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Presented at a workshop for nurses in Bujumbura, Burundi on 15 September 2016 by Professor Dr. Omar Hasan Kasule Sr. MB ChB (MUK), MPH (Harvard), DrPH (Harvard)
Abstract:
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Basic sources of Islamic Law as a background for discussing fiqhi
issues in medical practice, fiqh tibbi.
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Theory of Purposes of the Law, maqasid al shari’at, and the
principles of the Law, qawa’id al shari’at.
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Practical issues that are encountered in daily medical practice.
Sources of the Law, masadir al shariat:
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Qur’an as a primary source of law,
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Sunnat as a primary source of law,
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Secondary sources of the Law.
Classification of Regal Rulings: Medical Applications:
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Obligatory, waajib
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Recommended, manduub
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Prohibited, haraam
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Offensive, makruuuh
Rewards and Punishments for Various Acts:
The 5 Purposes of the Law in Medicine, maqasid al
shari’at fi al tibb: - 1
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Protection of ddiin, hifdh al ddiin,
} Protection of life, hifdh al nafs,,
} Protection of progeny, hifdh al
nasl,
} Protection of the mind, hifdh al
‘aql,
}
Protection of wealth, hifdh al mal:
The 5 Purposes of the Law in Medicine, qawa’id al
shari’at fi al tibb: - 2
}
The principle of intention, qa’idat al qasd,
} The principle of certainty, qa’idat
al yaqeen,
} The principle of injury, qa’idat al
dharar,
} The principle of hardship, qaidat
al mashaqqat,
}
The principle of custom or precedent, qaidat al urf:
Taharat for the
Sick, taharat al mariidh – 1:
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Tayammum is carried out when it is difficult
to use water.
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Fresh blood is not najs when in the body, blood of
epistaxis is not najasat[1] but must be washed away
immediately. Freshly spilled blood (venous or arterial) is not najasat but
must be cleaned away with water[2], [3] and does not
require repeating wudhu.
}
Pleural, peritoneal, pericardial, and synovial fluids are not najs and
must be washed away if they are outside their respective cavities.
}
Respiratory secretions are not najasat but must be
washed away.
Taharat for the
Sick, taharat al mariidh – 2:
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Upper GIT vomitus is not najs and does not
nullify wudhu. The lower GIT vomitus especially the lower intestine
has fecal excretory material that is najs. Vomitus that is severe
may contain intestinal contents and should always be considered najs.
}
Diarrhea is najs and nullifies wudhu.
}
Esophageal, gastric, and naso-gastric tubes are inserted for diagnostic
or therapeutic purposes. The fluids involved are not najs but
must be washed away to prevent their becoming nidi of infection.
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A tracheostomy tube may be inserted in cases of respiratory distress
and respiratory secretions may accumulate in it. These secretions are not najs.
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Stoma have to be cleaned and salat is done with them discharging.
Haidh – 1:
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Artificial menopause is necessary, dharuurat, if there is
serious disease like cancer.
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Delay of menopause is offensive if done for purposes of appearing young
to the general society. The Law in general is against any deceptions regarding
a person's age.
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Estrogen replacement therapy (ERT) can alleviate virtually all
menopausal symptoms. ERT has serious side effects that have to be considered
under the two principles of benefit and harm.
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The menstrual flow may be prolonged in association with menorrhaghia
and without it. The Law considers 15 days the maximum duration of the menstrual
flow. Salat and fasting are suspended during this time. Salat and other acts of
ibadat are resumed if the flow continues beyond 15 days since prolonged
bleeding, istihaadhat, is not considered menstruation.[5]
Haidh – 2:
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Artificial menopause is necessary, dharuurat, if there is
serious disease like cancer.
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DUB does not stop the woman from salat or saum and is treated as
urinary incontinence. The woman washes her vagina and perineum, pads herself,
makes wudhu and prays immediately to try to avoid being caught by more
bleeding.
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Sexual relations are allowed in DUB unless there is a medical
contra-indication.[6]
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The use of hormones to regulate the menstrual period in order to be
able to complete the rituals of pilgrimage is widely used. The same cannot be
done for Ramadhan.
Salat of the
sick, salat al maridh:
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The patient may have the following physical handicaps: inability to
face the qiblat, inability to stand, inability to sit, inability to
read, inability to bow, and inability to prostrate.
