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INTRODUCTION
Islam has a parsimonious and rigorously defined ethical theory of Islam based on the 5 purposes of the Law, maqasid al shari’at. The five purposes are preservation of ddiin, life, progeny, intellect, and wealth. Any medical action must fulfill one of the above purposes if it is to be considered ethical.
The basic ethical principles of Islam relevant to medical practice derived from the 5 principles of the Law which are: intention, qasd; certainty, yaqeen; harm, dharar. The Islamic principles are wider in scope and deeper than the European principles.
THE ISLAMIC THEORY OF ETHICS DERIVED FROM THE PURPOSES OF THE LAW, MAQASID AL SHARI’AT
Purpose 1: protection of ddiin: Protection of ddiin essentially involves ibadat in the wide sense that every human endeavor is a form of ‘ibadat. Thus medical treatment makes a direct contribution to ‘ibadat by protecting and promoting good health so that the worshipper will have the energy to undertake all the responsibilities of ‘ibadat. The principal forms of physical ‘ibadat are the 4 pillars of Islam: prayer, salat; fasting, puasa; pilgrimage, and hajj. A sick or a weak body can perform none of them properly. Balanced mental health is necessary for understanding ‘aqidat and avoiding false ideas that violate ‘aqidat.
Purpose 2: Protection of life, hifdh al nafs: The primary purpose of medicine is to fulfill the second purpose of the shari’at, the preservation of life. Medicine cannot prevent or postpone death since such matters are in the hands of Allah alone. It however tries to maintain a high quality of life until the appointed time of death arrives. Medicine contributes to the preservation and continuation of life by making sure that normal physiological functions are well maintained and causes of disease are removed or mitigated. Medical knowledge is used in the prevention of disease that impairs human health. Disease treatment and rehabilitation lead to better quality health.
Purpose 3: protection of progeny, hifdh al nasl
Medicine contributes to the fulfillment of this function by making sure that children are well cared so that they grow into healthy adults who can bear children. Treatment of infertility ensures successful child bearing. The care for the pregnant woman, perinatal medicine, and pediatric medicine all ensure that children are born and grow healthily. Intra-partum care, infant and child care ensure survival of healthy children.
Purpose 4: protection of the mind, hifdh al ‘aql
Medical treatment plays a very important role in protection of the mind. Treatment of physical illnesses removes stress that affects the mental state. Treatment of neuroses and psychoses restores intellectual and emotional functions. Medical treatment of alcohol and drug abuse prevents deterioration of the intellect.
Purpose 5: protection of wealth, hifdh al mal
The wealth of any community depends on the productive activities of its healthy citizens. Medicine contributes to wealth generation by prevention of disease, promotion of health, and treatment of any diseases and their sequelae. Communities with generally poor health are less productive than a healthy vibrant community. The principles of protection of life and protection of wealth may conflict in cases of terminal illness. Care for the terminally ill consumes a lot of resources that could have been used to treat other persons with treatable conditions. The question may be posed whether the effort to protect life is worth the cost. The issue of opportunity cost and equitable resource distribution also arises.
PRINCIPLES OF ETHICS DERIVED FROM THE PRINCIPLES OF FIQH, qawa’id al fiqh
Principle 1: The principle of intention, qa’idat al qasd
The Principle of intention comprises several sub principles. The sub principle in which each action is judged by the intention behind it, calls upon the physician to consult his inner conscience and make sure that his actions, seen or not seen, are based on good intentions. The sub principle based on ‘what matters is the intention and not the letter of the law’ rejects the wrong use of data to justify wrong or immoral actions. The sub principle in which ‘means are judged with the same criteria as the intentions’ implies that no useful medical purpose should be achieved by using immoral methods.
Principle 2: The principle of certainty, qaidat al yaqeen
Medical diagnosis cannot reach the legal standard of certainty, yaqeen. Treatment decisions are best on a balance of probabilities. Each diagnosis is treated as a working diagnosis that is changed and refined as new information emerges. This provides for stability and a situation of quasi-certainty without which practical procedures will be taken reluctantly and inefficiently. Existing assertions should continue in force until there is compelling evidence to change them. Established medical procedures and protocols are treated as customs or precedents. What has been accepted as customary over a long time is not considered harmful unless there is evidence to the contrary. All medical procedures are considered permissible unless there is evidence to prove their prohibition. Exceptions to this rule are conditions related to the sexual and reproductive functions. All matters related to the sexual function are presumed forbidden unless there is evidence to prove permissibility.
Principle 3: The principle of injury, qaidat al dharar
Medical intervention is justified on the basic principle that injury, if it occurs, should be relieved. An injury should not be relieved by a medical procedure that leads to an injury of the same magnitude as a side effect. In a situation in which the proposed medical intervention has side effects, we follow the principle that prevention of a harm has priority over pursuit of a benefit of equal worth. If the benefit has far more importance and worth than the harm, then the pursuit of the benefit has priority. Physicians sometimes are confronted with medical interventions that are double edged; they have both prohibited and permitted effects. The guidance of the Law is that the prohibited has priority of recognition over the permitted if the two occur together and a choice has to be made. If confronted with 2 medical situations both of which are harmful and there is no way but to choose one of them, the lesser harm is committed. A lesser harm is committed in order to prevent a bigger harm. In the same way, medical interventions with public interest have priority over consideration of the individual interest. The individual may have to sustain a harm in order to protect public interest. In the course of combating communicable diseases, the state cannot infringe the rights of the public unless there is public benefit to be achieved. In many situations, the line between benefit and injury is so fine that salat al istikharat is needed to reach a solution since no empirical methods can be used.
Principle 4: The principle of hardship, qaidat al mashaqqat
Medical interventions that would otherwise be prohibited actions are permitted under the principle of hardship if there is a necessity. Necessity legalizes the prohibited. In the medical setting, a hardship is defined as any condition that will seriously impair physical and mental health if not relieved promptly. Hardship mitigates easing of the shari’at rules and obligations. Committing the otherwise prohibited action should not extend beyond the limits needed to preserve the Purpose of the Law that is the basis for the legalization. Necessity, however, does not permanently abrogate the patient’s rights that must be restored or recompensed in due course; necessity only legalizes temporary violation of rights. The temporary legalization of prohibited medical action ends with the end of the necessity that justified it in the first place. This can be stated in an alternative way that ‘if if the obstacle ends, enforcement of the prohibited resumes’. It is illegal to get out of a difficulty by delegating someone else to undertake a harmful act.
Principle 5: The principle of custom or precedent, qaidat al urf
The standard of medical care is defined by custom. The basic principle is that custom or precedent has legal force. What is considered customary is what is uniform, widespread, and predominant and not rare. The customary must also be old and not a recent phenomenon to give chance for a medical consensus to be formed.
NOTES ON ‘PRIVACY AND CONFIDENTIALITY’
Privacy and confidentiality are often confused. Privacy is the right to make decisions about personal or private matters and blocking access to private information. The patient voluntarily allows the physician access to private information in the trust that it will not be disclosed to others. This confidentiality must be maintained within the confines of the Law even after death of the patient. Confidentiality falls under the teaching of the prophet about keeping secrets.
In routine hospital practice, many persons have access to confidential information but all are enjoined to keep such information confidential. Confidentiality includes medical records of any form.
The patient should not make unnecessary revelation of negative things about himself or herself.
The physician can not disclose confidential information to a third party without the consent of the patient.
Information can be released without the consent of the patient for purposes of medical care, for criminal investigations, and in the public interest.
Release is not justified without patient consent for the following purposes: education, research, medical audit, employment or insurance.
YOUR NOTES
NOTES ON ‘CONSENT AND REFUSAL OF TREATMENT FOR COMPETENT ADULTS’
No medical procedures can be carried out without informed consent of the patient except in cases of legal incompetence. The patient has the purest intentions in decisions in the best interests of his or her life. Others may have bias in their decision-making.
The patient is free to make decisions regarding the choice of physicians and treatments. Consent can be by proxy in the form of the patient delegating decision making or by means of a living will.
The patient must be free and capable of giving informed consent. Informed consent requires disclosure by the physician, understanding by the patient, voluntariness of the decision, legal competence of the patient, explanation of all alternatives, recommendation of the physician on the best course of action, decision by the patient, and authorization by the patient to carry out the procedures. Consent is limited to what was explained to the patient except in an emergency.
Refusal to consent must be an informed refusal (patient understands what he is doing). Refusal to consent by a competent adult even if irrational is conclusive and treatment can only be given by permission of the court. Doubts about consent are resolved in favor of preserving life.
Spouses and family members do not have an automatic right to consent for a competent patient. A spouse cannot overrule the patient’s choice.
Advance directives, proxy informed consent by the family are made for the unconscious terminal patient on withholding or withdrawal of treatment.
Physician assisted suicide, active euthanasia, and voluntary euthanasia are illegal even if the patient consented.
A do not resuscitate order (DNR) by a physician could create legal complications.
The living will has the following advantages: (a) reassuring the patient that terminal care will be carried out as he or she desires (b) providing guidance and legal protection and thus relieving the physicians of the burden of decision making and legal liabilities (c) relieving the family of the mental stress involved in making decisions about terminal care. The disadvantage of a living will is that it may not anticipate all developments of the future thus limiting the options available to the physicians and the family.
The device of the power of attorney can be used instead of the living will or advance directive.
Decision by a proxy can work in two ways: (a) decide what the patient would have decided if able (b) decide in the best interests of the patient.
Informed consent is still required for physicians in special practices such as a ship’s doctor, prison doctor, and doctors in armed forces. Police surgeons may have to carry out examinations on suspects without informed consent.
YOUR NOTES
NOTES ON ‘CONSENT AND REFUSAL OF TREATMENT FOR INCOMPETENT ADULTS and CHILDREN’
Consent for children
Competent children can consent to treatment but cannot refuse treatment. The consent of one parent is sufficient if the other one disagrees. Parental choice takes precedence over the child’s choice. The courts can overrule parents. Life-saving treatment of minors is given even if parents refuse. Parental choice is final in therapeutic or non-therapeutic research on children.
Mental patients
Mental patients cannot consent to treatment, research, or sterilization because of their intellectual incompetence. They are admitted, detained, and treated voluntarily or involuntarily for their own benefit, in emergencies, for purposes of assessment, if they are a danger to themselves, or on a court order. Suicidal patients tend to refuse treatment because they want to die.
The unconscious
For patients in coma, proxy consent by family members can be resorted to. If no family members are available, the physician does what he as a professional thinks is in the best interest of the patient.
