130430L - HEALTH CARE ETHICS 1: THEORIES and PRINCIPLES FROM AN ISLAMIC PERSPECTIVE (Word Slides - 2)

Lecture for 4^th year medical students at the Faculty of Medicine Salman University Kharj on 30^th April 2013 by Professor Omar Hasan Kasule MB ChB (MUK), MPH (Harvard), DrPH (Harvard)

PURPOSES OF MEDICINE

A. Protection of morality/ddiin

B. Protection of Life Nafs

C. Protection of Progeny, Nasl

D. Protection of the Mind, ‘Aql

E. Protection of Wealth, Al Mal

PRINCIPLES OF MEDICINE

A. The Principle of Intention, qasd

B. The Principle of Certainty, Yaqeen

C. The Principle of Injury: autonomy, beneficence, non-malefacence, justice

D. Principle of Hardship, mashaqqat

E. The Principle of Custom or Precedent, ‘aadat

INTRODUCTION

·         Concern with moral issues in medicine increased in the recent past due to new medical technology and increase in moral violations by medical practitioners.

·         In 1976 Beauchamps and Childress wrote authoritatively about ethical theory and ethical principles

·         The following international declarations covered legal medical issues from a European world-view: Declaration of Geneva, International Code of Medical Ethics, Declaration of Tokyo, Declaration of Oslo, and Declaration of Helsinki.

 

MODERN ETHICS

• Modern Ethical analysis can be normative (what ought to be done), or practical (what most people do), and non-normative (what is actually going on). Morality has became communal consensus about what is right and what is wrong making ethics became and changeable with change of community values.

• Beauchamp and Childress listed eight European ethical theories none of which can on its own explain all ethical or moral dilemmas. These theories can be listed as the utilitarian consequence-based theory, the Kantian obligation-based theory, the rights-based theory based on respect for human rights, the community-based theory, the relation-based theory, and the case-based theory.

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

ALTERNATIVE APPROACH TO ETHICS

• Consistent and robust ethical analysis is possible when based on the following purposes and principles. The five purposes are preservation of morality/ddiin, life, progeny, intellect, and wealth. Any medical action must fulfill one of the above purposes if it is to be considered ethical.
• The basic principles relevant to medical practice are: intention, kasd; certainty, yakin; and harm, dharar. The 4 ethical principles enunciated by Beauchamps and Childress are all subsumed under the principle of harm.

PROTECTION OF LIFE, nafs:

• The primary purpose of medicine is to fulfill the second purpose, the preservation of life. Medicine contributes to the preservation and continuation of life by making sure that the nutritional functions are well maintained.
• Medical knowledge is used in the prevention of disease that impairs human health. Disease treatment and rehabilitation lead to better quality health.

PROTECTION OF PROGENY, 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, 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.

PROTECTION OF THE MIND, ‘aql:

• Medical treatment plays a very important role in protection of the mind.
• Treatment of physical illnesses removes stress that affects the mental state.
• Treatment of neuroses and psychoses restores intellectual and emotional functions. Medical treatment of alcohol and drug abuse prevents deterioration of the intellect.

  

PROTECTION OF WEALTH, mal:

• The wealth of any community depends on the productive activities of its healthy citizens.
• Medicine contributes to wealth generation by prevention of disease, promotion of health, and treatment of any diseases and their sequelae.
• Communities with general poor health are less productive than a healthy vibrant community.
• The principles of protection of life and protection of wealth may conflict in cases of terminal illness. Care for the terminally ill consumes a lot of resources that could have been used to treat other persons with treatable conditions. The question may be posed whether the effort to protect life is worth the cost. The issue of opportunity cost and equitable resource distribution also arises.

THE PRINCIPLE OF INTENTION, 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 physician to consult his inner conscience and make sure that his actions, seen or not seen, are based on good intentions.
• The sub principle that what matters is the intention and not the words rejects the wrong use of data to justify wrong or immoral actions.
• The sub principle that means are judged with the same criteria as the intentions implies that no useful medical purpose should be achieved by using immoral methods.

THE PRINCIPLE OF CERTAINTY, yaqeen:

·         Medical diagnosis does cannot reach the legal standard of certainty. Treatment decisions are best on a balance of probabilities. Each diagnosis is treated as a working diagnosis that is changed and refined as new information emerges. This provides for stability and a situation of quasi-certainty without which practical procedures will be taken reluctantly and inefficiently.

·         Existing assertions should continue in force until there is compelling evidence to change them.

·         Established medical procedures and protocols are treated as customs or precedents.

·         What has been accepted as customary over a long time is not considered harmful unless there is evidence to the contrary.

·         All medical procedures are considered permissible unless there is evidence to prove their prohibition.

THE PRINCIPLE OF INJURY, dharar: 1

• Medical intervention is justified on the basic principle is that injury, if it occurs, should be relieved.
• An injury should not be relieved by a medical procedure that leads to an injury of the same magnitude as a side effect.
• In a situation in which the proposed medical intervention has side effects, we follow the principle that prevention of a harm has priority over pursuit of a benefit of equal worth.
• If the benefit has far more importance and worth than the harm, then the pursuit of the benefit has priority.
• Physicians sometimes are confronted with medical interventions that are double edged; they have both prohibited and permitted effects.

THE PRINCIPLE OF INJURY, dharar: 2

• The guidance of the Law is that the prohibited has priority of recognition over the permitted if the two occur together and a choice has to be made.
• If confronted with 2 medical situations both of which are harmful and there is no way but to choose one of them, the lesser harm is committed.
• A lesser harm is committed in order to prevent a bigger harm. In the same way medical interventions that in the public interest have priority over consideration of the individual interest.
• The individual may have to sustain a harm in order to protect public interest. In the course of combating communicable diseases, the state cannot infringe the rights of the public unless there is a public benefit to be achieved. In many situations, the line between benefit and injury is so fine that salat al istikharat is needed to reach a solution since no empirical methods can be used.

PRINCIPLE OF HARDSHIP, mashaqqat:

• Medical interventions that would otherwise be prohibited actions are permitted under the principle of hardship if there is a necessity. Necessity legalizes the prohibited.
• In the medical setting a hardship is defined as any condition that will seriously impair physical and mental health if not relieved promptly. Hardship mitigates easing of the sharia rules and obligations. Committing the otherwise prohibited action should not extend beyond the limits needed to preserve the Purpose of the Law that is the basis for the legalization.
• Necessity however does not permanently abrogate the patient’s rights that must be restored or recompensed in due course; necessity only legalizes temporary violation of rights.
• The temporary legalization of prohibited medical action ends with the end of the necessity that justified it in the first place. This can be stated in al alternative way if the obstacle ends, enforcement of the prohibited resumes/ It is illegal to get out of a difficulty by delegating to someone else to undertake a harmful act.

THE PRINCIPLE OF CUSTOM or PRECEDENT, ‘aadat:

• 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.