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Paper presented at the 6th International Nursing Conference held in Brunei 10-13 October 2004 by Professor Dr Omar Hasan Kasule, Sr. MB ChB (MUK), MPH and DrPH (Harvard) Deputy Dean for Research Faculty of Medicine UIA Kuantan Malaysia
ABSTRACT
Five issues in medical education: This paper discusses 5 conceptual issues in medical education from the Islamic perspective: purpose of medicine and medical education, integration, balance, service, and leadership.
The issues of purpose, integration, and balance: The purpose of medicine is to restore, maintain or improve the quality of remaining life. It cannot prevent or postpone death because ajal is in the hands of Allah. The aim of medical education is producing caregivers whose practice fulfills the 5 purposes of the Law within a holistic tauhidi context. Modern medical practice is fragmented by organ, disease process, and is not holistic. Islam can provide an integrative tauhidi paradigm to replace the non-tauhid world-view that is atomistic, analytic, and not synthetic. In the absence of an integrating paradigm, modern medicine lacks balance and equilibrium in its therapeutic approach. The Qur’anic concepts of middle path, wasatiyyat; balance, mizaan; equilibrium, i’itidaal, and action-reaction, tadafu’u, provide a conceptual framework for balanced medical practice.
The issue of service: Medicine should be taught as a social service with the human dimension dominating the biomedical dimension. Medical education should prepare the future caregiver to provide service to the community. This will require skills of understanding and responding to community needs that can be acquired by spending part of the training period in a community setting away from the high technology hospital environment.
The issue of leadership: The medical curriculum and experience should be a lesson in social responsibility and leadership. The best caregiver should be a social activist who goes into society and gives leadership in solving underlying social causes of ill-health. The caregiver as a respected opinion leader in close contact with patients must be a model for others in moral values, attitudes, akhlaq, and thoughts. She must give leadership in preventing or solving ethical issues arising out of modern biotechnology. She must understand the medical, legal, and ethical issues involved and explain them to the patients and their families so that they can form informed decisions. She should also provide leadership in advocating for the less privileged and provide leadership in advocacy for human rights.
1.0 5 MEDICAL EDUCATION: CONTENT AND ISSUES
1.1 IMPORTANCE OF THE STUDY OF MEDICINE
Medicine is closely associated with all the 5 purposes of the Law (diin, life, progeny, intellect, and wealth). Preservation of life and health is the second purpose of the Law. Good health is necessary for fulfilling the first purpose of the Law, preservation of morality, diin. Preservation of progeny, intellect, and wealth are also related to good health that is assured by medicine. Each community must have a sufficient number of medically skilled people. Study of medicine is therefore a communal obligation, fardh kifayat.
1.2 CONTENT
The basic training sites of the health professional are the masjid, the school, the university, the hospital, and the community. The masjid and the school are responsible for basic education and character formation. The university provides medical education. The hospital provides practical training.
Methods of medical education are varied but include combinations of observation, reading, discussion, and practice. The medical curriculum is divided into two parts: the pre-clinical and the clinical. Students learn basic medical sciences in the pre-clinical phase. These sciences form the research base. They also provide a base for further clinical studies. Clinical apprenticeship teaches practical skills.
In addition students should learn the basics and essentials of Islam, al ma’lum fi bi dharurat. They need to learn legal rulings, ahkaam fiqhiyyat, relating to medicine to be able to give practical advice to their Muslim patients. They must acquire teaching skills to be able to dispense health education to their patients. Knowledge of the social basis of disease provides all-round view of disease and its treatment.
The process of education is continuous. A health professional either formally or informally learns new things every day.
1.3 ISSUES
There are 5 conceptual issues in medical education from the Islamic perspective: purpose of medicine, purpose of medical education, integration, balance, service, and leadership. These 5 conceptual issues in medical education are discussed below from the Islamic perspective.
2.0 THE ISSUES OF PURPOSE, INTEGRATION, and BALANCE
2.1 THE PURPOSE OF MEDICINE:
Islam teaches a holistic view of medicine and medical treatment that includes the physical, psychological, social, and spiritual dimensions.
