The COVID-19 pandemic began in February 2020 in Karachi and within a couple of months, the disease had already occupied a large number of beds in ICUs. SIUT, the largest transplant center in Pakistan started a COVID OPD, ward, and intensive care facility for the public as part of the national effort to contain the first wave of COVID. At the same time, the hospital continued to provide care to its own patients.

This variant of COVID was new. The disease process was being understood slowly over time, and treatment was evolving. Most of the medicines being prescribed had not been tested before and were mainly given emergency approvals by drug regulators. But I want to bring up a very different aspect of COVID-19: family involvement in the COVID ICU. In the initial stages of the pandemic, allowing relatives into the COVID ICU was unimaginable. But this is exactly the strategy we adopted at SIUT.

At the start of the first wave of COVID, global standards of care included strict isolation of admitted patients to control disease transmission. COVID-19 guidelines from Pakistan’s Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) discouraged the presence of family members, except in the case of paediatric patients. Families were not allowed to visit and the only way to see loved ones admitted with COVID was with a mobile phone. Even dead bodies were handled with great care and funeral gatherings were restricted. In the beginning, doctors were as afraid of COVID as everyone else in the community. We were wearing full-body gowns, masks, eye shields, goggles, foot covers, gloves – even respirators in some instances. We had to write our names on our dresses to identify each other. Attendants were strictly not allowed inside. Nurses were also afraid. And then came a time when nurses started getting COVID. Fear spread like wildfire, and nurses began opting out of ICU duties. Some demanded fewer working hours, and we had to negotiate their timings with them. At the same time, the number of patients was increasing.

A few attendants of our patients insisted on staying in the ICU, mainly wives, sisters and children. They wanted to stay with their loved ones for different reasons, the most important being cultural norms which made families duty bound to care for sick kin. Initially, we refused to let family members into the ICU but ultimately, after consultation between infectious disease physicians, intensivists, and the hospital administration, we decided to allow them in. Only family members who were young, healthy and not pregnant were allowed as attendants. In addition to other safety measures set in place, they had to wear complete personal protection equipment (PPE), just as the nurses were wearing.

The reason for this allowance was multifactorial. Families strongly wished to be with their sick relatives, but there was also a practical benefit because of the care family members could provide. Short of staff during peak COVID, we found the family helpful at the bedside. We found that pain, agitation and delirium – major concerns in the ICU – were best managed by involving family members. Mobilizing patients out of bed was also a task where the family was helpful. As time progressed and the fear decreased at all levels, we realized that the impact of family involvement in the COVID ICU was tremendous. We began to see miraculous improvement in patients’ outcomes.

One of the patients was Mrs. B, a young female from a poor socioeconomic status with a history of psychiatric illness. She came with severe COVID pneumonia, complicated by kidney failure. She received a few sessions of dialysis, but the pneumonia was severe. She underwent a tracheostomy procedure which developed complications. Later, she had massive gastrointestinal bleeding, for which she required surgery and endoscopies. She had severe infections and bedsores. Several times we gave up on her and thought she would not survive even 24 hours. But she did survive. What made her recover and leave the ICU alive was her older sister who cared for her as though she was her mother. She always knew what her sister wanted, and she tried her best to provide it to her.

Then there was Mr. S.A.H, a dialysis-dependent, older man with complicated vascular access. He developed COVID pneumonia and was put on a ventilator. One day, I saw his daughter standing beside him, not doing anything. I asked her why she was not helping her father get better. She took my message positively, and her healing touch made the difference. The father, who was on continuous infusions of different medicines to control delirium and agitation, entirely regained his senses in only three days. The next day he was discharged from the ICU, in his senses and talking.

We admitted Mr. H.A, a doctor who developed COVID pneumonia on top of an already bad chest. He remained on BiPAP, the noninvasive breathing support, for a long time. He developed clotting in his lung vessels and was ultimately oxygen dependent. Due to his chest wall deformity, he was not able to sleep on his belly which is the recommended position for COVID patients. His wife devotedly cared for him, day and night, finally stealing her living husband back from the ICU. He remained on oxygen for at least six months before getting back on his feet.

Three problems in the ICU are detrimental to the recovery of patients, independent of the primary illness: pain, agitation, and delirium. Our experience showed that family involvement in the COVID ICU helped with all three problems, helping patients get out of the ICU bed. The ICU is a jail from which patients must be liberated; the family has a definite role in this.

