starts by presenting the ethico-legal basis of medical practice that is inn the form of maqasid
al shari’at and qawa’id al shari’at.
1.0 PURPOSES OF THE LAW, maqasid al shari’at,
PROTECTION OF DDIIN, hifdh al ddiin
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. 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
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.
PROTECTION OF PROGENY, hifdh al nasl
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.
1.4 PROTECTION OF THE MIND, hifdh al ‘aql
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
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.
2.0 PRINCIPLES OF THE LAW IN MEDICINE
THE PRINCIPLE OF INTENTION, qa’idat al qasd
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
diagnosis does cannot reach the legal standard of yaqeen. Treatment decisions are
best on a balance of probabilities. Each diagnosis is treated as a working diagnosis that is changed and refined as new information
emerges. Existing assertions should continue in force until there is compelling evidence to change them. All medical procedures
are considered permissible unless there is evidence to prove their prohibition. Exceptions to this rule are conditions related
to the sexual and reproductive functions. All matters related to the sexual function are presumed forbidden unless there is
evidence to prove permissibility.
THE PRINCIPLE OF INJURY, qaidat al dharar
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
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 shari’at
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
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.
3.0 REGULATIONS OF MEDICAL PROCEDURES, dhawaabit al tibaabat
3.1 EXAMINATION AND INVESTIGATION
consent is necessary for history taking otherwise it is considered trespassing on privacy and spying. History taking provides
an opportunity to discuss diseases of the heart that underlie physical disease. It is an opportunity for taubat and da’awat. It is also opportunity to advise on legal
matters such as foster relations and ‘iddat. The physician is not obliged
to report criminal information to the authorities unless there is demonstrable immediate public interest and necessity. Physical
clinical examination also requires informed consent. A patient can only be examined against his or her consent only if there
is a necessity relating to the life of the patient or to public interest such as criminal investigation. Mental patients can
are not legally competent to give consent; the necessary consent could be obtained from a guardian, wali. Examination
by a caregiver of the opposite gender requires special consideration. It is always preferable that physicians of the same
gender carry out the examination. A physician of the opposite gender can be used only if a situation of necessity arises.
A chaperone must be present. Examination limited to what is necessary. The results of laboratory investigations have the same
requirements for confidentiality as history and clinical examination. The results of radiological investigations are confidential.
Images that show the shape of the body parts can be considered showing ‘awrat
and should not be seen except by authorized people only and for specific purposes. Invasive investigations carry a higher
risk to the patient; their benefits should be carefully weighed against the benefits. These investigations should be carried
out only if there is a clear necessity, dharuurat.
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
surgical procedures include resection, restorative/reconstructive surgery, transplantation, blood transfusion, anesthesia,
and critical care. Transfusion of whole blood or blood components is widely accepted and raises few legal or ethical issues.
Blood donation is analogous to organ donation by a living donor. Transfused blood is not considered filth, najasat,
because it is not spilled blood. Blood transfusion is allowed on the basis of dharuurat.
There is no problem in blood donation between Muslims and non-Muslims because they share human brotherhood. There is no problem
in blood transfusion between a man and a woman. Blood transfusion does not abrogate the wudhu
of the donor or the recipient. Sale of blood is permitted using the analogy of sale of milk by wet nurse
who is paid for her services. Attempts must be made to minimize inappropriate mixing of male and female health care personnel
in a small confined space of the operating theater.
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.
4.0 REGULATIONS OF PHYSICIAN CONDUCT, dhawaabit al tabiib
4.1 VALUES, COMPETENCE, AND
is based on brotherhood. The physician must maintain the highest standards of justice. He should also follow the following
guidelines from the sunnat: 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).
procedures can be carried out without informed consent of the patient except in cases of legal incompetence. 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. Competent children can consent to treatment but cannot refuse treatment. The consent of one parent
is sufficient if the 2 disagree. Parental choice takes precedence over the child’s choice. Courts can overrule parents.
Life-saving treatment of minors is given even if parents refuse. Mental patients cannot consent to treatment, research, or
sterilization because of their intellectual incompetence. They are admitted, detained, and treated voluntarily or involuntarily
for their own benefit, in emergencies, for purposes of assessment, if they are a danger to themselves, or on a court order.
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.
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 or insurance.
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.
