Make your own free website on Tripod.com
Home

ISLAMIC MEDICAL EDUCATION RESOURCES-03

0102-MANAGEMENT OF DISEASE, (TATBIIB)

Lecture for 3rd year medical students on 10th February 2001 by Professor Omar Hasan Kasule, Sr.

OUTLINE

 

1.0 PRINCIPLES and PURPOSES

A. Purposes Of The Law, Maqasid Al Shari’at

B. Principle Of Certainty, Yaqeen

C. Principle Of Injury, Dharar

D. Principle Of Hardship, Mashaqqat

E. Principle Of Custom, ‘Aadat

 

2.0 EXAMINATION AND INVESTIGATION

A. History

B. Clinical And Mental State Examination

C. Laboratory Investigations

D. Radiological/Imaging Investigations

E. Invasive Investigations

 

3.0 MEDICAL TREATMENT

A.  Destruction

B.  Replacement

C. Modification of Biological Response

D. Psycho-active

E. Supportive

 

4.0 SURGICAL TREATMENT

A. Resection

B. Restorative/Reconstructive

C. Replacement

D. Anesthesia And Critical Care

E. Emergency Treatment/Critical Care

 

5.0 OTHER TREATMENT

A. Spiritual treatment

B. Traditional, alternative, and complementary treatment

C. Irradiation

D. Immunotherapy

E. Genetic therapy

 


1.0 PRINCIPLES and PURPOSES

A. PURPOSES OF THE LAW, MAQASID AL SHARI’AT

PROTECTION OF RELIGION, hifdh al din

Protection of ddiin is 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, siyaam; pilgrimage, hajj, and jihad. A sick or a weak body can perform none of them properly. General public health has a special relation to jihad. If the general health of a population is not satisfactory, there will not enough youths to be recruited into the armed forces. There will also not be enough healthy workers to provide the material and logistics required for successful prosecution of war. If the obligation of jihad is not fulfilled, the Muslim community will be defeated and subjugated by others who will not give Muslims freedom to practice religion.

 

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.

 

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

 

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. 

 

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. The issue of opportunity cost and equitable resource distribution also arises.

 

 

B. THE PRINCIPLE OF CERTAINTY, qaidat al yaqeen

In both the diagnosis of disease and choice of treatment, modern medicine does not reach the standards of yaqeen demanded by the Law. Experimental therapies are used without certainty of the effect. In many cases a presumptive diagnosis is made and treatment proceeds. Treatment may be symptomatic where there is no clue to the cause. Certainty, yaqeen, as a situation when there is no shakk or taraddud, does not exist in medicine. Everything is probabilistic and relative. Treatment decisions are best on a balance of probabilities. It is however not true to treat medical decisions as educated guess work because they are based on careful analysis and balance of empirical evidence. They also reflect that medicine is still an art. The experienced physician accumulates sufficient clinical experiences that make his judgments nearer the truth. Some practical issues may arise due to lack of 100% certainty in medicine. When a diagnosis is made, it should be treated as a working diagnosis until new information is obtained to change it. This provides for stability and a situation of quasi-certainty without which practical procedures will be taken reluctantly and inefficiently. In this case we apply the principle of the Law that a certainty cannot be voided, changed or modified by an uncertainty, al yaqeen la yazuulu bi al shakk. When an assertion is an established truth, it should not be changed by a mere doubt being raised about all or some of its components. Existing assertions should continue in force until there is compelling evidence to change them, al asl baqau ma kaana ala ma kaana. A pathological or clinical event is considered of recent occurrence unless there is evidence to the contrary, al asl idhafat al haadith ila aqrab waqtihi. An acquired attribute or change is not accepted as normal unless there is compelling evidence, al asl fi al umuur al ‘aaridhat al ‘adam. An existing condition whose origin or cause is not known should be left as is until there is evidence to the contrary, al qadiim yutraku ala qadamihi. This principle protects against unnecessary medical interventions in long-standing anomalies or deformities that do not appear to cause any discomfort. Established medical procedures and protocols are treated as customs or precedents. What has been accepted as customary over a long time is not considered harmful unless there is evidence to the contrary, al qadiim la yakuun dhararan. All medical procedures are considered permissible unless there is evidence to prove their prohibition, al asl fi al ashiya al ibaaha. Exceptions to this rule are conditions related to the sexual and reproductive functions. All matters related to the sexual function are presumed forbidden unless there is evidence to prove permissibility, al asl fi al abdhai al tahriim.

