160202P - THE ISLAMIC THEORY AND PRINCIPLES OF ETHICS WITHIN THE GLOBAL ETHICAL DIVERSITY

Presented online at the Postgraduate Program organized by Prime Institute of Public Health (PIPH) held in Peshawar, Pakistan on 02 February 2016 by Professor Omar Hasan Kasule Sr. MB ChB (MUK), MPH (Harvard), DrPH (Harvard) Faculty of Medicine, King Fahad Medical City, Chairman of the Ethics Committee and the Institutional Review Board, Riyadh, Saudi Arabia.

Introduction:

• This paper presents a system of ethical theories and ethical principles developed and used in West Asia, South East Asia, and other parts of the Muslim world over the past 17 years. 
• A basic premise of this framework is that ethics is embraced fully within the ambit of the Law since Islamic law contains both positive law and moral law.
• Under Islamic law the legal and the moral are perfectly equivalent; every moral is legal and vice versa and every immoral is illegal and vice versa.

Methods:

• 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.

Purposes of the Law (maqasid al shari’at) 1: early beginnings

• The Law has 5 governing higher purposes that are its legal theory; they govern all details and branches of the Law.
• The 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. 

Purposes of the Law (maqasid al shari’at) 2: later development

• 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.
• 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.

The 5 Purposes of the Law = ethical 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.

The 5 Purposes of the Law = ethical theory, con't.

• Morality/religion, hifdh al ddiin; 
• Life and health, hifdh al nafs; 
• Progeny, hifdh al nafs; 
• Intellect, hifdh al ‘aq
• Resources, hifdh al maal. 

The 5 Principles of the Law (qawa’id al fiqh) 1

• The principles were developed by legal scholars from basic sources of the Law by inductive reasoning. They provide quick tools for reasoning out complex cases.
• They were formulated in a systematic way in the 19th Gregorian century in the Turkish Ottoman Legal gazette called Majallat al Ahkaam Aladliyyat. 
• These principles were detailed for commercial transactions; the challenge today is to develop them in detail for medical application.

The 5 Principles of the Law (qawa’id al fiqh) 2

• The principles help in resolving ethical dilemmas in which the purposes may be apparently contradictory such as prolongation of life in the intensive care unit (protection of health) that is prohibitively expensive ((protection of resources). 
• They also provide more detailed and specific guidelines on matters covered in general by the Purposes.
• Each of these principles has many sub-principles that cover the whole spectrum of ethical dilemmas.

The 5 Principles of the Law = Islamic ethical principles 1

• Under the principle of certainty of intention (qa’idat al qasd) actions are judged by their inner intentions and motivations and not by their external manifestations. 
• Under the principle of certainty (qa’idat al yaqeen) decisions must be evidence-based. 
• Under the principle of injury (qa’idat al dharar) the benefits (maslahat) of an action must out-weight its harm (mafsadat) and if the two are of equal worth the action is not taken. 

The 5 Principles of the Law = Islamic ethical principles 2

• Under the principle of hardship (qa’idat al mashaqqat) legal prohibitions are temporarily set aside in order to undertake actions that will preserve life.
• Under the principle of custom (qa’idat al ‘aadat) existing consensus guidelines standard operating principles should be followed because they have the force of Law. 

The 4 ethical principles vs the Islamic ethical principles

• The 4 principles of Beaumont and Childress are subsumed under one Islamic principle of preventing injury (qa’idat al dharar). 
• AUTONOMY: The patient has the right of autonomy because she/he has his best interests at heart and cannot willfully and knowingly take a harmful decision. 
• BENEFICENCE / NONMALEFACENCE: Robust rules for the balance of injury and benefit in cases of ethical dilemmas.
• JUSTICE: Assurance of justice prevents harm due to injustice. 

Conclusion and recommendations:

• Islamic Law has formulations comparable to international formulations that adequately cover the needs of ethical theory and principles in ethical analysis.
• Ethical analysis in Muslim countries/communities will be easier and more acceptable if approached from Islamic Law.

160202P - ETHICO-LEGAL ISSUES IN GERIATRIC DENTAL CARE

Presentation at the workshop on ‘Facing the challenges of the ageing society’ held at the King Fahad Medical City Small Auditorium on February 2, 2016, by Prof Omar Hasan Kasule Sr. Chairman of the Human and Medical Ethics Committee

HOLISTIC VISION

• Holistic care requires that dental needs are considered alongside other health problems. 
• Dental problems like other health problems increase with age. Systemic diseases are correlated with dental conditions in the elderly. Tooth loss for example was found associated with atherosclerosis. 
• The elderly are heterogeneous. Oral quality of life is associated with the personality traits of the elderly so we need to individualize. 
• Treatment of oral conditions in the elderly is associated with many medical, social, psychological, and financial barriers that have to be overcome. Barriers to dental care of the elderly exist in the protected environment of the care homes. 
• ADOH index measuring dental functioning of the elderly 

ACCESS TO DENTAL CARE

• The oral health of the elderly is poor with a high need for dental care as well as an unmet need for oral health and dental dare.
• Cognitive impairment in the elderly means they are less able to take care of their dental health which results in dental problems.
• The elderly in residential homes may not have access to dental care due to a shortage of staff and facilities. Elderly abuse by the neglect of their dental needs. 
• Doctors in rural areas assessed the dental needs of the elderly less often than their urban counterparts. The Elderly admitted to ED because of a lack of community dental care resources. 
• The elderly in Senegal face many dental problems with extraction being the only treatment available 

CONSENT

• Dental treatment like all medical procedures must respect the patient’s autonomy by means of informed consent. 
• The elderly are not able to make decisions on dental care because of cognitive impairment and Alzheimer’s. 
• Measures may have to be taken to enhance decision-making capacity 
• When the elderly lack the competence to make independent decisions regarding their dental care and proxy decision-makers may have to make decisions for them. 
• When not sure a formal test of competence must be undertaken. 

RISK VS BENEFIT CONSIDERATIONS

• Dental interventions carry higher risks for the elderly because of other concomitant problems. 
• Conservative minimal intervention strategies are needed. 
• Dental interventions for cosmetic effects may have to be limited. Simple measures such as rinsing may improve the dental health of the elderly   
• Professional dental care improves elderly dental health in the short term. 
• Functionally oriented treatment was more cost-effective than tooth replacement with artificial prostheses. 
• Education of home health care nurses on dental care improves their care for the elderly. The elderly need education about oral health and oral diseases.
• Concept of expected remaining life span?

CASE SCENARIO #1

An elderly patient with severe painful periodontal disease that prevents him from eating resulting in severe malnutrition refuses treatment for fear that doctors will pull out his teeth. All attempts at explanation to convince him to consent fail. Assessment by the psychologists shows that he is competent. The dentists decide to sedate and treat him against his wishes after obtaining consent from his wife.

CASE SCENARIO #2

An elderly dental patient able to eat properly and in good nutritional status came to the dental clinic and asked for cosmetic oral surgery. The doctor refused to say that resources were limited to those whose life in danger.

CASE SCENARIO #3

An oral surgeon examined an elderly patient and got permission to extract a dead tooth under heavy sedation. She discovered during the procedure that there was an extra tooth that needed extraction but he had not got consent for the procedure.

