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Paper presented at a workshop for Indonesian Resource Persons at grand Chempaka Hotel Jakarta 23 July 2010 by Dr Omar Hasan Kasule MB ChB (MUK), MPH (Harvard), DrPH (Harvard) Professor of Epidemiology and Bioethics at the Faculty of Medicine King Fahad Medical City Riyadh, Visiting Professor of Epidemiology University of Malaya.
ABSTRACT
The paper describes the vision, mission, and implementation of the Islamic Input in the Medical Curriculum (IIMC) over the past 15 years in South East Asia . IIMC aims at producing a physician who integrated the best and most modern in technology and skills with perennial Islamic values. It teaches the Islamic epistemological perspective of basic medical sciences, ethico-legal fiqhi issues and challenges in a medical environment, and Islamic concepts of a healthy community. An emphasis is placed on a holistic and balanced approach to medicine by reference to Prophetic medicine, tibb nabaw. The maqasid and qawaid al shari'at have been the cornerstone of the Islamic Input in the medical curriculum (IIMC). Any medical action must fulfill one of the above purposes if it is to be considered ethical. The principles of the Law, qawa’id al shari’at, are practical extensions and interpretations of the maqasid. The futuristic vision of IIMC is that Islamic medical practice will in the next 20 years grow and reach or even the exceed the achievements of Islamic banking. The Islamic hospitals and clinics that will be established will need medical professionals trained to practice medicine according to the Qur’an, sunnat, and the purposes of the Law, maqasid al shari’at. The paper provides a detailed outline of IIMC and discusses teaching and evaluation methods.
1.0 INTRODUCTION
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. The principles of the Law, qawa’id al shari’at, are practical extensions and interpretations of the maqasid. The ethical theories and principles are derived from the basic law but the detailed applications require further ijtihad. Healthcare providers 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. The maqasid and qawaid al shari'at have been the cornerstone of the Islamic Input in the medical curriculum (IIMC)
The Islamic Input into the Medical Curriculum (IIMC) has become a reality in several medical schools over the past decade. The Kulliyah of Medicine of International Islamic University Malaysia Institute of Medicine Malaysia , Riphah International University Islamabad, Peshawar Medical College , and the 17 schools that are members of FOKI (Forum Kedokteran Islam Indonesia
IIMC is based on 3 assumptions: (a) that Islam has moral values that are universal and, being found in other religions and belief systems, can be taught to and be appreciated equally well by Muslim and non-Muslim students;. (b) a physician must understand Islamic Law relating to medicine, fiqh tibbi, in order to practice successfully in a Muslim community whose culture and social norms are shaped by the shari’at that is a comprehensive code affecting all aspects of the life of the individual and the community; and (c) a successful physician must be equipped with personal, communication, leadership, and management skills based on Islamic teachings and empirical social and managerial sciences.
IIMC teaches the Islamic epistemological perspective of basic medical sciences so that students can appreciate the signs of the Creator, ayat al allah, from the book of empirical scientific observation, kitaab al kawn, alongside appreciating the signs of the Creator from the book of revelation, kitaab al wahy.
IIMC in the clinical phase teaches students to help patients solve practical problems related to ablution, wudhu, prayer, solat, fasting, puasa, pilgrimage, hajj & umrah; and what is permitted, halal, as medicine, physical activities, nutrition, and other activities of daily living.
IIMC uses the theory of the purposes of the Law, maqasid al shari’at, principles of the Law, qawa’id al shari’at, specific legal rulings from the Qur’an and sunnat, and comparing with European ethico-legal sources as bases for discussing medical ethico-legal issues such as autonomy, privacy & confidentiality, professionalism, animal and human research, resource allocation, end of life issues, and medical malpractice. Also covered are issues that arise out of modern medical technology such as assisted reproduction, genetic testing, and transplantation. An emphasis is made on a holistic and balanced approach to medicine by reference to Prophetic medicine, tibb nabawi, and traditional / complementary medical systems such as unani, ayurdevic, and Chinese medicine.
The futuristic vision of IIMC is that Islamic medical practice will in the next 20 years grow and reach or even the exceed the achievements of Islamic banking. The Islamic hospitals and clinics that will be established will need medical professionals trained to practice medicine according to the Qur’an, sunnat, and the purposes of the Law, maqasid al shari’at.
