Date: Tuesday, June 27, 2023
Time: 8.30 am – 10.00 am
1. KBG Website Update
Dr. Nida shared the KBG website with the group and told them to inform the faculty about their institute’s events for inclusion. She also mentioned that the minutes of the KBG meeting need to be updated on the website. The charges for updating the website cost 40,000/-, and she requested the group to contribute the balance amount of 20,000/-. If the total contribution exceeds the required amount, it will be taken forward to next year as the annual fee of the website.
2. Clinical Ethics Case Discussion – Dr. Ali Kamran
Dr. Ali Kamran, Consultant General and Laparoscopic Surgeon at Ziauddin University Hospital, and PGD Class of 2023, presented a case of a 70-year-old male patient with advanced esophageal carcinoma, leading to complete blockage. The patient struggles to eat or drink, even finding it difficult to swallow saliva, and has faced recurrent chest infections from aspiration. Endoscopic tumor stenting isn’t an option, prompting referral to consider a feeding gastrostomy for nutrition. While the surgeon doubts the efficacy of this approach and its potential to worsen the patient’s suffering, the primary physician advocates against letting the patient starve to death. Dr. Kamran sought the group’s input on this ethical dilemma.
3. Teaching Videos for Nurses – Ms. Shabana Tabassum
Ms. Shabana Tabassum, Head of the Department of Health Information Management Services, at Patel Hospital, suggested creating local videos in Urdu to teach ethics to nurses. She emphasized that nurses have a deeper understanding of patients’ social issues and proposed that teaching ethics within a specific local or regional context can enhance understanding. Ms. Tabassum also pointed out that there is a lack of content tailored for nursing education and proposed that creating videos depicting scenarios can expand their cognitive horizons and encourage them to think critically.
4. What Can Go Wrong When Doctors Grant Professional Courtesy? Medscape Article for Discussion – Dr. Mumtaz Lakhani
At the request of Dr. Mumtaz Lakhani, the article ‘What Can Go Wrong When Doctors Grant Professional Courtesy?’ by Christine Lehman was shared with the group before the meeting for their reference. The article explores issues concerning professional courtesy towards colleagues and patients, tracing its evolution from an ethical duty to a potential breach of contract with legal consequences such as imprisonment and fines. It also offers suggestions for avoiding legal complications. Dr. Lakhani believed that educators and physicians are entitled to professional courtesy based on the insights from this article, emphasizing that while it was once an ethical obligation, it is no longer viewed as such.
Link: https://www.medscape.com/viewarticle/989330
Date: Tuesday, August 22, 2023
Time: 8.00 am – 9.40 am
1. Patient And Public Engagement in Research – Presentation And Discussion
Dr. Mariam Hassan discussed patient and public engagement in research using a personal case study. She emphasized the importance of collaborative research with the public, including active participation in research inquiries, shaping research designs, and contributing to research execution.
Dr. Mariam emphasized the importance of involving participants in all phases of research, from prioritizing topics to evaluating the work. She shared a diagram of the sequential research phases, including designing, enrolling patients, analyzing data, and implementing results.
Case
Dr. Mariam discussed a phase 3 oncology trial for advanced breast cancer, with the aim of extending patients’ survival by six months. However, the trial faced some difficulties in Pakistan due to negotiations with sponsors and regulatory hurdles, even though there was high demand for it. Only a few eligible patients were enrolled through an extensive assessment process, which included 24 inclusion and 24 exclusion criteria, particularly regarding pregnancy. Women of ‘childbearing potential’ were required to consent to regular contraception and undergo routine pregnancy testing. Participants received chemotherapy and other medications in three-week cycles, followed by the experimental drug and tumor reassessments every 12 weeks. Quality of life forms were provided, and treatment continued until disease progression, toxicity, or death. In addition, a lengthy and complex 24-page informed consent document was involved.
Dr. Mariam shared a specific patient’s experience, a 48-year-old single woman with a Fine Arts degree. She was initially hesitant due to concerns about bodily integrity but joined the study for altruistic reasons. However, she declined pregnancy testing, which required difficult negotiations with sponsors.
During the study, the patient provided valuable feedback on quality-of-life forms, highlighting the limitations of the standard form in capturing the depth of the illness experience. This feedback made Dr. Mariam realize that the form needed to be more qualitative. Although the patient initially responded well to treatment, her condition gradually worsened, affecting her daily activities. Although her condition did not necessitate treatment cessation, intermittent treatment breaks were introduced. Unfortunately, she was later withdrawn from the study due to brain metastases. The research team believed they had succeeded in extending her lifespan, but the participant felt abandoned by the team.
