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Paper presented at the retreat of the Melaka Health Department held at Swiss Garden Resort, Kuantan, Pahang on 21st February 2000 by by Prof Dr Omar Hasan Kasule, Sr. MB ChB (MUK), MPH, DrPH (Harvard), Deputy Dean for Research and Post Graduate Affairs, UIA.
ABSTRACT
This paper describes the Islamic concept of medical ethics at taught and practiced at the Faculty of Medicine of UIA. It starts by asserting that ethics can not be separated from morality and that the training of an ethical physician is a long involved and continuous process throughout the medical course and not just teaching of ethical guidelines and rules. Islamic universal moral values must be integrated in the scientific, clinical, and social aspects of medical teaching and practice. Most bio-ethical issues are treated as legal issues for which the Law, shariat, provides general guidelines. Problems arise with regard to gray areas and fine points of detail that fall in the area of shubuhaat. These must be approached with caution with the basic moral values and conscience as a guide. Practical guidelines of ethical etiquette, adab, are given for various medical scenarios.
Key words: Islamic - ethics - morality
1.0 INTRODUCTION
The UIA faculty of medicine, being the newest in Malaysia, admitted its first batch of students in June 1997. It has many features common in other Malaysian universities: content of the medical curriculum, duration of studies, examinations, and practical training. It in addition has unique characteristics of its own being Islamic and international. It has an integrated curriculum in which moral and ethical values are taught pari passu with the academic and practical aspects of medicine by the same instructors. UIA does not accept the distinction between ethics as a set of regulations agreed on by consensus in a particular profession and morality as basic inner beliefs. Ethics must reflect basic morality otherwise, like any other human rules, they can be circumvented by using one loop-hole or another. Ethics can not be learned in a course but can only be internalized so that they become part of the student's personality. The supreme objective is to produce a physician who will act ethically without consciously thinking about rules and regulations. Ethical behavior will have become part of behavior as is eating and drinking. The aim is to make sure that ethical behavior is not prompted by fear of punishment or promise for any reward. The only motivation should be from the inner conviction of the physician. Being an Islamic university, the teaching of ethics is based on the Islamic value system. These are the universal human values found in several other faiths and philosophies of life. Islam as a religion and way of life has the unique distinction of claiming universality in its basic teachings, practice, cultural, and intellectual values. It is therefore very easy for non-Muslim students to follow and understand the ethical input into the curriculum.
2.0 THE ISLAMIC IN-PUT CURRICULUM (IIC)
Tauhid: IIC is based on the holisitic tauhidi paradigm that does not look at medicine as a science and art isolated from the rest of society and human endeavors. A basic paradigm of IIC is that medicine and medical treatment are comprehensive involving physical, psychological, social, spiritual, and moral aspects. This paradigm is a practical consequence of the integrative tauhidi paradigm that is the basis of the Islamic civilization. IIC aims at producing a physician who is not only skilled in scientific medicine but also understands the spiritual and social aspects of disease. Such a physician sees the patient as a whole person living in a social and spiritual milieu and not just as a collection of symptoms and signs. The curriculum aims at universality and integration. Medicine must not be a collection of sub-specialties but an integrated whole.
Vision: The vision of IIC has two separate but closely-related components: value-orientation, also called Islamization, and medical ethics. Islamization deals with putting medicine in an Islamic context in terms of epistemology, values, and attitudes. Medical ethics deals with issues in the ‘gray area’ for which simple categorization as good & bad, legal & illegal is not easy. IIC basically tries to provide an Islamic intellectual and cultural context for medical concepts and practice. The approach has not been confined to technical aspects of medicine but has gone beyond to explore social, cultural, and epistemological issues that have an impact on the teaching and practice of medicine. IIC also contributes to the evolution of an ethical system or ethical guidelines that can help the Muslim physician and the patient make the best decisions in difficult circumstances that arise out of the recent developments in medical technology. Most of what falls under the rubric of medico-ethical issues in the west is actually medico-legal issues for which the shariat has basic guidelines.
Concepts and paradigms: The first objective of IIC is the introduction of Islamic paradigms and concepts related to medicine. The Muslim physicians must have some general concepts deriving from Islamic teachings that can guide their work and research. These concepts can be grouped in five major categories: faith, aqidat, knowledge, ilm & marifat, cosmos/universe, kaun, the human, insan, and concepts relating to transitions in the human condition: life (hayat), death (mawt), health (sihat), disease (maradh), and medical treatment (tatbiib).
Faith and science: The second objective of IIC is strengthening faith, iman, through study of Allah’s sign in the human body. Medicine and medical knowledge have been described as the altar of faith, al tibb mihrab al iman. Study of medicine leads to the conclusion that there must be a powerful and deliberate creator because such a sophisticated organism could not arise by chance. Contemplation of the structure and functioning of the human body lead a normal person to appreciation of the power of the Creator and to believe in Him.
Law and medicine: The third objective of IIC is appreciating and understanding the juridical, fiqh, aspects of health and disease, al fiqh wa al tibb. There is a close interaction between injunctions of Islamic law, fiqh, and medical practice. Muslim physicians must be aware of the general concepts so that they can give preliminary advice to the patients. Diseases and their treatment interfere with the patient’s duties to Allah and also to other humans by limiting rights and obligations.
