We are very fortunate that Zehra Nigah, a renowned, soft-spoken, octogenarian poet always dressed in a simple Saree, visits CBEC for conversations and to recite her captivating poetry to us.  Hailing from an intellectual, literary migrant family of Hyderabad Deccan (India), Zehra Nigah is one of the only two early female poets of the Subcontinent, the other being Ada Jafarey, to have achieved fame in the mostly male-dominated world of Urdu poetry. She began writing poetry as a child and since then has published three collections of poetry and an anthology.

What I admire most about Zehra Nigah’s poetry is her ability to present difficult social and political issues in the traditional poetic language. The word Nigah in her name means a gaze or a particular perspective. Through her subtle, multi layered poetry, she can describe the agony of a rape victim without resorting to graphic descriptions, and convey the horrendous aftermath of a drone strike on a community without mentioning the drone by name. In doing so, she relies on candid vocabulary but without losing civility and charm. Zehra Nigah is also known for her beautiful, evocative writing which explores the experiences of women in Asian cultures. She not only writes of the love and warmth of a mother for her children and her home, but also of wives who must make compromises, and of daughters compelled to conform to traditional norms against their wishes.

Zehra Nigah’s poem Samjhota (Compromise), reproduced here from her impressive collections, is among my favourites. Using vivid imagery, she captures the living experiences of a woman through the symbolic use of the Urdu word chadar. Chadar is a large, all enveloping garment Asian women wear to conceal their body from the world beyond their homes.  She uses chadar metaphorically to capture aspects of a woman’s life – tenderness, love, warmth, but also personal compromises she makes for the sake of her family.

In January 2023, Zehra Nigah will conduct a session on Humanities and Bioethics during CBEC’s Foundation Module for incoming PGD and MBE students. She will engage in a conversation with Dr. Arfa Sayeda Zehra, Professor of History and Literature, Forman Christian College, Lahore on the historical connections of Urdu literary traditions with Akhlaq (Ethics), Tehzeeb (Culture).

Compromise
(Translation by Farhat Moazam)

My chadar of compromises, soft and warm,
Woven over many years,
Embellished truths like blooms adorn it not
Threads of untruths weave through it not,
I shall conceal myself within it
And you will remain content, at ease!
Neither happy nor sad,
Stretched taut it shall make our home,
When spread our courtyard will blossom,
If raised the curtains will plummet

“Brevity is the soul of wit,” says Polonius in Shakespeare’s Hamlet. But, as 17th-century French philosopher and mathematician Blaise Pascal said, “I have made this letter longer than usual, only because I have not had time to make it shorter,” brevity is far more challenging than rambling essays. However, ever since author Steve Moss introduced the genre of 55-word stories in 1986, also called “shorties,” these have become a popular mode of creative, reflective expression for many, including physicians.

In medical disciplines, this mode of imaginative expression has been used as a means of connecting practitioners with their humanness, bringing to the fore their own feelings and expressions of which they themselves may be unaware. The amazing thing about these brief stories is that their authors need not be writers, or even connoisseurs of creative works. However, with each attempt at editing, they introduce more poignancy, improve the shorties and provide a surprising window into the writer’s own self.

In 2021, Professor Marcia Childress took a session with CBEC students on humanities and bioethics. This was the height of the Covid-19 pandemic, which was taking its physical and psychological toll on students and faculty alike. She asked our students to pen 55-word stories, reflecting their pandemic experiences. These students had no prior experience in writing stories, long or short, their literary contributions limited to dry scientific articles based on quantifiable data. After overcoming initial trepidation, the students enjoyed the exercise and produced a series of extremely reflective shorties, finding the process cathartic. CBEC faculty, also having experienced the ravages of the pandemic firsthand, took a cue from them and captured their own experiences in shorties.

‘Tis folly to be wise
Farid Bin Masood

Dada got severe Covid-19 symptoms.
He was isolated in a small room of a large home with a large joint family.
I, Daddy, and Chachu lied to everyone about the results to avoid panic.
All the family members did what they could for his betterment.
Dada still believes that it was just a chest infection.

