Medical Ethical Issues, an Islamic Perspective

Morality is a unique human subject. It is affected by a number of cultural factors, such as history, tradition, education, and religious beliefs. Ethics is based on two basic concepts: one is a "value" and the other is the duties "must". In the Islamic faith Health and illness as life and death are not mere facts, they include many values that must be respected. The disease, for example, is not only a medical scientific fact like other physiological phenomena. Despite the rise of secular people most of the arabs are believers and religion remains a significant force in society. Diseases and physical suffering have a big impact on the Muslim's life. It tests endurance, faith, and submission to one almighty God, who has healing powers for all patients. How staff ‘does’ good medical ethics depends on this perspective.

To understand the Islamic contribution to medical ethics, five topics are discussed; first, obeying. God's commandments; second, categorising of commandments; third, the 5 guiding principles of Islamic Law (maqased); fourth, judging actions by intention and fifth, refers to a warrant belief in the divine decree and the predestination.

In many Western countries multi-cultures and multi-religious textures are met including Muslim citizens and new immigrants. Medical Staff will be required at one point during their work to treat these Muslim patients; therefore, a minimum level of cultural awareness is a prerequisite for the delivery of care that is culturally sensitive. In this paper, there is the highlight of certain key teachings in Islamic medical issues and their applications. Hopefully, the insights gained will aid medical staff to better understand their Muslim patients and deliver care that pays due respect to their beliefs.

Muslims in the U.S. and in Europe come from diverse backgrounds. Understanding their beliefs and observances is crucial for providing culturally competent care. In bringing any religious perspective to bear on medico-moral issues, a willingness to listen and courtesy in the debate is necessary.

Morality is a unique human subject. It is affected by a number of cultural factors, such as history, tradition, education, and religious beliefs. Ethics is based on two basic concepts: one is a "value" and the other is the duties "must". Values are the stones of many moral human perceptions and theories. Moral values are affected by the place of residence of people, their own language, culture and their religion. Duties always are based on values; they are an interpretation of our "moral judgment". Some moral duties are common and universal. They are considered the basis of all humanity's logic [1].

Islam is the second largest of world religions. The word "Islam" in Arabic means a full and complete devotion to one God (Arabic: ALLAH). Health and illness like life and death are not mere facts, they include many values that must be respected. The disease, for example, is not only a medical scientific fact like other physiological phenomena. Badarneh [2] points out that disease and physical suffering have a big impact on the Muslim's life. It tests endurance, faith, and submission to one almighty God, who has healing powers for all patients. In terminally ill patients, the religious component and effect increase and it has great implications for solving ethical issues related to life and death as euthanasia, organ transplants and others.

Religions have always intended to guide their adherents to the right or the best decisions for the good of individuals and society [3]. In Islam "Good character," was eventually shaped as a successful amalgamation of the Quranic teachings, the teachings of the Sunnah (teaching and practice) of the prophet Muhammad, the precedents of Islamic jurists (Sharia and Figh) (jurisprudence), the pre-Islamic Arabian tradition, and non-Arabic elements embedded in or integrated with a generally Islamic structure.

Medical ethics in the Arabic country embraced an ethics of virtue over an ethics of duty. The notion is that if the nurse or the physician is a person of virtue and morally good will, she (he) will do what is right. The shift to an ethics of duty is taking place gradually in some places as it is in most Western countries. Muslim ethical thinking begins from the premise that the most fundamental relationship in the life of human beings is their relationship with God. Accordingly, the first subject of ethics is to understand the nature of the relationship between humanity and God [4]. Akhlaq. (Arabic, /æxˈlɑːk/, which means dispositions), is the practice of virtue, morality and manners in Islamic theology and falsafah (philosophy). Akhlaq is the most commonly used Islamic term for morality.

