I was excited to be on my way to Pakistan, but my family and colleagues were worried. Over a year ago, I was invited to teach in the Center of Biomedical Ethics and Culture (CBEC), SIUT in Karachi. I accepted the invitation immediately because I wanted to contribute to the Clinical Ethics Module for students enrolled in CBEC’s Postgraduate and MA in Bioethics programs, and because I wanted to learn from people in Pakistan. But now an anti-Islamic film trailer “Innocence of Muslims” had been posted on the Internet. Demonstrations were expected throughout the Muslim world.

In spite of the bad timing, everything about my visit went smoothly and safely. I had a great experience, and got to do what I wanted: to contribute to the programs and to learn a lot. I left Karachi with many deep impressions: the smell and taste of the food, the sights and sounds of the city, the sincerity of the people, the tradition of zakat (mandatory wealth tax on Muslims), the involvement of families in patient care, and the eagerness of the students to learn.

But what left the deepest impression on me were the ethical problems that concerned people face. My “students” at CBEC were medical doctors, clinical teachers, and hospital administrators in the middle of their careers. So I taught in a way that encouraged them to articulate ethical problems that arise in their lives. The work of articulating ethical problems in lived experience involves more than textbook ethics . It involves phenomenology, ethnology, politics, religious studies, patience, and skill. It also involves willing and disciplined students. With a little help from me, the students brought to light ethical problems that were intellectually interesting and vitally important. The problems were also disconcerting because they poignantly raised the question of what we should do, and they left me with the feeling that I was not doing enough. Here are a few problems that we discussed.

1. Families and decisions. I quickly saw how involved families are in caring for patients and making medical decisions on their behalf. In discussions, a few students simply accepted the family as the legitimate source of all decisions for the patient. A few other students wanted to privilege the autonomous patient as the sole legitimate decision maker. But most of my students in Pakistan wanted to find ethical ways to live and work in the middle ground between these two positions. That made sense to me. People are deeply social, shaped and (to some extent) defined by a nexus of relationships. But that doesn’t mean that we need to uncritically accept the existing relationships and initial requests. For example, tradition may give the eldest son more voice and authority than can be ethically justified in a particular situation. The doctor may need to elicit and listen to other voices. In many cases, the ethical task is to avoid marginalizing people while recognizing the importance of the family.

2. The duty to treat. Most students agreed that doctors have a duty to treat patients with infectious diseases. When people enter the medical profession, they tacitly agree to accept reasonable risks that are inherent in caring for patients. This view was not merely a theoretical conviction among my students. Many of them had experienced an occupational exposure. But when we pursued matters further, we came upon two problems. We weren’t sure how well the duty to treat holds up when health care professionals lack proper equipment and protection. The second problem focused on testing patients. In cases of occupational exposure, I think patients have a responsibility to be tested for the sake of the health care workers. But this view requires more discussion. The actual practices at Pakistani hospitals seem to have developed in different ways without adequate discussion.

3. The responsibility to practice in Pakistan. I discussed with the students the migration of health care workers from low and middle-income countries to wealthier countries. This was not a theoretical matter for the students. Many of them had trained or worked abroad, and many of them could leave and practice elsewhere. After we discussed the support that society provides to medical education, most agreed that physicians have some responsibility to practice in Pakistan, at least for a reasonable period of time. But all of us wondered how best to balance this social responsibility with family responsibilities and personal concerns. My students in Pakistan were rightly concerned about their own safety and the safety of the families. Here are many ethical questions to explore. When do family responsibilities and personal concerns overcome social responsibilities? What should the medical profession do to address violence against physicians? When are physician strikes ethically justified?

4. Responses to disasters. In the last decade, Pakistan has experienced a very serious earthquake and a number of severe floods. Many physicians have responded, individually and in groups, to help those affected. I deeply admire the values expressed by physicians’ immediate response, but work of this kind must involve many ethical issues. We need to examine the issues that arise in responding to disasters, but also issues that arise about preventing, preparing for, and recovering from disasters. Indeed, the first step is to “de-naturalize” disasters: To examine how and where human conduct and social structures contribute to the casualties and losses. Climate change and deforestation contribute to flooding; social structures make some people more vulnerable than others. Here is an area where bioethics, public health ethics, environmental ethics, and social ethics overlap.

I have sketched four of the twenty ethical problems that I came home thinking about. I hope that students and teachers in Pakistan will write case studies that bring to life some of these problems. Too many case studies in bioethics leave aside the social context. We need case studies that provide a better sense of the social context in which reflection and discussion take places. Too many case studies are thin and schematic descriptions that aim to illustrate a theoretical conflict. We need thick and detailed descriptions that require us to pick out what is morally salient, engage all our moral capacities, discuss the matter with others, and respond in better ways. Too many case studies are narrowly focused on particular clinical problems. We need case studies that also address broad social, environmental, and human concerns. Too many case studies limit our choices so that we must decide between two conflicting values. But in ethical life, we often need to find creative ways to reconcile conflicting concerns, and to find ways that reframe the whole problem.

