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ISLAMIC MEDICAL EDUCATION RESOURCES-03

0206- PROFESSIONAL ETHICS OF MUSLIM PHARMACISTS

Lecture for 1st year Pharmacy students on 27th June 2002 by Professor Omar Hasan Kasule Sr.

MOTIVATION AND COMMITMENT

Motivation is based on commitment, ikhlaas. Highly motivated individuals have clarity of vision and objectives, energy, drive, self confidence, accepting responsibility, and accepting correction or criticism. These characteristics are not in-born; they can be cultivated and nurtured in any individual. Jannat is a positive motivator. Jahannam is a negative motivator. Motivation can be intrinsic (self motivation), extrinsic (rewards), or reactionary (not real and temporary).

 

Commitment, ikhlaas, was described in the Qur’an in several verses (2:139, 98:5). It is expressed in the intention, Ikhlaas al niyyat. Work is the consequence of the intention. Every work is rewarded according to the intention behind it. Every person is rewarded according to his/her niyyat. The amount of reward is commensurate with the niyyat. On the day of resurrection people will be resurrected with their niyyat. Any work without niyyat is not recognized. The niyyat must be constant and consistent throughout the whole period of performance until completion. Start must be early and serious. Work is best judged by its last stages. The best of work is that which is consistent and continuous. In all performance, the human performs that which he is capable of even if the niyyat envisaged more.

 

Work is a test for the human and is responsibility. The Qur’an emphasizes the importance of work (6:135 and 67:15). There is reward for work done (2:85). Humans have freedom to choice in the work that they do (4:66). Work can be good, ‘amal hasan or bad, ‘amal sayyi. Some people try to decorate bad work to make it appear good (6:108 &  47:14). Bad work s condemned and has a bad reward. Good work reflects underlying faith (38:24 & 103:2-3). It is rewarded in the hereafter (2:25 & 99:7) and on earth (16:97 & 24:55). Work must be performed with the purest of intentions. Everything including the various organs of the body bear testimony to good work (24;24 & 41:20). Allah knows all the work done (2:74 & 99:6).

 

Any form of showing off must be avoided. Riyaa is a type of minor shirk. Working for the purposes of showing off, riyaa, is frowned upon. Turning motivation into performance is a challenge. Performance is affected by the individual's capacity to perform, the willingness to perform, and being given an opportunity to perform. Job satisfaction is how well a worker likes the job. High job satisfaction is directly related to high motivation. The relation between level of motivation and success/achievement is not always linear. Motivation is low at the start of a difficult task when the feeling is 'why waste effort on project likely not to succeed. When the project gets under way and results begin to appear, motivation level is high because of concrete results realized. Motivation is low towards the end of the project when things are moving well. The feeling is 'why bother when all is going so well!'.

 

Many of the theories on motivation in the literature reflect the European world-view and would not be applicable to Muslims. Muslims find their motivation in their religion and their cultural heritage. Any approach to motivation that ignores this will not succeed. The Prophet (PBUH) taught that every human endeavor is an act of worship and charity. Thus a Muslim working knows he is worshipping his Lord and this is a powerful motivator in itself irrespective of any material gain. The concept of strife towards excellence, ihsaan, is a great motivator for a Muslim. A Muslim looks at the salary and other material benefits as a means to enable him feed, clothe, and house himself and his family so that he can devote his energy to the work. He does not look at them as a just return for his labor. His labor is worship and only Allah can recompense for it. There are aspects of Muslim character that affect motivation: sharaf (fear of losing face, shame for self and family), thawab (reward in the hereafter), karam (generosity), and wafa (fulfillment).

 

EARLY MUSLIM PHYSICIANS AS A MOTIVATOR

Ancient Muslim Muslims and pharmacists were encyclopedic and all-rounded. They would lead prayers in the mosque, go and research on medicine, and may be return to teach Qur’an. They were able to excel while they maintained their Islamic identity. Islam is not incompatible with excellence in science or medicine.