Since health is the original state and illness is the exception, medicine must be health and not disease oriented. The main responsibility of the health care giver is to maintain health. The ancient Chinese were nearer to our view of medicine and the role of the health care giver. They paid their physician as long as they were in good health. Payments would be suspended on falling sick. They would resume when the illness was cured.
Illness to a Muslim has its positive aspects and can be a blessing and a reason for expiation of sins. The trial of illness is a source of much good for a believer. An incident case of illness should not be looked at in isolation. When viewed in a larger context, illness or disease need not always be seen as bad. The Qur’an teaches that a human may like something that is bad for him or may hate something that is good for him or her. Falling ill may save a person from going where he would be hurt or where he could commit a sin. Patho-physiologically the symptoms of ill health are useful even if people complain about them. Pain directs us to tissue injury so that corrective measures may be taken before the injury becomes more extensive. Exhaustion and collapsing may be the body’s way of forcing us to take a rest when we are over-stressed or overworked without adequate rest. Much of what manifests as disease are the body’s attempts to return to the natural or normal state.
The ultimate cure of illness is from Allah. The attending physician must realize that his efforts will succeed only if divine will intervenes and should therefore not be to arrogant. He should be aware that his efforts may either fail or succeed.
From an Islamic point of view, the aim of medicine is to maintain or improve the quality of remaining life. Medicine does not have as an aim the prevention of death or prolongation of life; the lifespan, ajal, is in the hands of Allah the Almighty. Life on earth has a fixed and limited span and no one has the power to extend it even for a brief moment.
Importance of quality of life is recognized by some physicians trained in the modern tradition but lacking an integrating tauhidi paradigm, they fail to define this quality in a holistic way. Islam can provide them with paradigms that enable them to pull everything together.
The Islamic Quality of Life Index (IQLI) should arise from the tauhidi integrative paradigm and is a comprehensive measure involving social, psychological, physical, spiritual, and environmental parameters. The quality of life is closely related to man’s understanding of the purpose of creation and the mission of humans on earth. Life becomes degraded, hayatan dhankan, in the absence of this understanding.
The quality of life is also closely related to lifestyle. A good healthy lifestyle is associated with a higher quality of life. A bad unhealthy lifestyle is associated with a low quality of life. Lifestyle is directly related to the risk of physical and mental illness as well as the response or adjustment to that illness.
A healthy lifestyle is characterized by: piety, generosity, charity, chastity, humility, trust, balance, moderation, patience, endurance, honor, dignity, integrity, moral courage, and wisdom.
An unhealthy lifestyle is mainly a manifestation of one of the following diseases of the heart: polytheism, shirk; rejection, kufr; pride and arrogance, takabbur; hatred and rancor, hiqd; envy, hasad; anger and rage, ghadhab, hypocrisy, nifaaq; miserliness, bukhl; and negative thoughts, suu al dhann. These diseases sooner or later lead to either physical or psychological transgression, dhulm, against self or others. Most human diseases can be traced to this transgression. Epidemiological studies if interpreted in an objective way provide sufficient data to relate ill-health to lifestyle and to quality of life.
2.2 PURPOSE OF MEDICAL EDUCATION
The Islamic paradigmatic approach to defining the purpose of medical education can be derived from the paradigm of tauhid and the general theory of the purposes of the Law, maqasid al sharia. The majority of scholars concur that the following 5 purposes are protected by the law: (a) religion, diin (b) life, nafs (c) procreation, nasl (d) intellect, aql (e) wealth, maal. Medical practice is intimately involved with all 5 of them but most so with nafs, nasl, and aql.
Once the purposes of medical intervention are established, the aim of medical education should be to produce health professionals who in their practice of medicine will fulfil the purposes or maqasid within a holistic context to ensure harmony and equilibrium. Thus the medical education system should aim at producing a health professional who will be health and not disease oriented, who will have the humility to know that he will exert his best and trust in Allah to cure the disease. He will not have the arrogance to feel that he can prevent death but will strive to improve the quality of life for people knowing that the Islamic index of the quality of life is derived from the holistic tauhidi view: physical, spiritual, social, psychological aspects, and proper balance among them. The health professional should in addition have the following practical and conceptual skills: understanding of the society, epidemiological understanding of health problems, scientific capability, clinical expertise, and leadership. These qualities must be in a context of faith, iman; tauhid, and fulfillment of the general purposes of the shari’at.
