100606P - CURRICULUM REFORM AT MUSLIM MEDICAL SCHOOLS

Dr Omar Hasan Kasule Sr

MB ChB (MUK), MPH (Harvard), DrPH (Harvard)

Professor of Epidemiology and Bioethics

Faculty of Medicine King Fahd Medical City

Riyadh, Saudi Arabia

Workshop on the 'Integration of the Islamic Input in the Medical Curriculum with Competence-Based Curriculum In Muslim Medical Schools' with the theme 'Curriculum Reform of Medical Education in Medical Schools affiliated to the Federation of Islamic Medical Associations' held at Bumi Senyiur Hotel Samarinda East Kalimantan Province Indonesia 4-6 June 2010

TABLE OF CONTENTS

Philosophy Of Islamic Medical Education: Epistemological And Curriculum Reform - PAGE 3

Ethical Issues In Medical Education: An Islamic Framework - PAGE 19

Towards Implementing The Islamic Input Curriculum         PAGE 31

1006 PHILOSOPHY OF ISLAMIC MEDICAL EDUCATION: EPISTEMOLOGICAL AND CURRICULUM REFORM

Paper presented at a Workshop on The Integration of the Islamic Input in the Medical Curriculum with Competence-Based Curriculum In Muslim Medical Schools' with the theme 'Curriculum Reform of Medical Education in Medical Schools affiliated to the Federation of Islamic Medical Associations' held at Bumi Senyiur Hotel Samarinda East Kalimantan Province Indonesia 4-6 June 2010 by Dr Omar Hasan Kasule MB ChB (MUK), MPH (Harvard), DrPH (Harvard) Professor of Epidemiology and Bioethics Faculty of Medicine King Fahd Medical City Riyadh EM omarkasule@yahoo.com. WEB http://omarkasule.tripod.com

ABSTRACT

The paper is based on the thesis that epistemological reform is necessary for educational excellence. The paper starts by summarizing basic concepts and paradigms of Islamic epistemology and methodology of research. It then discusses the current crisis of knowledge and education in the ummat manifesting as low motivation for learning and love or respect for knowledge. The solution of the education crisis will start by epistemological reform in each of the disciplines of knowledge. Epistemological reform is defined as identifying biases in basic paradigms and research methodology that reflect a non-tauhidi world-view. This is followed by reformulating basic epistemological concepts and paradigms of various disciplines from a tauhidi paradigm characterized by objectivity, istiqamat al ma’arifat, and universality, ‘aalamiyyat al ma’arifat, of knowledge. The paper briefly describes the necessary curriculum for undergraduate medical education.. The conclusion of the paper is that excellence in learning and research will be achieved after epistemological reform that will motivate students and teachers to pursue knowledge within the tauhidi framework that conforms to their inner values and world-view.

1.0 BASIC EPISTEMOLOGICAL CONCEPTS

1.1 What is Islamic epistemology?, nadhariyat al ma’arifat al islamiyyat

Epistemology is the science of knowledge, ‘ilm al ‘ilm. It is the study of the origin, nature, and methods of knowledge with the aim of reaching certainty. Islamic epistemology, nadhariyyat ma’rifiyyat Islamiyyat, is based on the tauhidi paradigm. Its fixed parameters are from revelation, wahy. Its variable parameters are conditioned by varying spatio-temporal circumstances. Its sources are revelation (Qur’an and sunnat), empirical observation and experimentation, and human reason. Its main challenge today is achieving objectivity, al istiqamat, which is staying on the path of truth and not being swayed by whims and desires.  Istiqamat comes only next to iman, as the Prophet said 'qul amantu bi al laahi thumma istaqim'.

1.2 Nature of knowledge, tabi’at al ma’arifat al insaniyyat

The Qur’anic terms for knowledge are: ‘ilm, ma’arifat, hikmat, basiirat, ra’ay, dhann, yaqeen, tadhkirat, shu’ur, lubb, naba’, burhan, dirayat, haqq, and tasawwur. The terms for lack of knowledge are: jahl, raib, shakk, dhann, and ghalabat al dhann. Grades of knowledge are ‘ilm al yaqeen, ‘ayn al yaqeen, and haqq al yaqeen. Knowledge is correlated with iman, ‘aql, qalb, and taqwah. The Qur’an emphasizes the evidential basis of knowledge, hujjiyat al burhan. The seat of knowledge is the ‘aql, and qalb. Allah’s knowledge is limitless but human knowledge is limited. Humans vary in knowledge.  Knowledge is public property that cannot be hidden or monopolized. Humans, angels, jinn, and other living things have varying amounts of knowledge. Knowledge can be absolute for example revealed knowledge. Other types of knowledge are relative, nisbiyat al haqiqat. The probabilistic nature of knowledge arises out of limitations of human observation and interpretation of physical phenomena.

1.3 Sources of knowledge, masadir al ma’arifat:

Revelation, wahy, inference, ‘aql, and empirical observation of the universe, kaun, are major sources of acquired knowledge accepted by believers. In terms of quantity, empirical knowledge, ‘ilm tajriibi, comes first. In terms of quality revealed knowledge, ‘ilm al wahy, comes first. There is close interaction and inter-dependence between revelation, inference, and empirical observation. ‘Aql is needed to understand wahy and reach conclusions from empirical observations. Wahy protects ‘aql from mistakes and provides it with information about the unseen. ‘Aql cannot, unaided, fully understand the empirical world.

1.4 Classification of knowledge, tasnif al marifat

Knowledge can be innate or acquired. It can be ‘aqli or naqli. It can be knowledge of the seen, ‘ilm al shahadat, and knowledge of the unseen, ‘ilm al ghaib. The unseen can be absolute, ghaib mutlaq, or relative, ghaib nisbi. Acquisition of knowledge may be individually obligatory, fard ‘ain, whereas other knowledge is collectively obligatory, fard kifayat. Knowledge can be useful, ‘ilmu nafiu. Knowledge can be basic or applied. There are many different disciplines of knowledge. The disciplines keep changing with advance of knowledge and understanding. A discipline is defined and is limited by its methodology.

1.5 Limitations of human knowledge, mahdudiyat al marifat al bashariyyat

The Qur'an in many verses has reminded humans that their knowledge in all spheres and disciplines of knowledge is limited. Human senses can be easily deceived. Human intellect has limitations in interpreting correct sensory perceptions. Humans cannot know the unseen, ghaib. Humans can operate in limited time frames. The past and the future are unknowable with certainty. Humans operate in a limited speed frame at both the conceptual and sensory levels. Ideas can not be digested and processed if they are generated too slowly or too quickly. Humans cannot visually perceive very slow or very rapid events. Very slow events like the revolution of the earth or its rotation are perceived as if they are not happening. Human memory is limited. Knowledge acquired decays or may be lost altogether. Humans would have been more knowledgeable if they had perfect memory.

2.0 CRISIS OF KNOWLEDGE and EDUCATION, azmat al ma’arifat wa al ta’aliim

2.1 Manifestations of the crisis

There is pervasive ignorance of uluum al diin and uluum al dunia. There is little respect for scholarship. Wealth and power are considered more important than scholarship. There is neglect of the empirical sciences. There is a dichotomy in the education system: traditional Islamic vs. imported European, ulum al diin vs ulum al dunia. Integration of the 2 systems has failed or has been difficult because it has been mechanical and not conceptual. The process of secularization in education has removed the moral dimension from the education and violated the aim of Islamic education to produce an integrated and perfect individual, insan kaamil. The brain drain from Muslim countries has compounded the educational crisis.

2.2 Ummatic malaise due to the knowledge crises

Knowledge deficiency and intellectual weakness are the most significant manifestation of ummat’s decadence. The intellectual crisis of the ummat is worsened by copying and using poorly digested alien ideas and concepts. The prophet warned the ummat about the lizard-hole phenomenon in which the ummat in later times would follow its enemies unquestionably like the lizard running into its hole. Among the manifestations of the ummatic malaise are action deficiency, political weakness, economic dependency, military weakness, dependence in science and technology, and erosion of the Islamic identity in life-style.

2.3 Historical background

The generation of the Prophet (PBUH) was the best generation. The best teacher met the best students and excellent results were obtained. Companions had excellent knowledge and understanding. Seeds of the current crisis appeared towards the end of the khilafat rashidat. New social and political forces overthrew the khilafat rashidat and the ideals it represented were distorted or abolished. Then the authentic ‘ulama and opinion leaders who remained faithful to the ideals of Islam were marginalized and persecuted. Intellectual stagnation then ensued. The process of secularization of the Muslim state progressed. Widespread ignorance and illiteracy became common. Many non-Islamic ideas and facts without valid proof have found their way into the intellectual and religious heritage of the ummat making the existing intellectual crisis even worse.

3.0 SOLUTION OF THE KNOWLEDGE CRISIS BY EPISTEMOLOGICAL AND CURRICULUM REFORM

3.1 The concept of reform:

Reform of knowledge is a process of recasting the corpus of human knowledge to conform to the basic tenets of ‘aqidat al tauhid. The process of reform does not call for re-invention of the wheel of knowledge but calls for reform, correction, and re-orientation. It is evolutionary and not revolutionary. It is corrective and reformative. It is the first step in the reform of the education system as a prelude to reform of society.