 

C. THE PRINCIPLE OF INJURY, qaidat al dharar

Medical intervention is justified on the basic principle is that injury, if it occurs, should be relieved, al dharar yuzaal. The physician should however cause no harm in the course of his work according to the principle of la dharara wa la dhirar. Injury should be prevented or mitigated as much as is possible, al dharar yudfau bi qadr al imkaan. An injury should not be relieved by a medical procedure that leads to an injury of the same magnitude as a side effect, al dharar la yuzaal bi mithlihi. When an injury is found in a patient it is presumed to be of recent origin unless there is evidence to the contrary, al dharar la yakuun qadiiman. 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, dariu an mafasid awla min jalbi al masaalih. If the benefit has far more importance and worth than the harm, then the pursuit of the benefit has priority. Physicians 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, idha ijtama'a al halaal wa al haram ghalaba al haraam al halaaal. 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, ikhtiyaar ahwan al sharrain. A lesser harm is committed in order to prevent a bigger harm, al dharar al ashadd yuzaalu bi al dharar al akhaff. In the same way medical interventions that in the public interest have priority over consideration of the individual interest, al maslahat al aamat muqaddamat ala al maslahat al khaassat. The individual may have to sustain a harm in order to protect public interest, yatahammalu al dharar al khaas li dafiu al dharar al aam. IN the course of combating communicable diseases, the state The state cannot infringe the rights of the public unless there is a public benefit to be achieved, al tasarruf ala al ra'iyat manuutu bi al maslahat.

 

D. PRINCIPLE OF HARDSHIP, qaidat al mashaqqat

Medical interventions that would otherwise be prohibited actions are permitted under the principle of hardship if there is a necessity, dharuurat. Necessity legalizes the prohibited, al dharuraat tubiihu al mahdhuuraat.dharuurat. 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, al mashaqqa tajlibu al tayseer. This is predicated on the general principle of Islam as an easy religion that cannot be made difficult and a burden for its followers, al ddiin yusr wa lan yashaada hadha al ddiin illa ghalabahu. The law is relaxed in restrictive situations, al amr idha dhaaqa ittasa. The law is restrictive in lax situations, al amr idha ittas’a dhaqa. 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, al dharuraat tuqaddar bi qadriha. 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, al idhtiraar la yubtilu haqq al ghair. The temporary legalization of prohibited medical action ends with the end of the necessity that justified it in the first place, ma jaaza bi ‘udhri batala bi zawaalihi. This can be stated in al alternative way if the obstacle ends, enforcement of the prohibited resumes, idha zaala al maniu, aada al mamnuu’u. It is illegal to get out of a difficulty by delegating to someone else to undertake a harmful act, ma haruma fi’iluhu, haruma talabuhu.

 

E. 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, al aadat muhakamat. What is considered customary is what is uniform, widespread, and predominant, innama tutabaru al aaadat idha atradat aw ghalabat, and not rare, al ibrat li al ghaalib al shaiu la al naadir. The customary must also be old and not a recent phenomenon to give chance for a medical consensus to be formed.

 

8.5.2 EXAMINATION AND INVESTIGATION

A. HISTORY

Patients have to consent before their medical history can be taken otherwise the physician will be trespassing on privacy and may be accused of spying, tajassus. The permission to take history is needed even if a proxy such as a spouse or a parent volunteers the history. The same applies to information collected from previous records. Any information obtained from or about a patient is confidential and its unauthorized disclosure is a breach of confidentiality.

 

The purpose of history taking is to discover the social or personal antecedents of disease as well as the natural history of the disease. This involves considerable probing into personal life and privacy. It provides a golden opportunity for both physician and patient to face diseases of the heart, amraadh al qalb, that affect physical health. The diseases of the heart may be transgression, dhulm; neglect, ghaflat; loss of self-control and following passions (sex, drug, and alcohol-addiction). There is an opportunity for the physician to exercise the function of da’wah and for the patient to make repentance, taubat.

