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Paper presented at the National Conference Workshop on Medical Ethics organized by the Ministry of Health 14-17 November 1999 at the Renaissance Hotel, Putrajaya, Kajang, Selangor Darul Ehsan. by Prof Omar Hasan Kasule, Sr.; Deputy Dean for Research and Post Graduate Affairs, UIA.
ABSTRACT
This paper describes the Islamic Input Curriculum (IIC). 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. It describes the 5-year Islamic Input Curriculum at UIA which integrates Islamic universal values in the scientific, clinical, and social aspects of medical teaching. IIC approach to teaching bio-ethical issues is presented as a practical example of how the curriculum is employed. 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.
Key words: Islamic - medical curriculum - ethics - morality
Internet: the full paper can be downloaded from http://www.iiu.edu.my/studyislam.htm
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 are 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.
Instructional manual: A manual for use by students and instructors has been prepared for the curriculum. The manual is organized in 5 volumes each containing 5 units and each unit consisting of 5-10 subunits. The first volume presents basic Islamic concepts and main paradigms that form the premises for the arguments presented in subsequent volumes. The second volume shows the student the power and majesty of Allah’s creation by analyzing the structure and functions of the human body to show that there is order and harmony. The third part presents legal, fiqh, issues that students will encounter in their daily life as practicing physicians. The fourth part presents social and ethical issues that are encountered in medical practice especially with the rapid advances in medical technology. The fifth part presents the history of medicine in the ummah and uses it as an inspiration to the young physician to work for a distinct Islamic expression in medicine that will lead to Islamization of medical sciences. The manual is written using original sources from the Quran and Hadith as well as established medical knowledge.
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.
Time Allocation for the Curriculum: Regular sessions are envisioned. The Islamic input is regular throughout the 5-year course of study. It is estimated that about 25% of the curriculum can be taught as special sessions on the Islamic input. The rest is taught as part of the regular medical lessons by the lecturers concerned. The lecturer will mention the Islamic aspects of whatever topic they are teaching. The Islamic input closely follows the relevant topics that are being taught in the general medical course. This enables the student to integrate information from more than one source in order to achieve a comprehensive understanding without being confused. It is estimated that 5.0 hours suffice for each of the 25 units in the manual. The Islamic input takes a cumulative total of 125 hours in the 5-year medical course.
Instructors for the curriculum: Non-specialist Instructors can teach the curriculum: The material is presented at an introductory non-specialized level. Any Muslim lecturer with basic knowledge of Islam can teach the material using the manual and teaching guidelines that are provided. A workshop is held for instructors at the start of each block to prepare them. It is proposed that the teacher of each medical subject should also teach its Islamic input to be able to integrate the material well. Guest speakers may be brought in for specific topics that require more specialist handling.
Class-room methodology: The interactive discussion approach is preferred. The aim is to raise curiosity, interest, consciousness, and not to indoctrinate. Students should come out of the course knowing what are the real issues and why they are important. They should be able to intelligently discuss the available solutions alternatives and choose the best. Verses of the Qur’an, hadiths, and texts of cases are the basis for each class session discussion. They are selected in such a way that they convey the Islamic concept(s) on the topic(s) being taught in the general medical course. The verses of the Qur’an and texts of hadiths concerned are written directly in the manual in both Arabic and translation. The discussion questions at the end of each sub-unit are to test comprehension. They also extend understanding by giving the student an opportunity to apply the concepts learned to an actual practical solution in the community. They enable the student to relate personal experience to the course contents.
Assessment Of Student Progress: Questions on the Islamic input are included in the written and oral tests and examinations that are given to students. The questions are not put in a separate section but are fully integrated with the rest of the medical questions. These questions however can not be more than 5% of the total grade points for the examination in order to preserve the professional integrity of the examination as a test of medical knowledge and competence. The assessment does not look for retention of specific facts. It will assess general understanding of the concepts and methodological approaches to be used in practical situations outside the class-room when the future physician encounters actual practical problems and conceptual challenges.
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 wholistic 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.