3.2 History of reform

The 2-3^rd centuries H witnessed a failed effort at knowledge transfer. Greek scientific knowledge was transferred to Muslims together with Greek philosophy and ideas that caused confusions in ‘aqiidat. Greek science depended more on philosophical deduction than experimentally-based induction. It discouraged the scientific tarbiyat of the Qur’an which emphasized observation of nature as a basis for conclusions. The recent knowledge reform movement towards the close of the 14^th century H aims at building an education system based on tauhid.

3.3 Reform of disciplines:

Reform has to start with reforming the epistemology, methodology, and corpus of knowledge of each discipline. It must be pro-active, academic, methodological, objective, and practical. Its vision is objective, universal, and beneficial knowledge in the context of a harmonious interaction of humans with their physical, social, and spiritual environment. Its practical mission is transformation of the paradigms, methodologies, and uses of disciplines of knowledge to conform to tauhid. Its immediate goals are: (a) reforming paradigms of existing disciplines to change them from parochiality to universal objectivity, (b) reconstruction of the paradigms using objective and universal guidelines, (c) re-classifying disciplines to reflect universal tauhidi values, (d) reforming research methodology to become objective, purposeful, and comprehensive (e) growth of knowledge by research, and (f) inculcating morally correct application of knowledge. The Qur’an gives general principles that establish objectivity and protect against biased research methodology. It creates a world-view that encourages research to extend the frontiers of knowledge and its use for the benefit of the whole universe. Scientists are encouraged to work within these Qur’anic parameters to expand the frontiers of knowledge through research, basic and applied.

3.4 Misunderstanding the reform process

Reform has been misunderstood as rejection of the corpus of existing human knowledge and disciplines. It has been misunderstood as creation of knowledge exclusive to Muslims. It has been misconstrued as rewriting existing text-books to reflect Islamic themes without deep thought about the paradigms and methodology. It has also been confined to spiritual reform of the student, scholar, or researcher. The following superficial approaches to reform have been tried and failed: ‘Insertion’ of Qur’anic verses and hadiths in an otherwise European piece of writing, searching for scientific facts in the Qur’an, searching for Qur’anic proof of scientific facts, establishing Qur’anic scientific miracles, searching for parallels between Islamic and European concepts, using Islamic in place of European terminologies, and adding supplementary ideas to the European corpus of knowledge.

3.5 Practical steps / tasks of the reform process:

The first step is a good grounding in Islamic methodological sciences of usul al fiqh, ‘uluum al Qur’an, ulum al hadith, and 'uluum al llughat. This is followed by reading the Qur’an and sunnat with understanding of the changing time-space dimensions. This is followed by clarification of basic epistemological issues and relations: wahy and aql, ghaib and shahada, ‘ilm and iman. This is followed by an Islamic critique of basic paradigms, basic assumptions, and basic concepts of various disciplines using criteria of Islamic methodology and Islamic epistemology. Islamic reviews of existing text-books and teaching materials are then undertaken to identify deviations from the tauhidi episteme and the Islamic methodology.

The initial output of the reform process will be Islamic introductions to disciplines, muqaddimat al ‘uluum, establishing basic Islamic principles and paradigms that determine and regulate the methodology, content, and teaching of disciplines. This parallels Ibn Khaldun’s Introduction to History, muqaddimat presented generalizing and methodological concepts on historical events. Publication and testing of new text-books and other teaching materials is a necessary step towards reform by putting into the hands of teachers and students reformed material. Developing applied knowledge in science and technology from basic knowledge will be the last stage of the reform process. This is because in the end it is science and technology that actually lead to changes in society.

4.0 OUTLINE OF AN UNDERGRADUATE MEDICAL CURRICULUM

INTEGRATING ISLAMIC VALUES

4.1 BACKGROUND PHILOSOPHY and CONCEPTS

4.1.1 RELIGIOUS BACKGROUND

Islam: The 3 fundamentals (Islam, Iman, & Ihsan), monotheism (Tauhid), Messengers and messages (risaalat), eschatology (aakhirat), Ithm (sinning), Dhulm (transgression).  Pre-determinism: qadar / taqdiir (causality, human will, human responsibility and accountability for actions / choices, human rights and limits to individual freedom., health promotion, disease prevention, the concept of pre-determination in relation to disease: causation, prevention, and treatment). Reconciliation between pre-determination and probability theory.

Other creeds (milal): The academic definition of religion (an object of worship, a prophet, theology, scriptures, doctrines & dogmas, rites, rituals, & ceremonies, icons or symbols, holidays, ethics and social teachings). Dogmas with medical implications in Buddhism, Hinduism, Nasraniyyat, Confucianism, Yahudiyyat, Shintoism, and Taoism, and others

4.1.2. HISTORICAL BACKGROUND

Civilization: Start of human civilization (khilafat, taskhiir, ‘omraan). Cycle of civilizations: World & Muslim history (phases of civilizational growth, factors or rise and fall of civilizations, achievements and failures, renewal and reform)

History of medicine: Ancient medicine; Concept of Islamic Medicine (definition as values and ethics and not specific therapeutic procedures). Prophetic Medicine (definition, sources, classification, examples, modern applications);  European TCM (naturopathy, homeopathy, osteopathy, chiropractic),  Chinese TCM (theory and philosophy, history, diagnostic techniques, treatments, efficacy and safety, modernization), Ayurdevic TCM (history, diagnosis, treatmemts, present status, scientific study). Unani TCM (historical background, humors, present status), Borneo TCM. Critique of biomedicine vs holistic medicine (depersonalization, atomistic vs holistic).

4.1.3 EPISTEMOLOGICAL BACKROUND

Theory Of Knowledge (epistemology): Knowledge (philosophy, history, sources, classification, methodology, objectivity vs bias, limitations).  The duality/dichotomy crisis (traditional vs European knowledge / education systems). The empirical methodology / scientific method (strengths, limitations, weaknesses), Integration of knowledge (the spiritual-matter duality and relation to medicine).

4.1.4 BASIC SCIENCES BACKROUND

Creation (cosmogenesis / genesis) and afterlife (eschatology): Creation of the universe (ultimate questions, start of the universe). Cosmology (signs of creation; will and power; physical laws, order, change and permanence). Creation of the human being (creationist vs evolution views), nature of the human (matter-spirit duality, strengths & weaknesses). Superiority of humans (intellect and moral values). Mission of humans on earth (khilafat & taskhiir). Diversity of humans (racial/ethinic, social, cultural). After-life (linear and incarnation). The concept of personhood (when does life start, when does legal personhood start).

Transitions in the status of life and health: Life (definition, nature, criteria, quality, worth/value). Death (definition, nature, process, criteria, and attitudes). Health (definition, quality, determinants, individual, family, community, protection, and promotion). Disease / illness (definition, classification, causes, positive and negative attributes and consequences). Treatment of disease (cure vs prevention, curability of all disease, complementation between prevention and cure, modalities of treatment, doa, slaughtering, superstition).

The human life cycle (growth and senescence): Intrauterine period (conception, stages, external and internal environments, ethico-legal implication of the start of life, disorders). Infancy and childhood (parenthood, physical, social, and psychosocial growth, disorders). Adolescence (definition, physical changes, problems of transition, mismatch between biology and wisdom / experience). Youth (definition, stress career vs family, cognition vs emotion, idealism vs pragmatism, morality vs hedonism). Middle age (definition, biological, social, psychological changes in men and women, the midlife crisis, menopausal problems: physical, psycho-social-sexual). Old age (definition,  theories og aging, homeostasis vs homeostenosis, ageing vs disease, characteristics, physical decline, psychosocial functions, care for the elderly: home vs institution, research on the elderly, common health disorders, exemption of the elderly from social and religious obligations), after life (linear vs cyclic concepts).

The Biological Miracle: The human organism (perfection, optimality, incomparability). Interaction of the external and internal environments (homeostasis, equilibrium, balance, central tendency, ecology, pathological repair & restoration). Functional unity of the organism (control, command, and communication systems of DNA, the nervous, endocrine, sensory, and immunological systems, negative vs positive feedback). Correlation of structure and function by organ systems: input-output (alimentary and urinary), transport (cardiovascular and respiratory), command, control, aned coordination (sensory, nervous, endocrine, immunological systems), locomotor, support, and protective (musculoskeletal and connective systems).

4.2 ETHICO-LEGAL-FIQH CONCEPTS & PRINCIPLES

4.2.1 BASICS OF LAWS

Fundamentals of the Law: Sources of Islamic Law (Qur’an, sunnat, ijma, qiyaas etc). Sources of European Law (statute, case law). Purposes of the Law: maqasid al shari’at (morality, life, progeny, intellect, resources). Principles of the Law: qawa’id al shari’at (intention, certainty, injury, hardship, custom). Types of legal rulings (halal, haram, mubaah, makruh, aziimat & rukhsat), Relation of ethics to law (the Islamic vs European perspectives). The law and human rights (Islamic vs the European perspectives). Equality before the law (non discrimination on grounds of race/ethnicity, national origin, creed, political affiliation, gender, age, and disability status).

