I love coffee, it puts me in the right mood, it helps me deal with my morning blues, and helps me get more done throughout the day. I could not get over the fact that I finally found a place that had great coffee and I could have a cup whenever I wanted.

I carried my brimming cup of black brew over to the table and sipped away quietly as everyone else slowly made their way into the room. It was the first day of the PGD course at

CBEC. At 8.00 am, we were introduced to Dr. Wahab Suri, Professor of Philosophy at University of Karachi. He was going to set the stage for the next couple of weeks. He was the opening act, the beginning of bioethics – Philosophy and Bioethics. I examined Dr Suri and watched him as he moved around the room introducing the class to philosophy. Suddenly he stopped in front of me, paused and looked straight at me. “What do you think will happen to you when you die?” Philosophical questions are an effective tool to stimulate and develop critical thought. However, I was not prepared for this question. I had never really allowed myself to think about it. It was something that I was afraid of. I wanted to say I didn’t know, but I was afraid of being judged by a room full of medics whom I had just met. Should I tell the truth, or should I make up an answer? I was silent, he read the fear on my face and the fumbling of my soul through my eyes. He carried on with his lesson. I will never forget my first day at CBEC.

We often do not have the time to delve too deep into ourselves; life’s practicalities and challenges do not allow it, so we adopt thoughts and ideas because it is easier. For the last 17 years, CBEC has been my Wonderland, Oz, and Narnia. I have been ‘Dorothy’ looking for my way home, I have been ‘Alice’ excited and amazed constantly chasing white rabbits, and I have been ‘Lucy’ realizing that I too can be brave and change things. At CBEC I found shade when it was too hot and shelter when it rained, a cup of coffee ready for me whenever I needed it.

At CBEC, you won’t just receive an education; you’ll become part of a nurturing community where you can find intellectual nourishment, support, and a sense of belonging. From exploring humanities to navigating the challenges of pandemics, CBEC offers a space where individuals can reflect, grow, and engage with difficult questions. I have my answer now to Dr Suri’s question, I am no longer afraid to think about difficult questions nor afraid to speak up. All I need is my cup of coffee.

I did my postgraduate diploma in Biomedical Ethics from CBEC in 2010. At that time, I was working as an Assistant Professor at the Department of Dermatology, Ziauddin University (ZU), Karachi. It was an amazing experience.

Being a science student all my life, my brain had been programmed to look for facts, realities and theories which meant that I always got clear answers to my queries. But the most shocking part for me as I pursued the PGD was the realization that there can be no one, clear-cut answer in any case of ethical dilemmas and moral quandaries. The purpose of class discussions was to make us “think.” It took me weeks to adjust and realize that I was the one asking odd questions in my search for the right answer in every session.

Before I learnt anything at CBEC, I had to follow the process of “unlearning.” I had to unlearn a belief that “I am always right” and that “everyone will accept my perspective.” CBEC created a feeling of unease, which is necessary to reflect upon the decisions we make whether in a clinical setting or while conducting research.

CBEC Faculty including Dr. Moazam and Dr. Aamir created this alternative world for people like me which changed us from the core. I found that your mentors can be your guides, friends and advisors all at the same time. I received guidance from faculty as I embarked upon the task to develop procedures and refine the working of the Ethical Review Committee (ERC) at ZU.

Over the past twenty years, CBEC has done a commendable job in educating healthcare-related professionals. One cannot ‘undo’ what I learnt there. While I am no longer in Pakistan, what I learnt at CBEC guides me while doing my clinical practice in Dubai, whenever I face dilemmas related to patients presenting with sexually transmitted diseases, or when I’m dealing with pharma companies. Thank you for creating this alternative world and for helping us to bring positive changes in clinical and research settings in Pakistan.

It was a hot summer day when a senior colleague from my medical school suggested that I consider enrolling for a course on Biomedical Ethics at CBEC in Karachi. With little prior knowledge of the content and nature of the course, I appeared for the interview knowing little that this small event was about to change my life forever. I had never been part of such a focused and meaningful interview with questions that targeted areas of the medical profession that had always perplexed me. The interview struck a chord in my heart. I was instantly hooked.

What transpired during my PGD year was a journey to learn, unlearn and explore. People hold onto their beliefs dearly and stubbornly, but if provided a safe and stimulating environment, it’s not uncommon for people to open their minds and expand their hearts to ideas contrary to their long-held notions.

Adult learning in general and medical education in particular have seen remarkable changes during the last three decades and it was refreshing to witness how faculty at CBEC merged traditional styles of teaching with contemporary methods of learning. Our modes of learning ranged from student-led teaching to facilitated group discussions. Using videos as teaching tools was significantly effective in stirring interesting debates around ethical issues. A broad-based curriculum was backed by a diverse faculty instrumental in delivering the course in its true spirit and meaning. It was mentally and emotionally challenging to cover topics across the spectrum swinging from philosophy and law to children and women rights. An important aspect of the course was how the historical background of biomedical ethics was connected with modern debates around organ donation and artificial support technologies. It was fascinating to define “life” and “death” from both philosophical and scientific paradigms. As a learner, I was intrigued by formal and informal feedback I was provided through length and breadth of the course. It provided an insightful perspective on my strengths and shortcomings both as a student and as a teacher.

Learning extended beyond classrooms through informal interactions with colleagues and faculty over tea and meals providing ample opportunity to clarify concepts. It also brought to the fore a much more relatable human interaction based on mutual respect and trust. Visits to the historical sights like Makli graveyard and Shah Jahan Mosque helped in “switching off” from rigours of dense coursework and building camaraderie among classmates.

