060613L - FUNDAMENTALS OF MEDICAL ETHICS

Lecture to 3^rd year medical students at the Kulliyah of Medicine International Islamic University, Kuantan, Malaysia on 13^th June 2006 by Professor Omar Hasan Kasule MB ChB(MUK), MPH (Harvard), DrPH (Harvard) Professor of Epidemiology and Islamic Medicine, Institute of Medicine Universiti Brunei Darussalam

1.0 PURPOSES AND PRINCIPLES OF MEDICINE

1.1 INTRODUCTION

Islamic Law is comprehensive. It is a combination of moral and positive laws. Secularized European law denies moral considerations associated with ‘religion’. Its failure to solve issues in modern medicine that required moral considerations led to the birth of the discipline of medical ethics. Muslims do not have a special discipline on medical ethics because medical ethical and moral issues are encompassed within Islamic Law. Concern with moral issues in medicine increased in the recent past due to new medical technology and increase in moral violations by medical practitioners. Europeans have written recently about ethics. In 1976 Beauchamps and Childress wrote authoritatively about ethical theory and ethical principles. The following international declarations covered legal medical issues from a European world-view: Declaration of Geneva, International Code of Medical Ethics, Declaration of Tokyo, Declaration of Oslo, and Declaration of Helsinki. Muslims did not need to publish any new declarations because principles of legal medicine are found within the Islamic Law. Islamic Law incorporates moral principles directly applicable to medicine.

1.2 EUROPEAN ETHICS

There are three European approaches to ethical analysis: normative (what ought to be done) or practical (what most people do), and non-normative (what is actually going on). Europeans have a problem dealing consistently with moral issues after removing religion from public life over the past 5 centuries of secularism. Morality became communal consensus about what is right and what is wrong. Thus ethics became relative and changeable with change of community values. European law does not follow a consistent moral guideline. It does not automatically ban all what is immoral and does not automatically permit all what is moral.

There is no one coherent European theory of ethics because of the historical background. During the Roman Empire a marriage of convenience held between Judeo-Christian concepts and pagan Greco-roman concepts. The marriage was strained by a partial return of Europeans to their Greco-Roman heritage and marginalization of the Christian Church starting with the renaissance and reformation through the enlightenment, modernism and now post modernism. In these circumstances it was difficult to define one coherent European ethical theory. Beauchamp and Childress listed eight European ethical theories none of which can on its own explain all ethical or moral dilemmas. These theories can be listed as the utilitarian consequence-based theory, the Kantian obligation-based theory, the rights-based theory based on respect for human rights, the community-based theory, the relation-based theory, and the case-based theory.

There are 4 basic European ethical principles according to Beachamp and Childress (1994) are: autonomy, beneficence, non malefacence, and justice.

1.3 ISLAMIC ETHICS

Morality in Islam is absolute and is of divine origin. The Law is the expression and practical manifestation of morality.  It automatically bans all immoral actions as haram and automatically permits all what is moral or is not specifically defined as haram. The Islamic approach to ethics is a mixture of the fixed absolute and the variable. The fixed and absolute sets parameters of what is moral. Within these parameters, consensus can be reached on specific moral issues. Islam considers medical ethics the same as ethics in other areas of life. There is no need for a special code for physicians. Islamic medical ethics is restating general ethical principles using medical terminology and with medical applications. The ethical theories and principles are derived from the basic law but the detailed applications require further ijtihad by physicians.

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 are derived from the 5 principles of the Law are: intention, qasd; certainty, yaqeen; harm, dharar. The Islamic principles are wider in scope and deeper than the European principles.

1.4 PURPOSES OF MEDICINE

PROTECTION OF DDIIN

Protection of ddiin is 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, siyaam; pilgrimage, hajj, and jihad. 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. Thus medical treatment of mental disorders thus contributes to ibadat. General public health has a special relation to jihad. If the general health of a population is not satisfactory, there will not enough youths to be recruited into the armed forces. There will also not be enough healthy workers to provide the material and logistics required for successful prosecution of war. If the obligation of jihad is not fulfilled, the Muslim community will be defeated and subjugated by others who will not give Muslims freedom to practice religion.

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, hifdh al nafs. Medicine cannot prevent or postpone death since such matters are in the hands of Allah alone. It however tries to maintain as high a quality of life until the appointed time of death arrives. Medicine contributes to the preservation and continuation of life by making sure that the nutritional functions are well maintained. Medical knowledge is used in the prevention of disease that impairs human health. Disease treatment and rehabilitation lead to better quality health.

