When are morals in medicine “custom-made?” When they’re based on a heady mix of economics, religion, and culture, parceled out by an elite, highly educated minority. Welcome to bioethics, Pakistani style.
According to Dr. Robyna Khan of the Aga Khan Hospital University in Karachi, bioethics in her country is based on different realities than those in the West. Speaking at U of T this past Wednesday, she explains that Pakistanis adhere to cultural norms and possess strong religious beliefs. These norms and beliefs permeate society and can override the ability of doctors to consistently follow a standard code of ethics in their practices. Economic woes often force physicians to adopt a “play it by ear” haphazard approach to difficult situations.
Dr. Khan provided the key to understanding the application of bioethics in third world countries. “There are two basic components that strongly influence the doctor-patient relationship in Pakistan: beneficence (do good) and non-maleficence (do no harm).”
She cited a case involving a one month-old baby afflicted with a severe gastro-intestinal disease that would kill the baby if not treated. Dr. Khan explains the dilemma for the father. “By necessity, decisions must take into consideration the financial survival of the whole family rather than stressing any one member’s right in isolation. [The] question of a newborn’s rights will be totally alien to this father. For him it is easier to have another baby rather than to provide for the treatment of this child.”
Finally, the surgeon arranged for the Welfare Department to pay for half the cost of surgery, while the father paid the other half in installments. “Physicians feel morally obligated to provide treatment. This sometimes means extending themselves beyond what would be considered their normal duties. To them, this is beneficence.”
The second case she mentioned highlighted the concept of “do no harm.” An aging man was diagnosed with terminal cancer. The diagnosis was disclosed to his family, who decided not to inform their father as it would make him lose hope and burden him with the stress of impending death. “Physicians do not disclose diagnosis to the patient but to the family. In western cultures this would be considered as compromising the rights of the patient, a breach of confidentiality. In the Pakistani situation it is non-maleficence. It is accepted as a form of protection from the harmful effects of bad news.”
Does risk of patient exploitation exist in these potentially skewed doctor-patient relationships? Dr. Khan confirms that some unscrupulous physicians may abuse their tremendous influence, as lawsuits are rare. Nonetheless, Dr. Khan insists that adherence to ‘beneficence’ and ‘non-maleficence’ by physicians generally works well in a deeply religious society. However, she does recommend more effective, systematic institutional checks on physicians to standardize approaches to health care. She concedes that poverty, tremendous respect for figures of authority like doctors, and a strong belief in a divinely preordained time of death continue to feed the current “Pakistani-style” of bioethics.
