In my seven years as head of the Center of Biomedical Ethics and Culture (CBEC) at the Sindh Institute of Urology and Transplantation (SIUT) in Karachi I am often asked by colleagues, “But you do bioethics. What’s religion got to do with it?” This unease with linking religion to bioethics also leads to advice such as “stick with secular principles and human rights” or “getting into religion will get you nowhere except into trouble.”
Such comments reflect an understanding of bioethics as a rational, philosophical discipline that can provide a common morality, universally understood and globally applicable, and which can transcend other value systems. Nevertheless, this is an existential issue for a bioethics center located in a country with 165 million Muslims. What should be the aims and functions, the raison d’être, of such a center in a country with tremendous cultural, ethnic, linguistic, and educational diversity and yet hierarchical, religious, profoundly family-centered lives in which for many right and wrong, good and bad, in personal, public, and professional interactions are grounded in Muslim values and longstanding cultural norms? Pakistan is a different world from the United States, the cradle of contemporary bioethics in which I received my surgical training and education in bioethics.
Contemporary bioethics was imported to Pakistan in the mid-1980s by members of the medical community, many of whom had trained in America. It was in effect a feat of transplantation rather than an indigenous phenomenon seeded and nurtured through societal discourse. The dominant paradigm that took root was Beauchamp and Childress’ principlism, which appeared, and still does, in lectures and workshops structured around the easy to remember, popular with Pakistani physicians, mantra of autonomy, beneficence, nonmaleficence, and justice.
Over subsequent years however, some of us began to see the irony of giving lectures (in English) in the morning to students and residents on the use of philosophical principles (with autonomy as the trump) for framing ethical issues, and then switching in the afternoon to clinical care of a public who spoke in Urdu, made collective decisions when kin fell ill, preferred to address us with relational terms used for family “elders” – their maa/baap (mother/father) or baji (older sister) – or doctor sahib (a suffix for someone in a higher position), and perceived us as “instruments of God’s mercy” to direct them in what they should do.
My years of surgical practice in this country have convinced me that, to paraphrase Clifford Geertz, the general order of existence for many Pakistanis (including health care professionals) is modulated by norms of family life and religious values absorbed while growing up Muslim. Many see religion as the legitimate and legitimizing locus for legal as well as ethical discourse concerning personal and professional matters. Kevin Reinhart, who teaches Islamic religious studies at Dartmouth, is correct when he writes that Sharia Law is also an ethical and epistemological system; religion and ethics are inextricably intertwined in the Muslim psyche cutting across social strata.
This view is borne out by our experience with students (generally equal number of females and males) enrolled in CBEC’s Postgraduate Diploma in Biomedical Ethics and M.A. Bioethics programs. It is not surprising to be asked by “scientifically” educated students while exploring the ethics of abortion, or end-of-life decisions, or organ transplantation, “What is the position of Sharia about this issue?” We welcome these questions as they help students to explore the diversity of opinions that may exist, and drive home the point that Muslim and non-Muslim writers err in perceiving Sharia Law as monolithic, uniform, and unchangeable.
In class students try to negotiate between rigid doctrinal positions and a purely rational stance and will often use local contexts and existing socioeconomic realities to form their arguments. During a discussion on a woman’s request to be inseminated with her husband’s posthumously harvested sperm, many students chose a religious framework. Some argued that such an act is forbidden in Islam and emphasized supporting remarriage of widows so that they could have children. Others chose to focus on the potential harm to a fatherless child and the social and financial difficulties faced by a woman raising a child by herself. A few challenged the stance of religious scholars, arguing that if Islam is a religion for all times and something was forbidden in the past, it should be reviewed based on changed circumstances. It was a minority who offered arguments in which autonomy, freedom to make choices, or reproductive rights took center stage.
A more recent debate featured the use of zakat (mandatory annual wealth tax on Sunni Muslims) which hospitals can use for poor patients and the fact that, in the opinion of most Muslim jurists, this money can only be used for Muslims. While some supported this by saying that the government had a separate fund (Bait ul Maal) for non-Muslims, others argued about the moral rightness of this rule in a country in which the small number of minority citizens (Christians and Hindus) are among the most impoverished.
Students also bring to class dilemmas they grapple with in clinical practice and which seldom involve the esoteric, sexy topics that dominate international bioethics conferences. An example is what would be the “ethical” decision in the case of a patient presenting with abdominal pain requiring investigations that are not covered by the insurance company if done on an outpatient basis. Several physicians in the group confessed that they routinely admit such patients if they are poor and the tests are beyond their reach. Except for a couple who considered deceiving the insurance company to be unethical, almost all argued that the doctor’s “moral duty and first responsibility” is towards patients; not admitting them would be an injustice to the most vulnerable in Pakistan.
Our experience offers food for thought for those embarking on teaching bioethics in societies that share some of the norms of Pakistan. For us, the important question remains how to ensure that CBEC does not evolve into one more among many others around the world offering academic programs and sought-after graduate degrees, important as these are, while remaining inattentive to local realities and disengaged from indigenous values and realities that shape personal, professional, and public moral spheres.
So, to answer the question with which I began this essay, religion will continue to have a great deal to do with bioethics in Pakistan. I believe that those who are serious about “doing bioethics” that is relevant must be able to understand, access, and think critically about not only philosophical principles but also values grounded in religion. Compartmentalizing bioethics into secular or religious, liberal or conservative, modern or traditional, universal or relativistic categories ignores shades of grey and the multiple identities within which each of us exists. Otherwise we run the risk of bioethics remaining an academic exercise meant for classrooms and conferences, a discipline which, according to William LaFleur, as quoted by Reneé Fox, “has become international without becoming internationalized.”
Farhat Moazam, M.D., Ph.D., a pediatric surgeon, is the founding chairperson of the Center of Biomedical Ethics and Culture in Pakistan and a Hastings Center Fellow.