Social and ethical issues in medicine: The fourth objective of IIC is understanding the social and ethical issues in medical practice and research, al qadhaya al ijtima’iyat wa al akhlaqiyat fi al tibb. Medicine is not taught or practiced in a social or ethical vacuum. Good physicians must understand how social problems and issues impact on health, disease and medical treatment. They also must appreciate how medical practice can create or solve social and ethical problems.
Methodology of analysis: IIC has followed a consistent methodology in analysis of medical phenomena in the light of the Qur’an and sunnat. Biological phenomena are presented as a miracle of the human body. The student is led to appreciate the majesty of Allah’s creation by pointing out the following recurring patterns in all organ systems: parity, symmetry, reserve functional capacity, functional adaptation, harmony and coordination. Legal and ethical issues are analyzed based on original sources in the text, nass, of Qur’an and hadith as well as the Purposes of the Law, maqasid al sharia, and Principals of the Law, al qawaid al fiqhiyyat al kulliyat, as will be explained subsequently.
3.0 APPROACHES TO TEACHING BIO-ETHICS
Over-view: Legal and ethical issues are analyzed based on original sources in the text, nass, of Qur’an and hadith as well as the Purposes of the Law, maqasid al sharia, and Principals of the Law, al qawaid al fiqhiyyat al kulliyat, that are directly derivable from the primary textual sources. In analyzing ethical issues arising out of modern developments in biotechnology, IIC has gone beyond the technical and narrowly legalistic framework to consideration of social roots and consequences of disease. Abortion, for example, is not analyzed only as a case of feticide but in its wider implication of facilitating sexual promiscuity by providing a way out of an undesired and unplanned pregnancy.
Purposes of the law, maqasid al shariat: The law was specifically promulgated for the interests or benefit (masaalih) of the people. The 5 Purposes of the Law, maqasid al sharia, arranged here in order of importance are preservation and protection of religion,diin; life, nafs; the mind, aql; progeny, nasl; and property, maal. On earth, unlike heaven, there is no absolute benefit, maslahat, or harm, mafsadat, the aim of the law is therefore to choose the best equilibrium. It is not always true that benefits are permitted, halal, and harms are prohibited, haram. The law alone defines what is a benefit and what is a harm; human intellect and desires are unreliable in this exercise.
Principles of the law, qawaid al sharia: Five principles are recognized by most scholars: intention, qasd; certainty, yaqeen; harm, dharar; hardship, mashaqgat; and custom or precedent, aadat. Each of the 5 principles is a group of legal rulings or axioms that share a common derivation by analogy, qiyaas.
Purposes and principles of the law in transplantation: The following is a summary analysis of how the Purposes and Principles of the Law can be applied to the legal and ethical issues of transplantation. Under the purpose of maintaining life, hifdh al nafs, there should be no injury to the health and human dignity of both the donor and the recipient. The associated side-effects, complications, and abuses for both the recipient and the donor are treated under 2 Principles of Law: hardship, mashaqqa, and injury, dharar. Under the principle of hardship, necessity and hardship legalize what would otherwise be objectionable or risky, al dharuurat tubiihu al mahdhuuraat; lessening donor risk has precedence over benefit to the recipient, dariu al mafasid muqaddamu ala jalbi al masaalih; and the complications and side-effects to the recipient must be a lesser harm than the original disease, ikhtiyaar ahwan al sharrain. Under the principle of injury, transplantation relieves an injury to the body, al dharar yuzaal, in as far as is possible, bi qadr al imkaan, but its complications and side-effects should be of lesser degree than the original injury, al dharar la yuzaal bi mithlihi. Abuse of transplantation by abducting or assassinating people for their organs could lead to complete prohibition under the principles of dominance of public over individual interest, al maslahat al aamat muqaddamat ala al maslahat al khhasat; prevention of harm has priority over getting a benefit, dar’u al mafaasid awla min jalbi al masaalih; and pre-empting evil, dariu al mafasid. The principles of custom and certainty are invoked in the definition of death and thus the earliest time for organ harvesting. Under the principle of custom, al aadat, brain-death does not fulfill the criteria of being a widespread, uniform, and predominant customary definition of death which is considered a valid custom, al aadat muhakkamat. The success of biotechnology in transplantation and other fields introduces a strong doubt, shakk, in the irreversibility of brain-death. Under the principle of certainty, yaqeen, existing customary definition of death should continue in force until there is compelling evidence otherwise, al asl baqau ma kaana ala ma kaana. Selling organs could open the door to criminal commercial exploitation and may be forbidden under the purpose of maintaining life, the principle of preventing injury, the principle of closing the door to evil, sadd al dharia, and the principle of motive. Protecting innocent people from criminal exploitation is a public interest that has priority over the health interests of the organ recipient. The principle of motive, qasd, will have to be invoked to forbid transplantation altogether if it is abused and is commercialized for individual benefit because the purpose will no longer be noble but selfish. Matters are to be judged by the underlying motive and not the outward appearances, al umru bi maqasidiha. The concepts of legal competence, ahliyyat, and free consent, adam al ikraah, are invoked for organ donors. In order to avoid any doubts, decisions about donation of organs should be made only by those giving the organs not because they own the organs but because, of all the players involved, they are the most intimately concerned and have no conflict of interest. They must however fulfill the conditions of legal competence which are: adulthood, soundness of mind, and no coercion. This practically excludes harvesting organs of minor children, the insane, or the unconscious
IIC and legal rulings: IIC is not a manual of legal rulings. It does not present ready solutions for practical medico-legal or medico-ethical problems and should not be used as a source of legal opinion, hukm & fatwa. Its main purpose is to present the issues involved, discuss the various options available from the Islamic and medical perspectives and leave it to the reader to make his/her choices. It encourages holistic thinking, tafkiir shumuuli and does not present issues as isolated problems. Each issue is presented in its social, legal, medical, and spiritual-religious perspectives so that an informed solution can be formulated. Attempts have been made to avoid the crisis of partial solutions, juz’iyyat, that has paralyzed the Muslim mind for a long time and has prevented it from being creative and innovative. A basic assumption IIC is that in complicated matters involving ethics and shariat, it is the individual (s) involved, the patient or close family, who should make the decision and choice. The role of physicians and jurists, fuqaha, is to make sure that the choice made is an informed one based on correct facts and a clear understanding of the various options involved as well as the implications of each.