2.0 MAQASID AL SHARI’AT IN MEDICAL PRACTICE
2.1 Protection of ddiin, hifdh al ddiin
Protection of diin essentially involves ‘ibadat in the wide sense that every human endeavor is a form of ‘ibadat. Thus medical treatment makes a direct contribution to ‘ibadat by protecting and promoting good health so that the worshipper will have the energy to undertake all the responsibilities of ‘ibadat. The principal forms of physical ‘ibadat are the 4 pillars of Islam: prayer, salat; fasting, puasa; and pilgrimage, hajj. A sick or a weak body can perform none of them properly. Balanced mental health is necessary for understanding ‘aqidat and avoiding false ideas that violate ‘aqidat. Thus medical treatment of mental disorders thus contributes to ‘ibadat.
2.2 Protection of life, hifdh al nafs
The primary purpose of medicine is to fulfill the second purpose of the shari’at, the preservation of life, hifdh al nafs. Medicine cannot prevent or postpone death since such matters are in the hands of Allah alone. It however tries to maintain as high a quality of life until the appointed time of death arrives. Medicine contributes to the preservation and continuation of life by making sure that the nutritional functions are well maintained. Medical knowledge is used in the prevention of disease that impairs human health. Disease treatment and rehabilitation lead to better quality health.
2.3 Protection of progeny, hifdh al nasl
Medicine contributes to the fulfillment of this function by making sure that children are cared for well so that they grow into healthy adults who can bear children. Treatment of infertility ensures successful child bearing. The care for the pregnant woman, perinatal medicine, and pediatric medicine all ensure that children are born and grow healthy. Intra-partum care, infant and child care ensure survival of healthy children.
2.4 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.
2.5 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 a healthy vibrant community. The principles of protection of life and protection of wealth may conflict in cases of terminal illness. Care for the terminally ill consumes a lot of resources that could have been used to treat other persons with treatable conditions. The question may be posed whether the effort to protect life is worth the cost. Healthcare providers must also be careful not to waste resources in the hospital.
3.0 PRINCIPLES OF MEDICINE, qawa’id al shari’at
3.1 The principle of intention, qa’idat al qasd
The Principle of intention comprises several sub principles. The sub principle that each action is judged by the intention behind it calls upon the healthcare provider to consult his inner conscience and make sure that his actions, seen or not seen, are based on good intentions. The sub principle ‘what matters is the intention and not the letter of the law’ rejects the wrong use of data to justify wrong or immoral actions. The sub principle that means are judged with the same criteria as the intentions implies that no useful medical purpose should be achieved by using immoral methods.
3.2 The principle of certainty, qaidat al yaqeen
Medical diagnosis and treatment must be based on certain evidence obtained from clinical examination and investigations. All medical procedures are considered permissible unless there is certain, yaqeen, evidence to prove their prohibition.
3.3 The principle of injury, qaidat al dharar
Medical intervention is justified on the basic principle is that injury, if it occurs, should be relieved. An injury should not be relieved by a medical procedure that leads to an injury of the same magnitude as a side effect. In a situation in which the proposed medical intervention has side effects, we follow the principle that prevention of a harm has priority over pursuit of a benefit of equal worth. If the benefit has far more importance and worth than the harm, then the pursuit of the benefit has priority. Healthcare providers sometimes are confronted with medical interventions that are double edged; they have both prohibited and permitted effects. The guidance of the Law is that the prohibited has priority of recognition over the permitted if the two occur together and a choice has to be made. If confronted with 2 medical situations both of which are harmful and there is no way but to choose one of them, the lesser harm is committed. A lesser harm is committed in order to prevent a bigger harm. In the same way medical interventions that in the public interest have priority over consideration of the individual interest. The individual may have to sustain a harm in order to protect public interest. In the course of combating communicable diseases, the state cannot infringe the rights of the public unless there is a public benefit to be achieved. In many situations, the line between benefit and injury is so fine that salat al istikharat is needed to reach a solution since no empirical methods can be used.
3.4 Principle of hardship, qaidat al mashaqqat
Medical interventions that would otherwise be prohibited actions are permitted under the principle of hardship if there is a necessity. Necessity legalizes the prohibited. In the medical setting a hardship is defined as any condition that will seriously impair physical and mental health if not relieved promptly. Hardship mitigates easing of the shari'at rules and obligations. Committing the otherwise prohibited action should not extend beyond the limits needed to preserve the Purpose of the Law that is the basis for the legalization. Necessity however does not permanently abrogate the patient’s rights that must be restored or recompensed in due course; necessity only legalizes temporary violation of rights. The temporary legalization of prohibited medical action ends with the end of the necessity that justified it in the first place. This can be stated in al alternative way if the obstacle ends, enforcement of the prohibited resumes/ It is illegal to get out of a difficulty by delegating to someone else to undertake a harmful act.
