Integrated Medical Education Resources: 160812 - TEACHING HEALTH PROFESSIONAL ETHICS FROM MAQASID AL SHARI’AT AND QAWA’ID AL FIQH: EXPERIENCE INTEGRATION OF KNOWLEDGE IN SOUTH EAST ASIA

By Dr Omar Hasan Kasule Sr. MB ChB (MUK), MPH (Harvard), DrPH (Harvard) Professor of Epidemiology and Bioethics Faculty of Medicine and Chairman of the Ethics Committee, King Fahad Medical City Riyadh and member of the Health Minister Scientific Advisory Council, Riyadh Saudi Arabia. omarkasule@yahoo.com

SUMMARY

• Motivation from my personal background in traditional Islamic education and secular western education

• Facing the crisis of dichotomy in general education

• Experiences of integration of knowledge in medicine:

• Ethical theory based on maqasid al shari’at

• Ethical theories based on qawa’id al fiqh

• Practical examples of use of maqasid and qawa’id in clinical situations

• Future challenges

FACING THE CRISIS OF DICHOTOMY IN EDUCATION 1

• Traditional Islamic education vs. Secular Western Education

• Uluum al ddiin vs uluum al duniya

• Qur’anic tauhidi world view vs Secular western materialistic worldview

• Falaah al duniya wa al akhirat vs falaah al duniya al maadiyyat

• Khalq vs tatwiir

• Nudrat vs si’at rizq al Allah

• Intelectual schizophrenia and confusion: within an individual and between individuals

• The solution to the crisis of dichotomy is integration of knowledge by joint reading of kitaab al wahy and kitaab al kawn.

FACING THE CRISIS OF DICHOTOMY IN EDUCATION 2

• 1977 First World Conference of Muslim Education identified the crisis of dichotomy as a major problem in Muslim education

• Late 1970s: African Islamic Religious Knowledge (IRK) panel met in Nairobi to prepare curricula for teaching Islamic knowledge in government schools

• 1980s

• 1980s My exposure to ideas of Islamization of Knowledge of Dr Ismail Faruqi and Dr Abdulhamid Abusulayman

• 1990-1995 As Director of the Education Project based in Herndon, Virginia worked with Islamic schools in the US and Canada to train teachers and produce teaching materials.

FACING THE CRISIS OF DICHOTOMY IN EDUCATION 5: International perspective

• 1990- International Bureau for Educational Resources and Research (IBERR) as an international grouping of associations of Muslim schools in UK (Yusuf Islam), US, (Abdullah Ali), South Africa (Maulana Ali Adam), and Nigeria (Sr Aisha Lemu).

• 1996 Sixth World Conference of Muslim Education produced integrated textbooks for South African Islamic Schools

INTEGRATION OF KNOWLEDGE IN MEDICINE (IOKM) 1: Definition

• Integration of knowledge is a process of reform, recasting, and re-orienting medical education, training, and practice to conform to the Islamic world view as manifest in ‘aqidat islamiyyat and Islamic Law, shari’at islamiyyat.

• It consists of (a) reforming the curricular of basic and clinical medical disciplines to conform to the principles of Islamic epistemology (b) teaching the Law as it relates to medicine and its practice, fiqh al tibb.

• The seeds of IOKM can be traced to the general Islamic reform movement that gained momentum with the celebration of the start of the 15th century of hijra and can be divided into 3 historical epochs.

INTEGRATION OF KNOWLEDGE IN MEDICINE (IOKM) 2: First Era (Pre-1980)

• The first era was the pre-1980 period in which some medical colleges like Azhar in Cairo and Yarsi in Indonesia required their students to memorize certain parts of the Qur’an and acquire specified Islamic knowledge before graduation.

• The motivation was to produce a religious doctor who would be a model to the Muslim patients. There was no interest in reforming or changing the medical curriculum itself.