4.0 ETHICAL ETIQUETTE WITH PATIENTS
Obligation to visit the patient, wujuub iyadat al mariidh: The ward rounds fulfil one of the social obligations of visiting the sick (KS 505). Visiting the sick has a lot of excellence, fadhl iyadat al mariidh, (KS 505). Care givers get a lot of reward from Allah for fulfilling this social obligation in addition to the rewards for their medical work The caregiver should interact with the patient as a fellow human. The human relation has priority over the professional patient-physician relation. Some bedside visits should therefore be purely social with no medical procedures or medical discussions.
Etiquette of visiting a patient, adab ‘iyadat al mariidh: The prophet regularly visited his companions who fell sick (KS 505, MB #1956). His behavior at the bedside of the patient is good guidance for both the physician and the other visitors to the patient. The books of sirah have preserved for us memories of such visits such as what the prophet said during the visit (KS 505). The following are recommended actions during a visit to the patient: supplication, dua, for the patient (KS 505, MB #1961), reading Qur'an for the patient (KS 505), and asking the patient for supplication, dua. The Qur'an is a cure, al Qur'an dawa (KS p. 338). Dua is a cure, al dua dawau (KS p. 338). The Prophet gave us guidance on what can be said and what should not be said in the presence of the patient (KS 505). The following are enjoined: asking about the patient’s feelings, sua'al anhu, doing good/pleasing things for the patient, ihsaan, making the patient happy, tatyiib nafs al maiidh, and encouraging the patient to be patient, tashjiu al mariidh (KS 505). The patient should be discouraged from wishing for death wishing death, tamanni al mawt (KS 524).
Appearance of the caregiver: The caregivers must make sure that they are clean and are dressed appropriately. The type and style of dress create impressions and convey messages. The dress, hair, and shoes of the caregiver must convey the impression of a serious, organized and disciplined person. The use of cosmetics should be limited to just covering up any defects and restoring the normal, average, and natural appearance. Excessive use of cosmetics conveys the impression of egoism and lack of seriousness. Perfumes should be used in moderation to suppress any unpleasant body odors. Excessive use, when the patient is aware that the caregiver is wearing perfume, is discouraged.
Mannerisms of the caregiver: Caregivers must have a cheerful disposition, imbisaat (MB #2045). They must deal with patients with leniency, rifq (MB # 2025). They must strive to do good, ma'aruf (MB #2024). They must also have only good thoughts about their patients, husn al dhann. They must avoid evil or obscene words (MB #2026). It is important for the caregiver to have full interaction with the patient but must still observe the rules of lowering the gaze, ghadh al basar, except when medical necessity dictates otherwise. Caregivers must not be arrogant and show off (MB #2116). They must adopt an attitude of humbleness, tawadhu'u (MB #2117) all the time.
Emotional involvement: It is very wrong for caregivers to adopt a detached emotionally-neutral disposition thinking that is the way of being professional. Caregivers must be loving and empathetic, tawadud & tarahum (MB #2018). They must show mercifulness, rahmat (MB #2020). The emotional involvement must however not go to the extreme of being so engrossed that rational professional judgement is impaired.
Covering of awrat: 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, maslahat, 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 infront of others. An epileptic woman who was embarrassed at the uncovering of her awrat during an attack came to the prophet. He prayed for her and Allah answered the prayer (MB #1954).
Medical procedures: Caregivers must be fully aware of their legal liabilities and responsibilities, mas'uliyat al tabiib (Sunan Abu Daud Kitaab al diyaat baab 24, Ibn Majah Kitaab al Tibb baab 16). The rules of seeking permission, isti' dhaan, must be followed whenever caregivers approach a patient. The patient must be forewarned about the approach of the caregiver and should not be surprised. The privacy of the patient must be respected and he or she should be examined after getting permission. Medical care must be professional, competent, and considerate. Medical decisions should consider the balance of benefits and risks. The general position of the Law is to give priority to minimizing risk over maximizing benefit, dar'u al mafsadat muqaddamu ala jalbi al maslahat. Any procedures carried out must be explained very well to the patient in advance.
Supporting care: The caregivers must listen to the felt needs and problems of the patients. They should ask about both medical and non-medical problems. Supportive care such as nursing care, nutrition, cleanliness, and ensuring physical comfort are as important as the medical procedures themselves. In terminal cases it is only the supporting care that can be given.