Muslims emulate the Prophet Muhammad’s deeds and traditions. His teachings shape attitudes toward birth, illness, death, and social structures. Being Muslim it is a duty to follow the Sunnah of the Prophet and try to show good Akhlaq towards all people no matter whether one is Muslim or non-Muslim. Good Akhlaq also includes sincerity, honesty and truthfulness in doing acts of worship like Charity, prayers, and Quran recitation. https://www.quranreading.com/

Five topics in moral thought and concepts are discussed below

The first one: Is moral values based on that good and evil play a big role in Muslims' lives. People are rewarded for doing good and sanctions for the evil they have done. Every Muslim must obey God's commandments. Islam assumes a priori that the man is autonomous and can choose voluntarily his acts and way. He is Mukhayar (free will and choice). On the other hand, there is a deterministic approach, which holds that human reality is fixed in advance and man has no control or influence on his daily life. He is Musayar (fully controlled by Allah).

Second: The five ethical categories (commandments) from permitted to non-permitted (Arabic: Ahkam (are:) farḍ/wājib – (Compulsory or obligatory or mandatory duty, Such as belief in Allah and that Muhammad is His messenger prophet, praying five times a day, fasting Ramadan by capable adult, giving Zakat (charity) pilgrimage to Mecca in Saudi Arabia and other things); mustaḥabb - (Recommended or supererogatory, such as making circumcised baby, breastfeeding, free blood and some organs donation); mubāḥ - (Neutral or indifferent); makrūh – (Disliked or disfavored, Such as smoking, divorce); haram – (Sinful or prohibited). (Abstaining is obligatory): (Moslems should absolutely avoid doing them and those who perform them require divine punishment. Including Heresy one Creator, perjury, theft, murder, suicide, prostitution, sperm or egg donation, bribery, payment, and receipt of interest on the loan, eating pork or wild animal meat, drinking alcohol, drinking blood, witchcraft, and magic therapy) [4].

Third: The 5 guiding principles of Islamic Law (maqased): Protection of an individual's freedom of belief. Maintenance of life. Maintaining the intellect. Protection of property. Keeping offspring [5].

Forth: Muslims refer to judging actions by intention (Arabic: Niyyah), and thus there are good intentions and malicious and evil ones, and there are declared intentions and hidden ones. On the one hand, it is recommended that anyone be honest with himself and with others and perform trusted actions for his own benefit [6]. On the other hand, it is not acceptable and prohibited to make forbidden commands and try to justify this with good intentions. An example of acting according to intention is when giving opiates as painkillers to prevent patient suffering.

Fifth: refers to a warranted belief in the divine decree and the predestination (Act of GOD) (Arabic: qadar) - The meaning of the term is that God knows the future of every person and that will happen to him from his birth to his death. The believer should accept good life events and negative ones [7]. Illness, pain, and death have moral and religious significance. A disease is considered a test for the believers [8]. The person must show patience and pray for a cure and restore health. The disease causes the cancellation and reduction of various sins. On the other hand, the unbeliever person may consider a disease as a punishment [9]. Belief in fate Islam does not prevent a person from seeking treatment and receiving it but encourages him to do so in order to keep his life.

Prophet Muhammad asked people to seek care that includes a combination of foods like fruits and honey and various herbs, all in accordance with certain rules. In addition, perform therapeutic bloodletting and read special verses from the Koran. The prophet declares: "Get treatment, Allah created for each disease a drug, except getting old ". In other say the Prophet forbade treatment by illegal means such as drinking wine, or magic.