As an undergraduate, I studied medicine and arts, majoring in philosophy and English at the University of Melbourne, Australia. After thoroughly enjoying my year of medical internship, I returned to university to complete an honours year in philosophy in the hope this would help me to decide whether to continue a career in medicine or pursue my passion for philosophy. After what felt like a lifetime of indecision as I struggled to balance the competing demands of my interests in the humanities and sciences, it was a relief to discover certainty within my heart during this honours year; I loved medicine, but a life of intellectual inquiry was the one for me.

Embarking on a PhD in applied ethics, and mindful of the limited job opportunities in this field, I nevertheless swore early on that no matter what, I’d never resort to “teaching ethics to medical students.” No doubt, I was influenced by the dismal “ethics” classes which I had experienced as a medical student, and the type of impoverished ethics teaching that I characterise as “pseudoethics.” My own intellectual snobbery was also influential; philosophical ethics seemed an obviously superior field to that of “medical ethics.” I felt that nothing could be less personally rewarding and less professionally impactful than summarising “the four principles” for a crowd of students who would rather be learning “real medicine.” I write this narrative in the hope of prompting reflection by others who may be in a similar position, and hesitant to invest time – if not their career – in ethics, for fear of such a desperate fate.

15 years later, I have the privilege and joy of leading one of the most robust ethics, law and professionalism programs for medical students in Australia. Over the past decade, I’ve had to navigate my own biases about ethics, medicine and teaching, as well as external challenges impacting my teaching plans and objectives, while striving to design, develop and deliver effective and appealing ethics curricula for medical students. If there’s one thing I’ve learned, it’s that there is no single formula that will guarantee success in teaching ethics to medical students; everyone must tailor their curriculum to their unique context. Even when you feel confident that you have a reliable learning activity or assessment task, cultural shifts between student cohorts, staff changes, or a pandemic can necessitate significant alterations to your curriculum and approach to teaching.

Early on in my teaching career, I worried most about what to teach medical students about ethics. It seemed irresponsible to leave out discussion of the grounding ethical theories, great thought experiments and ongoing debates about seminal issues, and indeed impossible to teach anything worth teaching without these components. All too soon, I began to understand the appeal – and hence the ubiquity – of the “four principles” approach to medical ethics teaching. Principlism is more easily distilled into a one hour “introduction to ethics” class and can be more readily applied in analysis of cases by students than a similarly abbreviated account of virtue ethics, for example.

However, when I joined Deakin University in 2016 and discovered a much more spacious ethics curriculum, I realised more time was useful, but not the solution to all my ethics teaching challenges. I began to focus more on how to teach, and how to design curricula in which teaching could have an impact. In particular, I worried how best to engage and retain the interest of medical students in the ethics program. For some medical students, ethics can seem a distraction from precious study time as they anxiously cram scientific knowledge and prioritise clinical skills development. With class attendance optional, I soon found little comfort in having curriculum time at the end of semester when many students stayed home to study for exams.

Paying greater attention to the quality of my teaching and learning resources, and focusing more on my broader engagement with students in the program has been valuable in several ways. I soon learned that investing hours of time in fancy slide sets or elaborate learning activities rarely had proportionate benefits in students’ satisfaction or achievement of learning outcomes. Instead, I found that taking the time to make curricula easy for students to navigate, clearly and simply communicating assessment expectations, and pre-emptive action to identify and address potential questions or concerns led to better engagement and satisfaction. Students also seemed happy with basic slides and simple case discussions, so long as the key learning points were clear, and the real-world relevance of learning was apparent.

When considering potential improvements to our program, I now reflect less on what and how I teach, and more on why we teach ethics to medical students. Every program will espouse goals of developing ethical and professional medical practitioners, fostering virtuous conduct and attitudes and so on. These are important goals, and a good ethics curriculum can and should play a key role in achieving them. However, so much of the formation of students’ characters has already occurred, and their experiences in the clinical environment as students and practitioners will typically exert a stronger influence on their values and behaviours than the classes formally dedicated to ethics. What, then, is the point of our ethics teaching?