Practical: visits to Mufti Office and Attorney General’s Chambers

4.2.2 THEORIES AND PRINCIPLES OF MEDICAL ETHICS

Theories of medical and biomedical ethics: Islamic theory: maqasid al shari’at (morality, life, progeny, intellect, and resources). European theories (deontology vs. teleology, consequentialism / utilitarianism, principlism, Kantian, virtue, relationship, and casuistry, communitarian ethics, feminist ethics, empirical).

Principles of medical and biomedical ethics: Islamic (intention, certainty, harm, hardship, custom) and secular European (autonomy, beneficence, nonmalefacence, justice), Christian, Buddhist, Jewish, and empirical. International ethical codes (Hippocratic, Nurenberg, Helsinki, World Medical Health Association, UNESCO Universal Declaration of Bioethics and human rights 2005)

Practical: visit to Brunei Medical Board offices

4.2.3 ISSUES OF CONSENT

Medical consent for competent patients: Patient autonomy (definition, legal and conceptual basis, significance in health care, limitations, patient autonomy vs physician paternalism, second opinion, conflict between human rights and requirements of medical treatment). Physician autonomy (forcing a procedure on a physician). Competence / capacity (definition, conditions, testing). Informed consent (definition, process, who asks?). Scope of consent (physician choice, physician of a different gender, treatment, refusal). Conditions for validity of consent (understanding, disclosure, weigh info, voluntary, aware can refuse). Information for informed consent (diagnosis, prognosis, treatment alternatives, risks and benefits). Capacity to consent (global vs specific, tests for capacity, enhancing capacity). Consent / refusal for the competent (process).

Practical: Visit to the emergency room in the evening.

Medical consent for incompetent patients: Consent / refusal for the incompetent (young children, older children, the mentally ill, the unconscious). Consent in emergencies (competent patient but no time for consent, incapacitated patients, resuscitation after attempted suicide, carrying out an unauthorized /unfamiliar procedure to save life, refusal of emergency treatment by a competent / incompetent person, advance refusal, forensic search of unconscious patients, off duty doctor in an emergency, disclosure of emergency room information to the police, forensic searches of emergency patients: blood alcohol levels, domestic violence and child abuse in ER, admission of relatives into ER). Physician assessment of best interests of the patient. Proxy decisions (parents, relatives, designated person). Advance statements (definition, scope, format, witnesses, advantages, and disadvantages). Consent by the court. Treatment options (economic and other considerations).

Practical: consent procedures in surgical and obstetric wards.

4.2.4 PRIVACY, CONFIDENTIALITY AND DISCLOSURE

Privacy and confidentiality: Privacy (definition, relation to patient autonomy). Confidentiality (definition, what information is considered confidential, anonymized information, violation with / without consent, disclosure about the deceased). Basis/ rationale / justification of confidentiality (clinical care. Autonomy and privacy, fidelity, social basis, legal basis). Truthfulness (obligation to tell the truth, information patient does not need/want to know, partial disclosure / white / technical lies, giving bad news, the physician’s body language).

Disclosure: Disclosure (by the patient, with consent for education, research, and insurance; without consent to other healthcare professionals and in the public interest). Conflict of duties regarding confidentiality and disclosure to: insurance, employer, HIV, witness in litigation (with consent, without consent). Disclosure of family history / genetic information (by the patient vs by the physician, request by the employer, request by the police).Generation and handling of medical records (SOAPIE, various forms of records, ideal record, omitting or removing information, legal ownership of records, ensuring record security, period of retention of records, patient access to records, access to records of the incompetent, issues in storage and retrieval of records). Disclosure to the mass media (public vs individual interest). Disclosure by doctors with dual obligations: occupational, army, police, prisons, sports, hospital manager (with consent, without consent). Physician in court: as a witness of facts vs expert witness (duty to patient vs public duty to justice, testifying for vs testifying against the patient).

Practical: visit to hospital medical records department.

4.2.5 RESEARCH

Research policies and procedures: Composition of Institutional research committee. Functions of an Institutional research committee / basis for ethical approval (scientific merit, competence of researchers, social value, risks vs benefits, informed consent, confidentiality, conflict or interests / roles, transparency, disclosure, publication / funding bias).  Types of fraud in research (not following GCP guidelines, no consent, data falsification, plagiarism, including names that did not participate, researchers not trained, falsifying authorship). Avoiding research fraud / malpractice (training in GCP, ethical and scientific review of research proposal, detailed recording of all research activities, researchers must be personally involved, quality assurance and audit, encourage whistle blowing.

Practical: visit to the Ministry of Health research ethics committee

Animal research: Handling animals before, during, and after research (kindness and good treatment, forbidding cruelty, nutrition, minimize pain, respect even in death). Purposes of animal research (spare humans from risk, the doctrine of taskhiir). Purposes and principles of the Law in animal research. Relevance to humans (similar physiology, findings not definitive human research still needed). Choice of animals for research (edible vs non-edible, pets, wild vs domestic, big vs small, dangerous vs innocuous).

Practical: visit to the animal house.

Human research: History (historical evolution, historical ethical violations). Phases of clinical trials (1,2,3, and 4). Therapeutic vs non-therapeutic research. Good clinical practice guidelines. Autonomy / informed consent (research on humans, research on records, postmortem research). Information given to patients before consent (the treatment, available information, missing information necessitating research, difference between the new and the standard treatments, alternative treatments, risks and benefits, measures to ensure safety). Freedom to withdraw. Material inducements. Confidentiality (anonymized data, personal details disclosed with consent). Research in emergency rooms. Inclusion of women and minorities. Research on the mentally incompetent. Record based research. Research on cadavers. Research on Children (consent by competent children endorsed by parents, parental consent for incompetent children, children’s physiological vulnerability, parental consent for research in child’s interest. Parental consent for research not in the child’s interests, benefits > risks, child overriding parental consent). Research on the elderly. Research on the mentally incapacitated. Research on prisoners. Research on students and employees. Research on members of uniformed services, army and police (consent vs obeying chain of command). Research on biological samples, organs, and tissues from living donors (informed consent if not anonymous, storage of material, benefits and risks, confidentiality). Research on organs and tissues from dead donors (consent by family, storage, confidentiality).  Research on embryos (sources of embryos, types of disease that benefit). Research on fetal tissues (spontaneous abortions, induced abortions, financial inducements). Biomedical research. Public health research. Health services research.

Practical: visit to a clinical trials operations office

4.3 ISSUES AT THE BEGINNING AND END OF LIFE

4.3.1 Beginning of life issues: Prenatal / pre-implantation gender testing in IVF. Induced abortion (maternal disease, unwanted pregnancy, gender selection, congenital anomalies).

Practical: visit IVF / fertility clinic

4.3.2 Stem cell technology:  Stem cells (definition, methods, use in disease therapy, use in research, sources of stem cells and ethical controversies).

4.3.3 Embryo/fetal research: Sources of embryos. Types of research that uses embryos (contraception, sterilization, reproductive cloning). Ethical guidelines and controversies.

4.3.4 Genetic technology: Genetic therapy. Genetic banks and patenting issues. Human-animal hybrids. The Human genome project. Genetic testing. Genetic screening. Pre-implantation diagnosis. Genetic engineering and therapy.

4.3.5 End of life issues:  Terminal illness (definition). Palliative care (definition, content, organization, institutional vs home, modalities, ethical and legal issues). Diagnosis of brain death (whole brain & higher brain). Initiating / withdrawing artificial life support (principles of saving life, certainty, resource conservation, autonomy). Euthanasia (definition, purpose of life, difference between legal withdrawal and euthanasia, acts of omission and commission). Physician assisted suicide. Solid organ transplantation (living and cadaver donor, xenotransplantation, use of anencephalic donor, neural transplantation, fetal transplantation). Post-mortem examination (purposes, process, ethico-legal controversies). Cadavers (research on cadavers, display and teaching on cadavers, dissection of cadavers, storage and use of human tissues).

4.4 ETHICO-LEGAL-FIQH ISSUES IN MEDICAL PRACTICE

4.4.1 NORMAL PHYSIOLOGICAL CONDITIONS

Issues in normal reproduction: Menstruation (salat, puasa, recitation, use of hormones to delay menses in Ramadhan and hajj, activities allowed/prohibited during menstruation).  Pre-menstrual tension (impact on social and religious obligations). Irregular menstruations in the climacteric period (impact on salat, puasa, sexual life). Prolonged menstruation (puasa, salat, coitus). Dysmenorrhea (salat). Menopause (definition, early induction medically or surgically, artificial delay, HRT). Human sexuality & sexual behavior (forms sexual expression and behavior, regulation of human sexuality, guidelines on coitus, moral/cultural relativism regarding sexual behavior). Contraception (legal permissibility, autonomy decisions: individual choice vs public policy, disagreement between spouses, risks and benefits of various methods, allowed and prohibited methods, contraception for the unmarried, sterilization of the mentally retarded, relation to sexual promiscuity, demographic impact, parental consent for minors). Pregnancy (legal minimum and maximum duration). Prenatal screening & diagnosis genetic/non-genetic (benefits & risks, non-therapeutic abortion, human rights of the embryo). Labor (puasa and salat). Delivery (autonomy in choice of method, refusal of CS, request for CS, maternal-fetal conflict). Postnatal care (iqamat and adhan at birth, naming, aqiiqat). Breast-feeding (duration, foster feeding).