The case studies that I imagine would contribute to bioethics in Pakistan. But they would do more than that. They would contribute to bioethics in the rest of the world.

Dr. Richard Cash touched and will continue to touch millions of lives globally following his death. As one of the developers of Oral Rehydration Therapy, his contributions to public health cannot be forgotten. But he was also a dedicated bioethics educator. I met Richard in 2001 at a research ethics conference in Karachi. He encouraged me to apply for the National Institutes of Health fellowship in Research Ethics at the Harvard School of Public Health. I complied and spent a year learning from him. A natural extension of this was inviting him to teach at CBEC, which he readily accepted. He was a friend and a mentor to faculty and a hit with students. Punctuating discussions with Urdu words like ‘han,’ ‘acha,’ he would discuss complex ethical notions with great ease. Few from the Global North teaching ethics in Asia have approached it with a local perspective. Richard was different. Whether it was eating chawal [rice] and fish curry with his fingers, or discussing the critical role of mothers-in-law in healthcare access for a childless daughters-in-law, he understood the local context. We have lost one of our own. Richard, rest in peace

In 2020, I was given the task of organizing the residency program of Urology at SIUT. Two postgraduate programs run concurrently at SIUT, one under the College of Physicians and Surgeons (CPSP) and the other MD/MS under the Sindh Institute of Medical Sciences (SIMS). Since residents belonging to either of these programs have to work together in the same premises, their curricula have to be as similar as possible. This was the first challenge that the faculty of Urology took up and successfully addressed. While devising the curriculum it dawned on the faculty that two additional modules were particularly necessary i.e. Biostatistics and Bioethics. Both subjects were considered pertinent to prepare residents for research but bioethics also holds immense importance within the clinical domain.

I kept searching and conversing with different people regarding the inclusion of bioethics in the curriculum. In all honesty, I did not know anything about the subject. I only had some vague ideas. I had always wished to create a space where frank conversations were allowed regarding pertinent issues in healthcare including end of life care, breaking bad news, and palliative care. I also wanted to change the culture of silence especially for our residents. In 2023 I came to the right place: CBEC. The faculty of CBEC listened to me and after careful deliberations drew up a curriculum containing 15 lectures that covered areas pertinent to bioethics including the importance of informed consent, maintaining privacy and confidentiality, and ethical issues at end of life. The curricula also include foundational concepts in research ethics and guide residents on obtaining ethical review clearance.

The Bioethics Lecture Series is now in its second cycle. Feedback from 15 students who attended all sessions in the first cycle has largely been positive, finding the lecture series useful and practical. Residents are often seen immersed and engaged in lectures. They are speaking their minds and there is a high probability that they take the correct message home.

The Bioethics Pedagogy workshops, under the CK-BTI program, were initiated in December 2021. While three such workshops have been conducted in Pakistan, no initiative of this nature existed for Kenyan participants. This workshop targeted bioethics educators who are now teaching Master’s in Bioethics program at two Kenyan universities, Mount Kenya University and Amref International University (AMIU). The workshop was facilitated by CBEC faculty, Dr. Bushra Shirazi and CBEC Associate Faculty, Dr. Muhammad Shahim Shamim. The purpose was to equip participants with practical strategies to deliver effective bioethics education.

Each day was organized around specific themes, incorporating interactive lectures, hands-on activities and feedback to enhance knowledge and skills. During the workshop, participants learned drawing up lesson plans and measurable objectives. They were also taught how to highlight ethical issues through the use of tools including videos, artworks and vignettes.

Participants appreciated the hands-on activities and critique received from facilitators and peers during the workshop. They suggested the inclusion of assessment techniques in bioethics for future workshops. It is hoped that through these efforts, teaching bioethics will become more engaging for different cohorts of students.

Grant writing is an important skill that researchers are increasingly required to possess. Keeping this in view, the Centre organized this practicum, the outcome of which was the successful submission of at least one grant proposal. Thirty participants, from diverse backgrounds, were selected based on their proposed grant idea.

The practicum was led by Dr. Elizabeth Bukusi, co-director of CK-BTI, based in Nairobi, Kenya. Four virtual sessions were conducted before the on-site sessions and at the end of these, it was expected that a tentative grant proposal would be developed. The on-site workshop was held in Karachi from August 5 to 8 which involved hands-on exercises, real-time peer reviews and personalized feedback. During the physical interactions, participants refined their proposals and learned how to draw up budgets. One month after this, an online session was also held for participants to receive additional feedback on their completed proposals.

