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September 2010, Volume 60, Issue 9

Editorial

Medical Ethics: A slow but sustained revolution in Pakistan’s healthcare

Muhammad Shahid Shamim  ( Medical Education Cell, Dow University of Health Sciences, Karachi. )
Muhammad Shahzad Shamim  ( Surgical Neurology, Aga Khan University Hospital, Karachi. )

"Change is the Measure of Time"
A few decades ago, it was considered unthinkable to accept a physician\'s deliberate action to hasten his/her patient\'s demise. Today, it is not only legal in parts of the world, but also considered a morally and ethically sound method of ending human life (assisted suicide and euthanasia).1-3 The strong winds of change in contemporary bioethics, often arising from technically developed Western European and North American regions, eventually bring their effects on under-developed countries like Pakistan. Although, the rich and heavily bonding cultures augmented by strong religious beliefs, in a "family" oriented hierarchical society like ours, provide much resistance to any change in general thinking patterns,4,5 change is nonetheless, inevitable.
In Pakistan, even the uneducated, poor, and presumably "powerless" patients have now begun to question their physicians for their right to know their options, their planned treatment and possible complications, something unheard off a decade ago. Medical student arguing over "Professor\'s" judgment on grounds of lack of evidence in literature was considered a sin par imagination. Times have changed now. Patients are more aware of their rights today then they were ever before. Similarly, students are better equipped with knowledge as well as understanding of clinical ethics. Moral values, physicians\' capabilities and motives of providing best possible care to patients have always been in medical professionals, but the relative societal norms are changing and society in general is moving towards increased awareness of an individual\'s rights.6 Information technology, in the form of electronic media (radio and television) and internet browsing have a major role to play in this paradigm shift.
Another important factor is the individual professionals, trained in bioethics, imparting thought and knowledge in different aspects of ethics to medical students, junior doctors and patients. These individuals have started their ethics related activities in different areas of the country.7 In some places these activities have been incorporated by Institutions, where they have been implemented as a part of the formal curriculum.8,9 These torch bearers of bioethics are mostly trained at Centre of Bioethics and Culture (CBEC) in Karachi, the only public sector institute providing training for award of diploma and masters in Bioethics in Pakistan. These CBEC alumni have started a wave of discussions on ethical issues throughout the country. This dispersion is not limited to medical students and junior doctors and family practitioners, but is also enlightening postgraduate trainees, nurses, technologists, physiotherapists and school children.7,10,11
Unlike previously, today\'s graduating doctors of many medical colleges of Pakistan are familiar with terminologies like informed consent, confidentiality, conflict of interest and plagiarism. Regular seminars and workshops are now being conducted in different parts of the country with attendance from all over.12 Publications and presentations from Pakistan on ethical matters are now often seen on national and international forums. Ethics review committees are now an integral part of academic hospitals and are a requirement for any substantial accreditation. Research similarly has now formally incorporated ethics as a mandatory consideration for all work. Funding agencies are also aware of the importance of ethics and require that ethical issues be properly addressed for all research work, either clinical or laboratory, prior to commencement.
The Pakistan Medical and Dental Council (PMDC) curriculum clearly advises the teaching of medical ethics to medical students during their five year undergraduate programme. However, like many other topics including disaster, information, education and communication, medical ethics is also not formally taught in most of the medical colleges of the country.13 It is about time that PMDC should make it mandatory for all the medical colleges to include ethics in the curriculum and also as part of the periodical evaluation of MBBS and BDS programmes. Similarly, medical universities and colleges should take initiatives in training their graduates and postgraduates in order to prepare them for facing and managing ethical issues in clinical practice, as this is the need of changing times in the country.

Reference

1.Fins JJ, Bancroft EA, Edwards MJ, Connor WE, Chin AE, Hedberg K, Fleming DW. Legalized Physician-Assisted Suicide in Oregon. N Engl J Med 1999; 341: 212-3.
2.Back AL, Wallace JI, Starks HE, Pearlman RA. Physician-Assisted Suicide and Euthanasia in Washington State JAMA 1996; 275: 919-25.
3.Tonelli MR, Lynn J, Orentlicher DN. Terminal Sedation. Engl J Med 1998; 338: 1230-1.
4.Abu-Nimer M. Conflict Resolution, Culture, and Religion: Toward a Training Model of Interreligious Peace building. J Peace Research 2001; 38: 685-704.
5.Moazam F, Jafarey AM. Pakistan and Biomedical Ethics: Report from a Muslim Country. Cambridge Quarterly of Healthcare Ethics 2005; 14: 249-55.
6.Khan B. Writ to Protect Your Fundamental Rights in Pakistan. (Online) Cited 2009 July 9. Available from URL: http://www.hg.org/article.asp?id=5627.
7.Official website: Centre of Biomedical Ethics and Culture. (Online) Cited 2009 July 9. Available from URL: http://www.siut.org/bioethics/projects.html.
8.Jafarey AM. Bioethics and Medical Education. Editorial, J Pak Med Assoc 2003; 53: 209-10.
9.Saeed N. Birth of Bioethics Group in Ziauddin University, Karachi. Bioethics Links 2009; 5: 3.
10.Siddiqui M. PGD Alumni bring Bioethics to Medical Technologists in Karachi. Bioethics Links 2009; 5: 4.
11.Wajahat Y. Biomedical Ethics Teachings to Postgraduate Doctors. J Med Ethics Hist Med 2009; 2: 15.
12.Activity report. (Online) Cited 2009 July 9. Available from URL: http://www.issuesinmedicalethics.org/114ar135.html.
13.Shirazi B, Shahzad Shamim M, Shahid Shamim M, Ahmed A. Medical ethics in surgical wards: knowledge, attitude and practice of surgical team members in Karachi. Indian J Med Ethics 2005; 2: 94-6.

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: