Bioethics, the investigation of ethical issues in medicine, biology, and health sciences, is in vogue in the developed world. Television news often shows feature stories on debates over the proper uses of such new developments as embryonic stem cells or gene therapy, and newspapers elicit public comments on their Internet sites. Societal responses to these technological advances are mediated through bioethics agencies within governments, working alongside numerous scholars and interested non-government organizations. National bioethics commissions in over forty countries offer reports and opinions to the public, influential legislators, and public officials. Laws and regulations are widely debated and influence the direction of science and healthcare (1).
The role of bioethics in most developing countries is quite different. The survey of the bioethics literature in Hyder and Nadeem's paper "Health Ethics in Pakistan" shows that the potential contribution of bioethics in that country to public contemplation of ethical issues in healthcare is only beginning to be realized. The lack of a well-developed capacity for debate and reflection in bioethics in a country like Pakistan is lamentable for those who believe that bioethics might offer hope to the country in meeting its challenges in healthcare.
As Hyder and Nadeem suggest, the paramount issue in Pakistan, as in most countries afflicted with widespread poverty, is the country's severe lack of resources for public health and healthcare. This, however, does not mean that bioethics is a luxury, a preoccupation of wealthier countries that will have to wait until Pakistan achieves further development. Underdevelopment rather sets a distinctive bioethics agendum, on which the ethics of resource allocation-of who will live and who will die, of whose suffering has the highest priority when not all can be helped-is of primary importance. Priorities for bioethics will reflect those of the health system, with more emphasis on prevention than on treatment and on common and communicable diseases rather than treatment of rare and chronic illnesses. Alongside the need for resources, and for just and accountable choices within these resource constraints, there is a need for a regulatory environment for the practice of medicine and for the pharmaceutical and biotechnology industries in which the public interest remains paramount. There is also a need to reinforce awareness of the rights of patients in the public and the health professions alike. The ethical issues at stake range from the largest questions of health system reform to the individual doctor's re-use of a disposable syringe.
The relative scarcity of published reflection in bioethics in a country, such as Pakistan, represents an opportunity, for the door is open to innovation and to development of bioethics as a field of scholarship and activity that is responsive to the distinctive conditions prevailing in the country. There is no need to carry over models from developed countries, duplicating their preoccupation with the latest products of science and technology. Bioethics in Pakistan and other developing countries can make a contribution that extends far beyond national boundaries if the field engages the everyday realities that make the delivery of humane and effective healthcare such a challenge.
A comparison of bioethics in a developing country, such as Pakistan, with that of richer countries requires an account of the latter that recognizes its diversity of purpose and method. Bioethics in the West is partly a field of academic study, located in schools of medicine, the social sciences, and philosophy; but this has worked alongside a reform movement outside the academy aimed at enhancing the well-being and self-determination of the individual patient and research subject. Bioethics drew strength both from its scholarly contributors and from the commitment and energy of the social movement that sought to rectify what it took to be a disregard of the patient by an unresponsive medical profession. …