These are difficult times for all of us. Dealing with patients in busy clinics, complicated rounds and exhausting academic activities has made teaching bioethics no less important but more challenging.

Universities and institutes have begun to at least acknowledge the field of bioethics but on the ground, they still struggle to give it due space and importance in their existing medical curricula. “We do not have time for it in our course.” “Ethics is not an essential topic.”  It is astonishing to see that your colleagues and faculty somehow do not understand the importance of medical ethics teaching for undergraduate and postgraduate medical students.

 And then there is the issue of bioethics pedagogy. In the context of a teaching hospital, the question arises whether ethics should be taught alongside the practice of medicine or as an independent module. Then there is the question of how to teach – through interactive lectures or in a small group discussion? As a teacher,  implementing different modes of teaching into very different setups, from lecture halls to small groups, is challenging for me.  Another difficult question is how to assess students in exams, as content that is taught is generally examined in a systematic way. The pandemic has further complicated the scenario. Social distancing, virtual classrooms and inattentive students have made the fluid and philosophical concepts of ethics even more difficult to teach and understand.

Another challenge is not having enough trained bioethics teachers. The faculty teaching ethics at Ziauddin are clinicians with busy schedules, and also teachers of other medical disciplines.  I have been teaching ethics for 5 years now, while also teaching medicine and working as a busy clinician. At times, it is extremely difficult to manage everything but still, I go on. Despite the challenges, learning and teaching medical ethics has been the most satisfying experience of my life.

“It’s not faith that you need but rationality.” This sentence touches upon one of the central themes in Kazuo Ishiguro’s latest book, Klara and the Sun. Released on March 02, 2021 and longlisted for the Booker Prize, this book is an extension of some of the areas that the Nobel Prize winning writer has previously explored.

The current work, which can be regarded as science fiction, provides a glimpse of a dystopian future in which machines potentially replace human beings not merely for technical purposes but also social ones. Machines now possess the emotional capacity to become friends with human children, specifically those who have been genetically engineered to become more intelligent, or as the book terms it, have been ‘lifted’. This may seem far-fetched but the phenomenon of being ‘lifted’ has parallels in contemporary society: Just as better education for children today is connected to socio-economic status and increased opportunities in life, being ‘lifted’ in Ishiguro’s novel signals higher status and a better chance at life.

Klara, a robot engineered to be an Artificial Friend (AF), narrates the story and it is through her worldview that events unfold. Rather like Ishiguro’s narrators in other books – a butler in The Remains of the Day and a cloned human in Never Let Me Go – her narration brings to the fore the perspective of the ‘other’, making the reader see the world in unfamiliar ways.

A core aspect of the story is the question of what it means to be a person. AF Klara is purchased from a store as a ‘friend’ for a human child, Josie. It is through Klara that the reader learns about Josie’s strange and mysterious illness, attributed potentially to her being ‘lifted’. Through Klara’s eyes, we catch a glimpse of the conundrum that Josie’s mother experiences as she realizes the adverse consequences of ‘lifting’ her child, facing the possibility of Josie dying. But Klara, powered through solar energy, believes that she can save Josie by asking the Sun for magical help. Josie’s mother, however, has an additional motive for buying Klara. She wants Klara to learn every aspect of Josie so that when she dies, Klara can replace her in a new robotic body identical to Josie’s. This is where Ishiguro points his readers to a difficult question: Is it possible for science and technology to replicate an individual in entirety, to fully capture their true essence? As Josie’s father asks, “Do you believe in the human heart? I am speaking in the poetic sense…Something that makes each of us special and individual?”

Ishiguro closely connects issues of personhood and humanity to the contemporary fear that machines will replace human beings. A passerby remarks to Klara in a hostile fashion when she accompanies Josie to a mall, “First they take the jobs. Then they take the seats at the theatre.” Josie’s father is also forced to conclude, “That science has now proved beyond doubt there’s nothing so unique about my daughter, nothing there our modern tools can’t excavate, copy or transfer.”

Towards the end of the novel, Klara ruminates,“But however hard I tried, I believe now there would have remained something beyond my reach. It wasn’t inside Josie. It was inside those who loved her.” Klara reaches a conclusion about what it means to be human, but questions about her own potential personhood remain.

CBEC has been disseminating bioethics education for the past 17 years but we have never really focused on training people how to actually teach bioethics. This gap was highlighted in the research conducted by our faculty Bushra Shirazi in pursuit of her Masters in Health Professional Education degree. Shirazi was exploring the status of undergraduate bioethics education in medical colleges of Karachi and came to the realization that major impediments in actualizing bioethics education in medical colleges included the paucity of bioethics trained faculty and the challenge of teaching bioethics to different cohorts with different educational requirements.

