“It takes the whole of life to learn how to live, and – what will perhaps make you wonder more – it takes the whole of life to learn how to die.”

– Seneca, 65 CE

The quest to defy death is as old as humanity itself, perhaps older. In the Abrahamic scriptures, including the Quran, the first human, Adam, is deceived by Iblis (Satan) into eating the forbidden fruit of paradise to acquire immortality (Quran 20:120). The avoidance of death and the quest to prolong life is a pattern repeatedly woven into the tapestry of human stories. In a Greek myth,^[1] Eos, the goddess of dawn, asks Zeus to grant her lover Tithonus (the prince of Troy) immortality but forgets to mention eternal youth along with it. A tragic end follows when Tithonus reaches a “hateful old age,” getting to a point where he is not able to even lift his limbs. Finally, Eos locks him into a chamber where he babbles endlessly. In another Greek myth, the Cumaean Sibyl (a Greek priestess) asks the god Apollo for a thousand-year life, but forgets to mention enduring youth. In the end, she too becomes the “prey of a long old age” and shrinks until she is confined to a jar, whispering, “I wish to die.”

The Roman Stoic philosopher Seneca remarked that it is not only difficult to learn how to live but that “it takes the whole of life to learn how to die.” A few thousand years down the road, humans have not yet succeeded in evading death but medical advancements in the last century are pushing back the boundaries, raising new questions about what kind of life is worth living and what it means to die well. In one of Plato’s dialogues (The Republic, Book III), Socrates says that Herodicus, regarded as the tutor of the Greek physician Hippocrates, tormented himself as well as others “by the invention of lingering death.” Herodicus, who had a chronic disease, spent his life trying to cure himself. Since recovering from that disease was impossible, he used his skills in medicine and therapy to keep himself going till he reached old age. Plato criticizes Herodicus for practicing such coddling medicine and argues that Aesculapius (the god of medicine) did not teach such medical practices – not out of ignorance but because Aesculapius was concerned about society’s functionality. In a well-governed society, according to Plato, there is a function specific to each member of that society, and no one has “leisure to be sick” and doctor himself all his days.

Whether we agree with Plato’s rather stern viewpoint about a useful life or not, it is hard to deny that medical advancements that are making it possible to live longer, are changing the ways in which we die. In traditional narratives of death in many societies, an old parent would die in his bed after having distributed inheritance and attended to his responsibilities. Death in a familiar environment, surrounded by loved ones, fulfilled the dying person’s psychological and emotional needs without involving many healthcare professionals. Death was deemed imminent and faced with patience and confidence. This was a constant in history across cultures. Prophet Muhammad’s companion Bilal bin Rabah on his death bed, sang, “Tomorrow we shall meet with our beloved ones, Muhammad (peace be upon him) and his companions.” The Sufi ascetics embraced death gladly, viewing it as a means of union with God. Ibn Qayyim al-Jawziyya explained that death was a way of union with God, saying, “Every lover yearns for the meeting with his beloved.”^[2]

In fifteenth century Europe, Christian texts titled Ars moriendi (the art of dying) were well known. These texts provided guidance on the proper rules and procedures for facing death in the best way. For those who gladly accepted it, death was not only a natural process but also had a spiritual and ‘other-worldly’ aspect. Dreams and the presentiment of death were common, even among ordinary people. French historian, Philippe Ariès, quotes from the history of Europe, the last words of kings, knights, saints, common people – even children – calmly facing death. “I shall not live two days,” “I see, and I know that my end has come,” “I feel that death is near,” “My death is at hand, that’s what it is,” were common phrases near death.

Despite the fact that people in earlier times prepared themselves for dying well, death did not ask before coming – nor could it be turned away. With the rapid scientific advancement in the last century, death has become less adventitious, at least, in technologically advanced societies where a large cohort of the population dies after going through the regular phases of life (education, marriage, career, and children) and reaching old age. Death no longer seems as unpredictable as before, but something has been lost: The presentiment of death has become rarer.

According to a well-known quote by Ivan Illich, “In every society, the dominant image of death determines the prevalent concept of health.” Death in our times has been medicalized. From an inevitable natural phenomenon or a call by God, death has transformed into the effect of an identifiable cause (disease) which it is possible to get the better of. The categorization of death into natural and unnatural/abnormal/accidental supplements this perception. Along with this, the idea of ‘savior’, formerly invested in the physician’s persona, has now materialized in the form of the healthcare institution and we turn to the hospital to save us from death. The resultant medicalization of society elevates the ‘power over death’ perception to a new level. Death feels optional. Consequently, people spend massive amounts of money on healthcare in the last few days of life. While this does not eliminate death it does create the most rational and normal form of death – a hospitalized death under the supervision of medical experts.