 

Abubakr Muhammad Bin Zakariyyah Al Razi (251-313H/865-923 CE) wrote more than 100 books the most famous being al Hawi al Kabir. He investigated diseases (gynecology, obstetrics, hereditary, eye, small pox, and measles), discovered surgical sutures, used anesthetics, used ammonia to control diarrhea, and considered psychological factors in disease treatment. He was director of hospitals in Baghdad Rayy.

 

Abu Ali Al Hussain Bin Abdillah Bin al Hassan Ibn Sina (370-428 H / 980 – 1037 CE) wrote many books the most famous being al Qanuun fi al Tibb. He recognized that TB was contagious, accurately described the symptoms of diabetes mellitus, and discovered ancylostoma. Besides medicine, Ibn Sina made contributions to science, mathematics, chemistry, and philosophy.

 

Abu Al Qasim Khalaf Bin Abbas Al Zahrawi (b. 912 CE, d. 404 AH/1013 CE) had interest in surgery, pharmacology, and anatomy. He designed over 200 surgical instruments. His book Kitaab al tasriif, became a standard textbook of surgery. He was an expert in cancer surgery and tooth extraction.

 

The family of Ibn Zuhr produced 6 consecutive generations of famous physicians the most famous being Abu Marwan Abdu Al Malik Ibn Zuhr (b. 1091 or 1094 CE d.487H / 1162 CE), who lived in Andalusia and Morocco and authored the book al Taysir translated into Latin and used in Europe.

 

Abu Al Waliid Muhammad Ibn Rushd (B. 1126 CE d.  595 H / 1198 CE) was interested in philosophy and also practiced medicine medicine. He wrote a medical work called al Kulliyat translated in Europe. He made the observation that smallpox infected only once. Alau Al Ddiin Abu Al Hasan Bin Abu Al Hazim Al Qurashi Al Dimashqi Ibn Al Nafees (d. 686H / 1288 CE) described blood circulation before William Harvey but this was not noticed in Europe. He authored Sharh tashriih al qanuun in which he explained pulmonary circulation

 

ISLAMIC ETHICAL THEORY AND ETHICAL PRINCIPLES

The ethical theory of Islam is found in the 5 purposes of the Law, maqasid al shari’at. The five purposes are preservation of ddiin, life, progeny, intellect, and wealth. Any medical action must fulfill one of the above purposes if it is to be considered ethical. Application of the above principles requires ethical principles. The basic ethical principles of Islam relevant to medical practice are derived from the 5 principles of the Law are: intention, qasd; certainty, yaqeen; harm, dharar, difficuly, mashaqqat, and precedent, aadat.

 

 

PROFESSIONAL MALPRACTICE

Malpractice is failure to fulfill the duties of the trust put on the pharmacist. The pharmacist is required to fulfil amanat and to undertake all the responsibilities of his profession. The term malpractice includes the legal concept of medical negligence.

 

Negligence is breach of duty owed to the patient resulting in damage or injury. Negligence is defined according to the customary standards of care that are established by the profession. There are many types of negligence such as breach of confidentiality, failure to warn about risks, failure to give proper instructions to the patient, failure to communicate properly with other professionals involved in patient care, poor sterilization, iatrogenic infections, drug reactions, and injections using the wrong site or the wrong route.

 

A pharmacist cannot practice unless registered or licenced. Licencing is based on education and practical training according to pre-set professional standards. A pharmacist should not do anything beyond the level of competence. He should never feel compelled to try what he or she does not know. Allah does not oblige a person beyond ability. Everybody should work according to ability (Bukhari K19 B18). The pharmacist should be prepared to be dismissed for refusing to do anything he considers un-ethical. He should be ready to blow the whistle on un-ethical behavior of their colleagues.

 

Legal liability is based on neglect of duty or delegation of work to unqualified persons, use of defective medications and medical devices. Once a job is started it must be completed. Work is assessed by its conclusion, al ‘amal bi al khawatiim (Bukhari K46 H11). The best of work is one that is continuous and lasting, khayr al ‘amal adwamuha (Bukhari K2 B32).