5.0 ETIQUETTE WITH PATIENTS and FAMILIES
5.1 BED-SIDE VISITS
The physician-patient interaction is both professional and social. The bedside visit fulfills the brotherhood obligation
of visiting the sick. The human relation with the patient comes before the professional technical relation. It is reassurance,
psychological and social support, show of fraternal love, and sharing. A psychologically satisfied patient is more likely
to be cooperative in taking medication, eating, or drinking. The following are recommended during a visit: greeting the patient,
dua for the patient, good encouraging words, asking about the patient’s feelings,
doing good/pleasing things for the patient, making the patient happy, and encouraging
the patient to be patient, discouraging the patient from wishing for death, nasiihat
for the patient, reminding the patient about dhikr. Caregivers should seek permission,
idhn, before getting to the patient. They should not engage in secret conversations
that do not involve the patient.
5.2 ETIQUETTE OF THE PATIENT
The patient should express gratitude to the caregivers even if there is no physical improvement.
Patient complaints should be for drawing attention to problems that need attention and not criticizing caregivers. The patient
should be patient because illness is kaffaarat and Allah rewards those who surrender
and persevere. The patient should make dua for himself, caregivers, visitors, and
others because the dua of the patient has a special position with Allah. When
a patient sneezes he should praise Allah and the mouth to avoid spread of infections. It is obligatory for the attendants
to respond to the sneezer. The patient should try his best to eat and drink although the appetite may be low. The caregivers
can not force the patient to eat. They should try their best to provide the favorite food of the patient. The believing patient should never lose hope from Allah. He should never wish for death. The patient should try
his best to avoid anger directed at himself or others. Getting angry is a sign of losing patience.
5.3 ETIQUETTE OF THE CARE-GIVER
caregiver should respect the rights of the patient regarding advance directives on treatment, privacy, access to information,
informed consent, and protection from nosocomial infections. Caregivers must be clean and dress appropriately to look serious,
organized and disciplined. They must be cheerful, lenient, merciful, and kind. They must enjoin the good, have good thoughts
about the patients, husn al dhann, and avoid evil or obscene words. They must observe
the rules of lowering the gaze, ghadh al basar, and khalwat. Caregivers must have an attitude of humbleness, tawadhu'u, They
cannot be emotionally-detached in the mistaken impression that they are being professional. They must be loving and empathetic
and show mercifulness but the emotional involvement must not go to the extreme of being so engrossed that rational professional
judgment is impaired. They must make dua for the patients because qadar can only be changed by dua.
They can make ruqya for the patients by reciting the two mu’awadhatain or any other verses of the Qur’an. They must seek permission, isti' dhaan, when approaching or examining patients. Medical care must be professional, competent, and considerate.
Medical decisions should consider the balance of benefits and risks. The general position of the Law is to give priority to
minimizing risk over maximizing benefit. Any procedures carried out must be explained very well to the patient in advance.
The caregiver must never promise cure or improvement. Every action of the caregiver must be preceded by basmalah. Everything should be predicated with the formula inshallah,
if Allah wishes. The caregivers must listen to the felt needs and problems of the patients. They should ask about both medical
and non-medical problems. Supportive care such as nursing care, cleanliness, physical comfort, nutrition, treatment of fever
and pain are as important as the medical procedures themselves and are all what can be offered in terminal illness. Caregivers
must reassure the patients not to give up hope. Measures should be taken to prevent nosocomial infections.
5.4 ETIQUETTE OF INTERACTION BETWEEN GENDERS
Both the caregiver and patient must cover awrat as much as possible. However,
the rules of covering are relaxed because of the necessity, dharurat, of medical
examination and treatment. The benefit, maslahat, of medical care takes precedence
over preventing the harm inherent in uncovering awrat. When it is necessary to
uncover awrat, no more than what is absolutely necessary should be uncovered. To
avoid any doubts, patients of the opposite gender should be examined and treated in the presence of others of the same gender.
The caregivers should be sensitive to the psychological stress of patients, including children, when their awrat is uncovered. They should seek permission from the patient before they uncover their awrat. Caregivers who have never been patients may not realize the depth of the embarrassment of being naked in
front of others. Medical co-education involves intense interaction between genders: Teacher-student, student-student,
and teacher-teacher. Interacting with colleagues of the opposite gender raises special problems. Norms of dress, speaking,
and general conduct; class-room etiquette; social interaction; laboratory experiments on fellow students; Clinical skills
laboratory: learning clinical skills by examining other students; Operation theatre. Medical personnel of opposite genders
should wear gender-specific garments during surgical operations because Islam frowns on any attempt to look like the opposite
gender. Shari’at guidelines on interaction with patients of the opposite
gender should be followed. Taking history, physical examination, diagnostic procedures, and operations should preferably be
by a physician of the same gender. In conditions of necessity a physician of the opposite gender can be used and may have
to look at the ‘awrat or touch a patient. The conditions that are accepted
as constituting dharuurat are: skills and availability. The preference between a Muslim of opposite gender vs non-Muslim of
same gender depends on the local situation.
5.5 DEALING WITH THE FAMILY
Visits by the family fulfill the social obligation of joining the kindred and should be
encouraged. The family are honored guests of the hospital with all the shari’at
rights of a guest. The caregiver must provide psychological support to family because they are also victims of the
illness because they anxious and worried. They need reassurance about the condition of the patient within the limits allowed
by the rules of confidentiality. The family can be involved in some aspects of supportive care so that they feel they are
helping and are involved. They should however not be allowed to interrupt medical procedures. Caregivers must be careful not
to be involved in family conflicts that arise from the stresses of illness.
6.0 ETIQUETTE IN THE HEALTH CARE TEAM
6.1 PRINCIPLES OF GROUP WORK
A group is several interdependent and interacting persons. Work is enjoined in groups that are united, cooperative,
open and trusting. Group members must be similar, empathetic, supportive, and sharing. Separation from group is condemned.
Group norms must be respected. Breaking norms, secretive behavior, concealment of information, and secret talks destroy groups.
Group membership has benefits of integration, stimulation, motivation, innovation, emotional support, and endurance. Group
performance is superior to individual performance. Group membership has the disadvantages of arrogance, suppression of individual
initiative, member mismatch, and intra-group conflict. Group formation has 4 stages: forming (acquaintance and learning to
accept one another), storming (emotions and tensions), initial integration (start of normal functioning), total integration
(full functioning), and dissolution. Mature groups have group identity, optimized feedback, decision-making procedures, cohesion,
flexibility of organization, resource utilization, communication, clear accepted goals, interdependence, participation, and
acceptance of minority views. Groups fail when constituted on the wrong basis, when members cannot communicate, when there
is no commonality (interests, attitudes, and goals), and when they have diseases of hasad,
nifaq, namiimah, gaybah, kadhb, riyah, kibriyah, hubb al riyasa, tajassus, and dhun al soo. An effective group follows
the Qur'an and sunnat, members feel secure and not suppressed, members understand and practice sincere group dynamics, members
are competent and are committed to the group and the leadership.
6.2 ETIQUETTE of TEACHING & LEARNING in THE HEALTH CARE TEAM
The hospital health care team is complex and multi-disciplinary with complementary and inter-dependent
roles. Members have dual functions of teaching and delivering health care. Most teaching is passive learning of attitudes,
skills, and facts by observation. Teachers must be humble. They must make the learning process easy and interesting. Their
actions, attitudes, and words can be emulated. They should have appropriate emotional expression, encourage student questions,
repeat to ensure understanding, and not hide knowledge. The student should respect the teacher for the knowledge they have.
They should listen quietly and respectfully, teach one another, ask questions to clarify, and take notes for understanding
and retention. They should stay around in the hospital and with their teachers all the time to maximize learning.
6.3 ETIQUETTE of CARE DELIVERY in THE HEALTH CARE TEAM
Each member of the team carries personal responsibility with leaders carrying more responsibility. Leaders must be
obeyed except in illegal acts, corruption, or oppression. Rafidah was good model of etiquette. She a kind, empathetic, a capable
leader and organizer, clinically competent, and a trainer of others. Besides clinical activities, she was public health nurse
and a social worker assisting all in need. The human touch is unfortunately being forgotten in modern medicine as the balance
is increasingly tilted in favor of technology.
6.4 THE HEALTH CARE TEAM: GENERAL GROUP DYNAMICS
Basic duties of brotherhood and best of manners must be observed. Encouraged
are positive behaviors (mutual love, empathethy, caring for one another; leniency, generosity, patience, modesty, a cheerful
disposition, calling others by by their favorite names, recognizing the rights of the older members, and self control in anger.