3.5 The principle of custom or precedent, qa'idat 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.
4.0 CURRICULUM CONTENT
4.1 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).
National legal systems: civil and shari’at laws: The national civil and criminal justice system (sources of the laws, types of courts and their jurisdiction, difference between civil and criminal procedures, process of trial, judgment and punishment, legislation specific to medical practice). National laws related to health. The national shari’at legal system (types of courts and jurisdictions, enabling legislation, the office of the State Mufti and medical fatwas).
4.2 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
4.3 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).
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).
4.4 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).
4.5 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.
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).
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.
4.6 Issues at the beginning and end of life
Beginning of life issues: Prenatal / pre-implantation gender testing in IVF. Induced abortion (maternal disease, unwanted pregnancy, gender selection, congenital anomalies).
Stem cell technology: Stem cells (definition, methods, use in disease therapy, use in research, sources of stem cells and ethical controversies).
Embryo/fetal research: Sources of embryos. Types of research that uses embryos (contraception, sterilization, reproductive cloning). Ethical guidelines and controversies.
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.
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 tissue
4.7 Ethico-legal-fiqh issues in medical practice
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).
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).
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).
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)
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
Input/output systems disorders: 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 disorders: 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 disorders: 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 disorders: 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
Sensory system disorders: 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)
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 neuropathy
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).
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 (puasa).
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.
4.9 Ethico-legal-fiqh issues in psychosocial applications
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)
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)
Community Action: enjoining the good and forbidding the bad, health promotion, social change, professional and occupational organizations, social welfare, disaster relief, refugees,
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,
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).
Judicial transactions: legal competence: ahliyyat
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).
4.10 Professionalism
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.
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.
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.
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.
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.
5.0 IMPLEMENTING THE CURRICULUM
5.1 Setting the vision for Islamic health care in the future.
The overall vision of the curriculum is based on fulfilling purposes, maqasid. These can be visualized at the level of the whole society or community. As a society, medical practice must be visualized within the 3 major purposes of khilafat al insan fi al ardh, imarat al ardh, and taskhiir al ardh lim al insaan. As an individual medical practice must be situated within the purposes of ubudiyyat (‘ibaadat & taqwa) and tazkiyat al nafs. In a practical and legal way medical practice must fulfill or not violate the 5 cardinal purposes of the Law: hifdh al ddiin, hifdh al nafs, hifdh al nasl, hifdh al aql, and hifdh al maal.
5.2 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.
5.3 The emerging Islamic healthcare industry
Several factors combine to foster the development of an Islamic health care industry. There is frustration with existing health care delivery due to human factors and not technology. There is a desire to explore the Islamic alternative: Muslim patients prefer an Islamic environ. The parallel of Islamic banking and finance also motivates Islamic healthcare. Lessons from Islamic banking: sufficient theory before & personnel training before practice
5.4 The process of curriculum change
Islamic input must have a relation to the national competence curriculum. It supplements and does not supplant the national goals. It is an added value to the process of medical education. At the start of the curriculum reform process we must decide what changes are to me made. These changes must be integrated in a harmonious way into the existing structures. The process should be gradual being more evolution than revolution.
5.5 Methods of teaching
The following methods have been used either singly or in combination to deliver the curriculum.
- Full integration into the lectures and PBL
- Case scenarios or case studies
- Clinical ethical rounds
- Practical training: taharat and ibadat
- Field visits: clinics, courts, research centers etc
The most effective approach has been the use of case studies.
5.6 Reading materials
Shortage of reading material has been a recurring problem. There are hardly any books or journals dealing with the Islamic input in the curriculum. It is suggested that specialized workshops be held at which experts present papers for discussion that are compiled into books and manuals. Efforts can also be made to translate existing material.
5.7 Teacher training
Success of the curriculum will require well trained teachers. It is suggested that some universities volunteer to provide the following programs:
- Diploma / masters in Islamic Healthcare Delivery
- Masters and doctorate by research on specific ethical issues
5.8 Curriculum evaluation: annual conference.
Annual curriculum review conferences can cover the following:
- Methods of teaching
Reading - Teacher training
5.0 Output evaluation
- Alumni association to maintain contact / tracer studies
- Questionnaire surveys: how are these graduates different from others