Some contemporary writers, especially from the medical fraternity, have also started focusing on this topic. Atul Gawande, in his essay, ‘Letting Go’, writes that anxiety about death is increasing in modern society. According to Gawande, until the actual declaration of death, there is often a state of denial regarding impending death by both the patient and the family. Possibly, the denial stems from this relatively new, institutionalized image of death as something that can be controlled, circumvented, defeated – or even chosen. As a result, the modern, hospitalized death often follows extraordinary efforts to ‘do everything’ to prolong life – regardless of the quality of that life. For those who are engaged in healthcare provision, a BMJ editorial asks a thought provoking question: “Would you like to die the way your patients do, doctor?”^[3] As Seneca wrote, the question of how to die is perhaps connected to the question of how to live –  the other side of the same coin.

[1] Homeric Hymn to Aphrodite

[2] Ibn Qayyim Al Jawziyya, Madarij Al Salikeen (Ranks of the Divine Seekers: A Parallel English-Arabic Text) Trans. Ovamir Anjum (Brill, 2020), Vol 2, 620.

[3] Enkin, Murray, Alejandro R. Jadad, and Richard Smith. “Death can be our friend” (2011). BMJ; 343.

The Centre of Biomedical Ethics and Culture turned ten in October 2014. We celebrated our first decade the way we know best – by creating more work for ourselves! As reported in the previous edition of the Bioethics Links, (accessible at:  http://www.siut.org/bioethics/Newsletter%20June,%202014.pdf), CBEC faculty decided that the Centre needed to be reviewed by an international group of peers so that we could get an unbiased opinion regarding our accomplishments, our shortcomings and our future trajectory. The fact that such a review of a bioethics centre had never been reported in English language literature did not deter us; we are quite used to inventing our own wheels. Our reviewers were also brave to accept the challenge of the unknown and take up the onerous task of doing something they had never done before. Their commitment lasted much longer than the four days they spent on campus; it consumed several weeks thereafter during which the eight willing academics visited CBEC, toiled hard to make sense of what they observed, and to put it all in a report that was submitted to the SIUT Director in June 2014.  Their findings resonated with those of three external evaluators who had submitted their analyses based on their experience with CBEC and its activities and a faculty report that had been sent to them.

Our reviewers found the academic programs to be rigorous, interactive and challenging. Commenting on the course work they said, “The quality and topic range of the modules are world class.” Regarding the impact of the programs, they opined that CBEC’s “bioethical influence has extended beyond its office walls to other medical and also non-medical institutional settings …”

The review team found several distinctive features of CBEC which set it apart from other bioethics centres around the world. In the opinion of one reviewer, among CBEC’s most distinguishing characteristic(s) was the “inclusion of the term and concept of ‘Culture’ in its name” and the attention given to religion as a source of ethics. Another commented that, “CBEC’s conception of ‘culture’…   attempts to link ‘particularism’ and ‘universalism’ through its recognition of the ‘commonalities’ along with the dissimilarities that persons who belong to different societies and cultures bring to a moral life … This kind of multi-faceted and knowledgeable perspective on culture(s) is one of CBEC’s most distinctive attribute. It is a perspective that is minimized or marginalized, if not largely ignored by many other bioethics centres.”

Reviewers noted that an important feature of the teaching is “how well grounded instruction is in the clinical realities that students face in their professional lives. A fine balance is struck between didactic teaching and exposure to conceptual bases of bioethics … many programs in the West and elsewhere, fail to find this balance.”

The review team also appreciated the formal inclusion of literature, poetry and humanities in formal educational sessions. They were particularly pleased with the way CBEC faculty keep in touch with the alumni and facilitate them in their various bioethics related activities. The efforts made to keep the network of alumni engaged in bioethics, years after their graduation was also noted.

While acknowledging the Centre’s achievements at national and international levels, the reviewers however felt that the small core faculty could eventually “burn out” if faculty and support staff were not increased, strongly recommending an increase in their numbers. While impressed by the research output from CBEC over the last decade reviewers recommended that we devise a research agenda and appoint faculty specifically trained in research to be able to use our potential to the optimal. Dr. Adib Rizvi, SIUT’s Director, knows how to consolidate his successes. Based on the review recommendations, he has asked CBEC to embark upon an immediate expansion of its programs.

Needless to say, CBEC faculty was delighted with the report! We also found the review process to be a learning experience providing us new insights into ourselves, while also helping us to chart our future directions.

