Fortnightly Medical Newspaper
published from Pakistan

Published by
Professional Medical Publications

November 15-30, 2010


ISSN: 1026-6828




We need a combination of Bioethics and Tibbi Akhlaqiat
Clinical unethical conduct is rampant in Pakistan and Ethics
Committees will not help improve it - Prof. Farhat Moazam

We must explore ways to indigenize medical ethics
something which belongs to us and we must ensure
that we can make a different on the ground
Physician’s interaction with Pharma Industry needs to be monitored
so that it does not harm patient interests - Prof. Rashid Jooma


KARACHI: Clinical unethical conduct is rampant in Pakistan and the formation of Ethics Committees will not help improve this situation. Time has come that we must explore ways to indigenize bioethics to something which belongs to us and we must also ensure that we can make a different on the ground. This was stated by Prof.Farhat Moazam Chairperson of Centre for Bioethics and Culture (CEBEC) at Sindh Institute of Urology and Transplantation (SIUT). She was delivering the keynote speech at the inaugural session of a seminar on Ethical issues in Education, Research and Healthcare at the Aga Khan University on November 5, 2010. The meeting attracted a large number of healthcare professionals from different disciplines of medicine interested in bioethics. Prof.Rashid Jooma Director General of Health in the Federal Health Ministry, Government of Pakistan who is also Chairman of National Bioethics Committee (NBC) was the chief guest on this occasion.
Bioethics in Pakistan, Prof. Farhat Moazam opined is an abstract exercise far away from where the ethics is. In her presentation she first gave an overview of birth of bioethics in USA followed by her observations and views on current status of bioethics in Pakistan which she felt was incoherent and inattentive to local needs. Bioethics, she said is a multidisciplinary field which started about sixty years ago in USA. It evolved in mid 20th century to tackle moral ethical dilemmas which surfaced due to improvements in medical technology. In 1960s, there was major social violence in USA; there were human rights movements, Vietnam crisis and increasing litigations against the healthcare professionals and scientific society. There were swelling of public sentiments, talk about individual rights and personal freedom along with unchecked authority of physicians besides increasing public hostilities.
In United States the founders of Bioethics were not the healthcare professionals but it was philosophers, sociologists and representatives of the public. However, in Pakistan it was the physicians and related personnel who started this movement in early 80s. However, since most of these physicians were trained in the West, they tried to transplant the American model of bioethics in Pakistan. There was too much emphasis on four basic principles i.e. Autonomy, Beneficence, Non-maleficence and Justice, This is known as Principilism. Just like we imported services and biotechnology, we did the same thing with bioethics. She pointed out that bioethics and biomedical sciences are different. As regards the current status of bioethics in Pakistan, there is too much emphasis on research ethics at the cost of clinical ethics. In the field of bioethics there are two parallel streams flowing in Pakistan, one is the Principilism by physicians trained in the West and the other is Islamic Bioethics. The later gradually has become more prominent in Pakistan which means turn away from anything which can be Western. It has become very fashionable to have talks, seminars and symposia on ethics in medical conferences these days. Moral values in Islam, Muslim physician’s views on abortion, transplantation etc., and their philosophical aspects are discussed at these scientific conferences. We have done nothing to see how both these can reconciled. There is little original thinking among us on issues we face in healthcare and she termed it a linguistic schizophrenia.
Continuing she explained it further stating that in the morning in the lectures at medical institutions we give too much emphasis on patient autonomy and are critical of paternalism but in the afternoon when we deal with the patients, we and the patients both practice paternalism. The patients says, Doctor Sahib you know the best and the physicians reciprocate it by telling the patient, Beta, Sab theek Ho Jai Ga and I have done my best. Instead of giving autonomy to patient and asking his/her viewpoint, we discuss the disease with the patient’s relatives and family members. Hence we practice entirely different than what we have been teaching in the morning to the young generation of physicians under training. What we teach the medical students might help them in passing USMLE or get good grades in tests but it does not help in improving the patient family interaction. There is intriguing priority to research ethics rather than giving priority to clinical ethics which should be the priority in Pakistan. We need to give more importance to clinical ethics rather than research ethics.
