The Center of Bioethics and Culture was established in Karachi, Pakistan in 2004. The underlying objective of its activities is to assist in capacity-building of faculty and staff in biomedical ethics and promote ethical medical practice in the country.

The postgraduate diploma (PGD) in biomedical ethics was introduced in 2006.The PGD at the Center is a one-year structured programme and at the moment is the only postgraduate-awarding degree programme in biomedical ethics in Pakistan. In 2007, 14 mid-career professionals from all over Pakistan were selected. The group comprises physicians from clinical and basic health sciences, a research scientist and a dentist. These students are required to participate in a web-based discussion group. The PGD bioethics 2007 discussion group has been set up to drive independent student learning. (1) Students take responsibility for selecting and discussing various ethical issues that crop up in their daily practice or that make headlines.

The PGD discussion group is a forum to discuss important bioethical issues. Discussions have been on such diverse subjects as stem cell research, organ trade, pharmaceutical industry and physician interaction, informed consent and patient autonomy in developing countries, and self-experimentation.

Recently a student initiated a discussion on suicide. This edited dialogue, based on an exchange of emails, provides an insight into the different opinions and ideas about suicide amongst medical professionals in Pakistan.

Ali: Dear Group, I have experienced today one of the most trying and confusing days of my life. I was torn between my duty as a physician and compassion for my patient. One of my oldest patients (more of a friend) came to see me today. I had not seen him since I referred him to an oncologist. He had come to tell me that he had been diagnosed as having acute leukaemia. He went on to say that he did not want to suffer a prolonged illness in which there would be unbearable pain, and he did not want to be a burden to his family. He asked me if I could help him. I told him that I could prescribe something for the anxiety he was experiencing. But he wanted something stronger. I knew what he was asking me for. I told him that I would do everything I could to help him with his pain. He looked at me with tears in his eyes and said goodbye.

I feel awful that this is all that I could do. Should I have done more?

Ashraf: Suicide and physician-assisted suicide are contrary to the sanctity of life. They are illegal and forbidden in Islam. You yielded to the “Do no harm” principle of the Hippocratic Oath.

Studies have highlighted that most individuals who contemplate or succeed at suicide are depressed or have other psychiatric conditions (2). In addition, in terminally-ill patients who contemplate suicide, the desire to die fluctuates over time (3). The absence of effective pain relief, compassion and care from their healthcare providers – or family or friends – or the fear that they will not receive these when needed have been implicated as factors that may induce suicidal thoughts in terminally-ill patients (4).

You did the right thing.

Natasha: I am sitting here mulling over an article I read on suicide in today’s issue of the newspaper Dawn (5). According to a report issued by the Lawyers Committee for Human Rights, Pakistan, in 2006 there was an average of 483 suicides every month in the country.

Why would a person do this? What makes you not want to get out of bed in the morning? Many of us are lucky enough to have lots of reasons to be thankful that we are alive. But what if one doesn’t have a reason, what if life is no longer worth living? When, after measuring life against death, death seems to be a better option? Weighing the options, if your choice is not disadvantaging others, should there be moral objection to end your life?

People who commit suicide or attempt it are readily condemned by society and religions. If almost 500 people a month are willing to defy God and become sinners and opt for burning in hell then things must be pretty bad for them.

Can we not let someone just die if they want to?

Moin: This is a difficult question to answer. According to Kant’s rights-based moral theory, if everyone has a right to life, it follows that everyone has a right to choose to die. If I have a right to life, it is your duty not to kill me: but I can release you from this duty by requesting you to kill me or give you my consent.

From a utilitarian perspective, the morality of any action is judged by its consequences for the agent and all others concerned. A person who asks for death has come to the conclusion that for him dying is better than staying alive. His choice of death will be morally right so long as the benefit of his remaining alive is less than the burden on him and others taking care of him.

Natasha: I searched for some more details on suicide in Pakistan and there were very few data. In fact we still do not have an age-standardised rate because of the religious and legal status of the act as a crime. However Prof Murad Khan, chairman of the department of psychiatry, Aga Khan University, has kindly provided me with the following details on suicide in Pakistan:

• There were a total of 5,800 suicides in Pakistan from January to September of 2006.
• In a study published in 2000, Khan and Reza (6) identified 306 suicides reported in Dawn during 1996-199The typical suicide was male (68 per cent of the cases reviewed) under the age of 30 (82 per cent), single (58 per cent), committing suicide for domestic reasons (78 per cent), and ingesting poisons (39 per cent). The men were more often single and the women married. The women were also a little younger than the men (23.4 versus 26.8 years). The men were most often unemployed and the women housewives.
• Age- and gender-specific rates show most suicides occurred in the age group 20-40 years and were more common in men, similar to the western world.

