I have been associated with CBEC as visiting faculty for the better part of a decade and have taught cohorts in the Master’s and Post-graduate diploma programs. My focus has been introducing students to approaches to religious ethics, the history of the academic study of religion in the Western academy, and theorizing how the dimensions of our lives we might label “religious” or “religion” are entangled with the rest of our lives.

I was honored to be invited to the 20th anniversary of CBEC in January 2025 as one of the presenters at the event. My presentation drew on the history of medical applications of mesmeric trances in India in the 19th century and the hopes pinned on spiritual telegraphy in the US in the same century for elucidating an important distinction between two different ways of thinking about bioethical problems. What I want to share with us in this brief essay are the contours of that distinction and the implications it has for how we might think about bioethics as a “problem-solving” discipline or area of inquiry.

On the one hand, it is possible to conceive bioethics as a discipline that conceptualizes and resolves problems of a “tame,” finite, specifiable, and resolvable nature. The term “tame problems” was coined by Rittel and Webber in 1973 to designate problems where “the mission is clear.”¹ These are problems that can be clearly formulated, about which you can suggest finitely specifiable pathways of resolution, and you are sure when the problem’s been “solved.” Webber and Rittel provide the example of a game of chess as a tame problem. You can specify the rules of the game, you can unambiguously identify when a game has been won or lost, and, in some sense, each chess game is isolatable from other chess games or non-chess games. As they put it: “Chess has a finite set of rules, accounting for all situations that can occur.”²

If bioethics were to be conceived as a response to a set of tame problems, then it stands to reason that the essential task of bioethics is providing a set of frameworks and approaches that can offer pathways, rules, and guidelines, via which the bioethical equivalents of a game of chess, or mathematical problems, are conceptualized and resolved. My contention is that approaches such as Fitz Jahr’s – one of the early “founders” and architects of bioethics – engage in this sort of theorization when they offer Kant-inspired “bioethical imperatives” as frameworks for resolving bioethical problems.

In his commentary on Jahr’s bioethical imperative, Hans-Martin Sass notes: “The Bioethical Imperative is a necessary result of moral reasoning based on empirical physiology and psychology of humans, plants, and animals; as such it needs to educate and steward personal and collective cultural and moral attitudes and calls for new respect and responsibilities toward all forms of life.”³

Similarly, Beauchamp and Childress use the phrase “the common morality” to refer to “the set of universal norms shared by all persons committed to morality…It is not merely a morality, in contrast to other moralities. The common morality is applicable to all persons in all places, and we rightly judge all human conduct by its standards.”⁴ What I want to point out is that such principles are appropriate to bioethics, if bioethics is conceived as a way to address tame problems.

On the other hand, if bioethical problems are not clearly specifiable in the way that a game of football, cricket, or chess might be specified, and they are more akin to what Rittel and Webber call “wicked problems,” then, perhaps the way to go about them is not to come up with an exhaustive approach or a set of frameworks. Rittel and Webber attribute ten characteristics to wicked problems in order to distinguish them from tame ones. Unlike tame problems, wicked problems resist finite formulation and there are no clearly specifiable criteria through which one can conclude that a problem has been “resolved.” Wicked problems are “radical,” in  that,  they  require  us  to  figure  out  how  one  might live-well-with-a-problem rather than eradicate or resolve it and imagine a world without it. They may be thought of as “existential problems” that one has to negotiate and figure out as a matter of course, rather than address at a particular point in time.

While Webber and Rittel draw on social policy-related problems to make their case, their framework can be employed to make sense of problems that one has to “cope with,” “resist,” “palliate” rather than overcome, eliminate, and cure. If we are to think of bioethics as a discipline that theorizes and conceptualizes wicked problems, then its claims should sound less like clearly articulated principles, pathways, and guidelines, and more like Richard Rorty’s claims about philosophy.