While her primary oncologist, also the PI of the team, continued her care, the patient felt there was a marked shift in the attention and care she received once she transitioned from an active trial patient to a patient with a metastatic progressive disease no longer participating in the trial. Throughout the study, the patient desired to provide detailed feedback, but no mechanism of reporting and incorporating it existed. She passed away a few months after her withdrawal.
Discussion
Based on this case, Dr. Mariam initiated a thoughtful discussion on the potential for conducting a similar study with a different approach.
2. Case Discussion –Ms. Shabana Tabassum
Ms. Shabana Tabassum, a CBEC PGD alumnus and Head of Health Information Management Services at Patel Hospital, presented a case study involving a 22-year-old primigravida at 32 weeks of gestation. The patient, who had not sought prenatal care before, was admitted on June 8, 2023, complaining of fever, chills, headache, seizures, vomiting, and restlessness persisting for 2-3 days. Diagnosed with meningoencephalitis, she was intubated for mechanical ventilation as her condition deteriorated, leading to a comatose state with a GCS score of 8 out of 15 and a stiff neck. A CT Brain scan and a lumbar puncture confirmed Naegleria fowleri infection, ultimately resulting in brain death. The fate of the fetus raised ethical dilemmas, with the family declining a cesarean section despite the baby’s viability. The family refused the CT scan for the following reasons: concerns about potential harm to the fetus, religious beliefs, absence of a female to take care of the newborn, financial burden, and a preference for a male child. The hospital’s Ethical Committee intervened to address concerns.
Date: Tuesday, October 3, 2023
Time: 8.30 am – 10.00 am
1. Benevolent Deception? – Presentation And Discussion
Dr. Muhammad Arsalan Khan, Transplant Surgeon and PGD Class of 2023, CBEC, SIUT, presented a case from the article ‘Lying to My Mom’ by Chris Feudtner and another from his personal experience. Dr. Arsalan and Mr. Farid bin Masood explored different aspects of deception and its justification, leading to a group discussion with varying opinions.
Case 1
Pediatrician Chris Feudtner’s elderly mother, living in a nursing home with dementia, was diagnosed with advanced colon cancer that had also spread to her liver. After considering the risks of treatments, managing cancer care, and his mother’s wishes, he decided not to pursue further medical investigations or treatments. He chose not to reveal her illness to her, believing there would be no benefit. His mother received hospice care, but after four months, she died in her sleep. Despite grappling with the decision, Dr. Feudtner found peace with his choice not to reveal the diagnosis to his mother.
Case 2
Dr. Arsalan’s uncle (Khaloo), in his 70s with diabetes and hypertension history, recently had a transient stroke causing slurred speech that resolved on its own. Further evaluations showed his heart functioning at only 25% capacity. Khaloo maintains a functional lifestyle, even going out for groceries shortly after. Dr. Arsalan discussed the medical report with his children, advising against informing Khaloo about his heart condition to avoid a potential negative impact on his quality of life.
As a physician, Dr. Arsalan usually informed patients’ family members about medical conditions instead of patients themselves. As a nephew, he chose not to share the specifics of his Khaloo’s illness with him, but informed Khaloo’s children instead. The family supported Dr. Arsalan’s compassionate decision to withhold information.
Discussion
Mr. Farid raised important questions about cases and used the framework from an article titled ‘Mapping the Moral Terrain of Clinical Deception’ by Abram Brummett and Erica K. Salter, published in the Hastings Center Report 2023. The questions were designed to assess the reasons for lying, deceiving, or withholding information in medical practice, aiding in self-assessment and decision-making. The justifications were categorized based on the four basic principles of bioethics into two groups.
2. Bioethics through the lens of humanities – Mr. Farid bin Masood
Mr. Farid showed a scene from the short film ‘A Train Runs Across the Desert.’ In the scene, a man sang a slow song while appearing to be behind bars. It became clear that he was singing to a family member who was terminally ill and bedridden. The lyrics depicted a conversation between a prisoner and a guard, with the prisoner suggesting that the guard was also a prisoner, just on the other side of the bars. The patient asked his brother to play a specific song on a harmonium but was told that the harmonium had been sold to pay for his medical expenses. The distressed patient expressed a desire to find freedom by dying under a train like their grandfather had.
