Farhat Moazam. Bioethics and organ transplantation in a Muslim society: a study in culture, ethnography and religion Bloomington and Indianapolis: Indiana University Press; 2006. ISBN 0-253-34782-3. 264 pages. Price not stated.

This book is the product of three months of participant-observation research in a dialysis and renal transplant unit in Karachi which conducts only genetically matched transplants. The author, a surgeon who went on to study bioethics, “sought to understand how donors, recipients, their families and healthcare professionals in one of the busiest transplantation institutions in Pakistan interpreted and utilized indigenous belief and value systems to make sense of difficult, profoundly stressful situations in life”.

The first chapter presents the general context — end-stage renal disease in Pakistan, and the health services here — followed by a description of five health professionals who the author describes as “the backbone of the local moral world of the Institute” where she conducts her research. Chapter 2 presents an overview of secular bioethics leading into a discussion of the ethical world of the institute. The third chapter focuses on the predicaments of people with ESRD and their families. The fifth reflects on the insider-researcher and her increasing involvement with the situation that she is observing. The fifth chapter summarises the key issues related to live related donation in a traditional Muslim society.

Pakistan has a highly privatised medical system similar to that in India, which means the vast majority of its people do not have access to affordable medical care. In this situation, “the Institute” stands out as ray of hope for the thousands of Pakistanis who develop end stage renal disease every year. Supported partly by government funds but mostly by donations, its mandate is to provide treatment for kidney disease free of charge to all its patients. This includes dialysis until a donor is becomes available from within the family.

This is something like trying to bail out a leaking boat with a teacup. Relatives are often reluctant to donate a kidney. Meanwhile the dialysis machines work round the clock to treat patients who with their relatives fill the waiting rooms, corridors and the compounds. The surgeons, physicians, counsellors and others — driven by an absolute commitment to the institute and its patients – are fighting with their backs against the wall to keep their patients alive.

Moazam’s research examines the question: what moral framework guides the actions of the group of health professionals in the Institute? She argues that the ethics of this group of health professionals is based on Islam and Pakistani culture: “It is a world in which primacy is given to relationships and interdependencies, and a sense of relational obligations. A strong belief in responsibilities of the powerful (in this case, the physicians) to the vulnerable translates into a professional code in which a fierce benevolence works in tandem with a sense of social justice in which the duty of healthcare patients, perceived as victims, is paramount.”

Their strong sense of right and wrong is informed not by a professional physician-patient relationship or principles such as autonomy as it might be the West. Their duty is to the family and not the patient alone, and they work with this family for its survival. They use their authority as health care providers to cajole, and even bully someone to donate a kidney, sometimes threatening to stop dialysis if the family does not come up with a donor. At the same time they will protect those they see as vulnerable from exploitation by the family. The health professional’s role is social as much as it is medical.

Moazam’s point is also that current international discussions on bioethics developed in the West cannot be transplanted to other cultures without recognition of the local realities that shape ethics and practice.

The arguments made in the book should provoke one to explore what it is about the unique ethos of the institute, when compared to other institutions in Pakistan as well as to non-Muslim societies with similar social structures. One might wish to look more deeply at how this ethos has developed in the Institute that is an oasis in a desert of commercially driven medical practice. It would also be worth looking at the doctor-patient-family intereactions in other cultures in this region. Is there something unique about bioethics and organ transplant – or the ethics of medical practice — in a Muslim society? Or is the ethos that Moazam describes so well something that could exist in other poor societies where religion and family play an important role in an individual’s life?