Practical: visits to gynecological and ante-natal clinics.

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Issues in activities of normal living: Physiological secretions and wudhu / salat (skin and integuments, hair, ear, nose, throat, mouth, urogenital, intravascular, interstitial, pathological secretions, & intubation, and catheterization). Environmental hygiene (bad odors in mosque and public gatherings).  Foods & drinks (sources, halal & haram, etiquette of meals, food hygiene, control of the appetite, waste of food, hunger and thirst). Physical activity (difference between physical activity and physical exercise, health, recreational, and other benefits). Standing, sitting, walking and running (purposes, bipedal locomotion, upright posture, dynamic and static balance, postural hypotension in prolonged salat). Sports (traditional, violent, participatory & non-participatory), sleep and rest (definition, a form of death, purposes, etiquette, dreams, disorders, legal competence of the sleeping person).

4.4.2 MEDICAL PROCEDURES

Diagnostic procedures: History (consent, scope, lifestyle questions, confidentiality, nasiha). Physical examination (consent, uncovering awrat, physician of opposite gender). Radiological examination (consent, confidentiality of images). Laboratory tests (consent, confidentiality, disclosure). Esophagoscopy and colonoscopy (wudhu, salat, puasa). Aggressive investigation of common symptoms (cost vs risk of missed diagnosis, legal liability for missed diagnosis). HIV testing (compulsory mass testing, compulsory testing of a suspect, targeted testing of high risk groups, testing at the workplace, pre-marital testing, anonymous testing for epidemiological purposes, disclosure to the employer and the spouse).

Practical: visit to outpatient clinic, laboratory and radiology departments.

Therapeutic procedures: Balance of benefit and injury (benefit>injury, benefit<injury, benefit=injury, choice between 2 evils, choice between legality and benefit, individual vs public interest, prohibited vs necessary, double effect).  Prescriptions and administration of medications (ethico-legal issues, financial violations, conflict of interests, pharmacogenetics, regulations of drug administration, request for lifestyle drugs, porcine derived anticoagulants). Medication and wudhu (oral and rectal routes, vomiting after medication). Medication and puasa (oral, rectal, intramuscular, intravenous, sublingual). Surgical procedures (disclosure of surgical risk, consent). Anesthesia (consent, wudhu, salat). Blood transfusion (safety, cross matching errors, consent/refusal, selling/buying, unwilling donors, donation by relatives, prisoners, and drug addicts). Resuscitation (without consent, principle of certainty about nett benefit, doctrine of futility). Cosmetic / reconstructive surgery (concept of changing Allah’s creation, beautification, prostheses, gender change, results less than desired, injury). Solid organ transplantation (indications, preventive transplantation, sale of organs, informed consent for donor and recipient, friend and family donors, living will on organ donation, issues of organ harvesting and determination of death, minor donors and recipients, ownership of organs, decision to donate for incompetent terminally ill and the dead, condemned prisoners as donors, opt-in and opt-out systems, organ donor card, organ donor register). Doctrine of double effect. The slippery slope. Ordinary vs heroic means in treatment. Acts of omission vs acts of commission. Use of drugs in sports. HIV treatment (compulsory treatment of pregnant HIV+ve, free retroviral drugs for HIV +ve)

Practical: visit to a hospital emergency room

4.4.3 CONDITIONS OF ILLNESS

Physical Acts Of Worship For The Sick: Toilet hygiene (istinjau, colostomy, urinal, discharging fistula). Wudhu (conditions that do/do not nullfy wudhu, wudhu with skin conditions, wounds, bleeding, urinary, and fecal incontinence; wudhu for immobilized patient, wudhu for hemiplegics, wudhu with extreme sensitivity to cold or heat, wudhu with dysfunctional bleeding). Tayammum (definition, conditions of recommendation: skin and cold, etiquette, soil / sand in the hospital), Ghus for the sick., salat (salat with musculoskeletal and neurological disability, joining and shortening salat for a reason; salat for immobilized patient, salat for the blind and deaf, salat in extreme cold/hot weather, salat with extreme thirst or hunger, salat with hemiplegia, vestibular disorders, postural disorders, dysfunctional bleeding). Puasa (diabetes, ulcers, vomiting, diarrhea), zakat, and hajj (muscoskeletal and neurological disability, hajj for the blind and deaf, vestibular disorders, postural disorders)

Practical ibadat pesakit: video, simulated patients, real patients.

Input/output systems: alimentary and urinary: Upper GIT conditions: nausea, vomiting /hemetamesis, peptic ulcer (wudhu, salat, pausa). Lower GIT conditions: rectal bleeding, incontinence, fistulae (wudhu, salat, puasa, and hajj). Urinary symptoms and signs: dysuria, pyuria, urgency, incontinence, hesitancy, strangury, terminal dribbling, tenesmus, urethral discharge, colored urine, hematuria (wudhu, salat, haj, coitus). Chronic renal failure (dialysis, renal transplantation). Urinary fistulae and catheters (wudhu, salat, and hajj). Renal colic (salat, hajj). Prostate disease: symptoms and signs, screening: PSA, treatment options: watch, bilateral orchidectomy, chemical orchidectomy wioth LHRH agonist, non-steroidal anti-androgen, radiotherapy +/- adjuvant LHRH, chemotherapy, .

Transport systems: cardiovascular & respiratory:  Dyspnea due to cardiovascular causes: (salat, hajj, puasa). Dyspnea due to respiratory causes: pneumothorax, pulmonary embolism, chronic bronchitis, emphysema (salat, hajj, puasa). Congestive cardiac failure (puasa).

Reproductive system:  Menopausal disorders (artificial menopause, osteoporosis, benefits and risks of HRT, preventive hysterectomy +/1 ovariectomy). Dysfunctional uterine bleeding: peri-menopausal, pre-menopausal, post-menopausal, malignancy (salat, puasa, hajj, coitus, hysterectomy +/1 ovariectomy). Erectile dysfunction: definition, causes, treatment (marital dissolution). Sexually transmitted disease (pre-marital screening, condoms for sexually active teenagers, confidentiality in treatment, partner tracing and notification). Pre-natal diagnosis / screening / genetic testing/treatment  (indications, methods, test performance, counseling pre and post, informed consent, risks and benefits, relation to abortion, human rights of the embryo/fetus). Assisted reproduction for infertility: in vivo and in vitro insemination (basic permissibility for a married couple, prohibition of ovum or sperm donation, premarital disclosure of infertility, postmortem IVF, masturbation, paternity and maternity disputes, disposal/use of unused fertilized ova, pre-implantation sex selection and diagnosis, selective fetal reduction, developing embryos for non reproductive purposes, IVF for sibling benefit, using fertilized embryos for cloning).

Locomotion, support, and connective system: Orthopedic problems: sprains & fractures, orthopedic fixation, osteomyelitis, osteoporosis, malignant bone neoplasms (salat, hajj, work-related injury, workmen compensation, factory work with tremors, physical activity, rest, and sleep). Limb disorders (salat and hajj), Gait disorders (salat and hajj). Involuntary movements:chorea, athetosis, spasciticity etc (salat, hajj, work with moving machinery, driving, accidents in activities of normal living). Myasthenia gravis (salat, puasa, hajj). Joint disorders with restricted/painful movements: osteoarthritis and rheumatoid arthritis (tayammum if cold exercabates the pain, salat, hajj, risk-benefit analysis of chronic pain medication, addiction to analgesics and opiates). Vertebral column pain: spondylosis, intervertebral disease, sponylolidthesis, ankylosing spondylitis, root compression, etc (salat, hajj). Laryngeal, pharyngeal, or oral disease (recitation of Qur’an, public duties like judging, leadership, and court testimony).

Practical: visit to the orthopedic department.

Sensory system:  Blindness and deafness (salat, hajj, court testimony, marital contracts, civil contracts, financial contracts, leadership, judgeship, employment). Olfactory disorders (wudhu, salat, halitosis in puasa, use of perfume in public). Taste disorders (selling and buying food). Tactile disorders (work accidents). Temperature disorders (heat stroke in hajj, salat and puasa in extreme temperatures, work accidents). Pain disorders: headache (salat in extreme pain, dyspareunia and marital stress). Hunger and thirst (delay of salat for hunger, puasa with extreme hunger/thirst).

Practical: visits to the eye, ENT, and pain clinics.

