“The medium is the message.” – Marshall McLuhan

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

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

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

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

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

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

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

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

To read Urdu version of this article, click here

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The COVID-19 pandemic began in February 2020 in Karachi and within a couple of months, the disease had already occupied a large number of beds in ICUs. SIUT, the largest transplant center in Pakistan started a COVID OPD, ward, and intensive care facility for the public as part of the national effort to contain the first wave of COVID. At the same time, the hospital continued to provide care to its own patients.

This variant of COVID was new. The disease process was being understood slowly over time, and treatment was evolving. Most of the medicines being prescribed had not been tested before and were mainly given emergency approvals by drug regulators. But I want to bring up a very different aspect of COVID-19: family involvement in the COVID ICU. In the initial stages of the pandemic, allowing relatives into the COVID ICU was unimaginable. But this is exactly the strategy we adopted at SIUT.

At the start of the first wave of COVID, global standards of care included strict isolation of admitted patients to control disease transmission. COVID-19 guidelines from Pakistan’s Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) discouraged the presence of family members, except in the case of paediatric patients. Families were not allowed to visit and the only way to see loved ones admitted with COVID was with a mobile phone. Even dead bodies were handled with great care and funeral gatherings were restricted. In the beginning, doctors were as afraid of COVID as everyone else in the community. We were wearing full-body gowns, masks, eye shields, goggles, foot covers, gloves – even respirators in some instances. We had to write our names on our dresses to identify each other. Attendants were strictly not allowed inside. Nurses were also afraid. And then came a time when nurses started getting COVID. Fear spread like wildfire, and nurses began opting out of ICU duties. Some demanded fewer working hours, and we had to negotiate their timings with them. At the same time, the number of patients was increasing.

A few attendants of our patients insisted on staying in the ICU, mainly wives, sisters and children. They wanted to stay with their loved ones for different reasons, the most important being cultural norms which made families duty bound to care for sick kin. Initially, we refused to let family members into the ICU but ultimately, after consultation between infectious disease physicians, intensivists, and the hospital administration, we decided to allow them in. Only family members who were young, healthy and not pregnant were allowed as attendants. In addition to other safety measures set in place, they had to wear complete personal protection equipment (PPE), just as the nurses were wearing.

The reason for this allowance was multifactorial. Families strongly wished to be with their sick relatives, but there was also a practical benefit because of the care family members could provide. Short of staff during peak COVID, we found the family helpful at the bedside. We found that pain, agitation and delirium – major concerns in the ICU – were best managed by involving family members. Mobilizing patients out of bed was also a task where the family was helpful. As time progressed and the fear decreased at all levels, we realized that the impact of family involvement in the COVID ICU was tremendous. We began to see miraculous improvement in patients’ outcomes.

One of the patients was Mrs. B, a young female from a poor socioeconomic status with a history of psychiatric illness. She came with severe COVID pneumonia, complicated by kidney failure. She received a few sessions of dialysis, but the pneumonia was severe. She underwent a tracheostomy procedure which developed complications. Later, she had massive gastrointestinal bleeding, for which she required surgery and endoscopies. She had severe infections and bedsores. Several times we gave up on her and thought she would not survive even 24 hours. But she did survive. What made her recover and leave the ICU alive was her older sister who cared for her as though she was her mother. She always knew what her sister wanted, and she tried her best to provide it to her.

Then there was Mr. S.A.H, a dialysis-dependent, older man with complicated vascular access. He developed COVID pneumonia and was put on a ventilator. One day, I saw his daughter standing beside him, not doing anything. I asked her why she was not helping her father get better. She took my message positively, and her healing touch made the difference. The father, who was on continuous infusions of different medicines to control delirium and agitation, entirely regained his senses in only three days. The next day he was discharged from the ICU, in his senses and talking.

We admitted Mr. H.A, a doctor who developed COVID pneumonia on top of an already bad chest. He remained on BiPAP, the noninvasive breathing support, for a long time. He developed clotting in his lung vessels and was ultimately oxygen dependent. Due to his chest wall deformity, he was not able to sleep on his belly which is the recommended position for COVID patients. His wife devotedly cared for him, day and night, finally stealing her living husband back from the ICU. He remained on oxygen for at least six months before getting back on his feet.