The Malang Laughed^
Farhat Moazam

The Malang laughed at my masked face,
Cautious, careful two meters away I stood.
“Death?” he smiled, “’Tis no lips heralding new life with whispered azaan, young bones grown old, distanced,
No hands wiping tears, arms offering embraces, shoulders bearing biers to final destinations.
I will die when my time comes, you die every day.”
(^Malang is a Muslim Dervish or Sufi)

It’s Everywhere
Bushra Shirazi

Fear of the unknown and trying to protect the loved ones by distancing.
Don’t touch, stay away!
Ironic and sad as it goes against the acts of life.
In reality one is born alone and dies alone. Why blame Covid?
Another truth, the existing psychosis of the loneliness and fear…
Who is next in line?

Reality Check
Aamir Jafarey

Covid: The clarion call. But I’m not a doctor. Not anymore.
I hide behind my keyboard furiously churning out op-eds and guidelines, much oohed and aahed, yet pointless.
Timepass.
I tweet and feeling important. I’m an ethicist.
No, I’m not; never was.
No longer a doctor, not an ethicist. Disappointment. Bad bet. Trapped.
Covid: Awakening.

Mountain Run
Anika Khan

Eighty-three years old.
Sinewy, puissant, she bounds up a mountain trail.
Panther-like she springs and leaps.
In an act of grace, wings sprout from her shoulders.
Still dreaming, she falls off her bed, fracturing a glass-brittle hip bone.
Ages seem to pass before the night dissolves into swirls of milky light and her daughter comes.

Que sera, sera
Sualeha Shekhani

She needs my touch.
She is breaking down,
“Reach out, hug her,”
But a few weeks ago
The strip had turned pink.
She is my best friend,
I reach out, cradle her in my arms
Holding my breath beneath my mask,
Whatever will be, will be,
Que sera, sera.

One of the ways that we introduce humanities to students in CBEC programs is through the use of the 1973 short story by Ursula Le Guin titled, “The Ones Who Walk Away from Omelas.” The story requires a written submission to a question connected to the story. For many of our graduate students, most of whom are mid-career professionals associated with different aspects of healthcare and research, this is perhaps the first time that they are exposed to such a piece of literature. Throughout their educational journey within the field of medicine in Pakistan, their exposure to soft sciences is limited with a primary focus on the “rational” hard sciences.

Why this particular story, one may ask? Centering on a summer festival in the utopian city of Omelas, the story engages the reader with vivid imagery and brilliant use of metaphors that Le Guin masterfully weaves within the plot of the story. Readers find themselves immersed as the author highlights the perpetual happiness of Omelas which depends upon the imprisonment of a child in a small, dark cell and who can never be set free.

Le Guin narrates the joy of the citizens of Omelas and the misery of the child without offering any judgments on what she describes. Therefore, the story allows the readers to appreciate that human beings can employ different approaches to living a moral life, that there is a world that exists beyond black and white, and that there is no one single answer or one truth. Using this story is an endeavor to broaden the horizons of our students by getting them to think beyond the narrow confines of science and medicine.

We also use other pieces of work in the vast literature of medical humanities such as, “The Doctor’s Stories” by Richard Selzer that connect directly with medicine, disease and illness. Such texts attempt to “teach” students how to be good doctors and to get them in touch with their emotional sides. In contrast, Le Guin’s story allows students to appreciate various artistic expressions as in themselves, for them to enjoy the way the story is written, to conjure up images of the beautiful city of Omelas that the author so eloquently describes and imagine themselves in it. I view this story as a way of integrating humanities into our bioethics curriculum in a non-instrumental fashion.

