990623P - MODERATION, BALANCE, AND JUST EQUILIBRIUM IN PREVENTIVE MEDICINE

Paper presented by Prof Omar Hasan Kasule, Sr. MB ChB (MUK), MPH, DrPH (Harvard) at a National Seminar on the Islamic Concept of Preventive Medicine jointly organized by IKIM and the National University of Malaysia (UKM) at IKIM Main Hall on 22-23 June 1999

ABSTRACT

The paper discusses the use of three concepts: wasatiyyah, mizan, and 'adl, in preventive medicine. Risk-factors of diseases and the associated human behavior are on a spectrum whose either extreme ends are bad. Homeostasis, a state of physiological equilibrium, is the basis for physical health. The essence of preventive medicine is to define and maintain the golden mean of moderation, balance, and equilibrium. The paper uses the argument of Imaam al Shatibi that there is no absolute benefit, maslahat, or absolute harm, mafsadat. The purpose of both the law and empirical science is to discover the point of equilibrium at which the balance between harm and benefit are optimally balanced. Both the Purposes of the Law, maqasid al shariat, and the Principles of the Law, qawaid al shariat, are used in defining and determining the point of equilibrium as well as resolving apparent contradictions various determinants of disease and health. The paper concludes that the three Islamic concepts are intimately involved in preventive medicine.

1.0 CONCEPTUAL BASIS

The Islamic perspective of disease prevention and control was treated in general in a recent paper by the author (1). This paper will discuss three specific Islamic concepts, derived from the Qur'an, as they relate to preventive medicine. The concept of wasatiyyat, is very important in all biological, physical, social, and even spiritual phenomena in the universe The Qur;an describes wasatiyyat as a defining characteristic of the ummat (2. 2:143) and righteous individuals (3. 68:28). It is the average or center that is a good representative of the whole (4. 5:89). The Qur'anic concept of mizaan refers to establishing balance between two opposing or contradictory tendencies. Mizaan is mentioned as a general concept of balance (5. 42:17, 55:7, 57:25) and with specific application to measurements in trade (6. 6:152, 7:85, 11:84-85, 17:35, 26:182, 55:8-9, 83:1-3). The concept of 'adl is described in biology (7. 82:7), speech (8. 6:152), government (9. 5:42-45), and the judicial process (10. 5:106, 65:2, 5:8). The concept of 'adl or i'itidal is the practical active establishment of a just equilibrium. The equilibrium may be in the center or at some other optimal point. It is not easy for humans to locate the just equilibrium without the guidance of revelation, wahy.

The Qur'anic concepts mentioned above find their biological equivalent in the concept of homeostasis which refers to the ‘various physiological arrangements which serve to restore the normal state once it has been disturbed' (11. Definition due to W.B. Cannon). Homeostasis establishes and maintains biological equilibrium between internal and external environments, change and constancy, action and reaction. Homeostasis emanates from the concept of tauhid. Tauhid implies that the whole cosmos and what it contains have one deliberate creator. Thus all the contents must relate to one another in some harmonious way since they belong to one and the same scheme of creation. It is unthinkable that the one creator could create systems that are contradictory to one another. The harmony must however be looked at in a dynamic way. Because there are constant changes, there must arise from time to time contradictions in the state of flux. Homeostasis is the mechanisms that restore the status quo following temporary disturbances that are inevitable in a dynamic system. Human disease represents breakdown of homeostasis. Most disease processes are however patho-physiological disturbance that follow and attempt to reverse biological, physical, or chemical insult or injury to the body in order to return the body to the state of equilibrium. Preventive medicine involves actions and behaviors that have as the ultimate aim the support and maintenance of the homeostatic state biologically, socially, and even spiritually.

The practical life and teachings of the prophet emphasize the concept of central tendency and avoiding either extreme. Extremes of any action even if permitted, halal, are usually destructive and are not desired; the best is the equilibrium of the middle path, khair al umuur awsatuha (12. MB # 2014 p 987). There must be a balance between rest and activity, release (istifragh) and retention (ihtibaas), sadness and happiness. Applications of the concept of moderation, balance, and equilibrium is found in almost all aspects of life: human behavior,  medical treatment, and use of environmental resources. The human habitat or the larger ecosystem that humans share with other living things must be maintained at a certain optimum equilibrium otherwise there will be adverse effects on life.