 

Pharmacy records are considered privileged communication with limited access and covered by privacy and confidentiality requirements. Documentation must fulfill the minimum requirements set by the Law. Records must be accurate, complete, adequate, clear, legible, and timely. Any tampering with or falsification of records is a serious crime. Whenever any change is made it must be done properly so that the original entry is still visible. Every entry must be dated and must be timed. The pharmacist may be found negligent with regard to disclosure based on considerations of breach of privacy, breach of confidentiality, breach of loyalty, and breach of contract.

 

Professional errors may ordinary and extra-ordinary and may be harmful or non-harmful. Compensation (dhamaan) for pharmacist errors arises when the pharmacist is not qualified, when the patient did not consent, and when the doctor is found to be negligent. There is still liability in erring while acting with good intentions, diyat al khataa. Court can award damages for personal injury, emotional distress, economic loss, death, breach of confidence. Protocols and guidelines can also be used to avoid mistakes. They define the standards of care expected.

 

Abuse of professional privileges can be by joining in un-ethical research on patients,  treatment and prescription errors, false documentation and certification, financial fraud, and breach of confidence. The pharmacist may be liable for causing iatrogenic infection by not following proper asceptic techniques or allowing an unlicenced person to performing professional tasks. Pharmacists must exercise care in dispensing controlled or harmful drugs. It is illegal to manufacture, possess, supply a controlled drug unless you have a licence for that class of drug. Prescription of controlled drugs must follow certain procedures. Diverting or giving away controlled substances is illegal. Control of hazardous substances/waste is a personal responsibility of the pharmacist. Sale of poisons is forbidden. It is forbidden to write prescriptions using secret formulas that only some pharmacists know is unethical.

 

Pharmacy fraud is committed by billing for medicine not delivered. It is illegal to get financial advantage from prescriptions to be filled by pharmacies owned by the physician. Kick-backs are unethical and are illegal. False or inaccurate documentation is a breach of the law. The pharmacist- patient relation requires that the physician keeps all information about he patient confidential. Breach of confidentiality can be done only in the following situations: court order, statutory duty to report notifiable diseases, statutory duty to report drug use, abortions, births, deaths, accidents at work, disclosure to relatives in the interest of the patient, disclosure in the public interest, sharing information with other health professionals, disclosure for purposes of teaching and research, disclosure for purposes of health management.

 

Breach of trust is a cause for censure because a pharmacist must be a respected and trusted member of the community. Sexual misbehaviour such as zina and liwaat are condemned. The pharmacist is likely to have arrogance because of his social prestige and social power. Showing off, riya, is minor shirk (Ahmad 5:428). Fraudulent procurement of a pharmacy licence, sale of pharmacy licences, and covering an unqualified practitioner are all indicators of a bad character. Abuse of trust includes inappropriate personal and sexual relations with patient and family. Abuse of confidence is disclosure of secrets. Abuse of power/influence is undue influence on patients for personal gain. The pharmacist is supposed to put the interests of the patients above personal interests. Inhumane behavior is forbidden. Abuse of drugs and alcohol and behavior unbecoming (indecent behavior, violence, conviction for felony).

 

With the commercialization of medicine in the form of private for profit hospitals and health insurance, serious business ethical issues have arisen in medicine. Patients became clients, customers, consumers, or purchasers. The concept of beneficence of the medical profession became replaced by business self-interest. The social function of the profession became replaced by the social function of business. The medical profession started looking at itself as a business. Market mechanisms were allowed to set medical priorities. Halaal business transactions are praised (Zaid H539, Zaid H540). An honest businessman enjoys high regard (Tirmidhi K12 B4). Leniency in transactions is required (Bukhari K34 B16). Full disclosure is required (Ibn Majah K12 B45. Measures must be fulfilled (Muwatta K31 H99). There is no blessing in immoral earnings (Darimi K20 B60). Unhealthy competition is forbidden (Bukhari K34 B58. Haraam and prohibited materials should not be sold (Ahmad 1:247. Cheating is condemned (Bukhari K34 B19). Also forbidden is financial fraud such as CBT, riba on bills, fee splitting, and bribing (Abudaud K23 B4). Special and secret arrangements between physicians and pharmacists to cheat patients are haraam. Charges must be reasonable especially for the poor. Promise of miracle cures is a crime.

Omar Hasan Kasule Sr. June 2002