Beginning of the PGD course was unsettling as it opened doors to uncertainty and unpredictability. But as the year drew to a close, initial confusions were replaced by a reassurance that in real life, it’s important to shun conviction and embrace complexities. Human lives are not simple and our interaction with medical science provides more questions than answers. As a healthcare provider, it’s paramount to stay humble and curious.

In 2023, when I decided to enroll for the PGD in Biomedical Ethics at the Centre of Biomedical Ethics and Culture, I wasn’t sure what to expect. I certainly did not realize that I would spend a significant amount of time studying and nor did I imagine the profound impact the year would have on me. Throughout the year, we confronted new challenges brought about by advances in science and technology as well as diverse and shifting societal values. I came to understand Heraclitus’s adage that “change is the only constant.”

The year breezed by quickly and before I knew it, we were appearing for the final exam. By this time, I had a clearer idea of what I wanted to do with the new knowledge that I had acquired. I decided to not only incorporate this into my daily clinical practice but also make my colleagues within my pediatric nephrology clinical unit aware of basic knowledge in bioethics so that we could become better, ethical physicians.

My PGD journey has taught me that while empirical evidence may not always provide clear-cut answers to ethical dilemmas, it can serve as the foundation for constructing well-reasoned arguments. Equally important, the PGD has developed in me the capacity to listen to a person sitting across from me, to understand her point of view and not just respond.

For me ultimately, bioethics should be a life-long commitment to personal growth that contributes to the betterment of society.

Bioethics is about value judgements that we make in life. My awakening to this fact goes back to my early service as an army physician in the mountains of Kashmir and deep inside Baluchistan, where I increasingly found myself thinking about the “why” and the “how” of distributive justice in local communities where “most in need are found with the least” especially in health.

This aroused my curiosity and led me to search for a robust understanding of issues of fairness and justice. In 2014, I discovered an online course “Introduction to Bioethics” from Georgetown University in the USA. Instead of quenching my curiosity, this course increased it further, and I started searching for formal bioethics programs in Pakistan. My search led me to the Centre of Biomedical Ethics and Culture (CBEC) located in Karachi. I followed it with full zeal and was admitted to its PGD program in 2016.

CBEC’s existence in Pakistan turned out to be a blessing. One year spent in CBEC and the level of education there truly enlightened me “On what matters,” to borrow the title of Derek Parafit’s book.

I consider 2016 an important year of my life which transformed the way I look at human interactions, rights, values, perspectives, and contexts. I learned that intellectual flexibility and humility are the greatest of virtues.

Seven years on, post-PGD, my life is different and interesting. The knowledge gained in 2016 has helped me to further my learning by teaching a few modules on bioethics to newly inducted physicians-in-service. I have conducted and co-facilitated a few workshops and guest lectures for different specialties  in  various  hospitals.  PGD has also honed my writing skills. Since 2016,1 have published articles in scientific and popular science journals on subjects focusing on the ethics of healthcare in military settings and, those pertaining to artificial intelligence.

My journey continues. I yearn for a day when I can return to CBEC as a student of the Master’s program, an opportunity I missed in 2018 due to work commitments. I would like to not only further my knowledge in the field of bioethics but to engage with more fundamental questions related to human existence in the world.

As a Kenyan human rights lawyer with an interest in research ethics, my decision to embark on the PGD in Biomedical Ethics from Centre of Biomedical Ethics and Culture in January 2020 marked a significant departure from the conventional academic trajectory. This choice catalyzed not only my academic journey but also shaped the profound intellectual and professional expedition I would experience that would lead me to scrutinize assumptions previously held dear from a legal standpoint.

From grappling with foundational concepts to dissecting intricate case studies, each module of the program prompted  me  to  critically  reassess  real-world  medical dilemmas through a novel perspective. I discovered the inherent limitations of the law in navigating decisions within medical practice. Despite initial hesitation about transitioning to virtual learning following the first on-campusmodule due to the COVID-19 pandemic, this shift did not dilute the rich discourse integral to CBEC’s bioethics pedagogy.

Throughout the intensive year-long program, I gained invaluable insights into the pragmatic aspects of ethical decision-making. While the world grappled with the COVID-19 crisis, I found myself captivated by the allure of bioethics. Whether reviewing research protocols for ethics review committees, teaching in CBEC-KEMRI Bioethics Training Initiative (CK-BTI) certificate courses, shaping policy and legislative frameworks in my human rights endeavors in Kenya, or advocating for ethical standards in everyday interactions, ethical values permeated my approach.

I came to recognize that the influence of the PGD program transcends the boundaries of mere coursework. It inspired me to spearhead initiatives aimed at fortifying research ethics and championing the rights of marginalized communities in research and healthcare settings in my country, thus expanding my engagement with bioethics beyond the confines of my legal expertise.

This transformative journey culminated in the conceptualization of my first solo manuscript, grounded in my PGD project—an achievement that will (once published) not only validate my academic journey but also underscore the pertinence of bioethics in shaping my voice and contribution to contemporary discourse. Presently enrolled in a Master’s program in Bioethics at Amref International University Nairobi, I am positioned to actively contribute to teaching, research and the advancement of bioethics in Kenya and the wider African region.

I am humbled by the depth of bioethics knowledge acquired and the network of like-minded individuals forged along the way. Armed with the ethos of the PGD program and the ethical principles espoused, I embark on future endeavors in both my professional and personal spheres.

With two surgical fellowships and an interest in medical education, I thought I was destined to become an academic surgeon. While involved in teaching ethics to my surgical residents, I felt the need to learn more about bioethics. Hence, in 2008,1 joined the PGD in Biomedical Ethics at the Center of Biomedical Ethics and Culture (CBEC), which broadened my understanding of the intricate dilemmas in healthcare practice and research. Through engaging discussions and real-world case studies, I gained a deep appreciation of the ethical values and principles that underpin every aspect of medical practice. Little did I know then that this transformative journey into the world of bioethics would eventually shape my professional trajectory.

As I explored the field of bioethics further, I became increasingly fascinated by the intersection of bioethics and medical education. I realised that ethical competence among healthcare professionals is not merely a desirable trait but a fundamental component of high-quality patient care. This realisation inspired a profound shift in my career from a surgeon to an educationist, with a focus on integrating bioethics education into healthcare curricula and training programs.

The lessons I learned through my affiliation with CBEC during and after the PGD also enhanced my understanding of the application of educational theories. The opportunity to learn alongside individuals from diverse backgrounds, including philosophy, law and sociology, enriched my learning experience. Additionally, it provided me with a holistic perspective on the interconnectedness of social, cultural and ethical factors in healthcare education.

My experience at CBEC served as a catalyst for my doctoral research on ethics in medical education and in exploring innovative pedagogies and strategies for introducing bioethics to medical students and healthcare professionals. I am grateful to CBEC for an experience that laid the foundation of my commitment to promoting bioethics in healthcare.

Anaesthetists are the energetic souls of operating theaters, rushing around, chattering and muttering, with the constant beeping of monitors and assorted equipment. They change the environment of the OT from barren fields to combat zones where the single aim is to achieve patient care and safety.

It was May 2017. I was told arrogantly by a surgeon colleague to anaesthetize a female patient without taking her consent. I knew from the core of my heart that this was wrong even though I did not possess formal education in bioethics. We are not taught ethics during medical college and there was no one at my institute whom I could turn to for information or support. I resisted and recorded the event in my notes.

This episode led me to join the PGD in Biomedical Ethics program of CBEC-SIUT, where I was to learn that the field of ethics extends beyond informed consent. During the year I spent at CBEC, my perspectives of ethical issues and dilemmas related to research and clinical practice were completely transformed.

After completing my PGD project of introducing the fundamental principles of bioethics to postgraduate trainees of Anaesthesiology, I realized I could still do even more in sensitizing my colleagues including trainees and faculty members from other medical disciplines. Since then, I have continued ethics education cycles every year. My quest continues although it’s not easy to make cracks in rigid dogmas and firm beliefs that people hold. I believe however, that my journey will bring change in the system if not today then tomorrow.

I first heard the word “Biomedical Ethics” from a friend who suggested that I should pursue a diploma in this subject from the Centre of Biomedical Ethics and Culture in SIUT. I was confused. I remembered that during high school and college, only non-Muslim students were required to take ethics as a subject whereas Islamic Studies courses were mandatory for Muslim students. However once I obtained the necessary details, I was convinced that I needed to apply and learn about ethics.

During my interview with Dr. Moazam and Dr. Aamir Jafarey, I recall mentioning the recent theft of a car from my 15-year-old son. Dr. Moazam asked me, “Isn’t it illegal to drive before 18 years?” I felt ashamed but at the same time, I thought to myself, “Acha to yeh doctoron ko sudharte hain [So they work to improve the moral conduct of physicians].”

My experience while doing the PGD was wholesome with wonderful faculty who left me wondering, “Aisay log Pakistan me hote hain? [Do people like these still exist in Pakistan?]” Throughout my education, I had only experienced  traditional  methods  of  teaching  involving didactic lectures. At CBEC, I was exposed to interactive sessions, role-plays and learning through videos. Philosophical and religious discussions made everything more interesting. I have fond memories of my time there and I still miss those days.

I was fortunate to have a colleague who had already begun efforts to introduce ethics at my university Liaquat University of Medical and Health Sciences (LUMHS) in Jamshoro. Following my graduation from the PGD, I began to work on the foundation laid there by my colleague. A couple of years later, LUMHS became the first public medical university in Pakistan to incorporate bioethics formally in medical education curriculum for medical students.

Initially the response of students and faculty was mixed with a few dismissive of the importance of ethics. For example, when we taught informed consent, some voiced that as doctors they know the best since they know about the patient’s disease. They would ask questions like, “Why should we tell patients everything and let them decide?” However, gradually these discussions gained acceptance among faculty and students alike.

My colleague and I also established an Ethics Review Committee at my university with the support of CBEC faculty. Human subject research, mandatory for major degree programs, was being conducted without ethics approval. The administration considered ERC a hurdle for students instead of realizing its importance for the protection of human participants. However, over time, the ERC became well established in the institution although running it still has its share of problems.

All is well that ends well. At present, bioethics education remains an integral part of the undergraduate curriculum at LUMHS, and the ERC continues to work well. In the future, we have plans to establish a Centre of Bioethics and Professionalism in our institution and have already received approval from our Academic Council.

The Diploma in Biomedical Ethics from Centre of Biomedical Ethics and Culture in 2014 has opened new horizons for me. In 2021, European Society of Medical Microbiology and Infectious Diseases (ESCMID) had a position in their Ethics Advisory Committee for a representative from low-middle- income country (LMIC). The CBEC faculty encouraged me to apply for it, provided reference letters and I was selected.

