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Health Ethics in Pakistan: A Literature Review of its Present State

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J6 HEALTH POPULPOPUL
J HEALTH NUTR NUTR2001 Mar;19(1):6-11
Mar 2001 © 2001 ICDDR,B: Centre for Health Hyder
and Population Research
AA and Nadeem S
ISSN 1606-0997 $ 5.00+0.20

Health Ethics in Pakistan: A Literature Review

of Its Present State
Adnan A. Hyder1 and Sarah Nadeem2
1
Department of International Health, Johns Hopkins University, 615 North Wolfe Street,
Suite E-8132, Baltimore, MD 21205, USA; and 2Medical Student, Aga Khan University,
Karachi, Pakistan

ABSTRACT
National literature on ethics provides an insight into the nature and development of a dialogue
on health issues within a population. This study investigated the health ethics discourse in
Pakistan. The purpose was to critically reflect on the nature and level of such discussions with
the aim of stimulating an interest in the ethical implications of health and medicine in developing
countries. The study evaluated the literature on biomedical and health ethics published in
Pakistan during 1988-1999. Overall, there is a dearth of published discourse on healthcare
ethics in Pakistan. Values that are considered to stem from religious teachings predominate in
discussions relating to medical ethics. A lack of effective policy and legislation concerning the
ethical practice of medicine is reported to have negative effects on the profession. Research
ethics has not been captured in the published papers in Pakistan. Consideration of ethical issues
in health is at an early stage in the country and may reflect the situation in a large part of the
developing world.

Key words: Ethics, Medical; Medical research; Healthcare; Pakistan

INTRODUCTION countries. These changes are reflected in the

sociomedical dialogue within a society (3).
The ethos of a society is intricately linked with the
character of its people, their values, and the role that
National literature on ethics provides an insight into
tradition and religion play in their lives. Traditionally,
the position of healthcare interactions and healthcare the nature and development of a dialogue on health issues
providers within developing societies is often privileged. within a population. It reflects the ongoing discourse
This relatively high social positioning is becoming more among different stakeholders in healthcare processes.
complex with the continuing and rapidly-occurring In addition, it comprises the views of health professionals
scientific developments in medical technology and on important challenges of their profession (4). The
clinical knowledge (1,2). The social dissemination of discourse on ethics in developed countries may differ in
these developments poses challenges to the norms and many respects from that in developing countries. In the
traditions of healthcare delivery, especially in developing former case, there usually exists a history of thought,
Correspondence and reprint requests should be deliberation, and exchange on ethical issues relating to
addressed to: Dr. Adnan A. Hyder all aspects of health, whereas in the latter situation, the
Assistant Research Professor dialogue could be early in its development, reflecting
Department of International Health initial viewpoints and focusing more on clinical and
Johns Hopkins University medical perspectives rather than on population-based
615 North Wolfe Street, Suite E-8132
Baltimore, MD 21205 perspectives. Advances in health ethics are part of the
USA progress of healthcare and health research in a national
Fax: (410) 614-1419; Email: [email protected] context.
Health ethics in Pakistan 7