Managing fever: Fever is a generalized often non-specific patho-physiological response. It is a cause of much discomfort. Caregivers should detect it early and treat it effectively. The prophet described fever as a blow of hot wind from hell-fire. He recommended using cold water to cool the body during fever (MB #1972). Any additional methods of reducing body temperature should be used.
Managing pain: The caregiver should comfort the patient in pain. He can explain that there is reward, ajr, for being patient when suffering (MB #1953). The patient should persevere and not wish for death, tamanni al mawt, because of extreme pain (MB #1958, 1959, 1960). The patient should be reassured that there is eventually a cure for every ailment, dawa li kulli dai (MB #1962) so that there is no loss of hope.
Control of infections: The prophet forbade a sick person visiting the healthy (KS 504) to prevent spread of infection. Precautions against spread of contagion were also recommended (MB #1969). Caregivers are obliged to make sure they have all their infectious diseases treated so that they are not a risk to their patients.
5.0 ETHICAL ETIQUETTE WITH THE FAMILY
Support: The family is also a victim when any member falls sick. The caregiver must provide psychological support to them. Sometimes even material support may be necessary. It should be remembered that part of the well being of the patient is to know that the family left behind is not suffering.
Reassurance: Illness is a cause of much anxiety for the family. The caregiver must take time to reassure the family by explaining what is going and assuring them that the best care is being given. They must be told not to give up hope because Allah in His power can reverse the most serious or critical conditions. In communicating with the family caregivers must make sure they do not violate medical confidentiality except where it is necessary, dharurat.
Involvement: Caregivers should similarly realize the importance of visits by relatives and friends and should plan their ward routines to maximize such visits. The family can be involved in some aspects of supportive care. This is helping them fulfill kindred obligations, silat al rahim. It uplifts the patient's morale to see that the family care and are around being involved.
Interference: Caregivers should be on the guard to make sure that the eagerness of the family to be of assistance and to be involved does not step beyond the limits. The family may interfere with medical care causing disturbance of the medical routines. This should be resisted with firmness.
Conflict: Illness is a stressful condition that generates anxiety in the family. It may initiate conflicts or aggravate existing ones. Caregivers may unwittingly find themselves in the middle of such conflicts. They should have the clarity of mind to understand that it is none of their business solving family conflicts. If they do they may regret it since they may become party to the conflict and are considered by some members of the family to favor other members.
6.0 INFORMED CONSENT
Choice of physician: As long as patients are conscious and are in full control of their mental faculties, they should be consulted about choice of physicians. Minors, unconscious patients, and those who have lost legal competence can not choose physicians. Their legal representative, waliy, will have to make the decisions. The caregiver must realise that choice of a physician is a continuing resolution and must make sure that there has been no change of mind on the part of the patient or the legal guardian. Permission to treat must be sought at every visit though not necessarily in a formal way. It is illegal to treat a patient against their will unless provided for otherwise by the Law in defined exceptional circumstances. As guidance to the patient in physician selection, the following order of priority is followed: Muslim of the same gender, non-Muslim of the same gender, and Muslim of the opposite gender.
Choice of treatment, food, and drink: The sunnah has given us guidance about forced feeding and forced treatment (KS 505: Sunan al Tirmidhi Kitaab al Tibb Chapter 3). The patient retains freedom to accept treatment or to reject it. The patient can not be forced to take any medication or undergoes any medical procedures. Treatment with new/experimental drugs or procedures requires informed consent. If the patient has lost legal capacity, ahliyat, by being unconscious or by losing mental capacity, the guardian, waliy, will take binding decisions on behalf of the patient. Illogical refusal of treatment or food could be grounds for finding a patient intellectually and legally incompetent making it necessary for the guardian to make the necessary decisions. Some situations of refusal of treatment are not issues of freedom of choice but have criminal implications. For example a patient with pulmonary tuberculosis who refuses treatment is committing the crime of endangering the lives of other members of the community. A parent who refuses immunization of a child is endangering the health of that child and other children in the community.
7.0 CONFIDENTIALITY
The secret, al sirr: The Qur'an mentioned the term secret in many verses (p. 570 2:77, 2:235, 2:274, 5:52, 6:3, 9:78, 10:54, 11:5, 12:19, 12:77, 13:10, 13:22, 14:30, 16:23, 16:75, 20:7, 20:62, 21:3, 25:6, 34:33, 35:29, 36:76, 43:80, 47:26, 60:1, 64:4, 66:3, 67:13, 71:9, 86:9). The term secret is relative. What may be a secret for one person may not be for another. What may be a secret in one place and at a particular time may no longer be a secret when time and place change. Secrets are of various degrees of importance. Revelation of some secrets could hurt an individual. Others can hurt the whole community or the whole ummat. Some secret information could be harmful if it is related directly to one individual but could be harmless if it is generalised.
