Medical practitioners in Muslim communities must know basic rules about puasa so that they can advise their patients with confidence

1.0 WHAT NULLIFIES PUASA

1.1 Deliberate eating and drinking

1.2 Induced vomiting[1]

1.3 Use of snuff or tobacco in the nose

1.4 Putting water in the ear until it reaches the interior

1.5 Excessive rinsing of the mouth or the nose

1.6 Insanity or loss of consciousness even if temporary

1.7 Menstruation (haidh) and post-natal bleeding (nifaas)

1.8 Penetration of an object or material into the alimentary or the genitourinary tracts

1.10 Deliberate sexual intercourse.

1.11 Injections with purpose of nourishment

1.12 Inhalants

1.13 Nose drops

1.14 Medication: oral, per vagina, and per rectum

1.15 Diagnostic enemas and barium meal examinations

2.0 WHAT DOES NOT NULLIFY PUASA

2.1 Wet sexual dream[2] and prostatic secretions.

2.2 If food is put in the mouth for some purpose and is then spat out

2.3 Non excessive mouth rinsing and nose flushing are permitted during puasa[3] [4].

2.4 Unintentional smelling food or any other pleasant odor;

2.5 Kohl applied to the eye does not nullify

2.6 Lying, kadhib, and back biting, ghaibat. 

2.10 Tooth-pick (siwaak)[5] or brushing teeth with toothpaste

2.11 Injections (im, sc, and iv) for medical treatment

2.12 Venepuncture

2.13 Bladder catheterization

2.14 Cooling the body such as tepid sponging, tabarrud, is allowed[6].

2.15 Eye drops

3.0 CONTROVERSIAL ISSUES (seek opinion of local religious authority)

3.1 Swallowing saliva

3.2 Swallowing phlegm

3.3 Masturbation (istimnaan)

3.4 Eating by mistake either due to forgetting or thinking the sun has set

3.5 Sexual intercourse by mistaking time to be after sunset (maghrib)

3.6 Endoscopic examinations: esophagoscopy, gastroscopy, and rectoscopy

3.7 Per rectal and per vaginal digital examination

3.8 Procedures of invitro fertilization and in vivo insemination.

3.9 Sub-lingual pills

4.0 MEASURES TO PREVENT PHYSIOLOGICAL HARM in PUASA

4.1 Continuous puasa with no break is forbidden[7].

4.2 Early breakfast was recommended[8].

4.3 Travelers are exempted from puasa[9].

4.4 Delaying the early morning meal (suhuur) was recommended[10].

4.5 A menstruating woman is temporarily exempted from puasa but has to makeup[11]. 4.5 4.6 Women in post-natal bleeding are exempted from puasa.

4.7 Pregnant and breastfeeding women, the elderly, and the sick are exempted[12].

5.0 MEDICAL GUIDELINES FOR FASTING:

5.1 Aim at maintaining or reducing weight during the puasa month

5.2 The diet should contain sufficient fiber to prevent constipation

5.3 Slowly digested foods with a long stomach transit times are preferred.

5.4 Enough water drinking at night to prevent dehydration and constipation

5.5 Adequate intake of calcium, magnesium, and potassium to prevent muscle crumps

5.6 Avoiding hot places and attempting to keep cool

5.7 Physician advice on puasa for diabetic patients (type 1 and 2)

5.8 Physician advice on puasa with peptic ulcers and renal stones

6.0 INFORMED REFUSAL OF MEDICAL INTERVENTION IN PUASA

6.1 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. The patient is free to make decisions regarding choice of physicians and choice of treatments. Consent is limited to what was explained to the patient except in an emergency.

6.2 Refusal to consent must be an informed refusal (patient understands what he is doing). Refusal to consent by a competent adult even if irrational is conclusive and treatment can only be given by permission of the court. Doubts about consent are resolved in favor of preserving life.

7.0 COMMUNICATION WITH PATIENTS WHO REFUSE MEDICAL ADVICE

The easiest approach is to know the religious ruling (hukm) on the matter and explain it to the patient. If there is no ruling and the procedure is necessary for life-saving, the doctrine of necessity (dharurat) is applied.

PUASA FOR THE DIABETIC

Metabolic Changes During Ramadan Fasting in Normal People and Diabetic Patients. R M Yousuf, MD, A R M Fauzi, MRCP, S H How, M. Med, A Shah, MSc. Int. Med. J. Vol. 2 No. 2 December 2003   www.e-imj.com

TABLE 3: LABORATORY VALUES* TESTED AMONG DIABETIC PATIENTS AND CONTROLS BEFORE FASTING (VISIT 1) AND DURING RAMADAN (VISIT 2)  

*all values are expressed as mean and standard deviation

NS: not statistically significant

Metabolic Changes During Ramadan Fasting in Normal People and Diabetic Patients. R M Yousuf, MD, A R M Fauzi, MRCP, S H How, M. Med, A Shah, MSc. Int. Med. J. Vol. 2 No. 2 December 2003   www.e-imj.com

TABLE 4: LABORATORY VALUES* TESTED AMONG DIABETIC PATIENTS/ CONTROLS BEFORE FASTING (VISIT1) AND ONE MONTH AFTER FASTING (VISIT3):   

  *all values are expressed as mean and standard deviation

 NS: not statistically significant.