There are many disputes about withdrawing nutrition, hydration, and treatment in a persistent vegetative state since the chance of recovery is low. There is no moral difference between withholding and withdrawing futile treatment.
Obstetrics
Labor and delivery are emergencies that require immediate decisions but the woman may not be competent and proxies are used. Forced medical intervention and cesarean section may be ordered in the fetal interest. Birth plans can be treated as an advance directive.
YOUR NOTES
NOTES ON ‘ARTIFICIAL LIFE SUPPORT IN TERMINAL ILLNESS’
Legal definitions of terminal illness and death
Terminal illness is defined as illness from which recovery is not expected. The manner in which death is defined affects the ruling, hukm, about life support.
The following are various definitions of death: (a) traditional: cardio-respiratory arrest (b) brain death. If death is defined in the traditional way, life support cannot be withdrawn at any stage. If the definition of cerebral death is accepted, life support will be removed from persons who still have many life functions (like respiration, circulation, sensation). The question of quality of life is also raised in the definition of life. The assumption is that there must be some quality to human life for it to be worth living. The exact definition of quality is still elusive. There is consensus among most jurists that brain stem death is legal death.
Palliative care
The aim of palliative care is good death which includes: pain control, psychological support, emotional support, and spiritual support. Death can be made a pleasant experience. Palliative care was traditionally in the family but it has recently moved to institutions. Lessons about palliative care can be learned from the terminal illness of the prophet and his companions. The Quran has taught the etiquette of caring for old parents.
Principle of certainty
Since the definition of death and the exact time of its occurrence are still matters of dispute, a major irreversible decision like withdrawing life support cannot be taken with no certainty. Islamic law strictly forbids action based on uncertainty.
The purposes of life and wealth
The purpose of preserving life may contradict the purpose of preserving wealth. Life comes before wealth in order of priorities. This however applies to expenditure on ordinary medical procedures and not heroic ones of doubtful value because that would be waste of wealth that has been condemned.
Legal rulings on initiating and withdrawing life support
The patient's choices about food and medical treatment may contradict the purpose of preserving life. Where life is under immediate threat, the patient's desires may be overridden.
The terminally ill patient, who takes a major risk, should make the final informed decisions after clarification of the medical, legal, and ethical issues by physicians and fuqaha. If the patient is incompetent then resort is made to proxy decision makers.
Self-interest may motivate some members of the family and others with personal interest to hasten the legal death of the terminally ill patient. According to Islamic law, any inheritor who plays any role direct or indirect in the death of an inheritee cannot be an inheritor.
YOUR NOTES
NOTES ON ‘ANTE-NATAL SCREENING AND TREATMENT’
Pre-natal screening
Pre-natal screening seeks to establish a risk profile to enable prevention, early diagnosis and early treatment. It is carried by taking family history, screening of blood, molecular tests, and ultrasound examination. The results of screening could precipitate unethical actions by parents. Informed consent should be obtained before undertaking some forms of screening such as ultrasound examination because the parents may not be ready for adverse results.
Pre-natal genetic screening
Pre-natal genetic screening using amniocentesis or chorionic villous sampling is carried out for women with a known high risk of carrying a genetically-abnormal baby. The risk may be known from adverse outcome in previous pregnancies or family history. Genetic screening should be undertaken with the purpose of knowing the genetic disorder in advance in order to prepare psychologically and financially for birth of an abnormal child. It should not be undertaken with the intention of pregnancy termination if adverse conditions are found.
Pre-natal diagnosis
The reasons for pre-natal diagnosis are: reassurance, desire for termination, preparation for abnormal birth (financially and psychologically), and in-utero treatment for example congenital adrenal hyperplasia. Methods of pre-natal diagnosis are: amniocentesis, chorionic villous sampling, percutaneous umbilical cord sampling, ultrasonography, CT and MRI. Amniocentesis is feasible after week 16 and cells obtained can be cultured. There is a risk that pre-natal diagnosis will be abused to terminate any pregnancy with an abnormality and this is a form of genocide. If it becomes widely available, pre-natal diagnosis could be abused by aborting perfectly normal children who happen not to have certain characteristics preferred by parents. Pre-natal diagnosis should therefore not be offered routinely.
Pre-natal treatment
This includes intrauterine fetal transfusion, intra-uterine surgery, intrauterine drug treatment of cardiac arrhyhthmias, and thyroid disorders.
Legal rulings
The principle of intention is the basic guideline for all issues of pre-natal screening and diagnosis. The procedures are allowed if carried out for purposes of reassurance, psychological or financial preparation for birth of an abnormal baby, or for starting early treatment. They are forbidden if the underlying intention is to commit abortion of abnormal fetuses. Under the principle of injury, the screening or diagnostic methods used must not harm the fetus or the mother.
YOUR NOTES
NOTES ON ‘UNWANTED PREGNANCY’
Ethico-legal issues of unwanted pregnancy
From ‘inevitable’ to ‘unwanted pregnancy’: The dissociation between sexual activity and pregnancy is recent in human history being attributed to contraceptive technology. Humans from time immemorial knew that pregnancy was an inevitable consequence of coitus. They understood that sexual pleasure came with the responsibility of pregnancy and child rearing. Child bearing and child rearing were not only burdens but were also desired pleasures of life. The issue of ‘unplanned’, ‘unintended’, or ‘unwanted’ pregnancy did not arise. Those who for religious or other purposes did not want pregnancy or child rearing opted for abstinence from sex and lived a life of hermits as monks and nuns. Eunuchs did not engage in sexual activity because their libido was destroyed by surgical castration. All human societies have had some forms of simple and largely ineffective contraception but could accept the pregnancy if it occurred. With availability of more effective contraceptive technology, it became possible to have sexual enjoyment without thinking about the consequence of pregnancy. However if contraception failed resulting in an ‘unwanted’ pregnancy, the fetus was aborted or the infant was given up for adoption. Abortion as a solution to contraceptive failure encourages sexual promiscuity by using contraceptives in the knowledge that if contraception fails legal abortion was available.
‘Unwanted pregnancy’ is unnatural: The purposes of the human reproductive function can be considered at the individual, family, community, and human levels. Reproduction at an individual level fulfils a deeply felt human desire for self-perpetuation. Parents are proud of their children[1] and naturally desire to have many[2]. Children help cement and strengthen the marital bond. At the community level, the Prophet Muhammad (Peace be upon him) encouraged Muslims to have as many offspring as possible to give glory to the community so that it may be the largest of communities. When righteous people have many children and bring them up to be righteous, they will be spreading light and truth in the next generation in a very effective demographic strategy. At the level of the human species, reproduction is necessary to ensure survival of the human race. Therefore ‘unwanted pregnancy’ is unnatural and runs contrary to the objective of human reproduction mentioned above especially the human survival instinct. It is against basic human nature. It occurs only in socially and morally adverse conditions.
‘Unwanted pregnancy’ and purposes of the Law: The Law was revealed to achieve 5 purposes: ddiin, life, progeny, intellect, and wealth. Protection of ddiin ensures a basic moral order. Protection of life ensures respect for life and maintenance of good health. Protection of progeny ensures reproduction and biological survival of the human species. Protection of the mind ensures good mental health. Protection of wealth ensures property rights. All consequences of ‘unwanted pregnancy’ violate the purposes of the Law. Pregnancy outside the bond of marriage violates the purpose of morality. Abortion, child abuse and neglect violate the purpose of life. A general principle of the Law is that life is sacred. ‘Unwanted pregnancy’ and ‘unwanted birth’ violate the purpose of progeny. Mental consequences for children and parents involved in ‘unwanted pregnancy’ violate the purpose of intellect. Adverse economic consequences on the mothers and children involved in ‘unwanted pregnancy’ violate the purpose of preserving wealth.
Principles of the law and ‘unwanted pregnancy’: The five major principles are: Intention, certainty, injury, difficulty, and custom or precedent. The principle of intention applies to ‘unwanted pregnancy’ that results from sexual promiscuity whose intention was enjoyment without responsibility. Escaping the consequences of irresponsible coitus by abortion violates the legal principle that the end does not justify the means. Under the principle of certainty, the original state is that of wanting to procreate and there are doubts whether ‘unwanted pregnancy’ is voluntary. My opinion is that the social stresses of modern life force persons to hate pregnancy and later regret the actions of abortion or giving up for adoption. Under the principle of injury we cannot remove the harm of ‘unwanted pregnancy’ by creating an even bigger harm of abortion. Under the principle of necessity, ‘unwanted pregnancy’ is not a dharurat that legalizes taking life. ‘Unwanted pregnancy’ violates the customary desire for children that is found in all natural human societies.
Determinants and causes of ‘unwanted pregnancy’
Hedonistic lifestyle: Islam is a religion of the middle. Muslims are encouraged to enjoy the good things of the world[3]. They are however warned against transgression[4]. Humans are free to enjoy the good life of the permitted but must maintain balance and equilibrium. A hedonistic lifestyle is a failing lifestyle seeking only passionate pleasure manifesting as addiction to bad habits and sins, social incompetence, laziness in basic responsibilities in the family and society, lack of seriousness and neglect of duties. The ultimate form of failure is loss of self-control and ending up being under the control of the low human desires. This lifestyle is associated with addiction to alcohol and drugs which opens the door to evil. In such a lifestyle, sexual transgressions will be committed without regard to consequent social responsibilities and a situation of ‘unwanted pregnancy’ arises.
Addiction to drugs: Sexual activity under intoxication is a cause of ‘unwanted pregnancy’. Khamr is defined in the Law as any substance that causes intoxication[5]. Khamr violates the purpose of the law relating to protection of human intellect. Every intoxicant is prohibited[6]. What intoxicates in large amounts is haram in small amounts. Thus the term khamr covers alcohol, illicit drugs, and all other psychoactive substances.
Sexual transgression: Adultery is the commonest sexual perversion and is the commonest cause of ‘unwanted pregnancy’. It is preceded and facilitated by pornography, absence of ghiira (concern for chastity), violation of the privacy of the home, trans-sexual dressing and behavior, free mixing of both genders, seclusion of unrelated males and females in secrecy, failure to lower the gaze, indecent and sexually provocative exposure, exposure of nakedness, and violation of the regulations of decent dress. Abnormal marital arrangements (temporary marriage, marriage with intention to divorce, and legally invalid marriage) can result in illegal sexual intercourse and ‘unwanted pregnancy’.
