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9.0 ISSUES OF PRIVACY, CONFIDENTIALITY, AND CONSENT
9.1 Notes On ‘Privacy And Confidentiality’
Privacy and confidentiality are often confused. Privacy is the right to make decisions about personal or private matters and blocking access to private information. The patient voluntarily allows the physician access to private information in the trust that it will not be disclosed to others. This confidentiality must be maintained within the confines of the Law even after death of the patient. Confidentiality falls under the teaching of the prophet about keeping secrets.
In routine hospital practice, many persons have access to confidential information but all are enjoined to keep such information confidential. Confidentiality includes medical records of any form.
The patient should not make unnecessary revelation of negative things about himself or herself.
The physician can not disclose confidential information to a third party without the consent of the patient.
Information can be released without the consent of the patient for purposes of medical care, for criminal investigations, and in the public interest.
Release is not justified without patient consent for the following purposes: education, research, medical audit, employment or insurance.
9.2 Consent And Refusal Of ‘Treatment For Competent Adults’
No medical procedures can be carried out without informed consent of the patient except in cases of legal incompetence. The patient has the purest intentions in decisions in the best interests of his or her life. Others may have bias in their decision-making.
The patient is free to make decisions regarding the choice of physicians and treatments. Consent can be by proxy in the form of the patient delegating decision making or by means of a living will.
The patient must be free and capable of giving informed consent. Informed consent requires disclosure by the physician, understanding by the patient, voluntariness of the decision, legal competence of the patient, explanation of all alternatives, recommendation of the physician on the best course of action, decision by the patient, and authorization by the patient to carry out the procedures. Consent is limited to what was explained to the patient except in an emergency.
Refusal to consent must be an informed refusal (patient understands what he is doing). Refusal to consent by a competent adult even if irrational is conclusive and treatment can only be given by permission of the court. Doubts about consent are resolved in favor of preserving life.
Spouses and family members do not have an automatic right to consent for a competent patient. A spouse cannot overrule the patient’s choice.
Advance directives, proxy informed consent by the family are made for the unconscious terminal patient on withholding or withdrawal of treatment.
Physician assisted suicide, active euthanasia, and voluntary euthanasia are illegal even if the patient consented.
A do not resuscitate order (DNR) by a physician could create legal complications.
The living will has the following advantages: (a) reassuring the patient that terminal care will be carried out as he or she desires (b) providing guidance and legal protection and thus relieving the physicians of the burden of decision making and legal liabilities (c) relieving the family of the mental stress involved in making decisions about terminal care. The disadvantage of a living will is that it may not anticipate all developments of the future thus limiting the options available to the physicians and the family.
The device of the power of attorney can be used instead of the living will or advance directive.
Decision by a proxy can work in two ways: (a) decide what the patient would have decided if able (b) decide in the best interests of the patient.
Informed consent is still required for physicians in special practices such as a ship’s doctor, prison doctor, and doctors in armed forces. Police surgeons may have to carry out examinations on suspects without informed consent.
9.3 Consent And Refusal Of ‘Treatment For Incompetent Adults And Children’
Consent for children
Competent children can consent to treatment but cannot refuse treatment. The consent of one parent is sufficient if the other one disagrees. Parental choice takes precedence over the child’s choice. The courts can overrule parents. Life-saving treatment of minors is given even if parents refuse. Parental choice is final in therapeutic or non-therapeutic research on children.
Mental patients
Mental patients cannot consent to treatment, research, or sterilization because of their intellectual incompetence. They are admitted, detained, and treated voluntarily or involuntarily for their own benefit, in emergencies, for purposes of assessment, if they are a danger to themselves, or on a court order. Suicidal patients tend to refuse treatment because they want to die.
The unconscious
For patients in coma, proxy consent by family members can be resorted to. If no family members are available, the physician does what he as a professional thinks is in the best interest of the patient.
There are many disputes about withdrawing nutrition, hydration, and treatment in a persistent vegetative state since the chance of recovery is low. There is no moral difference between withholding and withdrawing futile treatment.
Obstetrics
Labor and delivery are emergencies that require immediate decisions but the woman may not be competent and proxies are used. Forced medical intervention and cesarean section may be ordered in the fetal interest. Birth plans can be treated as an advance directive.
9.4 Suicide
Abstract
Suicide can be direct, deliberate, and violent relating to major depression, or can be slow and indirect relating to risky lifestyles. Islam prescribes severe legal and moral sanctions for suicide. Direct suicide related to psychogenic factors can be prevented by cognitive understanding of basic Islamic principles relating to life and belief in pre-destination. Life belongs to Allah and cannot be taken by a human. Belief in pre-destination enables a believer to understand and positively cope with adverse life experiences thus preventing resort to suicide.
