Introduction

Bioethics has become an integral element of health research and clinical practice. The subject was introduced in Pakistan in 1984 when the Aga Khan University added bioethics to the curriculum of undergraduate medical students (1). Since then, the interest in the subject has grown among healthcare professionals in the country. In 2001, the Pakistan Medical and Dental Council stipulated that all medical schools should include biomedical ethics in their curricula.

Despite this history, there is a dearth of faculty trained to teach this subject. Faculty with an interest in bioethics has organized groups to educate themselves through discussion. The first such group emerged in 1997 at the Aga Khan University to discuss ethical dilemmas encountered in clinical practice. This was a means of raising awareness among postgraduate trainees and faculty (2). Some faculty went on to obtain formal training and have now introduced bioethics education in other institutions.

The Center for Biomedical Ethics and Culture (CBEC) was established at the Sind Institute of Urology and Transplantation (SIUT) in 2004 in Karachi. It was the first centre in Pakistan to be recognized for education in and promotion of bioethics as an emerging field. Alumni of its postgraduate diploma programme are expected to carry out a project when they return to their own institutions, and educational activities are now being carried out in the National Institute of Child Health and Dow University of Health Sciences in Karachi; Liaquat University of Medical And Health Sciences in Hyderabad, and Sheikh Zayed Medical Complex in Lahore to name a few (3).

In Shifa College of Medicine, Islamabad, bioethics was formally introduced into the undergraduate curriculum in 2008. The module, which is taught in the preclinical as well as the clinical years, was set up by two faculty members who had received postgraduate diplomas from the University of Karachi in 2007, after their training at CBEC. The next step was to educate more faculty members to implement this curriculum in their own institutions, as part of their own curriculum, rather than relying on the expertise of a few select specialists.

The purpose of this study was twofold: to assess our faculty’s baseline knowledge on bioethics and ethical dilemmas in everyday practice and to learn how receptive they would be to become part of a bioethics discussion group. We also hoped to identify potential members of this group.

The establishment of the Bioethics Interest Group of Shifa was a project undertaken by the first author as a part of her course requirements in the postgraduate diploma bioethics program.

Methods

In December 2008, we conducted a workshop for the faculty, through the medical education department of Shifa College of Medicine, on “ethics and professionalism”. It was attended by 147 faculty members from the medical college, hospital and school of nursing. The purpose was to introduce faculty to these concepts so that they could carry them forward in their teaching. All those who attended the workshop were given a questionnaire to fill out before the workshop started. Confidentiality was ensured, because the names were not included in the datasheet. Faculty willing to participate returned the forms at the end of the workshop. Their e-mail addresses were also collected to invite them to the first meeting of the Bioethics Interest Group of Shifa when it was launched.

In addition to questions on basic demographic information, questions were asked on awareness regarding bioethics as a specialty and whether faculty members would want to join a bioethics interest group, within the same institution. These questions are shown in Table 3.

At the end of the questionnaire, participants were asked if they knew what an ethical dilemma was, to identify an ethical dilemma that they had faced, or heard about, and to explain why it was an ethical issue.

The proposal for this study was submitted to the Institutional Review Board (IRB) of Shifa College of Medicine for expedited review as it was considered to be a low-risk study. It was reviewed and approved by the head of the IRB before implementation.

Results

A total of 122 of 147 faculty members (83%) (49 male and 73 female) from the Shifa College of Medicine, Shifa International Hospital and Shifa College of Nursing filled and returned the questionnaire. Table 1 shows the distribution of their ages and Table 2 shows the designation tiers.

Table 1: Age Distribution (Total 122)
Age range	Frequency (%)
< 30	45 (37)
31-40	45 (37)
41-50	13 (11)
61-59	8 (6)
> 60	11 (9)

Table 2: Designation of Faculty of Study Sample (Total 122)
Designation	Frequency(%)
Instructors and Registrars	77 (63)
Assistant/Associate Professors	32 (26)
Professor/Consultant	13 (11)

Table 3 represents the responses when asked about their awareness of and interest in bioethics.

Table 3: Awareness and Interest of Faculty Regarding Bioethics (Total 122)
Questions	Yes Number (%)	No Number (%)	Not sure Number(%)
Are you aware of Bioethics as a specialty?	65 (53)	33 (27)	24 (20)
Would you be interested in educating yourself in Bioethics?	104 (85)	6 (5)	12 (10)
Would you like to become part of a Bioethics Group?	74 (61)	17 (14)	31 (25)
Do you know what an ethical dilemma is?	50 (41)	38 (31)	34 (28)

There was an association between respondent’s awareness levels for bioethics and their position on the academic hierarchy. Professors or senior consultants were more likely to be able to identify ethical dilemmas in practice than those at lower levels of the academic hierarchy were. Enthusiasm to join a bioethics group was greater among junior level faculty but this association was not significant. These are represented in Table 4.