While being popular, the assignment also poses a challenge for the students since it requires introspection into their inner selves. Over the years, they have approached this assignment in different ways since it leaves plenty of room for creative expression. As an example, one student picked up the story from where Le Guin leaves it by situating herself in the first-person narrative and taking us through the tumultuous thoughts that ran through her mind, and the emotions that tugged at her heart when the feeble and helpless child appealed to her to free him. Another student, a lawyer, approached the question through a purely analytical lens, stating all the facts upfront and then drawing upon relevant moral theories to reason her choice. Students’ backgrounds have also influenced their engagement with the story. A student from Africa drew a parallel between the misery of the child and happiness in Omelas to poverty in low-income regions being “inextricably linked” to the wealth of the rich countries. One physician, for example, deliberated upon the presence of both happiness and sadness in life as necessary conditions of human existence.

Since such texts highlight the centrality of human experience, it has also made students consider complex notions of happiness as well as the more profound question of a meaningful existence of human beings in the world. And that is perhaps an important element of an ethical inquiry – for individuals to look within themselves and reflect upon what constitutes a life worth living.

“To be a moral human being is to pay, be obliged to pay, certain kinds of attention.”

                                                                                                                                                                       “At the Same Time” Susan Sontag

In an age of scientific positivism and pragmatism, the humanities seem increasingly redundant, the poor cousins of more lucrative academic disciplines such as medicine, research and business, fields that have utility and that promise earning power. In educational institutions worldwide, economic constraints immediately lead to axing humanities courses, or at best, drastically reducing their scope – primarily because they are viewed as disciplines that are non-essential, peripheral. This view of the humanities discounts their importance as a constantly evolving archive of human thought and experience. In November 2009, I was a student in the Master in Bioethics program at the Centre of Biomedical Ethics and Culture (CBEC). A screening and discussion of the movie “Wit” (2001), based on Margaret Edson’s eponymous play that explores human mortality, sickness and medicine proved to be a powerful introduction to the ways in which bioethics can be taught.

The humanities have a distinctive importance in CBEC’s academic programs, interwoven into the entire academic cycle in ways that are both explicit and implicit – in dedicated sessions, and through the (sometimes spontaneous) integration of varied literary and visual media into other courses. As one of the faculty who led many humanities sessions at CBEC, I find this merging of the arts, ethics, and scientific advancements which give rise to ethical conundrums, both effective and compelling.

Through introduction to the humanities, students enrolled in CBEC academic programs are “obliged to pay, certain kinds of attention” to the moral and historical subtexts of varied media. Religion and philosophy encourage them to reflect on their own moral references. By reading literature, they begin to recognize the predicaments of others, their pain, their dilemmas. Through the exercise of imagination and observation, they learn to decode the moral, cultural and historical elements of a painting, and understand how a photograph capturing an instant in time can be a detailed moral commentary on an epoch.

Stories, poetry and images provoke not only rational analysis but also emotional and moral responses and although emotions are routinely vilified in ethical discourse, I believe moral reflection to be an amalgam of rationality, emotion, and perhaps, intuition. Students have discussed excerpts from Susan Sontag’s book, “Regarding the Pain of Others” and viewed iconic photographs, such as “Napalm Girl” (1972) which has become a defining image of the Vietnam War. The discussion focused on images as powerful tools of reportage and the blurred line between viewing and voyeurism. I remember a student remarking that she had seen so many images of suffering that they had become meaningless. Deconstructing images of war, paying “certain kinds of attention,” made her focus again on the humanity and pain of those portrayed in the photographs.

In one session, students viewed the painting, “The Last Burning Train” (2009) by Pakistani artist, Jimmy Engineer, which depicts a large assembly of migrants resting in the shade of an old tree on the way to Pakistan in 1947, following the partition of the Indian subcontinent. Students commented on the historical backdrop and studied the attitudes, faces and postures of different characters portrayed in the painting. One student interestingly remarked that the most important character depicted was the tree itself, because it stood witness not only to the carnage that took place in 1947 but to a longer period of human history spanning many generations.

In other humanities sessions, students discussed literature, such as physician and author, Richard Selzer’s short stories, including “Whither Thou Goest,” in which the wife of a deceased organ donor seeks the man who has received her husband’s heart. Reading Selzer’s stories allowed students to interpret the actions and underlying moral compulsions of his characters and come to conclusions that they had not initially anticipated.