The practicum has proven to be highly successful, as several participants have their proposals ready for submission. Additionally, two participants have also won an external award for their projects developed during the practicum. Building on this success, the Centre envisions organizing a similar practicum for northern Pakistan, incorporating valuable insights and lessons learned from this pilot program.

At the request of the Department of Quality Assurance at SIUT, CBEC in collaboration with the World Health Organization (WHO) organized workshops to celebrate Patient Safety Day that falls on September 17. This year’s theme was “Improving diagnosis for patient safety” with the slogan “Get it right, make it safe!” The two workshops that ran concurrently therefore highlighted patient safety related to lab diagnostics. Such workshops are essential to enhance ethical awareness.

How to Culture Ethics: Professionalism and Patient Safety in the Lab

Dr. Natasha Anwar (standing, picture on right), a molecular biologist, CBEC alumnus, and Associate Faculty at CBEC, led this workshop emphasizing the importance of ethics in laboratory practices and its direct impact on patient care. The workshop highlighted that ensuring high standards of patient safety starts with cultivating a strong ethical culture and professionalism in lab settings. Attended by profession- als from various institutions in Karachi, including medical technologists, pathologists, and researchers, the workshop used cases to illustrate ethical issues and the consequences of unsafe laboratory practices on patient safety.

Understanding Medical Error

Medical error is a leading cause of death globally, yet the fear of humiliation, reputational damage, and potential repercus- sions often hinder its identification and disclosure. In order to shed light on this, the workshop focused on clarifying concep- tual definitions of error, negligence and malpractice under the banner of patient safety. Dr. Nida Wahid Bashir (standing, picture on left), with Dr. Bushra Shirazi assisting, led this workshop and explored the ethical dimension of medical error and highlighted the importance of the development of robust systems in dealing with medical error and negligence. Partici- pants included physicians and medical technologists both from within SIUT and other institutions from Karachi.

The newest addition to the Local Moral Worlds series titled, “Whose Life Is It Anyway?” focuses on issues of medical decision-making for unconscious patients. The story follows Aslam, a 60-year-old man admitted to the ICU following a stroke. As he develops pneumonia, his family must grapple with the difficult decision of putting him on a ventilator. The scenario highlights the role and influence of the extended family in such situations. This video has also recently won the runner-up prize in the ‘Audiovisual Award in Bioethics,’ organized by the Víctor Grífols i Lucas, Foundation in Barcelona, Spain, out of 151 global submissions.

The video is available on our website: https://siut.org/bioethics/cbec-videos/

At the invitation of Dr. Rukhsana Majid, Head of the Department of Community Medicine, Quetta Institue of Medical Sciences (QIMS), CBEC faculty Dr. Farhat Moazam, Dr. Aamir Jafarey and Dr. Bushra Shirazi conducted a workshop titled “Introduction to Ethics in Health- care and Research.” This was the first time QIMS organized an event pertaining to biomedical ethics.

Thirty participants, including physicians, nurses and trainees from different institutions in Quetta, attended the workshop which covered basic concepts in clinical ethics including informed consent, and priva- cy and confidentiality. Sessions also highlighted distinctions between medical treatment and research along with a focus on publication ethics. The workshop was interactive and participants raised several issues that they faced in their daily encounters within clinical practice and research. Participants also approached the faculty to organize similar workshops in their institutions.

This workshop serves as an important milestone for ensuring the spread of bioethics education in Balochistan, a largely neglected province, and paves the way for other institutions in the region to develop their capacity in bioethics.

Arthur Kleinman, the renowned US-based psychiatrist and medical anthropologist coined the phrase “local moral worlds” to highlight how individuals experience the everyday, emphasizing the importance of context and relationships in understanding health and illness. We chose to use his term as the title of CBEC’s ongoing series of teaching videos to provide audiences an insight into how illness situations unfold in the Pakistani context.

Few videos exist that capture the ethical reality of clinical situations as they unfold in collectivistic cultures such as Pakistan. This deficiency led us to initiate producing teaching videos in 2010 embedded within the socioeconomic, cultural and religious realities of South Asia. Since then, CBEC has produced 12 videos that span from 10 minutes to 20 minutes for effective use in classrooms and during workshops. Our amateur productions offer a desi perspective, in a mix of Urdu and English, ensuring that the video clips resonate with local audiences. Many of these are based on case scenarios from real clinical encounters.