• 1980 The First International Conference of Islamic medicine in Kuwait and subsequent conferences focused on the historical contributions of Muslims in medicine, use of tibb nabawi in modern medicine, and fiqb tibbi as well as professionalism

INTEGRATION OF KNOWLEDGE IN MEDICINE (IOKM) 3: The Second Era (1980-1995)

• The second era was a struggle between two views of ‘Islamic Medicine’: historical vs modern

• A historical view that called for rediscovery of Muslim medicine practiced in the golden era of Islam and surviving as the Unani and other Muslim traditional medical systems

• A modern view that looked at Islamic medicine and values that if applied to modern scientific medicine would make it ‘Islamic’.

• Those who confirmed to the traditional view encouraged colleges of traditional medicine such as Hamdard in Pakistan.

• Those who conformed to the modern concept encouraged colleges that taught scientific medicine but had no concrete idea of the nature, contents, and methods of Islamic medicine in such a context.

• Not much progress could be made until this debate was settled in the mid-1990s when the modern view became predominant.

INTEGRATION OF KNOWLEDGE IN MEDICINE (IOKM) 4: The Second Era (1980-1995)

• Paper by Kasule ‘Islamic Medicine: Concept & Misunderstandings delivered at a seminar in Kuala Lumpur Malaysia in July 9-14, 1995 settled the issue of defining Islamic medicine by Islamizing modern scientific medicine through integrating Islamic values and paradigms.

• Islamic Medicine is defined as Medicine whose basic paradigms, concepts, values, and procedures conform to or to do not contradict the Qur'an and Sunnah.

• Islamic medicine is not a specific medical procedures or therapeutic agent used at a particular place or a particular time.

• Islamic medicine is universal, all - embracing, flexible, and allows for growth and development of various methods of investigating and treating diseases within the frame-work described above.

INTEGRATION OF KNOWLEDGE IN MEDICINE (IOKM) 5: The third era (1995-2004)

• The third epoch, 1995-present, saw the establishment and operation of medical colleges within universities that claimed the label Islamic because their curricula aimed at integrating Islamic values in the curricula

• Fulfillment of the recommendations of the First World Muslim Education Conference held in Makka that identified the dichotomy between religious and secular sciences as the main problem of Muslim education and called for its end by integrated education systems.

• Universities tried various approaches in resolving the dichotomy crisis and case studies can be presented for the benefit of all.

• This was also an epoch of intense dissemination of the ideas of IOKM in many countries with a very positive response.

• The Islamic Input in Medicine curriculum was applied at the International Islamic University in Malaysia.

INTEGRATION OF KNOWLEDGE IN MEDICINE (IOKM) 6: The fourth era third era (2005-present)

• Kasule in 2004 presented 2 papers in Amman on maqasid and qawaid in medicine and research [Muammar look up exact dates and exact titles of the papers from CV]

• The papers were subsequently republished and quoted and started a new era of integration in medicine by introducing an Islamic ethical framework to replace the secular one that was dominating medicine.

THE ISLAMIC INPUT CURRICULUM AT THE INTERNATIONAL ISLAMIC UNIVERSITY IN MALAYSIA: Pioneer role of the university

• The International Islamic University of Malaysia (IIUM) was established in 1983 with the mission of integrating human and revealed knowledge.

• All its faculties were required to reflect this mission in their curricula.

• Each student was required to take courses on the Qur’an, hadith, and fiqh

• Students were encouraged to take a double major combining a discipline of revealed knowledge and a discipline of human sciences.

• The faculty of medicine went further than all by full integration of the teacher, the teaching material, and the examination.

THE ISLAMIC INPUT CURRICULUM AT THE INTERNATIONAL ISLAMIC UNIVERSITY IN MALAYSIA: The Faculty of Medicine

• 1995-1997 was a period of preparing an integrated curriculum before admission of the first batch of medical students in 1997

• At the faculty of medicine lecturers of each medical discipline took special training and were themselves the teachers of the Islamic input.

• The teaching of Islamic values and Islamic fiqh were not offered as separate courses but were fully integrated in the medical course. Questions on the Islamic input were included as separate items or as part of an item in the general examination.

