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ETHICAL ISSUES IN MEDICAL EDUCATION: AN ISLAMIC FRAMEWORK
•Dr Omar Hasan Kasule MB ChB (MUK), MPH (Harvard), DrPH (Harvard) Professor of Epidemiology and Bioethics Faculty of Medicine King Fahd Medical City Riyadh EM omarkasule@yahoo.com. WEB http://omarkasule.tripod.com/
•ABSTRACT
•The paper is divided into 3 parts:
•the Islamic basis for ethical theories and principles, ethical issues related to the educational process, and teaching medical ethico-legal-fiqhi issues.
• The ethical framework of Islam is based on the basic elements of the shari'at, the purposes of the sharia, and the principles of the sharia.
• The medical education process raises ethico-legal issues such as the etiquette of behavior in the healthcare team, interaction between genders, postmortem examination and cadaver dissection.
• The teaching of medical ethics requires analysis of actual situations using Islamic principles while comparing to alternative approaches available in society.
•The paper provides a framework of what should be included in the ethico-legal-fiqhi curriculum of a Muslim-based medical school.
•1.0 THE SHARI'AT BASIS FOR MEDICAL JURISPUDENCE EDUCATION
•1.1 EVOLUTION OF MEDICAL JURISPRUDENCE, tatawwur al fiqh al tibbi
•1.1.1 First period: (0 to circa 1370H) it was derived directly from the Qur’an and sunnat.
•1.1.2 The second period: (1370-1420) rulings derived analogy, qiyaas, or scholarly consensus, ijma, istishaab, istihsaan, and istirsaal.
•1.1.3 The modern period: 1420H onwards: Ijtihad maqasidi
•1.2 SOURCES OF THE LAW, masadir al shariat
•1.2.1 Qur’an as a primary source of law
•1.2.2 Sunnat as a primary source of law
•1.2.3 Secondary sources of the Law
•1.3 CLASSIFICATION OF REGAL RULINGS: MEDICAL APPLICATIONS
•1.3.1 Obligatory, waajib
•1.3.2 Recommended, manduub
•1.3.3 Prohibited, haraam
•1.3.4 Offensive, makruuuh
•2.1 THE 5 MAQASID AS THE ISLAMIC THEORY OF ETHICS
•2.1.1 Protection of ddiin, hifdh al ddiin
•2.1.2 Protection of life, hifdh al nafs
•2.1.3 Protection of progeny, hifdh al nasl
•2.1.4 Protection of the mind, hifdh al ‘aql
•2.1.5 Protection of wealth, hifdh al mal
•2.2 THE 5 QAWA'ID AL SHARI'AT AS THE PRINCIPLES OF ETHICS
•2.2.1 The principle of intention, qa’idat al qasd:
•2.2.2 The principle of certainty, qa’idat al yaqeen
•2.2.3 The principle of injury, qa’idat al dharar
•2.2.4 The principle of hardship, qaidat al mashaqqat
•2.2.5 The principle of custom or precedent, qaidat al urf
•3.1 THE ETIQUETTE / ETHICS OF THE TEACHER, adab al mu'allim
•3.1.1 Characteristics of the teacher
•3.1.2 The learning process
•3.1.3 Communication with the students
•3.2 THE ETIQUETTE / ETHICS OF THE STUDENT, adab al muata'allim
•3.2.1 Respect for the teacher
•3.2.2 The learning process
•3.3 UNCOVERING AWRAT IN MEDICAL EDUCATION
•dharurat, of medical examination and treatment
• The benefit 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.
•permission from the patient before they uncover their awrat.
•3.4 GENDER ISSUES IN MEDICAL EDUCATION
•Medical co-education involves intense interaction between genders:
•Teacher-student, student-student, and teacher-teacher
•Medical personnel of opposite genders should wear gender-specific garments
•The conditions that are accepted as constituting dharuurat are: skills and
availability.
•3.4 POSTMORTEM EXAMINATION IN MEDICAL EDUCATION
•Permissibility of autopsy for educational purposes under the principle of necessity, qa’idat dharuurat:
•3.4.4 Alternative ways of achieving the educational objectives of autopsy
•3.4.4 Research on dead corpse
•4.1 CONTENTS OF THE ETHICO-LEGAL-FIQHI CURRICULUM
•4.1.1 Theories and principles of medical ethics
•4.1.2 Ibadat for the patient, ibadat pesakit
•4.1.3 The etiquette of the physician, adab al tabiib
•4.1.4 Issues in disease conditions, fiqh al amraadh
•4.1.5 Issues in modern medicine fiqh mustajiddaat al tibb
•4.2 METHOD OF TEACHING ETHICS: CASE STUDIES
•These are cases of actual ethical problems that are encountered in hospital practice.
•Source material should be provided in advance of any session.
•Students should be encouraged to look for relevant evidence in the Qur'an and sunnat
•4.3 SOURCE MATERIAL
•Resource material will be provided as required.
•Additional material can be obtained from http://omarkasule.tripod.com.