INTRODUCTION TO THE STUDY AND PRACTICE OF MEDICINE
MANUAL FOR MEDICAL STUDENTS & MEDICAL PRACTITONERS
VOLUME ONE: BASIC CONCEPTS
{Creed, Knowledge, Universe, Humans, Life & Death, Health & Disease}
5-VOLUME SERIES: INTRODUCTION TO THE STUDY AND PRACTICE OF MEDICINE
VOLUME ONE: BASIC CONCEPTS (MAFAHIIM ASAASIYAT)
1.0 The Creed (Al ‘Aqidat)
2.0 Knowledge (‘Ilm)
The Universe (Kaun)
The Human (Insan)
5.0 Transitions In Human Life (Manazil al hayat)
VOLUME TWO: SCIENCE & FAITH (‘ILM & IMAN)
6.0 The Human Body: A Biological Miracle (mu’ujizat al jism al insani)
7.0 Growth And Development (numuw al jism)
8.0 The Senses (hawaas)
9.0 The Organ Systems (a’adha)
10.0 The Human Mind (‘aql)
VOLUME THREE: MEDICINE AND FIQH (TIBB & FIQH)
Law and Its Methodology (fiqh & usul al fiqh)
I2.0 Understanding Acts of Ibadat (fiqh al ibadat)
13.0 Normal Physiological Processes (wadaif al a’adha)
14.0 Disease Conditions (amradh al a’adha)
15.0 Court Procedures ( al qadha)
VOLUME FOUR: SOCIETY AND ETHICS (MUJTAME & AKHLAQ)
16.0 Societal Institutions (muassasaat al mujtamae)
17.0 Social Issues (qadhayat al mujtamae)
18.0 The Physician (tabiib)
19.0 Bio-technology (taqniyat al ahyat)
20.0 Empirical Research (bahthi tajribi)
VOLUME FIVE: MEDICINE IN THE UMMAH: PAST, PRESENT, AND FUTURE
History (tarikh al tibb)
22.0 Current Status Of the Ummat’s Health (hadhir al sihat fi al ummat)
23.0 Medicine from the Qur’an (tibb Qur’ani)
24.0 Prophetic Medicine (tibb Nabawi)
25.0 Challenges (al tahaddiyaat)
TOPICS FOR FIRST YEAR STUDENTS
UNIT 1.0: THE CREED (Al ‘Aqidat):
1.1 One-Ness Of Allah (Tauhid)
1.2 Fundamentals Of Religion (Usul Al Ddiin)
1.3 Worship (Ibadat)
1.4 Self-Purification (Tazkiyat)
1.5 Sinning (Ithm)
UNIT 2.0: KNOWLEDGE (‘Ilm) :
2.1 Nature Of Knowledge (Tabiat Al Ilm)
2.2 Crisis Of Knowledge (Azmat Al Ma'arifat)
2.3 Methodology Of Knowledge (Manhajiyat Al Ma'arifat)
2.4 Islamization Of Knowledge (Islamiyat Al Ma'arifat)
2.5 Classical Islamic Sciences (Al Uluum Al Islamiyat)
UNIT 3.0: THE UNIVERSE (Kaun) :
3.1 Creation Of The Universe (Khalq Al Kaun)
3.2 Order In The Universe (Nidhaam Al Kaun)
3.3 Subservience To Humans (Taskhiir Al Kaun Li Al Insan)
3.4 Viscegerance Of Humans (Khilafat Al Insan)
3.5 Building A Civilization (Isti'imar Al Ardh)
UNIT 4.0: THE HUMAN (Insan) :
4.1 Creation Of The Human (Khalq Al Insan)
4.2 Nature Of The Human (Tabi'at Al Insan)
4.3 Superiority Of The Human (Tafdhil Al Insan)
4.4 Variety Of Humans (Tabayun Al Bashar)
4.5 Mission Of The Human (Risalat Al Insan)
UNIT 5.0: TRANSITIONS IN HUMAN LIFE (Manazil al hayat) :
5.1 Life (Hayat)
5.2 Death (Maut)
5.3 Health (Sihat)
5.4 Illness (Maradh)
5.5 Medical Treatment (Tatbiib)
TOPICS FOR 2nd YEAR STUDENTS
UNIT 6.0: THE HUMAN BODY: A BIOLOGICAL MIRACLE :
6.1 Perfection, Optimality, And Incomparability:
6.2 Control