160213P - CONCEPTUAL and PHILOSOPHICAL READING of KITAAB AL TAHARAT: ISLAMIC GUIDELINES on PERSONAL and ENVIRONMENTAL HYGIENE as A BASIS for BUILDING A HEALTHY CIVILIZATION

Presentation at the Center for Civilization Bayero University Kano Nigeria held in Kano on 13th February 2016 by Professor Omar Hasan Kasule Sr., Professor at the Faculty of Medicine and Chairman of the Ethics Committee at King Fahad Medical City Riyadh Saudi Arabia

Intellectual of Knowledge by Joint Reading of the 2 Books: kitaab al wahy and kitaab al kawn:

• Islam is an intellectual miracle therefore it is everlasting until the Last Day because unlike physical miracles it cannot be destroyed.
• Integration of knowledge is combining the reading of the 2 books: kitaab al wahy and kitaab al kawn. 
• Integration emanates from tawhid, the central concept of the Islamic civilization. In the area of hygiene for example we have integration of the ritual and the physical.
• Islam is suitable for every place and very time, al islam salihu li kulli zaman wa makaan. This implies reading kitaab al wahy with the spatio-temporal dimension in mind. The principles are perennial but details of applications differ with place and time.

Methodological Approach of this Paper in Reading the Book of Taharat: Concept Formation and Natural Philosophical Analysis:

• Conceptual approach is forming concepts by putting together apparently different ideas and practices under a logical conceptual umbrella to enable understanding and reasoning. The concepts running throughout the book of taharat are (i) taharat = hygiene (ii) hygiene is linked to population health (iii) a healthy population is the basis of civilization.
• The philosophical approach is to read the book of taharat shall be read from the perspective of medical science which is a branch of natural philosophy. The reading shows that Islamic hygienic guidelines (i) pre-date modern scientific concepts of communicable disease transmission first formulated by Dr Robert Koch towards the end of the 19th century (ii) provide practical guidance on disease prevention.

Our Publications on Civilization:

• Books on civilization published by IIIT - (Link) http://www.iiit.org/Publications/English/tabid/177/Default.aspx 
• Books in brief and occasional papers on civilization published by IIIT - (Link) http://www.iiit.org/Publications/BooksinBrief/tabid/326/Default.aspx 
• Writings of Dr. Abdulhamid Abusulayman - (Link) http://i-epistemology.net/v1/abdul-hamid-a-abu-sulayman.html 

Definition of Civilization:

• Is civilization moral values or is it a material culture? 
• Civilization implies urbanization. Good hygiene is needed to maintain a large urban population. 
• A material civilization once established can be good or bad. The Qur’an described qariyat tayyiban associated with  peace and tranquility (16;112, 21:11) while the bad qariyat was associated with dhulm (4:75) and fasad (27:34, 11:102). 
• The two criteria for a good human civilization were mentioned in the dialog between Allah and the angels before the creation of Adam: corruption (ifsaad) and spilling blood (safk al dima) (2:30). Judging by these criteria human history has not passed the grade: periods of corruption alternate with periods of violence. It is a difficult call to identify one week or one month in human history free of war anywhere on the globe.
• The term civilization has been misused to discriminate and exploit those considered less ‘civilized’. 

Basics of a Civilization: Time Management and Hygiene:

• Time management and hygiene are the founding blocks of a healthy and civilized life.
• Water is the universal and best cleanser or purifier needed for proper hygiene.
• Wudhu (cleaning the exposed parts of the body) a minimum of 5 times a day has both ritual and physical dimensions.
• Wiping the head and neck.
• Nostrils (istinshaar & instinshaaq) and the mouth (madhmadhat).
• Wiping on shoes and socks.
• Ghusl (washing the whole body) also has both ritual and physical cleansing dimensions. The prophet taught at least one bath a week[1] preferably on Fridays.[2]

Personal Hygiene at the Dawn of the Islamic Civilization:

• Oral hygiene (siwaak and madhmadhat). 
• Saliva, su'ur
• Nasal hygiene (istinshaar & istinshaaq).
• Nail hygiene: Nails, adhfar.
• Scalp hair hygiene.
• Moustache and beard hygiene. 
• Body hair (armpit, pubic, and trunk) hygiene 
• Hand hygiene.
• Toilet hygiene (Istinjah).
• Circumcision, khitaan, for hygiene.

Environmental Hygiene at the Dawn of the Islamic Civilization:

• Water hygiene: classification of water according to cleansing ability.
• Sources of water: small and large quantities of water in relation to cleansing.
• Hygiene of food and drinks.
• Slaughter of animals (dhabh): ritual and hygienic aspects.
• Haram food and relation to food hygiene.

Toilette Etiquette, adab qadhau al haajat:

• The physical and ritual duality is involved.
• Measures to prevent spread of infection and protect the environment.
• Measures to avoid urinary contamination of the body and clothes.
• Measures to prevent urinary contamination of the environment.
• Measures of cleansing from urinary contamination.

Concepts of Taharat - 1: The Esthetic Dimension of Taharat:

• The excretory function is necessary but creates undesirable waste products.
• Esthetics as philosophy.
• Esthetics as empirical experience.
• Seeking taharat is natural.

Concepts of Taharat - 2: The Physical And Ritual Dimensions:

• The physical and ritual duality of taharat and najasat.
• The ritual-physical duality in hadith and ibadat.
• The physical-ritual duality in the dua at the start and end of wudhu.
• The physical-ritual duality in tayammum.

Concepts of Najasat- 1: The Physical (Biological and Toxicological) Dimension:

• Najasat and human disease.
• Najasat and environmental biological pollution.
• Najasat and toxic environmental pollution.
• Endogenous najasat.
• Excretion is a vital body process to get rid of waste products of metabolism that would cause toxicity if retained in the body or would result in breakdown of fluid and electrolyte homeostasis.
• Excretion also involves an important dimension of environmental protection. Some of the waste products are treated while inside the body to make them less toxic by the time they are eliminated to the external environment.

Concepts of Najasat- 2: Legal Implications of the Duality of Najs:

• The legal definition of najs reflects the duality of the material and the ritual/moral.
• Non-najasat material has to be cleaned because it could turn into najasat.
• The law has specifically defined what is najs and has cleared doubts about some materials by asserting that they are not najs.
• The definition of what material is najasat is what is harmful as can be shown by modern scientific research and this falls under the principle of fiqh ‘qaidat al dharar.
• The term najs is most often used to refer to the two main human excretory products: feces, ghait / al buraaz and urine, bawl aadami.

Concepts of Najasat- 3: Non-najs Material According to the Law:

• Human fluids considered najasat: dam, haidh, madhi, blood etc.
• Animal material considered najasat: Dog saliva etc.
• Derivatives of najasat material.
• The human is never considered najasat.
• Non-najasat human secretions.
• Non-najasat animal secretion.

The Link Between Civilization and Taharat:

• Hygiene is part of religion: Taharat = nadahfat= clean, and najasat = filth = unclean. 
• Historical depopulation due to communicable diseases.
• Plague epidemics wiped out European populations: 40% in 541-542, 30-70% in 1346-1350 (Wikipedia). 
• The Chinese plague of 1641-1644 helped end the Ming dynasty. 
• Cholera pandemics killed 23million 1865-1917. The 1918 flu pandemic (January 1918 – December 1920) infected 500 million people across the world, resulted in the deaths of 50 to 100 million (three to five percent of the world's population[3]), making it one of the deadliest natural disasters in human history. Killed more people than World War 1.