The question of “how to teach bioethics” became the rationale for two Bioethics Pedagogy (BP) workshops run by CBEC faculty at the end of 2021. Applications were invited from our alumni and others who were involved in teaching bioethics at their institutions. The first BP workshop was offered in Karachi in November 2021 and was designed as a hybrid workshop, with 12 participants from Karachi and 12 online, from Kenya, Cameron, Singapore and from other cities of Pakistan. Based on small group work followed by actual teaching, the workshop provided hands-on practice in the use of videos, cases and interactive lectures to teach bioethics, for both onsite and online participants. Sessions were led by Bushra Shirazi and Shahid Shamim, both surgeons and medical educationists with formal bioethics training.

Beginning with lesson planning, the faculty provided an overview on how and where the three educational tools, videos, cases and interactive lectures, could be used optimally while teaching various bioethics topics. Participants were divided into three online and three onsite groups which worked on different modalities, developing lesson plans and conducting teaching sessions.

Our second BP workshop was organized for 12 selected applicants from Islamabad, Peshawar and Lahore and was an in-person event, designed as a full-time 4 day residential retreat in the picturesque setting of the Margalla hills beyond Islamabad. The retreat format allowed much more time for group work and fostered more effective teamwork. Several changes were brought into the structuring of the event based on the experiences and feedback from the first BP workshop in Karachi. The retreat format also allowed the faculty opportunities to explore non-conventional modalities of learning. These included a literary gathering after dinner on one of the workshop evenings, with faculty and participants contributing short stories and poetry that connected to ethics. On another evening students participated in a moral game that highlighted factors that influence ethical decision making, such as personal life experiences, social standing, gender, sexuality, and conduct.

Both BP workshops were very well received by the participants, and the faculty was left wondering why we had not initiated them years ago. With the experience of having conducted two BP workshops using different formats, we realize that there is a need for training opportunities which allow participants to engage with different strategies which can work with a variety of audiences – face to face, online and in the hybrid format. Not only can these interventions be a ‘stand alone’ feature, they can also be integrated on a regular basis into formal academic programs.

“The medium is the message.” – Marshall McLuhan

While teaching an undergraduate course in Karachi on the philosophy of poverty, I asked my students to list down words signifying ‘poor’ in Urdu. Combining their lists, we were able to identify 28 words. Majid Rahnema, an Iranian economist and an expert on poverty, wrote that while there were around 40 words in medieval Latin and more than 30 words in Persian to describe ‘poor’, there were only 3 to 5 words in most African languages, possibly reflecting understandings of ‘poverty’ in different cultures and historical periods.

The ways in which people perceive the world is influenced by the language they speak. Simultaneously, language is shaped by local context and closely reflects the worldviews and lived experiences of different communities. For instance, Eskimo languages have fifty words for snow, English has quite a few but Urdu has just a couple of words. Based on this understanding of language, we can infer that it is not only difficult to translate a text completely from one language to another, it becomes hard to convey the complete essence of some expressions in another language. Furthermore, concepts and notions that originate in a specific time and space are imbued with the cultural and social context of that time and space. This is of particular importance when discussing bioethics on a global scale.

In 1984, medical sociologist, Renee Fox, wrote in her article “Medical Morality Is Not Bioethics” that it was an ethnocentric fallacy to view bioethics as “acultural or transcultural.” She argued that bioethics is a “Western and American” cultural product, not a “neutral and universalistic term.” Writing about the experience of “indigenizing” bioethics in Pakistan, Farhat Moazam and Aamir Jafarey also note that although medical morality is a universal concern, bioethics is conceptually and methodologically rooted in “secular, Anglo-American philosophical traditions.” While the discipline has gained in universal importance, efforts to disseminate bioethics often tend to ignore local context and social realities.

In Pakistan, one of the challenges in teaching bioethics has been the language in which bioethics is disseminated. A number of native languages are spoken across Pakistan, but Urdu is the most commonly understood language. Although higher education is mostly conducted in English – one of the two official languages of Pakistan – the number of people who can actually converse in English is very small. Some subjects, especially scientific ones, are easily taught in English because they mainly require the transfer of factual information or skill. However, teaching ethics requires discourse and argumentation, not merely the transfer of knowledge.

Ali Lanewala, associate faculty at CBEC, believes that it is difficult for people to express ideas in a language that they never use for regular conversation. He recounts that introducing a mix of Urdu and English in his sessions to facilitate interactive discussion transformed his teaching experience. Nida Wahid Bashir, also associate faculty at CBEC, relates that nurses and paramedical staff attending her sessions on medical error and negligence find it cathartic to discuss cases in Urdu, a language in which they can easily express their emotions. Nonetheless, bioethics literature and resources are still primarily in English.

