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Islamic Medical Ethics in the Modern World

2 nd World congress on integration and Islamicisation of knowledge: Medical & Health Care Sciences . 21-23 Oct 2016 International Islamic University Malaysia (IIUM) Kuantan Malaysia. Islamic Medical Ethics in the Modern World. Dr. Mohamed Albar FRCP.

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Islamic Medical Ethics in the Modern World

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  1. 2nd World congress on integration and Islamicisation of knowledge: Medical & Health Care Sciences . 21-23 Oct 2016 International Islamic University Malaysia (IIUM) Kuantan Malaysia Islamic Medical Ethics in the Modern World • Dr. Mohamed Albar FRCP. • Medical Ethics Center International Medical Center • Jeddah, Saudi Arabia

  2. http://link.springer.com/book/10.1007/978-3-319-18428-9

  3. Definition of Medical Ethics • Ethics examines the rightness and the wrongness in human conduct. • Medical ethics is defined as “Analytical activity in which concepts, assumptions, beliefs, attitudes, emotions, reasons, and arguments underlining medico‑moral decision making are examined critically.

  4. Islamic Principles of Morality and Ethics in Islam 1. Intuitive Reasoning (al-fitra). • In every person there is an innate intuition that can guide him/her to right or wrong in, at least, the basic morals. • Killing an innocent person is repudiated and considered as an abominable, detestable crime, by all normal human beings. • The Qur’an extolled the unblemished innate nature in many verses.

  5. 2.Faculty of Reason (al-‘Aql) “There are signs for people who use their (minds)reason”.(Q. 16:1) • Human beings are endowed with the faculty of reasoning by which one can discern right from wrong. • This pure faculty could be enmeshed and lured by instincts and carnal desires. • All the vices will ensue if the carnal desires, egotism, arrogance, pride, hegemony, unsatiated desire for wealth and power, are not controlled by reason and revelation.

  6. 3. Divine Revelation (al-wahy, Tanzil): • God guides humanity by sending prophets and apostles, who are the bearers of the revelation. They are sent with a universal message from God, monotheistic faith in One God. • The Qur’an says: Say we believe in God, and His revelation given to us, and to Abraham, Ishmael, Isaac, Jacob, and the Tribes; and that given to Moses and Jesus, and that given to all prophets from their Lord. We make no difference between one and another of them; and we bow to God in submission (islam). (Q. 2:136–138)

  7. Islam is the religion that unites the entire humanity from Adam till doomsdayand considers all nations to have witnessed One God through the messages andteachings of their respective prophets: “There is no nation that was not given an admonisher”.(Q. 35:24).

  8. The value of Man We honored the progeny of Adam, provided them with transport on land and sea, given them for sustenance things good and pure, and conferred on them special favors above a great part of our creation. (Q. 17:70). And God said to the angels I will create on earth a vicegerent. (Q.2:30). • Respect of life: embryo, fetus, , newborn, child, adolescent ,and adult, male and female, of different creeds, colors and nationalities. • Respect of human dignity.

  9. The value of Man • Breaking the bones of the dead is equal in guilt to the breaking of the bones of the living (AboDa’ood, Al Behaaqi, Ahmed). • The Prophet who stood up in veneration for the passing by of a funeral of a Jew, at a time when Jews were waging war against him. One of his companions exclaimed: “It is only the funeral of a Jew”. The Prophet (PBUH) retorted: “Is it not a human soul?” (Sahih al-Bukhari, Kitab al-jana’iz).

  10. The value of Man • The unity of human beings is established in many verses of the Qur’an and the traditions of the Prophet. The value of a human being depends on his good deeds, and not on his wealth or position. “Oh mankind, We created you from a single (pair) of a male and female, and made you into nations and tribes that you may know each other. Verily the most honored of you in the sight of Allah (God) is he who is the most righteous of you”. (Q. 49:13)

  11. Islamic Law (shariah ) • Islamic Law : is a religious law of Islam derived from the Qur’an and the Sunna (The Tradition of Prophet Muhammad including his sayings, acts and approvals). • Islamic jurisprudence (al-fiqh) is a formulation of rules covering all human activity. In Islamic rulings acts are classified as obligatory, recommended, permissible, reprehensible, and forbidden.