It is a routine Tuesday morning with my usual cup of tea in the solace of my room at work. This hour of tea is my time to kindle my thoughts: sit at the computer, check my mail, and meet some deadlines before the day begins. It’s Tuesday and I have a theatre case, a mastectomy on a breast cancer patient. It’s mundane, it’s routine but I know from all these years of practice that for the patient it is a life changing day, I know there is hope for cure for which she lays her life in my hands.

Let’s not dwell on these frills, it was a usual theatre morning where I go and the activities begin. Operation theatres have an exclusive atmosphere where there is the chitter chatter with residents and colleagues, pulling each other’s leg as hardcore work is done. The theatre is like a charm bracelet, you love it without really knowing why. It is the same ring you wear every day, but if you forget to wear it on a particular day you feel incomplete. For some hardcore coffee drinkers, it is a freshly brewed shot of hot coffee and for the book lover a novel you would love reading again and again: there is no argument about the intensity of the relationship of a surgeon and her theatre.

Where was I? Yes, in theatre and I have just finished my breast case and enjoyed my second cup of tea when I receive a call from my registrar reminding me that it’s my call day. There is a young woman with a gut perforation most likely due to typhoid. She is prepared for the standard emergency laparotomy and I have her shifted immediately to the theatre and the elective cases must go on waiting. Waiting, yet another classical experience in the OR – when will they shift the patient? Just as I decide to check, a female resident comes to the surgeons’ room and says the patient is refusing surgery. My male colleagues, with sarcastic humour, goad me to go and speak to the patient with compassion and empathy, which they believe are female traits, to convince the patient for the inevitable surgery.

I walk into the theatre and see a young woman who is supposed to be twenty-five years of age but looks no more than eighteen, beautiful in her simplicity, insisting that she will be fine. She does not want surgery. I begin to explain what is wrong in a language (Urdu) which I believe she understands. I explain that her life is of value and attempt to explore her fears but all I get is refusal and that she will become OK. I emotionally blackmail her: she has six children who need her and this is a routine surgery. I reinforce that she should trust us. There is no shift, instead she asks me if I believe in God and when I acknowledge this I am told, “For the love of God I don’t want surgery, it does not matter if I die.” I walk out of OR flustered and upset wondering how this mother of six can be so stubborn. I doubt her comprehension, and am willing to deceive her and have her anaesthetized with absolutely no moral discomfort. Controlling my frustration and anger I decide to call her husband who had consented for her surgery. My colleague, observing the drama, teases me that this paternalism goes against the ethics of care I am known to talk about.

My patient is in a state of emergency, in sepsis, kidneys going into failure with a pathetic nutritional status. Her husband, gowned, comes to the operating theater to speak to her. A cute couple, he patiently tries to explain to her that it is for her good, she argues with him and says you deceived me into coming to the big city, just take me back, I don’t want this surgery. Others in the room are viewers of the communication but the couple is oblivious to everyone. Some intervene and try to make her see the light. Her husband and a technician switch into their local dialect, and between her half “yes” and half “no” and the husband by her side with his arms around her, she is anaesthetized and the operation is underway.

Routine typhoid perforation, contamination that requires a thorough washout and a stoma (temporary opening made in the intestine) for she is nutritionally depleted and her parameters would not take anything else. Registrars do a good job and she is shifted to a step-down ICU and does well.

The next day her parameters improving, she is talking. Her stoma is a little slow to function but that is expected after such a surgery. She demands food which most of us believe is a good sign of recovery. However, her husband is told that only sips of water are allowed. I believe that within the next twenty-four hours she can take fluids and suck on sweets for taste; feel pleased at seeing her expression when she sips packaged mango juice, savoring the flavor she wants to gulp it down fast. Smiling, I ask her to take it slow and to drink more after a while. She changes her role and becomes a friend, complaining about her husband not giving her anything to eat or drink. I tell her, he is just carrying out doctors’ orders. Humorously, I tell the husband that your wife though delicate, is a headstrong woman, and I take my leave feeling happy. Tomorrow is another day, should one not feel happy or satisfied?

I see her once in the morning when all is well, her stoma functioning and labs normalizing, but as the minutes turn to hours the picture has changed. By the end of the day there is something not right, she is restless and drowsy all in one, her urine is concentrated. Am I missing something, what can it be? I tell my registrar to keep a watch and make sure he evaluates her again before he leaves at the end of the day. The next I hear of her being shifted to intensive care because of tachypnoea (fast breathing) and being electively ventilated with the expected need of ionotropic support. Why for the life of me I ask, her chest was clear, her parameters were near normal, why, just why? It becomes a downhill ride from there on, she starts to get acidotic, we stand by the bedside and look at her head to toe, we debate her re-exploration, has she perforated again, there is a septic focus somewhere. The resuscitation goes on, the labs get repeated to no avail and we discuss and explore in search of a reason for sepsis. We remove the double lumen placed, we check the chest, to find no answers anywhere. The much-needed CT scan cannot be done for her condition would not allow that kind of movement.