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The following are solution alternatives: make-up salat, qadha
al salat; resting for moments in a sitting position to regain energy for
the next movement; praying in a sitting position; praying while sitting down
and cross-legged; praying while lying down on one side of the body; resting on
a staff in salat; Praying by gesturing with one part of the body e.g. finger;
and finally praying in the mind with no motions.
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The sick stop qiyam al layl and try to fulfill the 5
prescribed prayers.
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Salat can be interrupted for an urgent need that could be medical or
otherwise.
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Women are excused from salat during the period of
menstruation because of the associated physiological stress.
Measures to Prevent Physiological Harm in Saum:
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The prophet (PBUH) taught measures to ensure that saum does
not cause physiologic damage.
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Saum continuously from day to day, wisaal,
was forbidden.[7]
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Early iftaar was recommended.[8]
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Delaying suhuur was recommended.[9]
Medical guidelines on diet in saum:
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The aim should be maintaining normal body weight or actually reducing
it if overweight.
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Over-eating at iftaar and suhuur should
be avoided. It will cause weight gain and indigestion.
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The diet should contain sufficient fiber to prevent constipation. Fiber
and slowly digested foods with a long stomach transit times are preferred
because they delay the feeling of hunger.
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Enough water should be taken at night both for preventing dehydration
and preventing constipation. Adequate fluid and salt intake prevents lethargy
in the afternoon caused by low blood pressure.
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Inadequate sleep is a cause of headaches.
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Intake of adequate calcium, magnesium, and potassium will prevent
muscle cramps.
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Hot places should be avoided because they aggravate the dehydration.
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Cooling the body such as tepid sponging, tabarrud, is
allowed[10] during saum.
Diabetes mellitus in Saum:
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Diabetes has special consideration in saum because of
its direct relationship with food intake.
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Insulin-dependent diabetics have to reduce their insulin dose because
of reduced food intake during the day. In some cases this is not possible and
they have to be exempted from saum altogether especially if
their diabetic control is brittle.
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Insulin-dependent diabetics should be monitored very carefully because
hypoglycemia may arise due to insulin injections with inadequate dietary
intake.
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Non-insulin diabetics can undertake saum under medical
supervision. This will generally require changing times of medication, close
monitoring of blood sugar levels, and being alert to any hyperglycemic or
hypoglycemic crises.
}
Pregnant diabetics are exempted from fasting because diabetic control
is more difficult in pregnant women making fasting doubly hazardous for both
the mother and the fetus.
Other condition of illness & Saum:
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The sick are allowed to break saum[12] if trusted
nurses fear that saum will be deleterious to good health. The
missed saum is made up later[13].
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If the illness is chronic, maradh muzmin, then there will
be no opportunity for making up. The saum of a sick person is
valid but is makruh.
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The heirs can perform make-up fasting, qadha al saum, for
days missed by a deceased disabled by disease in terminal illness[14].
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Peptic ulcers are aggravated by raised acid levels and could be a
reason for exemption from saum.
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Low fluid intake could encourage growth of kidney stones and joint
problems due to deposition of excess solutes.
}
Old age is considered an excuse from saum[11] because
of physiological fragility and delicate nutritional requirements.
Saum in difficult
weather:
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Saum in conditions of extreme heat leads
to dehydration. Care should be taken to take enough fluids at suhuur and
not to expose oneself to extreme environmental temperatures.
}
In very cold areas, the metabolic rate is raised to be able to generate
sufficient heat for maintaining body temperature. In such conditions extra care
should be taken to consume enough food and to cover oneself properly to
minimize heat loss.
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Regions of the world near the two poles may have extremely long days in
summer and very short ones in winter. It is recommended that the times of suhuur and iftaar of
the nearest temperate region should be followed rather than following local
sun-rise and sunset.
Saum in
Pregnancy, Menstruation, and the post partum period:
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The pregnant woman, al hublah, is allowed to
break saum[15] if saum is a health risk.
}
The breast-feeding woman or nursing woman, al murdhii’[16],
is allowed to break saum if there is health risk.
}
The exemption from fasting is obligatory for the menstruating
woman, al haidh[17], and for a woman in the post partum
period, nifaas[18].
