Five issues in medical education: This paper discusses 5 conceptual
issues in medical education from the Islamic perspective: purpose of medicine and medical education, integration, balance,
service, and leadership.
The issues of purpose, integration, and balance: The purpose of medicine is to restore, maintain or improve the quality of remaining life. It cannot
prevent or postpone death because ajal is in the hands of Allah. The aim of medical
education is producing caregivers whose practice fulfills the 5 purposes of the Law within a holistic tauhidi context. Modern medical practice is fragmented by organ, disease process, and is not holistic. Islam can
provide an integrative tauhidi paradigm to replace the non-tauhid world-view that is atomistic, analytic, and not synthetic. In the absence of an integrating paradigm, modern
medicine lacks balance and equilibrium in its therapeutic approach. The Qur’anic concepts of middle path, wasatiyyat; balance, mizaan; equilibrium, i’itidaal, and action-reaction, tadafu’u, provide a conceptual
framework for balanced medical practice.
The issue of service: Medicine should be taught as a social service with the human dimension dominating the biomedical dimension. Medical
education should prepare the future caregiver to provide service to the community. This will require skills of understanding
and responding to community needs that can be acquired by spending part of the training period in a community setting away
from the high technology hospital environment.
The issue of leadership: The medical curriculum and experience should
be a lesson in social responsibility and leadership. The best caregiver should be a social activist who goes into society
and gives leadership in solving underlying social causes of ill-health. The caregiver as a respected opinion leader in close
contact with patients must be a model for others in moral values, attitudes, akhlaq,
and thoughts. She must give leadership in preventing or solving ethical issues arising out of modern biotechnology. She must
understand the medical, legal, and ethical issues involved and explain them to the patients and their families so that they
can form informed decisions. She should also provide leadership in advocating for the less privileged and provide leadership
in advocacy for human rights.
5 MEDICAL EDUCATION: CONTENT AND ISSUES
1.1 IMPORTANCE OF THE STUDY OF MEDICINE
Medicine is closely associated with all the 5 purposes of the Law (diin,
life, progeny, intellect, and wealth). Preservation of life and health is the second purpose of the Law. Good health is necessary
for fulfilling the first purpose of the Law, preservation of morality, diin. Preservation
of progeny, intellect, and wealth are also related to good health that is assured by medicine. Each community must have a
sufficient number of medically skilled people. Study of medicine is therefore a communal obligation, fardh kifayat.
The basic training sites of the health professional are the masjid, the school, the university, the hospital, and the community. The masjid
and the school are responsible for basic education and character formation. The university provides medical education. The
hospital provides practical training.
Methods of medical education are varied but include combinations of observation, reading,
discussion, and practice. The medical curriculum is divided into two parts: the pre-clinical and the clinical. Students learn
basic medical sciences in the pre-clinical phase. These sciences form the research base. They also provide a base for further
clinical studies. Clinical apprenticeship teaches practical skills.
In addition students should learn the basics and essentials of Islam, al ma’lum fi bi dharurat. They need to learn legal rulings, ahkaam
fiqhiyyat, relating to medicine to be able to give practical advice to their Muslim patients. They must acquire teaching
skills to be able to dispense health education to their patients. Knowledge of the social basis of disease provides all-round
view of disease and its treatment.
The process of education is continuous. A health professional either formally or informally
learns new things every day.
There are 5 conceptual issues in medical education from the Islamic perspective: purpose of medicine, purpose of
medical education, integration, balance, service, and leadership. These 5 conceptual issues in medical education are discussed
below from the Islamic perspective.
2.0 THE ISSUES OF PURPOSE, INTEGRATION, and BALANCE
2.1 THE PURPOSE OF MEDICINE:
Islam teaches a holistic view of medicine and medical treatment that includes the physical, psychological, social,
and spiritual dimensions.
Since health is the original state and illness is the exception, medicine must be health and not disease oriented.
The main responsibility of the health care giver is to maintain health. The ancient Chinese were nearer to our view of medicine
and the role of the health care giver. They paid their physician as long as they were in good health. Payments would be suspended
on falling sick. They would resume when the illness was cured.
Illness to a Muslim has its positive aspects and can be a blessing and a reason for expiation of sins. The trial
of illness is a source of much good for a believer. An incident case of illness should not be looked at in isolation. When
viewed in a larger context, illness or disease need not always be seen as bad. The Qur’an teaches that a human may like
something that is bad for him or may hate something that is good for him or her. Falling ill may save a person from going
where he would be hurt or where he could commit a sin. Patho-physiologically the symptoms of ill health are useful even if
people complain about them. Pain directs us to tissue injury so that corrective measures may be taken before the injury becomes
more extensive. Exhaustion and collapsing may be the body’s way of forcing us to take a rest when we are over-stressed
or overworked without adequate rest. Much of what manifests as disease are the body’s attempts to return to the natural
or normal state.
The ultimate cure of illness is from Allah. The attending physician must realize that his efforts will succeed
only if divine will intervenes and should therefore not be to arrogant. He should be aware that his efforts may either fail
From an Islamic point of view, the aim of medicine is to maintain or improve the quality of remaining life. Medicine
does not have as an aim the prevention of death or prolongation of life; the lifespan, ajal,
is in the hands of Allah the Almighty. Life on earth has a fixed and limited span and no one has the power to extend it even
for a brief moment.
Importance of quality of life is recognized by some physicians trained in the modern tradition but lacking an integrating
tauhidi paradigm, they fail to define this quality in a holistic way. Islam can
provide them with paradigms that enable them to pull everything together.
The Islamic Quality of Life Index (IQLI) should arise from the tauhidi
integrative paradigm and is a comprehensive measure involving social, psychological, physical, spiritual, and environmental
parameters. The quality of life is closely related to man’s understanding of the purpose of creation and the mission
of humans on earth. Life becomes degraded, hayatan dhankan, in the absence of this
The quality of life is also closely related to lifestyle. A good healthy lifestyle is associated with a higher
quality of life. A bad unhealthy lifestyle is associated with a low quality of life. Lifestyle is directly related to the
risk of physical and mental illness as well as the response or adjustment to that illness.
A healthy lifestyle is characterized
by: piety, generosity, charity, chastity, humility, trust, balance, moderation, patience, endurance, honor, dignity, integrity,
moral courage, and wisdom.
An unhealthy lifestyle is mainly a manifestation of one of the following diseases of the heart: polytheism, shirk; rejection, kufr; pride and arrogance,
takabbur; hatred and rancor, hiqd; envy,
hasad; anger and rage, ghadhab, hypocrisy,
nifaaq; miserliness, bukhl; and negative
thoughts, suu al dhann. These diseases sooner or later lead to either physical
or psychological transgression, dhulm, against self or others. Most human diseases
can be traced to this transgression. Epidemiological studies if interpreted in an objective way provide sufficient data to
relate ill-health to lifestyle and to quality of life.
2.2 PURPOSE OF MEDICAL EDUCATION
The Islamic paradigmatic approach to defining the purpose of medical education can be derived from the paradigm
of tauhid and the general theory of the purposes of the Law, maqasid al sharia. The majority of scholars concur that the following 5 purposes are protected by the law: (a)
religion, diin (b) life, nafs (c) procreation,
nasl (d) intellect, aql (e) wealth,
maal. Medical practice is intimately
involved with all 5 of them but most so with nafs, nasl, and aql.
Once the purposes of medical intervention are established, the aim of medical education should be to produce health
professionals who in their practice of medicine will fulfil the purposes or maqasid
within a holistic context to ensure harmony and equilibrium. Thus the medical education system should aim at producing
a health professional who will be health and not disease oriented, who will have the humility to know that he will exert his
best and trust in Allah to cure the disease. He will not have the arrogance to feel that he can prevent death but will strive
to improve the quality of life for people knowing that the Islamic index of the quality of life is derived from the holistic
tauhidi view: physical, spiritual, social, psychological aspects, and proper balance
among them. The health professional should in addition have the following practical and conceptual skills: understanding of
the society, epidemiological understanding of health problems, scientific capability, clinical expertise, and leadership.
These qualities must be in a context of faith, iman; tauhid, and fulfillment of the general purposes of the shari’at.
THE ISSUE OF FRAGMENTATION:
Modern medicine is characterized by narrow specialization and fragmentation. Health professionals know more and
more about less and less. The trend toward specialization in medical practice has strongly influenced medical educators to
diminish the practical content of the crowded undergraduate program and transfer some of it to post-graduate or vocational
training. A new graduate is therefore unable to treat a patient on his own until he becomes a specialist. Specialty practice
however has the great disadvantage of fragmenting patient care among several specialists such that there is no one practitioner
to care for the whole patient.
The following attempts have been suggested to overcome the problem of fragmentation: interdepartmental or inter-disciplinary
programs, integration of clinical and basic sciences, generalist and not specialist medical practice, vertical integration
(linking early with later years in the same discipline), horizontal integration (linkage between different disciplines), teaching
by organ systems, and using the problem-centered approach.
The concept of integration has been well accepted and propagated but not understood well when it came to practical
application. Attempts at integration are a response to a felt problem and are certainly a step in the right direction however
they have not solved all the problems; they even succeeded in creating a few new ones. Uncoordinated integration has succeeded
in producing a hypertrophic curriculum. There is pressure from each discipline to ‘integrate’ its material into
the curriculum. New disciplines such as genetics, statistics, epidemiology, demography, anthropology, and sociology are at
the door claiming their share of the undergraduate curriculum. New disciplines have been created to ‘integrate’
or bridge the gap between pre-clinical and clinical disciplines eg clinical biochemistry, clinical pathology, and clinical epidemiology. Interdisciplinary teams have been used as a tool of ‘integration’ in community
There are, however, defenders of a crowded undergraduate curriculum. They argue that students should be exposed
to all disciplines to enable them make informed choices about their future specialties. This reminds us of the story of an
’accomplished’ lawyer who knew a bit about every subject including law. The process of continuous additions to and pruning from the curriculum is going on and has been dramatically described as integration,
re-integration, and disintegration.
Fragmentation is a reflection of an underlying modern world-view
and did not come about in medical education by accident. This world-view started with the European renaissance when religion
was separated from public life and science. This set in motion centripetal forces that continually separate, fragment and
sub-divide. The body was separated from the soul. The mind was separated from the body. Science was separated from art in
medical practice. Each disease or organ was isolated and was dealt with in isolation.
It is not surprising that in a context of increasing fragmentation, the concepts of ‘total health’,
‘total disease’ are not easily accepted. It is not the ‘total human’ who gets sick but his organs
or tissues. It is however very surprising that Claude Bernard’s concept of a harmonious ‘milieu interieur’
and the appreciation of the biochemical unity of all life did not motivate practice of ‘total medicine’.
Some medical and nursing educators have recognized that fragmentation is a major problem and have set about attempting to achieve integration in medical
treatment and medical education. Some of these attempts were described above. Their limited success is due to lack of a guiding
Integration is not just putting two or more disciplines together. It is a fundamental philosophical attitude based
on a vision and a guiding paradigm. Only Islam can provide this paradigm. Criticism of the fragmented medical curriculum is
actually criticism of the underlying modern non-tauhid world-view. The
fundamental reason for failure of integration efforts is that the western world-view
is atomistic, it is good at analysis and not synthesis. It is incapable of synthesis because it lacks an integrating paradigm
2.4 THE ISSUE OF LACK OF BALANCE:
Lack of equilibrium is a secondary manifestation of lack of integration. A lot of
human illness is due to lack of balance and equilibrium; for example excessive intake of some foods leads to disease just
as inadequate intake leads to ill-health. The Qur’an calls for observing the middle, al wastiyyat. Violating the rule of the golden middle is associated
with many problems.
Ancient Muslim, Indian, Chinese, Greek medical systems understood the concept of
equilibrium. Modern European medicine lacks the concept of equilibrium or balance. It is replete with examples of overdoing
a good thing beyond the equilibrium point and creating even bigger problems. Some therapies are worse than the disease they are supposed to cure. The
quality of life of terminal cancer patients is made worse by chemotherapy and radiotherapy than the original disease perhaps
they could have been left to die in dignity. Pesticides were used to eradicate malaria but they led to human disease. The
best treatments of yesterday are known causes of malignancies today.
Some physicians trained in the western tradition recognize the problems of balance and integration but they cannot
propose a comprehensive solution because of lack of an underlying paradigm.
2.5 THE TAUHIDI PARADIGM, INTEGRATION AND BALANCE:
Tauhid is the main paradigm in Islamic civilization that forms a backbone of all intellectual discussion
of medical education. Tauhid al rububiyyat motivates the appreciation that there
is only one creator and that there is unity, harmony and useful interconnections
among different forms of life and the physical environment. Tauhid al uluhiyyat
motivates the appreciation that the Creator has definite purposes from creation
and that human life must fulfil those purposes. This implies that there are certain
laws that lead to a fulfilling life. Obeying those laws is associated with a healthy high-quality life-style. The tauhidi
paradigm implies integration and harmony of matter and soul, body and mind, parts and the whole.
The health professional should be trained to practice medicine as a total holistic approach to the human in the social, psychological, material, and spiritual dimensions and not an attack on particular diseases or organs. The example of the early Muslim physicians is worth emulating. They were well rounded in their education and their
practice of medicine. They were also integrated in the sense that their medical practice fitted in well with other social
activities. Al Qadhi Abd al Razaaq used to teach medicine and mathematics in the mosque in Bukhara until his death. Muwaffaq
al Ddiin Abd al Latiif al Baghdadi taught medicine in the Azhar mosque during his stay in Egypt.
Thus the context and the environment in which the teaching was carried out was integrative. It integrated medicine with the
mosque and worship.
The tauhidi approach to integration is putting medical knowledge, teaching
and practice in a larger context to making sure it is in harmony and is well coordinated with other related medical or non-medical
phenomena. It is therefore possible to envision a very ‘integrated’
doctor who at the same time is very specialized. Such a doctor will approach the patient as a whole human and not just as
organs or tissues.
ISSUE OF SERVICE
3.1 SPIRIT OF SERVICE
So far medical and
nursing schools have not been heroes of social medicine although there are projects here
and there that are successful and are laudable. In order for
these schools to face the challenge they will have to train students in such a way that
they internalize the values of social service. The Islamic paradigm of service requires that the health professional should be trained to understand medicine
as a social service. The human dimension should dominate over the biomedical one.
The selection of students, their training, and evaluation should emphasize human
service and not material gain for the health care givers. The school cannot be expected to effectively teach the spirit of serving others on its own. The values and attitudes of self-less service
for others are taught by the family and the community and are already well set by the time the student enters medical or nursing school. The school can only
build on and enhance basic values that students bring with them from their homes and communities. In such circumstances, the
school will do well to select those students who already have the vocation to serve.
3.2 ALLEVIATION OF POVERTY:
Material deprivation causes social and psychological stress in addition to the physical
impact of inadequate nutrition, housing, and sanitation. Socially conscious health professionals must be involved in programs to eradicate poverty and assure a reasonable standard of living. The
Qur’an calls upon society to look after the weak and less privileged: the widows, the poor, and the wayfarers. A Muslim must love for others what
he loves for himself..
The distinction between a faqir and a maskin is very significant. The former
is poor and is known to be poor so that aid can be extended. The latter is not known and he does not actively seek help. The
social services must have the ability to seek out those in need even if they do not come to them seeking aid.
Islam is a very practical religion. It has a culture of action and many of its teachings
are action-oriented. Islam does not only enjoins followers to serve others but has practical measures to ensure this occurs. Zakat is an obligatory
payment to the poor and the needy. The obligatory fasting of Ramadhan is training and inspiration for the rich to remember the poor because they voluntarily taste hunger and fully understand
the plight of the deprived. Many breaches of the law are expiated by kaffarat, normally
feeding the poor.
3.3 COMMUNITY-BASED EDUCATION:FOR THE MATERIALLY DEPRIVED
Medical schools have not been very successful in inculcating the spirit of self-less
service in depressed rural
or urban areas. Physicians and nurses are reluctant to serve in rural areas. It is argued that community-based learning will make the student more sensitive
to society’s problems. This makes sense since many of those who manage to make to medical or nursing schools are often from middle-class urban homes and have no contact with
the less privileged who live in rural areas or the urban slums.