Fear of poverty: Shaitan uses fear of poverty to frighten and control people[7]. Humans fear poverty[8]. If childbirth is perceived as a cause of future poverty, the pregnancy can be unwanted. Poverty is relative and is a perception. An individual with a lot of material assets may feel poorer than who has less. ‘Unwanted pregnancy’ is felt as a problem more among the well to do than the poor.
Egoistic greed: It is a paradox that both extremes of the scale of wealth are causes of ‘unwanted pregnancy’ because of the materialistic greed of fearing sharing with the offspring. Poverty may push indigent parents to hate pregnancy. The wealthy want to enjoy their hedonistic life style without sharing their time and wealth with children.
Low female status: When women are respected, they will be proud of their femininity and will value their reproductive roles and will want pregnancy if they are in good health. Identifying women with low status is a cause of ‘unwanted pregnancy’. Women in industrial society look at pregnancy as an obstacle to their ability to compete with men at the workplace. Prejudice against females has existed in the past and continues to exist today. The status of women was very bad in pre-Islamic Arabia[9]. Females were despised. There was preference for male births and hatred for females[10]. Parents were sad on the birth of a daughter[11]. Infant daughters were considered a blemish[12] and were buried alive[13]. Women were inherited as goods[14] and were denied the good things of life[15]. Some Christian groups blame women for the original sin of Adam and Hawa on the basis that it was Hawa who persuaded Adam to eat the fruit. The contemporary secular society treats the woman's body as a sexual object to be exploited in the commercial advertisement and entertainment industries. The woman is required to behave, act, work, and be treated like a man. This will in the end remove the social legal protection for the woman that is necessary because of her different biology and her functions as a mother and a wife. This violates the obvious principle that treating the dissimilar in an equal way is a gross injustice.
Gender discrimination: A pregnancy may be undesired in societies that systematically practice gender preference and gender discrimination. Often parents prefer males. Pregnancy with a female is therefore considered an ‘unwanted pregnancy’.
Sexual crimes: Pregnancy conceived as a result of illegal sexual intercourse, rape, and incest may be undesirable and the parents may consider feticide or infanticide as a way out of social embarrassment or as an escape from physical, psychological, and financial responsibilities of child rearing.
Maternal or fetal disease: A pregnancy may be undesired because of genetic diseases of the fetus as well as serious disease in the mother or the fetus.
Prevention of ‘unwanted pregnancy’
Sexual hygiene: Expression of human sexuality is as normal as the desire for food or shelter. Allah created sexual desire[16] as a powerful instinct that can overwhelm weak humans. The Law forbids complete rejection and suppression of the sexual instinct[17]. It has regulations for proper conduct of sexual relations by decreasing sexual stimulation or preventing getting near adultery[18]. Under normal circumstances, it is the family and the community that regulate sexual behavior. The state intervenes when sexual promiscuity becomes public and severe deterrent measures become necessary. Among social measures for regulating sexual expression are: fasting, puasa[19], protection of chastity[20], intolerance of sexual misbehavior in the family[21], not broadcasting sexual misbehavior[22], sexual self restraint by men and women[23], covering nakedness[24], lowering the gaze, seriousness in male-female communication in an atmosphere of solemnity, prohibition of seclusion of unrelated males and females[25], prohibition of free male-female mixing, prohibition of provocative sexual display[26], and respecting the privacy of the home such that strangers cannot enter the home without permission[27]. Both genders must have modesty. Modesty is the morality of Islam[28], a characteristic attribute of all messengers[29], an inner spiritual protective device that makes a person shun sin, and is part of faith[30]. The Qur’an described the modesty of the daughters of Shuaib in their meeting with Musa (PBUH)[31].
Early marriage: Delay of marriage for economic or other reasons encourages pre-marital sex that often results in ‘unwanted pregnancy’. Marriage is the only institution that allows full expression of human sexuality in a responsible way. It is, according to the Qur'an, a deep and serious relationship[32]. The spouses give good company to one another. Islam encourages marriage for all[33]. Marriage is protection against sexual immorality[34]. If a man sees an attractive woman he should go to his wife immediately because that protects him from potential sin[35]. Desire for sexual satisfaction is a major reason for marriage. It is considered offensive by the Law for a person who has no sexual desire at all to get married. A person who has desire for sexual satisfaction but has impediments like poverty or physical disability (disease, impotence) should control the desire by fasting. It is forbidden for a spouse to withhold sexual favors without a valid reason[36] because that may lead to sexual transgression. Marriage is a permanent institution, and cannot be a temporary sexual relationship. The following temporary sexual relations are forbidden by the Law: temporary marriage[37]; prostitution[38]; adultery between consenting adults, and marriage with the hidden intention to divorce after a time. Pregnancy out of wedlock following divorce is usually an ‘unwanted pregnancy’.
Maintenance of marriage: The Law has prescribed provisions for successful marriage starting from the marriage contract, description of rights and obligations, and mutual good treatment. Desirable characteristics in a spouse are religion, beauty, pedigree, lineage, wealth, social compatibility, and professional status. No person is to be married without his or her free consent irrespective of gender, age, or previous marital status. Conditions in the marriage contract have to be respected. Examples are stipulations about monogamy and stipulations about country of residence. A balance must exist between mutual rights and obligations. Spouses are a source of comfort for each other. Mutual kind and tolerant treatment between the spouses is needed in marriage. Ill-treatment of the spouse is forbidden. Divorce is permitted but is hated by Allah. Mutual good treatment, kindness, and tolerance prevent divorce. It is offensive for the husband to divorce for no reason. It is also offensive for the wife to ask for divorce for no reason. Divorce is not a solution to marital problems but an escape. It creates more problems than it seeks to evade. It is resorted to when all avenues to marital reconciliation have failed and it is feared that continuation of the marital relation will lead to acts of disobedience by either spouse.
Contraception: Use of contraception by a sexually active couple that has a valid reason for delaying child birth prevents ‘unwanted pregnancy’. There is a basic permissibility of contraception as is clear from the hadith of the prophet on coitus interruptus[39]. It is however considered offensive[40] and is prohibited without the wife’s permission[41]. Since child-bearing is one of the purposes of marriage, any decisions on contraception require mutual agreement between the two spouses otherwise one can claim denial of parenthood rights in marriage. In cases in which contraception is a necessity, dharuurat, for preserving the life of the mother, the agreement of the husband is not required but he has the option of recourse to divorce. Choice of the method of contraception must be based on the purposes and principles of the Law. It should not encourage immorality or in any way be conducive to spread of evil in violation of the purpose of preserving ddiin. It should not be harmful to the life and health of any of the parents under the purpose of preserving life. It should also not destroy life of the zygote or fetus because it is life preserved under the purpose of preserving life. It should not be a cause of stress that can lead to severe psychological disturbance in violation of the purpose of preservation of intellect. It should not permanent and irreversible because it would violate the principle of preservation of progeny.
Prohibition of zina: The Law prescribes several measures to prevent adultery: prohibition of seclusion of a man with a marriageable female, prohibition of looking with desire, prohibition of looking at nakedness of another person, and prohibition of display of beauty and ornamentation. The Law of adultery remains a final deterrent in situations in which immorality becomes so widespread that it is done openly in the public. The primary objective of the Law of adultery is to protect public morals from the commitment of illegal sexual activity in public where everybody including children can see the crime. Its strict conditions on evidence needed for conviction make it impossible to convict mutually consenting adults engaging in discreet illegal sexual activity. Islam relies on the family, the community, and tarbiyat to prevent such situations.
Severe punishment for rape: Rape is a severe crime that involves violence and violation of honor and modesty. The death penalty may be applied on conviction.
YOUR NOTES
NOTES ON ‘ABORTION’
Background
Abortion is the commonest form of feticide. It was practiced in ancient Egypt and Greece. Criminal abortion was common in industrial Europe and America in the early 20th century. In the second half of the century abortion was legalized and the number of operations performed increased. Forced abortion is still practiced in some countries.
Feticide is most common by abortion in the first and second trimesters. Examples of abortive methods include the following: abortion by menstrual extraction/regulation by suction of the uterus a few days after a missed period, abortion by dilatation and curettage for more advanced pregnancy usually after the 12th week, and the morning-after pill used to prevent implantation. Several ethical issues arise in abortion and all center on the definition of the start of life.
Legal rulings on abortion
Prohibition of abortion / feticide: All lives have equal worth whether in uteri or in terminal illness. Taking the life of any one person without legal justification is like killing the whole human race. According to the Law, abortion is criminal homicide because life is considered to start at conception. Islam forbids any form of harm to others either by spilling blood[42] or other forms of physical harm such as beating. Killing a human without a valid reason is forbidden[43] and homicide is a major sin being among the 7 worst sins[44]. The Law does not allow abortion of a fetus known to have congenital deformities. Also illegal, is abortion prompted by poverty, rape, incest, or adultery. The Law prescribes severe punitive measures for causing abortion of a fetus. The physician or any other accessory to abortion is guilty of the offense of causing abortion even if either or both parents consented to the procedures.
Abortion for severe maternal illness: The Law has allowed abortion in situations in which the life of the mother is threatened by continuation of the pregnancy. This is not a situation of preferring or valuing one life over another. If the pregnancy is allowed to continue, the life of the mother is endangered. Death of the mother also means death of the fetus because of the close dependence of the fetus on the mother. The actual choice is between saving one life and losing two lives. The Shari’ at guideline is to choose the lesser of two evils, abortion of the fetus instead or losing both mother and fetus. In all forms of abortion whether legal or illegal, the aborted fetus must be treated with respect. It must be washed, shrouded, and buried properly.
Legal punishments for abortion: The Law prescribes severe punitive measures for causing abortion of a fetus. Diya is paid if the fetus comes out with signs of life and dies thereafter. Ghurrat, which is less than diya, is paid if the fetus comes out dead. The physician or any other accessory to abortion is guilty of the offense of causing abortion even if either or both parents consented to the procedures. The Law is not clear in a situation in which the mother caused the abortion either by medical or surgical means. The Law is also not explicit about a situation in which both parents agree to the abortion.