Medical standards of care

Because Islam views itself as a total system governing all areas, Islamic medical ethics view the patient as a whole. Classical texts speak more about "health", than "illness", showing an emphasis on prevention rather than cure. The standards of care for Muslim physicians were first laid down in the 9th century by Ishaq ibn Ali al-Buhari, who wrote the Adab al-Tabib (Conduct of a Physician). He regarded physicians as "guardians of souls and bodies" and wrote twenty chapters on various topics related to medical ethics [10]. Each chapter deals with a specific topic of medical ethics. They fall into three general categories: the conduct of the physician, the conduct of the patient, and the conduct of the public at large towards the medical profession and their patients. The text covers a physician's personal beliefs and practices, placing great importance on his faith in God and personal health and hygiene, as well as his manner with his colleagues, nurses, and patients [11]. OATH of Hippocrates laid the foundations for modern medical ethics. This oath as the generations has become the prototype of all medical codes in the world except India and China. Hinduism and Buddhism have different views on the soul and reincarnation. Some Arab countries adopted for years the Muslim doctor's oath, (Appendix 1- Arabic). The oath emphasizes the conduct of the medical profession. It includes basic moral principles with a focus more on universal values with Islamic impact. Egyptian system went further and the Egyptian Nursing Syndicate applied the "nurse Pledge" to each ceremony of course graduation the pledge. The Pledge is a statement of the ethics and principles of the nursing profession; it is a modified version of the "Nightingale Pledge" (Appendix 2 Arabic).

Recently, some decisions have been a matter of life and death. Muslim people continue asking the staff:" Is it allowed to donate a kidney or other organs so that another person may live?"; "Should we turn off life support machines for a brain-dead patient to end the suffering of a terminally ill patient?. " " How far should the couple go in treatment for infertility so that they might, have a child?"; "Does performing C.P.R (cardiopulmonary resuscitation) on the comatose patient against his Prime request and well allowed?".

Before answering and resolving these issues, certain points need to be discussed, first- Muslims historically understood health and illness through the balance and imbalance model. The Qur’an is seen as a source of healing during distress. Islam recognizes the impact of mental and spiritual health on physical well-being. Most Muslims believe in some basic principles, such as -Life and Death is in Allah's Hands:" And a soul will not die but with the permission of Allah the term is fixed; "sūrat āl ʿim'rān" (Quran 3:145)." Every soul will taste death, and you will only be given your [full] compensation on the Day of Resurrection" Surat āl ʿim'rān" (Quran3:185). "To God, we belong, and to Him is our return’ Surat āl-Baqarah (Quran 2:156). These verses are used by medical staff and religious Muslim men to decrease the impact of the loss of a close family member. Muslims also believe that Human Beings Should not "play God's role" and that the human body is not a man's property. Because of this, committing suicide is forbidden"… Moreover, do not kill yourselves [or one another]. Indeed, Allah is to you ever Merciful." Surat An-Nisā' (Quran 4:29). Sometimes, if one cannot find answers in a verse of the Quran, he should refer to the teachings of the Sunnah of the Prophet Muhammad. It is demanding to rely on Muhammad's "golden rule of behaviors" when judging ethical matters: "You will not be a believer until he loves for his brother what he loves for himself." Bible equivalent to this: "Love your neighbor as yourself". From this view people have a duty to treat others with respect, doing good, causing no harm, being fair and, not forcing treatment, etc. Second point- some Muslims are not religious and they do not strictly follow the religion commands. For them, the traditional practices are losing their hold and people are looking for new ways of making sense of the new kinds of health dilemmas they face (most of them concerning the beginning or end of life). New practices are shaping, it is less the formal religious command that matters, as a need to express spirituality that encompasses the whole of life.

Doing’ medical ethics consists of identifying the medico-morally relevant facts in a particular situation; evaluating their significance in relation to the other facts; and then coming to a judgment about their rightness, wrongness, goodness, or badness. In making that judgment, criteria are applied. These involve ethical principles, balancing conflicting principles against each other. To do this in modern life, the staff and patients use the third source of sacred laws and guidelines besides the Quran and Sunnah which is called (Ijtihad)-the law of deductive logic. Islamic scholars (Ulama)) use their knowledge and judgment to make new legal rulings (fatwa). When making new fatwa the Ulama considered fiqh-doctrinal basis such as Necessity overrides prohibition (haram); removing harm; accepting the lesser of two harms. Public interest overrides individual interest; preventing harm is prior to doing good [2]. Scholars' opinions (fatwa) try to fit answers to Muslims' daily life issues.