This study investigated the health ethics discourse in were published in non-Pakistani journals (5-7). Only
Pakistan as an example of a developing country. The one journal in the country–Pakistan Journal of Ethics–
purpose was to critically reflect on the nature and level addressed the issues of medical ethics directly, and there
of such discussions aiming at stimulating an interest in were only two issues of that journal to-date. Grey
the ethical implication of health and medicine. The study literature was obtained from one institution in the private
evaluated the literature on biomedical and health ethics sector as well (8,9).
published in Pakistan. The hypothesis is that the ethics
Only one article concerned research ethics in an
discourse would be very early in its development and
indirect manner (10). Two papers specifically defined
will be diverse in focus. No such review has been
ethics in the text; one referred to ethics as “concerned
attempted or documented to date. with moral principles in relation to patient care, clinical,
investigational as well as experimental” (11). The other
MATERIALS AND METHODS one called it “the study of the general nature of morals
An extensive literature search was conducted using and of specific moral choices” (12). Much of the
electronic databases and reviews of journal indexes. published discourse took into account the relevance of
Electronically, MEDLINE, POPLINE and social, economic and political situation of Pakistan to
BIOETHICSLINE searches were completed using the state of healthcare ethics (13). Several themes
combinations of keywords, such as Pakistan, ethics, emerged from an analysis of the content of these papers.
medical ethics, biomedical ethics, healthcare, and equity. Economic challenges
Indices of national journals in Pakistan were searched
manually for the 1988-1999 period, since these are The notion of medical practice in a changing economic
mostly not indexed in international databases. Two environment has been raised, highlighting that “the
libraries and two bookstores of Karachi, the largest pressures of making two ends meet in an environment
metropolitan city of Pakistan, were also investigated of enormous inflation and unreasonable basic
manually as a convenience sample. In addition, field visits expenditure on self and family sustenance” (13). The
made by the authors were used for seeking unpublished challenge of “widespread demand for the highest skills
and/or unindexed literature (often called grey literature) without corresponding willingness to pay for
from universities and relevant individuals. Although professional services” was defined within this
papers that mentioned the role of religion were included, environment. These reflect the context within which
physicians and other healthcare providers work in
the religious literature and jurisprudence literature per
Pakistan where exists the need for generating an income
se in Pakistan were not explored in this study, since these
within a pool of relatively poor patients. The authors
sources are neither indexed nor published in scientific
further elaborate on the sense of frustration in the
journals.
practice of physicians because of “a readiness to be
The search results were reviewed and evaluated using exploited by quacks, an attitude accepted and provided
inclusion criteria such that papers concerning ethics in for by successive governments” (13). The definition of
Pakistan and/or published in the Pakistani scientific quacks included informal healthcare providers,
literature were selected. After inclusion of all relevant traditional healers, those practising medicine without
articles, an analysis for content, theme, nature of study, training, and illegal providers of services.
and source was carried out. Results were tabulated, and Paucity of resources
a critical analysis was performed for thematic issues,
either discussed or conspicuously absent from the Pakistan, being a poor country, has very limited
discourse. healthcare resources. Treatment options for individual
patients and between patients for free and subsidized
RESULTS treatments are common ethical dilemmas. Thus,
prioritizing illnesses and people is an enormous ethical
A review of literature revealed a total of 34 documents challenge and a very common part of everyday medical
relating to ethics from all electronic and manual searches. practice in Pakistan. These choices have been used in a
After reviewing the papers and application of the private institution to stimulate thinking on the ethical
inclusion criteria, only 11 fulfilled all three conditions, implications within the local context (8,9). For example,
while an additional 5 met only the first two criteria cases that explore the ethical dilemma of several patients
(Table). As the table indicates, most papers were presenting at the same time for a single ventilator are
editorials, and three studies with some empirical research being used for teaching purposes.
 8
Table. Review of ethics discourse in Pakistan
Year Source Author Title Type of paper Ethical topic
National journals

J HEALTH POPUL NUTR

1999 Newsletter of Aga Khan University Various reports Institutional newsletter Discussion of cases and editorials
the Bioethics Group
1997 Pakistan Journal Editors Various reports ‘New’ national journal Only two issues have been published to
of Ethics date; mixture of case studies and reviews
1997 The Professional Tahir MS Fall from the grace Editorial Declining status of doctors in Pakistani
society
1996 Journal of the Pakistan Jafary MH Euthanasia: changing trends Editorial Euthanasia, with particular emphasis
Medical Association on the Islamic perspective
1996 Journal of the Pakistan Sadiq MZ, Animal models in Editorial Ethics of animal use in research
Medical Association Khurshid SJ biomedical research
1996 Journal of the Ayub Ali A Medical ethics Editorial Definitions of ethics, medical ethics,

Mar 2001
Medical College infamous conduct. Detailed discussion
of categories of professional misconduct
1995 Journal of the Pakistan Naqvi AA Ethics of renal transplantation Special communication Ethical questions involved in renal
Medical Association in developing countries transplantation, with reference to the
different sources of donors
1995 Journal of the Pakistan Jafary MH Medical ethics, Islam Editorial ‘Ethics’ and ‘medical ethics’ defined;
Medical Association and our society history of codes of medical behaviour
1995 Pakistan Heart Journal Hasan M Medical ethics–past Editorial Medical ethics presented at two levels–
and present ideological and practical. History of
medical ethics presented with rules of
ethical behaviour
1990 Journal of American Hasan M All points made by Lundberg Editorial Ethics of medical profession as a ‘trade’;
Medical Association, are valid for Pakistan as well role of commercialization and economic
Pakistan Edition conditions in Pakistan on medical ethics
1988 Journal of the Pakistan Rajput AM Ethical issues in Special communication Ethical conflict between the doctor’s
Medical Association cardiac-pulmonary drive to sustain life versus the concept
resuscitation of relief of suffering and patient dignity
International journals
1996 Human Reproduction Schenker JG, Ethical and legal aspects of Empirical research Different aspects of assisted reproduction
Shushan A assisted reproduction...in Asia technology in Pakistan and other Asian
countries described
1993 Social Science Husein K et al. Developing a primary Empirical research A review of a community-based, urban
and Medicine healthcare management… PHC system, designed to achieve equity,