Concept of keeping secrets, kitman al sirr: Humans are capable of deliberately hiding and sitting on information (p. 986 3:72, 2:228, 2:271, 3:167, 4:42, 4:149, 5:61, 5:99, 6:28, 14:38, 21:110, 24:29, 27:25, 33:54, 60:1). Allah knows all what humans hide and reveal (p. 986 2:33). The natural default situation is for humans to divulge and share information during conversations even without being obliged or expecting any benefits. Keeping a secret therefore requires effort and discipline. Hiding information may be praiseworthy for example if a person does not reveal is iman infront of enemies, kitman al iman (p. 986 40:28). Keeping a secret, hifdh al sirr, entrusted to you in confidence is a sign of good Islamic character ( ). You may keep your own secrets from people who are potential enemies. The Prophet taught us to rely on keeping secrets in managing our affairs, al I'itimad ala al kitman fi qadhai al hajat ( ). Secrecy could be negative if it involves hiding the truth that should have been spread to others, kitman al haqq (p? 2:42, 2:146, 2:159, 2:173, 3:71, 3:187, 4:37, 5:15, 6:19). It is also negative to hide evidence, kitman al shahadat (p. ? 2:140, 2:283, 5:106). The basic position is to keep secrets and information and not reveal them even if there is no foreseeable harm. It is part of good Islamic character not to reveal all what a person knows. The Prophet taught that people should listen more and speak less.
Written Records: Secrets are kept within the person, al kitman fi al nafs (p. 987 2:235, 2:284, 3:29, 3:118, 3:154, 27:74, 28:69, 33:37, 40:19). With development of writing and electronic technology, we now have other ways of keeping secret information. The Qur'an mentioned the tools for producing written records as paper, sahifat (p 979 20:133, 52:2-3) and the pen, qalam (p 979 68:1, 96:4). The Qur'an used the term kitaab to refer to written records such as scriptures (p. 977 4:153, 6:7, 17:93, 21:103, 29:48, 34:44, 35:40, 37:157, 34:21, 62:5), the Qur'an ( ), the record of pre-destination, kitaab al qadr (p. 978 3;145… 57:22), the record of values, kitaab al qiyam (p. 979 98:3), the record of knowledge, kitaab al ilm (p. 979 27:40)., and correspondence letters (P. 979 27:28-29). He process of writing was mentioned about evidence, kitabat al shahadat (p 979 43:19) and contracts, kitabat al uquud (p. 979 2:235, 2:282-283). Writing of false records was severely condemned (p 979 2:79). The prophet gave guidance about writing and writers (KS p. 452). In a modern medical environment, many records are generated about each patient. These prove a challenge as far as keeping of secrets is concerned because many people can access them. Besides their use in medical care, the records ca be used for medical education, medical research, and for legal purposes. Prevention of access to records for educational purposes may fall under the prohibition of hiding knowledge, kitman al ilm.
Basis for medical confidentiality: Medical confidentiality has psychological, social, and legal bases. The psychological basis is the private and privileged relationship of trust between the patient and the caregiver. Revealing secrets that occurred to a third party is a violation of the trust. Such violation destroys future co-operation because the patient will hold back some information from the caregiver thus impairing correct diagnosis and appropriate management. The social basis lies in the prohibition of spreading rumors, namiimat (MB #2032) and backbiting. The legal basis is three Principles of the Law, qawaid al sharia, and the Law of Property. The Principle of Injury, dharar, states that an individual should not harm others or be harmed by others, la dharara wa la dhirar. The Principle of Hardship, mashaqqa, states that hardship mitigates easing of the sharia rules and obligations, al mashaqqa tajlibu al tayseer. Necessity legalizes the otherwise prohibited, al dharuraat tubiihu al mahdhuuraat. Necessity is defined as what is required to preserve the five Purposes of the Law (religion, life progeny, property, and intellect). If any of these five is at risk, permission is given to commit an otherwise legally prohibited action. The ownership of the records is not clear. Do they belong to the patient, the caregiver that wrote them, or the institution?. Using the law of property, a product belongs to the person who made it. In this case, the patient is the 'maker' of all the medical facts that are written and should be the acknowledged owner of the records. The patient is also the only person involved who has most to lose if records are misused. Thus, the contents of the medical records can not be revealed without the express permission of the owner. The general position regarding medical records is that they are a secret that can not be revealed without specific necessity, dharurat, as defined by the law.
Release of information by the patient: The patient should consider any injurious information as a secret and can not reveal it. If it is about his sins or dishonorable shameful things, fahishat, he is forbidden. The prophet condemned al mujahir. A Muslim should repent and conceal his sins (MB #2037).
Release of the information by the caregiver: It is prohibited for the caregiver to use the privileged medical information he has for any personal gain. For example, he can not use his knowledge of the health of a businessperson to buy shares in a certain company. He can not advise his relatives about marrying or not marrying a certain person because of what he knows about their health. Release of information in the public interest is a more complicated situation. The question arises whether a caregiver is obliged to reveal disease in a leader or airline pilot that could endanger the public? What should the caregiver do if he knows of a patient with a contagious disease that is in the community and is endangering others? Is it a violation of privacy for the caregiver to share medical information with other caregivers caring for the same patient? What about using the data for medical research or medical education? How much can the caregiver tell the relatives of the patient without compromising the regulation of keeping secrets? What should the caregiver do if approached by law enforcement agencies asking for specific medical information that can help them solve a crime? Can a caregiver testify in court against his patient using information obtained during the medical examination? All these are questions for which no easy answers can be given most of the time. The simplest situation is when the patient, the owner of the records, consents to their release provided no other individual is directly hurt by such a release. There are situations in which over-riding public interest will require refusing to release information even if the patient consents. If the patient or his guardian does not consent, the caregiver can not release information except in situations of legal necessity, dharurat, as defined above. Education, research, and crime investigations do not fall under the category of necessity. In cases of court litigation, The caregiver could testify in criminal cases that involve dhulm. The Qur'an forbids the revelation of the shameful unless there is dhulm (p 308 4:148, 24:19). The caregiver can not give false testimony (MB #1176). One of the ways for the caregiver to decrease his risk of revealing secret information is to have only the minimum needed for his work. This means that during history taking only those questions directly related to the medical problem should be asked. There should be no probing or digging for unrelated facts.