Neurological disorders: Stroke (salat, puasa, hajj, civil transactions). Epilepsy (salat, hajj, driving, factory work, job discrimination, injury due to inadequate anti-convulsive therapy). Parkinson disease (salat, hajj, employment). Dementias (salat, puasa, hajj, legal competence, civil and financial transactions, court testimony, tests of capacity). Brain tumors. Brain /skull trauma. Spinal cord injury: lower motor vs upper motor, hemiplegia/hemiparesis, paraplegia/paraparesis (salat, hajj, marriage). Aphasia/dysphasia (marriage and contracts, evidence, public leadership). Vestibular disturbances (salat, hajj). Peripheral neuropathies: diabetic neiropathy.

Practical: visit to neurology clinic.

Psycho-social conditions:  Legal impact of loss of competence (salat, hajj, zakat, marriage contract, divorce, wills and testament, financial transactions, legal proceedings). Human drives and the genesis of emotions positive and negative. Anxiety disorders (unbalanced drives, classification of anxiety: normal and pathological, anxiety vs fear and depression, normal and pathological anxiety, spiritual malady and cognitive impairment as causes of anxiety, salat in extreme anxiety, wudhu/salat with compulsive/obsessive disorders, prevention of anxiety by renewal of aqidat, ibadat, doa, and removal of stressors, socialization). Stress (competence, spiritual treatment of stress, salat with stress, prevention of stress, salat as cure of stress). Loss of consciousness: sleep, forgetfulness, anesthesia, coma (salat, puasa, zakat, civil, financial, and judicial transactions, proxy decisions by the guardian, wali). Personality disorders (salat, puasa, hajj, marriage). Psychiatric conditions /psychosis/schizophrenia (salat, zakat, hajj,stigmatization, compulsion:, Brunei Lunacy Act 1984, psychosurgery, ECT, confidentiality). Depression and suicide / para-suicide / harm to self and others (compulsory detention and treatment, process of mental committal, liability of physician who fails to identify potential suicide, conflict on suicide religious prohibition vs autonomy rights).  Psychogenic sexual disorders (definition: lack of libido, sexual dysfunction, sexual deviation, treatment, impact on marriage and divorce: divorce or khulu’u). Neurotic / anxiety / compulsive-obsessive disorders (salat, marriage and divorce, civil and judicial transactions).

Practical: visit to psychiatry clinic

Other conditions:  Patho-physiological disturbances: fever, dehydration, infecrtions, (wudhu, salat, hajj, civil and financial transactions). Hematological disorders: anemia, leukemia, lymphoma, coagulation disorders. Skin disorders: eczema, psoriasis, SLE, etc. Diabetes mellitus (ouasa).

Issues of special age and gender groups: Women and maternal conditions. Neonatal and infant conditions. Congenitally abnormal fetii / infants: anencephaly, spina bifida, hydrocephalus (delivery time: before or at term?, delivery method: vaginal or Ceserean?, CPR at birth, long-term life support). Child conditions. Geriatric physical dysfunction: musculoskeletal, falls, fractures, senses, nutrition (taharat, wudhu, salat, puasa, hajj). Geriatric psychoneurological conditions and dementias (civil and financial transactions, salat, puasa, hajj). Geriatric psychosocial dysfunction  (depression, dependency/loss of self esteem, sexual dysfunction, quality of life, civil transactions). Disabilities: rights and obligations. Research on the elderly. Drug prescriptions for the elderly.

4.5 ETHICO-LEGAL-FIQH ISSUES IN PSYCHO-SOCIAL APPLICATIONS

4.5.1 The Family Institution: Gender. Family as a natural social unit. Marriage. Parents and relatives. Child protection (definition of child protection, limits to parental rights, state intervention to protect children)

4.5.2 Community Problems: Description of culture (definition, relativism, relation to personality, ethnocentrism). Trans-cultural ethics. Life-style (essentials of life, dress and ornamentation, entertainment, social failure). Sexual perversions (background, antecedents, adverse effects, prostitution, abnormal coital behaviors, sexual paraphilias, and criminal sexual aggression, abnormal marital arrangements). Unwanted pregnancy (determinants and causes, adverse effects, relation to abortion, alternatives to abortion, prevention and mitigation). Addiction and substance abuse: nicotine, drugs, alcohol (causes, prevention and treatment, rehabilitation). Poverty. Violence. Child abuse & neglect (definition and classification of abuse, sexual exploitation, child protection, best interests, physician reporting /non-reporting of abuse to authorities: benefits and risks). Issues of women (discrimination)

4.5.3 Community Action: enjoining the good and forbidding the bad, health promotion, social change, professional and occupational organizations, social welfare, disaster relief, refugees, 

4.5.4 Civil Transactions: Health-related ethico-legal issues in marital contracts (selection of a spouse, forbidden spouses, marriage contract conditions, conjugal rights and responsibilities). Divorce & annulment (divorce in menstruation and pregnancy, purposes of post-dicorce waiting period). Inheritance. Endowments & gifts,

4.5.5 Occupational health issues: Pre-employment testing (infectious disease, addiction to drugs and alcohol, genetic, psychological). Testing during employment (purposes, disclosure to employer, sick leave, random test for drugs, removal of hazards).

4.5.6 Judicial transactions: legal competence: ahliyyat

4.5.7 Public health ethics:  Public health measures in an epidemic without consent (quarantine, isolation, mass immunization, mass treatment). Disease screening and surveillance. Control of infectious disease (control and eradication, infectious disease control Act). HIV (premarital testing, voluntary testing, counseling, confidentiality), HIV prevention (free condoms in schools, sterile needles for IV drug users). HIV: discrimination in employment, immigration, and healthcare. Vaccination / immunization (cost benefit analysis)

4.6 PROFESSIONALISM

4.6.1 Professional physician etiquette / conduct with patients: Physician competence, responsibility, and accountability. Doctor-patient relationship (compassion, competence, disclosure & truthfulness, confidentiality, etiquette of the patient, bedside visit, uncovering awrat, interaction with the opposite gender, interaction with the family). Fidelity obligations (patient-doctor contract, dual obligations: army, police, prisons, sports, factory, school & university, conflict of duties and conflict of interests). The disabled patient.

4.6.2 Professional etiquette with the terminally ill/dying: palliative care. The terminally ill / dying (comfort, hygiene, alleviation of pain, acts of worship, legal preparation, spiritual preparation). Death. Burial (customs, mourning,). Bereavement.

4.6.3 Collegial relations / etiquette in a health team: principles of successful group work. General and special group dynamics. Student-teacher relation. Mutual respect and cooperation. Conflict resolution. Whistle blowing on unethical behavior. Cooperation with traditional healers.

4.6.4 Professional misconduct: Abuse of privileges (unethical research, unnecessary treatment, iatrogenic infection, misuse of controlled drugs, false documentation). Private misconduct derogatory to the profession (sexual transgression, abuse of trust, violence and felonies). Financial misconduct (kick-backs and fee splitting, conflict of interest). Un-ethical business practices. Felonies. Dealing with the pharmaceutical industry. Conflict of financial interests (physician as a manager, occupational physician employed by the company, sports physician). Licensing and registration (specialist practice without certification). Promises of wonder cures. 

4.6.5 Malpractice & negligence. Definition of negligence/malpractice. Ingredients of a negligence suite. Avoiding negligence suits. Bolam principle as modified by Bolitho.  Patient complaint / grievance system as a tool to prevent malpractice.

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4.7 PERSONAL DEVELOPMENT (5%)

4.7.1 INDIVIDUAL DEVELOPMENT

Success as a medical student: Etiquette of the student and the teacher. Time management (concepts of time, planning and prioritization, balance, problems, meetings). Study techniques and strategies (lectures and note taking). Speed reading. Group study and teamwork (types of groups, group dynamics, factors of group success, etiquette of a healthcare team). Motivation (concepts & theories, methods, relation to performance and responsibility, motivation in the medical profession). Management of student stress. Conflict resolution. Cheating and plagiarism. The nature of medical education (purpose, integration, balance, service, and leadership). Physician rights (renumeration, professional independence, continuing medical education, refusal to undertake unethical procedures). Physician responsibility (to self and family, to society, to science).

Towards developing a scientific culture: Understanding. Thinking. Description. Analysis. Objectivity. Rationality. Prudence. Respecting the other opinion.

Character and behavior: Character, habits, and behavior. Positive personality traits (integrity, responsibility, courage, wisdom, patience, humility, self-restraint, modesty, simplicity, moderation, good acts, good company, principled life, positive image).

Self Development and personality enhancement: Self improvement (commitment, effort, learning from experience, interdependence, creativity, needs vs wants, positive attitude, futuristic outlook, assertiveness, self confidence, self reliance, contentment). Intellectual development. Social development. Skill development. Professional development (postgraduate training, apprenticeship, mentoring, goal setting, quality results, financial security, professional networking). Personal beliefs and conscience in health care especially abortion,

4.7.2 SKILL DEVELOPMENT

Communication: Concepts and theory of communication (definition, functions, channels, process, modes, elements of success, perception, styles, barriers). Communication in small groups (advantages of face to face communication, on first meeting, continuing in the group, factors of success, active listening, barriers to effective listening, etiquette of telephone and online communication). Purposes and types of written communication (letters, office memos, papers, reports, and manuals). Characteristics of good writing (precision, simple language, logic, believable, purposive, draft and review). Special characteristics of medical/technical writing. Publishing a paper. Problems in writing (blank page/writer’s block, writing to difficult persons, conveying unpleasant information). Public speaking (purposes, elements, the message, delivery, the audience). Dealing effectively with the mass media (strengths and weaknesses of various media, impact of media on health-related KAP).