Hyder AA and Nadeem S

effectiveness and affordability in Karachi
1991 Journal of Mehdi M Health implications of torture Editorial Discourse on the prevalence of torture
Medical Ethics in Pakistan with reference to the code of medical
ethics of the Pakistan Medical and
Dental Council
1990 Journal of Moazam F, Ethical dilemmas of healthcare Empirical research The ethics of allocation and provision of
Pediatric Surgery Lakhani M in the developing nations health services in Pakistan
1982 The Medical Journal Allbrook D Medical participation Letter Role of physicians in legal punishment
of Australia in flogging… in Pakistan
Health ethics in Pakistan 9

Individual motivation society...doctors don’t enjoy the same respect or status

The personal and professional motivation of both anymore…they are considered traders of skills, involved
individual practitioners and entire profession have been in fair and foul methods to capitalize these” (15).
specifically addressed. It was observed that “there has Disempowerment of physicians to the status of other
never been a greater need to emphasize the importance professionals is seen as a negative feature. In addition,
of ethics in medicine as it is today...moral values seem this change in social status is considered a result of
to have declined considerably, in the face of an professional conduct by healthcare providers themselves,
increasingly materialistic world” (11). This has been which has been viewed by society as a mix of ethical
further stressed with an observation that “at times there and unethical practices.
is gross violation of ethical principles in day-to-day Role of religion
medical practice as the financial motives become the
prime consideration.” This expresses a grave concern The role of religion in the Islamic Republic of Pakistan
that financial and economic motivation per se does and has been emphasized in the literature (11,12,16). Jafary
will affect the ethical practice of medicine in the country. reports, “in a Muslim society, there is a prevailing belief
However, authors have not followed up by offering that God has a remedy for every ill” (11). The motivation
practical solutions to these issues. to follow and respect a certain code of ethics is attributed
to the importance of actions relating to healing and
Policy and legislation treatment of the ill in religion. Religion also plays a
A lack of effective policy and legislation concerning the central role in the discussion of issues within healthcare.
ethical practice of medicine is reported to have negative For example, the debate regarding euthanasia and
effects on the profession. This situation also increases abortion is essentially a discourse against both the
the dependence of individuals to deal with ethico-legal practices, and the root cause of such a stance is that these
issues alone, or in consultation with colleagues, in an actions are considered “un-Islamic” (12).
informal manner. For example, the case of a rich The papers also portray that most professional and
businessman on regular maintenance haemodialysis public opinions in the country are highly influenced by
awaiting a renal transplantation has been reported (14). religion. Taking the example of renal transplantation, it
He brings with him a potential paid donor, a young is observed “citizens continue to remain resistant to the
labourer from the rural areas of Pakistan, “who is in dire idea...among the many factors contributing to this...is
need of money to pay off a debt to release his 9 years unfamiliarity perhaps with the position Islam takes on
old brother from bonded labour.” In Pakistan, there is organ donations and whether Muslims have any moral
“no policy and law...to restrict the sale of kidneys.” This obligations in this arena” (17). Religious views,
article speaks of how the surgeon faces numerous ethical therefore, are engrained within the expressed opinions
dilemmas within the context of just one case, with the on ethical issues in the country.
added complexity of the recipient and the donor
belonging to different social classes. DISCUSSION
Similarly, a survey on informed consent procedures A review of published discourse on ethics in Pakistan
has been reported in the grey literature, which is stated reveals several general trends. These include a focus on
to reveal that 46% of consents were incomplete at one ‘medicine’ as defined by formal western medical
hospital in the city of Karachi (9). In addition, Schenker practice, delivered by physicians only. There is no pursuit
provides information regarding regulations and access of ethics as a focus of the work of other health
to assisted reproduction services in Pakistan, among professionals. The physician-authors of papers, the types
other countries (7). Examples such as these are used for of journals where papers have been published, and the
illustrating the need felt by medical professionals for a physician-dominant mode of healthcare, especially
legal structure that helps them define and strengthen the curative healthcare, in Pakistan make this understandable
limits of their actions. They also illustrate that even where (3,18).
laws governing the action of healthcare providers do
exist, there are problems in implementation (8). The explicit consideration of economic development
as a threat to the moral basis of medical practice is
Social responses interesting. Historically, this has been the source of
Societal responses to the practice of medicine have also discussion in all societies, and continues to be a source
been stated thus: “there has been a decline in our of debate in the developing world. The fear that financial
10 J HEALTH POPUL NUTR Mar 2001 Hyder AA and Nadeem S

