Fighting the COVID-19 pandemic: A socio-cultural insight into Pakistan.

During the COVID-19 pandemic, healthcare professionals around the world were driven by universal values of solidarity and duty to provide care. However, local societal norms and existing healthcare systems influenced interactions among physicians, and with patients and their families. An exploratory qualitative study design using in-depth interviews was undertaken with physicians working at two public sector hospitals in Karachi, Pakistan. Using the constant comparison method of data analysis, several key themes were identified highlighting norms of kinship and interdependencies characteristic of collectivistic societies that influenced professional interactions. The role of seniors in the hierarchical society of Pakistan played a major role in provision of care. Physicians reported numerous challenges in dealing with patients and their families amidst public denial fueled due to ill-formed government policies. This included interruption of funeral rites which undermined public trust. The study provides insights into the local moral world of two healthcare institutions in Pakistan.

Realigning Pakistan's Bioethics Center during Covid-19.

The arrival of the Covid-19 pandemic in Pakistan necessitated that the Centre of Biomedical Ethics and Culture in Karachi realign its activities to changing realities in the country. As Pakistan's only bioethics center, and with no guidelines available for allocation of scarce medical resources, CBEC developed "Guidelines for Ethical Healthcare Decision-Making in Pakistan" with input from medical and civil society stakeholders. The CBEC blog connected to the center's bioethics programs for students from Pakistan and Kenya shifted to Covid-related issues specific to the context of existing social and political realities within these countries. As part of its outreach activities, CBEC initiated a popular Facebook series, #HumansofCovid, as an experience-sharing platform for health care professionals and members of the public. Narratives received vary from those by frustrated physicians under quarantine to those concerning street vendors left jobless and a transsexual person in whose opinion "social distancing" is not a new phenomenon for their communities.

Why women go to medical college but fail to practise medicine: perspectives from the Islamic Republic of Pakistan.

CONTEXT: Female medical students outnumber men in countries such as Saudi Arabia, India and Pakistan, yet many fail to practise medicine following graduation. In Pakistan, 70% of medical students are women, yet it is estimated that half of them will not pursue medicine following graduation. This is considered a major reason for physician shortages in the country. METHODS: We conducted a qualitative study drawing upon the 'role strain' theory to explore the views of final-year medical students from four medical colleges in Karachi, Pakistan, on female graduates not entering the medical field. Data were obtained through 20 individual in-depth interviews and two focus group discussions. Themes were developed inductively from the data using the constant comparison method. RESULTS: Pakistani parents actively channel daughters into medical education, considering medicine to be the most 'respectable' field. However, in a patrilocal society with norms of early, arranged marriages for daughters, there is a significant influence of in-laws and a husband on a woman's professional future. Parents perceive the medical degree as a 'safety net' should something go wrong with the marriage, rather than a step toward a medical career. Female respondents experience significant role conflict between their socially rooted gender roles as homemakers and mothers and their careers in medicine. Postgraduate training systems that are unfriendly to women provide further deterrents for women wishing to work. Contrary to popular belief, women not practising medicine is not the sole contributor to physician shortages. A significant factor appears to be male graduates migrating abroad for better training and financial prospects. CONCLUSIONS: Acceptance of traditional cultural values, including entrenched gender roles in society, deters women from practising medicine. To enable greater participation of women in the medical field, steps are required that will allow women to better manage family and work conflicts.

Reading Caplan in Karachi.

Bioethics education and discussions about ethical dilemmas are being increasingly reduced to teaching students how to balance the four, easily memorised philosophical principles popularised by influential American philosophers Tom Beauchamp and Jim Childress. The reality is that human beings approach and comprehend moral issues in diverse ways shaped by shared histories, cultural norms and values, kinship systems, lived experiences and existing socio-political realities. Therefore, ethical discourse limited to a culturally myopic Principlism that disregards the indigenous landscape can be an abstract and meaningless venture. The different moral lenses through which people can view the same issue is highlighted in this essay. It compares the analyses offered by American bioethicist Arthur Caplan of the blocking of polio vaccination by militants in northern Pakistan and of issues related to posthumous insemination, with the more nuanced, contextualised discussions about both topics offered by Pakistani students of bioethics in our Center. For this discipline to resonate with and make an impact on those we teach, an inclusive, more reflective and socially relevant approach is required. In my opinion, bioethics is a contact sport that should not be transformed into merely an academic exercise.

Prevention of Transnational Transplant-Related Crimes-What More Can be Done?

BACKGROUND: Many nations are able to prosecute transplant-related crimes committed in their territory, but transplant recipients, organ sellers and brokers, and transplant professionals may escape prosecution by engaging in these practices in foreign locations where they judge the risk of criminal investigation and prosecution to be remote. METHODS: The Declaration of Istanbul Custodian Group convened an international working group to evaluate the possible role of extraterritorial jurisdiction in strengthening the enforcement of existing laws governing transplant-related crimes across national boundaries. Potential practical and ethical concerns about the use of extraterritorial jurisdiction were examined, and possible responses were explored. RESULTS: Extraterritorial jurisdiction is a legitimate tool to combat transplant-related crimes. Further, development of a global registry of transnational transplant activities in conjunction with a standardized international referral system for legitimate travel for transplantation is proposed as a mechanism to support enforcement of national and international legal tools. CONCLUSIONS: States are encouraged to include provisions on extraterritorial jurisdiction in their laws on transplant-related crimes and to collaborate with professionals and international authorities in the development of a global registry of transnational transplant activities. These actions would assist in the identification and evaluation of illicit activities and provide information that would help in developing strategies to deter and prevent them.