My involvement with ESCMID has grown over the years with a special focus on engaging with ethical issues within infectious diseases. During the annual congress of ECCMID held in Portugal in 2022, I chaired a session on “Ethical issues in Infectious Diseases (ID).” I also involved Dr. Natasha Anwar (CBEC MBE Alumnus) and Rehan Khan (ID pharmacist from Lahore) in the conference who highlighted the inequities in COVID-19 vaccine distribution and access to antibiotics from an LMIC perspective.

In the following year, ECCMID was held in Denmark and I presented a study about the low LMIC representation in ID scientific journals, highlighting barriers such as language, colonial mindset and lack of mentors for research. In the most recent Congress, CBEC had a prominent presence. I chaired a session on “Clinical practice guidelines on ID: present and future” in which I stressed upon the lack of experts from LMICs in development of guidelines, cost considerations and access to diagnostics and treatments particularly newer antibiotics. An ID colleague as well as a CBEC PGD alumnus, Dr. Amjad Mahboob gave a talk, highlighting language barriers as one of the factors for the lack of research on neglected tropical diseases.

While doing my diploma, I had not imagined that ethics could contribute in such significant ways to my field, and that the PGD would prepare me to present Pakistan at an international level.

My journey continues. From next year, the Ethics Advisory Committee plans to initiate an online course on biomedical ethics on a regular basis targeting ID doctors and microbiologists. Our hope is to help them understand that the specialty of ID poses unique ethical and social challenges.

As a rookie house officer in a hospital in Karachi, one of the consultants asked what I would do in a case being discussed during a grand round centering on allocating resources between two children. One was a child whose parents had sold everything to keep him alive for a few more months versus a child who had a greater chance of living a longer life. I remember my righteousness, the consultant playing the ‘devil’s advocate’ and the conversation ending with my feeling furious.

My formal introduction to the subject of ethics came in 2016 when I joined CBEC for the Postgraduate Diploma in Biomedical Ethics. Like many physicians, I thought most issues are clearly defined but I learned otherwise during thought provoking sessions at CBEC. Following graduation, I served on the research ethics committee of my university and also helped in establishing a clinical ethics committee. My colleagues and I introduced bioethics in the university’s curriculum and conducted sessions with undergraduate and postgraduate students.

After 12 years, I moved to the UK to widen my surgical horizons. When asked to give an introductory presentation during the grand round as a new consultant in London I chose to talk about ‘“empathy.” The attendees included paramedic  staff,  medical  students,  house  officers  and consultants from different specialties. Noticeably, not a single surgeon was present. Many attendees approached me during the tea break to continue the discussion, inquiring about the situation of bioethics in Pakistan.

The healthcare system in the UK has defined policies but there is room for improvement. During COVID-19, I was the lead of emergency surgery in London. I remember junior doctors and nurses approaching me, scared and near tears, worried about themselves and their families. They were concerned that the Matron had asked them to not wear masks as this would frighten patients and spread panic.

Following my discussion with the Matron that patient care would be affected if the medical staff felt unsafe, she changed her stance and the Infectious Disease consultants sent out an official email to the Trust making mask-wearing mandatory in clinical spaces.

I attend webinars on ethics to keep myself updated, and participate in regular multi-disciplinary team meetings to address ethical issues. And I find myself always going back to what I learnt during my year at CBEC.

In 2014 CBEC completed its first ten years. Dr. Moazam requested Dr. Adib Rizvi, Director of SIUT, to organize a formal external assessment of the Center’s programs and activities. An External Review Committee (ERC) was constituted including national and international scholars with expertise in areas relevant to bioethics education and research. (See Box on right) The reviewers undertook an onsite visit to CBEC from May 7-10 to meet faculty, students, and alumni. Their report to Dr. Rizvi highlighted the Center’s achievements and challenges, and included valuable recommendations for the future. (See article by Dr. Alastair Campbell, ERC member).

As part of the external review process, three individuals closely involved with the Center since its inception were also asked to submit their impressions to the ERC. Brief quotations from these are presented here.

Dr. Renee C. Fox, Medical Sociologist, Professor Emerita, University of Pennsylvania, USA:

The accomplishments of CBEC “in the course of a mere decade of existence is extraordinary.” She noted that the Center’s “knowledgeable perspective on culture(s) is one of [its] most distinctive (and in my view, exemplary) attributes. It is a perspective that is minimized or marginalized … by many other bioethics centers.” Commenting on CBEC’s educational programs, Dr. Fox stated that “there are relatively few [existing centers and programs] in which such deep-structuring learning takes place.”

Dr. Paul Lombardo, Legal Historian, Professor of Law, Georgia State University, USA:

He highlighted what he considered unique features of CBEC’s educational programs. One is the “fine balance [that] is  struck  between  didactic  teaching  …  [and]  with  the exploration of how ethical norms may be applied in the clinical setting.” This is something “programs in the West and elsewhere, fail to find …” The second is the “constant attention [given] to the religious and moral bases of ethical behavior…” and the role these personal values “play in [the] lives [of] health care practitioners.”

Dr. Judith P. Swazey, Independent Scholar, Adjunct Professor Boston University, USA:

She commented on the Center’s video series, “Local Moral Worlds,” as “excellent teaching vehicles” for “courses in bioethics and/or social sciences and medicine.” She also appreciated CBEC’s reaching out to “a wider public audience through ventures such as CBEC Forum and Ethics and Culture Hour.” While commending the “very small faculty” for its “drive, commitment, knowledge and skills” to accomplish what it had in one decade, she highlighted (as did other reviewers) the urgency of recruiting more faculty.