Prof. Farhat Moazam then highlighted the unethical conduct of healthcare professionals in healthcare facilities. Patients bleed to death as they are denied admission to healthcare facilities until they deposit some cash, physicians appear on television channels and print media promoting diapers, physicians promote oncology drugs on calendars produced by Pharma industry; they promote soap while hospital administrators are on the board of multinational companies. We misguide, harm and even kill patients and then we discuss how to establish Ethics Committees and Institutional Review Boards. In the National Bioethics Committee as well, while the Research Ethics Committee has come up with some guidelines, the Clinical Ethics Committee has failed to make any headway. Research Ethics has made some progress because there is lot of funding available and there is some underlined agenda. In the present day when collaborative research on drugs has to be conducted with physicians drawn from Asia and Africa, local patients cannot be enrolled in these research projects unless they are approved by the relevant Ethics Committees and Institutional Review Boards, hence their importance. Ethics Committees, Prof. Farhat Moazam opined are only as good as ethical are its individual members and often they can be used as rubber stamp to legalize unethical things. We must see how we can shift to active participants from passive listeners. We need to come up with something which can travel on our roads but it requires hard work. We need a combination of both bioethics which is Western and secular and Tibbi Akhlaqiat which is called as Islamic Bioethics.
We must take bioethics seriously otherwise it will remain incoherent and not of much use and it will be a topic for seminars and symposia or medical conferences. It will remain irrelevant and useless. In the past we did not had many people with training in bioethics but now in 2010 we have over hundred people who have been trained in this field. We need to select those who are serious, bring in all of them and work together. Bioethics, she stated is a vocation and not a profession and I am a physician with interest in bioethics.
Prof. Rashid Jooma Chairman NBC in his speech said that clinical ethics is related to regulatory functions in which physicians work. A coherent legislation is not there to regulate medical practice of physicians. Physicians have no legal cover to protect themselves. So far we have largely focused on Research Ethics because of collaborative research developing new drugs, testing their safety and efficacy. National Bioethics Committee has encouraged individuals and institutions to have their own Research Ethics Committees besides it also provides a national forum where research proposals can be submitted and reviewed and this has been going on now for quite sometime.
Referring to the interaction of physicians with the Pharma industry, Prof.Rashid Jooma remarked that there is some cause for alarm. If you talk to the industry people, they will tell you that it is marketing which is more important and any company can swim or sink based on their marketing strategy. There has been five fold increases in the number of licensed drug manufacturers and in view of the serious competition, they offer inducements to physicians to build their market base. He was of the view that there is a need for some legislation. We have brought about some changes in the Drugs Act 1976, we are offering them more rational and research based support. They will be asked to declare their expenditures on marketing besides details regarding physicians sent abroad. Pakistan Medical and Dental Council is shortly going to approve guidelines how the physicians are expected to behave with Pharma industry which should not adversely affect the interests of the patients. It will also come up with guidelines how to govern activities of physicians, what they can do and what they cannot as regards their interaction with the pharmaceutical trade and industry but it does require some legislation, he added.
Earlier Dr.William Doe University Provost in his welcome address said that ethics are central to human rights. Dr. Rozina Karmaliani introduced the keynote speaker while Dr. Farhat Abbas introduced the chief guest Prof. Rashid Jooma. Prof. Mohammad Perwaiz Iqbal was chairman of the organizing committee of the seminar. The inaugural session was followed by a number of presentations on different topics related to ethics in medical education, research and healthcare.
Prof. Murad Musa in his presentation during the seminar pointed out that while quality is about meeting standards, ethics is about internalising values, in particular the core values of compassion and caring, fundamental to the medical and nursing professions. These core values are under threat and result in patient dissatisfaction in today’s highly commercialised, profit-driven world, he remarked.
Ethical and moral dilemmas pervade the practice of organ transplantation as pointed out by Arif Hasan, Consultant Cardiothoracic Surgeon, and At the Freeman Hospital Newcastle, UK. “The twin issues of informed consent and confidentiality have been at the heart of transplantation since its inception and continue to be challenged by rapid technological advances,” he added.
In the research session, the discussion focused on how all reputable institutions around the world give importance to the implementation of guidelines and policies in order to ensure that an organisation’s reputation is not marred by acts of plagiarism, misconduct or unsafe research practices. Unfortunately Pakistan does not follow the same standards. To safeguard the research community and to meet international standards, awareness about responsible research best practice need to be regularly highlighted.
Speakers also stressed that ethical review committees, institutional review boards, and other national mechanisms should be constituted to protect study participants in Pakistan. This is becoming increasingly important as the protection of participants in clinical trials is being recognised as both a national and an international concern. Pakistan needs a national forum where the ethical implications of health research and health care practices in the country can be discussed.



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