Date: Tuesday, February 13, 2024
Time: 8.30 am – 10.00 am
- Welcome and a Brief Recap of KBG Forum (20-Year Journey)
Dr. Mazhar Nizam, Medical Director at Patel Hospital, welcomed all participants and shared an overview of Patel Hospital’s 20-year engagement with CBEC and KBG. He highlighted the “Short Course on Biomedical Ethics” for postgraduates, conducted by Dr. Abeer Salim and Ms. Shabana over the past six years.
Dr. Aamir mentioned that 2024 marks 20 years since KBG’s inception and recommended documenting and publishing the forum’s success story. He emphasized KBG’s unique influence, which extends beyond Karachi. Dr. Shahid Shamim supported this initiative and offered to contribute to the write-up with Dr. Nida.
2. Indemnity Insurance for Research Participants in Pakistan – Dr. Muhammad Faheem Khan
Dr. Faheem (PGD Class of 2012, CBEC) presented on indemnity insurance in clinical trials, highlighting key issues such as compensation responsibility, risk assessment, and the lack of legal and institutional frameworks in Pakistan. He questioned local hospital practices in light of JCIA standards, and discussed ambiguities in policies from DRAP, NBC, and laws like the Fatal Accident Act and Diyat.
Forum members shared various perspectives: Dr. Nida stressed NBC’s role due to PIs’ limited authority; Dr. Aamir proposed institutional responsibility; Dr. Tashfeen highlighted gaps in AKU’s research insurance model; Dr. Sualeha noted NBC’s requirement for insurance policies but explained indemnity is rarely provided in non-fatal adverse events; Dr. Farid raised concerns about morbidity compensation and the absence of religious guidance; Dr. Shafqat recommended legal consultation on research subjects’ rights; Dr. Sulaiha clarified indemnity supports families in cases of participant death.
Action points included Dr. Sualeha gathering NBC input and Dr. Faheem liaising with NBC and legal departments to report back.
- Concerns Regarding Physician–Pharmaceutical Company Interactions – Dr. Asad Akram Farooqui
Dr. Asad highlighted ethical concerns about accepting gifts from pharmaceutical companies, warning that even small gifts could lead to more significant ethical dilemmas. Dr. Kaneez and Dr. Nada observed that such practices are prevalent in government institutions and surgical specialties. Dr. Faheem cautioned against the “slippery slope” of gift acceptance, while Dr. Mazhar distinguished between work-related and personal gifts. Dr. Nida raised concerns about physician bias and its impact on patient care, and Dr. Abeer emphasized how gifts can subtly influence prescribing practices and erode trust. Dr. Shahid Shamim suggested channeling pharmaceutical support through institutions for educational purposes. Dr. Hanna advised against direct comparisons with Western contexts, stressing physicians’ responsibilities in low-resource settings. Dr. Aamir proposed pooling pharmaceutical contributions to support resident education, and Dr. Nida referenced existing KBG guidelines, tasking Ms. Shabana with distributing them to members.
- AOB – KBG Website Fee Update
Dr. Nida informed the group that the annual fee for the KBG website has increased to PKR 17,000. Dr. Aamir generously paid this from his personal account and members were requested to reimburse the amount via Jazz Cash to Dr. Nida’s number. Any excess funds collected will be used toward next year’s fee. Detailed financial updates will be shared in the upcoming meeting.
Date: Tuesday, April 16, 2024
Time: 8.30 am – 10.00 am
- Addiction Among Doctors: Ethical Implications and the Role of Social Media – Dr. Zeelaf Munir
Dr. Zeelaf initiated a discussion on the growing issue of addiction among doctors in academic institutions, questioning the appropriateness of addressing such matters on social media. Her presentation included a YouTube video and evidence-based research. Dr. Aamir Jaffery linked the trend to the legalization of cannabis in Western countries, while Dr. Zeelaf expressed concerns about the potential harm to physicians’ prestige if addiction is publicized. Dr. Nida highlighted the dual challenge of assessing addiction’s impact on performance and raising awareness. Dr. Abeer questioned the effectiveness of disciplinary actions, and Dr. Sana suggested providing counseling support for addicted students. Dr. Mumtaz argued against punishment unless clinical performance is affected, and Dr. Mazhar pointed out the difficulty of addressing addiction outside the hospital. Dr. Nida emphasized privacy and discouraged public exposure of addicted doctors. Dr. Aamir and Ms. Sualeha suggested adopting regulations similar to those in aviation for alcohol consumption. The consensus was that institutions should create clear policies and support systems to address addiction while safeguarding privacy and professional standards.