Then begins a feeling of impending doom that most surgeons have experienced. The conversation becomes another set of routine sentences: Ph is acidotic, urine output is only 12 ml in the last hour, she cannot be dialyzed because her pressures are not being maintained, dose of inotropes have been increased but BP still low. Nothing, just nothing gets better and finally the call that always makes you feel you failed comes and the saga ends. Aptly said in such circumstances: “man proposes and God disposes”; as mere humans we cannot fight fate.

Later in the day I ponder: where did I go wrong, what did I miss, I should not have forced the surgery. However, deep down I know if another such case came I would do the same thing, in the hope that this one would make it. I see her face and it is still painful, it is too soon to closet and move on. My eyes blur to say no more.

Oh My Blog!
Beenish Syed

As a PGD student, my life became a roller coaster ride of never ending assignments, readings, and end of module tests.  But posting on the monthly “Blog” was my most daunting task. Before acquiring an “ethical lens” I was unable to see the ethical issues embedded in my daily routine as a doctor. So I decided to write about these on the Blog. To my delight, my postings generated lively discussions among my colleagues and the faculty.

Challenging My Own Beliefs
Atif Mahmood

When I first started my PGD journey, the hardest thing to do was to tackle morally dubious subjects. Having to navigate through difficult moral conundrums made me more aware of subtleties that exist outside textbooks and made me question my beliefs. However, this discomfort helped me grow, giving me a better knowledge of other people’s viewpoints and forming my own moral compass.

From Reels to Ethics
Saima Saleem

After years of working as a filmmaker and media person, embarking on my PGD journey in CBEC felt like a genre shift. Initially, I felt lost amongst the medical jargon but for me the most challenging part was to unlearn my own biases. In stark contrast to the hero-doctor image depicted in media, I realized the ethical tightrope medical professionals walk daily.

The Prejudice of Certainties
Arsalan Khan

Enrolling in PGD bioethics, entrenched in scientific facts and anchored in religion, I stumbled into the grays of uncertainties. The once clear “facts” blurred, exposing unexamined biases. Graduating from the one year program, I now recognize the paramount challenge: understanding other points of view, untainted by the distorting hues of personal opinion.

Refaat Alareer was born in Gaza City in September 1979 during the Israeli occupation of the Gaza Strip. He was killed on December 6, 2023 by an airstrike in northern Gaza during the present invasion underway of the Gaza Strip by the Israeli army.

Alareer was a poet and an activist, and professor of world literature and creative writing at the Islamic University of Gaza. He considered the power of storytelling as an important form of resistance and co-founded the organization “We are not Numbers,” a mentorship program for Palestinian writers. He was editor of Gaza Writes Back: Stories from Young Writers in Gaza, Palestine (2013), and Gaza Unsilenced (2015).

While sheltering in a UNRWA school, Alareer had received multiple death threats stating that the Israeli army knew his location. He sought refuge in his sister’s apartment which was subsequently bombed killing him together with his brother and nephew, and his sister and her three children.

Alareer wrote his poem “If I Must Die,” a few days before he was killed and it has been widely circulated and translated into over 40 languages since then. It was inspired by Black poet Claude McKay’s 1919 poem “If We Must Die,” a passionate denunciation of racism and all forms of oppression, and a call for resistance against such practices.

If I Must Die
Refaat Alareer (November 1, 2023)

If I must die,
you must live
to tell my story
to sell my things
to buy a piece of cloth
and some strings,
(make it white with a long tail)
so that a child, somewhere in Gaza
while looking heaven in the eye
awaiting his dad who left in a blaze —
and bid no one farewell
not even to his flesh
not even to himself —
sees the kite, my kite you made, flying up above,
and thinks for a moment an angel is there
bringing back love.
If I must die
let it bring hope,
Let it be a story

In 2011, more than 12000 Palestinian children flew kites on the beach of the Northern Gaza Strip during a summer camp organized by the United Nations Relief and Works Agency (UNRWA). They achieved the Guinness World Record for the largest number of airborne kites at a given time. During the event, the children also carried the portraits of 66 Palestinian children who had been killed in the Palestinian enclave by Israeli airstrikes during a previous conflict.