Rorty notes that the quest for arriving at a programmatic “method” or a set of “principles” that will clarify the nature of the problems that vex us is wishful thinking: “It is useless to hope that objects will constrain us to believe the truth about them, if only they are approached with an unclouded mental eye, or a rigorous method, or a perspicuous language.”⁵  For Rorty, the only recourse available to us in the face of “wicked problems” – think climate change, justice, distribution of material  resources,  living  with  a  chronic disease – is “conversation”: “Our conversation with our fellow-humans [is] our only source of guidance. To attempt to evade this contingency is to hope to become a properly-programmed machine.”⁶

In the face of intractable problems, Rorty suggests that we count and rely on “our loyalty to other human beings clinging together against the dark, not our hope of getting things right… Our glory is in our participation in fallible and transitory human projects, not in our obedience to permanent non-human constraints.”⁷

To my mind, Rorty’s claims against the search for procedural fixes to intractable problems offer two important insights. First, the search for procedure and method as our “savior” can be a symptom of our desire to evade the responsibility of constructing a fallible course of action and to, instead, posit an undeniable “principle,” a “non-human” constraint as the source of our actions. Our search for such principles may belie  our  desire  to  evade  the  messiness  of  human construction in the hopes  of becoming a “properly -programmed machine.”

Secondly, and perhaps more importantly, conceiving our ethical task as the construction of principles, procedures, and rules, is a way of preventing our thinking from becoming capacious, expansive, and political. It carries the risk of directing our intellectual labor to the construction of “scripts” and “cogs” that work within bureaucratic and professional settings, which we have to take as “givens,” as non-negotiable parameters within which our principles, rules, and procedures have to find their place.

I can do no better than cite Rihito Kimura’s hopes about bioethics as more than a set of procedures for resolving tame problems. He noted in 1986: “Bioethics is a totally new form of discipline which goes beyond the notion of interdisciplinary studies: it is suprainterdisciplinary; it is deprofessionalizing medicine; it is a civil action movement.”⁸ To my mind, too, the degree to which bioethics is a discipline that addresses wicked problems, it ought to be akin to Rorty’s claims and Kimura’s rallying cry.

References:
¹ Horst W. J. Rittel and Melvin M. Webber, “Dilemmas in a General Theory of Planning,” Policy Sciences 4, no. 2 (1973): 160.
² Ibid., 164
³ Hans-Martin Sass, “Fritz Jahr’s 1927 Concept of Bioethics,” Kennedy Institute of Ethics Journal 17, no. 4 (2007): 283. Emphasis added.
⁴ Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics (New York : Oxford University Press, 2013), 3.
⁵ Richard Rorty, “Pragmatism, Relativism, and Irrationalism,” Proceedings and Addresses of the American Philosophical Association 53, no. 6 (1980): 726.
⁶ Ibid.
⁷ Ibid., 727.
⁸ Quoted in Sass, “Fritz Jahr’s 1927 Concept of Bioethics,” 291.

Scholarly literature on gender in Pakistan has traditionally ignored the everyday experience of women, especially the domestic experiences of women within the household.[i] In order to explore this gap, we may have to turn to women’s voices that are present in non-formal archives such as diaries, biographies, memoirs, and even fiction—sources where we find women speaking in non-public spaces (Rouse 1996).[ii]

Following the above discussion, I elaborate on these insights by focusing on the 1960 film Saheli (Female Friend), to open up the question of domestic life and sexuality in Pakistan by turning to an underused archive: cinema. This analysis enables me to open up an argument about women’s representation in popular media in Pakistan, in order to create a different archive of women’s cultural and sexual politics and histories.

The passing of the Family Law Ordinance in 1961 was seen as major victory for women’s rights in Pakistan as it provided some legal curbs against polygyny, expanded the right for women to initiate divorce proceedings and also dealt favorably with inheritance rights for women. This move by General Ayub’s military government may not have been reflected in its cultural politics. The same year the Ordinance was passed, the film Saheli (1960) received five President of Pakistan medals for different categories. The film’s central theme was the friendship between two women and depicts one of them letting her friend marry her own husband as a second wife.

Let me offer a brief plot of the film and then share a reading that questions its more obvious interpretive reception (polygamy). The film was directed by S.M. Yusaf, a veteran of the Bombay film industry who had migrated to Pakistan and tells the story of two female friends, Jamila (Shamim Ara) and Razia (Nayyar Sultana), who grow up together in Rawalpindi with Jamila’s mother and her elder brother.

When Razia is called away to her relatives in Hyderabad, the two friends constantly miss each other and write letters to stay in touch. But these are intercepted by Jamila’s brother who has a soft spot for Razia, yet also has a mistress whom he keeps promising to marry. The friends, hence, are unable to communicate.