Ethico-legal issues of abortion
The start of life argument: My personal view is that abortion is criminal homicide because life is considered to start at conception. Some jurists have legalized abortion before the stage of ensoulment (either 40 days or 120 days depending on hadith interpretation). They reason that there is no human being before ensoulment. This is misunderstanding the import of the hadith. There is nothing in the hadith to say that life starts with ensoulment. Ensoulment represents an advanced stage of human life and not its start. Even if the ensoulment argument is accepted, early abortion is still a crime because it destroys a potential life. Some jurists have erroneously equated abortion with coitus interruptus and argued for its legalization. There is no basis in the Law for such a position because in abortion there is destruction of life whereas in ‘azl there is no life yet since life starts with conception. The proper comparison is to equate abortion with infanticide that was condemned by the Qur’an.
.
Abortion and sexual immorality: Besides considerations of taking life in abortion, abortion is immoral because it encourages sexual immorality and promiscuity. With easy accessibility and affordability of abortion services, people can have illegal sexual intercourse without fear of pregnancy and the legal responsibilities of parenthood.
Abortion and societal violence: Legalizing abortion encourages violence in society by disrespect to human life and making it of little or no value. Society then develops moral tolerance to violence and can readily commit acts of violence against an ‘unwanted pregnancy’ or any other innocent human.
Abortion and new medical technology: New medical technologies that need fetal tissues for research and therapeutic purposes can also lead to increase in abortion. Fetal tissue is used to treat bone marrow disease and Parkinson’s disease. Use of fetal tissue for research and medical treatment may encourage commercial exploitation if women get paid to become pregnant and abort in order to get fetal tissue. Research on fetal tissue that is aborted but still has signs of life raises serious ethical issues.
YOUR NOTES
NOTES ON ‘ORGAN DONATION’
Introduction
The first organs involved in transplantations were the skin, the bone, the teeth, and the cornea. Later kidney, heart, lung, and liver transplants were achieved. Glandular and neurohumoral organs will be transplantable in the future. Transplantation decisions are a balance between risks and benefits. Ethical and legal problems of transplantation are temporary, they will disappear with the use of xenografts, artificial organs, and cloned organs.
Legal rulings about transplantation
Use of textual evidence has limited success because the issues involved in transplantation are new and were not dealt with before. General Purposes of the Law, maqasid al sharia, and the General Principles of Fiqh, al qawaid al fiqhiyyat are the more appropriate tools. The main guide about transplantation is the purpose of maintaining life of the donor and the recipient. The evidence for transplantation from a human donor, living or dead, is by analogy to permission to eat flesh of a dead person in case of dharuurat.
Under the principle of hardship, necessity and hardship legalize what would otherwise be objectionable or risky. Lowering donor risk has precedence over benefit to the recipient and the complications and side-effects to the recipient must be of a lesser harm than the original disease.
Under the principle of injury, transplantation relieves an injury to the body in as far as is possible but its complications and side-effects should be of lesser degree than the original injury.
Abuse of transplantation by abducting or assassinating people for their organs could lead to complete prohibition under the principles of dominance of public over individual interest, as prevention of harm has priority over getting a benefit and pre-empting evil.
Under the principle of custom, brain death fulfills the criteria of being a widespread, uniform, and predominant customary definition of death that is considered a valid custom.
Selling organs could open the door to criminal commercial exploitation and may be forbidden under the purpose of maintaining life, the principle of preventing injury, the principle of closing the door to evil and the principle of motive. Protecting innocent people from criminal exploitation is in the public interest and has priority over the health interest of the organ recipient. Principle of motive will have to be invoked to forbid transplantation altogether if it is abused and commercialized for individual benefit because the purpose will no longer be noble but selfish. Matters are to be judged by the underlying motive and not the outward appearance.
Other considerations in transplantation are free informed consent, respect for the dignity of the human ownership and sale of organs, taharat of the organs, charity, and giving priorities to the interest of others.
The following are allowed: use of animal organs, use of artificial organs, auto-transplantation, and transplantation from a living donor.
Organs from prisoners condemned to death can be used provided there is dharuurat.
Indications, side effects, and complications
The indications of transplantation are irreversible organ failure and sub-optimal organ function. Transplantation on the basis of preventive maintenance of organs in good condition is not allowed. The associated side effects and complications of immune suppression, infection, neoplasia, graft rejection, and drug toxicity are treated under 2 principles of the Law: hardship, and injury.
Procuring and harvesting organs
The demand for organs is more than the supply. Human organs could be obtained either as voluntary gifts or voluntary sale. The donor may be living or may be dead. Living donors could be free persons or prisoners condemned to death. Harvesting organs from an individual without his or her free consent is not allowed by the law.
YOUR NOTES
NOTES ON ‘DRUG ADDICTION’
Definition of the addiction problem
Addiction can be to alcohol, tobacco, or psycho-active substances. It may also be addiction to habits, passions, and sins such as sex, sports, fame, food, or gambling. Other forms of addiction are to power, respect, and money.
Dependence and addiction
Drug dependence is of two types: physical dependence and psychological dependence. Addiction is inability to control use of a drug or enslavement to a habit (good or bad) through loss of self-control. Some forms of addiction are innately bad such as addiction to nicotine, addiction to drugs (alcohol, opiates, sedatives, marijuana, amphetamine, cocaine, and caffeine), addiction to gambling, and addiction to passions. Some forms of addiction start as habits and practices that are good innately but become bad due to excesses. This includes sports and food. The addiction process goes through various stages. It starts as a habit that becomes psychological dependence. It finally ends up as physiological dependence. Addiction has severe consequences. Addiction to intoxicants is prohibited because it nullifies the purpose of preserving intellect. It leads to poor health, psychiatric complications, crime, and violation of ddiin.
Rulings about khamr
Khamr is defined in the Law as any substance that causes intoxication. Alcohol, tobacco, and other psychoactive drugs are not food but are khamr because they change or impair the mind. With an impaired mind and loss of control a human becomes an animal. Any thing that causes clouding of the mind is called khamr. Every intoxicant is prohibited. What intoxicates in large amounts is haram in small amounts. The term alcohol refers to one type of khamr. Khamr is the key to sins and evils. Taking khamr is likened to worshipping idols. The recompense of a drinker of khamr is hell. Iman temporarily disappears from a person at the moment of taking khamr. The salat of a user of khamr is not accepted. Khamr is not a cure but is a disease. Wide-spread drinking khamr is an indicator of the coming of the Last Day. Khamr has harms and benefits. The harms are predominant. The benefits are few and temporary. The harm of khamr lies in its effects on health and its associated sins. Some people call khamr by another name in order to make it halaal. The Law has several measures to control addiction to khamr. Manufacture, sale, and distribution of khamr are prohibited. Raw materials for making khamr should not be sold to a potential manufacturer.
Non-alcoholic drug addiction
Nicotine addiction is a type of drug addiction. Addiction to narcotics & sedatives starts as normal pharmacological use of the drugs and progresses to harmful addiction. Illicit drugs with no pharmacological benefit are addictive.
Prevention and treatment of drug abuse
The root of addiction is passion. Measures should be taken to stop antecedents to addiction on the basis that what to leads to haram is haram. While preventing addiction we should not forget to treat the victims of addiction. Internal measures of addiction control are strengthening iman, taqwa, ibadat, and dhikr. External measures of addiction control include education, good use of spare time, and good company. Rehabilitation of addicts starts with telling them to repent. If they refuse they should be isolated socially. Cognitive therapy is used to sure the addict understands the impact of addiction on health, wealth, and family life.
YOUR NOTES
NOTES ON ‘SUICIDE’
Abstract
Suicide can be direct, deliberate, and violent relating to major depression, or can be slow and indirect relating to risky lifestyles. Islam prescribes severe legal and moral sanctions for suicide. Direct suicide related to psychogenic factors can be prevented by cognitive understanding of basic Islamic principles relating to life and belief in pre-destination. Life belongs to Allah and cannot be taken by a human. Belief in pre-destination enables a believer to understand and positively cope with adverse life experiences thus preventing resort to suicide.
Two forms of suicide
There are two ways of taking one’s life: direct and indirect. The direct is usually called suicide and involves deliberate violent measures of life termination. The underlying motivating factors may be pain, depression, or loss of hope. Some cases of suicide may be due to mental disease or temporary loss of sanity due to use of psychoactive substances. The indirect form of taking life results from pursuit of unhealthy life-styles that endanger life like cigarette smoking, use of alcohol, careless driving, refusal of immunization, neglect of medical care, and poor nutrition. Death is not as violent and does not occur immediately. The number of people who die from such slow suicide is far more than those who take violent measures to terminate their lives. Our discussion will be confined to violent suicide as a result of adverse life experiences.
Legal rulings on suicide
Suicide is condemned. Humans who attempt suicide commit a major crime of trying to arrogate to themselves power and privileges that are in the preserve of Allah alone. The Qur’an forbids self-destruction[45]. Anybody who kills himself with a metal weapon will be punished with the same weapon in the hereafter[46] and will be denied entry into paradise[47]. The funeral prayer is not offered for a deceased who killed himself[48]. The authorities may impose a disciplinary punishment for a person who attempts suicide and fails.
Prevention of suicide by cognitive understanding
Ownership of life: Understanding that life belongs to Allah will dissuade a person from attempting suicide. Life belongs to Allah and not the human. Allah gives and takes away life[49]. Humans are only temporary custodians of life enjoined to take good care of it. Humans have no control over death. Death is in Allah’s hands[50]. Humans therefore have no right to destroy their life or that of any other human. Doing so is one of the greatest transgressions.
Sanctity of life: Respecting the sanctity of life will dissuade a person from suicide. The sanctity of life is guaranteed by the Qur’an[51]. The life of each single individual whatever be his or her age, social status or state of health is important and is as equally important as the life of any other human[52]. Protection of life is the second most important purpose of the shari’at coming second only to the protection of the diin. It has priority over any other mundane consideration.
Prevention of suicide by belief in pre-destination
Belief in pre-determination: Belief in pre-determination can enable people to cope with adverse life events without resorting to suicide. They understand that all events are part of a divine plan. They believe that everything is fixed in advance[53] [54] and all events are under Allah's pre-determination[55]. They believe that pre-determination covers both the good and the bad[56]. They know that all human affairs are in the hands of Allah[57] and that the human should therefore seek support from Allah and surrender all affairs to Him[58].
Benefits of belief in pre-determination: Belief in pre-determination has many benefits that make human life happier and easier. It prevents a person from thinking of suicide in case of adverse life experiences. The first benefit is that the human who believes in pre-determination will be rich in his heart because he will know that what he has is what Allah gave him and will not hanker over what he does not have[59]. The second benefit is to avoid excessive joy and sadness[60]. This is because the believer knows that all is from Allah and will praise Allah for either the good or the bad. He also knows that Allah gives and takes away, and that life is cyclical. Adversity may be followed by prosperity and vice versa.