In Hans Holbein’s 1533 painting “The Ambassadors,” a white blob in the foreground is revealed to be a skull when viewed from a certain angle, a reminder of death. The humanities allow us to look at issues in this layered, complex way in which we discover depths we had not first suspected. Disciplines such as philosophy, religion, literature and the arts cannot be scientifically validated, but within them, it is possible to occasionally find something that cannot be grown in cutting-edge laboratories – the kernels of wisdom and compassion.

“…the proposition that we can look into another person’s heart with perfect clarity strikes me as a fool’s game. All it can do is cause us pain. Examining your own heart, however, is another matter. I think it’s possible to see what’s in there if you work hard enough at it”

                                                                                                                                                                                        “Drive my car” Haruki Murakami

A physician friend once laughingly accused me of being a “Sophist.” He meant it as a backhanded compliment, but it did get me thinking. In ancient Greece, Sophists were men of erudition and wisdom who could be hired as teachers or advocates for a particular argument. The criticism against them was that they could be paid to argue whichever point of view needed to be propagated. The comic playwright Aristophanes referred to them as “hair-splitting wordsmiths.” My friend meant to apply the term admiringly to how I could sit with seemingly anyone and get along with them including people who held diametrically opposed worldviews.

I have told this story many times to my students as a teaching point since my medical specialty, Psychiatry, defies easy categorization. We are medical doctors, to start with, but then veer off into territory that has little in common with what doctors do day to day. Our work also encompasses many areas which have little or nothing to do with what is taught in medical college: religion, philosophy, culture, anthropology, sociology and, yes, ethics. In addition, coming from a family of writers and performing artists, I had always been drawn towards music, poetry, dance, theatre, painting and the like. So the inclination to find some common ground between the work that I do day to day as a practicing psychiatrist and all of these other areas of interest had been around in my mind for a long time before I discovered, to my delight, the field of “Medical Humanities.”¹

As a young academic freshly returned from the USA to Pakistan, I also discovered sympathetic journal editors who liked my unusual (in Pakistan) take on matters related to psychiatry and medical practice. Many years ago, I developed an interest in the sensationalist, mercurial short storywriter Saadat Hasan Manto and wrote a piece about him.² Later I also wrote about other prominent men of letters from our region and the West including the “God of poetry” (Khuda-e Sukhan) Mir Muhammad Taqi Mir, the syphilitic French writer, Alphonse Daudet and others.^3,4

And along the way, it became obvious why medical humanities has become such an important part of core medical curricula in the West and how the humanities can, literally, make better doctors (and better human beings). Ethics, including “bioethics,” has of course been an established discipline in the West for close to a century when the term was first coined. And with the pace of technology accelerating with each passing day, it has assumed ever more importance: surrogate motherhood, cloning, end-of-life issues, organ donation, questions about gender, healthcare resources utilization, there is hardly any area in medicine that is untouched by ethical issues. As ethicists, we claim to set the highest “ideals” of behavior (as opposed to the “floor,” the basic minimum as defined by law). And in a rapidly evolving society like Pakistan, this is no small matter.