Pining for her friend, Jamila fakes an illness and wants the doctor to tell her mother that she should be sent to Razia to recuperate. The doctor, played by Darpan, falls in love with Jamila. She reciprocates his feeling and their marriage date is fixed. On the day of the wedding, the doctor dies in a car accident and Jamila, traumatized, enters a shock-like condition. The family takes her to Karachi to a specialist, renowned for healing psychological problems When Jamila opens her eyes in the Karachi hospital she sees Darpan again, who is now playing the character of the elder brother of the deceased doctor (but looks identical) and is married to Razia.

Jamila, of course, does not know this and she is eager to get married to the doctor. Razia persuades her husband to marry her friend as that is the only way she would recover from her condition.  Jamila gets married without knowing that Darpan is already married to Razia.

Jamila’s brother in the meantime takes the intercepted letters to Darpan and convinces him that his first wife, Razia was actually in love with him (Jamila’s brother).  The letters were of course addressed to Jamila but only through the term of endearment, habib (my love), and were signed by Razia. The doctor is convinced of his first wife’s unfaithfulness and is willing to give her up.

In the meantime, the doctor’s loyal servant tells Jamila that the person she was supposed to marry was dead and that Razia had sacrificed her marriage for Jamila’s happiness. Jamila calls Razia on the phone and hears her shriek. Jamila’s brother, who lusted after Razia, had forcefully entered her house and was threatening to rape her. Jamila arrives at the house with a gun, confronts her brother and shoots him through a broken window-pane.

The movie is actually a flashback that Jamila narrates in front of the judge hearing the murder trial. At the end, Jamila’s brother’s long-suffering mistress comes forward and says that he  was actually killed by her bullet.  She killed him, she says in her testimony, because she could not see him ruin another life. The last shot shows the two friends embracing each other and then riding back to their mutual home in a large convertible, the husband nowhere to be seen.

In her book Between Women: Friendship, Desire, and Marriage in Victorian England (2007), Sharon Marcus reads Victorian fiction to discuss female relationships in England of that era. She shows the intensity of these relationships in terms of mother-daughter dynamics, in female friendships, in the mutual investment of women in images of femininity and the range of different ways women associated with each other.

These homo-social relationships were deeply imbibed by ideas of altruism, generosity and mutual indebtedness. The book concedes that the power of men, patriarchy and the institution of heterosexual marriage defined lives for these women, but also asserts that we need to understand the strong affective and complex bonds that women had between each other that these forces could not undermine.

Although the film can be read as a melodrama, following Marcus, we can acknowledge that the two women protagonists of this film were part of a male dominated society where they could be seen to perpetuate the institution of heterosexual marriage and even polygamy. But the viewers also witness that the bond between Jamila and Razia is far stronger than what they have with their respective male companions. At the very beginning of the film, the script allows them to address each other as habib and mahboob, both terms of endearment used for lovers in the Urdu language. In fact, when they write to each other they do not address each other by name, but rather with  terms that are normally reserved for relationships between men and women (there is clearly an eroticized message being conveyed, which the censors or the general public did not object to).

Since the strongest bond of affection in the film is among these two women, the separation created by Razia’s departure to Hyderabad results in a creative dilemma that the script needs to resolve. This is akin to the tropes of firaq (separation) and vasl (meeting), so common in Urdu literary writings. In this case, irrespective of the conventional tropes, the reunion of these women could only happen with the removal of one male love interest. Hence, Jamila’s fiancé had to be killed in order for the friends to be together again, without conforming to the demands of two husbands. We may condemn the institution of polygamy, but in this film we may want to see it as cultural metaphor (a bowing to convention or a cinematic sleight of hand) that allows the two who truly desired each other to come together within the patriarchal tradition of taking the second wife. As mentioned above, despite the twists and turns, the relationship between the two women is the one that triumphs and the last scene focuses on them, while the husband is off camera.

The film does develop a triangle of desire between the two females and their mutual husband, but the male character remains superfluous and is used like a prop. In Saheli, the affection between the two women remains paramount and the narrative arc creates an ending that shows them being together. This in itself was a radical decision by the director. He pushes this narrative by subtly bringing attention to how women work, live, care for, provide support to, and also desire other women.

My revisiting (and re-reading) Saheli  may be a small step in opening up a discussion on forms of cultural aesthetics in Pakistan and their representation of what may remain unsaid and silenced in national histories, the history of desire, of sexuality, of domestic violence, of gendered subordination.

[i] Hence the famous title of a book—nods to Lenin’s tract notwithstanding—written by two Pakistani feminists, Khawar Mumtaz and Farida Shaheed, Women of Pakistan: Two Steps Forward, One Step Back? (1987).