Meaning of qadar and qadha: Qadar is pre-event and refers to pre-determination or pre-fixing of events. Qadha is post event and refers to the empirical or practical occurrence of what was pre-determined by qadar. There are 2 stages in the occurrence of any event. In the stage of qadar Allah pre-determines and knows what will happen but the human does not. The human is therefore enjoined to struggle as best as he can to achieve a desired objective which may be wealth, health, or progeny. In his ignorance of pre-determination, a human cannot stop his struggles arguing that qadar is fixed. However after the event has occurred, the believer is now in the stage of qadha and has to accept what happened and knows that it is with Allah’s permission[61] and exercises patience[62].
Limited human knowledge: In practice the limited knowledge of humans does not enable them to tell the end of events. What may appear an adverse life event may turn out to be good eventually. Humans cannot know for sure what is good and what is bad for them. They have to believe that all is from Allah[63] and that good and bad events are both a test for humans[64]. A believer will praise Allah (al hamd li al llaah) equally for both ‘good’ and ‘bad’ events or experiences because he knows they are all part of pre-destination. The terms ‘good’ and ‘bad’ in human experience and knowledge are relative. What may appear to be good may turn out to be bad[65]. What may appear to be bad may turn out to be good[66]. Humans can not see the whole picture. They may see some aspects of the whole picture and judge them to be good or bad. If they had knowledge of the whole picture and the correct context they would have interpreted the observed events or phenomena differently.
Conclusion
Islamic religious teachings can enable a person to understand and cope with adverse life events thus preventing resort to suicide.
YOUR NOTES
NOTES ON ‘GOOD DOCTOR ETIQUETTE (adab al tabiib) WITH PATIENTS AND THEIR FAMILIES’
Bed-side visits
The physician-patient interaction is both professional and social. The bedside visit fulfills the brotherhood obligation of visiting the sick. The human relationship with the patient comes before the professional technical relationship. It involves reassurance, psychological and social support, show of fraternal love, and sharing. A psychologically satisfied patient is more likely to be cooperative in taking medication, eating, or drinking. The following are recommended during a visit: greeting the patient, dua for the patient, good encouraging words, asking about the patient’s feelings, doing good/pleasing things for the patient, making the patient happy, and encouraging the patient to be patient, discouraging the patient from wishing for death, nasiihat for the patient, and reminding the patient about dhikr. Caregivers should seek permission, idhn, before getting to the patient. They should not engage in secret conversations that do not involve the patient.
Etiquette of the care-giver
The caregiver should respect the rights of the patient regarding advance directives on treatment, privacy, access to information, informed consent, and protection from nosocomial infections. Caregivers must be clean and dress appropriately to look serious, organized and disciplined. They must be cheerful, lenient, merciful, and kind. They must enjoin the good, have good thoughts about the patients and avoid evil or obscene words. They must observe the rules of lowering the gaze, and seclusion. Caregivers must have an attitude of humbleness. They cannot be emotionally-detached in the mistaken impression that they are being professional. They must be loving and empathetic and show mercifulness but the emotional involvement must not go to the extreme of being so engrossed that rational professional judgment is impaired. They must make dua for the patients because qadar can only be changed by dua. They can make ruqya for the patients by reciting the two mu’awadhatain or any other verses of the Qur’an.
Caregivers must seek permission when approaching or examining patients. Medical care must be professional, competent, and considerate. Medical decisions should consider the balance of benefits and risks. The general position of the Law is to give priority to minimizing risk over maximizing benefit. Any procedures carried out must be explained very well to the patient in advance. The caregiver must never promise cure or improvement. Every action of the caregiver must be preceded by basmalah. Everything should be predicated with the formula inshallah, if Allah wishes. The caregivers must listen to the felt needs and problems of the patients. They should ask about both medical and non-medical problems. Supportive care such as nursing care, cleanliness, physical comfort, nutrition, treatment of fever and pain are as important as the medical procedures themselves and are all what can be offered in terminal illness. Caregivers must reassure the patients not to give up hope. Measures should be taken to prevent nosocomial infections.
Etiquette of interaction between genders
Both the caregiver and patient must cover awrat as much as possible. However, the rules of covering are relaxed because of the necessity, dharurat, of medical examination and treatment. The benefit of medical care takes precedence over preventing the harm inherent in uncovering awrat. When it is necessary to uncover awrat, no more than what is absolutely necessary should be uncovered. To avoid any doubts, patients of the opposite gender should be examined and treated in the presence of others of the same gender. The caregivers should be sensitive to the psychological stress of patients, including children, when their awrat is uncovered. They should seek permission from the patient before they uncover their awrat. Caregivers who have never been patients may not realize the depth of the embarrassment of being naked in front of others.
Medical co-education involves intense interaction between genders: Teacher-student, student-student, and teacher-teacher. Interacting with colleagues of the opposite gender raises special problems: norms of dress, speaking, and general conduct; class-room etiquette; social interaction; laboratory experiments on fellow students; learning clinical skills by examining other students; and the operation theatre. Medical personnel of opposite genders should wear gender-specific garments during surgical operations because Islam frowns on any attempt to look like the opposite gender. Shari’at guidelines on interaction with patients of the opposite gender should be followed. Taking history, physical examination, diagnostic procedures, and operations should preferably be by a physician of the same gender. In conditions of necessity a physician of the opposite gender can be used and may have to look at the ‘awrat or touch a patient. The conditions that are accepted as constituting dharuurat are: skills and availability. The preference between a Muslim of opposite gender vs non-Muslim of same gender depends on the local situation.
Dealing with the family
Visits by the family fulfill the social obligation of joining the kindred and should be encouraged. The family are honored guests of the hospital with all the shari’at rights of a guest. The caregiver must provide psychological support to family because they are also victims of the illness because they are anxious and worried. They need reassurance about the condition of the patient within the limits allowed by the rules of confidentiality. The family can be involved in some aspects of supportive care so that they feel they are helping and are involved. They should however not be allowed to interrupt medical procedures. Caregivers must be careful not to be involved in family conflicts that arise from the stresses of illness.
YOUR NOTES
NOTES ON ‘GOOD DOCTOR ETIQUETTE (adab al tabiib) IN THE HEALTH CARE TEAM’
Etiquette of teaching & learning in the health care team
The hospital health care team is complex and multi-disciplinary with complementary and inter-dependent roles. Members have dual functions of teaching and delivering health care. Most teaching is passive learning of attitudes, skills, and facts by observation. Teachers must be humble. They must make the learning process easy and interesting. Their actions, attitudes, and words can be emulated. They should have appropriate emotional expression, encourage student questions, repeat to ensure understanding, and not hide knowledge. The student should respect the teacher for the knowledge they have. They should listen quietly and respectfully, teach one another, ask questions to clarify, and take notes for understanding and retention. They should stay around in the hospital and with their teachers all the time to maximize learning.
Etiquette of care delivery in the health care team
Each member of the team carries personal responsibility with leaders carrying more responsibility. Leaders must be obeyed except in illegal acts, corruption, or oppression. Rufaidah, the first Muslim nurse, was a good model of etiquette. She was kind, empathetic, a capable leader and organizer, clinically competent, and a trainer of others. Besides clinical activities, she was a public health nurse and a social worker assisting all in need. The human touch is unfortunately being forgotten in modern medicine as the balance is increasingly tilted in favor of technology.
The health care team: general group dynamics
Basic duties of brotherhood and best of manners must be observed. Encouraged are positive behaviors (mutual love, empathy, caring for one another; leniency, generosity, patience, modesty, a cheerful disposition, calling others by their favorite names, recognizing the rights of the older members, and self control in anger. Discouraged are negative attributes (harshness in speech, rumor mongering, excessive praise, mutual jealousy, turning away from other for more than 3 days, and spying on the privacy of others).
The health care team: special group dynamics
Gender-specific identity should be maintained in dress, walking, and speaking. Free mixing of the genders is forbidden but professional contact within the limits of necessity is allowed. Patients of the opposite gender are examined in the presence of a chaperone. The gaze should be lowered. Modest covering must be observed. Display of adornments that enhance natural beauty must be minimized.
YOUR NOTES
NOTES ON ‘DOCTOR MISCONDUCT’
Abuse of professional privileges
Un-ethical research on patients is abuse of professional privileges. Abuse of treatment privileges consists of unnecessary treatment, iatrogenic infection, and allowing or abetting an unlicensed practitioner. Abuse of prescription privileges is manufacturing, possessing, and supplying a controlled drug without a license, prescription of controlled drugs not following procedures, diverting or giving away controlled substances, dispensing harmful drugs, sale of poisons, and writing prescriptions using secret formulas.
Financial fraud may be pharmacy fraud (billing for medicine not supplied), billing fraud (billing for services not performed), equipment fraud (using equipment that is really not needed or using equipment of poorer quality), or supplies fraud. It is also illegal to get financial advantage from prescriptions to be filled by pharmacies owned by the physician. Kick-backs are unethical and illegal. False or inaccurate documentation is a breach of the law and includes issuing a false medical certificate of illness, false death certification, and false injury reports.
Court action could be brought against a physician for the following crimes against the person: manslaughter (voluntary & involuntary); euthanasia (active and passive): battery for forced feeding or treatment; criminal liability for patient death; induced non-therapeutic abortion; iatrogenic death; abusive therapy involving torture; intimate therapy; rape and child molestation; and sexual advances to patients or sexual involvement. The physician-patient relation requires that the physician keeps all information about the patient confidential. Breach of confidentiality can be done only in the following situations: court order, statutory duty to report notifiable diseases, statutory duty to report drug use, abortions, births, deaths, accidents at work, disclosure to relatives in the interest of the patient, disclosure in the public interest, sharing information with other health professionals, disclosure for the purposes of teaching and research, and disclosure for the purposes of health management.
Private mis-conduct derogatory to reputation, kharq al muru’at
Breach of trust is a cause for censure because a physician must be a respected and trusted member of the community. Sexual misbehavior such as zina and liwaat are condemned. Fraudulent procurement of a medical license, sale of medical licenses, and covering an unqualified practitioner indicate bad character. Physicians can abuse their position by abuse of trust (eg harmful or inappropriate personal and sexual relations with patients and their families), abuse of confidence (eg disclosure of secrets), abuse of power/influence (eg undue influence on patients for personal gain), and conflict of interest (when the physician puts personal selfish interests before the interests of the patient). Other forms of misconduct are in-humane behavior such as participation in torture or cruel punishment, abuse of alcohol and drugs, behavior unbecoming, indecent behavior, violence, and conviction for a felony.
