Bioethics is not taught as a subject discipline in the undergraduate and postgraduate curriculum in Pakistan. Recently, medical colleges have introduced the behavioural sciences in the undergraduate curriculum, but this has its own limitations, as students are not examined at the end of course work, as in other subjects, which they have to clear in order to get promoted.
The regulatory body of the country, the Pakistan Medical and Dental Council, revised the curriculum in 2014, introducing Medical Ethics (1). The discipline is limited to a few hours of tutorials, and hence not given due weightage in the final examinations. The topics identified under the heading of Medical Ethics include the National Recommended Guidelines, the Code of Medical Ethics and background concepts and components. These components are taught for the first four years of medical studies, with a total of 14 lectures. There is no formal assessment, as for other subjects. for this subject. As a result, students miss the tutorials, as they know in advance that they will not be examined on this knowledge. This is the only formal education which the undergraduate may attain in biomedical ethics at undergraduate level, in all medical colleges in the country. Whatever they learn later is from their own experience, by observing their peers, mentors and supervisors. The same holds true for postgraduate students. They are not taught biomedical ethics at all, and their supervisors become their “books” in the discipline of bioethics.
I have worked as an obstetrician and gynaecologist at a public sector hospital, for the last 25 years. My college and hospital is located in the vicinity of the. Center of Biomedical Ethics and Culture (CBEC), of the Sindh Institute of Urology and Transplantation (SIUT). This is the only institute in the country imparting formal degree level education in the discipline of Biomedical Ethics. Both the medical college and the hospital are the oldest in the country. The hospital is one of the largest tertiary care centres of the country, with bed strength of more than 2000. Being a tertiary centre, the hospital has chronically been over burdened with patients and understaffed. Like the patients, the doctors come here from all over the country, to complete their postgraduate training.
While doing my postgraduate diploma (PGD) from CBEC, the practical work included teaching the basic concepts of biomedical ethics to my postgraduate residents in the wards. During these sessions I realised how important the discipline was for the residents. These sessions helped me to start conversations in my own department about many issues pertinent to the field of obstetrics and gynaecology.
After finishing my Master’s degree, I organised a one-year ethics course for surgical residents in my institution. A syllabus was developed based on generic topics in contemporary bioethics like informed consent, medical error and negligence, and recurring ethical dilemmas. Departmental heads were invited to nominate residents for a monthly session of one to two hours duration. 25 residents were thus identified, and one faculty member from each department.
The sessions began with an introductory talk by the founder Chairperson of CBEC on what biomedical ethics means, and its importance in the modern era. This session was able to ignite interest among the participants about future sessions. This session touched upon philosophy, the role and practices of both Western and renowned Muslim physicians, like Ar-Razi, Ibn Sina and Al-Zahrawi. Totally, 10 sessions were organised through the year with residents and faculty members. Care was taken to draw examples from local scenarios and from day to day experiences to provide real guidance to the residents. These sessions were kept interactive in order to keep their interest alive. After each session, students were asked to write down their comments in the feedback form provided. This helped in the planning of the next session. A specific day and venue were identified for these sessions, and timely information was sent through email. These sessions were facilitated with support from other CBEC faculty members.
At the end of the year, the participants were invited to share their experience of attending these sessions to gauge what they had learned and whether they would like these sessions to continue. This happened to be the most enlightening session for the facilitators. Deficiencies in the course could be identified, and hearing of the change in the attitudes of participants was music to the ears of the facilitators.
“The initial session introduced the concept of healing, never have thought of the difference between healing and cure”. One of the participants said. She explained that after attending a session on the qualities of good physicians, she was able to change her own attitude towards her patients. Another said she was able to restrain herself from behaving rudely with patients, after attending these sessions and that: “The session on medical negligence and error could tell me how to disclose our mistakes to our peers, and how to avoid them in future “
A resident from obstetrics and gynaecology shared an important change in her practice of informed consent. “Previously I used to look for the husband and in laws to give me consent for surgical procedures, now I go to the woman first, since I realised that it’s her body, she must sign her consent form first.” The participants were told that the religious laws as well as the country’s laws provide women rights over their bodies, and the laws prohibit any kind of intervention on women without their permission‒ whether it is their body, their property, or their rights of marriage‒are all protected, as they have to give consent to a marriage.
Another resident from the obstetrics and gynaecology unit shared how her practice regarding women seeking abortion has changed after attending a session on the ethical aspects of abortion and the law and religious principles related to the subject. She said that earlier, she had used religion as a shield to send away women seeking abortion on various grounds. She further elaborated how she was unaware of the country’s laws and religious principles on abortion, yet she had denied the service to those who required it. The law permits abortion on medical grounds especially when it is necessary to save the life of the mother (2). There is social stigma involved in women seeking abortions for reasons other than medical conditions, which may include unintended pregnancies. This can lead to women seeking help from untrained professionals, resulting in medical complications and even death. At the session, we were able to introduce the concept that if doctors have reservations about providing abortion services on moral and religious grounds, they can at least guide the women to centres where such facilities are available.
Residents also reported that they wanted to be respectful towards their patients, but working in a public sector hospital, where they are overburdened, they find it hard to practise the basic principles of biomedical ethics. A few raised their concern that there are no clearly defined systems for ethical practice in public sector hospitals. They were reminded that it is individuals who make up systems, hence a change in the attitudes of individuals is an important beginning.
One of the participants shared the experience that during her clinical rotations as a medical student, her senior postgraduate would talk in an insulting manner to his patients, which was very painful for her. The course was able to strengthen her respect for her patients.
All the participants were of the opinion that though new residents should be inducted into the ethics course, they would themselves be unable to reinforce their new knowledge of ethics in an atmosphere where such continuing activities are lacking. A participant shared the interesting experience that when she enrolled for the course, her colleagues had taunted her for having no better use for her time, than to waste it in attending these sessions.
The feedback at the session on the ethics of physician-pharmaceutical company relations served as an eye opener. The practice of receiving gifts, lunches, etc has become so habitual to physicians that a majority thought it was acceptable. It was only after this session that a few doctors confided that they have stopped attending these launches and lunches organised by pharmaceutical companies.
Public sector hospitals are always difficult to manage. They are always over-burdened and always understaffed. They are visited by people who have nowhere else to go, where the power equation in the patient-doctor relationship is lopsided. Teaching bioethics and asking residents to practise it in their day to day practice is a daunting task. Public sector hospitals have many caveats, which makes the practice of clinical ethics look difficult. One example is that of taking consent from patients. Doctors always find this task difficult. A patient is always accompanied by at least three or four people, who may be directly or indirectly related to her/him. The situation becomes even more difficult when a female patient asks the doctor to seek consent from either her in-laws or husband, as only they can sign and she will not affix her thumb impression or give her signature. Explaining to these women that country and religious laws empower them to make decisions about their own lives is a daunting task. The ethical and social challenges are very different in public sector hospitals, as compared to private hospitals. The same infrastructural problems confront medical professionals in other countries of the region as well. These include short supply of medicines, absence of senior doctors during regular duty hours, faulty machines resulting in delayed treatment and harassment of medical professionals by frustrated patients and their attendants. In such situations, the practice of biomedical ethics appears a difficult task for healthcare professionals. Awareness of the basic principles of respect for patients, beneficence and non-maleficence and justice can bring a change not only at an individual level but eventually in the existing system as well.
Biomedical ethics is not only a subject; it is the moral and ethical value system, which needs to be reinforced in our daily medical practice. Commercialisation in the field of medicine has tainted the image of a physician. Biomedical ethics is trying to redeem this image.