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Any fasting undertaken in haidh and nifaas is
invalid.
Concept of Jawf:
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Any potentially nutritious substance that enters and stays the inside
cavity of the body, al jawf, nullifies saum.
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The term jawf has to be reinterpreted in view of
modern anatomical and physiological knowledge.
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In my understanding jawf means the alimentary canal
from the mouth to the anus.
Oral intake in Saum – 1:
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Deliberate eating and drinking and eating nullify saum.
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Smelling food or any other pleasant odor does not nullify saum Use
of snuff or tobacco in the nose nullifies saum. Deliberate smelling of
tobacco or any other type of smoking material nullifies saum. If the
smelling is non intentional it does not nullify the saum.
}
Madhmadhat andistinshaaq in wudhu are
permitted during saum.[19] It is however offensive to exaggerate them[20].
The decision of what is normal and what is excessive requires more discussion.
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More discussion is needed on swallowing saliva and swallowing phlegm
during saum.
Oral intake in Saum – 2:
} The mouth can be rinsed with pure water
without nullifying saum. Care must be taken to avoid swallowing.
}
Siwaak is permitted all through the day
of saum[21]. Use of a tooth brush with toothpaste is allowed if
care is taken to rinse out the mouth fully such that none of the toothpaste
remains in the mouth.
}
The ear-drum was traditionally considered a nullifier of saum but
unless the eardrum is perforated there is no direct connection between the ear
and the jawf. Eye drops enter the nostrils and may eventually reach
the pharynx probably reaching the jawf. Kohl applied to the eye
does not nullifysaum if its smell is not felt in the mouth.
Medical examination and investigations in
saum:
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Taking blood, urine, and stool samples for investigation does not
nullify saum.
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Diagnostic enemas and barium meal examinations nullify saum.
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Esophagoscopes, gastroscopes, and sigmoidoscopes that have lubricants
or other substances that will remain in the jawf nullify saum.
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Digital rectal examination involves inserting substances into the jawf and
may nullify saum.
}
Vaginal examination may nullify saum but the reasoning
involved is more complicated.
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Examination of the external auditory canal, endoscopy and
catheterization of the urethra and the urinary bladder should in normal
circumstances not nullify saum because they do not involve
entry into the jawf.
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Imaging that does not involve using contrast media in the jawf does
not nullify saum.
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IVP uses contract media injected in the blood stream and not the jawf.
Medical Treatments in Saum – 1:
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The general rule is that any substance that enters the body through any
of its openings, manfadh, nullifies fasting. The openings are the
two ends of the alimentary canal, the mouth and the anus.
}
Drugs of whatever form taken orally, per anus, nullify fasting. The
medication schedule can be modified such that drugs are taken only during the
night hours.
}
Sub-lingual medication absorbed from the oral cavity with none entering
the esophagus may not nullify saum.
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All drugs that are applied externally on the skin do not nullify
fating.
Medical Treatments in Saum – 2:
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Use of eye drops does not nullify fasting.
}
Nose drops may nullify fasting because they could drop into the pharynx
and be swallowed.
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Inhalants may nullify saum if they have droplets of
water that can enter the jawf.
}
Injections (sub-cutaneous, intra-muscular, and intra-venous) do not
nullify saum because they do not involve putting substances into the jawf.
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However, nourishing and rehydrating injections nullify the purpose
of saum.
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Hormonal preparations should not be used to delay menstruation in order
to avoid interrupting saum of Ramadhan.
Pilgrimage of the sick, hajj al mariidh:
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The physically disabled can circumbulate the ka’aba riding on a
vehicle or being carried by another person.
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The weak can leave Muzdalifat earlier to avoid the crowds.
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The very old and those with debilitating chronic diseases can ask
another person to perform hajj on their behalf. However, if the disease is
curable it is better to delay hajj until the next year.
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In case of a fracture, hajj is stopped and is repeated the next year.
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If disease occurs during hajj, the sick can be carried to Arafat
because al hajj Arafat and missing Arafat is missing the whole hajj. They are
assisted to complete the other rites as much as is possible.
Assisted Reproduction:
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In vivo insemination, al talqiih al istinaa’e al daakhilii: is allowed
if between husband and wife.
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In vitro fertilization, al talqiih al istinaa’e al khaariji: is allowed
if between husband and wife and there are no surrogate mothers.