- The Family Decision of Unplanned Pregnancy Termination: Can Clinicians Help? – Dr. Kaneez Fatima / Dr. Ayesha Mustafa
Dr. Kaneez Fatima and Dr. Ayesha Mustafa presented a case of a 27-year-old woman (P2+1) at 12 weeks gestation with a 9-month-old baby delivered via Cesarean, seeking termination of an unplanned but otherwise healthy pregnancy. They explored the legal, clinical, and ethical responsibilities of clinicians in such situations.
Mr. Masood Farid emphasized a holistic view of health, considering mental and social factors. Dr. Nida questioned the role of mental health in termination decisions, while Dr. Aamir Jaffery noted that current laws place discretion with the physician. Dr. Kaneez Fatima proposed two approaches: offering termination or counseling continuation, often seeking second opinions in high-risk cases, and highlighted abortion as a common outcome due to low contraceptive use. Dr. Nida raised concerns about gynecologists’ reluctance to discuss contraception, citing religious objections. Dr. Irfan warned of regret in socially motivated terminations. Dr. Mazhar pointed out doctors’ greater willingness to discuss contraception than to perform terminations, and Dr. Sualeha identified cost, side effects, and availability as barriers. Dr. Lakhani stressed patient autonomy and rights, while Dr. KF described international norms requiring approval by two consultants. Dr. Mazhar clarified that patient requests must be evaluated within legal and ethical frameworks. Dr. Aamir suggested continuing discussions on religious and legal perspectives in the next meeting.
- Physician–Family Disagreements Regarding Code Status in Critical Care – Dr. Rabia Ausaf
Dr. Rabia Ausaf presented a case of a 45-year-old male with obstructive jaundice who developed acute complications, including ARDS requiring ventilatory support after ERCP. Although signs of recovery were evident, the family requested withdrawal of support due to financial constraints, which the medical team opposed based on the patient’s expected recovery.
Dr. Sana highlighted that such cases are common and often misinterpreted as billing prolongation, emphasizing the need for early and transparent counseling. Mr. Masood questioned whether the patient had been directly consulted, to which Dr. Maria explained that direct engagement typically occurs only when serious outcomes are anticipated. Dr. Nida stressed the importance of pre-procedure discussions about complications like pancreatitis, along with the legal requirement for consultants to communicate with competent adult patients, and emphasized thorough documentation of counseling. Dr. Asad noted the challenges of addressing code status in emergency settings. Dr. Aamir raised concerns about financial motivations influencing treatment decisions, while Ms. Sualeha highlighted misconceptions about ventilator use and emphasized the need for education and religious clarity.
- Announcements
Ms. Shabana shared that the annual KBG website fee has increased to PKR 17,000. Dr. Aamir generously covered the cost, and members were asked to contribute their share via Jazz Cash to Dr. Nida. Any excess funds will be carried forward to the next year.
Date: Tuesday, June 11, 2024
Time: 8.30 am – 10.00 am
- We Should React to Atrocities in Gaza, Say Bioethicists – Dr. Shifa Naeem
Dr. Shifa opened the discussion by referencing a BioEdge article that had gone offline. She instead highlighted a related publication authored by KBG members Dr. Sualeha Sheikhani and Dr. Aamir Jaffery titled “Amid Explosions in Gaza, The Silence from the Bioethics Community is Deafening”, which prompted reflections on the ethical silence surrounding Gaza. Dr. Zaman suggested it be shared on the KBG forum, but Dr. Farhat clarified the article hadn’t been officially released yet. Dr. Shifa posed a broader question about how the group felt regarding Gaza. Dr. Kaneez Fatima expressed deep distress and helplessness. Dr. Farhat asked about the article’s relevance to the forum, prompting Dr. Shifa to assert the ethical importance of speaking up.
Dr. Riffat Zaman reflected on the emotional pain caused by news from Gaza and hoped for future political change. Dr. Nida emphasized the group should issue a public condemnation. Dr. Moazzam questioned the value of political statements, but Dr. Nida responded that public discourse shapes opinions. Dr. Asad noted fear of political backlash inhibits open criticism, while Dr. Nida pointed out that unlike in countries like Qatar, Pakistan allows greater freedom of expression. Dr. Moazzam elaborated on the International Bioethics Conference in Qatar, where discussions about Palestine were suppressed, though parallel sessions addressed human rights violations in Gaza. She suggested the KBG draft a public statement.