Public professional mis-conduct
Physicians in private practice must adopt good business practices. Halal transactions are praised[67]. An honest businessman is held in high regard[68]. Leniency in transactions is encouraged[69]. Full disclosure is needed in any transaction[70]. Measures and scales must be fulfilled[71]. Bad business practices are condemned. There is no blessing in immoral earnings[72]. Selling over another’s sale is prohibited[73]. Cheating is condemned[74]. Also condemned are financial fraud including criminal breach of trust, riba on bills, fee splitting, and bribery[75]. Sale of goodwill of a practice is allowed. Also allowed is agreement among partners that they will not set up a rival practice on leaving the partnership. Entering into a compact with pharmacists or laboratories involving fee splitting and unnecessary referrals is not moral. Treatment regimens can not be patented as an intellectual property. Physicians are entitled to a reasonable fee[76]. Medical fees cannot be fixed by government because the Prophet refused to fix prices[77].
YOUR NOTES
NOTES ON ‘MEDICAL MALPRACTICE / NEGLIGENCE’
Description and definitions
Malpractice is failure to fulfill the duties of the trust put on the physician. The term malpractice includes the legal concept of medical negligence. Negligence is breach of duty owed by the physician to the patient resulting in damage or injury. Negligence is defined according to the customary standards of care that are established by the profession.
There are 4 elements in medical negligence: discharge of duty, breach of duty, injury, and burden of proof. Medical negligence may be breach of duty resulting in causation of injury which calls for damages.
Negligence may also arise as battery which is injury due to intentional tort (a civil wrong in which liability is based on unreasonable conduct). The intentional torts are assault, battery, treatment without informed consent, false imprisonment or confinement, intentional infliction of emotional distress, and defamation (slander if verbal and libel if written).
Negligence also arises from abandonment of a patient or breach of confidentiality. Negligence also arises in liability for drugs and devices and as vicarious liability. A physician is also found negligent for negligent referrals, failure to warn about risks, and failure to report a notifiable disease. Negligence also covers professional errors. The errors may be ordinary or extraordinary. They may be harmful or non-harmful.
Types of liability
The following are types of liability: physician liability, professional errors, neglect of duty, vicarious liability, liability for defective products, and special types of causation. Physician liabilities include lack of informed consent, errors, and neglect of duty. Professional errors may be ordinary or extra ordinary. They may be harmful or non-harmful. Informed consent or expressed instruction of the patient does not relieve the physician of liability for errors. The physician is liable for discontinuing treatment without justification. Vicarious liability is when someone is made liable for a negligence they did not personally perform for example the employer. The supplier is liable for defective products.
Basis of liability
Liability is based on breach of contract, the tort of negligence, and breach of confidence. The physician-patient relationship establishes a contractual relationship that can be breached. The tort of negligence is invoked when there is breach of duty that leads to injury of either the patient or a third party. Three ingredients must be proved: (a) the physician owed a duty of care (b) the physician failed in that duty (c) the failure resulted in damage. The physician may also be liable for breach of confidence. The physician-patient relationship is based on confidence.
Malpractice suits: court procedure
The statute of limitations states that there is a fixed period after the breach during which tort action can be brought. The legal process follows several steps: filing a complaint by the plaintiff, serving a summons on the defendant, plea of guilty or not guilty by the defendant, discovery (lawyers for both sides collect more information by interviews, examinations, and collection of documents), opening statements at the trial by both sides, testimony and examination of witnesses, closing arguments, and judgment. The burden of proof of breach of standard of care lies with the plaintiff. Proof of breach is based on a balance of probabilities, on the ‘but-for’ test, and on causation of damage or risk. Physician defense against malpractice suits rests on absence of duty, no breach of duty, lack of causation, and lack of damage. Instead of a trial, alternative dispute resolution procedures may be used: arbitration, mediation using an expert facilitator, fact finding and investigation of the case by an expert. Damages can be awarded for personal injury, death, wrongful birth or wrongful life, emotional distress, economic loss, and breach of confidence.
Avoiding / prevention of malpractice suits
Malpractice suits can be avoided by obtaining and maintaining registration, sticking to defined professional standards of care, peer review, quality assurance, use of protocols, defensive medicine and politeness with patients. The best protection against medical negligence is the conscience of all health care workers to make sure that mistakes do not occur. Well written records can be a defense for the physician.
YOUR NOTES
NOTES ON ‘LEGAL TESTS FOR NEGLIGENCE: Bolam as modified by Bolitho’
THE BOOLAM CASE
In a famous case tried in 1957, important legal principles were pronounced by the judge and they have subsequently become part of the law.
The background to the case was that Bolam, a mentally ill patient, suffered fractures during electroconvulsive treatment. This type of treatment was accepted as a normal treatment for mental disorders at that time. The patient had consented to the procedure.
When he suffered a fracture he sued in court. Two problems arose. He was not given full information when he was making his consent because he was not told about the risk of fracture associated with electroconvulsive therapy which was estimated at 1 in 10,000. He was also not given a muscle relaxant that decreases the risk of fracture during the procedure.
At that time there existed differences in professional opinions. Some physicians considered informing the patient about the risk of fracture and using a muscle relaxant as necessary whereas others did not think so. There was therefore no single standard of care against which the actions of the attending physician could be judge to find him negligent or not negligent.
The judge ruled that doctors could not be found negligent if they acted according to a professional opinion accepted by a reasonable body of medical opinion even if there could exist a contrary opinion by another responsible body of medical opinion.
THE BOLITHO CASE
In a subsequent case of Bolitho, a patient who suffered brain damage because the doctor failed to intubate, the court ruled that doctors are expected to follow responsible medical opinion but would not be found negligent in cases in which that opinion did not stand up to logical analysis. The court thus set a principle that the court could over-rule medical opinion that was not logical in a specific case. The implication of this was that medical opinion was not the final arbiter of the standard of care to be used in defining negligence.
NOTES ON ‘ETHICO-LEGAL TRAINING FOR HEALTHCARE WORKERS: AN ISLAMIC DIMENSION’
1.0 INTRODUCTION
This paper is an outline of preliminary ideas about training healthcare workers in ethics from an Islamic perspective. Ethics are universal values and there is convergence among many religions and belief systems about these values. Islam differs from others in that ethics is part of its Law. This makes the enforcement of medical ethics a religious duty that many Muslim health care workers will respect because it is based on belief and not coercion.
The training will not be confined to Islamic sources only. Western theories and principles of ethics will also be covered and comparisons will be made with the Islamic ones. The Islamic sources of ethico-legal guidance are from the Qur’an and sunnat. If a direct text is not available, the theory of the Purposes of the Law, maqasid al shari’at, and legal axioms, qawa’id al fiqh, are used to derive ethical rulings. Guidance is also obtained from books and edicts, fatawa, on medical jurisprudence, al fiqh al tibbi. There is no one western theories of medical ethics that can be compared to the theory of maqasid al shari’at. The 4 western principles of ethics (autonomy, beneficence, nonmalefacence, and justice) can all be subsumed under one Islamic legal principle of injury, qa’idat al dharar.
2.0 THE CURRICULUM OUTLINE
2.1 Theories and principles of medical ethics
2.1.1 Purposes and Principles of Medicine and ethics, maqasid wa qawa’id al tibaabat
2.1.2 Regulations of Medical Procedures, dhawaabit al tatbiib
2.1.3 Regulations of Research Procedures, dhawaabit al bahath
2.1.4 Regulations of Physician Conduct, dhawaabit al tabiib
2.1.5 Regulations about Professional Misconduct, dhawaabit al inhiraaf al mihani
2.2 The etiquette of the physician, adab al tabiib
2.2.1 Etiquette with Patients and Families
2.2.2 Etiquette with the Dying
2.2.3 Etiquette with the Health Care Team
2.2.4 Etiquette of Research on Humans
2.3 Issues in disease conditions, fiqh al amraadh
2.3.1 Uro-Genital System, jihaaz bawli & jihaaz tanaasuli
2.3.2 Cardio-Respiratory System, qalb & jihaaz al tanaffus
2.3.3 Connective Tissue System,
2.3.4 Alimentary System, jihaaz al ma idat
2.3.5 Sensory Systems, al hawaas
2.3.6 Patho-physiological Disturbances
2.3.7 General Systemic Conditions
2.3.8 Psychiatric conditions, amraadh nafsiyyat
2.3.9 Neurological conditions, amraadh al a’asaab
2.3.10 Age-Related Conditions, amraadh al ‘umr
2.4 Issues in modern medicine fiqh mustajiddaat al tibb
2.4.1 Assisted Reproduction, taqniyat al injaab
2.4.2 Contraception, mani’u al haml
2.4.3 Reproductive Cloning, al istinsaakh
2.4.4 Abortion, isqaat al haml
2.4.5 Genetic Technology, taqniyat wiraathiyyat
2.4.6 Artificial Life Support, ajhizat al in’aash
2.4.7 Euthanasia, qatl al rahmat
5.4.8 Solid Organ Transplantation, naql al a’adha
5.4.9 Stem Cell Transplantation, naql al khalaayat
5.4.10 Change of Fitra, taghyiir al fitrat
3.0 METHODOLOGY OF TRAINING
The ethico-legal training program starts from the premise that there is a gap between what is and what ought to be and that this gap can be closed by training. Training is learning on the job and is therefore very practical in nature. The trainers do not give lectures but rather facilitate discussion and interaction among participants that leads to learning. The training will be based entirely on study and discussion of cases of actual ethical problems that are encountered in hospital practice. Source material will be provided in advance of any workshops. As far as possible training will be brought to each health center of hospital. A total of 5 workshops each lasting 2-3 hours will be needed to cover the curriculum. Each workshop will be opened by a short introduction from the workshop facilitator. Then the participants will be divided into discussion groups each dealing with a group of related cases. Groups will present their findings in the plenary session followed by a general discussion. The facilitator will summarize the principles learned as well as correct any misunderstandings.
4.0 TRAINERS AND TRAINING MATERIALS
Success of the project requires holding an initial training program to train the trainers. Then the trainers will train others. Resource material will be provided as required. Additional material can be obtained from http://omarkasule.tripod.com.