}
Ethical and legal issues: IVF post-divorce
and post morten is not permitted. Surrogate motherhood not permitted.
Assisted Reproduction – 1:
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Overview: The Law allows assisted reproduction
in fulfillment of the purpose of preservation of progeny, hifdh al nasl,
provided it does not violate the purpose of preserving lineage, hifdh
al nasab, and does not cause injury that violates the purpose of
life, hifdh al nafs, or introduce any immorality into society.
}
In vivo insemination, al talqiih al istinaa’e al daakhilii: Artificial
intra-uterine insemination with husband’s sperm, talqiih sina’i dhaati is
permitted by the Law provided safeguards are taken to ensure that spermatozoa
do not get mixed up in the laboratory or the clinic. The Law prohibits
artificial in vivo insemination of a wife with donated sperm from a strange man
or in vivo insemination of a strange woman with the husband’s sperm because
that would violate the principle of preserving lineage, hifdh al nasab.
Assisted Reproduction – 2:
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In vitro fertilization, al talqiih al istinaa’e al khaariji: The Law
permits in vitrofertilization (IVF) if the sperm and ovum are from
legally wedded husband and wife and the zygote is implanted in the same wife.
All other forms of IVF involving ovum or sperm donation are prohibited because
they violate the principle of hifdh al nasab.
}
Ethical and legal issues: Several
ethical issues arise in assisted reproduction: disclosure of infertility before
marriage, artificial insemination after death of the husband, legality of
masturbation for obtaining sperms, paternity and maternity of children born of
illegal procedures, disposal and use of unused fertilized ova, sex selection
and selective fetal reduction, embryo splitting, developing embryos for
purposes other than their use in assisted reproduction.
Contraception – 1:
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There is basic permissibility of contraception from the hadith on
coitus interruptus, tarkhis fi al ‘azal. This is permission for
each individual couple. Contraception as a national or community policy is
repugnant to the purposes of the Law and could lead to demographic
disequilibrium.
}
Decisions on contraception must be by mutual consent of the spouses. If
contraception is a dharuurat for preserving the life of the
mother, the husband’s agreement is not required.
}
Choice of the method of contraception must be based on the purposes of
the Law and Principles of the Law. There is no consensus among jurists on
sterilization as a method of contraception. Contraception as part of a national
population control policy is prohibited by Law.
Contraception – 2:
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Male contraception: The
permissible reversible methods for males are the condom, coitus
saxanicus, coitus reservatus, and coitus interruptus.
}
Female contraception
}
Permissible reversible methods for females are either mechanical (the
diaphragm, the cervical cap, the vaginal sponge) or chemical (spermicides, oral
contraceptive pills). Some forms of IUD are not permitted because they cause
early abortion.
Abortion:
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The purposes of the law,maqasid al shari’at, and its
principles, qawa’id a shari’at, focus on preventing ‘unwanted
pregnancy’, protecting the rights of the fetus and infant, and mitigating the
adverse effects of ‘unwanted pregnancy’ by social measures.
}
Abortion is the lesser of two evils in cases of serious maternal
disease because one life is lost instead of two.
}
In all forms of abortion whether legal or illegal, the aborted fetus
must be treated with respect. It must be washed, shrouded, and buried
properly.The nurse or any other accessory to abortion is guilty of the offense
of causing abortion even if either or both parents consented to the procedures.
Legal Definitions of Terminal Illness and
Death:
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Terminal illness is defined as illness from which recovery is not
expected.
}
If death is defined in the traditional way, life support cannot be
withdrawn at any stage.
}
If the definition of higher brain death is accepted, life support will
be removed from persons who still have many life functions (like respiration,
circulation, sensation).
Legal Rulings on Initiating and
Withdrawing Life Support:
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The terminally ill patient, who takes a major risk, should make the
final informed decisions after clarification of the medical, legal, and ethical
issues by nurses and jurists, fuqaha.
}
The family may request that life support be terminated if the patient
is in pain or coma.
Euthanasia:
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Active euthanasia, an act of commission that causes death, is taking
some action that leads to death like a fatal injection.
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Passive euthanasia, an act of omission, is letting a person die by
taking no action to maintain life.
}
Islamic Law views all forms of euthanasia, active and passive, as
homicide.