Table 4: Awareness and Interest of Faculty Regarding Bioethics According to Designation (Total 122)
	Are you aware of Bioethics as a specialty?				Would you be interested in educating yourself in Bioethics?				Would you like to become part of a Bioethics Group?				Do you know what an ethical dilemma is?
Designation	yes	no	Not sure	p-value	yes	no	Not sure	p-value	yes	no	Not sure	p-value	yes	no	Not sure	p-value
Instructors and Registrars	32	28	17	< 0.01	66	1	10	Not Significant	50	8	19	Not Significant	27	30	20	< 0.05
Assistant/Associate Professors	23	5	4		29	2	1		19	5	8		13	7	12
Professor/ Consultant	10	0	3		9	3	1		5	4	4		10	1	2

Out of the 50 people (41%) who stated that they were aware of the definition of an ethical dilemma, only 38 were able to describe one and point out the issues that it raised. 19 of these 38 were senior faculty members (full professors or senior consultants).

The common themes which emerged in the dilemmas were organ transplantation (n=14), abortion (n=15) and breaking bad news (n=9). These themes are relevant to current concerns in Pakistani society as is evident in publications in ethics journals (4, 5). Our respondents explained why they felt these were dilemmas, referring to religious reasoning, legal implications and a family-centered approach when dealing with patients in Pakistan.

14 respondents referred to “organ transplantation” as posing an ethical dilemma. (This study was conducted when the Organ Transplantation Bill was being discussed and was covered extensively in the Pakistani media.) They stated that it was a dilemma because: “Poor people forced to sell their kidneys to the rich”; A rich man can buy an organ if he needs it but what about a poor one? Selling of kidneys is becoming a common practice especially for the poor and “Monetary gains vs. saving a life”

Organ transplant was also discussed in terms of religion: The participants were not sure about the religious stance on the issue: Not sure if organ donation after death is allowed in our religion; Fatwas by maulvis say it is disrespectful for the human body, but I am not a religious expert.

One participant posed, as an ethical dilemma, the case of an elderly man who needed a kidney but none of his 3 adult children was willing to donate. For him the dilemma was: should the children be made to donate an organ to their ailing parent if they are not willing? The man needed a kidney but should the kids endanger their lives if he will live for only a couple of years?

All 15 participants who referred to “abortion” as an ethical dilemma were women. As abortion is illegal in Pakistan, women are forced to go to backstreet practitioners for such services, at the risk of infection and even death. From a religious point of view our respondents were not sure if it was allowed in Islam and this caused them some discomfort. Some expressed the dilemma between their religious views and their feeling that it was justified in certain circumstances: If it is case of rape, I would support abortion but am I being religiously correct? One posed it as a dilemma between the life of the mother and that of the foetus: If she has illegal abortion, is it life of mother or fetus? Which is important? Others also suggested that it was used for convenience: Abortion is against our religion. Should not be a form of family planning or emergency contraception. All were certain that Islam did not permit abortion: Woman does not have the choice of abortion because it is illegal and against Islam also.

All nine respondents who cited “breaking bad news” as an ethical dilemma referred to the situation in which a doctor diagnoses a patient with cancer. The question was: should the patient know about his or her diagnosis if family members want to protect them? They viewed the dilemma as weighing the interests of the patient who should know against the wishes of the family which dominates in Pakistan.

Relatives hide the diagnosis from the patient. Patient may ask if he has cancer, then what to do?

Tell the patient his diagnosis or listen to the family?

Some respondents described as ethical dilemmas arguments between doctors and patients over medical negligence, or if the hospital was unable to provide a bed for a sick patient. We view these as important issues but not per se “dilemmas” and did not include these as valid responses to our question.

The definition of dilemma which was discussed in the workshop following the study is where there are two options both of which are acceptable courses of action and accepting one choice will prevent selection of the other. When a hospital cannot admit a patient due to lack of available beds or funds, this is not a dilemma but may be a fault in hospital policy or planning.

Discussion

Bioethics as we understand it today originated in the United States and Europe and the values, language, content and thought processes behind ethical discourses are strongly influenced by the culture and technological advances of the western, developed world. While ethics is discussed in developing countries such as Nigeria (6), Thailand (7), Sri Lanka (8), India (9) and Bangladesh (10), these efforts are few and far between. Bioethics education needs to be developed in these countries. Bioethics groups play a role in this process, especially for faculty who are role models and mentors for the new generation of doctors.

In our group, self-reported awareness about bioethics as a specialty was limited to about half of our study sample. However, 85% were willing to improve their knowledge about the subject. It is encouraging that junior faculty members were more interested in joining a bioethics group if it was established in their institution. It was depressing that despite senior faculty’s greater awareness, they were not as enthusiastic to join. They had the potential to educate junior staff about bioethical issues and chose not to do so. The greater workload of senior faculty may also be a deterrent. When we later approached individual faculty members to join the bioethics group, senior members would ask: “What are we expected to do?” On hearing that it involved regular meetings most senior faculty excused themselves, stating that they had other commitments. As mentioned by Saeed (11) in a study of the impact of a bioethics group in a private institution of Karachi, among faculty regarding improvement in participation; we take hope that results would be similar (meaning an increase in faculty participation) once the project takes off.

Conclusion

Most of our respondents did not have adequate awareness about bioethics and ethical dilemmas. However, they were quite receptive towards establishment of a Bioethics Interest Group. The junior faculty showed greater enthusiasm to join and perhaps it would be appropriate and convenient for us to establish this group with relatively younger members.