The present study was designed with a purpose to assess the actual practice of informed consent, privacy and confidentiality by the doctors through direct observation of the entire process of patient care provided in outpatient departments (OPDs) of public and private hospitals, and correlate these ethical practices with patient perception of doctors' ethical practices. Our results show that the doctors took proper informed consent from very few patients coming to these hospitals. One of reasons behind such practice is that the cultural trends in Pakistan still tend to accept the paternalistic model of medical care. This is in line with the Asian culture as a whole, where the decision-making is often left purely to the doctors or other family members. Studies from Kashmir and Japan reflect similar practices wherein patients are willing to accept what doctors choose for them, while doctors are satisfied with their role of a decision-maker. [21–23]. For example in a study by Yousaf RM et al , 65% physicians in Kashmir and 35% physicians in Malaysia said they would listen to the family's request to withhold information from the patient. A study from Hong Kong also shows the patients and physicians to be more willing to accept the role of families in crucial decisions regarding medical care . Even in countries like Lithuania  and South Africa , the practices of doctors often do not meet the moral and legal requirements for medical ethics, although the observance of ethics is better than what our study has found in Pakistan.
While the situation in US was not much different till the 1960s , the current medical practice in US lays significant focus on the concepts of informed consent and shared decision-making. This differs substantially from the trends in Asia  and experts have gone to the extent of calling it a 'cultural artifact' in that reliance on this concept is not universal . Even in US, there is often a clash between these ethical standards and the moral intuitions of many physicians [30, 31].
Improper consent of some form was taken from a large number of patients at the private hospital but just a few from public hospital. No informed consent was taken from an alarming proportion of patients (90%) at the public hospital. Even in the private hospital more than half the patients were denied their right to informed consent. On the whole, the practice of informed consent was better at the private hospital but still far from the ideal. Several reasons may account for the differences. Firstly, doctors at private hospitals are better paid than their colleagues in the public sector, something that may translate into better performance at work and greater care for the patients. Secondly, doctors in the private sector are often employed on contracts that need regular renewal. Doctors' work is regularly monitored and assessed, and this renewal is often linked to patient satisfaction with care. Hence doctors in the private sector are more likely to respect the patients' fundamental rights related to their medical management. On the other hand, jobs in the public sector are secure and more or less permanent in nature. At the same time, there is little or no accountability of the doctors since there is usually no effort to elicit patients' opinion about the care provided to them. The results of our study are in line with those from a study conducted in a public sector hospital in Karachi that concluded that the current practice of informed consent was below the internationally acceptable standards . Even though that study commented only on preoperative informed consent, it is pertinent to note that the trend of both our studies is similar. Another study from a private hospital in Karachi also reported that the number of patients complaining of lack of privacy was greater than in the west .
Similarly, the principle of confidentiality (informational privacy) was also inadequately practised in our study. This is not surprising since even a study in a country like Canada, has shown that quite a few of the family physicians do not fully understand their obligations towards patient confidentiality . Furhtermore, the practice of confidentialty was more inadequate/unsatisfactory in the public sector hospital than the private one. While the reasons cited above may also contribute to this difference as well, there are others factors that must also be explored. Significant patient burden at general OPDs of public hospitals often makes it impossible for the doctors to follow the full protocol of informed consent and confidentiality. Usually the OPDs are in the form of big rooms in which on one side the patients are waiting (a part of their total waiting time in and outside the OPD room) while on the other, there are some examination tables (with or without a screen). In the center of the room, many doctors are interviewing and examining multiple patients and/or writing medical prescriptions. 2 to 4 patients are dealt with simultaneously. Seldom if ever are the attendants requested to leave the room while the patient is being interviewed or examined. Hence the patient and his/her problems are discussed in front of all present in the room. Such practice may prevent the patients in revealing their complete history and list of symptoms .
Provision of privacy during physical examinations was also inadequate in both hospitals. However, privacy-related practices were still somewhat better than the practices of informed consent and informational privacy. The private hospital again showed better ethical practices than the public hospital although in this case the difference was not statistically significant. This may be because in both settings, doctors have no choice but to carry out these examinations behind a screen, especially examinations requiring significant exposure. A study conducted at a private hospital in Karachi also shows that patients felt some lack of privacy on a significant number of occasions (47%) . Our figure in both hospitals is even higher than this. However, socio-demographic differences in the patient population, difference in the method of data collection and the fact that the study in Karachi was carried out on inpatients, precludes any concrete comparison with our results. Imam et al  have reported the patient 'opinions' regarding privacy while in our study trained data collectors graded the provision of privacy in comparison to professional standards. As stated earlier, patients can under- or overestimate their ethical rights and hence their opinion may not necessarily be in line with the ideal standards [8, 9]. This factor may also contribute to the different figure generated by our study. In comparison to an international study as well, our results show a much greater inadequacy in the provision of privacy to the patients .
Our study shows that compared to the public hospital, more patients in the private hospital believed that ethical practices were well observed by doctors interacting with them. This is fairly in line with the assessment of our data collectors where principles of informed consent, informational privacy and physical privacy were more often applied in the private hospitals as discussed earlier. We compared whether the patients' perception of these ethical practices matched correctly with the assessment of our data collectors. In 38/93 instances in the public hospital and 24/93 in the private hospital, patients' perception differed with the assessment of our trained data collector. This is a significant number, and again shows that many patients are unaware of, or misunderstand their ethical rights [8, 9]. Once again, the discordance is higher in the public hospital and this may be directly related to the lower socioeconomic status of these patients compared to those in the private hospital.
It is noteworthy, that there are also some other reasons for inadequate ethical practices in Pakistan. For example, although innovative ethical curricula have been shown to improve the confidence and practice of doctors with regards to medical ethics , PMDC does not include education in bioethics as a major component of the medical curriculum . It follows, that very few medical colleges in Pakistan impart formal training in bioethics. Such education is also largely omitted from postgraduate training programs. Lack of applied ethical training is also perceived in other countries like Germany  and even US , which has always championed the cause of bioethics. This lack of Pakistani education in ethics means that trainees can only learn from the practices of their consultants, most of whom belong to the era when a paternalistic approach towards the patients was in vogue. This leads to a vicious cycle where every subsequent generation of doctors believes in paternalism. Even doctors who favor practices like informed consent, often abandon these practices since they believe that most of their patients are uneducated and would not be able to decide what is best for them. It is true though, that often the patients do not want to take any decision and want the doctor to decide each and every thing for them. Furthermore, the lack of accountability and legal recourse means that doctors who do not respect patient ethics are never taken to task in this country.
However, regardless of the excuses provided for the lack of medical ethics, it should be kept in mind that the principles of informed consent, confidentiality and physical privacy must always be applied in medical practice [1, 4, 6, 38].