Bioethics in Pakistan: Yesterday, today and perhaps tomorrow

“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.