3. AOB: CK-BTI Bioethics Pedagogy Workshop, December 11-12, 2023
Dr. Jafarey presented the CBEC-KEMRI Bioethics Training Initiative (CK-BTI) to the audience. He explained that CK-BTI is a bioethics training program supported by the Fogarty International Centre of the National Institutes of Health, USA. This initiative is a partnership between CBEC (Center for Biomedical Ethics and Culture) and the Kenya Medical Research Institute (KEMRI), Kenya. He announced an upcoming two-day Bioethics Pedagogy workshop scheduled for December 11 and 12, 2023. This workshop targets bioethics educators across different educational levels. It is free of charge and will be facilitated by Dr. Bushra Shirazi and Dr. Muhammad Shahid Shamim.
Date: Tuesday, December 12, 2023
Time: 8.30 am – 10.00 am
1. Acceptable Limits of Inequality In Healthcare Provision (Case Discussion) – Dr. Nida Wahid Bashir
Dr. Nida presented a case study on healthcare inequality.
Case:
In a Low- to Middle-Income Country (LMIC), there exists a prominent private tertiary care hospital. Owing to an inadequate number of healthcare facilities relative to the city’s population and surrounding areas, a significant influx of patients seek treatment at this hospital. The hospital provides two distinct services.
The first service, priced at Rs. 1000 for consultation, necessitates patients to arrive early in the morning to secure a token number via a queue system. Subsequently, patients are attended to by one of ten trainee doctors. The waiting period typically ranges from two to four hours, during which each doctor aims to see a minimum of 30 patients per hour.
On the other hand, the deluxe service, priced at Rs. 10,000 for consultation, allows patients to choose a preferred doctor from a pool of four senior consultants using an online appointment system. The waiting time is limited to a maximum of 15 minutes, and patients and their companions are offered snacks and tea while waiting. Moreover, each patient receives a minimum of 30 minutes of dedicated consultation time with the senior consultant.
During the discussion on the theme of “Acceptable Limits of Inequality,” the group shared their perspectives.
2. Depiction of Graphic Images from Conflict Zones – Dr. Mumtaz Lakhani
Dr. Mumtaz Lakhani discussed the ethics of photographing graphic scenes during wars. She argued that the camera documents the harsh realities of conflict, shedding light on its consequences. Photographs inspire societal action against injustice, giving a voice to the silenced. Dr. Lakhani emphasized that while war is unethical, photography exposes its immorality, making it a respected practice. She also highlighted ‘The Seven Moons of Maali Almeida’ by Shehan Karunatilaka, winner of the 2022 Booker Prize, as a fictional thriller that delves into the idea of revealing the horrors of war through imagery. Dr. Lakhani discussed ethical issues in photography, such as intruding on private moments and blurring the line between truth and sensationalism. She emphasized the importance of accurately representing subjects, avoiding manipulation, and upholding impartiality and accountability. Photographers should respect their subjects, provide context, and avoid altering the truth.
3. Bioethics Through the Lens of Humanities – Dr. Muhammad Shahid Shamim
There was a discussion about the story ‘Mercy’ that was shared with the KBG via email prior to the meeting. Ms. Sualeha presented the summary (see below) of the story.
Summary of ‘Mercy’ – The story revolves around a patient suffering from pancreatic cancer whose pain has become intolerable. The narrator, a doctor, is approached by the patient’s wife and mother, who beg for relief, through euthanasia. The doctor goes to administer a lethal dose of morphine to ease the patient’s suffering but faces challenges with the injections. As the doctor tries to proceed with the act, he hesitates and ultimately cannot follow through.
Inspired by this narrative, Dr. Shahid penned a poem ‘Andheri Raat Ka Musafir,’ which he shared with the participants who admired the linguistic beauty of the poem and its impact.
4. Update on the Website – Mr. Farid bin Masood
Dr. Nida expressed gratitude to Mr. Masood for his diligent efforts in updating the website. The group was then presented with the updated version of the website and invited to regularly share news about bioethics-related events, as well as publications and articles, both domestic and international, with Mr. Masood or Dr. Nida, for uploading to the website. The minutes of meetings held between 2004 and 2022 have been updated, creating an archive of previously discussed topics. The group offered a few suggestions on how to improve the website. Mr. Masood and Dr. Nida have volunteered to maintain the website in the coming year.
5. KBG Meetings Host for Next Year – Dr. Nida Wahid Bashir
The host for the upcoming year will be Patel Hospital. Aga Khan University (AKU) and the National Institute of Child Health (NICH) have shown a strong interest in hosting the 2025 and 2026 KBG meetings, respectively. Dr. Moazam recommended Dr. Shahid Shamim as the lead representative from AKU. Additionally, Dr. Naima Zamir, Dr. Tayyaba Batool, and Dr. Jamshed Akhtar from NICH were invited to attend the meetings in person to gain a better understanding of how to manage the KBG meetings.