EXTERNAL REVIEW MEMBERS:

Dr. Richard Cash
Harvard School of Public Health, USA

Dr. Amar Jesani
Editor, Indian Journal of Medical Ethics, India

Dr. Mala Ramanathan
Anthropologist Researcher, Sree Chitra Tirunal Institute, India

Dr. Alastair Campbell
Director, Centre for Biomedical Ethics, National University of Singapore, Singapore

Dr. Rizwan Azami
Vice-President, College of Physicians and Surgeons Pakistan

Dr. Aasim Ahmed
Chairperson, Bioethics Group, AKU, Karachi, Pakistan

Dr. Tasleem Akhtar
Professor Emeritus, Khyber Medical University, Peshawar, Pakistan

Dr. Asma Fozia Qureshi
Chairperson, Department of Medical Education, SIUT, Karachi

Over the past two decades, CBEC’s research portfolio showcases a remarkable diversity. This reflects not only the varied interests of the faculty but also illustrates the academic liberty provided to faculty, unconstrained by international funding requirements, to engage in relevant conversations within bioethics.

Four thematic areas prominently emerge from CBEC’s work:

Ethical Issues Related to Kidney Donation: Given CBEC’s association with SIUT, organ transplantation has been a natural focus leading to several publications. Faculty research includes public perspectives on deceased kidney donation in Pakistan, a country where demand for organs far exceeds the supply. During Pakistan’s notorious years as a kidney bazaar, CBEC conducted an ethnographic study in rural Sargodha, Punjab, a kidney trade hub. Conversations with kidney vendors provided insights into the socioeconomic hardships driving organ sales.

Gender-related Issues: CBEC has explored gender debates through a sociocultural lens. One notable study examined why many female medical graduates do not enter the workforce, amid concerns over Pakistan’s poor physician-patient ratio. The study found that ingrained gender roles and the societal importance of marriage contribute to this trend. An abridged version of this study later appeared in the national lay press as well, stirring public discourse. Building on the study with medical students, faculty are now exploring perspectives of male and female surgeons about women in surgery in Pakistan,

Mapping Research Ethics Structures: CBEC undertook mapping Pakistan’s research ethics governance structures, assessing the number, structure, strengths, and weaknesses of ethical review committees. This effort aimed to highlight the research ethics landscape in Pakistan, and provide an evidence base illustrating the variation in the quality of ethical review across institutions, with hopes of informing policy for the national accreditation of ethics committees.

Ethical Issues in Clinical Medicine: Ethical issues in clinical practice such as informed consent, privacy, confidentiality, and disclosure have been explored, and how these concepts manifest within Pakistan’s cultural realities.

These thematic areas underscore CBEC’s commitment to addressing pressing bioethical issues through diverse and methodologically varied research but with a Pakistani twist.

The idea that led to the germination of the Centre of Biomedical Ethics and Culture at SIUT began as an informal discussion over coffee in the spring of 2003 in Virginia, USA. Having put my surgical career on hold for pursuing a fellowship in International Research Ethics at the Harvard School of Public Health while Dr. Moazam was writing her dissertation for her PhD in Religious Studies with a focus on cross-cultural bioethics at the University of Virginia (UVA). She mentioned in her emails to me about Dr. Adib Rizvi’s desire to have a centre for bioethics at SIUT.

As we sat there on the bench, we envisioned that the centre would offer academic courses in bioethics relevant for the country. How we would do this, was not clear to us at that time. As it happened, Dr. Rizvi was attending a transplant conference in Boston and asked Dr. Moazam to fly over to meet him there to take the discussion forward. Over lunch of daal chawal [lentil curry with rice] and other desi dishes in a food court, we discussed the establishment of Pakistan’s first bioethics centre. Not interested in details of how and what, Dr. Rizvi simply said, “shuroo karo [Just start it].”

I joined SIUT in June 2004, as a part-time faculty of the centre, continuing my work as a general surgeon at the Aga Khan University. Dr. Moazam was still in the US finishing her thesis. We communicated through daily, lengthy emails in which we set about planning what the Centre would do.

The Centre of Biomedical Ethics and Culture was inaugurated on October 8, 2004, for which Dr Moazam flew back to Karachi. She formally joined the centre full-time in early 2005. Our first academic venture was the conference, “The Evolution of Moral Thought: From Greeks to Contemporary Bioethics” held in April 2005. The interest of the public took us by surprise indicating a genuine interest in bioethics in a more formal fashion.

In order to develop an academic program, we conducted a needs assessment survey targeting medical university hierarchy. Our findings indicated a widespread interest in the subject. However, busy healthcare professionals did not appear to be keen on full-time enrollment. This was reasonable since a degree in bioethics at that time would not have secured employment or advanced careers in existing fields. Realizing this, we devised our Postgraduate Diploma (PGD) in Biomedical Ethics, initiated in 2006, as a blended one, with four on-campus modules and asynchronous distance learning between the contact sessions.

Twenty years on, as I reflect, it is amazing how a faculty of 1.5 and a staff of one, managed to do so much. In the year 2005  alone,  we  were  involved  in  41  events  including workshops in Karachi and elsewhere, international conferences, Socratic Hours, Ethics and Culture Hour, and clinical ethics rounds at SIUT.