• The Faculty of Medicine of the International Islamic University in Kuantan Malaysia has been running an Islamic Input into the Medical Curriculum Program (IIMC) since it started teaching in 1997

• IIMC has graduated several batches of students who have carried the philosophy or Islamized medicine to hospitals and other faculties.

THE ISLAMIC INPUT CURRICULUM AT THE INTERNATIONAL ISLAMIC UNIVERSITY IN MALAYSIA: objectives of the Islamic input curriculum

• Introduction of Islamic paradigms and concepts in medicine, mafahiim Islamiyat fi al Tibb for example concepts of life, death, causality.

• Strengthening faith, iman, through using basic medical sciences (like anatomy, physiology, biochemistry) to study and appreciate Allah’s sign in the human body

• Appreciating and understanding the juridical, fiqh, aspects of health and disease, al fiqh al tibbi.

• Understanding the social issues in medical practice and research

• Professional etiquette, adab al tabiib, from the Islamic perspective.

Muqaddimat al ‘Uluum al Sihhiyat

ISLAMIC INTRODUCTION TO THE HEALTH SCIENCES

MANUAL FOR UNIVERSITY TEACHERS and STUDENTS

PROFESSOR Dr. OMAR HASAN K. KASULE Sr.

THE ISLAMIC INPUT CURRICULUM AT THE INTERNATIONAL ISLAMIC UNIVERSITY IN MALAYSIA: Islamic input curriculum manual 2

• Theme One: Asaasiyyaat (Fundamentals) 1: ‘aqiidat (creed); 2: usuul al shari’at (foundations of the law); 3. ‘ilm & ma’arifat (epistemology); 4. khalq (creation / cosmogony); 5. taariikh al umam (world history); 6. taariikh al ummat (Muslim history); 7. al tajdid & al islah (renewal and reform);

• Theme 2: Fiqh Al Uluum Al Tibiyyat, (Basic Medical Sciences): 8. ‘ilm al hayaat (the science of life); 9. jism al insan (the organism: structure & function); 10. fiqh al ‘aadaat (activities of daily living);

THE ISLAMIC INPUT CURRICULUM AT THE INTERNATIONAL ISLAMIC UNIVERSITY IN MALAYSIA: Islamic input curriculum manual 3

• Theme Three: Fiqh Al Tibaabat (Clinical Sciences): 11. Akhlaaq Al Tibb (Ethics Of Medicine); 12. Fiqh Al Amraadh (Disease Conditions); 13: Fiqh Mustajiddaat Al Tibb (Modern Medicine);

• Theme Four: Fiqh Al Jama’at (The Community): 14. Arkaan Wa Humuum Al Jama’at (Institutions And Concerns Of The Community); 15. Fiqh Al Mu’amalaat (Transactions);

• Theme Five: Personal Skills: 16. Al Takwiin Al Asaasi (Basic Formation): 17.: Qiyadat (Leadership); 18. Idaarat (Management)

EXAMPLES OF INTEGRATED TEACHING 1: conceptual issues

• Continuum of life and death

• What is the purpose of medicine: quantity or quality of life

• Sunan al Allah fi al khalq: parity (zawjiyyat), symmetry

• Causality (sababiyah) in disease causation, prevention, and treatment

EXAMPLE OF THE INTEGRATED EXAMINATION QUESTIONS

1. Explain how the Qur'anic concepts of tawazun and I'itidaal relate to the control of plasma osmolality

2. Using your patho-physiological knowledge explain the statement 'pain is a bounty from Allah'

3. Briefly describe the proper etiquette, adab, of a Muslim physician when dealing with patients and their family members

4. Salat for a patient with (i) gastrostomy and (ii) colostomy

5. Salat for a female patient with (i) inter-menstrual spotting (ii) vesico-vaginal fistula

6. Describe how the Qur’an uses the term qalb to refer to intellectual function

7. Using your knowledge of biology, explain the Qur’anic statement that Allah brings forth life from death and death from life

SCALE FOR EVALUATION OF THE ISLAMIC INPUT 1

Development and Validation a Multidimensional Questionnaire; The Muslim Medical Student Questionnaire (MMSQ) among Malaysian Undergraduates.