Research on Cholera - 1:

• In 2010, 18 States reported cholera outbreaks with a total of 41,787 cases including 1,716 deaths (case-fatality rate [CFR]: 4.1%). This exceeded the mean overall CFR of 2.4% reported in Africa from 2000-2005 and the WHO acceptable rate of 1%.[4]
• A total of 5600 cholera cases and 340 cholera deaths were reported between December 1995 and May 1996 (attack rate = 86.3 per 100,000 population). Cases were more likely to have drunk street-vended water and less likely to have drunk tap water in their homes or to have washed hands with soap prior to eating food.[5]

Research on Cholera - 2a:

• A survey during the period 1 January to 31 December 1996 found 302 children affected by cholera. The overwhelming majority (95 per cent) of the cases were among residents of the unplanned, densely populated areas of the city. The case fatality rate was 5.3 per cent. This unpleasant situation can be favourably reversed if urgent attention is paid to the provision of potable water to the unplanned, densely populated areas of Ibadan city.[6]

Research on Cholera - 2b:

• In 80 cholera patients were hospitalized and six died. Poorly developed water and sewage disposal systems, contact with sea water, consumption of fishery products and leftover foods were the main risk factors identified.[7]
• In order to prevent future cholera epidemics, there is need to introduce intervention measures that address the root problems of poor sanitation and unsafe water supplies.[8]

Research on Diarrhea:

• Global deaths from diarrhea of children aged less than 5 years were estimated at 1.87 million approximately 19% of total child deaths.[9]
• A significant proportion of diarrheal disease can be prevented through safe drinking-water and adequate sanitation and hygiene.
• Research on Washing Hands: A Study of 154 Mothers’ Washing Hands:[10]
• 64 (41.6%) usually washed their hands with soapy water in a container.
• 30 (19.5%) used soap and running water.
• 60 (38.9%) used only water, either running or in a container. 
• After cleaning an infant's perineal area, 60 (40.3%) used soap and running water and 39 (25.3%) used soapy water in a container, 48 (31.2%) used plain water.
• Before feeding infants, 47 (30.5%) washed their hands with soap and running water.
• Conclusion: hand-washing practices by mothers are poor. Extensive education of the public is required to reduce the risks of childhood infections associated with lack of hand-washing.

Hand Washing and Diarrhea:

• Hand washing promotion probably reduces diarrhea episodes in both child day-care centers in high-income countries and among communities living in LMICs by about 30%. However, less is known about how to help people maintain hand washing habits in the longer term.[11]
• The risk of diarrhea was significantly higher among children whose mothers did not wash hands with soap before food preparation, before feeding their children and after leaving the toilet. Factors significantly associated with diarrhea were: poor water handling, presence of clogged drainage near the house and breeding places for flies).. Hygiene and sanitation conditions within households were risk factors for diarrhea. This study revealed the feasibility of developing and implementing an adequate model to establish intervention priorities in sanitation.[12]

References:

1. Mukhtasar Bukhari Hadith No 502
2. Buloogh al maraam No 100 
3. "Historical Estimates of World Population". Wikipedia. Retrieved 29 March 2013.
4. Dalhat MM. Descriptive characterization of the 2010 cholera outbreak in Nigeria. BMC Public Health. 2014 Nov 16;14:1167.
5. Hutin Y, Luby S, Paquet C.. A large cholera outbreak in Kano City, Nigeria: the importance of hand washing with soap and the danger of street-vended water. J Water Health. 2003 Mar;1(1):45-52.
6. Falade AG1, Lawoyin T. Features of the 1996 cholera epidemic among Nigerian children in Ibadan, Nigeria. (J Trop Pediatr. 1999 Feb;45(1):59-62.)
7. Eko FO1, Udo SM, Antia-Obong OE. Epidemiology and spectrum of vibrio diarrheas in the lower cross river basin of Nigeria. Cent Eur J Public Health. 1994 Jun;2(1):37-41.
8. Usman A1, Sarkinfada F, Mufunda J, Nyarango P, Mansur K, Daiyabu TM. Recurrent cholera epidemics in Kano--northern Nigeria. Cent Afr J Med. 2005 Mar-Apr;51(3-4):34-8. 
9. http://www.who.int/mediacentre/factsheets/fs330/en/
10. Opara P, Alex-Hart B, Okari T. Hand-washing practices amongst mothers of under-5 children in Port Harcourt, Nigeria. Paediatr Int Child Health. 2015 Sep 24
11. Ejemot-Nwadiaro RI1, Ehiri JE, Arikpo D, Meremikwu MM, Critchley JA. Hand washing promotion for preventing diarrhoea. Cochrane Database Syst Rev. 2015 Sep 3;9:CD004265
12. Oloruntoba EO1, Folarin TB1, Ayede AI2.. Hygiene and sanitation risk factors of diarrhoeal disease among under-five children in Ibadan, Nigeria. Afr Health Sci. 2014 Dec;14(4):1001-11.

160411P - PRIMER OF ETHICS FOR THE MEDICAL PRACTITIONER

Presented at a grand round of the Pediatric Department of King Salman Heart Center on April 11, 2016 by Prof Omar Hasan Kasule Sr. Chairman of the Ethics Committee King Fahad Medical City, Riyadh

European ethical theories

• Utilitarian consequence-based theory (balance of good and bad)
• Obligation-based theory (moral obligations)
• Rights-based theory based on respect for human rights (individual rights)
• Community-based theory (community decides)
• Relation-based theory (family and physician-patient relations)
• Case-based theory (practical case by case decision)

European ethical principles (Beauchamp and Childress 1994))

• Autonomy (patient decides)
• Beneficence (bring benefit)
• Non maleficence (do no harm)
• Justice (equity vs equality)

Islamic ethical theory based on maqasid al shari’at

• Protection of Morality, 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 / resources, hifdh al maal

Islamic ethical principles based on qawaid al fiqh

• The Principle of Intention (actions are judged by the intentions behind them), qasd
• The Principle of Certainty (no action is taken in extreme uncertainty), yaqiin
• The Principle of Injury (medical intervention should cause no injury), dharar
• Principle of Hardship (in case of difficulty the usual legal restrictions are relaxed), mashaqqat
• The Principle of Custom or Precedent (follow usual procedures unless there is evidence to the contrary), urf

Major Issues in Ethics

• Autonomous informed consent
• Privacy and confidentiality
• Fidelity

Case scenario #1

A 90-year old in the intensive care unit with stage 4 widely disseminated cancer and multi-organ failure was told by the doctors that there was nothing they could do to reverse the course of the disease and that they could only provide symptomatic treatment. He asked to be discharged to die at home. His children objected saying that he needed complex nursing that they could not provide at home. He was finally admitted to a private hospice that provided palliative care at great expense.

Case scenario #2

A 30-year old patient of multiple sclerosis had 5 years before while in good health designated her husband as the decision maker. When she lost consciousness the doctors needed a decision whether to put her on life support. The husband who had by that remarried and lived in a separate house decided against life support because it would prolong her suffering. Her father intervened and decided for life support because that would be in her best interests.

Case scenario #3: 

A university professor with previous episodes of transient stroke had written a directive and had it witnessed that if he lost consciousness he would not like to be resuscitated. Years later he was brought to the hospital unconscious from head injuries sustained in a car accident. The doctors reading his directive in his shirt pocket decided not to resuscitate him but his wife insisted that he be resuscitated.

Case scenario #4: 

Doctors wrote a Do-not-resuscitate (DNR) order for an 80-year old grandmother with disseminated untreatable ovarian cancer. Her family objected vehemently when told of this decision and sought its reversal. Before the dispute was resolved the patient collapsed after an episode of acute pneumonia unrelated to her original condition. The nurses following the DNR order did not call the resuscitation team.