Credit: UN Photo/Shareef Sarhan https://www.flickr.com/photos/un_photo/6029204185

The Ethics and Culture Hour (ECH) is an event that CBEC hosts for a wider audience at periodic intervals. Revived after a hiatus of two COVID inflicted years, the focus of this particular ECH was to look at the life and work of the Pakistani poet, Ada Jafarey, regarded as the First Lady of Urdu Poetry through the prism of her autobiography “Jo rahi so bekhabari rahi.“

The catalyst for the event was the recently released translation of the autobiography from Urdu to English, titled “A World of Her Own” by her son and CBEC faculty, Dr. Aamir Jafarey with his daughter Asra. As the translated work states, “this autobiography is the tale of an ordinary girl, and a woman from a traditional household … The girl was a captive of the loneliness that filled her heart, became the woman, who despite being confined to four walls wandered the expanse of her imagination freely.”

For Aamir, the initial motivation to embark on this challenging project was to make his 8-year-old daughter comprehend her grandmother’s story. As years went by, Asra joined as a formal collaborator in the translation while she pursued her graduate degree in English literature. During the event, Asra theorized the limitations of translated works, capturing her dissatisfaction with the product by stating “Almost there, but not quite.”

Nida Wahid Bashir, CBEC part time faculty, who had played a key role in the planning of the event, also served as the moderator for the evening. Dr. Moazam welcomed the guests and spoke about the centre. She also introduced Aamir Jafarey and invited him to talk about the translation. The two guest speakers were prominent poets of Pakistan, Mohtarma Zehra Nigah and Professor Pirzada Qasim, who spoke about Ada and her poetry. The evening ended with a ghazal performance by renowned singer Salman Alvi. Bushra Shirazi closed the session by giving a vote of thanks to all the people who were involved in making the ECH a success.

In October 2023, the Pakistan Association of Urological Surgeons (PAUS) invited me to give a State of the Art Lecture in their international conference held in Karachi. As a female surgeon, I chose to speak about the continuing challenges for women wishing to train in and practice surgery subtitling my talk Hunooz Dilli Dur Ast (Delhi is still far away). This famous phrase, traced to 14th century Sufi Nizamuddin Auliya remains, I believe, an apt metaphor for women wishing to pursue surgical careers.

During the 1970s and 1980s while training in general and pediatric surgery in the USA, I was the sole female trainee in surgical programs, and subsequently the only female surgeon for a decade I spent as faculty in an American university. I was constantly reminded how tough it was to become a surgeon, that “even men do not make it through training,” that surgery “requires a man’s temperament, women are too soft, emotional,” and given backhanded compliments that I “worked like a man.”

One could argue that matters have changed since then for women wishing to become surgeons. However, studies published within the last five years indicate that for many women Dilli dur ast remains the reality. The global increase in females graduating from medical colleges over the last three decades (now 50% to 65% of graduating classes) does not reflect a proportionate increase in women trainees/consultants in surgical specialties (excluding gynecology).

Due to lack of indigenous research, this information is unavailable from Pakistan but I suspect the numbers may not be too dissimilar. I conducted an informal, pre-talk survey of the three top healthcare institutions, all with sought after surgical training programs, that had organized the PAUS conference. Between them, they had well over 200 surgeons on staff of which roughly, 20 were women. Majority of female surgeons held junior positions and merely two women had made it to full professor.

A comprehensive scoping review about the experiences of female surgeons from 26 countries (Human Resources for Health, 2020) reveals several factors that continue to serve as hurdles for women. Among the most pernicious is the persistence of stereotypical gender roles, the old canard that “biology is destiny.” Notions that women are less courageous than men, emotional, less rational, are voiced as jokes and jibes directed against female trainees and surgeons. Such perceptions often translate into gender based discrimination against women in surgery with less opportunities in the Operating Room (OR), and emotional and physical harassment by male surgeons.

The scoping study specifically identifies lack of mentorship as an important global impediment reported by women trainees and younger surgeons. Sociological studies indicate that having female surgeons on the faculty can encourage young women to consider surgical careers. This pattern of a dearth of mentorship for women trainees, also surfaces during my conversations with younger female surgeons in Pakistan. Curiously, I also hear from some criticism of women who do “make it in surgery” yet remain unsympathetic to experiences of younger colleagues.

As a woman mentored by male surgeons, I believe it is important that we work towards not perceiving surgery as a war between the sexes. Experienced surgeons, female and male alike, can be effective mentors, tough but fair irrespective of the sex of trainees and younger colleagues.

The Spanish poet Antonio Machado writes, “Traveler, there is no path; the path is made by walking.” Female and male surgeons in Pakistan, and globally, have to walk together to make this path.