Discouraged are negative attributes (harshness in speech, rumor mongering, excessive praise, mutual jealousy, turning away
from other for more than 3 days, and spying on the privacy of others).
6.5 THE HEALTH CARE TEAM: SPECIAL GROUP DYNAMICS
Gender-specific identity should be maintained in dress, walking, and speaking. Free mixing of the genders is forbidden
but professional contact within the limits of necessity is allowed. Patients of the opposite are examined in the presence
of a chaperone. The gaze should be lowered. Modest and covering must be observed. Display of adornments that enhance natural
beauty must be minimized.
7.0 THE PATIENT AND ACTS OF IBADAT
PATIENT HYGIENE, nadhafat al mariidh
are not najasat: fresh blood inside the body, interstitial space fluids, effusions,
and physiological secretions (esophageal, gastric, and naso-gastric). The fluids from an ileostomy are not najasat but those of a colostomy are najasat. A person with a discharging fistula makes widhu and prays. Fistulas
(vesico-vaginal, vesico-intestinal, urethro-vaginal, urethro-rectal, or urethro-cutaneous) may discharge stool or urine. Persons
with discharging stomas and fistulas make wudhu and offer salat immediately.
7.2 TAHARAT FOR THE SICK
Wudhu has physical, psychological, and social or emotional benefits. It is washing
or wiping with a wet hand the exposed parts of the body (face, hands, forearm, head, and feet) once, twice, or thrice. It
suffices to wipe the turban, the top of socks, or the bandage. Wudhu is nullified
by passing urine, feces, or flatus; urethral discharge; prostatic discharge; menstruation;
deep sleep; vomiting; and touching the external genitals. Wudhu is not nullified
by medical treatment involving bleeding; touching a woman with no sexual desire or intentions; bleeding from a fresh wound;
inter-menstrual bleeding; and kissing. A person who has no wudhu cannot touch or
read the Qur'an. In the absence of water, tayammum is carried out for wudhu, in extreme cold, some disease conditions and wounds that would be aggravated by use of water. Tayammum is wiping the face, hands, and forearms after lightly touching soil with dry hands.
7.3 SALAT OF THE SICK, salat al maridh
patient may have the following physical handicaps: inability to face the qiblat,
inability to stand, inability to sit, inability to read, inability to bow, and inability to prostrate. The following are solution
alternatives: make-up salat, qadha al salat; resting for moments in a sitting position
to regain energy for the next movement; praying in a sitting position; praying while sitting down and cross-legged; praying
while lying down on one side of the body; resting on a staff in salat; Praying
by gesturing with one part of the body e.g. finger; and finally praying in the mind with no motions. The sick stop qiyam al layl and try to fulfill the 5 prescribed prayers. Salat can
be interrupted for an urgent need that could be medical or otherwise. Soldiers on the battle field can pray abridged prayers
and physical movements are changed. Women are excused from salat during the period
of menstruation because of the associated physiological stress.
7.4 SAUM FOR THE SICK
and patients with chronic or terminal illness are permanently excused from saum. They can choose to feed the poor instead
or their heirs can make up their missed saum (qadha) if they die. Patients with curable illnesses, pregnant or breasfeeding
women, women in haidh or nifaas are temporarily excused from saum but they have to make up (qadha al saum) before the
next Ramadhan. Saum in haidh or nifaas is invalid. Hypoglycemia and dehydration are prevented by prohibition of continuous
saum and encouragement of early iftaar and late suhuur. Diabetics should consult trusted physicians before saum. The following
do not nullify saum: drugs applied externally on the skin, eye drops, nose drops (if not swallowed), injections (sub-cutaneous,
intra-muscular, and intra-venous), and sub lingual tablets. Elective medical procedure should be delayed until after saum.
The following nullify saum: inhalants, nourishing i.v. injections, drugs taken orally or rectally.
HAJJ FOR THE SICK, hajj al mariidhThe physically disabled can circumbulate the ka’aba
riding on a vehicle or being carried by another person. The weak can leave Muzdalifat earlier to avoid the crowds. The very
old and those with debilitating chronic diseases can ask another person to perform hajj on their behalf. However if the disease
is curable it is better to delay hajj until the next year. In case of a fracture,
hajj is stopped and is repeated the next year. If disease occurs during hajj, the sick can be carried to Arafat because al
hajj Arafat and missing Arafat is missing the whole hajj. They are assisted to complete the other rites as much as is possible.