What can we provide in our teaching and assessment of ethics that will offer more than the basic conceptual and theoretical knowledge that might be acquired through reading a textbook, and more than the practical application of such knowledge which may be more effectively demonstrated in the clinical setting – assuming of course that preceptors there are suitably competent? This vital question now informs the rationale for my own teaching – why do I teach ethics? – and from this, shapes the content and methods of much of my teaching.

The “why” will be different for everyone. Personally, I teach in order to equip medical students with what I believe are essential skills they need to practice medicine ethically, and to support ethical decision-making and action by others. These skills comprise critical thinking, reasoning, and the ability to identify ethical considerations and to communicate clearly when discussing ethics. With these skills, students may be more capable of continuing their ethics education and training as independent learners in the clinical environment, and may be less susceptible to the risks of the “hidden curriculum” of medicine.

Regardless of the foundational concepts, principles or issues being explored in a particular class or assessment task, I strive to stimulate engagement with and evaluation of these skills. While these skills may well be taught and learned in the clinical environment, an explicit focus on their development is less likely in that context. Furthermore, these are skills that educators with specific ethics training and experience are perhaps best equipped to teach at the foundational level. This, in short, is an opportunity for my teaching to have a real impact on students, and hence on the individuals and communities they will one day serve as doctors. I also find this way of teaching more aligned with my earlier career aspirations of engaging in and fostering intellectual inquiry.

I occasionally wince when marking student papers that glibly refer to ‘the four pillars of ethics’ and appear to show that we have, after all, merely taught them psuedoethics. Nevertheless, majority of our students frequently astound me with their insights and the rapid progression of their skills in ethics over the four years of our program. Rather than becoming resigned to teaching ethics to medical students, as I feared when I first obtained an academic job, I have become ever more delighted by this responsibility. Teaching has proven to be an intellectually rewarding experience, and one that I firmly believe has a real and positive impact in the world.

“Looking Back”
Farhat Moazam

I embarked on the journey alone but
One by one they came, we became a caravan

Serendipity can lead to the most rewarding ventures in life. In 2002, as a doctoral student in the University of Virginia, I chose to conduct an ethnographic study on organ transplantation in Pakistan in the Sindh Institute of Urology and Transplantation (SIUT), a public sector healthcare institution in Karachi. Late at night as I sat analyzing my data, Dr. Adib Rizvi, Director of SIUT, would walk in, pull up a chair and we, both surgeons, would compare notes about our day – he his experiences in the OR and clinics and I the moral quandaries I had discovered interviewing patients, families, and physicians. One day, Dr. Rizvi looked at me and said, “Come back to Pakistan. We need a center for what you are studying.”

From that comment germinated the Center of Biomedical Ethics and Culture (CBEC). Inaugurated in SIUT on October 8, 2004, its beginnings were modest – one full-time and one part-time faculty (myself and Aamir Jafarey) and one staff member housed in a narrow L-shaped room with two poky offices – but the goals expansive. The Center would serve as the academic and intellectual resource in bioethics for Pakistan and the region and establish a presence in the international community. Including the word “Culture” in the Center’s name was deliberate. It flagged the emphasis in our educational and research activities on engaging with local cultural values, including religion, and socioeconomic realities that shape personal and professional moral lives. This would serve as a corrective to the philosophical, analytic paradigm dominating modern bioethics.

Today, twenty years later, CBEC has four full-time faculty and over a dozen national and international associate faculty from fields that constitute the core of interdisciplinary bioethics. Over a hundred graduates from the Center’s formal bioethics programs, Master’s and a Postgraduate Diploma, and many more professionals who have attended CBEC workshops, are now in institutions around Pakistan and the region. In 2017, CBEC was designated a WHO Collaborating Center in Bioethics, and began the CBEC KEMRI Bioethics Training Initiative (CK-BTI) program though an NIH grant.

The June 2024 Bioethics Links in your hands today, or on your screen, is a special edition to commemorate CBEC’s two decades of existence. For us, working on this newsletter was a time of self-reflection about who we are. Assembling the content involved ferreting out (scattered) old reports, correspondences and photographs. Heeding poet Robert Burns “to see ourselves as others see us,” we also requested teachers and graduates to share their impressions. A special thanks to faculty Sualeha Shekhani and Farid bin Masood and staff Aamir Shehzad in helping to make this edition possible.

*Professor and Chairperson, Centre of Biomedical Ethics and Culture, SIUT