Mr. Farid bin Masood raised the silence around atrocities in Sudan and Yemen and questioned if bias affects whose suffering gets attention. Dr. Shifa acknowledged this, but argued the Gaza crisis is uniquely systematic and long-standing. She volunteered to help write a response. Dr. Abeer noted increasing censorship on social media and the muted stance in countries like Saudi Arabia, yet stressed that KBG should still publish a statement. Mr. Farid recommended short articles in Urdu and English. Dr. Moazzam supported a joint article and offered assistance. Dr. Nida confirmed that she, Dr. Shifa, Mr. Farid, Dr. Abeer, and Dr. Moazzam would collaborate on the piece and submit it to newspapers including Dawn, The News, Express, and Daily Jang.
- How Does a Restrictive Legal Framework on Abortion Impact Access to Safe Services? – Dr. Ayesha Mustafa
Dr. Ayesha presented Sections 338A, 338B, and 338C of the Pakistan Penal Code, which outline abortion laws under the categories of isqat-e-hamal and isqat-e-janin. She emphasized the law’s ambiguity and the burden it places on physicians. Dr. Kaneez highlighted that denying abortions often pushes women toward unsafe providers, leading to severe complications. She cited a 2023 Sindh-based survey showing poor access to safe abortions as a contributor to maternal mortality.
Dr. Moazzam noted that while the law is vague, it actually offers flexibility under terms like “good faith” and “necessary treatment,” and that the issue is more about internal biases among gynecologists. She shared personal experiences where religion was used as a barrier, pointing out that many so-called social reasons for abortion—such as health risks from repeated pregnancies—should actually be seen as medical. She recommended referrals when physicians are unwilling to perform abortions themselves.
Dr. Riffat Moazzam stressed the importance of mental health in such cases, as psychological unpreparedness can seriously affect a woman’s well-being. Dr. Nida added that the stigma attached to the term “social” must be reconsidered. Dr. Moazzam recommended using the term “societal,” as societal pressures often influence physical and mental health. In response to a query about punishment, Dr. Moazzam clarified that such cases rarely go to court due to interpretative leeway in health-related laws. Dr. Farina inquired about hospital protocols, and Dr. Kaneez responded that there’s a pressing need to educate providers and establish uniform departmental policies to ensure safe and consistent care.
- PMA–KBG Collaborative Short Certificate Course for Junior Doctors – Presented by Dr. Nida on Behalf of Dr. Shahid Shamin
Dr. Nida presented this agenda item in Dr. Shahid’s absence, describing his initiative: the Junior Ethical Doctor Initiative (JEDI), a six-week certificate course co-organized by PMA and KBG. Designed for junior doctors without formal bioethics training, the course includes six Saturday workshops (three hours each), with a 25-participant cap. Dr. Nida will circulate the list of topics to allow KBG members to volunteer. The course is expected to launch at the end of July 2024. Dr. Moazzam expressed disappointment at Dr. Shahid’s absence and suggested the item be revisited in the next meeting for a more detailed discussion.
- Announcements
Dr. Nida informed the group that this year’s website fee has been paid, leaving a balance of PKR 7,000. To cover next year’s fee, an additional PKR 10,000 is required. Contributions will be collected during the next meeting via Jazz Cash. Any surplus will be saved for future use.
Date: Tuesday, August 13, 2024
Time: 8:30 AM – 10:00 AM
- Publications
Dr. Nida shared that the jointly authored article “A Criminal Silence Over War Crimes” was published by Dawn News, though it appeared under her name alone. She is currently working on an Urdu translation. Ms. Shabana reminded the group that KBG is nearing its 20th anniversary. Members discussed writing a reflective piece on KBG’s journey. Dr. Farhat emphasized the significance of this milestone, highlighting the sustained commitment of KBG’s core members and Patel Hospital’s unwavering support.
2. Milk Banks in Pakistan
Presenter: Mr. Farid Bin Masood
Mr. Farid opened a session discussing the recent attempt to establish milk banks in Pakistan. Ms. Shabana emphasized the Islamic perspective on breastfeeding and the need to maintain kinship records due to the concept of milk kinship in Islam. Mr. Farid explained that Darul Uloom Karachi had initially approved the project but later retracted support over policy compliance concerns, leading to its suspension.
The institute’s policy limited donor milk use to medically vulnerable infants under 34 weeks, with strict kinship documentation, a one-to-one donor-child policy (despite fatwa approval for pooled milk), restricted usage to Muslim recipients, free services, and stringent hygiene and tracking protocols. Mr. Farid noted that only Iran among Muslim countries has a functional milk bank, with similar attempts failing in Turkey and Bangladesh due to public criticism.