2.3 THE ISSUE OF FRAGMENTATION:
Modern medicine is characterized by narrow specialization and fragmentation. Health professionals know more and more about less and less. The trend toward specialization in medical practice has strongly influenced medical educators to diminish the practical content of the crowded undergraduate program and transfer some of it to post-graduate or vocational training. A new graduate is therefore unable to treat a patient on his own until he becomes a specialist. Specialty practice however has the great disadvantage of fragmenting patient care among several specialists such that there is no one practitioner to care for the whole patient.
The following attempts have been suggested to overcome the problem of fragmentation: interdepartmental or inter-disciplinary programs, integration of clinical and basic sciences, generalist and not specialist medical practice, vertical integration (linking early with later years in the same discipline), horizontal integration (linkage between different disciplines), teaching by organ systems, and using the problem-centered approach.
The concept of integration has been well accepted and propagated but not understood well when it came to practical application. Attempts at integration are a response to a felt problem and are certainly a step in the right direction however they have not solved all the problems; they even succeeded in creating a few new ones. Uncoordinated integration has succeeded in producing a hypertrophic curriculum. There is pressure from each discipline to ‘integrate’ its material into the curriculum. New disciplines such as genetics, statistics, epidemiology, demography, anthropology, and sociology are at the door claiming their share of the undergraduate curriculum. New disciplines have been created to ‘integrate’ or bridge the gap between pre-clinical and clinical disciplines eg clinical biochemistry, clinical pathology, and clinical epidemiology. Interdisciplinary teams have been used as a tool of ‘integration’ in community medicine.
There are, however, defenders of a crowded undergraduate curriculum. They argue that students should be exposed to all disciplines to enable them make informed choices about their future specialties. This reminds us of the story of an ’accomplished’ lawyer who knew a bit about every subject including law. The process of continuous additions to and pruning from the curriculum is going on and has been dramatically described as integration, re-integration, and disintegration.
Fragmentation is a reflection of an underlying modern world-view and did not come about in medical education by accident. This world-view started with the European renaissance when religion was separated from public life and science. This set in motion centripetal forces that continually separate, fragment and sub-divide. The body was separated from the soul. The mind was separated from the body. Science was separated from art in medical practice. Each disease or organ was isolated and was dealt with in isolation.
It is not surprising that in a context of increasing fragmentation, the concepts of ‘total health’, ‘total disease’ are not easily accepted. It is not the ‘total human’ who gets sick but his organs or tissues. It is however very surprising that Claude Bernard’s concept of a harmonious ‘milieu interieur’ and the appreciation of the biochemical unity of all life did not motivate practice of ‘total medicine’.
Some medical and nursing educators have recognized that fragmentation is a major problem and have set about attempting to achieve integration in medical treatment and medical education. Some of these attempts were described above. Their limited success is due to lack of a guiding vision.
Integration is not just putting two or more disciplines together. It is a fundamental philosophical attitude based on a vision and a guiding paradigm. Only Islam can provide this paradigm. Criticism of the fragmented medical curriculum is actually criticism of the underlying modern non-tauhid world-view. The fundamental reason for failure of integration efforts is that the western world-view is atomistic, it is good at analysis and not synthesis. It is incapable of synthesis because it lacks an integrating paradigm like tauhid.
2.4 THE ISSUE OF LACK OF BALANCE:
Lack of equilibrium is a secondary manifestation of lack of integration. A lot of human illness is due to lack of balance and equilibrium; for example excessive intake of some foods leads to disease just as inadequate intake leads to ill-health. The Qur’an calls for observing the middle, al wastiyyat. Violating the rule of the golden middle is associated with many problems.
Ancient Muslim, Indian, Chinese, Greek medical systems understood the concept of equilibrium. Modern European medicine lacks the concept of equilibrium or balance. It is replete with examples of overdoing a good thing beyond the equilibrium point and creating even bigger problems. Some therapies are worse than the disease they are supposed to cure. The quality of life of terminal cancer patients is made worse by chemotherapy and radiotherapy than the original disease perhaps they could have been left to die in dignity. Pesticides were used to eradicate malaria but they led to human disease. The best treatments of yesterday are known causes of malignancies today.