Musa R, Abdul Rani MF, Che Ahmad A, Draman S

Objective: Handful medical schools have implemented the Islamic medical inputs in their medical curriculums. Nevertheless we are facing a setback as there is no standard assessment tool to measure the effectiveness of this special academic input for undergraduate programme. The objective of this study is to design a scale that is able to gauge the impact of Islamic input based on various aspects among undergraduates. Methods: The construction of a new scale is based on 5 stages of standard questionnaire design. To validate the newly designed scale, the scale was administered to all the students who granted their consents. Results: A total of 520 medical students from all academic years of a medical school enrolled in the validation stage. Bartlet’s KMO value is 0.9. From 46 items, 67% had good factor loading (>0.4). Cronbach’s alpha values of 0.78, 0.85 and 0.13 were obtained for Attitude, Practice and Knowledge domains respectively. We identified 3 domains by using exploratory factor analysis. Conclusion: The scale is having good psychometric values for both reliability and validation.

SCALE FOR EVALUATION OF THE ISLAMIC INPUT 1: Knowledge items

K1 There are 4 pillars in Maqasad Syariah

K2 “Aqal” is one of the pillars in Maqasad Syariah

K3 A Muslim female patient should only see a female gynaecologist.

K4 Islam encourages a 3-month pregnant mother to fast during Ramadhan provided there is no medical problems

K5 In any circumstances, Muslim patients can take medications which contain pig by- products.

K6 Taking oral medication while fasting will not break the fast.

K7 A Muslim doctor is allowed to perform vasectomy or tubal ligation when it is requested by the patients.

K8 Using eye drops will nullify fasting.

K9 Muslim physicians should not care for homosexual patients with AIDS as this is endorsing homosexuality.

K10 Sunnat Dhuha prayer is performed in middle of the night.

K11 The concept of Ruksah is applied to simplify the performance of prayers during difficult situations.

K12 Performance of Tayammum involves 4 body parts.

K13 Fasting is encouraged on Tuesday and Friday

K14 Surah Al-Fatihah is also known as a healing surah.

K15 A false Hadith is also known as Hadith Dhoif (weak)

K16 The use of Qada’ in performing prayers is applicable when it involves a long operation hours.

SCALE FOR EVALUATION OF THE ISLAMIC INPUT 2: Attitude items

A1 I do not see the need to inculcate spiritual values in my medical practice

A2 Constant request for an update from either patient or family members should not be encouraged.

A3 The concept of Maqasid Syariah should be applied to problematic cases encountered in clinical medicine.

A4 I consciously adopt Islamic values when dealing with my patients

A5 When revealing the diagnosis of HIV to a patient, I believe it should be done in private.

A6 Medical confidentiality is important in my practice

A7 My work as a doctor is an Ibadah

A8 I feel that the effort that I do is not well rewarded.

A9 I work mainly for the salary.

SCALE FOR EVALUATION OF THE ISLAMIC INPUT 3: Practice items

P1 I relate to the Quran and Hadith in my reasoning.

P2 I make effort to read Quran regularly

P3 I greet almost every patient that I meet with Salam.

P4 I communicate effectively with my colleagues and patients.

P5 I always perform prayer while on duty.

P6 I perform congregational prayers 5 times per day.

P7 When patients inquire about Rukshah in sickness, I am able to deal with it.

P8 I am comfortable talking to intensely demanding patients’ relatives.

P9 I allocate time to explain about the disease to my patients or the relatives.

P10 I am not late for clinical appointments such as clinics, ward rounds and meetings.

P11 I remind my colleagues or subordinates about professionalism.

P12 I am happy with the way I deal with people around me and they respond to me positively too.