Similarly, in 2006, when we launched the PGD program, we were involved in 40 different events, both nationally and internationally. Now in 2024, with more faculty and 3 full-time staff members, while we are much better placed as far as hands on deck are concerned, we continue to be stretched thin.

Our portfolio of work has increased severalfold over the years. Since 2017, as a WHO Collaborating Centre of Bioethics, CBEC contributing to WHO-directed projects and missions. In collaboration with Kenya Medical Research Centre (KEMRI), in 2017, we initiated the CBEC-KEMRI Bioethics Training Initiative (CK-BTI), funded by Fogarty International Centre of the National Institutes of Health USA. This program is now in its 7^th year and second funding cycle

We have managed to maintain our standards as we have expanded our canvas. However, one centre can do only so much. Our alumni are expected to carry the flame further as we continue to offer our academic programs, broadening the scope of what we do in order to meet the requirements of changing times.

A big black hole – that was what bioethics seemed like to me. You sent in a research protocol for review to an ethics review committee. You waited with bated breath. You did not know when you would get a response or what it would look like. You dared not ask questions of the secretariat or the chairperson. It was all “hush hush.” And their word was final, even if it looked like the questions asked did not seem related to the protocol you had submitted. Like a big black hole, if you dared to stick your hand into it, you might be bitten and would not even know what had bitten you.

My frustration as a medical researcher sent me down a path of trying to understand bioethics. Why was bioethics important and how could systems that were critical to the conduct  of  research  be  responsive  to  the  needs  of researchers in Kenya? After four failed admission attempts for “administrative and other reasons” I finally got into the University of Cape Town’s ‘IRENSA” NIH Fogarty-funded Diploma in Research Ethics. Completion allowed me to “sit at the table” and initiate discussions on improving systems at my institute KEMRI. But that was not adequate to quench my thirst for bioethics training. I needed more.

I started seeking a Master’s level training. Unfortunately, most programs required a one-year full residential stay in the country in which the university was based. No training programs were available in Kenya. The Centre for Biomedical Ethics and Culture was the only institute that offered Master’s level education in a blended format. This was a perfect fit for me as I had significant administrative responsibilities as the Deputy Director at my institute.

I decided to apply, unaware that until then their training had been focused entirely on Pakistan. Fortunately, I passed the stringent preliminary examinations required and was subsequently accepted as the first non-national scholar in the Master’s program. After two years of intensive learning and empirical research, I realized that there still remained a gap in capacity building in Kenya. The CBEC program with its alternate year intake and the limited number of trainee slots for international scholars was not going to be able to water the desert sufficiently to yield adequate harvest from the Kenyan soil.

An idea of a partnership between KEMRI and CBEC took root and was pruned over a couple of attempts to yield fruit as a successful NIH grant award: The CBEC KEMRI Bioethics Training Initiative (CK-BTI). This has resulted in over 700 trainees from a variety of backgrounds trained in various certificate courses designed to improve knowledge of research ethics committee members, researchers, clinicians and other healthcare-related professionals.

Two Kenyan universities are currently approved to offer Master’s in Bioethics and the CK-BTI continues to build capacity by providing pedagogy training for the faculty at the two universities. Through this, we hope that we will continue to water the ever-growing tree of bioethics in Kenya by fueling it with innovations in teaching and education.

Let me begin by offering my sincere and enthusiastic congratulations to all the CBEC faculty, staff, and students on the centre’s 20th anniversary. One of the highlights of my academic career has been the opportunity to visit CBEC in 2023 to participate as a visiting faculty member.

I received my December 2023 copy of Bioethics Links the very week in which I was invited to write a brief word on my experience as a foreign faculty member at CBEC. That issue contains a photo of the graduating class of 2023, the very students who were present during my visit. I’ve enjoyed perusing that photograph and reflecting on the many wonderful exchanges I had with faculty and students during my time there. I’m sure I learned more from those brief encounters than what I was able to impart to all those with whom I had the pleasure of interacting.

There are more wonderful experiences to comment on than what I’m able to do in the space available here, but I will note briefly some of the highlights. I was particularly impressed by the caliber of the students enrolled in the academic programs, many of whom are senior clinicians. It was exciting to be part of a bioethics program that is having immediate and enduring impacts throughout South Asia, North Africa and beyond. Drs. Moazam, Jafarey and others have created a safe and stimulating environment for rigorous intellectual exchanges amongst those from varying cultural and religious traditions.

Aside from the academic experience, the cultural experience was extraordinary. I enjoyed unparalleled hospitality during my short stay, and I particularly enjoyed the communal lunches which provided opportunities to get to know a few individuals on a more personal level. I was treated to a tour of the impressive hospital in which the Centre is housed, as well as a local museum. It was exciting to experience some of the local culture including a wonderful meal at a seaside restaurant. Some of that excitement, I must admit, might be described as ‘anxiety’ as our various drivers navigated the Karachi traffic at what seemed to me to be an exceedingly rapid pace.

The only negative aspect of my visit to CBEC was related to the time it took to journey half way around the globe to get there, and then the challenge of adjusting to the jet lag. If I were to visit again I’d plan to come a few days earlier so that all of the above-noted positive experiences would have been even more enjoyable with a well-rested body and mind. Again, my heartfelt congratulations to everyone at CBEC. I wish a continuing success in your next 20 years and beyond.

The year 2024 marks two decades since the establishment of the Center for Biomedical Ethics and Culture (CBEC) at the SIUT in Karachi, a commendable milestone worth celebrating.