[ii] Autobiographies and fiction have been used effectively in the Indian context, especially in historical writings on gender by participants in the subaltern studies project. In the Pakistani context, there is some work by feminist scholars who have engaged with female voices from low-income backgrounds on their experiences during processes of urban conflict or forced migration. See Chaudhry (2004) and Khattak (2001), among others.

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.

“Double shot, extra hot, please” I said as I ordered my coffee at a Starbucks in Charlottesville, in the vicinity of the University of Virginia. The extra caffeine was required to prime my brain for the discussion that I was about to have with Dr Moazam, who was at that time based in this quaint little university town, completing her PhD with a focus on bioethics from the Department of Religious Studies, University of Virginia.

This was 14 years ago. I had borrowed by brothers’ old van, and driven down from Boston, where I was pursuing my year-long Fellowship in International Research Ethics and the Harvard School of Public Health as a Fogarty Fellow, to meet Dr Moazam. Our one point agenda was a discussion on the yet very nebulous concept of a bioethics centre in Pakistan, an idea floated a couple of years earlier by Dr Adib Rizvi, Director of SIUT where Dr Moazam had been doing her research for her PhD.

I can’t claim that we had at that time envisioned CBEC as it had turned out today, in its early teens now. But bioethics in Pakistan predates CBEC by at least 20 years. The first formal space for bioethics was created in 1984 in the Aga Khan University (AKU) in Karachi, where Biomedical ethics was gradually introduced in the curriculum of medical students in AKU by Dr Jack Bryant, an American public health physician and the then Chairman of the Department of Community Health Sciences. This was later also extended into the courses of the School of Nursing at AKU. Bioethics thus earned its small space in the classroom in at least one medical institution in the country.

In addition to these educational initiatives, an informal Bioethics Group (BG) was initiated at AKU in 1997 by Dr Moazam, comprising of clinicians and nurses who had an interest in bioethics. The BG, now in its 20^th year, still meets fortnightly over lunch to discuss ethical issues and has emerged as a premier self-education and discussion forum for bioethics.

The late 1990s also saw an enhanced demand for workshops on research ethics, and training for IRB members all over Pakistan, more so from Karachi. The initial awareness and interest in bioethics was limited to research ethics, driven by pragmatic reasons for training people to populate IRBs and open possibilities for external findings for their research, publication and accreditation.  This was not unique for Pakistan, and much of the developing world academia was scrambling to enhance capacity in this area. Many individuals, including this author, availed opportunities through programs focusing on research ethics (with some having a broader focus on bioethics as well) funded by the Fogarty International Centre of the National Institutes of Health of the US government at institutions in Canada, US, and Australia. What is noteworthy is that whereas these were all academics who took time off from their clinical work to pursue bioethics, it was purely based on their own initiative and not as a result of a focused institutional strategy to enhance bioethics capacity, with institutional support limited to granting an extended leave of absence for them. Another interesting aspect in this initial phase of formal bioethics capacity enhancement is that whereas these foreign opportunities were open to all, it was only members of the medical community that availed of them. The people who shaped bioethics in Pakistan were therefore primarily from the medical sciences, and with little no involvement of philosophers, social scientists, religious scholars or lawyers.

In Pakistan, bioethics was born at a medical university, and remained there for about 15 years, fueled primarily by individual efforts. It was only in the early 2000s that it finally became a serious academic discourse with the advent of indigenous, degree awarding bioethics programs, and a wider circle of participants.

The first academic degree program that was offered in bioethics in the country was CBECs Postgraduate Diploma in Biomedical Ethics (PGD) which commenced in 2006 and a Masters in Bioethics (MBE) which commenced in 2010. Whereas both these programs are continuing to date, a Masters in Bioethics program started by AKU in 2009 with NIH funding, ceased after the funding dried up in 2012, and the university did not step in to sustain it.

All these programs have been open to medical as well as non-medical applicants; however have attracted mostly medical scientists, clinicians and researchers with very few social scientists, educationists, journalists expressing an interest in this new emerging discipline in the county. Philosophers and religious scholars, generally seen to be in the leadership of bioethics initiatives in the West, have practically had to be coaxed to contribute to the discipline, as faculty in academic sessions on philosophy and religion, which are integral to any bioethics coursework. Whereas several medical institutions have now taken the initiative of starting bioethics departments, and offer courses at different levels, to the best of the authors’ knowledge, no philosophy department in the country offers courses in bioethics as yet.