When I think of spaces in Karachi, places where I can go alone or with my female friends, I think of being enclosed within four walls. Spaces and places are the same here. They consist of the same four walls, with the limited activity Karachi offers. The only aspect that changes is their interior design. Because spaces for women in Karachi are confined to four walls, a sample book on aesthetics, yet claustrophobic.

The term ‘walkable cities’ is the utopia I envisioned growing up, but it’s a bit of a buzz-word now. It’s an easy win in any argument when a relative asks me why I want to go abroad, what’s so special about Chicago. “Why don’t you stay in Karachi with your family?” ask my relative aunties. “Walkable cities, Aunty.” I reply with a smile, nod and walk away knowing there’s no response they could possibly give to this.

***

In Phadke’s book “Why Loiter” (2011), she talks about how it’s not only unfriendly people that make a place unsafe, but also unfriendly spaces. Design choices that make public spaces obscure and private feed into the notion that the public street is dangerous, and solidifies the gendered distinction that public spaces are to be occupied by men, and the ghar (house) is the only safe spot for women.

While conducting a research study conducted with a colleague in 2020 that involved online surveys with hundreds of women, a rough list of factors affecting the safety of a place for women emerged. The prominent ones included lighting, openness, visibility, security, walk-path, public transport and gender disparity. All these factors are essential when designing a space; after all, who doesn’t think of them when designing a space for public use? However, these metrics are rarely applied within the context of public spaces in Pakistan.

The crux is that the elimination of female comfort when designing public spaces is not taken into account reflecting a deliberate disregard in order to maintain a patriarchal equilibrium, to keep women out of public spaces not meant to be theirs.

***

I’ve spent the last five months walking on the streets of

Chicago. The Institute I attend is in the middle of the metropolitan overlooking Millennium Park and the Art Institute of Chicago. My lovely, small apartment that I share with my friend is almost a 40 minute commute from there. Twenty minutes of that commute is a walk, and the rest is by the train.

The idea of walkability is so novel to everyone I know in Karachi that my stories of the Chicago Transport System will be met with awe. No one in Chicago bats an eyelid when I say that in my circle of fifteen in the city, nobody owns a car despite being in their mid-twenties. This is so because for Chicagoans, cars are not a necessity since for the most part the city is walkable, filled with at least 11 different train tracks and thousands of buses. You can get from the suburbs to downtown without needing a car. You can walk to the grocery store without fearing for your life. You can cross the road and have cars stop for you without fearing someone driving over you. All of which is utopian for someone from Karachi.

***

I am back in Karachi for my winter break. Somehow after spending a few months in Chicago, my automatic response of walkable cities to aunties does not roll off my tongue so easily now. It’s because I realize that I would not be caught dead using the underground subway after 10pm in Chicago, I recheck the train schedule five times before I descend down into the station, and I use the ten-minute walk between stations to call someone because the streetlights are still too dim to feel safe. The metrics of safety for women are not perfect in Chicago either. There is a stark difference in security and lighting once you leave the Downtown Loop and enter the rest of the city. I am realizing that my bar for freedom of mobility for women has been so low that Chicago seemed a utopia to me, but only because it does provide a bare minimum for women which Karachi fails to do.

Here in Karachi, I drive my beat-up white Mira to pick up my friends Ariba and Mariyam because driving them around is safer than calling an Uber. We cruise the city in the hours between noon and maghrib (sunset), we dodge calls from our mothers when we cross the timestamp of 5 p.m., we hop from one cafe to another, and we end up at V.M Sanctuary, an indoor space to work.

We raise our cups of mediocre chai (tea), and we laugh about how we are the awara (wayward) girls in our families. The so-called progressives who have traded the four walls of our homes for the four walls of these cafes.

A young couple had eloped. Belonging to different tribes, but living in the same mohallah (neighborhood) they had committed the most dishonorable act. It was decided by the panchayat (council of elders consisting of men) to lure them back with promise of marriage celebrations. Dressed in their finest, both were killed by their respective families and buried in unmarked graves without funeral rites to reclaim lost family honor.

The above scenario is one instance of “femicide,” murder of women, which illustrates deep-rooted patriarchal values embedded within society. Honor killing, intimate partner violence, domestic or sexual violence, all pose a threat to women’s safety in Pakistan.

The practice of honor killing, colloquially referred to as Karo-Kari and Siyah-kari target both men and women although in majority of the cases, women are its victims. The parallel quasi-judicial systems, Jirga or Panchayats, issue verdicts declaring more women than men guilty and punishable. Different factors account for someone to be labeled as “kari” (black). Marrying outside the tribe, wanting to marry outside the family, being seen talking to a male at a public place is sometimes enough to be killed. The perpetrators of this crime are often members of the immediate family who carry out orders to murder for the sake of “ghairat” [traditional concepts of familial shame].