3.4 COMMUNITY-BASED EDUCATION FOR THE MATERIALLY WELL-OFF
The disease profile and hence the pattern of medical care in Brunei and Malaysia
are changing with the rapid socio-economic development. The old diseases of poverty (parasitic infections, under-nutrition,
poor sanitation) are disappearing. New diseases due to an unhealthy lifestyle of the now richer population are appearing.
Over-nutrition, lack of exercise, substance abuse, stress, and psychiatric morbidity are on the increase. The old social and
psychological safety nets provided by the family are disappearing leaving many people lonely and vulnerable. Students of today will have to be trained to deal with the new patterns of morbidity. Medical and nursing schools will have to set up education projects in wealthy communities
of urban areas that were not traditionally involved in community-based programs.
3.5 PRIMARY HEALTH CARE:
Medicine is passing through a period of innovative approaches to
health care delivery. One of the most recent of these is the concept of primary health care (PHC) that essentially refers
to the first point of contact of a patient with the health care system. PHC can be simple in a rural area or quite sophisticated.
It does not have the connotation of second-class medicine.
The PHC strategy requires training a health professional who will
be able to do the following: respond to health needs and expressed demands of the community; work with the community so as
to stimulate healthy life style and self-care; educate the community as well as the co-workers; solve, and stimulate the resolve,
of both individual and community health problems; orient their own as well as community efforts to health promotion and to
the prevention of diseases, unnecessary sufferings, disability and death; work in, and with, health teams, and if necessary
provide leadership to sick teams;
continue learning lifelong so as to keep their competence up-to-date and even improve it as much as possible.
We can envisage medical education in the future taking place in primary care settings in both its simple and sophisticated
4.0 THE ISSUE OF LEADERSHIP
4.1 LEADERSHIP IN SOCIETY:
Islam teaches that everybody is a leader in one way or another. A health
care professional has a bigger leadership role than do ordinary persons. The best health care giver should be a social
activist who goes into society and gives leadership in solving underlying social causes of ill health. The health care giver must play the role of leader in the
community. He can lead when in the community and not the hospital. Inside the four walls of the hospital he or she acts as a technician and not a leader. The traditional medical school curriculum does not equip the future
health professional with leadership skills in the form of class room teaching
or actual field experience.
4.2 THE HEALTH PROFESSIONAL AS A MORAL MODEL:
The health care giver is a respected opinion leader therefore his
or her moral values, attitudes, akhlaq, and thoughts must be a model for others.
4.3 LEADERSHIP ON MEDICO-LEGAL AND ETHICAL ISSUES:
There is an increasing interest among Muslim physicians and fuqaha in
legal and ethical issues that arise due to recent advances in medical technology. The health
care giver is expected to give leadership to patients on ethical issues that arise out of modern biotechnology. He
must be trained not as a mufti who gives legal rulings but as a professional who understands the medical, legal, and
ethical issues involved and can explain them to the patients and their families
so that they can form informed decisions. In order to play this role well, the
future health professional must have some grounding in Islamic law and other
Muslim physicians, contemporary and ancient, did not write a lot about professional ethics in medicine because
they assumed that a Muslim society is ethical and is a protection against ethical
transgressions. However recent experiences in many countries have shown that
there are so many unethical conduct and that special corrective measures are needed.
Unfortunately medical and nursing curricula do not prepare the future health
professional to be a leader in ethics. They give information about ethics but cannot make a future health care giver
an ethical person. Ethics cannot be taught as an academic discipline. Ethics have to be internalized so that they may inspire and guide.
4.4 LEADERSHIP IN ADVOCACY FOR THE LESS PRIVILEDGED
The health care giver comes into contact with people suffering from various
physical ailments. He is acutely aware of the relation between illness and social handicaps such as poverty or discrimination.
He therefore should be sensitive to the social root causes of disease. He cannot therefore confine himself to treating disease
but must seek to remove the root causes by acting as an advocate for the less privileged.
4.5 LEADERSHIP IN ADVOCACY FOR HUMAN RIGHTSViolation of human rights is often a direct cause of physical
and emotional illness. It is part of preventive medicine that physicians are involved in efforts to ensure that all humans
enjoy their human tights.