Paper presented at the Kampung Baru Medical Center on 28th September 2002 by Prof Omar Hasan Kasule, Kulliyah of Medicine, International Islamic University, Kuantan. EM omarkasule@yahoo.com

Introduction: 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. 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


Historical background: Ethics have been part of medicine from the beginning. Some statements in the Hippocratic oath deal with professional medical ethics. Ibn Sina wrote about ethics. Concern with ethics in the past was not as intensive as it is at the moment. It was assumed that physicians would be ethical and moral in their work and this was true to a large extent because religiosity was a leading characteristic of life in the past. Towards the last quarter of the 20th century ethical considerations became a major concern for two reasons. The first reason is that developments in medical technology gave rise to problems such as life-support, in-vitro fertilization and others that had moral dimensions. The second reason was the increase in moral violations by medical practitioners. The medical profession found itself in a dilemma because moral values were not part of the secular medical curriculum. Secularism gradually encroached civil life Starting in the 16th century renaissance. By the 20th century, all aspects of European life including medicine had become secularized. The practical manifestation of this secularization was the marginalization of religious and moral values and confining them to the private arena of individual’s belief. When medical problems that required moral solutions arose, the medical profession and society at large were not ready to face the challenges. The positive secular laws that existed were deficient in resolving moral problems. It became necessary to develop secular medical ethics as a new discipline to deal with the challenges. Muslims did not face a similar dilemma because they kept their divine Law, shari’at, intact. Islamic Law, unlike European secular law, is based on a complete system of morality and can therefore handle all moral problems that arise in medicine from a legal perspective. It also is very flexible being adaptable to many new and novel situations. Strictly speaking Muslims do not need to talk of ethics as a separate discipline because it is already included in their Law.

European ethics: Ethics is defined as various ways of understanding and examining the moral life. The approach to a moral problem in medicine is determined by the background culture, philosophy of life and worldview. There are three European approaches to ethical analysis: normative or practical, and non-normative ethics. The normative is what ought to be done. Applied ethics is what most people do. It seeks to find practical solutions to actual problems without necessarily theoretical considerations. Non-normative ethics tries to establish factually what the actual situation is. Non-normative ethics is a description of what is going on. It may also be related to language, concepts, methods, and meanings. The European view of morality is very different from that of Islam. Europeans have a problem dealing consistently with moral issues after removing religion from public life over the past 4 centuries of secularism. Morality to them is communal consensus about what is right and what is wrong Beauchamp & Childress 1994). For example codes of professional conduct are a consensus reached within each profession. Government policies and guidelines also convey moral consensus reached within the political process. Court rulings and precedents also lay down moral values. Ethical guidelines can be developed while reasoning through ethical dilemmas (a situation in which there is good evidence for two opposing points of view). Ethical guidelines can also be developed while dealing with practical dilemmas for example when personal interest is in conflict with professional obligations or moral principles.
Islamic ethics: Morality and ethics in Islam are absolute and are of divine origin. Human consensus not deriving from divine legislation cannot be a source of binding ethical guidelines. All what humans do it to apply the legal and moral teachings of Islam to practical situations. European law and practice are very deficient when dealing with ethical issues. The law does not always and consistently follow morality. In Islam the law is the expression and practical manifestation of morality. European law does not have to permit all morally acceptable practices neither does it automatically ban all immoral activities. This contrasts sharply with Islam that automatically bans all immoral actions as haram and automatically permits all what is moral or is not specifically defined as haram. The issue of whether ethics are constant or not is irrelevant. The basic moral and legal principles are broad enough to encompass the needs of all times and places. The detailed applications change with the growth of science and technology. The Islamic approach to ethics is a mixture of the fixed absolute and the variable. There are fixed principles that set the parameters beyond which it is absolutely immoral to operate. Within these parameters, consensus can be reached on specific moral issues. The consensus may be in the form of a custom, ‘aadat, which in Islamic Law has legal force. Islam holds that ethics cannot be divorced from morality. Ethics can also not be divorced from Law. Islamic Law is a compendium of ethics, morality, and legal rules. The purposes of the law and its principles are therefore the basis of ethics. Islam holds that the human mind, unless corrupted by shaitan, is capable to working out rationally what is right and what is wrong for most problems of life. There are however a few gray areas for which moral reasoning needs to be guided by wahy to reach correct conclusions.