YOUR NOTES
CASES FOR DISCUSSION
GROUP #1 (CASES ON PRIVACY AND CONFIDENTIALITY)
Case #1: A patient with diastolic blood pressure of 120 mmHg failed to return to the Health Center for treatment. The nurse called the head of the village and asked him to convince the patient to come. In order to press on him the urgency of the matter, she had to explain all the details of the history and examination that had been carried out on the patient.
Case #2: A clerk in the records department casually mentioned impotence of a patient to his friends at the village restaurant. Word spread quickly around the village resulting in cancellation of the patient’s engagement. The fiancée sued in court and the patient committed suicide. The clerk felt no remorse. He argued that he was doing a public duty by stopping a potentially unhappy marriage.
Case #3: A neurologist informed his wife over dinner about an elderly school bus driver who had Parkinson disease and had to take an unusually high dose of medication to suppress the tremors. The medication made the patient sleepy all day. The wife asked for the name and realized that the patient was a driver for her school transport company who had been coming to work late in the past 2 weeks. She dismissed him the next morning.
GROUP #2 (CASES ON DISCLOSURE)
Case #4: Midwives refused to inform a mother and hid a congenitally malformed baby from her for a week. They gave the mothers various excuses for not showing her the baby. When the mother became very angry the pediatrician came to talk to her and told her that she had an abnormal baby. He said ‘in my experience children with this type of abnormality do not survive longer than a month’. When the patient asked for the cause of the abnormality the pediatrician replied ‘It is all your fault, you should not have become pregnant above the age of 40’. The mother broke down and cried. She left the hospital 2 hours later without being formally discharged.
Case #5: The manager of a national airline was worried about the erratic behavior and mistakes of one of the senior pilots. He asked around and found out the name and address of the pilot’s family doctor who was in private practice. He wrote to the private practitioner to provide records about treatment of the pilot for vision and psychological problems. He asked specifically for information on drug abuse. The private practitioner called and gave the information but told the manager that he could not put it down in writing since he had not discussed the matter with the patient. Two weeks later the private practitioner received an offer of a free ticket for himself and his wife to a holiday resort. The letter from the airline public relations office said that the airline was carrying out a promotion and that names of beneficiaries had been selected at random from the telephone directory. The doctor subsequently went on the trip with his wife.
Case #6: A medical researcher stationed at the hospital used to take an aliquot from every blood specimen to test for HBV. The hospital authorities knew what he was doing but the patients were not informed because he did not record names of patients. One day out of curiosity he tested a specimen for HIV and found it positive. He was confused what to do regarding disclosure. He called a meeting of the senior staff in the hospital to discuss the matter. He also included a respected lawyer from the town to provide a non-medical perspective.
Case #7: A community pediatrician had reported abuse of a couple’s first child to the authorities. The authorities called in the parents to discuss the matter. The abusing father was so angry that he divorced his wife for giving information to the pediatrician. He later took the wife back under the rujuk provisions of the Law. At the next visit the pediatrician noted signs of child abuse and asked the mother. The mother confirmed the abuse but asked the pediatrician not to follow up the matter for the sake of her marriage and family. The pediatrician this time did not report to the authorities.
Case #8: A midwife who had contracted HIV due to transfusion hid her status for 5 years. She was very meticulous during deliveries observing all precautions and during that time no patient was reported to have been infected. After a family quarrel her husband revealed her status to the newspaper. The editor failed to interview her before publication of the report. The midwife refused a request by the head of obstetrics to have an HIV test. The hospital suspended her and charged her for criminal negligence in the high court.
GROUP #3 (CASES ON CONSENT TO TREATMENT)
Case #9: A bed-ridden patient with limited movements and sensation communicated by sign language and limited speech. She could recognize letters and could write sentences by nodding when the right letter was touched. She indicated that she did not want physiotherapy, wanted to divorce her spouse, and wanted to give the family home to the kind doctor taking care of her. She wanted to disinherit her sons for not sitting around her bed and caring for her daily. She wanted to return to her home and leave the nursing home.
Case #10: A patient with a benign prostatic enlargement and mild urinary retention asked the urologist for prostatectomy. The urologist refused after examination revealed no complications and a normal PSA level. Because there was only one urologist in the government hospital, the patient sued the hospital in the High Court to force them to carry out the operation. Due to delays in scheduling a hearing the patient went overseas and had the operation done. Histological examination showed low grade prostate carcinoma confined within the prostatic capsule.
Case #11: A patient was brought to the emergency room by the police after attempting to kill himself by hanging. He was unconscious when first brought in and had a signed suicide note in his shirt pocket saying that he wanted to die. The doctors ignored the note and started resuscitation measures. The patient became conscious after 30 minutes and protested at the medical treatment arguing that he wanted to die. The doctor was thinking of stopping resuscitation measures when the patient’s father and wife arrived and instructed the doctor to continue resuscitation.
GROUP #4 (CASES ON REFUSAL OF TREATMENT)
Case #12: A 40-year old theater nurse refused to accept the diagnosis of breast cancer and refused surgery. The tumor grew larger, broke through the skin and became foul smelling because of bacterial infection. The hospital director put her on unpaid leave.
Case #13: A 40-year old policeman refused surgery to drain a pyomyositis abscess. He still refused surgery after the abscess burst spontaneously. The surgeons sedated him and carried out the surgery without his consent.
Case #14: A 30-year old soldier with a history of schizophrenia refused a chest X-ray for a severe cough lasting 2 months. His commanding officer authorized using force to take the X-ray and to treat him accordingly. The army doctors were not sure what to do but being army officers they obeyed orders of the commanding officer.
Case #15: A 42-year old actress pregnant for the first time refused an elective caesarean section. She continued to refuse the procedure when labor became obstructed and signs of fetal distress appeared. The obstetrician went ahead to operate on the basis of consent by the husband. The baby was delivered alive and well.
Case #16: A 14-year old patient refused admission because he hated the physicians on the pediatric ward. The father agreed with the patient but the mother disagreed. Both parents agreed with the patient’s refusal of any blood transfusion which the doctors considered necessary since the hemoglobin level had fallen to a dangerous level.
Case #17: A 60-year old retired nurse refused HRT after a diagnosis of osteoporosis was made. She argued that HRT was anticipating and contradicting Allah’s pre-determination, takdir.
GROUP #5 (CASES ON NEGLIGENCE & MALPRACTICE)
Case #18: A patient with no obvious injury after a minor accident was discharged without X-ray investigations. He developed back problems 3 months later leading to leg paralysis. He sued the hospital for negligence.
Case #19: A 45-year old mother of 5 grown up children had hysterectomy because of prolonged, heavy, and irregular menstruation. The surgeon took care to preserve the ovaries and therefore saw no need to put her on HRT. Three years later she had a hip fracture due to osteoporosis treated by hip replacement and she was started on HRT. Six months later she developed pain in the right groin and investigations revealed cancer of the ovary which had to be removed. Her daughter who was a nurse in the hospital argued her to sue the hospital for malpractice but she herself was not very sure of what had gone wrong.
Case #20: An aspiring actor was advised by her media consultants to change her facial features in order to succeed in landing major and lucrative acting roles. She went to a doctor who advertised his cosmetic surgery services on the television and women’s magazines. She signed a consent form for surgery but did not see a notation in the footnotes that the operation was entirely at her own risk. Six months later and after a series of operations she was angry. Her face was asymmetric and her eye lids drooped. She asked for his license as a plastic surgeon. He told her he was a general surgeon who had interest in plastic or cosmetic surgery. With her career ruined she decided to take him to court.
Case #21: A patient with epilepsy well controlled on drugs for the past 10 years, experienced a minor epileptic seizure. His physician increased the drug dosage and told him all would be well and that he could go back and resume driving the school bus. The patient asked for an MC to explain his day’s absence to the manager of the school bus company. The next morning the patient crushed the bus into a wall as he was driving it out of the garage. He explained that he felt sleepy at the time of the accident.
GROUP #6 (CASES ON LIFE SUPPORT IN TERMINAL ILLNESS)
Case #22: A patient with brain stem death is kept on artificial life support at the insistence of the family because announcing the death immediately will have an adverse effect on the values of the family business on the stock exchange.
Case #23: The family took an unconscious man to hospital reluctantly because they believed he was dead. He was admitted to the ICU and was put on artificial life support. For a period of 4 weeks the family insisted on withdrawal of life support because they would be ruined financially by the high ICU costs. The physicians refused withdrawal of life support because his brain stem was functional. The patient woke up in the 5th week.
Case #24: A patient is brought to the emergency room after a car accident. The examining doctor found some signs of life but refused to institute life support because he was convinced it was futile. The patient died a few minutes later. The accompanying family members were furious and accused the doctor of negligence. They threatened to sue. The doctor advised them to wait for results of the postmortem examination that would show that death was inevitable. They refused to have any postmortem because it was against their religious beliefs.
Case #25: A patient admitted to the ICU after a car accident was confirmed by 3 specialist surgeons to be in a persistent vegetative state. The doctors wanted to discontinue life support but the family refused because there were signs of life like reflex flexion of joints and blinking of the eyes. The hospital decided to seek a court injunction after keeping the patient in the ICU for 6 months without any obvious improvement.
GROUP #7 (CASES ON REPRODUCTIVE ISSUES)
Case #26: A mentally retarded sexually active 14-year old teenager was taken to the family planning clinic to receive contraceptives without the knowledge of her parents. Due to irregular use of the pills she became pregnant and her aunt took her overseas for an abortion. On return she advised her parents to take her for sterilization. The parents preferred hysterectomy because in her retarded condition she could not maintain menstrual hygiene. The family gynecologist preferred depo provera.
Case #27: A couple married for 10 years without a child decided to have IVF. Before the procedure was completed, the husband died. The wife insisted on using the stored semen of her dead husband. The relatives of the husband objected. The first wife who had been divorced 15 years earlier with one girl also asked for the semen for an IVF procedure that she hoped would enable her have another baby to act as a bone marrow donor for her daughter who had leukemia and had failed to find a matching donor.
Case #28: A 14-year old sexually active girl was treated at the outpatient clinic for sexually transmitted disease. The doctor advised her on the use of condoms to prevent disease. She asked the doctor to keep the matter a secret even from her parents. She became extremely promiscuous after that until the whole village knew about her behavior. The news deeply embarrassed the parents. They learned from a distant relative who worked at the outpatient clinic that she had been advised about the use of condoms by the doctor and that she had obtained the condoms from the family planning clinic.