History taking is also an opportunity for discovery of legal complications such as foster relations that prohibit marriage, defective marriages concluded during ‘iddat. In complicated medical conditions, history taking may be an opportunity for discussing costs of medical care with the patient. The physician taking history may face a major ethical dilemma when in the course of taking history, the patient volunteers information about a criminal action that should be prosecuted. If the physician keeps the information to himself, he is not fulfilling the duty required of him as a citizen to report crime to the authorities.

 

B. CLINICAL and MENTAL STATE EXAMINATION

The issues of consent and confidentiality discussed above for history taking are also relevant to clinical or mental examinations. A patient can only be examined against his or her consent only if there is a necessity, dharuurat. The necessity may relate to the life of the patient or may be in public interest such as examining a suspected criminal for evidence about the crime. Mental patients can are not legally competent to give consent; the necessary consent could be obtained from a guardian, wali. Examination by a caregiver of the opposite gender requires special consideration. It is always preferable that physicians of the same gender carry out the examination. A physician of the opposite gender can be used only if a situation of necessity arises.

 

C. LABORATORY INVESTIGATIONS

PURPOSE

The purposes of laboratory investigation are to provide base-line information, establish a diagnosis, exclude alternative diagnoses, evaluate severity, plan treatment, and predict prognosis. Results of laboratory tests are used in the process of decision making at all stages of clinical management. Usually treatment is based a provisional diagnosis. The final or discharge diagnosis is confirmed towards the end of the disease episode.

 

TYPES OF INVESTIGATIONS

Modern medical science has placed at the disposal of the clinician. Hematological investigations are carried out for anemia, hemoglobinopathies, bleeding disorders, blood grouping, blood compatibility. Histopathological diagnosis described the pathological process and indications of possible initial insults. Microbiological investigations are  bacteriological, virological, and parasitological. Biochemical investigations include renal function tests, liver function tests, fluids, electrolytes, and acid-base balance. Genetic/chromosomal analysis is used increasingly in disease diagnosis. They pose a special problem because genetic findings in a patient give information about genetic make-ups of parents and siblings. Thus disclosure of the patient’s genetic findings may require in addition the consent of the relatives concerned. Biological markers are used in diagnosis and follow up of disease treatment the commonest being: HCG for trophoblastic tumors & hepatocellular carcinoma; AFP, HCG, HBD, PLAP for germ cell tumors; CEA for GIT tumors, CA125 for ovarian cancer; PSA for prostate cancer; CA and S-3 for breast cancer; and SCC for skin cancer. The results of laboratory investigations have the same requirements for confidentiality as history and clinical examination.

 

D. RADIOLOGICAL/IMAGING INVESTIGATIONS

Radiological investigations reveal a lot of information with minimal invasion. The commonest are: X-ray, MRI, ultra-sound, radio-imaging examinations. The results of radiological investigations are confidential. Images that show the shape of the body parts can be considered showing awrat and should not be seen except by authorized people only and for specific purposes.

 

E. INVASIVE INVESTIGATIONS

Invasive investigations carry a higher risk to the patient; their benefits should be carefully weighed against the benefits. The commonest investigations are: endoscopy (GIT, Colposcopy, peritoneal), coronary angiography, biopsy, autopsy, and diagnostic laparatomy. These investigations should be carried out only if there is a clear necessity, dharuurat.

 

3.0 MEDICAL TREATMENT

A.  DESTRUCTION

Antibiotics destroy disease-causing organisms. Cytotoxics destroy altered and abnormal tissues. Anti-metabolites and antagonists interfere with metabolic reactions. Antitoxins bind with and remove abnoxious agents, living and non-living. Detoxification is involved in rendering harmless any substances that are harmful to health.

 

B. REPLACEMENT

Hormonal replacement therapy is used for a variety of conditions. Some therapeutic approaches stimulation natural secretion of deficient hormones. Fluids and electrolytes are replaced as part of supportive therapy.

C. BIOLOGICAL MODIFICATION & MODULATION

Modification of biological response by products such as interferons is a novel approach to therapy that carries the risk of fundamental imbalances in homeostasis.