At the same time, in a society like ours, riven by poverty, social inequality and violence, what use is an abstract concept like “ethics”? The answer is obvious: if we claim to set the highest standards of conduct and behavior, we are the ones who must identify and define the factors which condemn so many people to utter destitution and, more importantly, must suggest ethical answers to them. As Manto says “If you are unaware of the times in which we are living, read my short stories. If you cannot tolerate them, it means this age is intolerable. My writing is not at fault. I do not wish to agitate people’s thoughts and emotions. How can I disrobe civilization, culture and society when it is, in fact, already naked?”⁵ Manto here encapsulates the essence of political economy, philosophy and empathy into four lines of text which, if one wanted, could be expanded into a whole class (or a whole course of study). Let’s take another example: when John Lennon, the lead singer of the world- famous band “The Beatles” wrote and sang his iconic song “Imagine” (1971), it became an international anthem for peace and tolerance. Those few lines, set to a quiet, haunting melody asked us to “Imagine there’s no countries/It isn’t hard to do/Nothing to kill or die for/And no religion, too/Imagine all the people/Livin’ life in peace/Imagine no possessions/I wonder if you can/No need for greed or hunger/A brotherhood of man.” That song can teach us more about empathy and social ethics than a semester’s worth of classes. When Pablo Picasso painted his “Guernica,” he needed nothing else to illustrate the horrors of war, injustice and the pain of humankind such that when a Nazi Gestapo officer in occupied Paris pointed to the painting and brusquely asked Picasso “Did you do that?” Picasso famously replied, “No, you did.”

All of this is not to say that a formal study of ethics (or any other discipline) can be circumvented by reading a poem or listening to a song. In an area as delicate as bioethics, context matters and, especially for budding bioethicists, the core concepts and fundamentals need to be learned and understood well before venturing into the “real world.” But teachers can find much that is useful (and engaging!) in the humanities. And today, when all the talk in academia is about “interdisciplinary” and “transdisciplinary” studies, why would we not utilize the distilled wisdom in literature, poetry, music, philosophy and so many other disciplines to teach ethics? Even here in Pakistan, the Higher Education Commission which regulates all college and university education in Pakistan has come out with a mandate for humanities to be taught as a core course in all undergraduate disciplines. Of course, all of this presupposes that bioethics teachers are themselves, at least familiar with some of these areas. In our part of the world, reciting a famous verse by the poet Ghalib or a saying by Persian writer and poet Sheikh Saadi has been a way of making a point for centuries. Thus incorporating humanities into teaching bioethics should be an easy task. When Saadi says “Buzurgi b’aql, na b’saal/tawangari b’dil, na b’maal” (eldership is (by virtue) of intellect, not age/Wealth is (by virtue) of magnanimity, not riches), he is commenting on so many things: youth, old age, wisdom, happiness, wealth, poverty, the “generation gap” and so on. Learning about “Beneficence,” “Autonomy” and so on is essential but literature, poetry, music and other humanities can help us imbibe all of these concepts so easily and quickly while expanding the horizons of our mind beyond the narrow confines of classrooms, hospitals and clinics.

And in the end, what is ethics except for a way, as Murakami says, of trying to understand what is inside our heart of hearts; the universal standards that make us human and bind all of us together in our common humanity, across the ages and across all distances. If we can touch something inside another person’s heart by feeling what is inside ours, our shared humanity can teach us all we need to know.

References:

¹ Cole TR, Carlin NS, Carson RA. Medical humanities: an introduction. Cambridge University Press; 2014 Oct 31.

² Hashmi AM, Aftab MA. The Touch of Madness: Manto as a Psychiatric Case Study. Pakistan Journal of Medical Sciences. 2013 Sep;29(5):1094.

³ Dreams are wiser than men: Papercuts [Internet]. DWL. 2016 [cited 2022Oct23]. Available from: https://desiwriterslounge.net/articles/dreams-are-wiser-than-men/

⁴ Latif A, Malik MF, Hashmi AM. In the Land of Pain. Annals of King Edward Medical University. 2016 Sep 9;22(3).

⁵ Jalal A, Jalal N (eds). Manto “Adab-e Jadeed”, Sang-e-Meel Publications, Lahore, 2012.

Pakistani media has been highlighting the plight of transgenders in the country and a number of newspaper reports have appeared recently about widespread discrimination, hostility, and verbal and physical violence towards them. In the recent past transgenders have faced brutal attacks and, denied timely medical intervention, have lost their lives. This attitude towards transgenders rests on a binary understanding equating biological sex to gender and a rigid categorization of female and male, women and men. Any variation from this rigid schema is perceived as a wilful aberration, individuals who choose to live in “unnatural” ways. Pakistani society, including many healthcare professionals, seem unaware of emerging studies which reveal that some individuals can experience gender dysphoria (sometimes beginning in childhood), a condition in which their emotional and psychological identity as male or female is opposite to their biological sex.