Disease situations are very complicated and could even involve a manifest contradiction among various preventive interventions. Imaam al Shatibi, the leading Muslim thinker on the Purposes of the Law, provided guidance on the resolution of such issues. He argued that there is no absolute benefit, maslahat, or harm, mafsadat (13). The purpose of the law is therefore to choose the best equilibrium between the harm and the benefit. Selection of the right equilibrium as well as the resolution of contradictions is further guided by the Purposes of the Law, maqasid al shariat (13), and Principles of the Law, qawaid al sharia (14).

Scientific knowledge on which preventive prescriptions are based is not perfect. This could raise serious practical problems in situations of uncertainty. We will divide these problems in two distinct groups: problems dealing with finding the moderate position and problems involving choice between two contradictory positions each with its own risks and benefits. The right solution is not always easy to find and no general rules can be given. Each situation should be considered on its own merits.

 3.0 ESTABLISHING and MAINTAINING THE OPTIMUM

Table #1 shows examples of problems in preventive medicine involving establishing the moderate position between two extremes of the spectrum. We can be guided in the choice of the correct preventive approach by using the theory of Purposes of the Law. The law was revealed to fulfil specific underlying purposes that will ensure success in this world and fulfil the interests and benefits, masaalih, of the people. The 5 Purposes of the Law, maqasid al sharia, arranged here in order of importance are: preservation of morals and religion, hifdh al diin , protection and maintenance of human life, hifdh al nafs,  protection of the human intellect, hifdh al aql, protection of the progeny, hifdh al nasl, and protection of property rights, hifdh al maal. The order of priority in selecting preventive interventions should follow the order above. Protection of religion has priority over protection of life. Protection of life has priority over protection of wealth which necessitates expending all available resources to prevent and cure disease. Protection of life has priority over protection of progeny thus in case of cancer, reproductive organs will be removed surgically to prevent disease spread. Protection of human intellect has priority over protection of progeny; persons with labile potentially psychotic personalities could be advised to avoid child-bearing whose additional stress will lead them to frank psychiatric disease. Protection of human intellect has priority over protection of wealth thus alcohol and psycho-active drugs are prohibited even if they may have economical advantages.

4.0 RESOLVING CONTRADICTIONS

Table #2 shows examples of choice between two positions that appear contradictory. Finding the right decision must be based on the guiding principles of the law and empirical evidence. Five principles are recognized by most scholars: intention, qasd, certainty, yaqeen, injury, dharar, difficulty, mashaqqat and custom or precedent, aadat .Each of the 5 Principles is a group of legal rulings or axioms that share a common derivation. We will refer to only two of the five principles in this paper: dharar and masghaqqat. The Principle of Injury, dharar, states that an individual should not harm others or be harmed by others, la dharara wa la dhirar. This leads to prohibition of both active smoking, harm to self, and passive smoking, harm to others. Injury should be mitigated as much as is possible, al dharar yudfau bi qadr al imkaan or should be relieved, al dharar yuzaal, if possible. This sub-principle is the basis for pro-active action to maintain homeostasis, prevent,  or treat disease rather than being fatalistic.  An injury should not be relieved by a similar injury, al dharar la yuzaal bi mithlihi, as happens in situations of vicious circles. The Principle of Hardship, mashaqqa  states that necessity legalizes the prohibited, al  dharuraat tubiihu al mahdhuuraat. Necessity is defined as what is required to preserve the 5 Purposes of the Law. If any of these 5 is at risk, permission is given to commit an otherwise legally prohibited or commonly unacceptable things like violation of individual rights. Coercive public health measures are permitted under this rubric. Prevention of a harm has priority over pursuit of  a benefit of equal worth, dariu an mafasid awla min jalbi al masaalih.  A harmful new treatment modality is prohibited even if it has some efficacy against disease. If the benefit has far more importance and worth than the harm, then the pursuit of the benefit has priority for example when the benefits of the new treatment outweigh its harmful effects by a very large margin. When confronted with a choice between 2 harmful choices, the lesser of two harms is selected, ikhtiyaar ahwan al sharrain and a lesser harm is committed in order to prevent a bigger harm, al dharar al ashadd yuzaalu bi al dharar al akhaff. Amputation of a cancerous limb is a lesser evil that the spread of fatal malignancy. Public interest has priority over individual interest, al maslahat al aamat muqaddamat ala al maslahat al khaassat. The individual's freedom of choice is abridged by laws against smoking in public places because public interest is paramount.