•4.4.1 PRIVACY AND CONFIDENTIALITY
•A neurologist informed his wife over dinner about an elderly school bus driver who had
Parkinson disease and had to take an unusually high dose of medication to suppress the
tremors. The medication made the patient sleepy all day. The wife asked for the name and
realized that the patient was a driver for her school transport company who had been coming to
work late in the past 2 weeks. She dismissed him the next morning.
•4.4.2 DISCLOSURE
•The manager of a national airline was worried about the erratic behavior and mistakes of one
of the senior pilots. He asked around and found out the name and address of the pilot’s family
doctor who was in private practice. He wrote to the private practitioner to provide records about
treatment of the pilot for vision and psychological problems. He asked specifically for
information on drug abuse. The private practitioner called and gave the information but
told the manager that he could not put it down in writing since he had not discussed the matter
with the patient. Two weeks later the private practitioner received an offer of a free ticket for
himself and his wife to a holiday resort. The letter from the airline public relations office said that
the airline was carrying out a promotion and that names of beneficiaries had been selected at
random from the telephone directory. The doctor subsequently went on the trip with his wife.
•4.4.3 CONSENT TO TREATMENT
•A patient was brought to the emergency room by the police after attempting to kill himself by
hanging. He was unconscious when first brought in and had a signed suicide note in his shirt
pocket saying that he wanted to die. The doctors ignored the note and started resuscitation
measures. The patient became conscious after 30 minutes and protested at the medical
treatment arguing that he wanted to die. The doctor was thinking of stopping resuscitation
measures when the patient’s father and wife arrived and instructed the doctor to continue
resuscitation.
•4.4.4 REFUSAL OF TREATMENT
•A 40-year old policeman refused surgery to drain a pyomyositis abscess. He still refused
surgery after the abscess burst spontaneously. The surgeons sedated him and carried out the
surgery without his consent.
•4.4.5 NEGLIGENCE & MALPRACTICE
•A patient with no obvious injury after a minor accident was discharged without X-ray
investigations. He developed back problems 3 months later leading to leg paralysis. He sued
the hospital for negligence.
•4.4.6 LIFE SUPPORT IN TERMINAL ILLNESS
•A patient with brain stem death is kept on artificial life support at the insistence of the family
because announcing the death immediately will have an adverse effect on the values of the
family business on the stock exchange.
•4.4.7 REPRODUCTIVE ISSUES
•A couple married for 10 years without a child decided to have IVF. Before the procedure was
completed, the husband died. The wife insisted on using the stored semen of her dead
husband. The relatives of the husband objected. The first wife who had been divorced 15 years
earlier with one girl also asked for the semen for an IVF procedure that she hoped would
enable her have another baby to act as a bone marrow donor for her daughter who had
leukemia and had failed to find a matching donor.
•4.4.8 ORGAN DONATION
•A father of a child with end-stage renal disease got tired of taking her for dialysis every week.
He had failed to find a live or a cadaveric donor for her in his country. He considered traveling
to a nearby country where kidneys could be bought but he was not sure. He also considered
marrying a young wife (his first wife had died) and hopefully produce a child who could be a
donor.
•4.4.9 DRUG ABUSE AND SUICIDE
•A patient, whose engagement had been called off in the week that he failed his university entry
examinations, started smoking, drinking alcohol, and using illicit drugs to forget his problems
but to no avail. He was admitted to the medical ward after suffering a nervous breakdown. He
was violent and abusive on the ward and refused to take his medication. Two weeks from his
admission he left the ward without telling anyone and went and killed his former fiancée at her
home. He later became very agitated and depressed and within 10 hours he also committed
suicide. His parents and the parents of his ex-fiancee jointly sued the hospital.
•4.4.10 DOCTOR ETIQUETTE
•A physician prescribed a new unlicensed drug donated to him by a pharmaceutical company.
The physician had shares in the company. He had no previous personal knowledge of the drug.
The patient developed an immediate allergic reaction. The physician blamed the nurse for not
asking about drug allergies before injecting the drug.
•4.4.11 RESOURCES
•A 65-year old man whose brother had just died from coronary heart disease walked into the
health center and asked for examination because he was afraid that his heart may also have
problems. The triage nurse asked him if he had any specific complaints. He replied that he has
none and that he was in perfect health. The nurse rebuked him for wasting her time. ‘Don’t you
the see line of 120 really ill people waiting to see a doctor? How can we waste time in
someone healthy like you?’. The man left but was admitted to the ICU 5 days later with
myocardial infarction and he died after 2 days.
•4.4.12 PHYSICIANS WITH DUAL OBLIGATIONS
•A national football team physician examined a player and found that he had a chronic shoulder
dislocation and advised that he should not play again until it was treated. The player protested
because he had always played with that condition since he was young. The team manager
threatened to dismiss the physician if he did not certify the player as fit to play because that star
player was the only hope of the team to win in an international match the next day.
•4.4.13 POSTMORTEM
•A police officer died a few minutes after admission from what was suspected injuries
sustained in the course of his duty. The police department insisted on a postmortem to
determine the cause of death in order to make decisions about compensation. The family was
divided. Some were opposed to postmortem and others wanted to go ahead.