AKU Bioethics Group: Fountainhead for Bioethics in Pakistan

On April 11, 2018, the Aga Khan University (AKU) Bioethics Group (BG) organized a symposium to commemorate its 20th anniversary. For the occasion BG members and AKU faculty were joined by many from the city who had been associated with the BG in the past but have moved on to other healthcare institutions where they continue to pursue bioethics related activities. The audience in the symposium reflected the unique role played by the BG in the growth and dissemination of bioethics in AKU and beyond, something that was perhaps not envisioned by its founders two decades ago.

The BG was formed in 1997, spearheaded by Dr. Farhat Moazam who was then Associate Dean, Postgraduate Medical Education. Bioethics had been taught to AKU medical students since 1986 through the efforts of Dr. Jack Bryant, Chair of Department of Community Health Sciences. However, according to Dr. Moazam, the BG was formed to bring the teaching and practice of bioethics into the clinical settings and to involve clinicians and residents. She gives credit to Dr. James Bartlett, a psychiatrist and then AKU Dean of Faculty of Health Sciences, for generating her interest in bioethics. She recalls him handing her a Hastings Center Report and later sponsoring her for a 5 day workshop at the Kennedy Institute of Ethics in Washington DC.

After her working paper on the proposed BG was discussed and approved in the Dean’s Forum, department chairs were invited to nominate one member from their respective departments in order to form the group. The first BG meeting was held on June 13, 1997, attended by 8 members: 4 physicians (a nephrologist, a neonatologist, an anesthesiologist, and a pediatric surgeon), 2 nursing professionals, a clinical psychologist and a social scientist. Besides discussing Terms of Reference and the working paper, members were enthusiastic in educating themselves; consequently, all meetings included discussion of published papers on clinical/research ethics.

The monthly 90-minute meetings of the BG provided a safe space to discuss dilemmas faced in clinical care. By early 1998, the group began undertaking activities meant to include the larger AKU community. An Ethics Grand Round, the first such event to be conducted in Pakistan, was held in the School of Nursing on March 27, 1998. Titled “Death with Dignity,” the format included a presentation by a resident about a 58 year old, terminally ill, ventilator-dependent man admitted in the ICU, whose son wanted to take his father home against medical advice. The session generated an enthusiastic and lively discussion by the well-attended audience, and Ethics Grand Rounds is a popular BG event that continues to date.

Also in 1998, the BG published a one-page, black and white newsletter, prepared in Dr Moazam’s office since few offices had computers. This was replaced by a colored and glossy 5 page version the following year with funds from the Dean whose help, encouragement, and accessibility were integral to the continuation of the BG. The first formal “ethics consult” in the history of AKU Hospital, and perhaps of the country, was sought from the BG by a surgeon about a ventilator dependent 18-year old male with Down’s syndrome. This landmark case was subsequently published in The Journal of Clinical Ethics in 2003, in an article titled “At the Interface of Cultures.” In 2001, while pursuing recognition by the Joint Commission on International Accreditation the hospital Medical Director turned to the BG for help setting up the required Hospital Ethics Committee (HEC). Several members of the HEC, including its first Chair, were BG members.

In addition to ethics consults, the HEC also organized biennial symposiums that helped take bioethics beyond AKU to others interested in this field. A noteworthy event of the second HEC Clinical Ethics Symposium in 2003 was the decision to create a city wide bioethics group to include healthcare professionals from both private and public sector institutions in Karachi. This idea was pursued by Dr. Nida Wahid Bashir, an AKU alumnus and a general surgeon at Patel Hospital, and the Karachi Bioethics Group (KBG) was born in 2004 with members from 11 hospitals in Karachi. Fourteen years later, KBG continues to meet every two months with different hospitals playing host to the group each year.

The BG (with now twice the number of members than at its inception) continues in AKU and focuses on revisions, expansions and methodologies best suited to teaching bioethics in the undergraduate and post graduate curriculum. However BG’s position as the fountainhead of medical ethics in Pakistan two decades ago remains in place. Its founding chair, Dr. Moazam, left AKU in 2000 to pursue a PhD from the Department of Religious Studies in the University of Virginia. She returned to Pakistan to set up the Center of Biomedical Ethics and Culture (CBEC) in SIUT which was inaugurated in October 2004. She was joined in CBEC by Dr. Aamir Jafarey who had returned after completing a fellowship in research ethics from Harvard University and also happened to be among the earliest BG members. Several former and current BG members continue to interact closely with CBEC including as teaching faculty in its programs.

Currently CBEC is the only institute in Pakistan which provides formal postgraduate education in bioethics and awards graduate level degrees in the discipline. Through the Center’s alumni, bioethics has been introduced to students, trainees, clinicians and researchers in institutions across the country such as Ziauddin University Hospital, Karachi, Shifa College of Medicine, Islamabad and Shaikh Zayed Hospital, Lahore, to name a few. CBEC faculty and its alumni are members of the National Bioethics Committee of Pakistan, and the Center was recently awarded the status of WHO Collaborating Center for Bioethics. The ripples that began twenty years ago are now spreading beyond the borders of Pakistan through a NIH funded program, the CBEC-KEMRI Training Initiative, mandated to develop formal bioethics training programs in Kenya for East African countries.