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Nurses have not right to interfere with ajal that was
fixed by Allah. Disease will take its natural course until death.
Solid organ transplantation:
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The indications of transplantation are irreversible organ failure and
sub-optimal organ function.
}
Transplantation on the basis of preventive maintenance of organs in
good condition is not allowed because the Law does not allow action based on
uncertainty.
Reconstructive / Restorative Surgery:
}
Reconstructive/restorative surgery is carried out to correct natural
deformities, deformities due to disease, and deformities due to complications
of disease treatment.
}
Malformations may be congenital or acquired. The purposes of surgery on
congenital malformations are: restoration of the normal appearance to relieve
psychological pressure or embarrassment and restore function. These purposes do
not involve change of fitra but restoration of fitra to
its state before the injury.
}
Restorative surgery for deformities due to disease or treatment do not
involve change of fitra since they are returning to the
normal.
}
Surgery for hiding identity of a witness is allowed.
}
A surgical operation to reveal the true gender of an apparent
hermaphrodite is not change of fitrabut an attempt to restore fitra altered
by hormonal or chromosomal damage. Such operations have another objective of
trying to preserve or restore the reproductive function.
Cosmetic Surgery:
}
Cosmetic surgery has a sole purpose of enhancing beauty with no medical
or surgical indication.
}
It is not allowed in most cases but exceptions do exist.
Embalming:
}
Embalming is treating a dead corpse with substances that prevent it
from decay or decomposition. Embalming does not prevent but delays the
decomposition process.
}
Burial should be immediate. In an exception to the general rule,
embalming could be a better alternative in a situation in which a person dies
in a foreign place with no Muslims knowledgeable or willing to give him an
Islamic burial. It may be better in such a case to embalm the body and
transport it to where it can get a decent and honorable Islamic burial.
Autopsy:
}
Definition: The term autopsy or necropsy is used to refer to
dissection and examination of a dead body to determine the cause(s) of death.
It may be carried out for legal or for educational purposes.
}
Permissibility of autopsy for educational purposes under the principle
of necessity, qa’idat dharuurat.
}
Ethico-legal issues in autopsy for legal or forensic purposes.
Privacy and Confidentiality:
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Privacy and confidentiality are often confused.
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In routine hospital practice, many persons have access to confidential
information but all are enjoined to keep such information confidential.
Confidentiality includes medical records of any form.
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The patient should not make unnecessary revelation of negative things
about himself or herself.
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The nurse cannot disclose confidential information to a third party
without the consent of the patient.
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Information can be released without the consent of the patient for
purposes of medical care, for criminal investigations, and in the public
interest.
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Release is not justified without patient consent for the following
purposes: education, research, medical audit, employment or insurance.
Consent and Refusal of Treatment for Competent
Adults’ – 1:
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No medical procedures can be carried out without informed consent of
the patient except in cases of legal incompetence. The patient has the purest
intentions in decisions in the best interests of his or her life. Others may
have bias in their decision-making.
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The patient is free to make decisions regarding the choice of nurses
and treatments. Consent can be by proxy in the form of the patient delegating
decision making or by means of a living will.
}
The patient must be free and capable of giving informed consent.
Informed consent requires disclosure by the nurse, understanding by the
patient, voluntariness of the decision, legal competence of the patient,
explanation of all alternatives, recommendation of the nurse on the best course
of action, decision by the patient, and authorization by the patient to carry
out the procedures. Consent is limited to what was explained to the patient
except in an emergency.
Consent and Refusal of Treatment for Competent
Adults’ – 2:
}
Refusal to consent must be an informed refusal (patient understands
what he is doing). Refusal to consent by a competent adult even if irrational
is conclusive and treatment can only be given by permission of the court.
Doubts about consent are resolved in favor of preserving life.
}
Spouses and family members do not have an automatic right to consent
for a competent patient. A spouse cannot overrule the patient’s choice.
}
Advance directives, proxy informed consent by the family are made for
the unconscious terminal patient on withholding or withdrawal of treatment.
}
Nurse assisted suicide, active euthanasia, and voluntary euthanasia are
illegal even if the patient consented.
}
A do not resuscitate order (DNR) by a nurse could create legal
complications.