Case #29: A married woman with 6 young children came to the hospital asking for an abortion because she had become pregnant while her husband was half-way through a 4-year prison sentence for violent behavior. She was afraid for her life. She had just discovered a secret about her husband from a police officer that the husband has killed his first wife 20 years earlier because of a jealous rage and had escaped the gallows on a legal technicality because of police incompetence in investigating the case.
Case #30: A 40-year old housewife with 8 living children is brought reluctantly to the contraceptive clinic by the husband. The husband asks for tubal ligation because he cannot afford to look after more children. The wife insists that Allah will provide for all the children irrespective of the husband’s financial situation.
GROUP #8 (CASES ON ORGAN DONATION)
Case #31: A leading politician with end-stage kidney failure presents at the transplant clinic with a distant cousin who is an impoverished farmer from the countryside. He says that the relative has agreed to be a live donor for him. The cousin states that he will donate the kidney but on further questioning he does not seem to know what a kidney is and where it is found in the body. The transplant team seemed reluctant to go ahead with the procedure. The politician gets angry and gets them reprimanded by the Minister of Health. They resign en masse and sue the politician and the Ministry of Health for unjustified interference in their work.
Case #32: A doctor in end-stage renal failure brings over 50 relatives for blood group testing and tissue matching for kidney for live kidney donation. Only one relative was a suitable donor on the basis of tissue and blood group matching but he refused to be a donor unless a new house was built for him and he was given a big amount of money. One other relative was not a tissue match but matched for blood group and was willing to donate the kidney for free.
Case #33: A patient of terminal renal disease received a cadaveric transplant and recovered well. Two years after the operation he received a note from a stranger demanding payment of a large sum of money. The stranger claimed to be the son of the kidney donor who had died during surgery for intestinal obstruction. The stranger claimed that a source within the hospital had informed him that the deceased’s kidney has been removed without the knowledge and permission of the family.
Case #34: A father of a child with end-stage renal disease got tired of taking her for dialysis every week. He had failed to find a live or a cadaveric donor for her in his country. He considered traveling to a nearby country where kidneys could be bought but he was not sure. He also considered marrying a young wife (his first wife had died) and hopefully produce a child who could be a donor.
GROUP #9 (CASES ON DRUG ABUSE AND SUICIDE)
Case #35: A patient, whose engagement had been called off in the week that he failed his university entry examinations, started smoking, drinking alcohol, and using illicit drugs to forget his problems but to no avail. He was admitted to the medical ward after suffering a nervous breakdown. He was violent and abusive on the ward and refused to take his medication. Two weeks from his admission he left the ward without telling anyone and went and killed his former fiancée at her home. He later became very agitated and depressed and within 10 hours he also committed suicide. His parents and the parents of his ex-fiancee jointly sued the hospital.
Case #36: The patient was a brooding type who was always sad. He had a mental break down when his wife had a spontaneous abortion of a 3-month pregnancy. He was taken to the hospital emergency room. The attending physician finding nothing physically wrong with him, decided to discharge him. The physician ignored the repeated talk of the patient about following his dead baby into the grave and just gave him valium and sent him home. When the effect of valium wore off at home he became agitated. His wife found him 10 minutes later lying unconscious on the bed with a half-empty bottle of detergent next to him. She called an ambulance that arrived in record time. By the time he was seen by the physician in the emergency room, he had recovered some consciousness and could talk. He told the physician that he wanted to die. He categorically refused to consent to the procedure of gastric lavage to remove the detergent from his stomach. A psychiatrist called to assess his mental competence concluded that he was competent to make decisions.
GROUP #10 (CASES ON DOCTOR ETIQUETTE, adab al tabiib)
Case #37: A physician prescribed a new unlicensed drug donated to him by a pharmaceutical company. The physician had shares in the company. He had no previous personal knowledge of the drug. The patient developed an immediate allergic reaction. The physician blamed the nurse for not asking about drug allergies before injecting the drug.
Case #38: A 60-year old surgeon was known by everybody in the hospital to cause pain while examining patients without prior explanation and consent. He used to make lewd jokes about female patients. He discussed diagnoses with his drinking partners and details of many patients were known in the community. A junior doctor who complained to the hospital director was told to keep quiet. Nobody else dared to complain about him because of his seniority.
Case #39: A well-known businessman was diagnosed with drug-resistant tuberculosis. He refused admission to the TB ward because of his social position. He contacted the hospital manager who was his golf partner to pressure the junior doctor to admit him to a room on a normal ward. When the junior doctor refused, he was transferred to another department and the admission went ahead.
GROUP #11 (CASES ON RESOURCES)
Case #40: A 65-year old man whose brother had just died from coronary heart disease walked into the health center and asked for examination because he was afraid that his heart may also have problems. The triage nurse asked him if he had any specific complaints. He replied that he has none and that he was in perfect health. The nurse rebuked him for wasting her time. ‘Don’t you the see line of 120 really ill people waiting to see a doctor? How can we waste time in someone healthy like you?’. The man left but was admitted to the ICU 5 days later with myocardial infarction and he died after 2 days.
Case #41: The ICU staff were in a dilemma because 2 patients presented at the same time and they had only one free bed. The first patient was 90 years old and has been admitted three times before with myocardial infarction. His sons forced him to come to hospital; he had expressed preference to stay and die at home in peace. The second patient was a 30-year neurosurgeon. He was the only one in the whole country. He had been involved in a serious car accident and was in coma.
Case #42: A 37-year old mother, who had just had a normal delivery with considerable blood loss, protested at being discharged the next day. She needed rest and could not get that at home where she had 5 children to look after. The midwives told her they needed the bed for other patients. She was readmitted the next day with fatal postnatal hemorrhage.
GROUP #12 (PHYSICIANS WITH DUAL OBLIGATIONS)
Case #43: A worker sustained severe injury while at work. Under pressure from the management, a company physician refused to certify disability qualifying the worker for a hefty compensation. The worker sued the employer. While the case is still in court the worker died and the physician refused to certify that gangrene of the injured hand contributed to his death.
Case #44: A national football team physician examined a player and found that he had a chronic shoulder dislocation and advised that he should not play again until it was treated. The player protested because he had always played with that condition since he was young. The team manager threatened to dismiss the physician if he did not certify the player as fit to play because that star player was the only hope of the team to win in an international match the next day.
GROUP #13 (POSTMORTEM)
Case #45: A child’s asthma progressed to respiratory failure and death. The father refused tom give up his heavy smoking and the mother refused to get rid of their cats to which the child is allergic. Hospital authorities request for a postmortem examination to establish the cause of death for fear that they may be charged unfairly for negligence in the death of the child. The social workers also request a postmortem because they suspect that parental negligence contributed to the death. The family rejects postmortem claiming the child died from a curse and not disease.
Case #46: A police officer died a few minutes after admission from what was suspected injuries sustained in the course of his duty. The police department insisted on a postmortem to determine the cause of death in order to make decisions about compensation. The family was divided. Some were opposed to postmortem and others wanted to go ahead.
NOTES
[1] Qur’an 9:55, 9:85
[2] Qur’an 9:69 19:77, 34:35, 57:20
[3] Qur’an 5:5 & 16:72
[4] Qur’an 5:87
[5] Bukhari Kitaab al maghazi Baab 60
[6] Bukhari Kitaab al maghazi Baab 60
[7] Qur’an 2:268
[8] Qur’an 9:28
[9] Bukhari Kitaab al Libaas Baab 31
[10] Qur’an 6:140, 17:31
[11] Qur’an 16:58-59, 43:17
[12] Qur’an 16:58-59, 43:17
[13] Qur’an 81:8-9
[14] Qur’an 4:19
[15] Qur’an 6:139
[16] Qur’an 3:14
[17] Bukhari 7:1,
[18] Qur’an 17:32
[19] Bukhari 1:732
[20] Bukhari 7:133)
[21] Ahmad 2:69
[22] Qur’an 4:148, 24:19
[23] Qur’an 23:5
[24] Qur’an 24:31
[25] Bukhari Kitaab al Nikah Baab 111
[26] Qur’an 24:31
[27] Bukhari 8:258
[28] Ibn Majah Kitaab al Zuhd Baab 17
[29] Tirmidhi Kitaab al hajj Baab 1
[30] Bukhari Kitaab al iman Baab 3
[31] Qur’an 28:23-28
[32] Qur’an 4:21
[33] Bukhari Kitaab al Nikah Baab 1
[34] Abudaud Kitaab al Nikah Baab 42
[35] Muslim Kitaab al Nikah Hadith 9 & Hadith 10
[36] Bukhari Kitaab al Nikah Baab 85
[37] Bukhari 7:52
[38] Qur’an 24:33
[39] Bukhari Kitaab al Nikah Baab 96
[40] Muslim Kitaab al talaq Hadith 31
[41] Ahmad 1:31
[42] Qur’an 2:30 & 2:84
[43] Qur’an 2:30
[44] Bukhari Kitaab al Wasaaya Baab 23
[45] Qur’an 2:195
[46] Bukhari Kitaab al janaiz Baab 84
[47] Muslim Kitaab al iman Hadith 178
[48] (Muslim Kitaab al Janaiz Hadith 107
[49] Qur’an 15:23
[50] Qur’an 25:3
[51] Qur’an 17:33
[52] Qur’an 5:32
[53] Qur’an 25:2
[54] Qur’an 33:38
[55] Qur’an 65:3
[56] Muslim Kitaab al Iman Hadith 1
[57] Muslim Kitaab al qadar Baab 17
[58] Muslim Kitaab al qadar Hadith 34
[59] Ahmad and Tirmidhi
[60] Qur’an 57:22-23
[61] Qur’an 64:11
[62] Qur’an 3:120, 3:186
[63] Qur’an 4:78
[64] Qur’an 21:35
[65] Qur;an 2:216
[66] Qur’an 2:216
[67] Zaid Hadith 539
[68] Tirmidhi Kitaab al Buyu’u Baab 4
[69] Bukhari Kitaab al Buyu’u Baab 16
[70] Ibn Majah Kitaab al Tijaarat Baab 45
[71] Muwatta Kitaab al Buyu’u Hadith 99
[72] Darimi Kitaab al Riqaaq Baab 60
[73] Bukhari Kitaab al Buyu’u Baab 58
[74] Bukhari Kitaab al Buyu’u Baab 19
[75] Abudaud Kitaab al Aqdhiyat Baab 4
[76] Bukhari Kkitaab al ijarah Baab 16
[77] Abudaud Kitaab al Buyu’u Baab 49