Case scenario #5:

A 70-year old man with advanced cancer and severe pain not responsive to morphia asked the doctor to kill him and save him from suffering. The doctor refused claiming that he could not commit illegal homicide. The doctor also refused to give the patient any advice about suicide. On the patient’s insistence the doctor agreed to stop hydration and nutrition to enable slow death.

Hint: withholding food and hydration is passive euthanasia

Case scenario #6:

A car accident victim in severe shock was wheeled into the emergency room with un-recordable blood pressure or pulse. The doctor did not declare death but against the insistence of family members refused to institute life support because he reasoned there was no hope. The patient was declared dead 1 hour later. The family threatened to sue the doctor.

Case scenario #7:

A 90-year old with multi organ failure and clinical signs of brain stem death was on life support occupying the last available bed in the intensive care unit because the doctors were afraid to disclose death to the family that had many vocal and angry members. However when 50 survivors from an air crash site were brought it, the doctors decided to withdraw life support from the old man to free up at least one ICU bed.

Scenario #8:

A police man died suddenly during a fight with criminals who were later arrested. The police authorities wanted to carry out a post mortem to determine the cause of death in order to charge and punish the criminals with homicide. Some members of the family objected to the post mortem on the grounds that it was against the shari’at. Other members supported the post mortem because of insurance compensation purposes.

Case scenario #9:

An intensive care unit doctor kept a brain stem dead patient on artificial life support to maintain the vitality of his organs until the arrival of the transplant team to harvest the heart and lungs donated by the patient while still conscious in favor of his cousin who was born with severe congenital abnormalities and would die without the transplantation.

160421P - PROFESSIONALISM AND ETHICS IN THE ICU

Presentation at the 7th Annual Conference of the Saudi Critical Care Society held at Burj Rafal Hotel Kempenski in Riyadh on April 21, 2016 by Professor Omar Hasan Kasule Sr. MB ChB (MUK), MPH (Harvard), DrPH (Harvard) Chairman of the Human and Medical Ethics Committee 

OVERVIEW

• Describe the theory and principles of medical ethics and how they integrate into clinical practice
• Define professionalism, its dimensions, and its assessment
• Discuss ICU practice from the perspective of the dimensions of professionalism

ETHICS AND PROFESSIONALISM-THE INNER AND OUTER DIMENSIONS

• Ethics and professionalism are closely inter-linked in good patient care but they come from different conceptual backgrounds. Both are difficult to define exactly. 
• In my view ethics is the inner dimension while professionalism is the outer dimension. Ethics is difficult to police but some consequences of lack of ethics can be detected
• Professionalism being an outer dimension would have been easy to police if it was easy to define.
• The relation between ethics (right vs wrong) and law (legal vs illegal) is complex and differs between the Islamic and Western perspectives. Is right = legal? Is wrong = illegal? How about exceptional circumstances (dharurat)?

MAQASID AL SHARI’AT AS THE MEDICAL ETHICAL THEORY 

• Preservation of morality (hifdh al diin)
• Preservation of life (hifdh al nafs)
• Preservation of progeny (hifdh al nasl)
• Preservation if intellect (hifdh al ‘aql)
• Preservation of resources (hifdh al maal)

PRINCIPLES OF MEDICAL ETHICS: Western perspective

• Principle of autonomy: the patient is the ultimate decision maker in all matters relating to medical care
• Principle of beneficence: all medical activities should aim at accruing benefit for the patient
• Principle of non-malefacence: medical procedures should not cause harm to the patient
• Principle of justice: delivery of medical care should be equitable

PRINCIPLES OF MEDICAL ETHICS (qawa’id al fiqh): Islamic perspective 1

• Principle of intention (qa’idat al qasd): all medical decisions are judged by the underlying intention (al umuur bi maqasidiha)
• Principle of certainty (qa’idat al yaqeen): medical procedures must be based on certainty i.e must be evidence-based
• Principle of hardship (qa’idat al mashaqqat): in case of necessity, normal rules are suspended (al dharuuraat tubiihu al mahdhuuraat)
• Principle of custom (qa’idat al ‘aadat): what is generally accepted as normal practice guidelines must be respected (al ‘aadat muhakkamat)

PRINCIPLES OF MEDICAL ETHICS (qawa’id al fiqh): Islamic perspective 2

• Principle of injury (qa’idat al dharar): the benefits of a procedure must exceed the side effects for it to be carried out 
• The principle of injury covers the principles of  autonomy, beneficence, and malefacence
• Autonomy = it is only the patient who can best protect his/her interests
• Beneficence = benefit (maslahat)
• Nonmalefacence = harm (mafsadat)

CASE# 1: 

ICU night nurses are stressed by having to work for 13 hours because they have to wait for day nurses to take over after the morning huddle and endorsement. Day nurses are stressed by being asked to give topics during the morning huddle. There is stress from CHABI and JCIA. There is daily stress from doctors, patients and their family. Due to these working conditions in ICU nurses are unable to concentrate on patient care due to the stressful environment.

CASE #2: 

Physician A called in for consultation assessed the patient and told physician B (the attending physician) that the patient needed ultrasound to rule out acute abdomen. Physician B quoting official hospital policy disagreed insisting that if acute abdomen is suspected general surgeons should be called in. Physician A suddenly started to raise his voice with high tone and shouting in front of the patient with all staff and patients and visitors watching. Physician A then left while physician B was thinking ‘this attitude is affecting me as a health care provider. Shouting and disrespecting me in my work place and I wonder, why he would do such attitude to me’

DEFINITION OF PROFESSIONALISM

• Professionalism is a topical issue in the practice and teaching of medicine. The definition of professionalism varies by place, time, and culture.
• Professionalism is defined as behaviors and attitudes. A fair level of agreement can be reached by physicians, nurses, and the public on tangible behaviors that constitute professionalism. 
• Professionalism is part of the social contract involving responsibility of the professional to society.
• In earlier times professionalism could be defined as a set of skills but today this is not possible
• It is easier to define professionalism negatively as professional malpractice and negligence. 

INTANGIBLES OF PROFESSIONALISM

• Behaviors are easier to observe and measure than are attitudes and other intangibles that are acquired by apprenticeship or experience, but which cannot be described in concrete terms. 
• Intangibles that can explain similar reactions by professionals to a situation without having to discuss or refer to a rule or code. The intangibles can almost be called ‘trade secrets’ or practical wisdom (phronosis). 
• Intangibles can be considered under the Islamic legal principle of custom, ‘urf, with various formulations such as: what is known as customary has the force of law, al ‘aadat muhakkamat (Majallat Article No 36)  and what is known customarily is considered an agreed condition among the practitioners of a profession like trade, al ma’aruf ‘urfan ka al mashroot shartan (Majallat Article No. 43 and 44). 

THE AMERICAN BOARD OF INTERNAL MEDICINE (ABIM) listing of 6 dimensions of good professionalism 

• Altruism
• Accountability
• EXCELLENCE
• Duty
• Honor and integrity
• RESPECT FOR OTHERS

THE AMERICAN BOARD OF INTERNAL MEDICINE (ABIM) listing of elements that erode professionalism

• Abuse of power and sexual harassment
• Conflicts of interest
• Professional arrogance
• Physician impairment
• Fraud in research. 

PROPOSED ISLAMIC FORMULATION OF THE BASIC VALUES OF PROFESSIONALISM

• Faith (iman)
• Consciousness (taqwat)
• BEST CHARACTER (AHSAN AL AKHLAQ),
• EXCELLENT PERFORMANCE (ITQAAN AL ‘AMAL),
• Strife toward perfection (ihsan), 
• Responsibility (amanat), 
• Self-accountability (muhasabat al nafs).

CAUSES OF STRESS 1: patient care

• Stress leads to job fatigue both physical and mental among all nurses not only those in ICU 
• ICU is stressful because of contact with patients in distress and provision of intensive care. 
• ICU nurses experience moral distress and burnout. Moral distress was not correlated to burn-out indicating they may have different causation. Burnout was correlated to anticipated turnover.
• DNR is a source of moral stress but it did not affect nurse performance. No passive and active change in nurse activities after implementation of the DNR decision 
• Physical demand was the most important stressor for nurses. 

CAUSES OF STRESS 2: staffing 

• Staffing relate to patient outcomes    and patient safety   
• Hour-compliant duty increased resident sleep quality and quantity as well as increased satisfaction 
• The implementation of mandatory 24-h, in-house, attending intensivist coverage was associated with earlier decision-making across a number of domains related to end-of-life care. Time from ICU admission to decision to withdraw mechanical ventilation and time to decision to change to do-not-resuscitate code status both were shortened by 2 days.

CAUSES OF STRESS 3: shifts

• High-intensity daytime physician staffing in the ICU was not significantly associated with lower mortality in a modern cohort .
• Night shift is expected to affect work performance but it was found that Night shift nurses well adapted to night work  , despite the high percentage of morning chronotypes, possibly due to their 8-h shift duration. Parental responsibilities may, however, influence shift work tolerance.

CAUSES OF STRESS 4: environment

• Employment and organizational issue contribute to nurse stress in ICU 
• The ICU environment (noise and workplace) is stressful
• Difficulty in finding a place to sit down, hectic workplace, disorganized workplace, poor-conditioned equipment, waiting for using a piece of equipment, spending much time seeking for supplies in the central stock, poor quality of medical materials, delay in getting medications, unpredicted problems, disorganized central stock, outpatient surgery, spending much time dealing with family needs, late, inadequate, and useless help from nurse assistants, and ineffective morning rounds 

COPING WITH STRESS

• Nurses cope today and leave tomorrow
• Nurses had the resilience to continue working in a stressful environment 
• 5-minute Minded fullness meditation before the shift was found useful 
• The addition of a dedicated service corridor works in the new unit for improving noise control and staff stress and satisfaction.
• Leadership style affects performance: whenever the nursing workload peaked, the determine and persuade styles were used.

RESPECT FOR OTHERS / CONFLICTS

• ICU nurses subject to bullying with weak preventive measures 
• Inter-professional communication to improve patient outcomes 
• Conflicts occur in ICU: team-family, intra-tear, and within the family. Some of the team-family conflicts non-rational.
• Nurse involvement in decision making protects against ethical conflicts 
• Stress and speed impact the research consent process? Informed consent for research in ICU: is it proper? . Can we have non consensual research . Pre-emptive consent 

REFERENCES:

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160423 - PHYSICIAN CONDUCT and MISCONDUCT

Presentation at an ‘Internship Day’ workshop Ibn Sina National College for Medical Studies, Jeddah on 23 April 2016 by Professor Omar Hasan Kasule Sr. MB ChB (MUK), MPH (Harvard), DrPH (Harvard) Faculty of Medicine, King Fahad Medical City

Values, Competence, And Responsibility - 1

• The physician-patient is based on brotherhood. The patient is a fellow human being in suffering and not an ‘object’ or a ‘case.’
• The physician should follow the following values in his professional work: good intentions, avoiding doubtful things, leaving alone matters that do not concern him, loving for others what she loves for herself, causing no harm, giving sincere advice, avoiding the prohibited, doing good acts, renouncing greed, avoiding sterile arguments, respect for life, basing decisions and actions on evidence.

Values, Competence, And Responsibility - 2

• Following the dictates of conscience, righteous acts, quality work, guarding the tongue, avoiding anger and rage, respecting and not transgressing God’s limits, consciousness of God in all circumstances, performing good acts to wipe out bad ones, treating people with the best of manners, restraint and modesty, maintaining objectivity, seeking help from God, and avoiding oppression or transgression against others.
• The physician should be professionally competent, balanced, have responsibility (amanat) and accountability. He must work for the benefit of the patients and the community. 

Medical Decisions - 1

• 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 their decision-making. 
• The patient must be free and capable of giving informed consent. Informed consent requires disclosure by the physician, understanding by the patient, voluntariness of the decision, legal competence of the patient, recommendation of the physician on the best course of action, decision by the patient, and authorization by the patient to carry out the procedures. 

Medical Decisions - 2

• Consent is limited to what was explained to the patient except in an emergency.
• Physician-assisted suicide, active euthanasia, and voluntary euthanasia are illegal even if performed after informed consent by the patient.
• The patient is free to make decisions regarding the choice of physicians and choice of treatments. Consent can be by proxy in the form of the patient delegating decision making or by means of an advance statement (advance directive, living will).
• 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.

Medical Decisions - 3

• Spouses and family members do not have an automatic right to consent. 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.
• 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 physicians of the burden of decision making and legal liabilities (c) relieving the family of the mental stress involved in making decisions about terminal care. 

Medical Decisions - 4

• The disadvantage of a living will is that it may not anticipate all developments of the future thus limiting the options available to the physicians 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 physicians 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.

Consent of the Incompetent - 1

• Competent children can consent to treatment but cannot refuse treatment. The consent of one parent is sufficient if the 2 disagree. Parental choice takes precedence over the child’s choice. Courts can overrule parents. Life-saving treatment of minors is given even if parents refuse. Parental choice is final in therapeutic or non-therapeutic research on children.
• Mental patients cannot consent to treatment, research, or sterilization because of their intellectual incompetence. They are admitted, detained, and treated voluntarily or involuntarily for their own benefit, in emergencies, for purposes of assessment, if they are a danger to themselves, or on a court order.
• Suicidal patients tend to refuse treatment because they want to die. 

Consent of the Incompetent - 2

• There are controversies about nutrition, hydration, and treatment for patients in a persistent vegetative state since the chance of recovery is low.
• There is no moral difference between withholding and withdrawing futile treatment.
• Labor and delivery are emergencies that require immediate decisions but the woman may not be competent and proxies are used. Forced medical intervention and cesarean section may be ordered in the fetal interest. Birth plans can be treated as an advance directive. 

Disclosure and Truthfulness

• As part of the professional contract between the physician and the patient, the physician must tell the whole truth.
• Patients have the right to know the risks and benefits of medical procedures in order for them to make an autonomous informed consent.
• Deception violates fidelity.
• If disclosure will cause harm it is not obligatory.
• Partial disclosure? White or technical lies?
• Disclosure to the family and other professionals is allowed if it is necessary for treatment purposes.
• Physicians must use their judgment in the disclosure of bad news to the patient. 

Privacy and Confidentiality - 1

• Privacy and confidentiality are often confused. Privacy is the right to make decisions about personal or private matters and blocking access to private information.
• The patient voluntarily allows the physician access to private information in the trust that it will not be disclosed to others.
• This confidentiality must be maintained within the confines of the Law even after the death of the patient.
• In routine hospital practice, many persons have access to confidential information but all are enjoined to keep such information confidential. 

Privacy and Confidentiality - 2

• Confidentiality includes medical records of any form.
• The patient should not make an unnecessary revelation of negative things about himself or herself. The physician can not disclose confidential information to a third party without the consent of the patient.
• Information can be released without the consent of the patient for purposes of medical care, for criminal investigations, and in the public interest.
• The release is not justified without patient consent for the following purposes: education, research, medical audit, employment, or insurance.