Some physicians trained in the western tradition recognize the problems of balance and integration but they cannot propose a comprehensive solution because of lack of an underlying paradigm.
2.5 THE TAUHIDI PARADIGM, INTEGRATION AND BALANCE:
Tauhid is the main paradigm in Islamic civilization that forms a backbone of all intellectual discussion of medical education. Tauhid al rububiyyat motivates the appreciation that there is only one creator and that there is unity, harmony and useful interconnections among different forms of life and the physical environment. Tauhid al uluhiyyat motivates the appreciation that the Creator has definite purposes from creation and that human life must fulfil those purposes. This implies that there are certain laws that lead to a fulfilling life. Obeying those laws is associated with a healthy high-quality life-style. The tauhidi paradigm implies integration and harmony of matter and soul, body and mind, parts and the whole.
The health professional should be trained to practice medicine as a total holistic approach to the human in the social, psychological, material, and spiritual dimensions and not an attack on particular diseases or organs. The example of the early Muslim physicians is worth emulating. They were well rounded in their education and their practice of medicine. They were also integrated in the sense that their medical practice fitted in well with other social activities. Al Qadhi Abd al Razaaq used to teach medicine and mathematics in the mosque in Bukhara until his death. Muwaffaq al Ddiin Abd al Latiif al Baghdadi taught medicine in the Azhar mosque during his stay in Egypt. Thus the context and the environment in which the teaching was carried out was integrative. It integrated medicine with the mosque and worship.
The tauhidi approach to integration is putting medical knowledge, teaching and practice in a larger context to making sure it is in harmony and is well coordinated with other related medical or non-medical phenomena. It is therefore possible to envision a very ‘integrated’ doctor who at the same time is very specialized. Such a doctor will approach the patient as a whole human and not just as organs or tissues.
3.0 THE ISSUE OF SERVICE
3.1 SPIRIT OF SERVICE
So far medical and nursing schools have not been heroes of social medicine although there are projects here and there that are successful and are laudable. In order for these schools to face the challenge they will have to train students in such a way that they internalize the values of social service. The Islamic paradigm of service requires that the health professional should be trained to understand medicine as a social service. The human dimension should dominate over the biomedical one.
The selection of students, their training, and evaluation should emphasize human service and not material gain for the health care givers. The school cannot be expected to effectively teach the spirit of serving others on its own. The values and attitudes of self-less service for others are taught by the family and the community and are already well set by the time the student enters medical or nursing school. The school can only build on and enhance basic values that students bring with them from their homes and communities. In such circumstances, the school will do well to select those students who already have the vocation to serve.
3.2 ALLEVIATION OF POVERTY:
Material deprivation causes social and psychological stress in addition to the physical impact of inadequate nutrition, housing, and sanitation. Socially conscious health professionals must be involved in programs to eradicate poverty and assure a reasonable standard of living. The Qur’an calls upon society to look after the weak and less privileged: the widows, the poor, and the wayfarers. A Muslim must love for others what he loves for himself..
The distinction between a faqir and a maskin is very significant. The former is poor and is known to be poor so that aid can be extended. The latter is not known and he does not actively seek help. The social services must have the ability to seek out those in need even if they do not come to them seeking aid.
Islam is a very practical religion. It has a culture of action and many of its teachings are action-oriented. Islam does not only enjoins followers to serve others but has practical measures to ensure this occurs. Zakat is an obligatory payment to the poor and the needy. The obligatory fasting of Ramadhan is training and inspiration for the rich to remember the poor because they voluntarily taste hunger and fully understand the plight of the deprived. Many breaches of the law are expiated by kaffarat, normally feeding the poor.
3.3 COMMUNITY-BASED EDUCATION:FOR THE MATERIALLY DEPRIVED
Medical schools have not been very successful in inculcating the spirit of self-less service in depressed rural or urban areas. Physicians and nurses are reluctant to serve in rural areas. It is argued that community-based learning will make the student more sensitive to society’s problems. This makes sense since many of those who manage to make to medical or nursing schools are often from middle-class urban homes and have no contact with the less privileged who live in rural areas or the urban slums.