P13 I practise the Prophet’s sunnah in my life

P14 I recite Bimillah (By the name of Allah) almost every task in my life.

P15 I practise Islamic counselling to my patients

P16 I perform sunnat Dhuha, Tahajud and Witr.

P17 I follow the Akhlak of Prophet Muhammad SAW

P18 I can recognize Bid’ah and Khurafat in the community.

P19 I can deal with a Janazah according to Syariah.

P20 I constantly remind my patients about the need to perform prayers.

P21 I memorize common short Surahs in Al Quran

ETHICAL THEORY FROM MAQASID AL SHARI’AT 1: Introduction

• Islam has a parsimonious and rigorously defined ethical theory of Islam based on the 5 purposes of the Law, maqasid al shari’at.

• Any medical action must fulfill one of the above purposes if it is to be considered ethical.

• The principles of the Law, qawa’id al fiqh, are practical extensions and interpretations of the maqasid.

• The ethical theories and principles are derived from the basic law but the detailed applications require further ijtihad.

• Health professionals in their conduct and decision making must constantly be aware of the maqasid to practice medicine in an ethical and legal way accepted by the shari’at.

• Maqasid and qawa’id move us from the fiqh of parts (fiqh al juz’iyaat) to the fiqh of the whole (fiqh al maqasid)

ETHICAL THEORY FROM MAQASID AL SHARI’AT 2: Historical background [

 The study aimed at discovering ethical theories and ethical principles in Islamic Law to compare with generally accepted theories and principles.

 Results first presented at the Scientific Conference of the Jordanian Islamic Medical Association in Amman in 2004 and have been presented at many conferences in other countries.

 Two sources of Islamic Law were used: (a) The purposes of the Law (maqasid al shari’at) developed starting in the 5th Islamic century as the basis for an Islamic ethical theory and (b) Principles of the Law (qawa’id al fiqh), as the basis for ethical principles.

 Development of this legal theory can be traced to the 5th Islamic century and the pioneers were Shaikh al Haramain al Juwayni and his student Hujjat al Islam Abu Hamid AlGhazzali. Contributions were made 2 centuries later by Shaikh al Islam Ibn Taymiyah and his student Abu Qayyim al Jawziyat

 The theory was formulated systematically in the form it is used today by the Spanish Andalusian scholar of the Maliki School of Law, Abu Ishaq AlShatibi in his 8th century legal manual Almuwafaqaat fi usuul al shari’at.

ETHICAL THEORY FROM MAQASID AL SHARI’AT 2: Historical background [

 The theory was not used a lot in the past 7 centuries because the legal dilemmas that arose were simple and could be resolved by existing legal texts and precedents.

 Modern medical technology has given rise to many legal and ethical dilemmas that can be resolved only by reference directly to the legal theory.

 For an act to be considered ethical, it must conform to or not violate one of the 5 major purposes of the Law.

 The advantage is that one internally consistent legal or ethical theory is applied to various situations.

 The 5 purposes aim at protecting (hifdh), preserving (ibqaa), and promoting (tatwiir) of 5 entities that among them cover all aspects of human endeavor and medical treatment.

MAQSAD 1: Protection of ddiin, hifdh al ddiin

• Protection of diin essentially involves ‘ibadat in the wide sense that every human endeavor is a form of ‘ibadat.

• Thus medical treatment makes a direct contribution to ‘ibadat by protecting and promoting good health so that the worshipper will have the energy to undertake all the responsibilities of ‘ibadat.

• The principal forms of physical ‘ibadat are the 4 pillars of Islam: prayer, salat; fasting, puasa; and pilgrimage, hajj.

• A sick or a weak body can perform none of them properly.

• Balanced mental health is necessary for understanding ‘aqidat and avoiding false ideas that violate ‘aqidat. Thus medical treatment of mental disorders thus contributes to ‘ibadat.