Pediatric Deceased Donation-A Report of the Transplantation Society Meeting in Geneva.

The Ethics Committee of The Transplantation Society convened a meeting on pediatric deceased donation of organs in Geneva, Switzerland, on March 21 to 22, 2014. Thirty-four participants from Africa, Asia, the Middle East, Oceania, Europe, and North and South America explored the practical and ethical issues pertaining to pediatric deceased donation and developed recommendations for policy and practice. Their expertise was inclusive of pediatric intensive care, internal medicine, and surgery, nursing, ethics, organ donation and procurement, psychology, law, and sociology. The report of the meeting advocates the routine provision of opportunities for deceased donation by pediatric patients and conveys an international call for the development of evidence-based resources needed to inform provision of best practice care in deceased donation for neonates and children.

Pakistan's experience with kidney transplantation and trade: a call for international solidarity.

Pakistan has taken a long and tortuous road towards curbing the trade in organs within its borders. Yet, despite the phenomenal gains, several challenges remain in this area. For example, robust and sustainable deceased donor programmes must be established to meet the needs of a country which has a high prevalence of kidney disease and failure. Further, it is necessary to offer an alternative source of organs for transplantation to desperate patients who resort to buying these from the "market". Cultural factors and religious beliefs about the sanctity and inviolability of the corpse, as well as the lack of public and professional education regarding the procurement of organs from the deceased, pose considerable barriers that must be surmounted. We believe it is equally important that transplant professionals and the governments of affluent countries consider measures to discourage, if not prevent, their citizens from travelling to impoverished countries such as Pakistan to buy organs. Without a commitment, ethical and legal, to international solidarity in this matter, the goals that are already difficult for developing countries to achieve, ie, establishing deceased donor programmes and bringing an end to organ trafficking, will be even harder to achieve.

To donate a kidney: public perspectives from Pakistan.

Despite the majority opinion of Muslim jurists that organ donation is permitted in Sharia, surveys indicate continuing resistance by lay Muslims, especially to donating organs following death. Pakistan, a country with 165 million Muslims, currently reliant on live donors, is considering steps to establish deceased donor programs which will require public acceptance and support. This article analyzes the results of in-depth interviews with 105 members of the public focusing on opinions and knowledge about juristic rulings regarding kidney donations, donor-family dynamics in deceased donation decisions, and attitudes towards buying kidneys. The objective was to determine the influence if any of cultural and religious values, and norms of traditional family structures and kinships, on decisions to donate. Study participants view donation of kidneys, particularly from the deceased, through a different lens from that used by jurists and physicians, one that also does not conform to familiar paradigms defining ethical organ donation. A socially modulated understanding of Islam passed down the generations, and longstanding family-centric norms, shape the moral worldview of many rather than academic juristic rulings or non-contextual concepts of autonomy and rights. The results of this study also highlight that medical science may be universal but its application occurs within particularities of cultural and religious values, social constructs of the self and its relationship with others, and different ways in which humans comprehend illness, suffering, and death. These findings are of relevance both to transplant related professionals and bioethicists involved with this field.

Pakistan and kidney trade: battles won, battles to come.

This essay provides a brief overview of the rise of organ trade in Pakistan towards the end of the last century and the concerted, collective struggle--of physicians and medical associations aided by the media, journalists, members of civil society, and senior judiciary--in pressuring the government to bring about and implement a national law criminalizing such practices opposed by an influential pro-organ trade lobby. It argues that among the most effective measures to prevent re-emergence of organ trafficking in the country is increasing ethical live donations and above all, establishing sustainable, public supported deceased donor programs. To do this, the transplant community must recognize that organ transplantation is not merely a donor-recipient-physician transaction but a complex issue in which decisions to donate an organ are influenced by indigenous values and belief systems about human illness, life and death.

Plagiarism and the medical fraternity: a study of knowledge and attitudes.

OBJECTIVE: To assess knowledge and perceptions of plagiarism in medical students and faculty of private and public medical colleges in Karachi. METHODS: A questionnaire based study was conducted on groups of 4th year medical students and medical faculty members. Group A consisted of medical students while group B comprised faculty members. The questionnaire contained 19 questions that assessed knowledge and attitudes of the respondents regarding various aspects of plagiarism. RESULTS: The total number of medical students (Group A) studied was 114 while the faculty number (Group B) was 82. Nineteen percent Group A and 22% of Group B displayed the correct knowledge about referencing materials from the internet or other sources. Seventeen percent of respondents in Group A and 16% in Group B had correct information about the use of quotation marks when incorporating verbatim phrases from external sources. Regarding Power Point presentations, 53% of respondents from Group A and 57% from Group B knew the appropriate requirements. There was a statistically significant difference among the two groups regarding the issue of self plagiarism, with 63% of respondents in Group A and 88% in Group B demonstrating correct understanding. Both groups showed a general lack of understanding regarding copyright rules and 18% of Group A and 23% of respondents in Group B knew the correct responses. Eighteen percent of respondents in Group A and 27% in Group B claimed to have never indulged in this practice. CONCLUSION: There is a general lack of information regarding plagiarism among medical students and faculty members.

Research and developing countries: hopes and hypes.

The paper outlines the universal problem of ensuring ethical practices in human subject research, and focuses on specific difficulties faced in the developing world with particular reference to Pakistan. It discusses the influence of traditional and hierarchical social norms of physician-patient relationships in heightening these problems. Two emerging issues of specific concern in Pakistan are described: an exponential rise in multinational clinical drug trials, and commercial ventures offering unproven stem cell "therapy" for all kinds of diseases. The importance of introducing ethical practices in research within the context of local cultural and socioeconomic realities is highlighted.