This brings us to another challenge in bioethics pedagogy. When viewed through a different cultural and linguistic framework, some bioethical concepts may not truly connect to lived experience. During a survey at two hospitals in Karachi, Farhat Moazam recalls asking patients in the waiting areas how they would describe a ‘good’ doctor, and an ‘ethical’ doctor. To facilitate respondents, the term ‘ethical doctor’ was translated into Urdu as ‘Ba-akhlaq Daktar’. The results were surprising: using the Urdu term ‘ba-akhlaq’ (ethical) yielded very different connotations from the English word ‘ethical’, possibly corresponding to classical virtue ethics. Participants’ responses mostly characterized an ‘ethical’ doctor as a compassionate, parental figure who cared for patients as though they were kin. There was no reference to informed consent. Moreover, the respondents saw no difference between a good doctor and an ethical doctor, and only 2 respondents mentioned professional expertise as a characteric of a good doctor.

Another example is that of teaching concepts such as ‘rights’ to people who live In a closely-knit, highly interdependent, collectivistic society. ‘Rights’ can be translated  as Haq or huqooq abstractly but the Urdu words carry different undertones, for a haq (right) exists within a relationship and is tied to someone else’s obligation, for instance, the obligation of children to respect their parents and obey them. Hence, several foundational notions in bioethics, such as autonomy, informed consent, privacy, etc., may seem unfathomable, or at least, not fully relatable, when transplanted to countries such as Pakistan.

Teaching and developing bioethics resources in local languages is an important step towards making the discipline accessible. But to become fully relevant, bioethics education has to be rooted in local cultural realities and cognizant of the historical and social trajectories that have shaped the expression of both language and morality.

To read Urdu version of this article, click here

“Double shot, extra hot, please” I said as I ordered my coffee at a Starbucks in Charlottesville, in the vicinity of the University of Virginia. The extra caffeine was required to prime my brain for the discussion that I was about to have with Dr Moazam, who was at that time based in this quaint little university town, completing her PhD with a focus on bioethics from the Department of Religious Studies, University of Virginia.

This was 14 years ago. I had borrowed by brothers’ old van, and driven down from Boston, where I was pursuing my year-long Fellowship in International Research Ethics and the Harvard School of Public Health as a Fogarty Fellow, to meet Dr Moazam. Our one point agenda was a discussion on the yet very nebulous concept of a bioethics centre in Pakistan, an idea floated a couple of years earlier by Dr Adib Rizvi, Director of SIUT where Dr Moazam had been doing her research for her PhD.

I can’t claim that we had at that time envisioned CBEC as it had turned out today, in its early teens now.

But bioethics in Pakistan predates CBEC by at least 20 years. The first formal space for bioethics was created in 1984 in the Aga Khan University (AKU) in Karachi, where Biomedical ethics was gradually introduced in the curriculum of medical students in AKU by Dr Jack Bryant, an American public health physician and the then Chairman of the Department of Community Health Sciences. This was later also extended into the courses of the School of Nursing at AKU. Bioethics thus earned its small space in the classroom in at least one medical institution in the country.

In addition to these educational initiatives, an informal Bioethics Group (BG) was initiated at AKU in 1997 by Dr Moazam, comprising of clinicians and nurses who had an interest in bioethics. The BG, now in its 20^th year, still meets fortnightly over lunch to discuss ethical issues and has emerged as a premier self-education and discussion forum for bioethics.

The late 1990s also saw an enhanced demand for workshops on research ethics, and training for IRB members all over Pakistan, more so from Karachi. The initial awareness and interest in bioethics was limited to research ethics, driven by pragmatic reasons for training people to populate IRBs and open possibilities for external findings for their research, publication and accreditation.  This was not unique for Pakistan, and much of the developing world academia was scrambling to enhance capacity in this area. Many individuals, including this author, availed opportunities through programs focusing on research ethics (with some having a broader focus on bioethics as well) funded by the Fogarty International Centre of the National Institutes of Health of the US government at institutions in Canada, US, and Australia. What is noteworthy is that whereas these were all academics who took time off from their clinical work to pursue bioethics, it was purely based on their own initiative and not as a result of a focused institutional strategy to enhance bioethics capacity, with institutional support limited to granting an extended leave of absence for them. Another interesting aspect in this initial phase of formal bioethics capacity enhancement is that whereas these foreign opportunities were open to all, it was only members of the medical community that availed of them. The people who shaped bioethics in Pakistan were therefore primarily from the medical sciences, and with little no involvement of philosophers, social scientists, religious scholars or lawyers.

In Pakistan, bioethics was born at a medical university, and remained there for about 15 years, fueled primarily by individual efforts. It was only in the early 2000s that it finally became a serious academic discourse with the advent of indigenous, degree awarding bioethics programs, and a wider circle of participants.

The first academic degree program that was offered in bioethics in the country was CBECs Postgraduate Diploma in Biomedical Ethics (PGD) which commenced in 2006 and a Masters in Bioethics (MBE) which commenced in 2010. Whereas both these programs are continuing to date, a Masters in Bioethics program started by AKU in 2009 with NIH funding, ceased after the funding dried up in 2012, and the university did not step in to sustain it.

All these programs have been open to medical as well as non-medical applicants; however have attracted mostly medical scientists, clinicians and researchers with very few social scientists, educationists, journalists expressing an interest in this new emerging discipline in the county. Philosophers and religious scholars, generally seen to be in the leadership of bioethics initiatives in the West, have practically had to be coaxed to contribute to the discipline, as faculty in academic sessions on philosophy and religion, which are integral to any bioethics coursework. Whereas several medical institutions have now taken the initiative of starting bioethics departments, and offer courses at different levels, to the best of the authors’ knowledge, no philosophy department in the country offers courses in bioethics as yet.

From classrooms to boardrooms, being “done” sitting on swivel chairs, bioethics in Pakistan has defined for itself an indoor trajectory and never really taken on the mantle of activism or even advocacy in any sustained and meaningful manner. The one major legislation on a bioethical matter, organ trade which impacted the poorest of the poor, was initiated and spearheaded by an advocacy campaign by SIUT, with the medical fraternity and media contributing. The role of the bioethics community in general was at best, peripheral.

The bioethics discourse in the country has up till now also generally steered clear of “non-medical” ethical issues, like for instance the exploitative displacement of poor communities for multimillion rupee development initiatives aimed for the rich, or bonded labor, honor killings and so on. One reason for this is perhaps the preponderance of medical fraternity in bioethics in Pakistan, and plenty of “hot” issues within the medical domain to discuss.

This rather narrow focus on clinical and research of bioethics is bound to change as non-medical people pursue it as an academic discipline. Already, through CBEC, advances have been made into school systems, with structured workshops being offered to high school teachers, and sporadic sessions being organized for students.

One major challenge for bioethics to emerge as a choice destination for emerging academics is that there is practically no return on investment possibilities at the moment in the country for anyone investing time and effort in a degree in bioethics. There is also still hardly any meaningful “official” recognition for bioethics, with the Pakistan Medical and Dental Council, the College of Physicians and Surgeons of Pakistan and the Higher Education Commission yet to make any space for bioethics in their respective domains. Even with the introduction of academic degree level educational programs in Pakistan, bioethics remains very much a personal quest, with no real career prospects.

This past summer, during my break from school in the US, I was fortunate enough to travel to Pakistan and intern at the Sindh Institute of Urology and Transplantation (SIUT), in the Center of Biomedical Ethics and Culture (CBEC) and the Center for Human Genetics and Molecular Medicine.

At CBEC, I learned about the process of sociological research. I participated in discussions on various topics and worked on creating an updated list of educational films with relevance to bioethics. I was particularly interested in the rights and freedoms available to minor patients, as well as the ethical issues associated with organ transplantation. During my internship, I also led an ethical discussion focused on Richard Selzer’s short story, “Raccoon.” I enjoyed analyzing the many ethical facets of the story with CBEC faculty while uncovering its messages about the physician-patient relationship and about the all-consuming nature of pain.

Although part of my internship was conducted virtually because of a lockdown in Karachi, I was still able to communicate and work as I would have in person. Struggling with certain concepts and asking CBEC faculty questions about their work helped me gain more confidence and improved my communication skills. While interning at CBEC, I began to focus on the importance of bioethics and bioethical education curriculums for young people such as myself. I noticed a lack of materials and resources available to teach bioethics to younger students, and realized the importance of expanding the scope of bioethics discussions to include younger demographics.

Thus, with help from CBEC faculty, I began working on a research project on the perceptions of students in Pakistan and the United States regarding bioethics. Since the lockdown, I have been continuing my research virtually. My goal is to better understand the perceptions and attitudes of young people regarding bioethics while contrasting responses from Pakistan and the United States in order to inform future educational frameworks for teaching younger students about bioethics.

Interning at CBEC has taught me so much about bioethical issues and the gray areas that characterize much of our healthcare system. It has instilled a newfound passion in me for sociology and qualitative research. I am greatly looking forward to completing my research study over the next few months.