MAQSAD 2: Protection of life, hifdh al nafs

• The primary purpose of medicine is to fulfill the second purpose of the shari’at, the preservation of life, hifdh al nafs.

• Medicine cannot prevent or postpone death since such matters are in the hands of Allah alone. It however tries to maintain as high a quality of life until the appointed time of death arrives.

• Medicine contributes to the preservation and continuation of life by making sure that the nutritional functions are well maintained.

• Medical knowledge is used in the prevention of disease that impairs human health.

• Disease treatment and rehabilitation lead to better quality health.

MAQSAD 3: Protection of progeny, hifdh al nasl

• Medicine contributes to the fulfillment of this function by making sure that children are cared for well so that they grow into healthy adults who can bear children.

• Treatment of infertility ensures successful child bearing.

• The care for the pregnant woman, perinatal medicine, and pediatric medicine all ensure that children are born and grow healthy.

• Intra-partum care, infant and child care ensure survival of healthy children.

MAQSAD 4: Protection of the mind, hifdh al ‘aql

• Medical treatment plays a very important role in protection of the mind.

• Treatment of physical illnesses removes stress that affects the mental state.

• Treatment of neuroses and psychoses restores intellectual and emotional functions.

• Medical treatment of alcohol and drug abuse prevents deterioration of the intellect.

MAQSAD 5: Protection of wealth, hifdh al mal

• The wealth of any community depends on the productive activities of its healthy citizens.

• Medicine contributes to wealth generation by prevention of disease, promotion of health, and treatment of any diseases and their sequelae.

• Communities with general poor health are less productive than a healthy vibrant community.

• The principles of protection of life and protection of wealth may conflict in cases of terminal illness.

• Care for the terminally ill consumes a lot of resources that could have been used to treat other persons with treatable conditions.

• The question may be posed whether the effort to protect life is worth the cost.

• Health professionals must also be careful not to waste resources in the hospital.

QA’IDAT 1: The principle of intention, qa’idat al qasd

• The sub principle that each action is judged by the intention behind it calls upon the nurse to consult his inner conscience and make sure that his actions, seen or not seen, are based on good intentions.

• The sub principle ‘what matters is the intention and not the letter of the law’ rejects the wrong use of data to justify wrong or immoral actions.

• The sub principle that means are judged with the same criteria as the intentions implies that no useful medical purpose should be achieved by using immoral methods.

QA’IDAT 2: The principle of certainty, qaidat al yaqeen

• Medical diagnosis and treatment must be based on certain evidence obtained from clinical examination and investigations.

• All medical procedures are considered permissible unless there is certain, yaqeen, evidence to prove their prohibition.

QA’IDAT 3a; The principle of injury, qaidat al dharar 1

• Medical intervention is justified on the basic principle is that injury, if it occurs, should be relieved.

• An injury should not be relieved by a medical procedure that leads to an injury of the same magnitude as a side effect.

• In a situation in which the proposed medical intervention has side effects, we follow the principle that prevention of a harm has priority over pursuit of a benefit of equal worth.

• If the benefit has far more importance and worth than the harm, then the pursuit of the benefit has priority.

QA’IDAT 3a; The principle of injury, qaidat al dharar 2

• Health professionals sometimes are confronted with medical interventions that are double edged; they have both prohibited and permitted effects. The guidance of the Law is that the prohibited has priority of recognition over the permitted if the two occur together and a choice has to be made.

• If confronted with 2 medical situations both of which are harmful and there is no way but to choose one of them, the lesser harm is committed.

QA’IDAT 3b; The principle of injury, qaidat al dharar 3

• A lesser harm is committed in order to prevent a bigger harm.

• Medical interventions that in the public interest have priority over consideration of the individual interest. The individual may have to sustain a harm in order to protect public interest.

• In many situations, the line between benefit and injury is so fine that salat al istikharat is needed to reach a solution since no empirical methods can be used.

QA’IDAT 4a: Principle of hardship, qaidat al mashaqqat 1

• Medical interventions that would otherwise be prohibited actions are permitted under the principle of hardship if there is a necessity. Necessity legalizes the prohibited.