Human Rights activists estimate that around 1000 women are murdered annually in Pakistan in honor killings.¹ As per unofficial statistics from southern parts of Sindh province, at least 217 people including 152 women were murdered in honor-related crimes in 2022.² Sources in Sindh Police Department confirm that 141 women have been reported as murdered in honor-killings this year.

An alarming aspect of honor killing is that it is often made to simulate suicide. Such cases pose a special challenge and require a high index of suspicion during autopsy and investigations, to accurately declare the cause of death, especially where non-violent approaches are used including poisoning and hanging.

The legal standing of honor killing in Pakistan has a long history with unsuccessful attempts to control it. In 2004, the Criminal Law Amendments in sections of the Pakistan Penal Code (PPC) and Criminal Procedure Code officially recognized honor killings as a form of murder thereby paving the way for it to be prosecuted in regular courts of law.

However, murder under the existing Qisas & Diyat Act 1991, is considered a compoundable offence. This allows the complainants to pardon the accused through a compromise arrived at voluntarily. They can also either claim or refuse diyat (compensation or blood money payable to the legal heirs of the murdered). This creates challenges in the application of the 2004 PPC amendment.

In 2016, Qandeel Baloch, a social media celebrity, was killed by her brother for bringing “shame” upon her family. The accused was subsequently pardoned by his and (the victim’s) parents. This created an uproar both nationally and internationally. Books and movies focusing on Qandeel’s life were developed to bring attention to this cause. All this served as a catalyst for the introduction of the Honor Killings Act 2016.

The Act defined honor killing as “murder” with penal punishments, categorizing it as “fasad-fil-arz” (producing chaos in society). This term, drawn directly from Muslim jurisprudence serves to see the act as a danger to the wider community shifting the nature of the crime to one committed against the State and not only an individual. This concept is also used to decide the severity of punishment awarded by assessing the past convictions of the accused, the nature of the offence and the accused being a danger to the wider community.

The Act however has several loopholes. As an example, determining the “past conduct” of the accused in awarding punishment can serve as a double-edged sword. If the accused has no past history of violence, the degree of punishment can be reduced.

Moreover, since the prosecution must establish that the murder indeed qualifies as honor killing, the credibility and expertise of the prosecutors are crucial factors in the implementation of the existing laws. Lack of training, incompetence and callous attitude of prosecutors can contribute to miscarriage of justice. External and internal influences can also tilt the scale in favor of the powerful.

More importantly, the existence of two sets of law continues to complicate delivery of justice in most cases. Despite the existence of 2016 Act, the Qisas and Diyat Act 1991 still stands leaving the door open for negotiations and compromise, even if the case goes to trial. However to date, no published evidence exists with respect to the percentage of cases that end in a compromise.

While the long-term effects of the laws have yet to be established, increasing social awareness and civil outcry about violence against women in the wider Pakistani society continues to provide impetus for changes within the legal systems. As an example, the Domestic Violence Bill passed in 2021 can be considered a landmark achievement for including emotional and psychological abuse within the definition of violence against women. Pakistani society has a whole long way to go in eliminating crimes against women but the response of the civil society provides a glimmer of hope for change.

References:

1. https://www.hrw.org/world-report/2022/country-chapters/pakistan
2. https://tribune.com.pk/story/2407440/217-killed-in-the-name-of-honour-in-2022-report

Gender equality is a modern ideal, which has only recently, with the expansion of human rights and feminist discourses, become inherent to generally accepted conceptions of justice. But what presents Muslims today with a distinct problem is that family law and gender norms are still based on classical fiqh rulings that uphold a patriarchal model of family, treat women as second-class citizens, and place them under male authority.

The religious legitimation of patriarchy has been the subject of heated debate among Muslims since the early twentieth century. Feminist participants in this debate form two broad camps. The first are those who consider religion to be inherently patriarchal and see engagement with it to be a futile and incorrect strategy. The second group comprises those who see such an engagement as essential for a viable challenge to the hegemony of patriarchal interpretations of the Shari‘a. This second group (among which I include myself) by the 1990s had acquired the label of ‘Islamic feminists.’ They argue for the necessity of a brand of feminism that takes Islam as a source of legitimacy and confronts patriarchy from within the tradition.