From classrooms to boardrooms, being “done” sitting on swivel chairs, bioethics in Pakistan has defined for itself an indoor trajectory and never really taken on the mantle of activism or even advocacy in any sustained and meaningful manner. The one major legislation on a bioethical matter, organ trade which impacted the poorest of the poor, was initiated and spearheaded by an advocacy campaign by SIUT, with the medical fraternity and media contributing. The role of the bioethics community in general was at best, peripheral.

The bioethics discourse in the country has up till now also generally steered clear of “non-medical” ethical issues, like for instance the exploitative displacement of poor communities for multimillion rupee development initiatives aimed for the rich, or bonded labor, honor killings and so on. One reason for this is perhaps the preponderance of medical fraternity in bioethics in Pakistan, and plenty of “hot” issues within the medical domain to discuss.

This rather narrow focus on clinical and research of bioethics is bound to change as non-medical people pursue it as an academic discipline. Already, through CBEC, advances have been made into school systems, with structured workshops being offered to high school teachers, and sporadic sessions being organized for students.

One major challenge for bioethics to emerge as a choice destination for emerging academics is that there is practically no return on investment possibilities at the moment in the country for anyone investing time and effort in a degree in bioethics. There is also still hardly any meaningful “official” recognition for bioethics, with the Pakistan Medical and Dental Council, the College of Physicians and Surgeons of Pakistan and the Higher Education Commission yet to make any space for bioethics in their respective domains. Even with the introduction of academic degree level educational programs in Pakistan, bioethics remains very much a personal quest, with no real career prospects.

I was excited to be on my way to Pakistan, but my family and colleagues were worried. Over a year ago, I was invited to teach in the Center of Biomedical Ethics and Culture (CBEC), SIUT in Karachi. I accepted the invitation immediately because I wanted to contribute to the Clinical Ethics Module for students enrolled in CBEC’s Postgraduate and MA in Bioethics programs, and because I wanted to learn from people in Pakistan. But now an anti-Islamic film trailer “Innocence of Muslims” had been posted on the Internet. Demonstrations were expected throughout the Muslim world.

In spite of the bad timing, everything about my visit went smoothly and safely. I had a great experience, and got to do what I wanted: to contribute to the programs and to learn a lot. I left Karachi with many deep impressions: the smell and taste of the food, the sights and sounds of the city, the sincerity of the people, the tradition of zakat (mandatory wealth tax on Muslims), the involvement of families in patient care, and the eagerness of the students to learn.

But what left the deepest impression on me were the ethical problems that concerned people face. My “students” at CBEC were medical doctors, clinical teachers, and hospital administrators in the middle of their careers. So I taught in a way that encouraged them to articulate ethical problems that arise in their lives. The work of articulating ethical problems in lived experience involves more than textbook ethics . It involves phenomenology, ethnology, politics, religious studies, patience, and skill. It also involves willing and disciplined students. With a little help from me, the students brought to light ethical problems that were intellectually interesting and vitally important. The problems were also disconcerting because they poignantly raised the question of what we should do, and they left me with the feeling that I was not doing enough. Here are a few problems that we discussed.

1. Families and decisions. I quickly saw how involved families are in caring for patients and making medical decisions on their behalf. In discussions, a few students simply accepted the family as the legitimate source of all decisions for the patient. A few other students wanted to privilege the autonomous patient as the sole legitimate decision maker. But most of my students in Pakistan wanted to find ethical ways to live and work in the middle ground between these two positions. That made sense to me. People are deeply social, shaped and (to some extent) defined by a nexus of relationships. But that doesn’t mean that we need to uncritically accept the existing relationships and initial requests. For example, tradition may give the eldest son more voice and authority than can be ethically justified in a particular situation. The doctor may need to elicit and listen to other voices. In many cases, the ethical task is to avoid marginalizing people while recognizing the importance of the family.

2. The duty to treat. Most students agreed that doctors have a duty to treat patients with infectious diseases. When people enter the medical profession, they tacitly agree to accept reasonable risks that are inherent in caring for patients. This view was not merely a theoretical conviction among my students. Many of them had experienced an occupational exposure. But when we pursued matters further, we came upon two problems. We weren’t sure how well the duty to treat holds up when health care professionals lack proper equipment and protection. The second problem focused on testing patients. In cases of occupational exposure, I think patients have a responsibility to be tested for the sake of the health care workers. But this view requires more discussion. The actual practices at Pakistani hospitals seem to have developed in different ways without adequate discussion.