Fidelity

• The principle of fidelity requires that physicians be faithful to their patients. It includes: acting in faith, fulfilling agreements, maintaining relations, and fiduciary responsibilities (trust and confidence).
• Fidelity is not based on a written contract. Abandoning the patient at any stage of treatment without alternative arrangements is a violation of fidelity. 
• The fidelity obligation may conflict with the obligation to protect third parties by disclosing contagious disease or dangerous behavior of the patient. 
• The physician may find himself in a situation of divided loyalty between the interests of the patient and the interests of the institution. 
• The conflict may be between two patients of the physician such as when maternal and fetal interests conflict. Physicians involved in clinical trials have conflicting dual roles of physicians and investigators.

Abuse of Professional Privileges - 1

• Un-ethical research on patients is abuse of professional privilege. This usually takes the form of research without informed patient consent.
• 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. 

Abuse of Professional Privileges - 2

• It is illegal to get financial advantage from prescriptions to be filled by pharmacies owned by the physician. 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.
• Court action could be brought against a physician 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. 

Private Mis-conduct Derogatory to Reputation: Muru’at

• Breach of trust is a cause for censure because a physician must be a respected and trusted member of the community.
• Sexual misbehavior such as zina and liwaat are condemned. 
• Physicians can abuse their position by abuse of trust (eg harmful or inappropriate personal and sexual relations with patients and their families), abuse of confidence (eg disclosure of secrets), abuse of power/influence (eg undue influence on patients for personal gain), and conflict of interest (when the physician 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.

Business Mis-Conduct - 1

• Physicians in private practice must adopt good business practices. 
• Halal transactions are praised. An honest businessman is held in high regard.
• Leniency in asking for payment is encouraged especially when serving in poor communities. 
• Full disclosure is needed in any transaction. 
• Measures and scales must be fulfilled when dispensing drugs. 
• Bad business practices are condemned. There is no blessing in immoral earnings. Unethical competition is prohibited. Cheating is condemned. Also condemned are financial fraud including criminal breach of trust, fee-splitting, and bribery. 

Business Mis-Conduct - 2

• Sale of the goodwill of practice is allowed. Also allowed is agreement among partners that they will not set up a rival practice on leaving the partnership. Entering into a compact with pharmacists or laboratories involving fee-splitting and unnecessary referrals is not moral.
• Treatment regimens cannot be patented as intellectual property.
• Physicians are entitled to a reasonable fee. Medical fees cannot be fixed. They are based on mutual agreement between the physician and the patient.

Conflict of Interest

• A physician who at the same time is the manager of a for-profit hospital could be tempted to put the profit motive before good health care by cutting down expenditure on necessary treatment.
• An occupational physician may find himself fulfilling his professional duties to the patient and protecting the financial interests of his employer.

160428P - DEALING WITH PATIENTS OF DIFFERENT SOCIO-CULTURAL BACKGROUNDS

Presentation at a ‘Department Grand Round Topics’ Small Auditorium, King Fahad Medical City, Riyadh on 28 April 2016 by Professor Omar Hasan Kasule Sr. MB ChB (MUK), MPH (Harvard), DrPH (Harvard) Faculty of Medicine, King Fahad Medical City

INTRODUCTION: 2 Main Themes Of Cross-Cultural Interaction:

• All humans have the same biological and social origin. There are some minor biological, social, and cultural differences that are part of Allah’s scheme to make an interdependent world by enabling people to identify and know one another. These differences cannot be denied neither can they be misused for any other purpose other than for which they exist.
• Cross-cultural communication: We must understand socio-cultural variation among patients: age, gender, education, social class, and health-related behavior. These differences can create socio-cultural barriers to doctor-patient communication unless mitigated. 

Common Biological Origin:

• All human beings are from Adam. Modern discoveries about DNA and the molecular basis of life prove that there is a biological commonality that must have been caused by a common origin.
• Unity of humanity (wahdat al basahariyat) is based on a common biological origin.
• As far as we know all offspring of Adam are on planet earth. It is however possible that some of them live on some other planets; science has yet to settle this doubt.
• Although humans are from the same biological origin, there are observable differences among them. These differences coincide to a large extent with the geographical habitat in which they live. It is better to classify humans on the basis of ethnicity and not a race. The word race is non-scientific and is difficult to define and operationalize accurately.

Common Social Origin:

• Humans started as one family that of Adam. They were at one time one community or nation (ummat wadihat) but differences developed between them and they became many groups (p 152 5:48…42:8). Because humans all arose from one primordial civilization, we can detect many similar social institutions in people living in different parts of the globe.
• Differences in social organization arose as humans moved to live in different environments. The environment has a decisive effect on social life and social behavior. Social organizations and behaviors differ by the habitat: forests, deserts, and open plains.

Biological Similarities and Differences - 1:

• Biological similarities among humans: basic biological similarity among races: chemical, genetic (DNA), inter-breeding. The cell is the basic building block. There is specialization among cells therefore they differ in structure and some of their physiological functions. 
• Humans are a spectrum and not discrete groups with clear boundaries. Colors and physical features merge at the interfaces of human contact. 
• The Qur’an has talked about differences in skin color and languages (ikhtilaaf al alwan & ikhtilaaf al alsinat p 79 30:22) as well as differences in tribes and nations (ikhtilaaf al qabail & ikhtilaaf al shu’ub (p 79 49:13).
• The first major classification of humans is that based on gender. Males and females are different biologically, psychologically, and emotionally. These differences do not indicate superiority or inferiority. They are rather part of Allah’s scheme for a balanced society. The differences enable the man and woman to have specialized functions that complement one another. 

Biological Similarities and Differences - 2:

• Basic biological differences among humans: color, languages, races (Caucasian, mongoloid, negroid). These differences were created by Allah and did not arise as passive adaptations to the environment. There are gradations and different shades of color even within one race.
• Skin color is due to melanin and carotene. The darker races have more melanin. The mongoloid races have more carotene. Melanin protects the body from dangerous ultra-violet rays. Albinos are humans with a genetic defect that causes a deficiency of melanin; they have to wear eyeglasses or other protective body clothing to be able to walk in the sun.
• There is no pure race living on earth today. Humans have mixed a lot. DNA studies are likely to show this diversity of humans.

Social Similarities and Differences:

 Variations among humans can be at the ethnic, family, or individual level.

 Customs differ from community to community. Customs are ways of living followed by a great many people. They are transmitted from generation to generation. A custom starts when people find an easy and convenient beneficial way of doing something. Some customs come from religion. Some are short-lived whereas some continue for a long time. Customs is a factor of similarity within the community and factors of differences between communities.

 Language differences are among Allah’s signs. Allah created differences in languages. Languages change continuously as they adapt to different needs of communities.

The individuality of Every Person:

• Each individual has a unique biological and spiritual identity.
• Not all people will be the same even when given equal opportunities. Some individuals will achieve distinction because of: intelligence, special aptitudes, motivation, personality, and travel. These differences do not by themselves confer any superiority.
• The only true criterion of human excellence is taqwa and only Allah (SAW) can determine an individual’s level of taqwa.

What is Culture?

• Definition,
• Relativity,
• Underlying value systems and world view,
• Different is not the same as wrong,
• Non-western cultures including the Islamic one are holistic in outlook. 