Examples of muslim scholars (fatwa) on medical issues

Doing’ medical ethics from a religious perspective has arisen recently for at least three reasons. First, the ability of medical technologies to do more has brought questions that bear upon traditional Moslem moral teaching: abortion, artificial insemination, and embryo experimentation. Islamic institutions and leaders have pronounced in all these areas.

"Infertility care”: Muslims recognize that all life and death happens according to the Will of God. According to Sunnah “Seek treatment, because Allah did not send down a sickness but has sent down a medication for — except for death”. Scholars agree that there is nothing in Islamic law, which forbids many types of fertility treatment, as long as the treatments do not go outside the bounds of the marriage relationship. If chosen, in vitro fertilization must be done with sperm and egg from a husband and wife, and the embryos transplanted into the wife's uterus. Assisted reproductive technologies that blur marital and parental ties are forbidden: such as donor eggs or sperm from outside the marriage relationship, surrogate motherhood, and in-vitro fertilization after a spouse's death or divorce of the married couple. Second, the substantial role of Islamic bodies in education and in end of life care has been challenged.

Euthanasia and Physician-Assisted Suicide: The European Council for Fatwa and Research (ECFR) wrote in a July 30, 2008 article titled "Final Statement: Eleventh Ordinary Session of the European Council for Fatwa and Research". "Having considered the different legal stances Western countries take concerning Euthanasia, both in approval or rejection, the Council decided the following: The prohibition of the direct active euthanasia and the prohibition of suicide and assisting in bringing it about, for according to Shari’ah killing a patient suffering from a terminal illness is not permissible for the physician, the patient’s family or the patient himself. The patient whatever his illness and however sick he (or she) is shall not be killed because of desperation and loss of hope in recovery or to prevent the transfer of the patient’s disease to others, and whoever commits the act of killing will be a deliberate killer. The Qur’anic text confirms without any doubt that homicide is forbidden absolutely, as Allah Almighty says: 'and take not life, which Allah has made sacred, except by way of justice and law sūrat l-isrā (Quran 17:33). It is unlawful for the patient to kill himself (or herself) and it is unlawful for somebody else to kill him (or her) even if he requested that. The former case will be suicide and the latter will be aggression against the other by killing him, for his permission does not render the unlawful act lawful. The patient does not possess his own soul to permit somebody else to take it. The Islamic Medical Association (IMA) stated in its testimony, "Euthanasia and Physician-Assisted Suicide," submitted to the Institute of Medicine Committee on Care at the End of Life on May 13, 1996….. At the same time, the IMA holds the view that when the treatment becomes futile; it ceases to be mandatory… Under such conditions, however, the basic human rights of hydration, nutrition, nursing, and pain relief cannot be withheld" ProCon.org [12]. However, the Islamic Code of Medical Ethics states, "it is futile to diligently keep the patient in a vegetative state by heroic means... It is the process of life that the doctor aims to maintain and not the process of dying". This means doctors can stop trying to prolong life in cases where there is no hope of a cure. According to the Islamic Medical Association of America (IMANA) when death becomes inevitable, as determined by physicians taking care of terminally ill patients, the patient should be allowed to die without unnecessary procedures." IMANA says that turning off life support for patients deemed to be in a persistent vegetative state is permissible. This is because they consider all mechanical life support procedures as temporary measures.