The last contact module of CBEC’s academic year in December focuses on Gender and Ethics and in previous years it has included an introduction to the complexities of understanding transgenders. This year however, it was decided to expand the module to explore human construction of gender and how this determines an individual’s place in society and her or his access to the public sphere. Connected to this, for the first time, a number of sessions were devoted to help students develop a deeper understanding of transgender as a concept, and its historical, religious, and legal underpinnings. In order to move beyond abstract discussions to lived realities, CBEC decide to invite transgender individuals to meet with the students in flesh, to talk about their lives, to narrate their difficulties and their aspirations in their own voices.

The first interaction was a moving encounter with a male transgender who when asked to introduce himself stated poignantly, “You can decide ‘who’ I am after my conversation with you.” Describing a life coloured by rejection and loneliness, he remarked, “No one ever accepted me…I never accepted myself.” Born biologically female, he identified himself as a boy from childhood, a practice that his family initially accepted, perhaps finding it amusing in a very young child. He recalled his shock and feelings of revulsion when his parents asked him to wear a dupatta (scarf worn by females) when he turned thirteen. He told them that girls and not boys wore dupattas and continued to wear male attire despite his family’s increasing antagonism towards what they now perceived as deviant behaviour. He narrated how devastated he felt when he began to menstruate, and that he made four attempts to kill himself over the subsequent years. “Girls always seemed to like me. They felt safe with me. I would accompany them when they went to the bazaar to protect them,” he said with a smile. He recounted his heartbreak at witnessing the marriage of a woman he particularly liked. Divorced a few years later, he is now taking care of her and plans to find a suitable husband for her. Asked by one of the students why he did not tell her about his feelings for her, he replied sadly, “I have nothing to offer her.”

This session was followed by a conversation with two members of the Khawaja Sira community in Karachi. The term Khawaja Sira has long roots that can be traced to ancient Jewish, Muslim, Persian and other Middle Eastern civilizations, and referred initially to castrated men who were administrators put in charge of female dwellings. In recent times however the term Khawaja Siras within South Asian countries denotes female transgenders who subsist as dancers during celebrations of birth of children, weddings, etc. and are now increasingly turning to begging or walking the streets as sex workers. Social pariahs, they have been deprived of the most basic legal rights including a national identity card, the ownership of which is a prerequisite to exercising citizenship rights such as voting and inheritance. In 2012, Pakistan’s Supreme Court ruled that members of the Khawaja Sira community are citizens of the country with equal rights to others, and that they be issued national identity cards acknowledging a third gender as a legal entity. In practice, however, this ruling is yet to be implemented.

The Khawaja Sira, Ms. Bindiya Rana, who interacted with students is a prominent public figure, a well known transgender activist working for the rights of her community. She is also the first from her community to participate in a local election in Karachi (which she lost). In her talk, delivered with flair and caustic humour, Ms. Rana highlighted the social ostracism transgenders continue to face in every facet of their lives including when they approach physicians and hospitals for medical care. She recounted the humiliation they faced when they applied for national identity cards and were asked to undergo medical tests to establish their sex, something no other citizen is required to undertake. In response, the Khawaja Sira community protested on the streets and although this condition was subsequently removed, the uphill battle for legal identity and rights for transgenders continues. In Ms. Rana’s words, in the preoccupation with male and female we forget insaniyat (humanity). She remarked, “We are humans like you”. The second Khawaja Sira guest was a young student who is currently studying for a law degree. She recounted how she left her native town Lahore because of the harassment she faced in college and that she is now studying in Karachi where she accepted by her teachers.

For the students and faculty, the conversations with the transgenders were revelatory bringing home an increased awareness of the difficulties faced by individuals who fall outside the circle of what society considers normal. The impact of sitting across the table from transgender individuals and listening to their stories in their own voices was a moving experience. A topic that may have seemed distant and esoteric became tangible and real when examined through personal narratives of pain and deprivation.