Negotiation skills: Nature and purpose of win-win negotiation (purpose, elements of success, conducive circumstances, interests and concessions, multi-issue negotiation, alternatives to win-win). Negotiation strategies (winning strategy, negotiation power). Negotiation tactics (aggressive, friendly, evasive, provocative, risk taking, incremental approach, brinkmanship). Management of a negotiation session (commitment, personal relations, self discipline and self control, learn the other side, planning a strategy, phases and agenda setting, demands and offers, narrow differences, final bargaining, persuasion, implementation and follow up). Difficult negotiations (win-lose, deadlock).

Leadership Skills: Basic characteristics of effective leadership. Personal Attributes of leaders. Conceptual leadership skills. Technical leadership skills (communication, decision making, planning and execution, team leadership, motivation, conflict resolution, maintaining relations). Human skills of leaders (concern, respect, compassion etc). Diseases of leaders (personality, and poor human relations). Diseases of followers (hypocrisy, insincerity, bad advice for leader, flattery).  Model leaders in medicine;

Management Skills for health services: Strategy, planning, and implantation. Control and evaluation. Quality assurance/quality improvement. Decision-making (principles, process, and steps of rational decision making). Problem-solving (principles, process, and steps of rational problem solving. Crisis management (definition, stages, identification, isolation, and intervention). Economic analysis in health (terminology, CBA, CEA, and CUA). Health policy (allocation of health resources, preventive vs curative medicine, justice). Health finance (reasons for high cost of medical care, managed care, waste control, cost control). Health services delivery (barriers, access and poverty). Basics of organizational management (organizational design, structure, culture, and development; recruitment, placement, and maintenance of personnel; job design, description, and assignment; advantages & disadvantages of specialization; training process, advantages and disadvantages of delegation, worker appraisal). Basics of organizational financial management. Health information management systems (definition of MIS, types and structure of databases, information dissemination, privacy and confidentiality).

1006 ETHICAL ISSUES IN MEDICAL EDUCATION: AN ISLAMIC FRAMEWORK

Paper presented at a Workshop on The Integration of the Islamic Input in the Medical Curriculum with Competence-Based Curriculum In Muslim Medical Schools' with the theme 'Curriculum Reform of Medical Education in Medical Schools affiliated to the Federation of Islamic Medical Associations' held at Bumi Senyiur Hotel Samarinda East Kalimantan Province Indonesia 4-6 June 2010 by Dr Omar Hasan Kasule MB ChB (MUK), MPH (Harvard), DrPH (Harvard) Professor of Epidemiology and Bioethics Faculty of Medicine King Fahd Medical City Riyadh EM omarkasule@yahoo.com. WEB http://omarkasule.tripod.com

ABSTRACT

The paper is divided into 3 parts: the Islamic basis for ethical theories and principles, ethical issues related to the educational process, and teaching medical ethico-legal-fiqhi issues. The ethical framework of Islam is based on the basic elements of the shari'at, the purposes of the sharia, and the principles of the sharia.  The medical education process raises ethico-legal issues such as the etiquette of behavior in the healthcare team, interaction between genders, postmortem examination and cadaver dissection. The teaching of medical ethics requires analysis of actual situations using Islamic principles while comparing to alternative approaches available in society.  The paper provides a framework of what should be included in the ethico-legal-fiqhi curriculum of a Muslim-based medical school.

1.0 THE SHARI'AT BASIS FOR MEDICAL JURISPUDENCE EDUCATION

1.1 EVOLUTION OF MEDICAL JURISPRUDENCE, tatawwur al fiqh al tibbi

1.1.1 First period

There are three stages in the evolution of fiqh tibbi. In the first period (0 to circa 1370H) it was derived directly from the Qur’an and sunnat.

1.1.2 The second period

In the second period (1370-1420) rulings on the many novel problems arising from drastic changes in medical technology were derived from secondary sources of the Law either transmitted (such as analogy, qiyaas, or scholarly consensus, ijma) or rational (such as istishaab, istihsaan, and istirsaal).

1.1.3 The modern period

The failure of the tools of qiyaas to deal with many new problems led to the modern era (1420H onwards) characterized by use of the Theory of Purposes of the Law, maqasid al shari’at, to derive robust and consistent rulings. Ijtihad maqasidi is becoming popular and will be more popular in the foreseeable future. The theory of maqasid al shari’at is not new but many people had not heard about it because its time had not yet come. By the 5-6^th centuries of hijra the basic work on the closed part of the Law derived directly from primary sources was complete. Any further developments in the law required opening up new the flexible part of the law which necessitated discussion of the purposes of the law. It was at this time that al Ghazali and his teacher Imaam al Haramain al Juwayni introduced the ideas that underlie the concept of maqasid al shari’at. Other pioneers of the theory of maqasid al shari’at were Imaam an Haramain al Juwayni and his student Abu Hamid al Ghazzali (d. 505 H), Sheikh al Islam Ahmad Ibn Taymiyyah (d. 728H) and his student Ibn al Qayyim al Jawziyyat (d. 751H). The field of the purposes of the law witnessed little development until revived by the Abdalusian Maliki scholar Imaam Abu Ishaq al Shatibi in the 8th century AH who elaborated Ghazzali's theory. Our subsequent discussion of the purposes of the law is from al Shatibi's book al muwafaqaat fi usuul al shariat

1.1.4 Relation between law and ethics

Islamic Law is comprehensive being a combination of moral and positive laws. It can easily resolve ethical problems that secularized law, lacking a moral religious component, cannot solve. Many contemporary ethical issues in medicine are moral in nature and require moral guidance that can be provided only from religion. 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 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. 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. Legal axioms or principles, qawa’id al shari’at, guide reasoning about specific ethico-legal issues and are listed as intention, qasd; certainty, yaqiin; injury, dharar; hardship, mashaqqat; and custom or precedent, ‘urf or ‘aadat.

1.2 SOURCES OF THE LAW, masadir al shariat

1.2.1 Qur’an as a primary source of law

The Qur'an is 'Allah’s words revealed to Muhammad (PBUH) in Arabic, transmitted to us in continuity, written in the mashaf, whose recitation is worship, commencing with surat al fatihat and ending with surat al nas. Verses of the Qur’an were revealed adhoc each associated with sabab al nuzuul. It was memorized and also written down immediately. Abubakar collected the written records and Othman issued one official version in the Quraishi dialect that is used all over the world.

The Qur’an is practical, rational, and miraculous. Its 3 themes are ‘aqidat, spiritual refinement, and practical guidance. Legal rulings, ayat al ahkaam, are a minority of its more than 6000 verses being distributed munakahaat 70, mu'amalat 70, jinayaat 30, iqtisaad 10 verses, qadha 13 verses, government 10 verses, and international law 25 verses. The Qur’an is comprehensive and complete but deals with issues in a generic and not specific way. Its verses are muhkamat or mutashabihat. It challenges the intellect, does not indoctrinate, and gives room for opposing views.

It is divided into 114 surats. Each surat starts with the basmalah except surat al baraa. It is divided into 30 juz’us each divided into 2 hizbs. Rub'u or thumun are subdivisions of the hizb. The Makkan verses, dealing with aqidat, are short, poetic, and powerful. Madinan verses are longer dealing with details of societal organization.

The prophet read the Qur’an in 7 different ways, The Qur’an can be recited as tartiil or as tajwid. As a source of legislation the Qur’an provides general foundations and principles. Qur'anic evidence for legal rulings is either qatui, or dhanni. The Qur'an is the primary source of law. All other recognized sources are secondary to the Qur'an and are validated by it.

1.2.2 Sunnat as a primary source of law

Sunnat, a subgroup of hadith and part of wahy, is defined as words, actions, and tacit agreement of the Prophet. A hadith consists of a sanad, and matn. It can be hadith nabawi or hadith qudsi. Writing of hadith started late. Hadith collections are classified as sihaah, sunan, masanid, and muwatta’at. Hadith is described as mutawatir if narrated by many, mash'hur if reported by at least 2, and aahaad if reported by only 1 sahabi. It be tashri'i if legislative or ghayr tashri' if it is not. The grades of hadith authenticity in descending order are: sahiih, jayyid, and hasan. Muttafaq ‘alayhi is reported by both Bukhari and Muslim. Musnad has a chain of narrators to the prophet. Muttasil has an unbroken chain of narrators. The sanad stops at a sahabi in mawquf and at a tabi’e in a marfu’u hadith. In mursal the tabi’e reports directly from the prophet. Munqati’u has an incomplete sanad. Dha’if lacks the attributes of the sahiih and hasan. Sunnat can affirm, explain, or elaborate the Qur'an or bring up matters not mentioned in the Qur’an. Obedience of the prophet implies following his sunnat. The sunnat comes second to the Qur'an as a source of law. The daliil of the sunnat may be definitive, qatai, or probable, dhanni. The sunnat is interpreted in the light of general principles of the Qur'an, the social situation in the prophetic era, and the Arabic language.