8.0 ETHICAL ETIQUETTE WITH THE DYING
Making the dying patient confortable: Narcotics are given for severe pain. Drugs are used to allay anxiety and fears. The caregivers should maintain as much communication as possible with the dying: patience. They should attend to needs and complaints and not give up in the supposition that the end was near. Attention should be paid to the patient's hygiene such as cutting nails, shaving hair, dressing in clean clothes. As much as possible the dying patient should be in a state of rutual purity, wudhu, all the time.
Ibadat: The dying patient should as far as is possible be helped to fulfil acts of worship especially the 5 canonical prayers. Physical movements should be restricted to what the patient's health condition will allow. There us guidance on salat even for the unconscious patient (KS 505)
Spiritual preparation. Death of the believer is an easy process that should not be faced with fear or apprehension. The process of death should be easier for the believer than the non-believer (KS 525). The soul of the believer is removed gently (KS 525, 525, 525). Believers will look at death pleasantly as an opportunity to go to Allah. They should be told that Allah looks forward to meeting those who want to meet Him (KS 525). Dying with Allah's pleasure (KS 525) is the best of death and is a culmination of a life-time of good work. Thinking well of Allah is part of faith (KS 525) and is very necessary in the last moments when the pain and anxiety of the terminal illness may distract the patient's thioughts away from Allah. Having hope in Allah at the moment of death (KS 525) makes the process of dying more acceptable.
Helping patient make a will: During the long period of hospitalization, the health care givers develop a close rapport with the patient. A relationship of mutual trust can develop. It is therefore not surprising that the patient turns to the care givers in confidential matters like drawing a will. The health carwe givers as witnesses to the will must have some elementary knowledge of the law of wills and the conditions of a valid will, shuruut al wasiyyat. One of these conditions is that the patient is mentally competent. The law accepts clear signs by nodding or using any other sign language as valid expressions of the patient's wishes. The law allows bequeathing a maximum of one third of the total estate to charitable trusts, waqf, or gifts. More than one third of the estate can be bequeathed with consent of the inheritors. Debts must be paid before death or before the division of the estate.
The last moments: The last moments are very important. The patient should be instructed such that the last words pronounced are the kalimat, the testament of the faith. Once death has occurred the body is placed in such a way that it is facing the qiblat. Eyes are closed and the body is covered. Qur'an and dua are then recited.
Etiquette of morning: The health care giver should take the initiative to inform the relatives and friends. They should be advised about the shariah rules on mourning. Weeping and dropping tears are allowed. The following are not allowed: tearing garments, shaving the head, slapping the cheek, wailing, and crying aloud. On receiving the news of death it suffices to say ' we are for Allah and to Him we will return'(KS 525). Relatives are conforted by telling them hadiths of the prophet about death. These hadiths talk about the reward of the person who loses his beloved one and he is patient (KS 524) and the excellence of one who loses three children (KS 524).
Preparation for burial: The health care team should practise total care by being involved and concerbed about the processes of mourning, preparation for bural and the actual burial. They should participate along with relatives as much as is possible. The body must be washed and shrouded before burial. The washing should start with the right. The organs normally washed in wudhu are washed first then the rest of the body is washed. Perfime can be used, Women's hair has to be undone. After washing the body is shrouded, kafn, in 2 pieces of cloth preferably white in colour.
Salat al janazat: The books of sunnat have given guidance about the etiquette of salat al janazat (KS 162). As many persons as possible should participate in this salat. If 100 persons pray for the dead, it is shafaa (KS 162). Dua (istighfar) in salat al janazat (KS 162).
Accompanying the funeral procession, tash'yii an janazat: Burial should not be delayed, ta'ajil bi al janzat (KS 161). Following the procession is enjoined (KS 159). There are big rewards for accompanying the funeral procession (KS 159). There is more reward for accompanying the funeral procession and staying until burial is completed (KS 160). The funeral bier is carried ny men. Hurrying in marching to the grave is recommended.
Burial (dafn): face to Makka.
After burial: consoling relatives, making food for the bereaved, adab of mourning (hidaad), condolences (ta’ziyah), inna lilaahi wa inna ilayhi rajiuun. Talking good about the dead.
Talking about the deceased: Say only good things. The good words about the dead, thanau al nass ala al mayt (KS 160)
Special cases: Case of woman who dies with a fetus in her woumb. Opening grave for forensic exam. Carrying the dead for burial in another country
9.0 ETHICAL BEHAVIOR IN THE HEALTH CARE TEAM
Composition of the health care team: The health care team in a teaching hospital is very complex. It is multi-disciplinary and its members play complementary and inter-dependent roles. It consists of both university and hospital personnel all engaged in the care of patients. The academic personnel are the medical faculty as well as the students (under-graduate and post-graduate). The hospital staff is the consultants, nurses, nursing aides, auxiliary medical personnel. All members of the team have the dual function of both teaching and delivering health care. The teaching process is complex. There is programmed and structured teaching. However most of the teaching is passive; there is a lot of learning of attitudes, skills, and facts by being present and watching what is being done to the patient. There is also continuous learning from one another. Students learn from consultants but consultants may also get new insights from students.