6.3 Equilibrium And Homeostasis
6.4 Interactions With The Environment
6.5 Pathological Processes:Repair & Restoration Of Equilibrium
UNIT 7.0: GROWTH AND DEVELOPMENT (numuw al jism) :
7.1 Intra-Uterine (Rahim)
7.2 Infancy & Childhood (Tufuulat)
7.3 Youth (Sinn Al Shudd)
7.4 Middle Age (Sinn Al Rushd)
7.5 Old Age (Shaykhuukhat)
UNIT 8.0: THE SENSES (hawaas) :
8.1 Vision (Basar)
8.2 Hearing (Sam’u) And Equilibrium (Istiwa)
8.3 Chemical Sensation
8.4 Surface Sensory System
8.5 Other Sensory Modalities
UNIT 9.0: THE ORGAN SYSTEMS (a’adha) :
9.1 Uro-Genital System (Jihaz Bawli & Jihaz Tanasuli)
9.2 Musculo-Skeletal System (‘Idhaam & ‘Adhalaat)
9.3 Cardio-Respiratory System (Ddam & Tanaffus)
9.4 Alimentary System (Maidat)
9.5 Protective Systems
UNIT 10.0: THE HUMAN MIND (‘aql) :
10.1 The Nervous Systems (Jihaz Al Asabi)
10.2 The Intellectual Function (‘Aql)
10.3 The Sleep Function (Nawm)
10.4 The Memory Function (Dhaakirat)
10.5 Human Emotions
TOPICS FOR 3rd YEAR STUDENTS-
UNIT 11.0: LAW AND ITS METHODOLOGY (FIQH & USUL AL FIQH) :
11.1 Basic Concepts And Terminology (Mafahim Asasiyyat)
11.2 Sources Of The Law (Adillat Al Ahkaam)
11.3 Development Of The Law (Tatawwur Al Fiqh)
11.4 Purposes Of The Law (Maqasid Al Shariat)
11.5 Principles Of The Law (Qawaid Fiqhiyyat)
UNIT 12.0: UNDERSTANDING ACTS OF WORSHIP (FIQH AL IBADAT) :
12.1 Prayer (Salat)
12.2 Fasting (Saum)
12.3 Poor Due (Zakat)
12.4 Pilgrimage (Hajj)
12.5 Jihad
UNIT 13.0: NORMAL PHYSIOLOGICAL PROCESSES (WADHAIF AL A’ADHA)
13.1 Reproduction
13.2 Hygiene: Excreta And Secretions
13.3 Nutrition
13.4 Activity And Rest
13.5 Social Interaction
UNIT 14.0: DISEASE CONDITIONS (AMRADH AL A ‘ADHA) :
Disorders Of Growth
14.2 General Systemic Conditions
14.3 Conditions Of Organ Systems
14.4 Conditions Of Children
Conditions Of The Elderly
UNIT 15.0: COURT PROCEDURES (AL QADHA) :
15.1 Legal Capacity (Ahliyyat)
15.2 Evidence (Shahadat)
15.3 Punishments (Huduud & Taziir)
Inheritance (Mawariith)
15.5 The Family
TOPICS FOR 4th YEAR MEDICAL STUDENTS
TOPICS FOR 4th YEAR MEDICAL STUDENTS
UNIT 16.0: SOCIETAL INSTITUTIONS (MUASSASAT AL MUJTAMAE’)
16.1 The Family (Bayt)
16.2 The Community (Jama’at)
16.3 The Law (Shariat)
16.4 Public Governance And Policy (Dawlat)
16.5 Wealth (Maal)
UNIT 17.0: SOCIAL ISSUES (QADHAYAT AL MUJTAMAE)
17.1 Background Influences
17.2 Sexual Perversions
17.3 Addictions
17.4 Extremes Of Wealth And Poverty
17.5 Accidents And Violence
UNIT 18.0: THE PHYSICIAN (TABIIB)
18.1 Motivation
18.2 Etiquette Of Human Relations
18.3 Leadership
18.4 Management
18.5 Dawa
UNIT 19.0: BIO-TECHNOLOGY
19.1 Infertility
19.2 Contraception
19.3 Termination Of Life
19.4 Organ And Tissue Transplantation
19.5 Change Of Fitrat
UNIT 20.0: RESEARCH
20.1 Use Of Humans
20.2 Use Of Animals
20.3 Genetic Engineering
20.4 Research Policy And Practice
20.5 Other Issues