motivation may lead to unethical practice by individual national mechanisms to protect human subjects need to
physicians is clearly the result of both changing medical be discussed and put into place in Pakistan, as may be
practices and a developing national economy. the case in other developing countries. Additional work
Remuneration by pharmaceutical agencies, increasing is required to explore this important area within the
user-fees, burgeoning private practices, and the use of context of the developing world.
more diagnostic technologies, add to the changing
Overall, there is a severe lack of published discourse
financial landscape. An overall environment of scarcity
on healthcare ethics in Pakistan. The launching of the
in Pakistan makes these changes more acute and visible,
Pakistan Journal of Ethics is an exception, although only
especially as public access and quality of care still leave
two issues have appeared since inception in 1997. This
a lot to be desired (19).
journal needs to be resurrected to provide a formal
Physicians have traditionally wielded great power medium for promoting and encouraging a richer dialogue
in communities, and have seen themselves superior to on ethics of biomedical issues in the country. This journal
other professionals. The societal response of giving also needs to be regularized and indexed, both nationally
medicine a status similar to other professions has raised and internationally.
concerns in Pakistan. This is a process of development
In addition to a specific journal on this issue, papers
in view of the fact that with economic progress,
that reflect the ethical issues in health and medicine need
education, and greater public awareness, healthcare
to be encouraged in the other scientific journals as well.
becomes transparent. The local and national media have
played a great role in this regard to demystify the working A national forum needs to be developed to discuss the
of healthcare providers. As a result, the provider-patient ethical implications of healthcare practices and also
interaction becomes less top-down and more horizontal. health research in the country. This is becoming
This disempowerment of physicians is disturbing to the increasingly important as the protection of human
profession and health professionals. However, it is not subjects is being recognized as both an international and
viewed with the same concern by the public and needs a national concern. The international community needs
to be seen as an essential component for a more involved to encourage greater dialogue within developing
healthcare system in the country. countries, such as Pakistan, and to promote the
development of codes of professional practice and
The ethical foundation of many social functions is national ethical guidelines for research (22). Recently,
derived from a value-base. The final stated common the World Health Organization and the Fogarty Center
value-base for Pakistan is the religion Islam. for International Health at the National Institutes of
Beneficence, non-maleficence, justice, care, and concern Health, USA, together with partners from the developing
are all embedded within the sources of Islamic scripture world, have taken a step in this direction by promoting
and thoughts. At the same time, culture also plays an the formation of the Global Forum on Bioethics in
important role in the exploration and implementation of Research. In addition, the recently-released guidelines
any ethical issues in the country. Religion, tradition, for establishing ethical review committees in developing
practices, and behaviour make up components of such a countries also provide another valuable resource for
cultural base. It is, thus, difficult to tease out the overall developing nations (23). These developments are
cultural context and the contribution of each one of these encouraging and need to bear on the intra-national
elements, although religion seems dominant in this development of such ideas in countries like Pakistan.
specific context. It is, therefore, expected that the values
that are considered to stem from religious teachings will CONCLUSION
predominate in discussions relating to medical ethics,
Ethics is an extremely important facet of public health
and that has been noted in several papers reviewed in
in all parts of the world, especially today, with the
this study.
emergence of new conflicts between science and society
Research ethics have not been captured in the (24,25). A richer discussion in both real settings and
published papers in Pakistan. This is an area of great scientific literature is needed. This will result in a
importance that has escaped notice of the national frequent and constructive dialogue with greater
thinkers and policy-makers. The conduct of appropriate understanding of ethical issues within regional and
and ethical research in international settings has been national contexts. Such a process may eventually lead
the focus of recent international reports (20-22). Ethical to the development of better working solutions and
review committees, institutional review boards, and other methods, which will be beneficial to both healthcare
 Health ethics in Pakistan 11

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developing world. 14. Khan KS. Kidney for sale. Newslett Bioethics Group
1999;2(3):1-2.
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