A group of five young women walked into the tall historical building with a myriad of feelings: apprehension, excitement and a sense of purpose. We were equipped with tape recorders, notebooks, cellular phones and different aids for the purpose of research. However, to our amazement, we found out that before entering the vicinity of the ‘dangerous zone’, we had to hand over the different electronic devices. This included cell phones, tape recorders and even flash drives. We had arrived at the premises of Women’s Central Jail, Karachi, with the objective of investigating the nature of female crime within Pakistan through conducting in-depth interviews with female prisoners. Our aim was to understand the kind of crimes women tend to commit and the possible reasons which lead them to perpetrate these acts.

What followed was a series of contradictions and surprises. We were led by a jail warden to a small room, utilized mainly as a sitting room for prisoners. We were also able to attract attention from the different women prisoners, who watched us with a mixture of curiosity, awe and resentment. We made ourselves comfortable in the room while a jail warden set out to recruit subjects for interviews. Since we were inside the room, we could not observe the way that they were being asked to participate in the research. Three or four women arrived in a group, shy and hesitant. A constable accompanied them and stayed there during the course of the interviews. It was unclear whether this was for our safety or because the prison was wary that its ‘misdeeds’ and ‘misconduct’ would be reported to us (we had been initially mistaken as journalists or people from the press). In any case, this probably deterred the subjects from speaking freely about the nature of their crime.

We were holding conversations in a small room, with two interviews being taken at one time. During this process different jail wardens kept coming in and going out, some women had children with them who proved to be a distraction and other prisoners would occasionally interrupt the interviews to add their bit. This might have also influenced the research outcome. We also encountered something quite unexpected. “Humein phansaya gaya hai,” (We have been falsely accused) was a statement we heard, which was shocking. None of the women we interviewed confessed that they had committed the crime! Later, in a separate interview with a constable, we were told that the lawyers of these prisoners had advised them not to speak of their crimes. They were told to behave as ‘victims’ rather than as perpetrators.

We interviewed women who were in the prison for numerous reasons. Some of them had killed their husbands, one had managed to kill her entire family so that she could run away with the man she loved, and a few had kidnapped children for ransom prompted by poor socio-economic conditions. A widely publicized case, where a wife had murdered her husband and made curry out of his flesh was discussed within the jail with relish, thus leading to a natural curiosity to speak to the perpetrator. The warden who had been assigned to help us stated that it would be difficult to recruit her. We requested if we could ask her ourselves. The woman walked confidently around the large area which served as the ground for the women prisoners, where they would sit during the day. Her fellow prisoners also steered clear of her. We approached her quite hesitantly, stating our purpose. She looked at us, up and down, and shook her head, indicating disagreement to be part of our research. We retreated after she said “Mein kyun bataon, jab meiney kuch kya hee nahi hai,” (Why should I tell when I have committed no crime).

Another incident also merits description. There were two women from Africa, both convicted due to drug trafficking across borders. To get a glimpse as to what could have led to this unique crime, the warden was requested to ask for their permission for inclusion within the research. They refused. However, when we were going out, finished with interviewing for that day, they approached us themselves, standing haughty and proud. They were curious about us just like we were curious about them. They asked us where we were from and inquired about our purpose for visiting the jail. Quite chatty, they remarked that our area of study (social sciences) was quite interesting. Slightly emboldened by their friendliness, one of us asked them if they would like to be part of the study. They declined and walked off. What struck me at this point was that the personalities and the demeanor of the women who agreed to participate versus those who declined were quite different. The latter were strong, stood tall and defiant. The former had somewhat submissive postures; two of them had also cried during the process of telling their story.