1.2.3 Secondary sources of the Law

Ijma is agreement of all mujtahids existing at one time on a particular legal ruling based on nass. It can be ijma sariih or ijma sukuuti. Qiyas is use of a ruling of one matter for another matter when the two share the same illat. Pre-Islamic laws, shara'u man qablana, were either abrogated or confirmed by the Qur’an. The word of the companion, qawl al sahabi, is a source of law under specified conditions. Custom or precedent, ‘aadat or 'urf, is a source of law if it does not contradict nass, there is ijma on it, and is in the public interest, and closes the door to evil. Istishaab is continuation of an existing ruling until there is evidence to the contrary. Istihsaan is preference for one qiyaas by a mujtahid. Istislaah is assuring a benefit or preventing a harm used in mu’amalat but not ‘ibadat. Maslahat mursalat is public interest based on ra’ay when there is no nass. Sadd al dhari'at is prohibition of an act that is otherwise mubaah because it has a high probability of leading to haram.

1.3 CLASSIFICATION OF REGAL RULINGS:  MEDICAL APPLICATIONS

1.3.1 Obligatory, waajib

Waajib is the most important legal ruling. The shafi’e school considers waajib the same as faradh. Individual obligations, fardh aini, cannot be delegated.  Performance of a collective obligation, fardh kifai, by any member of the community absolves the rest from sin. However only those with the necessary competence can perform the collective obligations. The rest are not obliged even if they are members of the community.

1.3.2 Recommended, manduub

Recommended, manduub, is also called sunnat or masnuun, nafilat, mustahabb, tatawu'u, ihsaan, fadhiilat. It is ordained without compulsion. The manduub has got the following levels of excellence: confirmed, sunnat muakkada; and not confirmed, sunnat ghayr muakkadat. The sunnat muakkadat is what the Prophet used to carry out continuously and left it only on rare occasions.

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1.3.3 Prohibited, haraam

Prohibited/unlawful, haraam is defined as omission of the waajib or commission of the haraam. The original position for all human acts is permission and prohibition is the exception. Thus textual evidence is required to prove prohibition but is not required to prove permission. The situation is reversed in sexual matters in which the original position is haraam and permission is the exception requiring textual evidence. Only Allah can make something haraam. Haraam is prohibited because it is impure and harmful. An act that aggravates disease is haraam. An act that leads to haraam is also haraam. An act that cures disease is waajib. A general principle is that the halaal is clear and the haraam is clear and between the two are inconclusive matters, mutashaabihaat For inconclusive matters what leads to bad or evil is makruuh and what leads to good is manduub.

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1.3.4 Offensive, makruuuh

Offensive/reprehensible/disaaproved, makruuh, is an act that is discouraged by the Law giver without compulsion. It is better to avoid the makruh. The makruh is an introduction to the haram and must therefore be avoided.

2.0 THE MAQASIDI  AL SHARI'AT AS A MEDICAL ETHICS EDUCATION

2.1 THE 5 MAQASID AS THE ISLAMIC THEORY OF ETHICS

2.1.1 Protection of ddiin, hifdh al 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. A sick or a weak body cannot perform physical ‘ibadat properly. Balanced mental health is necessary for understanding ‘aqidat and avoiding false ideas that violate true ‘aqidat.

2.1.2 Protection of life, hifdh al nafs: The primary purpose of medicine is to fulfill the second purpose of the Law, 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 physiological functions are maintained. Medical knowledge is used in the prevention of disease that impairs human health. Disease treatment and rehabilitation lead to better quality health.

2.1.3 Protection of progeny, hifdh al nasl: Medicine contributes to the fulfillment of the progeny 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, peri-natal 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.

2.1.4 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.

  

2.1.5 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 general poor health are less productive than healthy vibrant communities. 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.

2.2 THE 5 QAWA'ID AL SHARI'AT AS THE PRINCIPLES OF ETHICS

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

2.2.2 The principle of certainty, qa’idat al yaqeen: Medical diagnosis cannot reach the legal standard of absolute certainty, yaqeen. Treatment decisions are based on a balance of probabilities. The most probable diagnosis is treated as the working while those with lower probabilities are kept in mind as alternatives. 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. The principle of certainty asserts that uncertainty cannot abrogate an existing certainty. Existing assertions should continue in force until there is compelling evidence to change them. All medical procedures are considered permissible unless there is evidence to prove their prohibition.

2.2.3 The principle of injury, qa’idat 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 an injury has priority over pursuit of a benefit of equal worth. If the benefit has far more importance and worth than the injury, 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 injurious and there is no way but to choose one of them, the lesser injury is committed. A lesser injury is committed in order to prevent a bigger injury. In the same way medical interventions that are in the public interest have priority over consideration of individual interest. The individual may have to sustain an injury in order to protect public interest. In many situations, the line between benefit and injury is very fine.

2.2.4 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. Necessities legalize the prohibited, al daruuraat tubiihu al mahdhuuraat, and mitigate easing of legal rules and obligations. In the medical setting a hardship is defined as any condition that will seriously impair physical and mental health if not relieved promptly. 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. The temporary legalization of prohibited medical action ends with the end of the necessity that justified it in the first place.

2.2.5 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.

3.0 ETHICO-LEGAL-FIQHI ISSUES IN THE MEDICAL EDUCATION PROCESS

3.1 THE ETIQUETTE / ETHICS OF THE TEACHER, adab al mu'allim

3.1.1 Characteristics of the teacher

Teachers should take their task very seriously. The education process, involving giving and receiving knowledge is noble[i]. Teachers should have the humility to know that their knowledge is limited and that they can always learn more. Arrogance because of knowledge is condemned[ii].

3.1.2 The learning process

Teachers must make the learning process interesting and avoid boredom[iii]. They should make the atmosphere and circumstances of learning easy for the students[iv]. Teachers must be careful in their actions, attitudes, and words at all times because being models and leaders they are seen and are emulated. They must be aware that sometimes they can teach using body language without saying anything[v]; they have to be careful about their public dispositions They should be ready to carry out their function at all times and at any opportunity[vi].

3.1.3 Communication with the students

They should have an appropriate emotional expression. They can raise the voice to emphasize an important point[vii]. They can show anger or displeasure when a mistake is committed[viii]. Asking students questions to ascertain their level of knowledge is part of the teaching process and is not in any way a humiliation for them[ix]. Teachers should make sure that the students understand by constant repetition[x]. Teachers should strive to pass on to the students as much knowledge as they can. Hiding knowledge is a cause of punishment, uqubat man katama ‘ilma[xi].

3.2 THE ETIQUETTE / ETHICS OF THE STUDENT, adab al muata'allim

3.2.1 Respect for the teacher

The Islamic etiquette of the relation between the student and the teacher should be followed. In general the student should respect the teacher. This is respect to knowledge and not the individual. The prophet taught admiration and emulation of the knowledgeable[xii].

3.2.2 The learning process

 Students should be quiet and respectfully listen to the teacher all the time[xiii]. Students should cooperage such that one who attends a teaching session will inform the others of what was learned[xiv]. Students can learn a lot from one another. The student who hears a fact from a colleague who attended the lecture may even understand and benefit more[xv]. Students should ask questions to clarify points that they did not understand or which seem to contradict previous knowledge and experience[xvi]. Taking notes helps understanding and retention of facts[xvii]. Study of medicine is a full-time occupation; students should endeavour to stay around the hospital and their teachers all the time so that they may learn more and all the time. They should avoid being involved in many other activities outside their studies[xviii].

3.3 UNCOVERING AWRAT IN MEDICAL EDUCATION

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.

3.4 GENDER ISSUES IN MEDICAL EDUCATION

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.

3.4 POSTMORTEM EXAMINATION IN MEDICAL EDUCATION

3.4.1 Definition: The term autopsy or necropsy is used to refer to dissection and examination of a dead body to determine the cause(s) of death. It may be carried out for legal or for educational purposes. 

3.4.2 Purposes of autopsy: Post-mortem examination serves several purposes. It can be done for scientific research to understand the natural history, complications, and treatment of a disease condition. It can be done for further education of physicians and medical students especially when they compare their clinical diagnosis with the evidence from autopsy a process usually referred to as clinico-pathological correlation. The lessons learned will improve their diagnostic and treatment skills in the future and decrease the incidence of clinical mistakes.

3.4.3 Permissibility of autopsy for educational purposes under the principle of necessity, qa’idat dharuurat: Dissection of cadavers has been very important for medical education over the past decades when there was really no alternatives to dissection. Cadaver dissection was therefore permissible under the legal principle of necessity, dharuurat. The reasoning is that cadaver dissection enables future doctors to be trained well to treat patients which fulfils the second purpose of the Law, preservation of life or hifdh al nafs. The situation of necessity explained above takes precedence over considerations of violating human dignity by dissecting the body under the general principle of the Law that necessities legalize what would otherwise be prohibited, al dharuuraat tubiihu al mahdhuuraat. However this can only be carried out if there is informed consent from the family members who have the authority to consent as prescribed by the Law. As far as possible this consent should take into consideration the will of the deceased on this matter if it was known before death. However human dignity cannot be violated more than necessary. The body should still be handled with respect and consideration. All tissues cut away should be buried properly and the remaining skeleton should also be buried in a respectful way.