PROTECTION OF PROGENY, hifdh al nasl

Medicine contributes to the fulfillment of this function by making sure that children are cared for well 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 healthy. Intra-partum care, infant and child care ensure survival of healthy children.

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.

  

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 general 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.

1.5 PRINCIPLES OF MEDICINE

THE PRINCIPLE OF INTENTION

The Principle of intention comprises several sub principles. The sub principle that 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 ‘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 that means are judged with the same criteria as the intentions implies that no useful medical purpose should be achieved by using immoral methods.

THE PRINCIPLE OF CERTAINTY, qaidat al yaqeen

Medical diagnosis does cannot reach the legal standard of 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.

THE PRINCIPLE OF INJURY, qaidat al dharar

Medical intervention is justified on the basic principle is 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 that in the 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 a 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 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 sharia 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 al alternative way if the obstacle ends, enforcement of the prohibited resumes/ It is illegal to get out of a difficulty by delegating to someone else to undertake a harmful act.

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.

2.0 REGULATIONS OF MEDICAL PROCEDURES, dhawaabit al tibaabat

2.1 EXAMINATION AND INVESTIGATION

Patient consent is necessary for history taking otherwise it is considered trespassing on privacy and spying. History taking provides an opportunity to discuss diseases of the heart that underlie physical disease. It is an opportunity for taubat and dawa. It is also opportunity to advise on legal matters such as foster relations and iddat. The physician is not obliged to report criminal information to the authorities unless there is demonstrable immediate public interest and necessity. Physical clinical examination also requires informed consent. A patient can only be examined against his or her consent only if there is a necessity relating to the life of the patient or to public interest such as criminal investigation. Mental patients can are not legally competent to give consent; the necessary consent could be obtained from a guardian, wali. Examination by a caregiver of the opposite gender requires special consideration. It is always preferable that physicians of the same gender carry out the examination. A physician of the opposite gender can be used only if a situation of necessity arises. A chaperone must be present. Examination limited to what is necessary. The results of laboratory investigations have the same requirements for confidentiality as history and clinical examination. The results of radiological investigations are confidential. Images that show the shape of the body parts can be considered showing awrat and should not be seen except by authorized people only and for specific purposes. Invasive investigations carry a higher risk to the patient; their benefits should be carefully weighed against the benefits. These investigations should be carried out only if there is a clear necessity, dharuurat.

2.2 MEDICAL TREATMENT

Medical treatment may involve destruction (antibiotics, cytotoxics, anti-metabolites, antagonists, antitoxins, and detoxification), replacement (hormones, fluids, electrolytes), biological modification & modulation, psycho-active therapy, and supportive treatment (diet, rest, analgesia etc). It is prohibited to use haram materials and najasat as treatment. What is prohibited as food or drink is also prohibited as medicine. Exceptions are made in cases of dharuurat. Medicine taken orally does not nullify wudhu. Any medicine that is taken but is not swallowed and is vomited out is considered like vomitus. Medicine given per rectum nullifies wudhu. Subcutaneous or intravenous or intramuscular injections do not nullify wudhu unless there is extensive external bleeding. Any medicine taken orally or rectally or any insertion of a scope will nullify saum.

2.3 SURGICAL TREATMENT

Permitted surgical procedures include resection, restorative/reconstructive surgery, transplantation, blood transfusion, anesthesia, and critical care. Transfusion of whole blood or blood components is widely accepted and raises few legal or ethical issues. Blood donation is analogous to organ donation by a living donor. Transfused blood is not considered filth, najasat, because it is not spilled blood. Blood transfusion is allowed on the basis of dharuurat. There is no problem in blood donation between Muslims and non-Muslims because they share human brotherhood. There is no problem in blood transfusion between a man and a woman. Blood transfusion does not abrogate the wudhu of the donor or the recipient. Sale of blood is permitted using the analogy of sale of milk by wet nurse who is paid for her services. Attempts must be made to minimize inappropriate mixing of male and female health care personnel in a small confined space of the operating theater. In emergency treatment/critical care, financial considerations complicate the picture when destitute patients who cannot pay present at the emergency room.

