Paper presented at workshops on medical ethics at various campuses in England 09-31 December 2006 by Dr Omar Hasan Kasule MB ChB (MUK), MPH (Harvard), DrPH (Harvard) Professor of Epidemiology and Islamic Medicine, Universiti Brunei Darussalam
ABSTRACT
The first part of the paper restates the basic tenets of the monotheistic creed, ‘aqidat al tauhid: Oneness of God, tauhid al dhaat; Oneness of creation, tauhid al rubuubiyyat, & oneness of worship, tauhid al uluhiyyat. The second part explains how tauhid has implications for our daily life based on issuing from one creator: brotherhood and equality, consistent and harmonious physical, social, economic, political laws as well as holistic medical care. The third part described holistic tauhid-derived health care for patients and their families.
1.0 BASIC TENETS OF ‘AQIDAT al TAUHID
1.1 Tauhid al ddhaat:
The essence of tauhid is the oneness of the creator, wahdaniyyat al llaah.[1] The creator is one in everything: His essence, ddhhat al llaah; His actions, af’aal al llaah; His names, asmau al llaah; His attributes, sifaat al llaah; His divinity, al uluhiyyat, deserving of worship, istihqaaq al ‘ibadat; giving benefit, al nafa’u; causing harm, al dharru; taking life, al imaatat; and giving life, al ihyau. Everything on earth relates to the crearor and is under Him. All human actions are for the sake of the One Creator and none else including: love, hubb; anger, ghadhab, friendship, walau; enmity, mu’adaat; worship, ‘ibadat, fear, khawf; and hope, raja. Reliance, isti’anat, is only on the Creator. Only the Creator gives and takes away. Belief in only one creator negates polytheism, shirk. Shirk is belief in multiple gods, ta’addud al alihat; or belief in associates with the creator, shurakaa.
1.2 Tauhid al rububiyyat
The concept of rububiyyat is the assertion that there is a creator and a sustainer for the universe and all its contents. The creator cannot be created and has neither beginning nor end. The concept of auto-creation, existence without a creator, is untenable because it leads to the logical absurdity of an object 'existing' before it existed. Belief in the oneness of the Creator-God, tauhid al rububiyyat, is inborn. Any normal human being will innately and instinctively know that there is one creator for the universe. Tauhid al rububiyyat is a logical imperative. It is impossible for the harmonious and well-coordinated universe to have more than one creator. No two creators could agree so perfectly without any contradictions. Tauhid al rububiyat also explains the harmonious interactions in the eco system, the food chains and the food webs.
1.3 Tauhid al uluhiyyat
Tauhid al uluhiyyat implies worship of one God alone. Nothing else can be associated with Him in worship. The purpose of the creation of the universe is worship of God that is an expression of gratitude to the creator. All creations involuntarily worship God; it is only humans who sometimes disobey because they were given free will that is misused. Kufr, denial of God, is ingratitude. Shirk, associating God with anything else in worship, is an unforgivable sin. Shirk is the cause of religious and social anarchy.
2.0 IMPLICATIONS OF TAUHID
2.1 The Islamic World-View, Tasawwur Islami
Tauhid is oneness of the Creator-God that implies oneness of the created universe. The testament of tauhid is 'there is no god but one God, la ilaha illa al llaahu, consists of a negation followed by an affirmation. Tauhid encapsulates the Islamic world-view and is the basis of Islamic culture and civilization. Tauhid is an intellectual challenge since the concept of one God above and beyond human and the whole universe is an intellectual and abstract reality that can be only grasped at the highest levels of intellectual competence. Tauhid provides an integrating framework for the whole universe in whose absence there would be irreconcilable contradictions. Tauhid is the basis for physical and social laws that govern science, technology and society. The perfection, order, and harmony of the universe and the human body are an empirical proof for oneness of the creator. Tauhid, as belief in one creator and sustainer gives purpose and a sense of direction to human civilization.
2.2 Integration
Tauhid is the most powerful concept that provides an integrating framework for the whole universe. All other concepts and empirical phenomena derive from and are explainable by tauhid. Human knowledge and action must have a tauhidi basis to be valid and useful. There would be irreconcilable contradictions in the absence of the integrating framework of tauhid.
2.3 Consistence with Physical Laws:
All creation and all phenomena of the universe derive from the one and same source. If the source is one, then there are relationships among all objects and phenomena in the universe. These relationships are the basis for physical and social laws, sunan Allah fi al kawn. These laws are the basis for science, technology, and social organization. Scientific research seeks to discover and exploit these laws as well as the associated causal relations.
2.4 Human Brotherhood and Equality
Tauhid explains the unity of mankind because of a common origin.[2] The differences of nations and tribes have the purpose of mutual identification[3] and do not negate the common human brotherhood.
2.5 Science and Technology
Tauhid presents the vista of a wide expansive universe which motivates search for knowledge far and wide. Acknowledging existence of one Creator, implies that there are fixed physical laws in the universe, sunan Allah fi al kawn. These are the basis for predictable causal relations. The purpose of science is to identify and define these causal relations. Technology exploits or manipulates the causal relations to create benefits, sometimes harm, for humans.
2.6 Social Organization
Tauhid, by emphasizing a common creator for everything, implies that there must exist social laws needed for smooth functioning of the universe especially human society. Under tauhid the need for a community and family is obvious.[4] Both are structured organizations that ensure integrated harmonious human existence.
2.7 Economic Organization
The basic economic teaching under tauhid is that sustenance is from Allah.[5] The wealth that an individual gets should not be a cause of arrogance because it is essentially not his or hers. Human economic activities are undertaken with a sense of responsibility knowing that economic resources are in the hands of Allah and that the human is just a vicegerent. The human will therefore undertake economic activity within a moral context defined by Allah. This context requires that economic activity shall promote moral well-being, social and human justice.