Three problems in the ICU are detrimental to the recovery of patients, independent of the primary illness: pain, agitation, and delirium. Our experience showed that family involvement in the COVID ICU helped with all three problems, helping patients get out of the ICU bed. The ICU is a jail from which patients must be liberated; the family has a definite role in this.

As an undergraduate, I studied medicine and arts, majoring in philosophy and English at the University of Melbourne, Australia. After thoroughly enjoying my year of medical internship, I returned to university to complete an honours year in philosophy in the hope this would help me to decide whether to continue a career in medicine or pursue my passion for philosophy. After what felt like a lifetime of indecision as I struggled to balance the competing demands of my interests in the humanities and sciences, it was a relief to discover certainty within my heart during this honours year; I loved medicine, but a life of intellectual inquiry was the one for me.

Embarking on a PhD in applied ethics, and mindful of the limited job opportunities in this field, I nevertheless swore early on that no matter what, I’d never resort to “teaching ethics to medical students.” No doubt, I was influenced by the dismal “ethics” classes which I had experienced as a medical student, and the type of impoverished ethics teaching that I characterise as “pseudoethics.” My own intellectual snobbery was also influential; philosophical ethics seemed an obviously superior field to that of “medical ethics.” I felt that nothing could be less personally rewarding and less professionally impactful than summarising “the four principles” for a crowd of students who would rather be learning “real medicine.” I write this narrative in the hope of prompting reflection by others who may be in a similar position, and hesitant to invest time – if not their career – in ethics, for fear of such a desperate fate.

15 years later, I have the privilege and joy of leading one of the most robust ethics, law and professionalism programs for medical students in Australia. Over the past decade, I’ve had to navigate my own biases about ethics, medicine and teaching, as well as external challenges impacting my teaching plans and objectives, while striving to design, develop and deliver effective and appealing ethics curricula for medical students. If there’s one thing I’ve learned, it’s that there is no single formula that will guarantee success in teaching ethics to medical students; everyone must tailor their curriculum to their unique context. Even when you feel confident that you have a reliable learning activity or assessment task, cultural shifts between student cohorts, staff changes, or a pandemic can necessitate significant alterations to your curriculum and approach to teaching.

Early on in my teaching career, I worried most about what to teach medical students about ethics. It seemed irresponsible to leave out discussion of the grounding ethical theories, great thought experiments and ongoing debates about seminal issues, and indeed impossible to teach anything worth teaching without these components. All too soon, I began to understand the appeal – and hence the ubiquity – of the “four principles” approach to medical ethics teaching. Principlism is more easily distilled into a one hour “introduction to ethics” class and can be more readily applied in analysis of cases by students than a similarly abbreviated account of virtue ethics, for example.

However, when I joined Deakin University in 2016 and discovered a much more spacious ethics curriculum, I realised more time was useful, but not the solution to all my ethics teaching challenges. I began to focus more on how to teach, and how to design curricula in which teaching could have an impact. In particular, I worried how best to engage and retain the interest of medical students in the ethics program. For some medical students, ethics can seem a distraction from precious study time as they anxiously cram scientific knowledge and prioritise clinical skills development. With class attendance optional, I soon found little comfort in having curriculum time at the end of semester when many students stayed home to study for exams.

Paying greater attention to the quality of my teaching and learning resources, and focusing more on my broader engagement with students in the program has been valuable in several ways. I soon learned that investing hours of time in fancy slide sets or elaborate learning activities rarely had proportionate benefits in students’ satisfaction or achievement of learning outcomes. Instead, I found that taking the time to make curricula easy for students to navigate, clearly and simply communicating assessment expectations, and pre-emptive action to identify and address potential questions or concerns led to better engagement and satisfaction. Students also seemed happy with basic slides and simple case discussions, so long as the key learning points were clear, and the real-world relevance of learning was apparent.

When considering potential improvements to our program, I now reflect less on what and how I teach, and more on why we teach ethics to medical students. Every program will espouse goals of developing ethical and professional medical practitioners, fostering virtuous conduct and attitudes and so on. These are important goals, and a good ethics curriculum can and should play a key role in achieving them. However, so much of the formation of students’ characters has already occurred, and their experiences in the clinical environment as students and practitioners will typically exert a stronger influence on their values and behaviours than the classes formally dedicated to ethics. What, then, is the point of our ethics teaching?

