Islam has a parsimonious and rigorously defined ethical theory of Islam based on 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. The Islamic principles are wider in scope and deeper than the European principles.
PURPOSES OF MEDICINE (ETHICAL THEORY)
Protection of ddiin, hifdh al ddiin:
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. 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.
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.
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.
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.
PRINCIPLES OF MEDICINE (ETHICAL PRINCIPLES)
The principle of intention, qa’idat
al qasd: The Principle of intention comprises several sub principles. The sub principle that each action is judged
by the intention behind it calls upon the physician 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.
The principle of certainty, qaidat
al yaqeen: Existing assertions should continue in force until there is
compelling evidence to change them. Established medical procedures and protocols are treated as customs or precedents. All
medical procedures are considered permissible unless there is evidence to prove their prohibition.
The principle of injury, qaidat
al dharar: 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. 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. 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.
A lesser harm is committed in order to prevent a bigger harm. In the same way 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 the course of combating communicable diseases, the state cannot infringe the rights of the public unless
there is a public benefit to be achieved. 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.
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. 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. 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 al 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.
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.
REGULATIONS OF MEDICAL PROCEDURES, dhawaabit al tibaabat
Medical treatment: Medical treatment may involve destruction (antibiotics,
cytotoxics, anti-metabolites, antagonists, antitoxins, and detoxification), replacement (hormones, fluids, electrolytes),
biological modification & modulation, psycho-active therapy, and supportive treatment (diet, rest, analgesia etc). It
is prohibited to use haram materials and najasat as treatment. What is prohibited as food or drink is also prohibited as medicine.
Exceptions are made in cases of dharuurat. Medicine taken orally does not nullify wudhu. Any medicine that is taken but is
not swallowed and is vomited out is considered like vomitus. Medicine given per rectum nullifies wudhu. Subcutaneous or intravenous
or intramuscular injections do not nullify wudhu unless there is extensive external bleeding. Any medicine taken orally or
rectally or any insertion of a scope will nullify saum.
Other treatments: Dua, ruqyah, tawakkul, and raja are spiritual treatments.
Immunization and other preventive measures are treatment before disease and are not denial of qadar. It is permitted to slaughter
on behalf of the sick taqarruban ila al llaah and to give the poor. It is prohibited to slaughter for the jinn and
the shaitan. Various traditional, alternative, and complementary therapies are permitted if they are of benefit. Other permitted
treatment modalities are irradiation, immunotherapy, and genetic therapy.
REGULATIONS OF PRFOFESSIONAL CONDUCT
Values, competence, and responsibility: The physician-patient is based
on brotherhood. The physician must maintain the highest standards of justice. He should also follow the following guidelines:
good intentions, avoiding doubtful things, leaving alone matters that do not concern him, loving for others, causing no harm,
giving sincere advice, avoiding the prohibited, doing the enjoined acts, renouncing greed, avoiding sterile arguments, respect
for life, basing decisions and actions on evidence, following the dictates of conscience, righteous acts, quality work, guarding
the tongue, avoiding anger and rage, respecting transgressing Allah’s limits, consciousness of Allah 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 Allah, and avoiding oppression or transgression against others. The physician should be professionally competent
(itiqan & ihsaan), balanced (tawazun), have responsibility (amanat) and accountability (muhasabat).
He must work for the benefit of the patients and the community (maslahat).
Informed consent: No medical procedures can be carried out without
informed consent of the patient except in cases of legal incompetence. 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. Consent can be by proxy in the form of the patient delegating decision
making or by means of a living will.
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 procedure in order for them to make an autonomous informed consent. Deception violates fidelity. If disclosure
will cause harm it is not obligatory. Partial disclosure and white or technical lies are permissible under necessity. Disclosure
to the family and other professionals is allowed if it is necessary for treatment purposes. Physicians must use their judgment
in disclosure of bad news to the patient.
Privacy and confidentiality: 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 death of the patient. In routine hospital
practice many persons have access to confidential information but all are enjoined to keep such information confidential.
Confidentiality includes medical records of any form. The patient should not make 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. Release is not justified without patient consent for the following purposes: education, research,
medical audit, employment ofr 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). It 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.
REGULATIONS ABOUT PROFESSIONAL MISCONDUCT
Abuse of professional privileges: Un-ethical research on patients is abuse of professional privileges. 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. It is also 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.
The physician-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.
Private mis-conduct derogatory to reputation, kharq al 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. Fraudulent procurement of a medical license, sale of medical licenses, and covering an unqualified practitioner
indicate bad character. 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.
Public professional mis-conduct: Physicians in
private practice must adopt good business practices. Halal transactions are praised[i]. An honest businessman is held in high regard[ii]. Leniency in transactions is encouraged[iii]. Full disclosure is needed in any transaction[iv]. Measures and scales must be fulfilled[v]. Bad business practices are condemned. There is no blessing in immoral earnings[vi]. Selling over another’s sale is prohibited[vii]. Cheating is condemned[viii]. Also condemned are financial fraud including criminal breach of trust, riba on
bills, fee splitting, bribery[ix]. Sale
of goodwill of a 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 can not be patented as an intellectual property. Physicians are entitled to a reasonable
fee as ajr al tabiib[x]. Medical fees cannot be fixed by government because the Prophet refused to fix prices[xi].