3. The responsibility to practice in Pakistan. I discussed with the students the migration of health care workers from low and middle-income countries to wealthier countries. This was not a theoretical matter for the students. Many of them had trained or worked abroad, and many of them could leave and practice elsewhere. After we discussed the support that society provides to medical education, most agreed that physicians have some responsibility to practice in Pakistan, at least for a reasonable period of time. But all of us wondered how best to balance this social responsibility with family responsibilities and personal concerns. My students in Pakistan were rightly concerned about their own safety and the safety of the families. Here are many ethical questions to explore. When do family responsibilities and personal concerns overcome social responsibilities? What should the medical profession do to address violence against physicians? When are physician strikes ethically justified?

4. Responses to disasters. In the last decade, Pakistan has experienced a very serious earthquake and a number of severe floods. Many physicians have responded, individually and in groups, to help those affected. I deeply admire the values expressed by physicians’ immediate response, but work of this kind must involve many ethical issues. We need to examine the issues that arise in responding to disasters, but also issues that arise about preventing, preparing for, and recovering from disasters. Indeed, the first step is to “de-naturalize” disasters: To examine how and where human conduct and social structures contribute to the casualties and losses. Climate change and deforestation contribute to flooding; social structures make some people more vulnerable than others. Here is an area where bioethics, public health ethics, environmental ethics, and social ethics overlap.

I have sketched four of the twenty ethical problems that I came home thinking about. I hope that students and teachers in Pakistan will write case studies that bring to life some of these problems. Too many case studies in bioethics leave aside the social context. We need case studies that provide a better sense of the social context in which reflection and discussion take places. Too many case studies are thin and schematic descriptions that aim to illustrate a theoretical conflict. We need thick and detailed descriptions that require us to pick out what is morally salient, engage all our moral capacities, discuss the matter with others, and respond in better ways. Too many case studies are narrowly focused on particular clinical problems. We need case studies that also address broad social, environmental, and human concerns. Too many case studies limit our choices so that we must decide between two conflicting values. But in ethical life, we often need to find creative ways to reconcile conflicting concerns, and to find ways that reframe the whole problem.

The case studies that I imagine would contribute to bioethics in Pakistan. But they would do more than that. They would contribute to bioethics in the rest of the world.

Dr. Richard Cash touched and will continue to touch millions of lives globally following his death. As one of the developers of Oral Rehydration Therapy, his contributions to public health cannot be forgotten. But he was also a dedicated bioethics educator. I met Richard in 2001 at a research ethics conference in Karachi. He encouraged me to apply for the National Institutes of Health fellowship in Research Ethics at the Harvard School of Public Health. I complied and spent a year learning from him. A natural extension of this was inviting him to teach at CBEC, which he readily accepted. He was a friend and a mentor to faculty and a hit with students. Punctuating discussions with Urdu words like ‘han,’ ‘acha,’ he would discuss complex ethical notions with great ease. Few from the Global North teaching ethics in Asia have approached it with a local perspective. Richard was different. Whether it was eating chawal [rice] and fish curry with his fingers, or discussing the critical role of mothers-in-law in healthcare access for a childless daughters-in-law, he understood the local context. We have lost one of our own. Richard, rest in peace

In 2020, I was given the task of organizing the residency program of Urology at SIUT. Two postgraduate programs run concurrently at SIUT, one under the College of Physicians and Surgeons (CPSP) and the other MD/MS under the Sindh Institute of Medical Sciences (SIMS). Since residents belonging to either of these programs have to work together in the same premises, their curricula have to be as similar as possible. This was the first challenge that the faculty of Urology took up and successfully addressed. While devising the curriculum it dawned on the faculty that two additional modules were particularly necessary i.e. Biostatistics and Bioethics. Both subjects were considered pertinent to prepare residents for research but bioethics also holds immense importance within the clinical domain.