One of the central challenges that Muslim women face in their struggle for equality is how to address in a systematic way the gap between modern notions of justice, in which equality is inherent, and ideas of justice that underpin established understandings of the Shari‘a, in which individuals are accorded rights on basis of their faith, status – and gender – as defined in classical fiqh. To bridge this gap, we need scholars and activists who can work together to bring fresh perspectives on Islamic teachings, and to explore common ground with advocates of human rights and feminism. We need constructive dialogue to overcome two blind spots in approaches to gender issues in Islam and human rights.

On the one hand, scholars of Islam are largely unaware of the importance of gender as a category of social analysis; they oppose both feminism, which they understand to mean women’s dominance of men, and human rights, which they see as alien to Islamic tradition. On the other hand, some feminists and human rights advocates have little knowledge or appreciation of religious modes of thought and religion-based laws, rejecting them as antithetical to their project. However, most women whose rights they champion are believers and live according to the teachings of Islam, thus effective change can come only through engagement with those teachings.

In other words, to achieve sustainable and deep-rooted change, we need dialogue and consensus. We should demonstrate the injustices that arise from patriarchal customs and laws based on the pre-modern interpretations of the Shari‘a, and offer defensible and coherent alternatives within a framework that recognizes equality and justice. But is this possible? Can we ground our claim to equality and arguments for reform simultaneously in Islamic and human rights frameworks? Can there be an egalitarian interpretation of Shari‘a?

Feminist voices and scholarship in Islam are part of the new wave of reformist thinkers that contend that the human understanding of Islam is flexible, that Islam allows change in the face of time, place and experience, and that Islam’s tenets can be interpreted to encourage both pluralism and democracy. But instead of searching (like earlier reformers) for an Islamic genealogy for modern concepts like gender equality, human rights, and democracy, they place the emphasis on how religion is understood and how religious knowledge is produced.

They do not reject an idea simply because it is Western, nor do they see Islam’s textual sources as providing a blueprint, a built-in programme of action for the social, economic, and  political problems of the Muslim world. What they give us is ethical guidance and principles for the creation of just laws. The Qur’an upholds justice and exhorts Muslims to stand for justice; but it does not define it. Rather, it indicates the path to follow, which is always time-bound and context-specific.

These thinkers have developed theories and strategies for reform. Chief among them are the distinctions between religion and religious knowledge and between the changeable and the unchangeable (mutable and immutable, accidentals and essentials, descriptive and prescriptive) in the texts; they seek to discern the aims (maqasid) of the Shari‘a, and to locate in their historical and political contexts both the sacred texts and the rulings that classical jurists derived from them.

Islamic feminists are re-inserting women’s concerns and voices – which were silenced by the time that the fiqh schools emerged – into the processes of production of religious knowledge and law making. In this sense, they must be seen as part of the larger struggle for the democratization of production of knowledge in Islam and for the authority to interpret its sacred texts.

In modern times, when nation-states have created uniform legal systems and selectively reformed and codified elements of classical Islamic law, and when new forms of political Islam have emerged that use Islamic law as an ideology, one of the main distinctions in the Islamic tradition has been distorted and elided. This is the distinction between Shari‘a and fiqh. In Muslim belief, Shari‘a is God’s will as revealed to the Prophet Muhammad. Fiqh, or jurisprudence, denotes the process of human endeavour to discern and extract legal rulings from the sacred sources, the Qur’an and the Sunnah. This distinction, which underlies the emergence of the various jurisprudential schools in the tradition, and, within them, a multiplicity of positions, has immense epistemological and political ramifications.

It allows contestation and change; it enables us to separate the legal from the sacred, and to ask basic questions such as, how do we know what the Shari‘a is? How do we know what we know about gender rights in Islam? Who decides what ‘Islam’ mandates? The distinction is therefore crucial to the arguments of committed feminists who choose to locate their feminism within Islamic tradition.

Let me end by saying that the close link between theology and politics can be a double-edged sword. It has been one of the main obstacles that Muslim women face; but it has also the potential to be an effective means for challenging patriarchal laws and unjust structures. The rise of political Islam in the second part of the twentieth century, and the politics of the ‘War on Terror’ in the present century, have shed new light on how ideological dichotomies such as ‘secular’ versus ‘religious’ feminism, or ‘Islam’ versus ‘human rights’ have masked the real site of the battle – the conflict between, on the one side, patriarchal and authoritarian structures, and, on the other, egalitarian and democratic ideologies and forces. If we recognize this, then we can aspire to real and meaningful change, and begin to transform the deep structures that have shaped our religious, cultural and political realities.

This is an abridged version of an article first published in Al-Raida Journal, Vol 44, Issue 2, 2020, pp. 85-91