• In the medical setting a hardship is defined as any condition that will seriously impair physical and mental health if not relieved promptly.

• Hardship mitigates easing of the sharia rules and obligations.

• Committing the otherwise prohibited action should not extend beyond the limits needed to preserve the Purpose of the Law that is the basis for the legalization.

QA’IDAT 4b: Principle of hardship, qaidat al mashaqqat 2

• Necessity however does not permanently abrogate the patient’s rights that must be restored or recompensed in due course; necessity only legalizes temporary violation of rights.

• The temporary legalization of prohibited medical action ends with the end of the necessity that justified it in the first place.

• This can be stated in an alternative way if the obstacle ends, enforcement of the prohibited resumes/ It is illegal to get out of a difficulty by delegating to someone else to undertake a harmful act.

QA’IDAT 5: The principle of custom or precedent, qaidat al urf

• The standard of medical care is defined by custom.

• The basic principle is that custom or precedent has legal force.

• What is considered customary is what is uniform, widespread, and predominant and not rare.

• The customary must also be old and not a recent phenomenon to give chance for a medical consensus to be formed.

USE OF MAQASID and QAWA’ID IN DECISION MAKING

• No new decisions can be taken without new evidence.

• According to Article 4 certainty cannot be voided by doubt (al yaqiin la yazuulu bi al shakk).

• According to Article 74 there is no recognition of imagination or guessing (la ‘ibrat li al tawahhum).

• According to article 5, without new evidence things should be left as they are (al asl baqaau ma kaana ala ma kaana) and according to Article 6 old things are left as they are (al qadiim yutraku ala qidamihi).

• The exception is when dealing with injury that must be removed immediately and must not be considered an old phenomenon that must be left alone. According to Article 7 injury cannot be old (al dharar la yakuun qadiiman).

• If an event or injury is found it should be considered to have occurred at the nearest possible time according to Article 11 (al asl idhhafat al hadith ila aqrab aqwaatuhi)

USE OF MAQASID and QAWA’ID IN END OF LIFE DECISIONS:

• Each health care giver is responsible for his decisions.

• If an action is illegal it is equally forbidden to undertake it as it is to ask someone else to undertake it according to Article 35 (ma haruma fi’iluhu haruma talabuhu).

• In all situations decisions should follow established guidelines according to Article 41 (al ‘aadat muhakkamat).

• In case of life support, it is easier not to start than to have to stop according to Article 55 (yughtafar fi al baqaa ma la yughtafar fi al ibtida).

• Continuation of an existing action is easier than starting a new one according to Article 56 (al baqau ashalu min al ibtida).

USE OF MAQASID and QAWA’ID IN EMERGENCY TREATMENT 1

• Conflicts between the ideal and the actual emergency room practice can be resolved by reference to the purposes of the law, maqasid al shari'at, and principles of the law, qawa'id al fiqh.

• The principle of necessity, qa'idat al dharurat, allows waiving normal practices like informed consent to protect life.

• The principle of intention, qa'idat al yaqeen, requires that all intervention and research must be based on evidence as much as is possible in the emergency situation.

• The principle of injury, qa'idat al dharar, requires minimizing harm while maximizing benefits in emergency procedures, protection of privacy and confidentiality.

USE OF MAQASID and QAWA’ID IN EMERGENCY TREATMENT 2

• End of life decisions involving artificial life support are based on finding the right evidence-based balance between the purpose of protecting life, hifdh al nafs, and the purpose of conserving resources, hifdh al maal; the final decision guided by the principle of certainty depends on evidence of benefit of the resuscitation.

• Under the principle of custom, qa’idat al ‘aadat, programmed decision-making routines, protocols and guidelines should be used in the emergency room.

• Under the principle of necessity, research necessary for improvement of emergency care can be carried out without prior consent by the patient or the guardians if certain specific conditions are fulfilled.