Two forms of suicide
There are two ways of taking one’s life: direct and indirect. The direct is usually called suicide and involves deliberate violent measures of life termination. The underlying motivating factors may be pain, depression, or loss of hope. Some cases of suicide may be due to mental disease or temporary loss of sanity due to use of psychoactive substances. The indirect form of taking life results from pursuit of unhealthy life-styles that endanger life like cigarette smoking, use of alcohol, careless driving, refusal of immunization, neglect of medical care, and poor nutrition. Death is not as violent and does not occur immediately. The number of people who die from such slow suicide is far more than those who take violent measures to terminate their lives. Our discussion will be confined to violent suicide as a result of adverse life experiences.
Legal rulings on suicide
Suicide is condemned. Humans who attempt suicide commit a major crime of trying to arrogate to themselves power and privileges that are in the preserve of Allah alone. The Qur’an forbids self-destruction[1]. Anybody who kills himself with a metal weapon will be punished with the same weapon in the hereafter[2] and will be denied entry into paradise[3]. The funeral prayer is not offered for a deceased who killed himself[4]. The authorities may impose a disciplinary punishment for a person who attempts suicide and fails.
Prevention of suicide by cognitive understanding
Ownership of life: Understanding that life belongs to Allah will dissuade a person from attempting suicide. Life belongs to Allah and not the human. Allah gives and takes away life[5]. Humans are only temporary custodians of life enjoined to take good care of it. Humans have no control over death. Death is in Allah’s hands[6]. Humans therefore have no right to destroy their life or that of any other human. Doing so is one of the greatest transgressions.
Sanctity of life: Respecting the sanctity of life will dissuade a person from suicide. The sanctity of life is guaranteed by the Qur’an[7]. The life of each single individual whatever be his or her age, social status or state of health is important and is as equally important as the life of any other human[8]. Protection of life is the second most important purpose of the shari’at coming second only to the protection of the diin. It has priority over any other mundane consideration.
Prevention of suicide by belief in pre-destination
Belief in pre-determination: Belief in pre-determination can enable people to cope with adverse life events without resorting to suicide. They understand that all events are part of a divine plan. They believe that everything is fixed in advance[9] [10] and all events are under Allah's pre-determination[11]. They believe that pre-determination covers both the good and the bad[12]. They know that all human affairs are in the hands of Allah[13] and that the human should therefore seek support from Allah and surrender all affairs to Him[14].
Benefits of belief in pre-determination: Belief in pre-determination has many benefits that make human life happier and easier. It prevents a person from thinking of suicide in case of adverse life experiences. The first benefit is that the human who believes in pre-determination will be rich in his heart because he will know that what he has is what Allah gave him and will not hanker over what he does not have[15]. The second benefit is to avoid excessive joy and sadness[16]. This is because the believer knows that all is from Allah and will praise Allah for either the good or the bad. He also knows that Allah gives and takes away, and that life is cyclical. Adversity may be followed by prosperity and vice versa.
Meaning of qadar and qadha: Qadar is pre-event and refers to pre-determination or pre-fixing of events. Qadha is post event and refers to the empirical or practical occurrence of what was pre-determined by qadar. There are 2 stages in the occurrence of any event. In the stage of qadar Allah pre-determines and knows what will happen but the human does not. The human is therefore enjoined to struggle as best as he can to achieve a desired objective which may be wealth, health, or progeny. In his ignorance of pre-determination, a human cannot stop his struggles arguing that qadar is fixed. However after the event has occurred, the believer is now in the stage of qadha and has to accept what happened and knows that it is with Allah’s permission[17] and exercises patience[18].
Limited human knowledge: In practice the limited knowledge of humans does not enable them to tell the end of events. What may appear an adverse life event may turn out to be good eventually. Humans cannot know for sure what is good and what is bad for them. They have to believe that all is from Allah[19] and that good and bad events are both a test for humans[20]. A believer will praise Allah (al hamd li al llaah) equally for both ‘good’ and ‘bad’ events or experiences because he knows they are all part of pre-destination. The terms ‘good’ and ‘bad’ in human experience and knowledge are relative. What may appear to be good may turn out to be bad[21]. What may appear to be bad may turn out to be good[22]. Humans can not see the whole picture. They may see some aspects of the whole picture and judge them to be good or bad. If they had knowledge of the whole picture and the correct context they would have interpreted the observed events or phenomena differently.
Conclusion
Islamic religious teachings can enable a person to understand and cope with adverse life events thus preventing resort to suicide.
NOTES
[1] Qur’an 2:195
[2] Bukhari Kitaab al janaiz Baab 84
[3] Muslim Kitaab al iman Hadith 178
[4] Muslim Kitaab al Janaiz Hadith 107
[5] Qur’an 15:23
[6] Qur’an 25:3
[7] Qur’an 17:33
[8] Qur’an 5:32
[9] Qur’an 25:2
[10] Qur’an 33:38
[11] Qur’an 65:3
[12] Muslim Kitaab al Iman Hadith 1
[13] Muslim Kitaab al qadar Baab 17
[14] Muslim Kitaab al qadar Hadith 34
[15] Ahmad and Tirmidhi
[16] Qur’an 57:22-23
[17] Qur’an 64:11
[18] Qur’an 3:120, 3:186
[19] Qur’an 4:78
[20] Qur’an 21:35
[21] Qur’an 2:216
[22] Qur’an 2:216