Healthcare Worker’s (HCW) Respect for Other Cultures:

• HCW should be aware of his cultural values and avoid imposing them on others.
• HCW should avoid a stereotyped conceptualization of other’s cultural values it is better to ask rather than assume.
• HCW should respect the cultural values of the interviewee regarding disease definition, disease causation, and disease treatment and should build further communication on this understanding.
• HCW should identify cultural values and practices that can interfere with scientific medical treatment and try to find a midway solution.

Why HCW’s Fear Raising Cross-Cultural Issues:

• Fear of being called prejudiced,
• Feeling inadequate or inexperienced,
• Ignorance of the culture,
• Fear of misunderstanding,
• Fear of rejection,
• Uncertainty about patient’s cultural background (Lloyd and Bor p 89).

Advice on Cross-Cultural Communication:

• Be aware of your cultural values,
• Learn the cultural background,
• Learn which cultural differences affect treatment,
• Show patients, you respect cultural differences,
• Build on what is common between you and the patient,
• Be open-minded about unfamiliar cultural differences, 
• Accommodate cultural ideas if they do not compromise treatment,
• Explain you are not an expert in cultures (Lloyd and bor p. 89).

Cultural Do’s?

• Use open questions,
• Explore cultural differences only if necessary,
• Be honest about what is not clear to you,
• Show respect to cultural differences. (Lloyd and bor p.90)

Don’ts of Cross-Cultural Communication:

• retend to understand cultures unclear to you,
• Being judgmental, 
• Making assumptions,
• Assuming cultural issues are unimportant (Lloyd and bor p.90).

Common Mistakes in Language Use:

• Misunderstanding/misinterpretation of common terms and phrases,
• Technical vs common language,
• Formal vs colloquial language,
• Meanings of words determined by the local context,
• Words with different philosophical/conceptual origins and implications.
• Distorted translations by the family of official interpreters who say what they think the patient should have said.

Common Mistakes in Manner of Speaking:

• Speed of speaking vs speed of information processing: variation by gender, social class.
• A volley of questions with no time to digest and respond.
• Interviewer and interviewee speaking at the same time.

Common Mistakes in Body Language / Non-Verbal Communication:

• Eye contact,
• Touching

Dealing with the Family:

• Who speaks and decides for the patient?: individualistic vs communalist approaches

Reference:

• Managing the cross-cultural interview ‘advice on cross-cultural communication with patients’ in Lloyd M and Bor R (2nd edition) Communication Skills in Medicine. Churchill Livingstone London 2004.

160614P - ETHICO-LEGAL ISSUES RELATED to MALPRACTICE and MEDICAL NEGLIGENCE

Presentation at a ‘Grand Round of the Pediatric Department,’ of King Salman Heart Center, King Fahad Medical City, Riyadh on 14 June 2016 by Professor Omar Hasan Kasule Sr. MB ChB (MUK), MPH (Harvard), DrPH (Harvard) Faculty of Medicine, King Fahad Medical City

DEFINITION and DESCRIPTION

 Malpractice is failure to fulfill the duties of the trust put on the physician.

 Negligence is breach of duty resulting in damage or injury.

 Negligence defined according to the standard of care.

EXAMPLES of NEGLIGENCE 

 Treatment without informed consent

 False imprisonment or confinement

 Intentional infliction of emotional distress

 Defamation: slander if verbal and libel if written

 Abandonment of a patient

 Breach of confidentiality

 Negligent referrals

 Failure to warn about risks

 Failure to report a notifiable disease

 Professional errors that may be ordinary or extraordinary; harmful or non-harmful. 

BASIS of LIABILITY

 The physician owed a duty of care 

 The physician failed in that duty 

 The failure resulted in damage. 

MALPRACTICE SUITS: COURT PROCEDURE

 Filing a complaint by the plaintiff

 Serving a summons on the defendant

 Plea of guilty or not guilty by the defendant

 Discovery (lawyers for both sides collect more information)

 Opening statements at the trial by both sides

 Testimony and examination of witnesses, closing arguments, and judgment.

 The burden of proof of breach of standard of care lies with the plaintiff.

AVOIDING / PREVENTION of MALPRACTICE SUITS

 Obtaining and maintaining registration

 Sticking to defined professional standards of care

 Peer review, quality assurance, and use of protocols

 Defensive medicine and politeness with patients

 Conscience of all health care workers to make sure that mistakes do not occur.

 Well written records can be a defense for the physician. 

LEGAL TESTS FOR NEGLIGENCE I: The Boolam Case

 Boolam, a mentally ill patient, suffered fractures during electroconvulsive treatment. This type of treatment was accepted as a normal treatment for mental disorders at that time. The patient had consented to the procedure. When he suffered a fracture he sued in court. The judge ruled that doctors could not be found negligent if they acted according to a professional opinion accepted by a reasonable body of medical opinion even if there could exist a contrary opinion by another responsible body of medical opinion.

LEGAL TESTS FOR NEGLIGENCE II: The Boolam Case

 In a case of Bolitho, a patient who suffered brain damage because the doctor failed to intubate, the court ruled that doctors are expected to follow responsible medical opinion but would not be found negligent in cases in which that opinion did not stand up to logical analysis. The court thus set a principle that the court could over-rule medical opinion that was not logical in a specific case. The implication of this was that medical opinion was not the final arbiter of the standard of care to be used in defining negligence.  

CASE # 1

 A medical officer pierced the ear drum of a patient who protested loudly about the pain and eventually became deaf in that ear. A consultant who was standing by did not say anything. The patient sued both the medical officer and the consultant.

CASE # 2

 A medical officer by chance at the site of an accident tried resuscitation and failed. He was sued by the victim’s family.

CASE # 3

 A surgeon carried out an operation using a new technique unknown in the hospital but the patient recovered well with no complications.

CASE # 4

 A consultant at a dinner without seriously questioning the patient advised doubling the anti-coagulant dose. The patient died of hemorrhage the next day.

CASE # 5

 A physician forgot to prescribe an antibiotic for a patient with acute lobar pneumonia but the patient recovered uneventfully after one week.  

CASE # 6

 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.

CASE # 7

 A 45-year old mother of 5 grown up children had hysterectomy because of prolonged, heavy, and irregular menstruation. The surgeon took care to preserve the ovaries and therefore saw no need to put her on HRT. Three years later she had a hip fracture due to osteoporosis treated by hip replacement and she was started on HRT. Six months later she developed pain in the right groin and investigations revealed cancer of the ovary which had to be removed. Her daughter who was a nurse in the hospital argued her to sue the hospital for malpractice but she herself was not very sure of what had gone wrong.

CASE # 8

 An aspiring actor was advised by her media consultants to change her facial features in order to succeed in landing major and lucrative acting roles. She went to a doctor who advertised his cosmetic surgery services on the television and women’s magazines. She signed a consent form for surgery but did not see a notation in the footnotes that the operation was entirely at her own risk. Six months later and after a series of operations she was angry. Her face was asymmetric and her eye lids drooped. She asked for his license as a plastic surgeon. He told her he was a general surgeon who had interest in plastic or cosmetic surgery. With her career ruined she decided to take him to court.

CASE # 9

 A patient with epilepsy well controlled on drugs for the past 10 years, experienced a minor epileptic seizure. His physician increased the drug dosage and told him all would be well and that he could go back and resumes driving the school bus. The patient asked for an MC to explain his day’s absence to the manager of the school bus company.  The next morning the patient crushed the bus into a wall as he was driving it out of the garage. He explained that he felt sleepy at the time of the accident. 

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

by

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. 