Paucity of information due to non-admittance of the crime along with the research setting made it impossible for us to meet the initial objectives of our study. I walked out of the prison with my colleagues, with a sense of unfinished business. However, I also realized that I had experienced a few realities that were unexpected and unsettling. In general, researchers would like to know the facts as much as they possibly can. We had mulled over whether to request for case files of the prisoners who were interviewed. The head of the prison had suggested this. Therefore, in essence it was legal to undertake this step. However, we considered the ethical dimension of this action. The research centered on the relationship between the interviewer and interviewee, and knowing more than what we found during the conversation would have violated this. Hence, we came to the conclusion that what may be legal might not necessarily be ethical.

I also thought over the two instances of prisoners refusing to give the interview. Had the other subjects been somehow ‘coerced’ to give the interview? Research ethics identifies prison populations to be vulnerable to coercion. This is where the idea of voluntary participation comes about. How many of the women had actually fully consented to be part of the investigation? In retrospect, I remembered that the warden had actually insisted that she could make any woman talk if we so desired, but we had told her to ensure that none of the prisoners were forced. We had  ensured that our consent forms were in Urdu naively assuming that the subjects would know how to read. We had also insisted that a jail warden acted as a witness to every interview. She did so but after she had belittled us for being overcautious and finicky.

I left the jail with several insights. Lack of awareness about research ethics, including voluntary participation, may lead to such behavior. It made me think that perhaps ethics of research should not be restricted to people doing the research but also made available to the general population. While leaving with a sense of unfinished business, I also concluded that research centered in the sociological world is filled with uncertainty, and therefore, research protocols require some flexibility. An illustration of this is that we were unable to use tape recorders and thus the interviews could not be recorded. This made data collection more difficult and useful information may have been lost in the process. I also realized that, as a researcher, I would have to be well-versed in ethics, and even more importantly accept the responsibility to apply this knowledge.

On December 12 and 13, 2022, CBEC-SIUT, a WHO collaborative centre for bioethics, will host a two-day hybrid seminar titled “Scientific & Ethical Challenges in Human Reproduction: Perspectives from EMR” in collaboration with EMRO. This seminar is available to attendees from all across the country, region, and world; however, registration is necessary. The first day’s focus will be “Artificial Reproductive Technology in the EMR Region,” while the second day’s theme will be “Genomic Challenges and Emerging Ethical Issues.” To register, scan the QR code on the poster or click the link: https://forms.gle/TRMhhCkKoB8ZzDnTA

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.

In our next CBEC Forum, investigative journalists Saba Imtiaz and Tooba Masood will take us through the life and mysterious death of renowned Urdu poet and civil servant, Syed Mustafa Zaidi. Using this lens, they will provide a glimpse into the politics, socialite culture, activism, and gender dynamics during the 1970s in Pakistan. The forum will also feature recitals of Zaidi’s poetry.

Saba Imtiaz is a freelance journalist, author, and researcher. She writes about culture, urban life, food, and religion. She is the author of the novel Karachi, You’re Killing Me! which was adapted into the Indian film Noor. Saba has reported features from Pakistan, Jordan, Afghanistan, and Lebanon. She is currently based in The Netherlands.

Tooba Masood-Khan is a multimedia journalist and reporter. She writes about Karachi’s archives and history including city’s cinemas and pre-independence buildings and markets. She was long-listed for the Zeenat Haroon Rashid writing prize in 2020. She is a graduate of SOAS, University of London.

Both Saba and Tooba are currently co-producing and co-hosting a podcast, Notes on a Scandal, which has gained national and international attention. They are also co-authors of a book project titled, Society Girl.

This session will be conducted in a hybrid format, with a limited number of physical seats at CBEC. Those interested in attending the session in person are requested to register by emailing at cbec.siut@gmail.com before September 25, 2022.

To attend online, please click the Zoom link below:

https://us02web.zoom.us/meeting/register/tZ0vceirqzMuHtfIhTUo2HYVTTQBftGbzWkv

This session will also be live-streamed on our Facebook page.

Centre of Biomedical Ethics and Culture (CBEC), SIUT
WHO Collaborating Centre for Bioethics,
Karachi, Pakistan.

Website: http://siut.org/bioethics/
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