USE OF MAQASID and QAWA’ID IN HEALTH INSURANCE

• Health insurance planned and implemented according to the Law is considered a form of mutual self help, takaful ijtimae.

• The purpose of protecting life, maqsad hifdh al nafs, makes equitable access to the basic and necessary health services, khadamaat sihhiyyat assasiyyat wa dharuriyyat, a basic right of every citizen to be fulfilled by the family, the community, and the state in that order of increasing responsibility.

• Health services beyond the basic necessary are considered a privilege, they fall under the categories of needs, haajiyaat; complements, mukammilaat, and embellishments, tahsinaat; can be provided to each according to economic ability.

• Health insurance helps reduce disparities in health care among various socio-economic groups but does also introduce new ones.

USE OF MAQASID and QAWA’ID IN DO NOT RESISCITATE DECISIONS 1

• Consideration of DNR should relate exclusively to cardio-respiratory failure. Practical issues arising in the implementation of DNR from the perspectives of maqasid al shari’at and qawa’id al shari’at.

• The issues covered relate to uncertainties, qa’idat al yaqeen, protection of life, hifdh al nafs; protection of the patient from potential harm, qa’idat al dharar; conservation of resources, hifdh al mal.

• DNR orders shall be written for patients in an established death process i.e. cardio-respiratory failure beyond Young’s point ‘z’. Patients with terminal incurable conditions who develop acute and reversible cardio-respiratory arrest should be resuscitated if they will have a nett benefit from CPR lasting for a reasonable time.

USE OF MAQASID and QAWA’ID IN DO NOT RESISCITATE DECISIONS 2

• The paper proposes 5 components of DNR (cardiopulmonary resuscitation involving chest compressions and oxygenation, endotracheal intubation, mechanical ventilation, defibrillation, and vaso-active/ionotropic medication) that may be provided in any order and combination on a case by case basis.

• DNR patients on a case by case basis may/may not get renal dialysis, blood transfusion, parenteral nutrition, pulmonary hygiene, normal treatment e.g. antibiotics.

• All patients irrespective of their DNR status deserve supportive care: clearance of secretions, hydration, nutrition, pain management, supplemental oxygen, sedation, antipyretics, anti emetics, relieve of constipation, relief of urinary retention, relief of dypnea and cough.

USE OF MAQASID and QAWA’ID IN BRAIN DEATH 1

• Ethical issues relating to brain death can be analyzed according to the purposes of the Law, maqasid al shari’at, and principles of the law, qawa’id al fiqh, to reach conclusions of practical importance.

• Early determination of death by use of brain death criteria is motivated by the need to harvest transplantation organs earlier, save intensive care resources by earlier cessation of life support, and obtaining tissues for research before deterioration. These motives would violate the principle of intention, qa’idat al qasd, which requires that actions be judged by underlying intentions and that the end does not justify the means. In this case the nobility of the ends and their public interest are motivating factors.

USE OF MAQASID and QAWA’ID IN BRAIN DEATH 2

• The requirement, by the principle of certainty, qa’idat al qasd, of evidence-based proof of death are partially fulfilled by brain death criteria, tests, and examinations.

• The principle of custom, qa’idat al ‘aadat, is partially fulfilled because there is no universal consensus on criteria of brain death; the criteria vary by country, by institution, and over time.

• There is consensus on clinical tests in determining brain stem death but no such consensus exists for confirmatory instrumental tests.

• According to the principle of custom, changes of the consensus over time are valid and reflect growth of knowledge and technology.

USE OF MAQASID and QAWA’ID IN BRAIN DEATH 3

• Recommendation 1: Brain stem death, determined by clinical examination with or without instrumental confirmation, should remain the mainstay of death definition notwithstanding the uncertainties that have been discussed above because the public interest inherent in organ harvesting and saving ICU resources has higher consideration than these concerns.

• Recommendation 2: Legal rulings, fatwa, on brain death should be reviewed every 3 years to take into consideration new developments in medical knowledge and technology.