Sarosh Saleem

Arima, in the paper ‘Double-effect sedation: do physicians not intend a decrease in consciousness when it is caused by drugs that can also reduce specific symptoms?’, offers a nuanced analysis of moral questions regarding palliative sedation, distinguishing between single effect sedation (SES) and double effect sedation (DES), and effectively challenging the doctrine of double effect (DDE) in justifying DES. He argues against the often justified DES under the DDE in terminally ill patients.1 In what follows, we offer a different justification for rejecting DDE in terminally ill patients receiving sedation. Arima reviews Sulmasy’s application of DDE to DES in cases where drugs to treat specific symptoms like pain, dyspnoea, seizures and so on, cause decreased consciousness as a side effect.2 Additionally, DDE should apply only if the reduced consciousness is temporary or the disease has already hindered valuable experiences of the patient. DDE is justified based on the argument that these side effects are foreseeable yet unintended by the physicians. Arima challenges this prevailing justification of DES. He applies the principle of ‘instrumental rationality’ to contend that in situations where unconsciousness or reduced consciousness is deemed necessary to achieve the intended relief, the reduced consciousness cannot …

Western bioethics has evolved from discussions centered around paternalism and individual autonomy to the concept of Shared Decision‐Making (SDM). This approach to decision‐making aims to uphold patients' autonomy while prioritizing open communication and collaboration. When it comes to making decisions for infants or children, both parents and pediatricians share the responsibility. Parents' personal experiences, values, and beliefs play a central role in the concept of SDM. However, there is still ongoing debate regarding whether physicians should convey their own values, preferences, and recommendations. In Pakistan, clinical decision‐making is predominantly the domain of physicians. Physicians are regarded as figures of respect and authority, and seeking a physician's opinion is common. In a patrilineal and family‐oriented society, medical paternalism is accepted and valued by patients and their families. Autonomy is viewed through a different lens in this cultural setting. This paper presents a narrative analysis of the contrasting approaches to clinical decision‐making in these two cultural contexts. It raises thought‐provoking questions about how clinicians navigate decision‐making dynamics, particularly when faced with different expectations from patients and families. The juxtaposition of these approaches prompts reflection on the potential impact of cultural and societal norms on ethical considerations in healthcare. The paper criticizes the moral hegemony of autonomy and argues for rethinking the separation of autonomy and paternalism in Western bioethics, offering Consensual Paternalism, which represents shared yet unconventional decision‐making.

Gender discrimination in the medical profession is a pressing issue in Pakistan, and the derogatory term “Doctor Bride” has perpetuated harmful stereotypes about female doctors. This paper argues that gender biases and societal expectations hinder women from pursuing careers in medicine. The focus on the term and stereotyping of female doctors is based on prejudice, which results in epistemic injustices. It fails to address the systemic issues that keep female doctors out of clinical practice. The cultural norms and prejudices towards women in professional settings exacerbate the challenges they face in pursuing a medical career. These challenges include social and cultural expectations of prioritizing family over careers, biases in healthcare organizations, and discouragement for married women or those with children to pursue certain specialties. This paper highlights the need to address gender discrimination and create a more inclusive environment for women in the medical profession in Pakistan and globally.

The necessity of obtaining pediatric assent for research participation is well established within international ethical guidelines. However, the effective implementation of these guidelines poses significant challenges for research ethics committees in numerous developing countries, such as Pakistan, characterized by diverse cultural and socio-economic contexts. This paper critically examines the moral underpinnings of assent, rooted in the principle of respect for persons, which aims to empower, engage, and educate children involved in research processes. Through a case example, this paper reveals the unique obstacles faced by researchers and clinicians in Pakistan, which stem from socio-cultural norms and economic disparities. Such challenges endanger the ethical foundation of assent, creating a disconnect between its philosophical basis and practical execution. Although international guidelines permit contextual adaptation of assent procedures, such flexibility is not adequately articulated within the guidelines, nor is it typically prioritized in practice. This gap undermines the purpose of assent and inadvertently increases the risk of harm to child participants—not from the research itself but rather from a process designed to protect and empower them. This paper emphasizes greater awareness among stakeholders regarding these challenges, urging a reimagined assent process in diverse global contexts. By introducing a clear rationale within research guidelines, the intent is to ensure that researchers and Institutional Review Boards (IRBs) prioritize the contextual understanding of assent, transforming it from a mere procedural formality into a meaningful practice that mitigates potential risks to children and adolescents involved in research.

In this article, we first review the development of clinical ethics in pediatrics in the United States. We report that, over the last 40 years, most children’s hospitals have ethics committees but that those committees are rarely consulted. We speculate that the reasons for the paucity of ethics consults might be because ethical dilemmas are aired in other venues. The role of the ethics consultant, then, might be to shape the institutional climate and create safe spaces for the discussion of difficult and sometimes contentious issues. Finally, we report how pediatric clinical ethics has evolved differently in a number of other countries around the world.

End of Life decision-making, in pediatrics is critical, imparting a great burden of responsibility on those involved in the process. The decision-making is multidimensional. Pediatricians encounter many ethical concerns during this process. Qualitative, phenomenological research based on indepth interviews of 12 pediatricians from three tertiary care hospitals of Karachi, Pakistan. Data was analyzed using Nvivo 9 software. Six themes were identified, a) Major factors are clinical information and available resource; b)Itis clinically and psychologically challenging; c) Participation of parents is influenced by emotional, socio-economic and religious factors; d) Communication is the most crucial aspect of conflict resolution; e) Institutional policies and expert opinions guide pediatricians f) Clinical Ethics consultation is underutilized in Pakistan. The parents and pediatricians are responsible for decisions aligned to the best interest of children. The role of Pediatricians is critical as they look for the best possible ways to provide care through limited healthcare resources. Parents generally base their views on social and spiritual values. We recommend that healthcare organizations in Pakistan adopt clinical ethics consultation as a source of facilitation and support for these difficult decisions.