I kept searching and conversing with different people regarding the inclusion of bioethics in the curriculum. In all honesty, I did not know anything about the subject. I only had some vague ideas. I had always wished to create a space where frank conversations were allowed regarding pertinent issues in healthcare including end of life care, breaking bad news, and palliative care. I also wanted to change the culture of silence especially for our residents. In 2023 I came to the right place: CBEC. The faculty of CBEC listened to me and after careful deliberations drew up a curriculum containing 15 lectures that covered areas pertinent to bioethics including the importance of informed consent, maintaining privacy and confidentiality, and ethical issues at end of life. The curricula also include foundational concepts in research ethics and guide residents on obtaining ethical review clearance.

The Bioethics Lecture Series is now in its second cycle. Feedback from 15 students who attended all sessions in the first cycle has largely been positive, finding the lecture series useful and practical. Residents are often seen immersed and engaged in lectures. They are speaking their minds and there is a high probability that they take the correct message home.

The Bioethics Pedagogy workshops, under the CK-BTI program, were initiated in December 2021. While three such workshops have been conducted in Pakistan, no initiative of this nature existed for Kenyan participants. This workshop targeted bioethics educators who are now teaching Master’s in Bioethics program at two Kenyan universities, Mount Kenya University and Amref International University (AMIU). The workshop was facilitated by CBEC faculty, Dr. Bushra Shirazi and CBEC Associate Faculty, Dr. Muhammad Shahim Shamim. The purpose was to equip participants with practical strategies to deliver effective bioethics education.

Each day was organized around specific themes, incorporating interactive lectures, hands-on activities and feedback to enhance knowledge and skills. During the workshop, participants learned drawing up lesson plans and measurable objectives. They were also taught how to highlight ethical issues through the use of tools including videos, artworks and vignettes.

Participants appreciated the hands-on activities and critique received from facilitators and peers during the workshop. They suggested the inclusion of assessment techniques in bioethics for future workshops. It is hoped that through these efforts, teaching bioethics will become more engaging for different cohorts of students.

Grant writing is an important skill that researchers are increasingly required to possess. Keeping this in view, the Centre organized this practicum, the outcome of which was the successful submission of at least one grant proposal. Thirty participants, from diverse backgrounds, were selected based on their proposed grant idea.

The practicum was led by Dr. Elizabeth Bukusi, co-director of CK-BTI, based in Nairobi, Kenya. Four virtual sessions were conducted before the on-site sessions and at the end of these, it was expected that a tentative grant proposal would be developed. The on-site workshop was held in Karachi from August 5 to 8 which involved hands-on exercises, real-time peer reviews and personalized feedback. During the physical interactions, participants refined their proposals and learned how to draw up budgets. One month after this, an online session was also held for participants to receive additional feedback on their completed proposals.

The practicum has proven to be highly successful, as several participants have their proposals ready for submission. Additionally, two participants have also won an external award for their projects developed during the practicum. Building on this success, the Centre envisions organizing a similar practicum for northern Pakistan, incorporating valuable insights and lessons learned from this pilot program.

At the request of the Department of Quality Assurance at SIUT, CBEC in collaboration with the World Health Organization (WHO) organized workshops to celebrate Patient Safety Day that falls on September 17. This year’s theme was “Improving diagnosis for patient safety” with the slogan “Get it right, make it safe!” The two workshops that ran concurrently therefore highlighted patient safety related to lab diagnostics. Such workshops are essential to enhance ethical awareness.

How to Culture Ethics: Professionalism and Patient Safety in the Lab

Dr. Natasha Anwar (standing, picture on right), a molecular biologist, CBEC alumnus, and Associate Faculty at CBEC, led this workshop emphasizing the importance of ethics in laboratory practices and its direct impact on patient care. The workshop highlighted that ensuring high standards of patient safety starts with cultivating a strong ethical culture and professionalism in lab settings. Attended by profession- als from various institutions in Karachi, including medical technologists, pathologists, and researchers, the workshop used cases to illustrate ethical issues and the consequences of unsafe laboratory practices on patient safety.

Understanding Medical Error

Medical error is a leading cause of death globally, yet the fear of humiliation, reputational damage, and potential repercus- sions often hinder its identification and disclosure. In order to shed light on this, the workshop focused on clarifying concep- tual definitions of error, negligence and malpractice under the banner of patient safety. Dr. Nida Wahid Bashir (standing, picture on left), with Dr. Bushra Shirazi assisting, led this workshop and explored the ethical dimension of medical error and highlighted the importance of the development of robust systems in dealing with medical error and negligence. Partici- pants included physicians and medical technologists both from within SIUT and other institutions from Karachi.