Islamic medical ethics: Islam considers medical ethics the same as ethics in other areas of life. There is no special code for physicians. What we call medical ethics is restating general ethical principles using medical terminology and with medical applications. The medical ethical codes can be derived from the basic law but the detailed applications require further intellectual effort, ijtihad, by physicians. Discussion of ethics brings into focus conflicts between rights and obligations. Rights may be positive or negative. Rights are correlated to obligations. Rights of one person may conflict with those of another one thus creating a moral dilemma. A human is free to enjoy his or her rights to the maximum as long as that enjoyment causes no harm to some one else, la yajuuz li sahib haqq al yasta’amila haqqahu fima yadhurru ghayrahu. Strange as it may sound, some ethical problems are solved by avoiding them. This is part of the Islamic teaching of avoiding doubtful thinks and being modest or restrained. The prophet taught us to leave what causes us doubts to what does not cause such doubt, da’ ma yuribuuka ila ma la yuriibuka (Bukhari K34 B2). Restraint, hayaa, is part of iman, al hayaa min al iman (Bukhari K2 B3). Haya is the morality of Islam, khulq al Islam al hayaa (Ibn Majah K37 B17). Hayaa is a decoration, al hayaa ziinat (Bukhari K60 B54). There are two basic models of moral justification: deduction and induction. Deduction is a top-down approach popular among Hanafi jurists in which a general principle is applied to to specific cases. Induction is a bottom-up approach in which each case is considered on its own merits. Induction relies a lot on analogy, qiyaas, Inductive processes involving many cases can lead to a generalization that is considered an ethical theory.


Principle of autonomy (intention): The principle of autonomy assures the patient of the right to make decisions on medical care. The basis of autonomy is legal competence, ahliyyat, that involves both liberty and capacity. Liberty is independence from any controlling external pressures that can influence or sway the decision. Capacity is the intellectual and physical ability to reach a decision. Autonomy is lost in cases of legal incompetence. The physician is not obliged to follow patient wishes if they involve doing illicit, illegal, or self-destructive acts. Informed consent is autonomous authorization of medical procedures and has 7 basic elements: 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 to carry out the procedures. As long as patients are conscious and are in full control of their mental faculties, they should be consulted about choice of physicians. Under informed consent the patient makes an autonomous authorization of medical intervention. The patient can withdraw this authorization at any time. Consent by proxy is possible by use of a substitute decision maker.

Principles of beneficence & non-malefacence: Beneficence, provision of benefits while limiting risk, is derived from the shari’at principle of harm, dharar. Beneficence is an obligation classified as fard ‘ain if there is only one physician in the community. The physician should not be paternalistic when discharging the duties of beneficence. Cost considerations and resource constraints may limit beneficence. Non-malefacence is defined as an obligation on the physician not to do harm. Not all cases of maleficence are due to failure of beneficence. Maleficence can present as professional negligence, double effect (ie harm done in the course of doing something good), euthanasia, and assisted suicide. The principle of non-malefacence is derived from the principle of harm, dharar. Non-malefacence takes precedence over beneficence according to the principle of the shari’at, dafi’u al mafsadat muqaddam ‘ala jalbi al maslahat.


Principle of justice: Justice means fair play, no unfair discrimination, and fair allocation of resources. Fairness, not the same as equal, is making sure that no human gets an advantage or disadvantage beyond due to attributes beyond human control. The principle of formal justice requires that equals be treated equally and unequals be treated as unequally in order to achieve equity.


Principles of patient-physician interaction: The patient-physician relation is brotherhood being guided by core values of commitment, loving good for others sincerity, respecting life, conscience, quality work, controlling the tongue, taqwa, good acts, avoiding anger, good manners, restraint, modesty, objectivity, avoiding oppression or transgression. The relation is based on 4 principles: veracity, privacy, confidentiality, and veracity. The principle of veracity entitles the patient to full disclosure by the physician. The principle of privacy assures the patient of the right to make decisions about personal or private matters. Under the principle of confidentiality the physician cannot confidential information obtained about the patient except to other caregivers and in courts lf law. Education, research, medical audit, employment and insurance inquiries are not considered situations of necessity that justify violation of confidentiality. The principle of fidelity requires that physicians be faithful to their patients, act in faith, fulfill agreements, maintain relations, and discharge fiduciary responsibilities (based on trust and confidence). Abandoning the patient at any stage of treatment without alternative arrangements is a violation of fidelity.

Omar Hasan Kasule September 2002