The teacher's etiquette: Teachers should take their task very seriously. The education process, involving giving and receiving knowledge is noble (MB#70). 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 (MB#102). Teachers must make the learning process interesting and avoid boredom (MB#62). They should make the atmosphere and circumstances of learning easy for the students (MB#63). 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 (MB# 75 and 76); 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 (MB#74). They should have an appropriate emotional expression. They can raise the voice to emphasize an important point (MB#55). They can show anger or displeasure when a mistake is committed (MB#79, 80, and 81). 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 (MB#56). Teachers should make sure that the students understand by constant repetition (MB#82).
The student's etiquette: 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 (MB#66). Students should be quiet and respectfully listen to the teacher all the time (MB#101). Students should cooperage such that one who attends a teaching session will inform the others of what was learned (MB#78). 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 (MB#61). Students should ask questions to clarify points that they did not understand or which seem to contradict previous knowledge and experience (MB#88). Taking notes helps understanding and retention of facts (MB#93). 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 (MB#98).
Etiquette of medical care: Each member of the team carries personal responsibility, mas'uliyat (KS p. 45 and p.338). Leaders of the team carry more responsibility than the others. Leaders must be obeyed (KS p. 44) to be able to carry out their work well. They however should not be obeyed in committing illegalities, corruption, or oppression, dhulm (KS p. 45). The story of Rufaidah is very instructive in the etiquette of medical care for a Muslim. Rufaidah, the first professional nurse in Islamic history. She lived at the time of the Prophet Muhammad (PBUH) in the 1st century AH/8th century CE. Her history illustrates all the attributes expected of a good nurse. She was kind and empathetic. She was a capable leader and organiser able to mobilise and get others to produce good work. She had clinical skills that she shared with the other nurses whom she trained and worked with. She did not confine her nursing to the clinical situation. She went out to the community and tried to solve the social problems that lead to disease. She was a public health nurse and a social worker. Rufaidah is an inspiration for the medical and nursing professions in the Muslim world. Rufaidah bint Sa'ad, is recognized as the first Muslim nurse. Her full name was Rufaidat bint Sa'ad of the Bani Aslam tribe of the Khazraj tribal confederation in Madinah. She was born in Yathrib before the migration of the Prophet Muhammad (PBUH). She was among the first people in Madina to accept Islam and was one of the Ansar women who welcomed the Prophet on arrival in Madina. Rufaidah's father was a physician. She learned medical care by working as his assistant. Her history illustrates all the attributes expected of a good nurse. She was kind and empathetic. She was a capable leader and organizer able to mobilize and get others to produce good work. She had clinical skills that she shared with the other nurses whom she trained and worked with. She did not confine her nursing to the clinical situation. She went out to the community and tried to solve the social problems that lead to disease. She was both a public health nurse and a social worker. When the Islamic state was well established in Madina, Rufaidah devoted herself to nursing the Muslim sick. In peace time she set up a tent outside the Prophet's mosque in Madina where she nursed the sick. During war she led groups of volunteer nurses who went to the battle-field and treated the casualties. She participated in the battles of Badr, Uhud, Khandaq, Khaibar, and others. Rufaidah's field hospital tent became very famous during the battles and the Prophet used to direct that the casualties be carried to her. At the battle of the trench (ghazwat al khandaq), Rufaidah set up her hospital tent at the battle-field. The Prophet Muhammad (PBUH) instructed that Sa'ad bin Ma'adh who had been injured in battle be moved to the tent. Rufaidah nursed him, carefully removed the arrow from his forearm and achieved hemostasis. The prophet visited Sa'ad in the hospital tent several times a day. Sa'ad was to die later at the battle of Bani Quraidhat. Rufaidah had trained a group of women companions as nurses. When the Prophet's army was getting ready to go to the battle of Khaibar, Rufaidah and the group of volunteer nurses went to the Prophet Muhammad (PBUH). They asked him for permission "Oh messenger of Allah, we want to go out with you to the battle and treat the injured and help Muslims as much as we can". The Prophet gave them permission to go. The nurse volunteers did such a good job that the Prophet assigned a share of the booty to Rufaidah. Her share was equivalent to that of soldiers who had actually fought. This was in recognition of her medical and nursing work. Rufaidah's contribution was not confined only to nursing the injured. She was involved in social work in the community. She came to the assistance of every Muslim in need: the poor, the orphans, or the handicapped. She looked after the orphans, nursed them, and taught them. Rufaidah had a kind and empathetic personality that soothed the patients in addition to the medical care that she provided. The human touch is a very important aspect of nursing that is unfortunately being forgotten as the balance between the human touch and technology in nursing is increasingly tilted in favor of technology. History has recorded names of women who worked with Rufaidah: Umm Ammara, Aminah, Umm Ayman, Safiyat, Umm Sulaim, and Hind. Other Muslim women who were famous as nurses were: Ku'ayibat, Amiinat bint Abi Qays al Ghifariyat, Umm 'Atiyyah al Ansariyat, and Nusaibat bint Ka'ab al Maziniyyat.