Dr. Jalal Akber clarified that social media misrepresentation led to misinformation, emphasizing that the milk was meant solely for preterm infants without maternal milk access, with donor identities disclosed and documented. Dr. Shahid Shamim and Dr. Mazhar critiqued the project’s strategy and suggested a reintroduction with better planning. Dr. Jalal confirmed plans for a smaller-scale relaunch with a new name. Dr. Moazzam and Dr. Aamir contributed historical and religious insights, highlighting altruistic milk sharing rooted in Islamic tradition.
3. PMA–KBG Certificate Course for Junior Doctors
Presenter: Dr. Shahid Shamim
Dr. Shahid introduced a short certificate course in collaboration with PMA and KBG to address the lack of bioethics training in medical curricula. The course will consist of six three-hour Saturday workshops at PMA House, Karachi, covering topics such as clinical ethics, communication ethics, ethics of prescription, research ethics, publication ethics, and a summary session with feedback and certification.
The program targets senior students and junior doctors from both public and private institutions, with a course fee of Rs. 1200 for all sessions. Certification will be jointly issued by PMA (Karachi) and KBG, and KBG members will serve as facilitators.
Postgraduate trainees from Patel Hospital shared positive feedback on previous ethics sessions, noting improvements in awareness and critical thinking about ethical challenges in clinical practice. Dr. Shahid encouraged KBG members to participate as facilitators and provide suggestions to enhance the course.
4. Announcements
Dr. Aamir Jaffery shared that admissions are open for CBEC’s 2025 Postgraduate Diploma (1 year) and Master’s Program (2 years) in Bioethics. Both programs include four on-campus sessions (8 AM – 6 PM), with the rest of the coursework conducted remotely. Participants are expected to take leave for on-campus sessions. Application deadline: September 29, 2024.
Date: Tuesday, October 15, 2024
Time: 8:30 AM – 10:00 AM
1. Code Status and the Family Dynamics – How to Deal With It?
Presenter: Dr. Neelam Abbasi (PG Trainee, Patel Hospital)
Dr. Neelam presented two ethically challenging cases regarding code status decisions and family dynamics in critical care.
In Case A, a 42-year-old hypertensive female arrived unconscious with GCS 3/15 and gasping respirations, requiring ventilatory support. Her siblings refused intubation, citing past trauma with ICU care, and her brother signed a DNR form. She passed away two hours later in the HDU, raising the ethical question of whether physicians should proceed with intubation in gasping patients without family consent. Dr. Amir questioned the patient’s salvageability, while Dr. Neelam stressed that intubation was crucial for stabilization and diagnosis. Dr. Moazzam and Dr. Nida argued that saving the patient’s life ethically and legally takes precedence. Ms. Farzana highlighted that general ER consent covers life-saving interventions. Dr. Shahid Shamim and Dr. Aamir emphasized the need for hospital administration to support physicians, especially in private setups where families might later contest ICU bills. The consensus reaffirmed the priority of patient welfare in emergencies, coupled with thorough documentation and clear communication.
In Case B, a 52-year-old male with TB and respiratory distress was attended by his approximately 18-year-old daughter, who signed written consent for intubation, while his son gave verbal “full code” consent from abroad. After the patient’s death two days later, the son contested the consent, claiming the daughter’s age and inexperience invalidated her decision. Dr. Shahid Shamim and Dr. Moazzam stressed the importance of robust documentation, including age verification, listing all relatives involved, and recording phone consent when applicable. Dr. Neesha suggested adding witness signatures to strengthen records, while Dr. Asad Akram recommended documenting all family members present during counseling to reduce future conflicts. The recurring challenge of dealing with multiple, and sometimes conflicting, family decision-makers was also acknowledged.
2. Balancing Public Health and Individual Rights – TB Isolation vs. Patient Autonomy
Presenter: Dr. Maria Malick Alvi (Junior Consultant Medicine)
Dr. Maria Malick Alvi presented a case involving a patient with confirmed TB who left the hospital against medical advice (LAMA) during the infectivity window to cast his vote. The patient refused to wear a mask and disclose his TB status, raising ethical and public health concerns about balancing individual autonomy and public safety.
Dr. Moazzam emphasized that public health concerns take precedence over individual rights in cases of communicable diseases, although physicians lack the legal authority to forcibly restrict patients, making reporting to public health authorities their responsibility. Dr. Neelum and Dr. Sualeha discussed the ethical and legal support for reporting such cases while respecting confidentiality. However, they highlighted the challenge of effectively enforcing isolation policies, noting the existence of relevant laws in Pakistan, such as COVID-19 isolation mandates, but acknowledging weak practical enforcement.