Reported suicide rates are probably an underestimation of the true extent of the problem in Pakistan. Because the law states that suicide and attempted suicide are illegal acts, both are likely to be underreported because of the consequences. Perhaps if suicide were not such a taboo people in need of help would be able to speak to someone without the fear of any consequences. It will be more productive to understand these people and encourage them to discuss their problems.

Bushra: People are not only inclined to commit suicide as a result of a pathological process: depression, desperation and so on. Will you not entertain a situation when a person says that he has lived his life and makes a rational decision without duress and with a sound mind to die since he is used to making all his decisions all his life, why not this one? He is lucid. He has made a decision. The fact that the decision appears irrational to us does not make him crazy. Can a sane man want to kill himself? If so, should he be allowed to, morally?

You are basically saying suicide is a problem among our youth so we need to counsel them to prevent unnecessary death. It is a problem among unemployed men so we need to counsel them and prevent them from doing it. However, when it comes to someone who is terminally ill and wants to kill themselves, are you saying that we should help them?

Natasha: The eventuality of a terminally-ill patient is death. I do not think it is wrong to lessen the pain and anguish for such an individual. I think it comes to determining if the person is making a rational decision or not. Would that decision change if circumstances were to change? For example for patients on dialysis may be found to suffer from severe depression had suicidal thoughts but when treated for the depression they may no longer have such notions. I feel it is important to discuss thoughts of suicide with someone. A society that condemns suicide religiously and legally inhibits discussion and a possible solution. If at the end of the day the individual is lucid and has made a rational decision, then I see nothing morally wrong in that.

Moin: We see patients who have been have been put on artificial life support. These patients have failed to respond to treatment. As physicians we know that it is better for the patient that we withdraw life support but letting a patient die feels wrong. As doctors we have been trained to save patient lives. Daniel Callahan in his article ‘When self-determination runs amok’ (6) says that it feels wrong to physicians because they feel that they are causally responsible for the death of that patient. It appears to breach expectations, obligations to the patient and family.

But morally, Callahan continues, the physician has no duty to continue treatment once it has been proved to be ineffective. A doctor should stop treatment once it will no longer benefit a patient. The doctor should step aside to allow an inevitable event.

Ali: A friend of mine is a physician. His father had terminal cancer with metastasis to the bones. The pain was so intense that he needed morphine to relieve pain. In order to relieve the excruciating pain the morphine dose had to be increased to dangerous levels. My friend was caught in this dilemma between relieving his father’s pain and at the same time risk taking his father’s life. In the end he opted to let his father die in peace, free of pain. In medical ethics parlance this is known as the doctrine of “double effect”

Discussion

Adult learning is built on the assumption that adults are autonomous and self directed learners. The web-based discussion group format is useful because it is tailored for busy healthcare professionals. The various ethical issues are selected by students who draw on their experiences to explore ethical issues and dilemmas.

As the members of the group are healthcare professionals they can identify themselves with situations where they have been involved in end-of-life issues, in situations where they have withdrawn or withheld treatment from critically ill patients. They have felt the anguish of such difficult situations, as have other physicians; that it might be better for a patient to die than suffer in agony (6). Research on the topic is difficult because suicide and attempted suicide are considered illegal acts. There have been few reports on suicide in Pakistan (7).

Physician-assisted suicide is a growing concern for medical professionals. Few reports on physician-assisted suicide in Pakistan are available. Qidwai et al have reported on the perception of patients towards physician-assisted suicide at a teaching hospital in Karachi, Pakistan (8). The study found that nine per cent of patients advocated physician-assisted suicide. Of course, this study cannot be generalised to the rest of the country.

The group explored various aspects of this sensitive issue, to examine the moral and philosophical reasons for committing suicide. It felt that there should be systems of communication to enable individuals in the community to talk about suicide. The authors also feel the need for more research on suicide and physician-assisted suicide in Pakistan.