4.0 PRACTICAL APPLICATION: DIET AND DISEASE

Generally malnutrition is an underlying factor in all diseases due to its effect on the immune system. Specific diseases are known to be related to malnutrition: hypertension, coronary heart disease (CHD), diabetes mellitus, and various types of cancer. Hypertension is associated with high sodium intake. CHD is associated with intake of saturated fat. Stomach cancer is associated with dietary intake of nitrosamines. Colon cancer is associated with diets that have high protein and high fat content.  Gallstones are associated with high cholesterol and high sugar diets. Dental caries are associated with prolonged contact of sugar with the teeth. Urinary calculi are associated with high phosphate diets.

Epidemiological evidence indicates that for most nutritional diseases, it is excessive intake that constitutes a risk. Moderate intake of nutrients is not harmful and is even needed for homeostasis. Preventive medicine could lead to elimination of much human disease by encouraging change of dietary habits. The teachings of the prophet on nutritional intake reflect the concepts of moderation, balance, and equilibrium that were defined above. The prophet taught the rule of the thirds as a guide for food intake: one third for solid food, one third for water, and one third for air (15. Musnad al Imaam Ahmad). He also taught that Muslims are a community who do not eat until they are hungry and when they eat they do not fill their belly. Ibn al Qayim defined three levels of food as necessary, hajat, sufficient, kifayat, and excess, fadhlat. The necessary amount of food is that necessary for maintenance of life and health. The sufficient is more than the necessary and satisfies the psychological desire for food. The excess is what is beyond the body's needs and is definitely harmful to health. Excessive intake will lead to disease by overwhelming and impairing homeostatic mechanisms.

Humans appetite for food, a survival instinct, is so strong that the important obligation of salat is delayed when food is presented (16. Muslim # 1134, 1137, 17. MB # 403 p 227). Besides the instinctive urge to eat, underlying visions of life and its purpose, culturally-dependent food preferences, patterns of social eating, food availability, and food advertising. There is a difference in attitude to feeding between the believer and non-believer (18. Shahih al Bukhari Kitaab 70 Baab 12; 19. Sahih Muslim Kitaab 36; 20. Sunan al Tirmidhi Kitaab 23 Baab 20, 21. Sunan Ibn Majah Kitaab 29 Baab 3; 22. Sunan al Darimi Kitaab 8 Baab 13; 23. Muwatta Malik Kitaab 49 Baab 9 and 10). The believer eats to get energy for ibadat. The non-believer may eat for enjoyment or to get energy for evil. There is blessing in the food of the believer; he gets satisfied easily. The non-believer has to eat more food to get the same satisfaction. The Prophet Muhammad (PBUH) in a very revealing hadith mentioned that a believer eats in one bowel whereas a non-believer eats in 7 bowels.

Fasting of Ramadhan is one the major acts of obligatory physical ibadat. Muslims are encouraged to undertake supererogatory fasting. Fasting cleanses the body, al siyam zakat al jism (24.  Sunan Ibn Majah Kitaab 7 Baab 44). It is a lesson in self-control. Its biological implication is teaching self-control and self-discipline in a practical way. Fasting besides its function as a type of ibadat, is training in the control of human appetite.

REFERENCES

Kasule, Omar Hasan: Disease Prevention And Control: Islamic Perspectives: Paper Presented At A Workshop On Cultural Aspects Of Cancer Control And Palliative Care Organized By The University Of Melbourne Key Center For Women Health Held At Noosa Queensland 12-14 June 1999

2:143

68:28).