Consent and Refusal of Treatment for Competent
Adults’ – 3:
}
The living will have the following advantages: (a) reassuring the
patient that terminal care will be carried out as he or she desires (b)
providing guidance and legal protection and thus relieving the nurses of the
burden of decision making and legal liabilities (c) relieving the family of the
mental stress involved in making decisions about terminal care. The
disadvantage of a living will be that it may not anticipate all developments of
the future thus limiting the options available to the nurses and the family.
}
The device of the power of attorney can be used instead of the living
will or advance directive.
}
Decision by a proxy can work in two ways: (a) decide what the patient
would have decided if able (b) decide in the best interests of the patient.
}
Informed consent is still required for nurses in special practices such
as a ship’s doctor, prison doctor, and doctors in armed forces. Police surgeons
may have to carry out examinations on suspects without informed consent.
Bed-side visits:
}
The nurse-patient interaction is both professional and social. The
bedside visit fulfills the brotherhood obligation of visiting the sick. The
human relationship with the patient comes before the professional technical
relationship.
}
Bedside visits It involves reassurance, psychological and social
support, show of fraternal love, and sharing. A psychologically satisfied
patient is more likely to be cooperative in taking medication, eating, or
drinking.
Recommended actions during bed-side visits:
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Greeting the patient
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Dua for the patient
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Good encouraging words
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Asking about the patient’s feelings,
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Doing good/pleasing things for the patient,
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Making the patient happy,
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And encouraging the patient to be patient,
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Discouraging the patient from wishing for death,
}
Nasiihat for the patient, and reminding the
patient about dhikr.
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Caregivers should seek permission, idhn, before getting to
the patient.
}
Caregivers should not engage in secret conversations that do not
involve the patient.
Etiquette of the care-giver – 1:
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Respect the rights of the patient regarding advance directives on
treatment, privacy, access to information, informed consent, and protection
from nosocomial infections.
}
Clean and dress appropriately to look serious, organized and
disciplined.
}
Cheerful, lenient, merciful, and kind. They must enjoin the good, have
good thoughts about the patients and avoid evil or obscene words.
}
Observe the rules of lowering the gaze, and seclusion.
}
An attitude of humbleness.
}
Not emotionally-detached in the mistaken impression that they are being
professional. They must be loving and empathetic and show mercifulness but the
emotional involvement must not go to the extreme of being so engrossed that
rational professional judgment is impaired.
}
Dua for the patients because qadar can
only be changed by dua.
}
Ruqya for the patients by reciting the
two mu’awadhatain or any other verses of the Qur’an.
Etiquette of the care-giver – 2:
}
Seek permission when approaching or examining patients.
}
Medical care must be professional, competent, and considerate.
}
Medical decisions should consider the balance of benefits and risks.
}
Procedures carried out must be explained very well to the patient in
advance.
}
Never promise cure or improvement.
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Every action of the caregiver must be preceded by basmalah.
}
Everything should be predicated with the formula inshallah,
if Allah wishes.
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Listen to the felt needs and problems of the patients.
}
Ask about both medical and non-medical problems.
}
Supportive care such as nursing care, cleanliness, physical comfort,
nutrition, treatment of fever and pain are as important as the medical
procedures themselves and are all what can be offered in terminal illness.
}
Reassure the patients not to give up hope. Measures should be taken to
prevent nosocomial infections.
Etiquette of interaction between genders – 1:
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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 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.
Etiquette of interaction between genders – 2:
}
Medical co-education involves intense interaction between genders: Teacher-student,
student-student, and teacher-teacher. Interacting with colleagues of the
opposite gender raises special problems: norms of dress, speaking, and general
conduct; class-room etiquette; social interaction; laboratory experiments on
fellow students; learning clinical skills by examining other students; and the
operation theatre.
}
Medical personnel of opposite genders should wear gender-specific
garments during surgical operations because Islam frowns on any attempt to look
like the opposite gender.
}
Shari’at guidelines on interaction with
patients of the opposite gender should be followed. Taking history, physical
examination, diagnostic procedures, and operations should preferably be by a
nurse of the same gender. In conditions of necessity a nurse of the opposite
gender can be used and may have to look at the ‘awrat or touch
a patient. The conditions that are accepted as constituting dharuurat are:
skills and availability.