General duties and rights of brotherhood: The following are general rights of brotherhood that all members of the health care team owe to one another: returning greetings, following the funeral procession, accepting invitations, visiting the sick, and responding to sneezer. The following are additional duties: tolerance, forgiveness, helping the oppressed, solving problems, fulfilling needs, compassion and kindness, gratefulness, protecting the honor of others, fulfilling promises and commitments, respect, sincere advice or nasiiha. It is part of the duties of brotherhood to avoid underrating and humiliating others. It is considered part of good behavior to remove any annoyance from the public places, imatat al adha an al tariiq (KS p. 69). In general, everybody must behave with the best of manners, husn al khulq (KS p. 69).
Etiquette of inter-personal interaction: Greeting is necessary whenever members meet again even after a short separation. A small group will initiate greeting the larger group (MB#2057). The walking person initiates greeting the one sitting down (MB #2068). Everybody must be greeted whether known or not known (MB#2059). Those in an assembly must make room for any new comer (MB#2063). Two individuals should not engage in secret conversation in the presence of others (MB#2018) because that may create an impression of backbiting and suspicion. Standing up when a person enters is a sign of respect (KS 67). You should not force a sitting person from his seat (KS 67). When a person goes away for a temporary period, he has the right to reclaim his seat (KS 67). The following positive behaviors and attributes should be encouraged in the team: mutual love, tawadud, and empathetic caring for one another, rahmat & hilm (MB#2018, KS p. 68); leniency, rifq, in everything (KS p. 68); co-operation and mutual support, ta'awun (MB #2026); generosity, karam (MB #2028); truthfulness, sidq (MB #2039); patience, sabr (MB #2040); modesty, haya (MB #2043, 2044); cheerful disposition, imbisaat (MB #2045); calling people by their favourite names, ahabb al asma (MB #2055, 2056); recognising the rights and the position of those older than you, irfan haqq al kabir (KS p. 68); and self control in anger, malk al nafs inda al ghadhab (KS p. 68). The following negative attributes should be avoided: harshness in speech (MB #2029), rumour mongering, namiimat (MB #2032), excessive praise of others in their presence, al ghulw fi al thana (MB #2033, KS p. 68), mutual jealousy and turning away from other, tahasud & taba'ud (MB #2034 & 2035, KS p. 68), avoiding interaction with a colleague, hijrat, for more than 3 days following a misunderstanding (MB# 2038); anger, ghadhab (MB #2041); spying on the privacy of others, tatabu'u awrat al nas (KS p. 68); You should avoid repeating the same mistake twice (MB #2046). It is required not to volunteer information about your personal weaknesses, al satr ala al nafs (MB #2037, KS p. 98), unless it involves correcting a mistake related to the general medical work
The health care team: special group dynamics: The medical team must of necessity include men and women. The interaction between the two genders is close and continuous which creates a special situation. Four basic issues arise: (a) manner of dressing (b) mixing of the 2 genders, ikhtilat (c) seclusion of a male with an unrelated female, khalwat (d) and lowering the gaze, ghadh al basar. Males and females in the team must dress and behave distinctly. Trans-sexual or unisex dressing and behaviour, takhannuth & stirjaal, removes the instinctual gender identity. Each gender should maintain its psychological, emotional identity and physical appearance in manners of dress, walking or speaking. Trying to blur the distinction interferes with the complementality that is supposed to exist between the two genders. The complementality is necessary to ensure co-operation. Blurring the differences could also make sexual misconduct easier. The Qur'an forbade free mixing of the genders, ikhtilat, in general (33:53). Islam fosters a bi-sexual society. This is however not absolute. There are cases when social and professional intercourse between unrelated men and women in necessary. It is allowed but with strict precautions to prevent any transgressions. A woman is for example allowed to serve male guests according to a hadith reported by Bukhari from Sahl Ibn Sa;d al Ansari. A woman can treat a male patient if there is necessity. A bisexual society does not prevent the women from being an active member of society. She can pursue her professional interests even outside the home provided she observes the rules of hijab. Forbidding seclusion of a man with an unrelated woman, khalwat, is a strong temptation for evil and should be avoided. The prophet forbade a man to be with an unrelated woman in the absence of a third person. When a man is in isolation with an unrelated woman shaitan is between the two and could lead them astray (hadith reported by Imaam Ahmad on the authority of Amir Ibn Rabiah). Looking at the opposite sex with desire is prohibited. The eye is a great communication organ. The Qur'an ordered Muslim men and women to lower their gaze, ghadh al basr (24:30)-31. Lowering the gaze could be complete or partial. It is partial because of practical necessity. Lowering the gaze doses not mean closing the eyes. It means being careful not to look fixedly or lustfully at the opposite sex. One of the ways of preventing lustful looks is covering what is considered nakedness, awrat. Both men and women must be modest by covering their awrat. Looking at the awrat of another person is forbidden whether that person is of the same or opposite gender. The prohibition includes both looking with or without desire (hadith reported by Muslim, Abu Daud, al al Tirmidhi). As part of preventing possible illegal relations, display of adornments that enhance natural beauty is restricted by the Qur'an (24:31, 33:59)