3. Announcements
Ms. Shabana noted that the December KBG meeting will be Patel Hospital’s last session as host. Dr. Shahid Shamim (Aga Khan University Hospital) volunteered to host the KBG meetings for 2025. Ms. Aiman Farheen will serve as the coordinator. The planning team includes Dr. Rubina and Dr. Tashfeen.
Date: Tuesday, December 10, 2024
Time: 8:30 AM – 10:00 AM
- Baby Caring Device by Kangaroo Care AI
Presenter: Mr. Farid Bin Masood
Mr. Farid introduced Kangaroo Care, a company featured on Shark Tank Pakistan, which pitched a locally manufactured newborn incubator and secured funding of PKR 30 million—a significant achievement given the typical reliance on expensive imports. The incubator, entirely designed and assembled in Pakistan (except for semiconductors), includes in-house software and features like Baby Cry Detection (BCD) to classify cry types for caregivers. With a production cost of PKR 75,000–85,000 and retail price of PKR 150,000–200,000, Kangaroo Care has sold 400 units to hospitals and clinics over 18 months.
Though the device has received positive feedback from physicians, it is not yet approved by DRAP and is seeking CE and FDA certifications, requiring PKR 8–10 million. Ms. Shabana raised concerns about selling uncertified medical devices, while Ms. Farzana urged streamlined regulatory processes to support innovation. Dr. Mazhar emphasized rigorous testing, citing lessons from ventilator production during COVID-19. Dr. Tashfeen introduced Health Technology Assessment (HTA), equating quality with evidence and ethics. Dr. Shahid questioned the device’s novelty but stressed the need for regulation.
Dr. Nida pointed out the importance of trained personnel and cautioned against equating low cost with compromised quality, while Ms. Sualeha addressed equitable technological advancement. Dr. Aamir highlighted adherence to DRAP protocols and flagged AI bias risks from non-local datasets. Dr. Moazzam called for clear testing mechanisms, and Mr. Farid distributed DRAP Medical Devices Rules – 2017 for guidance. Dr. Sualeha noted limited awareness among students about ethical and regulatory systems. Dr. Nida and Dr. Shahid emphasized improving regulatory processes rather than bypassing them to foster ethical innovation.
- Duplication in IRB Approval of Case Report
Presenter: Dr. Faheem Khan
- Dr. Faheem Khan presented a case involving two separate teams submitting case reports on the same clinical case to the IRB at different times (Dec 2023 and June 2024), unaware of each other’s intent to publish. Both reports received IRB clearance (approval and exemption), resulting in two distinct manuscripts at different publication stages. The issue raised concerns over IRB oversight, data ownership, authorship ethics, and institutional confidentiality.
- Dr. Aamir questioned whether case reports fall under IRB’s purview, as they are not traditional research. Ms. Shabana clarified that journals now require IRB approval to address confidentiality and consent. Ms. Farzana emphasized institutional sensitivities, while Dr. Moazzam advocated for transparency in reporting complications. Dr. Rumina noted that similar data can lead to varying interpretations without ethical conflict, and Dr. Abeer suggested cross-specialty collaboration for comprehensive reporting.
- Dr. Neesha stressed the need for consent from the treating consultant, while Dr. Nida argued that institutions, not individual physicians, own the data. Dr. Mazhar referenced a similar case of PG research published without proper IRB clearance. Ms. Shabana and Dr. Tashfeen proposed solutions like departmental inquiries, document verification, and potential retraction. Dr. Aamir recommended reporting fraudulent IRB claims to CPSP and setting institutional precedents.
- Dr. Moazzam highlighted the importance of counseling PGs and reinforcing ethical practices. Dr. Faheem clarified the distinction between hospital-owned physical records and patient-owned data, adding that retrospective, de-identified data might not require consent.
Unaddressed Agenda Item
Presenter: Dr. Sadia Shakoor
Topic: Formative Study on Preventing Unethical Prescribing by GPs in Karachi
Note: Discussion deferred due to time constraints and will be carried forward to the next meeting.
Closing Remarks
Dr. Mazhar Nizam (Medical Director, Patel Hospital) thanked all participants for their contributions and highlighted the value of these meetings for ethical development, especially for junior faculty. He commended Dr. Abeer for running the Biomedical Ethics Short Course for eight years, now integrated into the postgraduate curriculum, and praised Ms. Shabana for organizing and sustaining KBG initiatives. Dr. Moazzam appreciated Patel Hospital’s ongoing support, acknowledging its critical role in sustaining the group—a rare example of continuity in ethical initiatives in Pakistan.