Founded in 2004, the Center is not only one of the oldest and most prestigious institutions working on bioethics in the region, but it has developed an excellent reputation at an international level, with notable contributions in areas such as ethics of organ transplantation, research ethics, global health ethics, and clinical ethics.

It is the only Center in Pakistan and the Eastern Mediterranean Region dedicated to enhancing education and research in bioethics through formal degree programs in bioethics (offered free to make them accessible to everyone), constituting an extraordinary resource for Pakistan, the region, and the whole world. One of CBEC’s distinctive features – as indicated in its title – is its focus on exploring the intersection of culture and ethics, recognizing the significant role of cultural contexts in ethical reasoning.

The collaboration of the Centre with the World Health Organization (WHO) on health ethics reaches all the way back to its inception, as Professor Farhat Moazam, CBEC’s director, served on WHO Expert Groups on ethics of organ, tissue, and cell transplantation in 2003. Since then, CBEC has been intensifying its joint work with WHO, both with Geneva Headquarters as well as the Cairo Regional Office, in various areas. In recognition of its excellence and collaborations with WHO in diverse areas, the Centre was designated a WHO Collaborating Centre for Bioethics in 2017, making it the first one in the entire Eastern Mediterranean Region (EMR).

The Global Network of Collaborating Centres on Bioethics was initiated in 2009 recognizing that many ethical issues are inherently global in nature, and in today’s world require a global understanding and joint response at an international level.

Since joining this Network and the WHO family in 2017, CBEC has been of key importance for WHO’s work in Bioethics. First, for WHO Headquarters at the global level, CBEC  has  been  providing  crucial  contributions  to  the formulation of WHO guidance documents and policy frameworks, in areas such as ethics of emergencies and epidemics, fostering National Ethics Committees, research ethics, and organ and tissue transplantation. In doing so, it has been representing a unique regional perspective and voice and strengthening an intercultural approach to bioethics.

Furthermore, at the regional level, CBEC has been a key institution for fostering collaboration in bioethics, supporting the Research Ethics Committee, and providing a unique hub for educational and regional training initiatives in bioethics within the EMR. More recently, it has also been strengthening collaborations across regions, for example with Africa.

In summary, CBEC’s two-decade journey reflects a strong commitment to advancing bioethics education and research in Pakistan and beyond, with numerous contributions to global bioethical initiatives and partnerships – it is truly a unique Centre.

WHO owes deep gratitude to all the faculty members of CBEC for their expertise and their unremitting support in advancing WHO’s agenda on health ethics, with special thanks to the two co-leads of the WHO Collaborating Center, Professor Farhat Moazam and Professor Aamir Jafarey. It is hoped that in the next 20 years, CBEC will continue to thrive and deepen its collaboration with WHO.

When Dr. Farhat Moazam invited me to visit Karachi in 2004 to speak at the inauguration of CBEC, I was thrilled that I would be visiting a part of the world that I knew only from newsreels and travel photos. I assumed I would be making a few talks, seeing a few sights, and collecting an unusual stamp in my passport to display as I reported my experiences at a destination that would prompt remarks from friends and colleagues.

Next winter I hope to make my 10th visit to Pakistan, with an entirely different set of expectations. On my first trip, I was treated as a special guest alongside visitors whose achievements should have earned them far more deference than I could claim. Since then I have learned that the warmth of hospitality is a hallmark of Pakistani response to all guests. The relationships I have developed with friends and valued colleagues in Pakistan draw me back time after time.

But the trajectory that CBEC has followed is much more important than my impressions as a visitor. It began as a small outpost on the subcontinent that trained a handful of physicians and others in the health science world to think clearly as they confronted the complex bioethical questions raised all around Pakistan. A critical mass of well-informed CBEC graduates has now developed into a cohort of experts who serve in all regions of the country. In two decades, CBEC has become a well-recognized hub for training, consultation and access to expertise on crucial issues.

CBEC has also developed an extraordinary outreach program, including a joint training venture that has sent CBEC faculty to Nairobi, Kenya, and has brought Kenyan students to Karachi to further enrich the mixture of those who matriculate in the bioethics curriculum. The Centre has published a series of educational videos and is regularly represented in academic journals and through presentations nationally and internationally. It would have seemed foolhardy twenty years ago to predict this level of success.

I have had the good fortune to teach each of the current faculty members at CBEC as they received their training in bioethics, and to watch them grow over the years into seasoned teachers themselves whose work is recognized far beyond SIUT and the Karachi community. Over forty years of teaching I have often been reminded of the comment of American historian Henry Adams: “A teacher affects eternity; he can never tell where his influence stops.” I am proud to have been associated with a place where I had a small hand in creating the big splash that CBEC now produces. I am confident in saying that the influence that these efforts generate in many parts of the world will outlive us all.

The Centre of Biomedical Ethics and Culture (CBEC) in SIUT, still the only center in this discipline in Pakistan, will celebrate its 20th anniversary this year. Soon after the Center’s inception, Dr. Manzoor Ahmed, my teacher and the doyen of philosophy in this country, introduced me to Dr. Moazam and since 2006, I have been part of CBEC’s teaching faculty. During the Foundation Module, I introduce basic philosophical concepts, and their deep, historical connection to ethics, to students enrolled in the Center’s Postgraduate Diploma and Master’s in Bioethics programs.

human subject research or are practicing physicians who take care of patients and fight to save their lives. They are therefore individuals responsible for making decisions that can have serious moral and social consequences. Among my challenges is to help students realize the relationship of the biological human body with human metaphysical and social domains, and to grasp that the connection of the sacred/spiritual to the secular/temporal spheres in life, especially in Pakistan, is important in the totality of healing.