  12. The Sources of Islamic Law • (a) The Qur’an: contains the revelation that the Prophet Muhammad received directly from God. It is the most authentic source of religious and moral directives that can be extrapolated to formulate judicial decisions touching all practical matters in everyday life of the community. • (b) The Sunna: consists of all the sayings, deeds and approved directives and prescriptions provided by the Prophet Muhammad, known as the “Tradition”

  13. The Sources of Islamic Law • (c)The Ijma’: is the consensus of the companions of the Prophet after his death on certain issues not found in the Qur’an and the Sunna. • (d) The Qiya’s: is analogical reasoning that allows the jurists to extrapolate fresh decisions from a case already known through the Qur’an or the Sunna. • (e) Maslah(unrestricted public interest and benefit): formulated by Maliki jurists on the basis of public and personal interests of the people. It was also accepted by other religious schools of Sunni jurisprudence.

  14. The Sources of Islamic Law • (f) The principle of ‘Urf or ‘A’ da: This is a major source of problem resolution that embodies considerations based on custom, tradition or local habits. This category includes all the professional codes and practices pursued by specialists in the field. • There are other minor sources.

  15. Al-Juwayni(d 478/1085) said: “The aims of Shari’ah are the interests of the entire humanity.” AlGhazali(d 505/1111) discussed al-maqasid under the public interest. Al-Tufi(d 716/1316) : public good fulfills the objectives of the teachings of God and His Prophet. Public interest is more important than what we might understand from original texts. IbnQayyimsaid(d 751H/1350) : “Al-Shari’ah is built on keeping the interests (masalih) of the people during this life and hereafter, built on justice, mercy, wisdom and interest of the creatures”. The Aims of Islamic Law(Al maqasid)

  16. The Aims of Islamic Religious Law • The cardinal essentials of Islamic teachings are: (1) Preservation of Faith (din) (2) Preservation of Life (al-nafs) (3) Preservation of Mind (al-‘aql) (4) Preservation of Progeny (al-nasl) (5) Preservation of Honor (al-‘irdh) (6) Preservation of Property (al-mal) • Anything that is deleterious to the above should be avoided, and anything that will preserve the above is meritorious and should be done.

  17. Legal Maxims: (QawaedAlfiqh) Examples: “That who practice medicine without due knowledge is liable”. “The person who inflict harm is liable even if he doesn’t intend to do it”. “difficulty brings ease” “confession brings liability” “ Rules of customs are similar to rules of agreement” “special guardianship is stronger than public one”

  18. “The general harm is worse than harm on one group or person.” “harm should always be removed” “ The lesser evil may be accepted to ward off the greater one” “Whatever becomes allowed for hardship, becomes prohibited if the hardship is relieved” Legal Maxims: (Qawaed Alfiqh)

  19. “Basics of Rulings” By Al Izz ibn Abdulsalam “The aim of medicine is to preserve health, restore it when it is lost, remove ailment or reduce its effects. To reach that goal it may be essential to accept lesser harm, in order to ward off the greater one, or lose a certain benefit to procure a greater one”. Aim of medicine

  20. Seeking Remedy 1.Obligatory (mandatory): a) Life saving situations. b) Infectious diseases that will endanger the community health e.g. T.B. c) Abstaining from therapy may endanger the life or health of the recipient e.g acute appendicitis. d) Mandatory immunization schemes for infants and children (proved benefit).

  21. 2.Remedy Encouraged and Preferred a) In all cases where therapy is likely successful, and harm from that mode of therapy is most unlikely. The Prophet Mohammed (PBUH) said: “O servants of Allah seek remedy, for Allah has not put an ailment except that he puts its remedy except one ailment”. They asked: what ailment? He said: “old age”. And in another Hadith he said: “death”. أخرجه الحاكم وأبو داوود والترمذي والنسائي وابن حبان وأحمد وغيرهم

  22. 3.Seeking Remedy not Preferred • Many companions (صحابة) refused therapy in their last illness, as they felt it would be futile e.g. Abubaker Assidiq: the 1st Caliph MuathibnJabal Abu Darda’a • There are few Hadiths that encourage abstaining from therapy (in such situations). حديث السبعين ألفا الذين لا يرقون ولا يسترقون وعلى ربهم يتوكلون. حديث المرأة السوداء التي كانت تصرع فقال لها: ”إن شئت دعوت الله لك و إن شئت فاصبري ولك الجنة“ قالت ”أصبر“

  23. 4. Seeking Remedy is Prohibited a) If it involves amulets (الرقية ) ،(التمائم ) (other than Quran), sorcery ( السحر ، الشعوذة ), divination (الكهانة والعرافة, or talismans الطلسمات) ). It encroaches on creed. b) Any medication made of liquor, or any intoxicating drink. c) Use of Pork or Porcine material. d) Killing animals e.g.. frogs etc.. And using them as medicine. e) Using blood. In life saving condition It will be allowed to use these substances and if there is no alternative medication. It should be prescribed by competent Muslim physician.

  24. Islamic jurists since the time of Abdulmalik Ibn Habib (died 236H/853 C.E.) who wrote a book on Tibbi Nabawi declared that: “ to practice medicine the Practitioner: 1) should be licensed by the Muhtasib that he has sufficient knowledge of his practice; 2) should obtain the consent of the patient or his guardian if not competent. If he has not fulfilled one or both then he is liable.” Consent & Liability

  25. If the Practitioner has fulfilled both of these criteria, and the patient died due to no mistake or negligence of the Practitioner, then the Practitioner is not liable. (Imam Shafi in his book Al Om vol.6/186) Consent & Liability

  26. “Legal permission negates tortious liability” is an Islamic Jurisprudence axiom, provided that the practitioner was not accused of negligence or departure from the standard care. This is stated by all Muslim jurists throughout history e.g. Shafi, Maalki, Abu Hanifa, Ahmed Ibn hanbal and their followers. Consent & Liability

  27. If the practicing Physician is well known and has all the required license, but on that occasion he made an unintentional mistake, which resulted in harm to the patient, then he should compensate the patient. Consent & Liability

  28. If an error is done unintentionally there will be only compensation (Tort). However, if the error is due to blatant negligence then disciplinary measures can be taken. Consent & Liability

  29. Islamic Medical Ethics • “If a person practices medicine without due knowledge, then he is liable” Abu Da’ood. • “No man is wise except through experience” AlBokhari & Muslim. • “Whoever guards the secret of a Muslim, Allah S.W. will guard his secret in this life and on resurrection day” Muslim. • “The religion (Islam) is sincere counseling and good advice” AlBokhari & Muslim. • “Do no harm” Abu Da’ood.

  30. Modern Ethical Principles • Modern Bioethics refused the paternalistic rules of Hippocrates and amalgamated both the utilitarian and Kantian deontology to formulate new rules. • The most accepted are those forwarded by Beauchamp and Childress known as the four principles: autonomy, nonmaleficence, beneficence and justice. • They are generally accepted but there are differences in the details of the rulings.

  31. Ethical Principles in Medicine • Respect for the autonomy of persons: respecting the self-determination of individuals and protecting those with diminished autonomy. “No compulsion in religion”. “Are you going to compel people to be Muslims?” • Beneficence:(الإحسان) giving highest priority to the welfare of persons and maximizing benefits to their health. • Non-maleficence(لا ضرر ولا ضرار): avoiding and preventing harm to persons or, at least, minimizing harm. • Justice : the medical services should be distributed justly through the whale community, nations and worldwide.

  32. End of Life Issues The First Resuscitating machine! • Ibn abiUsaibia (600-668 H/1204-1267 AD) mentioned in his book Tabakat Al Atiba that court physician, Salih ibn Bahla resuscitated the life of the cousin of Haroon Ar Rashid (149-193 H / 766 - 809 AD) by using bellows and a sniff called (El Kundus) through the patient’s nose.

  33. End of Life Issues Islamic View of Treating Terminal Illness (with holding & withdrawing) • It is not imperative on a Muslim to seek remedy, except in life saving situations, and where the illness is infectious and is going to affect the community. • The health authorities can impose certain measures like enforcing treatment or quarantine certain highly infectious diseases, for the safe guard of the community.

  34. End of Life Issues Islamic View of Treating Terminal Illness (with holding & withdrawing) • The rule of autonomy entails a competent major person who can decide for himself what is best for him. In pediatrics the parents or the custodian of the child usually takes the decision in the best interest of the child. The Qhadi (the magistrate) can replace a new custodian to act in the best interest of the child. The court in Kuwait enforced renal dialysis for a child suffering from renal failure despite the parent’s wishes.