2.4 OTHER TREATMENTS

Dua, ruqyah, tawakkul, and raja are spiritual treatments. Immunization and other preventive measures are treatment before disease and are not denial of qadar. It is permitted to slaughter on behalf of the sick taqarruban ila al llaah and to give the poor. It is prohibited to slaughter for the jinn and the shaitan. Various traditional, alternative, and complementary therapies are permitted if they are of benefit. Other permitted treatment modalities are irradiation, immunotherapy, and genetic therapy.

3.0 RESEARCH: THEORY, PRACTICE, and POLICY

3.1 RESEARCH IN ISLAM

Islam puts emphasis on seeking knowledge. The search for knowledge is a difficult but necessary process as we learn from the story of Musa and the righteous man. Islam encourages benefitting and using knowledge. There is no consideration for knowledge not accompanied by practical application. Tadabbur involves critical observation and consideration of information. Tadabbur involves critical consideration of information. Humans are encouraged to derive empirical knowledge from observation of the earth and their own bodies. The observation referred to is serious and deliberative, al nadhar bi al tadabbur. Tadabbir is required even with the holy text of the Qur’an. Thought can be based on empirical observation. The observation can be of the earth. It can also be by observation of the human body. Islam encourages active intellectual effort in looking for knowledge. The process of ijtihad is exertion of maximum intellectual effort to discover the truth or understand the relation between truths. Ijtihad is also used to discover and identify falsehoods. There are parallels between the tools of ijtihad used by classical Muslim scholars and the processes of reaching conclusions in modern scientific research. The process of inductive logic used in medical research is the same as qiyaas usuuli used by scholars of the methodology of the Law. The process of reaching a scientific consensus is similar to the process of scholarly consensus. The prophet taught that there is a cure for every disease. There is an injunction to search for cures by processes of medical research.

3.2 RESEARCH PRACTICE

The Ethics committee approves research proposals and protocols that have ethical implications. It ensures the highest ethical standards in any research and protection of research subjects as stipulated in the Helsinki declaration, and protection of researchers from committing mistakes that lead to criminal prosecution. It monitors the conduct of the study to detect any ethical violations. Membership should include major medical and surgical specializations, hospital physicians, hospital nursing staff, general practitioners, pharmacists, statisticians, ethicists, and lay persons from the community. All genders and age groups must be represented. The research application form consists of the following: identifying information, description of the research, protocol and dates, methodology of research, and ethico-legal issues. The patient/volunteer information sheet provides information on the research: purposes, procedures, duration, risks, benefits, and ethico-legal issues. The informed consent form ensures that the research subject understands the research and voluntarily agrees to participate. A confidential questionnaire for research subjects should include questions on the adequacy of the information sheet amd voluntary consent. A confidential review questionnaire for researchers should include items about: start and end of the study, protocol amendments, progress of recruitment, provision of information, obtaining consent, withdrawal of consent, adverse events, and outcome of research.

3.3 RESEARCH POLICY

Research is a departure from the commonly accepted treatment. Recruitment into studies should reflect the community’s ethnic, gender, and age distribution. Results of an unbalanced study may not be applicable to all groups. Decisions on research priorities may be made on a scientific basis or a non-scientific basis (political, socio-cultural, elite interests). The source of funding may in an indirect and discreet way influence the conduct of research and the report of its findings thus leading to lack of objectivity. Islam enjoins dissemination of knowledge. Islam encourages dissemination of research findings by teaching or publication. Islam prohibits hiding knowledge. Drug companies that sponsor research to develop patentable products do not appreciate the type of transparency advocated by Islam. Publication of research results serves scientific communication and scientific networking. Concern about copyright and intellectual property rights limits dissemination of knowledge by publication. Biases in publication arise at the level of researchers who normally do not submit negative studies for publication. Editors prefer publishing positive studies. Biases in selection of papers for publication arise from the peer review process due to old boy networks. Despite the best of efforts to police itself, the scientific research community still has cases of research fraud. Fraud manifests as cooking or doctoring data, selective reporting of data, suppression of negative information, and ‘stealing’ others’ work. Financial gain, reputation, and the pressure to publish or perish are the driving forces behind fraud.

