-state commercial organizations (All Russia Association of the Blind).

The scientific and expert community should do as follows: to initiate interdisciplinary research to estimate long-term effects of inclusion from the bioethical point of view. Its effect on the quality of life, self-regulation, and social health of all participants of the educational process should be examined.

Ultimately, successful inclusion requires doctors to move beyond just diagnosing illnesses and setting standards and focus instead on advocating for a patient’s rights, health, and ability to thrive within their daily life. Implementation of the suggested measures allows not only meeting formal legislation requirements but also turning the bioethical principles into a living guideline for action by providing every student with a right for education and decent life not just on paper, but in reality.