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Presented at the Bandung International Conference on Medical and Health sciences held on September 25, 2021, by Dr Omar Hasan Kasule Sr MB ChB (MUK), MPH (Harvard), DrPH (Harvard) Professor of Epidemiology and Bioethics at King Fahad Medical City Riyadh
ABSTRACT:
PROBLEM WITH THE TERM ‘ETHICS’:· Islamic bioethics is subsumed under the shari’at. It is derived and conforms to the 5 major objectives of the shari’at (maqasid al shari’at) as well as the operational principles of fiqh (qawa’id al fiqh).
· Ethics is best understood as ethical dilemmas that require solutions by balancing conflicting priorities. Ethical dilemmas can be formulated as conflicts between and among the objectives, principles, rights, and responsibilities.
· Some dilemmas can be resolved by fiqh rulings, but others require additional analysis using maqasid and qawa’id.
· Solutions to ethical dilemmas are derived from ‘ilm naqli as interpreted by ‘ilm aqli.
· Most of bioethics revolves around the purpose of life. Clinical case scenarios will be used to illustrate the analysis of the dilemmas[1].
THEORY OI MEDICAL ETHICS BASED ON MAQASID AL SHARI’AT:· I start by apologizing for using the term ‘ethics’ because of the necessity of communication this being the term that is widely known in the English language.
· Strictly speaking what we have is the shari’at that encompasses ethics, and we should ideally use the terms fiqh or shari’at instead of ethics.
· All ethical issues are legal issues from the Islamic perspective because ethical = moral = legal.
· The term akhlaq al tabiib or adab al tabiib have wider connotations than medical or health ethics.
· A theory of medical ethics from the Islamic perspective was presented by the author in 2004 at the International Scientific Convention Amman, Jordan 15-17 July 2004.
· The first paper was titled ‘Medical Ethics from Maqasid al Shari’at’ [2]. The second paper was titled ‘Ethics and etiquette of human research’[3].
· The two papers presented a theory of ethics based on the 5 purposes of the Law (maqasid al shari’at) and the 5 principles of the Law (qawa’id al fiqh).
· Both maqasid and qawa’id are based on transmission (naql) and practical interpretation by reason (aql). T
· The maqasid and qawa’id were derived inductively from the primary sources of the Qur’an and sunnat.
· The maqasid provide the general theory while the qawa’id provide detailed tools for reasoning out ethical dilemmas.
THE 5 PRINCIPLES OF FIQH:· Morality (hifdh al ddiin),
· Life and health (hifdh al nafs),
· Progeny (hifdh al nasl),
· Intellect (hifdh al aql),
· Property (hifdh al maal).
ETHICAL DILEMMAS AS A BALANCE BETWEEN AND AMONG CONFLICTING CONSIDERATIONS - 1:· Principle of intention (qa’idat al qasd) which asserts that all procedures are judged by the underlying intention (niyyat)
· Principle of certainty (qa’idat al yaqeen) asserts that all actions must be based on certain evidence
· Principle of harm (qa’idat al dharar) asserts that benefits must be maximized, and harms must be minimized.
· Principle of difficulty (qa’idat al mashaqqat) that asserts that exceptions to existing regulations can be made in cases of necessity (dharuurat)
· Principle of precedent (qa’idat al ‘urf) which asserts that generally accepted professional procedures must be followed.
ETHICAL DILEMMAS AS A BALANCE BETWEEN AND AMONG CONFLICTING CONSIDERATIONS - 2:· Ethical reasoning based on the balance of objectives, principles, rights, and responsibilities based on the two sources of knowledge: transmission (naql) and reason (aql).
· Ethical dilemmas are most often couched in terms of conflicts: right vs responsibility, right vs right, responsibility vs responsibility, and purpose vs purpose and principle vs principle.
· The basic premise is that ethical precepts are solely from naql but aql is needed to understand naql and apply it to practical ethical dilemmas.
THE PURPOSES AND PRINCIPLES: CONFLICT AND BALANCE - 1:· There are also ethical dilemmas that can be resolved based on empirical reasoning because they are based on principles already established by naql but their application requires aql.
· From the author’s experience most ethical dilemmas in clinical practice end up being solved by balancing these conflicts.
· The conflicts are apparent and not inherent because the shariat is itself internally consistent and not contradictory.
THE PURPOSES AND PRINCIPLES: CONFLICT AND BALANCE - 2:· For terminal patients in intensive care, we must balance the purpose of preserving health against the purpose of preserving resources.
· The purpose of preserving religion such as saum may conflict with the purpose of preserving health if saum has adverse health effects on the sick.
· In in vitro fertilization, the purpose of progeny / reproduction may conflict with the purpose of life when extra fertilized ova must be destroyed.
· The principle of certainty must be balanced against the purpose of life when therapy is instituted based on a tentative diagnosis.