What can we provide in our teaching and assessment of ethics that will offer more than the basic conceptual and theoretical knowledge that might be acquired through reading a textbook, and more than the practical application of such knowledge which may be more effectively demonstrated in the clinical setting – assuming of course that preceptors there are suitably competent? This vital question now informs the rationale for my own teaching – why do I teach ethics? – and from this, shapes the content and methods of much of my teaching.

The “why” will be different for everyone. Personally, I teach in order to equip medical students with what I believe are essential skills they need to practice medicine ethically, and to support ethical decision-making and action by others. These skills comprise critical thinking, reasoning, and the ability to identify ethical considerations and to communicate clearly when discussing ethics. With these skills, students may be more capable of continuing their ethics education and training as independent learners in the clinical environment, and may be less susceptible to the risks of the “hidden curriculum” of medicine.

Regardless of the foundational concepts, principles or issues being explored in a particular class or assessment task, I strive to stimulate engagement with and evaluation of these skills. While these skills may well be taught and learned in the clinical environment, an explicit focus on their development is less likely in that context. Furthermore, these are skills that educators with specific ethics training and experience are perhaps best equipped to teach at the foundational level. This, in short, is an opportunity for my teaching to have a real impact on students, and hence on the individuals and communities they will one day serve as doctors. I also find this way of teaching more aligned with my earlier career aspirations of engaging in and fostering intellectual inquiry.

I occasionally wince when marking student papers that glibly refer to ‘the four pillars of ethics’ and appear to show that we have, after all, merely taught them psuedoethics. Nevertheless, majority of our students frequently astound me with their insights and the rapid progression of their skills in ethics over the four years of our program. Rather than becoming resigned to teaching ethics to medical students, as I feared when I first obtained an academic job, I have become ever more delighted by this responsibility. Teaching has proven to be an intellectually rewarding experience, and one that I firmly believe has a real and positive impact in the world.

“Looking Back”
Farhat Moazam

I embarked on the journey alone but
One by one they came, we became a caravan

Serendipity can lead to the most rewarding ventures in life. In 2002, as a doctoral student in the University of Virginia, I chose to conduct an ethnographic study on organ transplantation in Pakistan in the Sindh Institute of Urology and Transplantation (SIUT), a public sector healthcare institution in Karachi. Late at night as I sat analyzing my data, Dr. Adib Rizvi, Director of SIUT, would walk in, pull up a chair and we, both surgeons, would compare notes about our day – he his experiences in the OR and clinics and I the moral quandaries I had discovered interviewing patients, families, and physicians. One day, Dr. Rizvi looked at me and said, “Come back to Pakistan. We need a center for what you are studying.”

From that comment germinated the Center of Biomedical Ethics and Culture (CBEC). Inaugurated in SIUT on October 8, 2004, its beginnings were modest – one full-time and one part-time faculty (myself and Aamir Jafarey) and one staff member housed in a narrow L-shaped room with two poky offices – but the goals expansive. The Center would serve as the academic and intellectual resource in bioethics for Pakistan and the region and establish a presence in the international community. Including the word “Culture” in the Center’s name was deliberate. It flagged the emphasis in our educational and research activities on engaging with local cultural values, including religion, and socioeconomic realities that shape personal and professional moral lives. This would serve as a corrective to the philosophical, analytic paradigm dominating modern bioethics.

Today, twenty years later, CBEC has four full-time faculty and over a dozen national and international associate faculty from fields that constitute the core of interdisciplinary bioethics. Over a hundred graduates from the Center’s formal bioethics programs, Master’s and a Postgraduate Diploma, and many more professionals who have attended CBEC workshops, are now in institutions around Pakistan and the region. In 2017, CBEC was designated a WHO Collaborating Center in Bioethics, and began the CBEC KEMRI Bioethics Training Initiative (CK-BTI) program though an NIH grant.

The June 2024 Bioethics Links in your hands today, or on your screen, is a special edition to commemorate CBEC’s two decades of existence. For us, working on this newsletter was a time of self-reflection about who we are. Assembling the content involved ferreting out (scattered) old reports, correspondences and photographs. Heeding poet Robert Burns “to see ourselves as others see us,” we also requested teachers and graduates to share their impressions. A special thanks to faculty Sualeha Shekhani and Farid bin Masood and staff Aamir Shehzad in helping to make this edition possible.

*Professor and Chairperson, Centre of Biomedical Ethics and Culture, SIUT