CASE STUDIES OF USE OF MAQASID AND QAWA’ID 1

Case 1

In a measles mini-epidemic in the South of the city, the Ministry of Health orders vaccination of all children with no immunization records. A pediatrician living at the UM campus with non-school going toddlers refuses to take his children for vaccination arguing that the risk of vaccination complications was higher for his children than the risk of measles infection. 

Case 2

A mentally retarded Down syndrome youth aged 15 years had been to court several times for sexual attacks on toddlers. The judge ordered the doctors to suppress his sexual aggression by use of hormones and if that was not effective to remove his testes.

CASE STUDIES OF USE OF MAQASID AND QAWA’ID 1

Case 3

A urologist with 20 years’ experience in renal transplant refused to donate one of his kidneys to his identical twin brother who had found no other matching kidney. The Saudi Council for Health Specialties started de-registration proceedings for failure to give benefit obligatory on all physicians

Case 4

A new company in Riyadh advertised on TV and newspapers offering direct genetic testing services. Consumers would pay for a kit using a credit card and they would use the kit to collect a sample of blood by finger prick and send it back by mail. Results would be sent back after a week. 

CASE STUDIES OF USE OF MAQASID AND QAWA’ID 1

Case 5

In a bird flu epidemic, all citizens were advised to go during working hours to three immunization centers set up at the three university centers in the city: KSU, KSUHS, and Imam Muhammad Universities.it was made clear that the vaccination was not compulsory.

Case 6

A nurse manager has just discovered that his colleague, a surgeon, is HIV+ve, but has kept the information secret and continued operating on patients taking infection control precautions. An emergency case requiring immediate surgery is wheeled into the emergency room at midnight and there is no other surgeon available.

CASE STUDIES OF USE OF MAQASID AND QAWA’ID 1

Case 7

A 50-year old with 3 young wives complained of erectile dysfunction caused by his anti-hypertensive medication. When the government hospital refused to provide free Viagra he stopped his anti-hypertensive medication and suffered a stroke.

Case 8

An elderly patient with advanced esophageal cancer refused insertion of a nasogastric feeding tube and insisted on taking sold food that he could not swallow. He said he would prefer to die from starvation than accept the tube. The surgeons sedated him and inserted the tube without his consent and kept him under sedation so that he cannot complain

CASE STUDIES OF USE OF MAQASID AND QAWA’ID 1

Case 9

A 30 year old soldier with insulin dependent juvenile diabetes asked for free Viagra from a government clinic before his second marriage and was denied. He did not have enough money to buy the drug for himself. He claims that his first marriage was destroyed by erectile dysfunction

Case 10

A 20 year old drug addict in and out of rehabilitation centers for the past 5 years with no improvement asked for marijuana or any drug that would satisfy his craving to be given within the hospital so that he would not have to commit crimes on the streets to feed his addiction

IMPACT IN MALAYSIA

• Students and faculty from IIUM who moved to the Universiti Sains Islam introduced the Islamic Input program from IIUM with many modifications and improvements.

• The newly established faculty of medicine at the University of Brunei also adopted IIMC. 

• The Cyberjaya University College was established with a clear philosophy of integrating Islamic values in the curriculum but it followed a path different from that of IIUM. 

• Several other universities in Malaysia were interested in IIMC and held seminars and workshops although they did not formally adopt the system but in practice their Islamically-oriented staff included many Islamic elements in their teaching.

IMPACT IN INDONESIA 1

• The period 2004-2010 witnessed intense efforts in Indonesia to introduce elements of IIMC to Islamic universities that did not have it or to enhance it in universities that already had it. 

• Indonesia had a tradition of Islamic Universities, over 400 of them, that existed alongside Christian universities and therefore had a clear motive to articulate their Islamic ideology and identity 

• Indonesia had over 200 Islamic hospitals with an association called MUKISI having chapters all over the Republic. There was a clear interest in producing Islamically-oriented doctors to work in these hospitals. 

• Indonesian universities even government ones had more academic freedom than universities in other countries. 

IMPACT IN INDONESIA 2

• The Indonesian association of Islamic medical schools facilitated the introduction of IIMC in all its 16 members. 

• In the period 2005-2009 seminars on IOM were held almost on a weekly or monthly basis in major cities with enthusiastic participation by lecturers and students: Jakarta, Jogajkarta, Padang, Makassar, Malang, Semarang, etc. 

• Many faculties developed IIMC courses and offered them. 

• Books and journals were published. 

• Universiti Muhammadiyah in Jogjakarta even went to the extent of offering postgraduate programs in Islamic medicine. IMPACT OF IIMC OVERSEAS

IMPACT OUTSIDE SOUTHEAST ASIA 1

• The period 2005-2010 witnessed the rapid dissemination of IIMC in other countries through seminars and workshops organized by CIMCO and other organizations.

• Raphah International University and Peshawar Medical College in Pakistan adopted curricula with IIMC. 

• Several Bangladeshi universities were interested despite a strong secular tendency in the country that opposed anything Islamic. 

• IIMC was disseminated at workshops and conferences in Yaman, Kenya, Tanzania, Nigeria, Ghana, UK, South Africa, Egypt, Saudi Arabia, Jordan, Saudi Arabia, and Turkey. 

IMPACT OUTSIDE SOUTHEAST ASIA 1

• The dissemination of IIMC was targeted at faculties of medicine, Muslim hospitals and, Islamic medical associations.

• The Consortium of Islamic Medical Colleges (CIMCO) adopted IOM from its inception and has been encouraging its members to make progress in this direction with remarkable success. 

• It is commendable that efforts were made to produce books as a collaborative efforts of all brothers and sisters.

CHALLENGES TO IIMC

• There are two outstanding challenges to IIMC: (a) solidifying the Islamic conceptual background and (b) producing teaching materials. 

• Both challenges are related to one another because a conceptual base is needed for writing books. 

• The books once written will stimulate further thinking and conceptual development. 

CONCEPTUAL CLARIFICATIONS 1

• Work is needed to clarify basic concepts of what is Islamic medicine? 

• What are the attributes if an ideal Muslim physician? 

• How does Islamic medical practice differ from the standard practice? 

• What are Islamic ethico-legal rulings on modern controversial medical technologies?

CONCEPTUAL CLARIFICATIONS 2

• How can Islamic values be integrated in the already overloaded medical curriculum?

• How much of the Qur’an, hadith, and fiqh should a doctor know?. 

• We have so far had limited publications on these issues and more work is needed. 

• I am not disappointed because I know that good and lasting ideas take time to be shaped. Too much haste can lead to disappointments.

TEACHING RESOURCES

• Teachers of IIMC have few resources to refer to. 

• We need to set up mechanism for sharing and exchanging the few resources that exist.

• It will be only after accumulation of a lot of written material that we shall feel confident that IIMC is on solid ground.

FUTURE OF IOM/IIMC

• IIMC has a bright future because the increasing Islamization of Muslim societies, in minority and majority-Muslim countries, is creating institutions that need manpower to run them including schools, banks, insurance companies, hospitals and clinics. 

• The graduates of IIMC programs will be needed in the Islamically-oriented clinics and hospitals that are mushrooming all over the Muslim world. 

• Faculties of medicine therefore have a clear market segment to satisfy. This will also help guide curriculum development.

FUTURE MUSLIM HEALTH CARE INDUSTRY

• The future of IIMC and the Muslim Healthcare Industry (MHCI) is in my view brighter than even that of Islamic banking and finance. 

• MHCI is moving more slowly to allow deeper development of conceptual tools;

• MHCI has started with manpower training using IIMC.