5:89

42:17, 55:7, 57:25

6:152, 7:85, 11:84-85, 17:35, 26:182, 55:8-9, 83:1-3)

82:7)

6:152)

5:42-45

 5:106, 65:2, 5:8

Definition due to W.B. Cannon

MB # 2014 p 987

al Shatibi,Abu Ishaq: Al muwafaqat fi usul Al Sharia Vol.2 : Kitaab Al Maqasid. Dar Al fikr Al Arabi. No date

Sheikh Ahmad bin al Sheikh Muhamad al Zarqa: Sharh al Qawaid al Fiqhiyyat [Explanation of the Principles of the Law].  Dar al Qalam. Beirut. 1996 CE/1417 AH

Musnad al Imaam Ahmad

Sahih Muslim hadith # 1134, 1137,

Mukhtsar al Bukhari: Hadith # 403 p 227. Daru-us-Salam Publications. Riyadh, Saudi Arabia1994

Shahih al Bukhari, Book of Foods

Sahih Muslim, Book of Drinks

Sunan al Tirmidhi, Book of Foods

Sunan Ibn Majah, Book of Foods

Sunan al Darimi, Book of Foods

Muwatta Malik Book of the Characteristics of the Prophet

Sunan Ibn Majah, Book of Fasting

SLIDE #1: 3 ISLAMIC CONCEPTS

CONCEPT	DEFINITION	EXAMPLES
Wasatiyyat	Avoiding the extremes	Moderation in amount and frequency of food intake
Mizan	Balance or equalization of opposing tendencies	Balance between calorie intake and calorie expenditure
'Adl/I'itidaal	Establishing and maintaining a level of equilibrium	Control of blood sugar levels

SLIDE #2: EXTREMES OF THE SPECTRUM

LOWER END OF THE SPECTRUM	HIGHER END OF THE SPECTRUM
Neurotic anorexia leading to under-nutrition	Compulsive over-eating leading to overnutrition and obesity
Inadequate calorie intake leading to marasmus	Excessive calorie intake leading to obesity
Hypo-vitaminosis A leading to blindness	Hypervitaminosis A leading to cranio-fascial abnormalities
Pyridoxine deficiency leads to peripheral neuropathy	Excessive pyridoxine leads to peripheral neuropathy
Hypo-vitaminosis C leading to scurvy	Hyper-vitaminosis C leading to diarrhoea and oxalate stones
Hypervitaminosis D leading to rickets and osteomalacia	Hypervitaminosis D leading to weight loss, growth failure,
Inadequate sun exposure leading to rickets	Excessive sun exposure leading to basal cell carcinoma of the skin
Extreme vegetarian diet leading to protein deficiency	Excessive meat intake leading to colon cancer and CHD
Physical inactivity leading to cardiovascular disease	Excessive physical activity leading to musculoskeletal injuries
Teenage motherhood leading to poor obstetric & social outcome	Delayed motherhood (<40yr) leading to chromosomal anomalies
Breast conservation surgery leading to cancer recurrence	Radical mastectomy leading to cosmetic & psychological distress

SLIDE #3: CONTRADICTIONS

SITUATION A	SITUATION B
No chemotherapy for cancer leading to spread of the disease	Chemotherapy leading to bone marrow suppression
Manufacturing industry leading to increased wealth	Air pollution leading to cancer and other diseases
Immunization leading to adverse vaccine reaction	Non-immunization leading to higher disease risk
Ovariectomy in ovarian cancer to stop disease spread	Complications of early and artificial menopause
Psychological distress of childlessness	Medico-legal and psychological complications of IVF
Health risk of further child-bearing	Medico-legal and ethical problems of contraception

SLIDE #4: PURPOSES OF THE LAW

Protection of religion, hifdh al ddiin

Protection of life, hifdh al nafs

Protection of progeny, hifdh al nasl

Protection of the mind, hifdh al aql

Protection of property, hifdh al mal

SLIDE #5: PRINCIPLES OF THE LAW

The Principle of Motive, qasd

The Principle of Certainty, yaqeen

The Principle of Injury, dharar

The Principle of Hardship, mashaqqat

The Principle of Custom and Precedent, aadat