3.4.4 Alternative ways of achieving the educational objectives of autopsy: The following arguments cast doubt on the degree of necessity for cadaver dissection in medical education. The cadaver is treated before dissection and does not truly represent the structure or appearance of tissues in a living person. Secondly with availability of computer graphics and anatomical models, medical students can learn human anatomy very conveniently and more efficiently. The necessity of educational autopsies can be reduced by modern endoscopic and imaging technology that can enable inspecting internal structures of a corpse without the making an incision to inspect internal tissues. If the educational objective can be achieved fully using such technology then the rational for the necessity will disappear and educational autopsies will be considered repugnant to the Law.

3.4.4 Research on dead corpse

There are several types of research on the recently dead that can be permitted under the principle of necessity if they will result in better health care that fulfills the second purpose of the Law, preservation of life or hifdh al nafs. Forensic pathologists may carry out research to study the process of decomposition of the body. They then can use that information to estimate time since death in cases of criminal homicide.

4.0 TEACHING ETHICAL ISSUES FROM AN ISLAMIC PERSPECTIVE

4.1 Contents of the ethico-legal-fiqhi curriculum

4.1.1 Theories and principles of medical ethics

• Purposes and Principles of Medicine and ethics, maqasid wa qawa’id al tibaabat
• Regulations of Medical Procedures, dhawaabit al tatbiib
• Regulations of Research Procedures, dhawaabit al bahath
• Regulations of Physician Conduct, dhawaabit al tabiib
• Regulations about Professional Misconduct, dhawaabit al inhiraaf al mihani

4.1.2 Ibadat for the patient, ibadat pesakit

• Taharat for the sick, taharat al mariidh

·         Haidh

• Salat of the sick, salat al maridh
• Saum for the patient, saum al mariidh
• Medical guidelines on diet in saum

·         Saum in difficult weather

• Saum in pregnancy, menstruation, and the post partum period:
• Medical examination and investigations in Ramadhan
• Medical treatments in Ramadhan

·         Pilgrimage of the sick, hajj al mariidh

4.1.3 The etiquette of the physician, adab al tabiib

• Etiquette with Patients and Families
• Etiquette with the Dying
• Etiquette with the Health Care Team
• Etiquette of Research on Humans

4.1.4 Issues in disease conditions, fiqh al amraadh

• Uro-Genital System, jihaaz bawli & jihaaz tanaasuli
• Cardio-Respiratory System, qalb & jihaaz al tanaffus
• Connective Tissue System,
• Alimentary System, jihaaz al ma idat
• Sensory Systems, al hawaas
• Patho-physiological Disturbances
• General Systemic Conditions
• Psychiatric conditions, amraadh nafsiyyat
• Neurological conditions, amraadh al a’asaab
• Age-Related Conditions, amraadh al ‘umr

4.1.5 Issues in modern medicine fiqh mustajiddaat al tibb

• Assisted Reproduction, taqniyat al injaab
• Contraception, mani’u al haml
• Reproductive Cloning, al istinsaakh
• Abortion, isqaat al haml
• Genetic Technology, taqniyat wiraathiyyat
• Artificial Life Support, ajhizat al in’aash
• Euthanasia, qatl al rahmat
• Solid Organ Transplantation, naql al a’adha
• Stem Cell Transplantation, naql al khalaayat
• Change of Fitra, taghyiir al fitrat

4.2 Method of teaching ethics

Apart from basic lectures on theoretical issues, most of the teaching should be in the form of discussing case studies. These are cases of actual ethical problems that are encountered in hospital practice. Source material should be provided in advance of any session. Students should be encouraged to look for relevant evidence in the Qur'an and sunnat. Each session will be opened by a short introduction from the 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.

4.3 Source material

Resource material will be provided as required. Additional material can be obtained from http://omarkasule.tripod.com.

4.4 Examples of case studies

4.4.1 Privacy and confidentiality

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.

4.4.2 Disclosure

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.

4.4.3 Consent to treatment

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.

4.4.4 Refusal of treatment

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.

4.4.5 Negligence & malpractice

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.

4.4.6 Life support in terminal illness

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. 

4.4.7 Reproductive issues

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.

4.4.8 Organ donation

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. 

4.4.9 Drug abuse and suicide

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.

4.4.10 Doctor etiquette

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.

4.4.11 Resources

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.

4.4.12 Physicians with dual obligations

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.

4.4.13 Postmortem

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.

TOWARDS IMPLEMENTING THE ISLAMIC INPUT CURRICULUM

Paper presented at a Workshop on The Integration of the Islamic Input in the Medical Curriculum with Competence-Based Curriculum In Muslim Medical Schools' with the theme 'Curriculum Reform of Medical Education in Medical Schools affiliated to the Federation of Islamic Medical Associations' held at Bumi Senyiur Hotel Samarinda East Kalimantan Province Indonesia 4-6 June 2010 by Dr Omar Hasan Kasule MB ChB (MUK), MPH (Harvard), DrPH (Harvard) Professor of Epidemiology and Bioethics Faculty of Medicine King Fahd Medical City Riyadh EM omarkasule@yahoo.com. WEB http://omarkasule.tripod.com

1.0 SETTING THE VISION FOR ISLAMIC HEALTH CARE IN THE FUTURE

1.1 OVERALL PURPOSES

• Society: khilafat, imarat, & taskhiir
• Individual: ubudiyyat (‘ibaadat & taqwa), tazkiyat al nafs
• Law (5 maqasid): Ddiin, Life, Family, Intellect, Property

1.2 MAQASID AL SHARI’AT IN HEALTH CARE

• Islam has a parsimonious and rigorously defined ethical theory of Islam based on the 5 purposes of the Law, maqasid al shari’at
• Any medical action must fulfill one of the above purposes if it is to be considered ethical.
• Healthcare workers in their conduct and decision making must constantly be aware of the maqasid to practice medicine in an ethical and legal way accepted by the shari’at.

1.3 THE EMERGING ISLAMIC HEALTHCARE INDUSTRY

• Frustration with existing health care delivery due to human factors and not technology
• Desire to explore the Islamic alternative: Muslim patients prefer an Islamic environ
• The parallel of Islamic banking and finance
• Lessons from Islamic banking: sufficient theory before & personnel training before practice

2.0 THE PROCESS OF CURRICULUM CHANGE

2.1 Islamic input in relation to national competence curriculum

2.2 What changes do we want to make

2.3 Integration

2.4 Evolution and not revolution

3.0 METHODS OF TEACHING

3.1 Full integration into the lectures and PBL

3.2 Case scenarios or case studies

3.3 Clinical ethical rounds

3.4 Practical training: taharat and ibadat pesakit

3.5 Field visits: clinics, courts, research centers etc

4.0 READING MATERIALS

4.1 Specialized workshops at which experts present papers for discussion that are compiled into books and manuals

4.2 Collection and translation of material

5.0 TEACHER TRAINING

5.1 Diploma / masters in Islamic Healthcare Delivery

5.2 Masters and doctorate by research on specific ethical issues

6.0 CURRICULUM EVALUATION: annual conference.

6.1 Methods of teaching

6.2 Reading materials

6.3 Teacher training

7.0 OUTPUT EVALUATION

7.1 Alumni association to maintain contact / tracer studies

7.2 Questionnaire surveys: how are these graduates different from others

Notes

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[i] (MB70 Bukhari 1:79)

[ii] (MB102 Bukhari 1:124)

[iii] (MB62 Bukhatri 1:68)

[iv] (MB63 Bukhari 1:69)

[v]  (MB75 Bukhari 1:85 and MB76 Bukhari 1:86)

[vi] (MB74 Bukhari 1:83)

[vii] (MB55 Bukhari 1:57)

[viii] (MB79 Bukhari Bukhari 1:90, MB80 Bukhari 1:91, and MB81 Bukhari 1:92)

[ix] (MB56 Bukhari 1:59)

[x] (MB82 Bukhari 1:95)

[xi] (KS390 Abudaud K24 B9, Tirmidhi K39 B3, Ibn Majah Intr B24, Ibn Sa’ad J4 Q2 p56, Ahmad 2:263, Ahmad 2:296, Ahmad 2:305, Ahmad 2:344, Ahmad 2:352, Ahmad 2:495, Ahmad 2:499, Ahmad 2:508, Tayalisi H2534)

[xii] (MB66 Bukhari 1:73)

[xiii] (MB101 Bukhari 1:122)

[xiv] (MB78 Bukhari 1:89)

[xv] (MB61 Bukhari 1:67)

[xvi] (MB88 Bukhari 1:103)

[xvii] (MB93 Bukhari 1:112)

[xviii] (MB98 Bukhari 1:118)