Consider the example of informed consent in clinical practice. While a universal standard, physicians in Pakistan may struggle with obtaining consent from a married woman who states that her husband takes all decisions on her behalf including the medical. How should physicians handle such situations where ethical principles of contemporary bioethics clash with the value systems of exisitng cultures?

A recent video focuses on aspects of decision-making in the case of an incapacitated patient who is a member of a large extended family. An upcoming one will cover issues related to obtaining assent in children for treatment within strong hierarchical family structures in which parents make decisions for their children, sometimes even beyond adolescence.

Our previous videos have highlighted local tensions that arise due to public health measures such as quarantine, and the influence of public mistrust of foreign researchers. While these aspects would be present in other contexts, the mores and responses to B such measures often play out differently in the local morals worlds of South Asia.

Our videos do not aim to provide answers to students. Rather they seek to reflect the ethical tensions in play from the Pakistani perspective, which may also be applicable to other South Asian countries. These then offer a microcosm of the sociocultural landscape so that students can reflect on the ethical conflicts between theory and practice.

This couplet from the contemporary Urdu poet, Faryad Aazar, summarizes the essence of our videos:

‘Tis possible, at times, to shrink an entire river to a mere vessel,

At others, for a single drop to contain an entire ocean within.

In art and literature, the global canons including our own embrace creatively written theological essays and summaries, faith-based parables, hymns and devotional poetry, religious music, and frescos and sculpture, etc. Later, in the 19th and 20th centuries, literature and music inspired by new political ideologies was also included. Such content and forms constitute a significant part of classical literature in many languages and our shared human civilizational history, impacting the individual and collective morality. Along with this, there were also resistance art and literature flourishing across cultures and civilizations.

After the Renaissance in Europe and arrival of the Romantic and Modernist literary movements, the age came when Karl Marx and Sigmund Freud deeply influenced the human mind. These developments were followed by de-colonisation and national liberations leading to a different appreciation of art and literature. It is contemporary literary criticism that promotes the role of political non-conformism and the critique of power at the heart of creative expression.

Apart from those involved in artistic pursuits or academic activities, the popular imagination even today would see ethics and morality as ideas leading to an individual’s submission to abstraction and divinity, and her subscription to social conservatism based on culture or tradition. On the contrary, the most powerful piece of art that moves you the most is the one which critiques and subverts the past and the present. Therefore, I find myself a little puzzled in how to approach the question the worthy editors want me to explore: “How does Urdu literature speak to the moral self that we bear today?”

This exploration may help understand if literature shapes the way we make judgments or take actions in our daily lives. Being a minor student of literature who has little or no theoretical grounding in psychology, cognitive science or ethics, I am responding to this question from a personal point of view using my hazy literary lens.

Urdu is a relatively new language compared to other major languages that are spoken in our part of the world. It is twinned with Hindi and both were together called by a variety of names including Hindi, Hindvi, Hindustani, etc. before registers were standardized anew by the British. Several dialects of Urdu were spoken in Deccan, Rajasthan and Punjab. However, it started becoming the lingua franca of Northern India with Deccan as an outpost in the South in the 17th century. In late Mughal court days and across many native states in the Subcontinent, people started using the language for ordinary conversations among them. The British made it into a semi-official and legal language for local legislators and lower courts. However, English remained the language of real power and Urdu remained subservient to English in the linguistic hierarchy. But due to being the lingua franca, it also became the language of resistance in anti-colonial and progressive political movements. Since those using Urdu by far outnumbered its native speakers, whatever was produced in the language reached greater number of people.

Urdu literature has contributed in shaping the worldview of its readers from the beginning but it was not until the 19th century, particularly after the 1857 War of Independence, that it assumed a definitive role in defining the moral and political choices its readership made and its indirect downstream consumers through its varied readership. Sir Syed Ahmed Khan and his comrades were at the helm of the reformist movement. Interestingly, there is also an enormous body of religious literature in Urdu – not just about Islam but Hinduism and Christianity. But we are concerned here with literary writing.

After the sketchy background about Urdu literature and its relationship with our moral self, let me come to this day and age. In 2024, Urdu literature speaks to the moral self of two different kinds of persons. Both of them may want to act ethically with different ideological imperatives and conflicting social demands. One person comes from the Islamic religious strand and the other from the secular civilizational strand. In recent literary writing, from Qudratullah Shahab and Ashfaq Ahmed to Bano Qudsia and the likes resonate with the first kind of person. From Rajinder Singh Bedi and Saadat Hasan Manto to Fahmida Riaz and likes will resonate with the second person. Then there are many third, fourth or fifth persons who navigate and oscillate between the two types, knowing that there are only shades of gray in our world. Urdu literature continues to speak to its readers and impacts them in different ways. At the end of the day, it is art. To each his own.