RIGHTS AND RESPONSIBILITIES: CONFLICT AND BALANCE - 1:· The principle of harm revolves around balancing benefits of a medical intervention such as drugs against its adverse outcomes.
· The dilemma of conflict and balance are often solved by using the principles that enable more detailed reasoning.
· For example, life support can be terminated on the basis that there is certainty of death as assessed by brain death criteria. Conflicts among principles are solved by various tools that may involve using empirical data or empirical reasoning.
RIGHTS AND RESPONSIBILITIES: CONFLICT AND BALANCE - 2:· The treating physician must balance his responsibility to protect the health of the patient versus his responsibility to protect and uphold the patient’s right to autonomy. This balance is sometimes very complex that calls have been made to restrict patient autonomy in the interests of the patient.
· A terminal patient who refuses treatment must balance his right to autonomous decision making versus his responsibility from Allah to protect and preserve his body and his health.
· A medical researcher must balance his responsibility to scientific knowledge versus his responsibility to care for patients.
CENTRALITY OF THE PURPOSE AND RIGHT TO LIFE OF LIFE IN BIOETHICS - 1:· A medical administrator must balance his responsibility to provide the best care to the patient against his responsibility to control costs and balance the budget.
· A terminal patient in the intensive care unit represents another dilemma of balancing the right to life by continuing in the ICU (very expensive) against the right of other patients with reversible who may benefit more from admission.
· Balance must also be established between protecting health of terminal patients and waste of resources on a person not expected to recover.
CENTRALITY OF THE PURPOSE AND RIGHT TO LIFE OF LIFE IN BIOETHICS - 2:· Life and health belong to Allah He can give them and take them away as He wishes. The human is a temporary custodian of his life and health and has responsibilities of a custodian to take care of them.
· To be more precise the concern of ethics is about health and not life. As humans we can do something about protecting good health. We cannot however control death it is in the hands of the creator alone.
· Humans die only once and cannot return to earthly life.
· Disease and its treatment are under Allah’s qadar. We cannot tell whether disease is a punishment for sins, but we know that disease can be atonement for sins.
CENTRALITY OF THE PURPOSE AND RIGHT TO LIFE OF LIFE IN BIOETHICS - 3:· A human being has a right to life as well as to what maintains health in the optimum condition such as nutrition, hydration, medical treatment, freedom from pain and suffering, sleep, and recreation.
· The right to informed autonomous consent by the patient to medical interventions is the main tool by which the patient protects his life from destruction. This right can be prospective by use of the tool of advance directive.
· Generally, the decision of a competent patient is predominant even if illogical and harmful.
CENTRALITY OF THE PURPOSE AND RIGHT TO LIFE OF LIFE IN BIOETHICS - 4:· Proxy decision makers decide for incompetent patients, but conflicts arise for example the state may take away autonomy from parents who are not acting in the best interests of the child.
· Besides responsibility to the self, the patient has responsibilities to others (organ donation) and to society (being a clinical research participant).
· We may also encounter situations of physician autonomy vs patient autonomy when the physician refuses to treat a potentially violent patient.
CENTRALITY OF THE PURPOSE AND RIGHT TO LIFE OF LIFE IN BIOETHICS - 5:· Many ethical dilemmas relating to life are solved by fiqhi rulings, but the more complex ones require invoking ethical theories and principles.
· The definition of the moment of death arose with the use of artificial life support that gave rise to brain death as legal definition of death and the matter is still controversial.
· There is ethical pushback against biotechnology’s commodification of life that marginalizes the human dimension.
· Many decisions in terminal life require answering the ethical question who owns life? Basically, life belongs to Allah and the patient, or his proxy decision makers have temporary custody, and their decisions must conform to Allah’s laws.
CENTRALITY OF THE PURPOSE AND RIGHT TO LIFE OF LIFE IN BIOETHICS - 6:· Prevention and treatment of disease both pre-natally and post natally are part of Allah’s pre-determination and are not against it. In the ignorance of Allah’s pre-determination (qadar) we take all empirical measures based on available human knowledge with the understanding that in the end Allah’s will be done.
· Treatment of disease is a responsibility for the patient, the medical profession, and the state but it cannot be forced on the patient. Treatment procedures must consider the balance of the benefit/risk ratio at present and the future.
· Treatment of disease terminal illness aims at the quality and not quantity of life however we can reach a point of futility when we stop unnecessary interventions.
NOTES:· However, management of pain is never stopped because it is part of quality of life. There must be established a balance between pain control and social functioning that is compromised by sedative analgesics.
· Euthanasia and physician assisted suicide are prohibited because they are against the purpose of life.
· Abortion is prohibited except in cases of conflict between the maternal right to life vs right of the embryo.
· Low quality of life in congenital anomaly births does not justify abortion or withdrawal of life support.