Who decides to resolve ethical issues in a medical setting? Among Jews, there is Rabi who is an adviser in the Israeli hospital ethical committee. Muslims have a "Scholar" (Mufti), who stands for the religious aspects in Arabic/Muslim countries. Among the Christians, there is a Priest whom they ask for guidance. Each of the three people (patient doctor and scholar) has a clear role and actually has duties than rights. The doctor has the scientific and medical knowledge and the obligation to use this knowledge for the benefit of patients. The doctor has a duty to inform the patient (unless legally forbidden from doing so) of any healthcare choice within the boundaries set by the law, together with an obligation to make that choice possible. The patient is committed to himself and he must obtain information that will fit his feelings, fears, and needs. Scholars represent the religious rules and guidelines. When three people are involved in listening to each other with an open mind and discussing all aspects of the decision, there is hope that the decision will relieve the patient and his family, and will help them without creating a religious conflict. So it is strongly advised to form ethical committees in hospitals, which include a religious person )Scholars (from all three different religions. the consequence of good medical ethics lies in applying the wisdom of the long traditions of Judaism, Christian, and Muslim writing, thinking, worship, and practice.

Ethical reflection of the nurses in the Arab countries

In practice, many ethical standards are universal: Almost all Arabic countries, are signatories to the UN Declaration of Human Rights and almost all follow the Helsinki Declaration that describes the ethics of medical research. In most Arab countries the nursing staff still adopts the International Code of Nursing ICN-1982/1973 and makes culturally adapted versions based on Islamic beliefs. This way can help solve daily ethical dilemmas. Some examples of Arabic colleges of nursing will be mentioned and their websites show us the way they teach nursing ethics. University of Khartoum the capital of Sudan teaches medical ethics in the course fundamental of nursing. It included the rights and responsibilities of the nursing staff to patients and their families; commitment to herself to promote personal development in the profession; and commitment to an employer, and to society. She teaches values based on the guidelines of the International Code of Ethics. The students of the Faculty of Nursing at King Saud University in Saudi Arabia established a forum for learning medical ethics - they stress the issue of human dignity and the importance of preserving the rights without discrimination. The students study nursing ethics in the course "Fundamentals of Nursing" and in the course "Concepts in Nursing". They study universal principles including respect for the person and his customs and beliefs. Safeguarding the rights of the patient as maintaining confidentiality and privacy, informed consent, telling the truth, custody, etc. The website of Nursing for All in Saudi Arabia http://www.nursing4all.com/ shows many lectures on nursing ethics and constitutional implications that maintain the patient's rights which are universal and based on the International Code of Ethics. On its website, the College of Nursing- University of Babylon at IRAQ a written complete lectures for students of Nursing and midwives "Code of Ethics". The lecturers emphasize the values of justice, doing good, keeping human dignity and equality, and respect for human rights based on the book of the Quran. The role of nurses in treating patients; maintaining a healthy environment; self-promotion and development of the profession. Values that are highlighted are Dignity, Trustworthiness, informed Consent, Working as a Team, Confidentiality, Privacy, Professional Knowledge and Competence. American University of Beirut -Lebanon Faculty of Medicine members list on its website the importance of nursing ethics application which is not much different from the rules of ethics for the doctors and they say" they are parallel". The Faculty of Medicine website contains links to various information on nursing Ethics including the new nursing ethical code [13]. https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/coe-view-only/

Medical Staff will be required at one point during their work to treat Muslim patients; therefore, a minimum level of cultural awareness and sensitivity is a prerequisite for the delivery of care that is culturally adopted. As mentioned above most Muslim patients are guided by their beliefs and values which are based mainly on religious faith. Illness, pain, and death have moral and religious significance. The standards of care for Muslim physicians and nurses are based on professional oaths which are not different from the modern international codes of medical ethics. That oath's emphasis is conducted morally with more focus on Islamic impact.

Who decides to resolve ethical issues in a medical setting? Still a question for more discussion. Scholars represent the religious rules and guidelines. On the other hand, some Muslims are not religious and they do not strictly follow religious commands. For them, the traditional practices are losing their hold and people are looking for new ways of making sense of the new kinds of health dilemmas. New practices are shaping, it is less the formal religious command that matters, as a need to express spirituality that encompasses the whole of life.

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