3.4 COMMUNITY-BASED EDUCATION FOR THE MATERIALLY WELL-OFF
The disease profile and hence the pattern of medical care in Brunei and Malaysia are changing with the rapid socio-economic development. The old diseases of poverty (parasitic infections, under-nutrition, poor sanitation) are disappearing. New diseases due to an unhealthy lifestyle of the now richer population are appearing. Over-nutrition, lack of exercise, substance abuse, stress, and psychiatric morbidity are on the increase. The old social and psychological safety nets provided by the family are disappearing leaving many people lonely and vulnerable. Students of today will have to be trained to deal with the new patterns of morbidity. Medical and nursing schools will have to set up education projects in wealthy communities of urban areas that were not traditionally involved in community-based programs.
3.5 PRIMARY HEALTH CARE:
Medicine is passing through a period of innovative approaches to health care delivery. One of the most recent of these is the concept of primary health care (PHC) that essentially refers to the first point of contact of a patient with the health care system. PHC can be simple in a rural area or quite sophisticated. It does not have the connotation of second-class medicine.
The PHC strategy requires training a health professional who will be able to do the following: respond to health needs and expressed demands of the community; work with the community so as to stimulate healthy life style and self-care; educate the community as well as the co-workers; solve, and stimulate the resolve, of both individual and community health problems; orient their own as well as community efforts to health promotion and to the prevention of diseases, unnecessary sufferings, disability and death; work in, and with, health teams, and if necessary provide leadership to sick teams; continue learning lifelong so as to keep their competence up-to-date and even improve it as much as possible.
We can envisage medical education in the future taking place in primary care settings in both its simple and sophisticated modes.
4.0 THE ISSUE OF LEADERSHIP
4.1 LEADERSHIP IN SOCIETY:
Islam teaches that everybody is a leader in one way or another. A health care professional has a bigger leadership role than do ordinary persons. The best health care giver should be a social activist who goes into society and gives leadership in solving underlying social causes of ill health. The health care giver must play the role of leader in the community. He can lead when in the community and not the hospital. Inside the four walls of the hospital he or she acts as a technician and not a leader. The traditional medical school curriculum does not equip the future health professional with leadership skills in the form of class room teaching or actual field experience.
4.2 THE HEALTH PROFESSIONAL AS A MORAL MODEL:
The health care giver is a respected opinion leader therefore his or her moral values, attitudes, akhlaq, and thoughts must be a model for others.
4.3 LEADERSHIP ON MEDICO-LEGAL AND ETHICAL ISSUES:
There is an increasing interest among Muslim physicians and fuqaha in legal and ethical issues that arise due to recent advances in medical technology. The health care giver is expected to give leadership to patients on ethical issues that arise out of modern biotechnology. He must be trained not as a mufti who gives legal rulings but as a professional who understands the medical, legal, and ethical issues involved and can explain them to the patients and their families so that they can form informed decisions. In order to play this role well, the future health professional must have some grounding in Islamic law and other Islamic sciences
Muslim physicians, contemporary and ancient, did not write a lot about professional ethics in medicine because they assumed that a Muslim society is ethical and is a protection against ethical transgressions. However recent experiences in many countries have shown that there are so many unethical conduct and that special corrective measures are needed.
Unfortunately medical and nursing curricula do not prepare the future health professional to be a leader in ethics. They give information about ethics but cannot make a future health care giver an ethical person. Ethics cannot be taught as an academic discipline. Ethics have to be internalized so that they may inspire and guide.
4.4 LEADERSHIP IN ADVOCACY FOR THE LESS PRIVILEDGED
The health care giver comes into contact with people suffering from various physical ailments. He is acutely aware of the relation between illness and social handicaps such as poverty or discrimination. He therefore should be sensitive to the social root causes of disease. He cannot therefore confine himself to treating disease but must seek to remove the root causes by acting as an advocate for the less privileged.
4.5 LEADERSHIP IN ADVOCACY FOR HUMAN RIGHTS
Violation of human rights is often a direct cause of physical and emotional illness. It is part of preventive medicine that physicians are involved in efforts to ensure that all humans enjoy their human tights.