Establishing a formal institution of bioethics is presumed by some as a luxury to aspire to in a low middle-income country with a post-colonial society. Perhaps it is considered too daunting a task to critically discuss the moral challenges in a country where resources are severely limited and access for many to healthcare services is far less than optimum. In fact, these very factors make education in bioethics imperative.

The growth of bioethics as a distinct field of knowledge, considered to be the intersection of life sciences with ethical issues, has increased substantively around the world. The term “bioethics” was first used by Van Rensselaer Potter in the 1970s. According to him, it is “biology combined with diverse humanistic knowledge forging a science that sets a system of medical and environmental priorities for acceptable survival.”¹

Potter revisited the notion of survival in a profound manner. His definition of survival did not merely imply biological survival. He believed that the comprehensive survival of human beings as a species cannot be guaranteed through ahuman,  positivistic  and  naturalistic  methodological investigations. The field of bioethics is therefore necessary since a solely objective understanding of human beings risks crossing the normative limits necessary for continuing existence on earth.

Hard sciences like biology, genetics, pharmacy, biochemistry, microbiology that rely on objective scientific facts and positivistic scientific methodologies, require incorporating the human element that is provided by humanities, philosophy and religious studies. The birth of modern medicine and its increasing reliance on biomedical technology and objectivity has excluded this feature from the practice of medicine. The growth of science/technology and unregulated research combined with the human desire to control nature and time requires ethical circumspection and tempering. This makes programs in bioethics education not a luxury, but a necessity in contemporary times.

My aim in the bioethics programs at CBEC has been to enable students not to merely understand philosophical terms and concepts, but to provoke them to move beyond scientific, positivistic ways of thinking and to engage with abstract concepts, and the ways in which these play out in their interactions with patients and families. I consider my contributions to the process of enhancing the conceptual capacities of healthcare professionals, front line soldiers in creating a healthy Pakistan, among my most meaningful roles as a teacher. It has been an honor to work with CBEC and its faculty who have made it their life-long mission to build ethics capacity in the country.

Reference:

[1] For details see, Potter, V R (1971): Bioethics: Bridge to the Future (Princeton, NJ: University of Princeton Press) quoted in Vijay Kumar and Deepak Kumar Bioethics, Medicine and Society: A Provocative Trilogy, op.cit. p 13.

It is ten years since I served as a member of the External Review team for the Centre of Biomedical Ethics and Culture, and I am delighted to write a few words of appreciation for this remarkable bioethics centre as it reaches its 20th anniversary. Before my retirement in 2016, I had the privilege of founding three biomedical centres in New Zealand, England and Singapore, and I also served as President of the International Association of Bioethics (IAB) and as the Chair of two Bioethics World Congresses, in London and in Singapore. On the basis of this experience, I can say unhesitatingly that CBEC stands out as one of the world’s leading centres in the field, this distinction being underlined by its recognition as a WHO Collaborating Centre.

Let me first note the important distinctiveness in its title: ‘Biomedical Ethics and Culture.’ This very explicit reference to cultural influences in bioethics is hugely important, given the dominance of Western cultural values in the academic literature, and it has particular resonance in Pakistan, which was founded as an Islamic state. The direct way in which CBEC has dealt with this is through its excellent series of teaching videos, which engage fully in religious and cultural issues in Pakistan, yet also remain a relevant resource in other cultural and religious settings.

The Centre received high praise from the 2014 External Review team, but their Report also noted that the wide range of CBEC’s commitments – Master’s, Diploma and Certificate courses, plus training and support meetings throughout Pakistan – could not realistically be sustained with its current academic and support staff and its very limited accommodation. These concerns have been addressed and it is heartening to note that there are now four full-time faculty, as well as a range of associated faculty, full-time additional support staff and a full floor in a new building. However, I remain concerned about the continuing pressure on senior staff, especially as the Centre continues to expand – a victim of its own success! While study leave has been authorised by the host institution, this has not yet been fully taken up, which leads to a real risk of burnout. I trust that in the near future all full-time teaching staff will take the opportunity of the academic refreshment that sabbatical leave provides.

Another great achievement of the Centre in its second decade has been an increased international profile. The faculty continues to foster international links through membership of international committees and numerous publications in bioethics and other journals. An impressive new international collaboration results from a Fogarty grant enabling CBEC to partner with the Kenyan Medical Research Institute to set up certificate programs and initiate a Master’s program in Kenya. This outreach is one more testimony to the high status that the Centre has achieved.

In conclusion, I would like to add a personal note. My association with CBEC over many years has greatly enriched my own understanding of bioethics, most especially the challenges we face in an increasingly multicultural (but often very conflict-ridden) world. As the Editorial in the latest Journal of Medical Ethics strongly argues, we isolate bioethics from political and social issues at our peril.1 CBEC has shown me how the social context of bioethics is a core aspect of the discipline. But more than that, now that I am fully retired, I treasure even more the enduring friendships with Farhat Moazam and with Aamir Jafarey I have gained over the years. Collaboration and friendship across professional, generational and national boundaries are sure ways of fostering a bioethics that speaks truth to power and to give hope to the dispossessed.

Reference:

1. Shahvisi A. The ethical is political: Israel’s production of health scarcity in Gaza. Journal of Medical Ethics 2024;50:289-291.