 

D. PSYCHO-ACTIVE

Psychoactive treatment aims at symptom control, a reflection of the primitive stage of our understanding of psychiatric diseases. With more research the organic basis for most of these diseases will become clear. Drugs can be used to make major alterations in brain biochemistry. Besides drugs the following approaches can be used in treating mental conditions: reciting the Qur’an, dua, dhikr, and tadabbur al Qur’an.

 

E. SUPPORTIVE

Diet and rest are time-tested measures of supportive treatment. Fluids and electrolytes are a form of supportive treatment. Nutritional support can be enteral or parenteral. A patient cannot be forced to eat or drink, la yukrahu al mariidh ala al ta’am wa al sharaab (KS 505). The patient should be given any food that they like, idha ishtaha marridh ahadukum shai’an faliyuti’imuhu (KS 505). Some food should be avoided, ma yajibu tajannubuhu min al ta’am (KS 506). However if the patient’s desires are judged harmful to health, he should be advised. If he persists an assessment of his legal capacity is made. If found legally deficient, forced feeding may be instituted according to the physician instructions. Nothing can be done for a competent patient. Monitoring of nutrition is by  diet charts, anthropometric, hematological, and biochemical assessments. Exercise has an important role in disease management. The best medicine is walking, khayru ma tadaawaytum bihi al mashyu.

 

4.0 SURGICAL TREATMENT

A. RESECTION

Surgery can be curative or palliative. The physiological response to surgery involves the  sympathetic nervous system, the endocrine, and the vascular systems. The reactions can be acute phase response or may be delayed.

 

B. RESTORATIVE/RECONSTRUCTIVE

Plastic surgery is used to close wounds that fail to heal. Hand plastic surgery is carried out for  reconstruction, reduction, and augmentation of hand function. Cosmetic surgery is undertaken for purposes of beautification or restoration of normal appearance.

 

C. REPLACEMENT

TRANSPLANTATION

The kidney and the heart are the main organs involved in transplantation. A major problem is rejection that may be hyperacute, acute, or chronic. Pre-operative HLA tissue typing & post-operative immune suppression prevent rejection. The ethical issues of transplantation have been discussed elsewhere.

 

TRANSFUSION

Transfusion is a now a very common procedure. There are several types of transfusion:: RBC transfusion, plasma substitutes transfusion, and platelets transfusion. The problems of transfusion are immune complications & transfer of infection.

 

D. ANESTHESIA and CRITICAL CARE

The following pre-operative tests are routinely carried out: Biochemical, CBC, CXR, HIV, ECG. Clinical assessment of risk for surgery involves assessment of the cardio-vascular system and the respiratory system. Endocrinal disorders such as diabetes mellitus have to be assessed because they can cause complications during and after surgery. Pre-medication is using drugs to allay anxiety, anxiolytics; dry internal secretions; and control pain, analgesia. General anesthesia starts with induction of anesthesia before start of surgery. Once stability is achieved, the role of the anesthetist becomes maintenance. At the end of surgery, there is reversal and recovery. Local anesthesia is achieved by local infiltration, field block of nerves, and spinal, epidural, para-vertebral anesthesia. The operating theater must maintain an antiseptic environment to prevent infection. Attempts must be made to minimize inappropriate mixing of male and female health care personnel in a small confined space.

 

E. EMERGENCY TREATMENT/CRITICAL CARE

Emergency or critical care is needed in situations of respiratory failure, multiple organ failure, cardiac failure, and circulatory failure / shock. Respiratory failure or adult RDS is sue to sepsis, trauma, emboli, severe head injury, aspiration, near drowning, irritant gas or chemical, drug overdose, liver failure, transfusion reaction, and diabetic keto-acidosis.

Cardio-respiratory support consists of mechanical ventilation after intubation and arterial gas monitoring. Ethical problems arise in the triage of patients under pressure of time and making decisions on who gets priority treatment. Financial considerations complicate the picture when destitute patients who cannot pay present at the emergency room.

 

5.0 OTHER TREATMENT

A. SPIRITUAL

 

B. TRADITIONAL, ALTERNATIVE, and COMPLEMENTARY THERAPY

Blood-letting in Ramadhan, hukm al haajim wa al mahjuum fi ramadhan (KS 333)

 

C. IRRADIATION

 

D. IMMUNOTHERAPY

 

E. GENETIC THERAPY

Professor Omar Hasan Kasule, Sr. February 2001