Dealing with the Family:
}
Visits by the family fulfill the social obligation of joining the
kindred and should be encouraged. The family are honored guests of the hospital
with all the shari’at rights of a guest.
}
The caregiver must provide psychological support to family because they
are also victims of the illness because they are anxious and worried. They need
reassurance about the condition of the patient within the limits allowed by the
rules of confidentiality.
}
The family can be involved in some aspects of supportive care so that
they feel they are helping and are involved. They should however not be allowed
to interrupt medical procedures.
}
Caregivers must be careful not to be involved in family conflicts that
arise from the stresses of illness.
Etiquette of teaching & learning in the
health care team:
} The hospital health
care team is complex and multi-disciplinary with complementary and
inter-dependent roles. Members have dual functions of teaching and delivering
health care. Most teaching is passive learning of attitudes, skills, and facts
by observation.
} Teachers must be
humble. They must make the learning process easy and interesting. Their
actions, attitudes, and words can be emulated. They should have appropriate
emotional expression, encourage student questions, repeat to ensure
understanding, and not hide knowledge.
}
The student should respect the
teacher for the knowledge they have. They should listen quietly and
respectfully, teach one another, ask questions to clarify, and take notes for
understanding and retention. They should stay around in the hospital and with
their teachers all the time to maximize learning.
Etiquette of care delivery in the health care
team:
}
Each member of the team carries personal responsibility with leaders
carrying more responsibility.
}
Leaders must be obeyed except in illegal acts, corruption, or
oppression.
}
Rufaidah, the first Muslim nurse, was a good model of etiquette. She
was kind, empathetic, a capable leader and organizer, clinically competent, and
a trainer of others. Besides clinical activities, she was a public health nurse
and a social worker assisting all in need. The human touch is unfortunately
being forgotten in modern medicine as the balance is increasingly tilted in
favor of technology.
The health care team: general group dynamics:
}
Basic duties of brotherhood and best of manners must be observed.
}
Encouraged are positive behaviors (mutual love, empathy, caring for one
another; leniency, generosity, patience, modesty, a cheerful disposition,
calling others by their favorite names, recognizing the rights of the older
members, and self-control in anger.
}
Discouraged are negative attributes (harshness in speech, rumor
mongering, excessive praise, mutual jealousy, turning away from other for more
than 3 days, and spying on the privacy of others).
The health care team: special group dynamics:
}
Gender-specific identity should be maintained in dress, walking, and
speaking.
}
Free mixing of the genders is forbidden but professional contact within
the limits of necessity is allowed.
}
Patients of the opposite gender are examined in the presence of a
chaperone.
}
The gaze should be lowered.
}
Modest covering must be observed.
}
Display of adornments that enhance natural beauty must be minimized.
Abuse of professional privileges 1:
}
Abuse of treatment privileges consists of unnecessary treatment,
iatrogenic infection, and allowing or abetting an unlicensed practitioner.
Abuse of prescription privileges is manufacturing, possessing, and supplying a
controlled drug without a license, prescription of controlled drugs not
following procedures, diverting or giving away controlled substances,
dispensing harmful drugs, sale of poisons, and writing prescriptions using
secret formulas.
}
Financial fraud may be pharmacy fraud (billing for medicine not
supplied), billing fraud (billing for services not performed), equipment fraud
(using equipment that is really not needed or using equipment of poorer
quality), or supplies fraud. It is also illegal to get financial advantage from
prescriptions to be filled by pharmacies owned by the nurse. Kick-backs are
unethical and illegal. False or inaccurate documentation is a breach of the law
and includes issuing a false medical certificate of illness, false death certification,
and false injury reports.
Abuse of professional privileges 2:
}
Court action could be brought against a nurse for the following crimes
against the person: manslaughter (voluntary & involuntary); euthanasia
(active and passive): battery for forced feeding or treatment; criminal
liability for patient death; induced non-therapeutic abortion; iatrogenic
death; abusive therapy involving torture; intimate therapy; rape and child
molestation; and sexual advances to patients or sexual involvement.
}
The nurse-patient relation requires that the nurse keeps all
information about the patient confidential. Breach of confidentiality can be
done only in the following situations: court order, statutory duty to report
notifiable diseases, statutory duty to report drug use, abortions, births,
deaths, accidents at work, disclosure to relatives in the interest of the
patient, disclosure in the public interest, sharing information with other
health professionals, disclosure for the purposes of teaching and research, and
disclosure for the purposes of health management.