4.0 REGULATIONS OF PHYSICIAN CONDUCT, dhawaabit al tabiib

4.1 VALUES, COMPETENCE, AND RESPONSIBILITY

The physician-patient is based on brotherhood. The physician must maintain the highest standards of justice. He should also follow the following guidelines from the sunnat: good intentions, avoiding doubtful things, leaving alone matters that do not concern him, loving for others, causing no harm, giving sincere advice, avoiding the prohibited, doing the enjoined acts, , renouncing greed, avoiding sterile arguments, respect for life, basing decisions and actions on evidence, following the dictates of conscience, righteous acts, quality work, guarding the tongue, avoiding anger and rage, respecting transgressing Allah’s limits, consciousness of Allah in all circumstances, performing good acts to wipe out bad ones, treating people with the best of manners, restraint and modesty, maintaining objectivity, seeking help from Allah, and avoiding oppression or transgression against others. The physician should be professionally competent (itiqan & ihsaan), balanced (tawazun), have responsibility (amanat) and accountability (muhasabat). He must work for the benefit of the patients and the community (maslahat).

4.2 MEDICAL DECISIONS

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 their decision-making. 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, recommendation of the physician on the best course of action, decision by the patient, and authorization by the patient to carry out the procedures. The patient is free to male decisions regarding choice of physicians and choice of treatments. Consent can be by proxy in the form of the patient delegating decision making or by means of a living will.

Valid consent must be voluntary, informed, and by a person with capacity to consent. It involves explaining the procedure contemplated, making sure the patient understands, and offering the patient a choice. 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. 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. 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, doctors in armed forces. Police surgeons may have to carry out examinations on suspects without informed consent.

CONSENT OF THE INCOMPETENT

Competent children can consent to treatment but cannot refuse treatment. The consent of one parent is sufficient if the 2 disagree. Parental choice takes precedence over the child’s choice. 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 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. Nutrition, hydration, and treatment can be withdrawn in a persistent vegetative state since the chance of recovery is low. There is no moral difference between withholding and withdrawing futile treatment. Labor and delivery are emergencies that require immediate decisions but the woman may not be competent and proxies are used. Forced medical intervention and ceserian section may be ordered in the fetal interest. Birth plans can be treated as an advance directive.

4.3 DISCLOSURE AND TRUTHFULNESS

As part of the professional contract between the physician and the patient, the physician must tell the whole truth. Patients have the right to know the risks and benefits of medical procedure in order for them to make an autonomous informed consent. Deception violates fidelity. If disclosure will cause harm it is not obligatory. Partial disclosure and white or technical lies are permissible under necessity. Disclosure to the family and other professionals is allowed if it is necessary for treatment purposes. Physicians must use their judgment in disclosure of bad news to the patient.

4.4 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. 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 ofr insurance.

4.5 FIDELITY

The principle of fidelity requires that physicians be faithful to their patients. It includes: acting in faith, fulfilling agreements, maintaining relations, and fiduciary responsibilities (trust and confidence). It is not based on a written contract. Abandoning the patient at any stage of treatment without alternative arrangements is a violation of fidelity. The fidelity obligation may conflict with the obligation to protect third parties by disclosing contagious disease or dangerous behavior of the patient. The physician may find himself in a situation of divided loyalty between the interests of the patient and the interests of the institution. The conflict may be between two patients of the physician such as when maternal and fetal interests conflict. Physicians involved in clinical trials have conflicting dual roles of physicians and investigators.

5.0 REGULATIONS ABOUT PROFESSIONAL MISCONDUCT

5.1 ABUSE OF PROFESSIONAL PRIVILEDGES

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 he 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 purposes of teaching and research, disclosure for purposes of health management.

5.2 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.

5.3 PUBLIC PROFESSIONAL MIS-CONDUCT

Physicians in private practice must adopt good business practices. Halal transactions are praised (Zaid H539). An honest businessman is held in high regard (Tirmidhi K12 B4). Leniency in transactions is encouraged (Bukhari K34 B16). Full disclosure is needed in any transaction (Ibn Majah K12 B45). Measures and scales must be fulfilled (Muwatta K31 H99). Bad business practices are condemned. There is no blessing in immoral earnings (Darimi K20 B60). Selling over another’s sale is prohibited (Bukhari K34 B58). Cheating is condemned (Bukhari K34 B19). Also condemned are financial fraud including criminal breach of trust, riba on bills, fee splitting, bribery (Abudaud K23 B4). 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 as ajr al tabiib (Bukhari K37 B16). Medical fees cannot be fixed by government because the Prophet refused to fix prices (Abudaud K22 B49).