  35. Fatwas allowing Withholding / withdrawing resuscitative measures • There are many Fatwas (legal Islamic Decisions) allowing withdrawal of all resuscitative measures when brain death is diagnosed. The respirator could be switched off, and any drugs given stopped. • The decision of diagnosing brain death is always a medical one and the ensuing ending of resuscitative measures should not be left to the family. It is a medical decision.

  36. Brain Death

  37. The Permanent Committee for Research & Fatwa, Fatwa No 6619 on 15/2/1404 (1983) Riyadh Q. If a person is on life support measures, but it was proved that his brain has stopped functioning irreversibly, is it permissible to remove the life supporting machines? A. In such a case, it is permissible to stop the life support machines, as he is considered dead. The movement of the heart and respiration are only through the machines working on a person with no life. But it is imperative to ascertain his death after lifting the life support machines, and before declaring death.

  38. The Council of The Islamic Fiqh Academy (OOIC) 3rd Session (11-16 Oct. 1986) Amman - Jordan Resolution No. 5 According to Sharia’h a person is considered dead, and all the Shariah rules regarding death become effective if he /she shows one of the following two signs: • Complete cardio-respiratory arrest and confirmation by physicians that such arrest is irreversible.

  39. Cessation of the brain activity and confirmation by physicians that such cessation is irreversible, and that the brain has entered the state of decomposition. • Under these circumstances the intensive care equipment supporting him can be stopped, even though some organs of his body, like his heart, continues to function with the help of the supporting equipment.

  40. Islamic Jurisprudence Council of Makkah Al Mukkarammah 10th Session (Oct. 17-21, 1987), Resolution No. 2 • The life supporting Equipment could be lifted from the patient whose brain functions have completely and irreversibly stopped, and has been decided by three Specialist Physicians, even though the heart and respiration are still functioning (with the help of machines). • However such a person will not be considered legally dead until his respiration and circulation stops irreversibly after lifting the life support machines.

  41. The Permanent Committee for Research and Fatwa, Fatwa No. 12086 on 28/3/1409 (1989) Questions on using resuscitative measure on the following cases: Q. 1. If a person arrives to the hospital already dead? A. 1. There is no need to use any resuscitative measure in such case. Q. 2. If the medical file of the patient is already stamped: Do not resuscitate, according to the patient’s will or his Proxy’s and the patient is unsuitable for resuscitation. A. 2. If 3 competent specialized Physicians agree that he is unsuitable for resuscitation, then there is no need of such measure.

  42. Continue Questions and Answers Q. 3. If 3 physicians have decided that it is inappropriate to resuscitate a patient who is suffering from a serious irremediable disease, and that his death is almost certain. A. 3. If the disease is irremediable and his death is almost certain, as witnessed by 3 competent Physicians there is no need to use resuscitative measures.

  43. Q. 4. If the patient is mentally or Physically incapacitated and is also suffering from stroke, or late stage cancer or having severe cardio pulmonary disease or already had several cardiac arrests. A. 4. If the condition of the patient is as prescribed, and the decision not to resuscitate has been reached by 3 competent specialist Physicians, then it is permissible not to resuscitate.

  44. Q.5. If the patient had irremediable brain damage after a cardiac arrest? • A.5. If the condition is authenticated by 3 competent specialist physicians, then there is no need for the resuscitative measures as these will be useless

  45. Q.6. If the treating Physicians decided that resuscitation will be useless in a certain patient, is it permissible not to resuscitate even though the patient or his relatives asked for resuscitative measures to be carried on. A.6. If resuscitative measures are deemed useless and inappropriate for a certain patient in the opinion of 3 competent specialist physicians, then there is no need for resuscitative measures to be carried. The opinion of the patient or his relatives should not be considered, as it is a medical decision and it is not in their capacity to reach such a decision.

  46. End of Life Issues • Islamic View of Treating Terminal Illness (with holding & withdrawing) • Similarly if the treating Physicians find a certain modality of treatment is useless or going to increase the suffering of the patient, that modality of treatment should not be enforced from the start. Simply that means with holding certain useless or harmful mode of treatment. The Prophet Mohammed (PBUH) says “ above all do non harm” and this rule of non-maleficence is the corner stone of all medical ethics.

  47. End of Life Issues • Persistent Vegetative StateKaren Ann-Quinlane 1975

  48. Baby K ( 1992 – 1994 ) Virginia USA court ordered life support for more than 2 years ,until his death .

  49. Persistent Vegetative State

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