Private mis-conduct derogatory to reputation, kharq al muru’at:
}
Breach of trust is a cause for censure because a nurse must be a
respected and trusted member of the community.
}
Sexual misbehavior such as zina and liwaat are
condemned.
}
Fraudulent procurement of a medical license, sale of medical licenses,
and covering an unqualified practitioner indicate bad character.
}
Nurses can abuse their position by abuse of trust (e.g. harmful or
inappropriate personal and sexual relations with patients and their families),
abuse of confidence (e.g. disclosure of secrets), abuse of power/influence
(e.g. undue influence on patients for personal gain), and conflict of interest
(when the nurse puts personal selfish interests before the interests of the
patient).
}
Other forms of misconduct are in-humane behavior such as participation
in torture or cruel punishment, abuse of alcohol and drugs, behavior
unbecoming, indecent behavior, violence, and conviction for a felony.
Medical Malpractice / Negligence:
}
There are 4 elements in medical
negligence: discharge of duty, breach of duty, injury, and burden of proof.
Medical negligence may be breach of duty resulting in causation of injury which
calls for damages.
}
Avoiding / prevention of malpractice suits: Malpractice suits can be avoided by obtaining and
maintaining registration, sticking to defined professional standards of care,
peer review, quality assurance, use of protocols, defensive medicine and
politeness with patients. The best protection against medical negligence is the
conscience of all health care workers to make sure that mistakes do not occur.
Well written records can be a defense for the nurse.
Theories and principles of medical ethics:
} Purposes and Principles of Medicine and
ethics, maqasid wa qawa’id al tibaabat.
}
Regulations of Medical Procedures, dhawaabit al tatbiib.
}
Regulations of Research Procedures, dhawaabit al bahath.
}
Regulations of Nurse Conduct, dhawaabit al tabiib.
}
Regulations about Professional Misconduct, dhawaabit al
inhiraaf al mihani.
7 The etiquette of the nurse, adab al tabiib:
}
Etiquette with Patients and Families
}
Etiquette with the Dying
}
Etiquette with the Health Care Team
}
Etiquette of Research on Humans
Issues in disease conditions, fiqh al amraadh:
}
Uro-Genital System, jihaaz
bawli & jihaaz tanaasuli,
}
Cardio-Respiratory System, qalb & jihaaz al tanaffus,
}
Connective Tissue System,
}
Alimentary System, jihaaz al ma idat,
}
Sensory Systems, al hawaas,
}
Patho-physiological Disturbances,
}
General Systemic Conditions,
}
Psychiatric conditions, amraadh nafsiyyat,
}
Neurological conditions, amraadh al a’asaab,
}
Age-Related Conditions, amraadh al ‘umr.
Issues in modern medicine fiqh mustajiddaat al tibb:
}
Assisted Reproduction, taqniyat al injaab,
}
Contraception, mani’u al haml,
}
Reproductive Cloning, al istinsaakh,
}
Abortion, isqaat al haml,
}
Genetic Technology, taqniyat wiraathiyyat,
}
Artificial Life Support, ajhizat al in’aash,
}
Euthanasia, qatl al rahmat,
}
Solid Organ Transplantation, naql al a’adha,
}
Stem Cell Transplantation, naql al khalaayat,
}
Change of Fitra, taghyiir al fitrat.
References:
[1] BG69 Ibn Majah and Ahmad
[2] MB171 Bukhari 1:228
[3] MB170 Bukhari 1:227
[5] MB171 Bukhari 1:228
[6] KS154 Abu Daud K1 B118, Darimi K1 B85, Muwatta K2 H108
[7] Bukhari K30 B20
[8] Bukhari K30 B45
[9] Ahmad 5:147
[10] Bukhari K30 B22
[11] Bukhari K65 S2
[12] Bukhari K65 S2 B25
[13]
2:183-185
[14] Bukhari 3:168
[15] Bukhari K65 S2 B25
[16] Bukhari K65 S2 B25
[17] Bukhari K6 B6
[18] ( )
[19] Bukhari K30 B22
[20] Tirmidhi K6 B69
[21] Abudaud 2364