2.8 Holistic medical care
Critique of the Biomedical Model[6]:
Health care based on a holistic medical model is superior to one based solely on the biomedical model. The biomedical model is invasive, costly, materialistic, narrowly focussed, inflexible, and seeks to control and regiment. Its materialism treats health as a commodity. It dehumanizes and demystifies the body by treating it as a ‘machine’, a ‘thing’ or a ‘physico-chemical phenomenon’. It depersonalizes the patient as a case of pathology and not as a human because it is more interested in the disease and not the person. It allows a technical relation to replace a human physician-patient bond. Biomedicine is not holistic because it concentrates only on somatic aspects of disease and equates disease to illness whereas the latter is wider in scope. It limits disease causation to pathological anatomy or patho-physiology and rejects or marginalizes spiritual, cultural, social, and psychological factors
The concept of tauhid motivates looking at the patient, the disease, and the environment as one system that is in equilibrium; thus all factors that are involved with the three elements are considered while making decisions. Tauhid also motivates looking at a patient as one organism and not a convenient combination of organs and pathologies. The patient has physical, social, psychological, and spiritual dimensions that have to be considered together in an integrated and holistic fashion.
3.0 HOLISTIC CARE FOR PATIENTS and THEIR FAMILIES
3.1 Bed-Side Visits
Obligation to Visit the Patient, wujuub iyadat al mariidh
The physician-patient interaction is a dual function, professional and social. The physician must know both roles and be competent in both. The ward rounds fulfill one of the social obligations of visiting the sick. Visiting the sick is an obligation.[7] Visiting the sick has a lot of merit, fadhl iyadat al mariidh.[8] Care-givers get a lot of reward from Allah for fulfilling this social obligation in addition to the rewards for their medical work. The caregiver should interact with the patient as a fellow human. The human relation has priority over the professional patient-physician relation. Some bedside visits should therefore be purely social with no medical procedures or medical discussions. The social and human aspects of the physician-patient interaction make the physician more humane and he will make fewer mistakes professionally. The social interaction gives the patient more reassurance and psychological calmness which may have beneficial effects on immune competence. A psychologically satisfied patient is more likely to be cooperative in taking medication, eating, or drinking. The bed-side visit is an opportunity for the caregiver to show fraternal love. The prophet enjoined us to show love to those we love, idha ahabba al rajul akhahu faliyu’ulimahu.[9] The visit is also an opportunity to share with others. The prophet taught that a person cannot be a believer until he loves for his brother what he loves for himself, la yuminu ahadukum hatta yuhibba li akhiihi ma yuhibbu li nafsihi.[10] The caregiver is undertaking a mission of relief, igaathat al malhuufi, in the course of his work.
Prophet’s Visiting a Patient
The prophet regularly visited his companions who fell sick.[11] He visited Sa’ad ibn ‘Ubadat in his illness, ziyarat al nabiyy li sa’ad fi maradhihi.[12] He even visited patients who were among the evil persons such as Abd al laah bin Ubayy bin Suluul.[13] His behavior at the bedside of the patient is good guidance for both the physician and the other visitors to the patient.
Greeting the Patient
The following are recommended actions during a visit to the patient. The caregiver should greet the patient before speaking about anything else, al salaam qabla al kalaam.[14] The physician has the obligation to initiate the greeting because the etiquette is that the standing person is the one to initiate greetings, al maashi yusallimu ‘ala al qaa’id.[15]
Dua for the Patient
The caregiver makes a supplication, dua, for the patient.[16] The dua can be generalized to pray for relief from fever and pain, dua min al humma wa al awjaa’u.[17] Reading Qur'an for the patient is recommended.[18] Recitation of the Qur’an is accompanied by calmness, nuzuul al sakinat ‘inda qira’at al Qur’an.[19] The Qur'an is the best medicine, khayr al dawa al Qur’an.[20] Dua is a cure, al dua dawau.[21]
Talking With the Patient
The Prophet gave us guidance on what can be said and what should not be said in the presence of the patient.[22] Positive words encourage while negative ones discourage the patient and indirectly affect response to treatment mediated by psycho-immune mechanisms. The good word is charity, al kalimat al laytinat sadaqat.[23] The following are enjoined: asking about the patient’s feelings, sua'al anhu, doing good / pleasing things for the patient, al ihsaan ilayhi; making the patient happy, tatyiib nafs al maiidh; and encouraging the patient to be patient, tashji’u al mariidh.[24] The patient should be discouraged from wishing for death wishing death, tamanni al mawt.[25] The caregivers should use the opportunity of interaction with the patient to give them advice, nasiihat, because religion is sincere advice, al ddiin al nasiihat.[26] Special emphasis should be placed on remembering Allah because the Prophet remembered Allah at all times, dhikr al llaah ‘ala kulli al ahyaan.[27]
The physician should behave with the patient as if he is visiting him at home with all the respect and considerations that are due. This covers getting permission, isti idhaan[28] and manner of conversation. It is for example prohibited for the caregivers to engage in secret discussion, najwa, that does not involve the patient.[29] The physician should appreciate and understand the psychology of the patient who is deprived of the bounty of good health and is likely to be depressed. The prophet said many people are deprived of two bounties, health and relaxation, ni’mataan maghbuun fiihina kathiir min al naas al sihat wa al ‘aafiyat.[30]
Mannerisms of the Caregiver
Caregivers must have a cheerful disposition, imbisaat.[31] They must deal with patients with leniency, rifq;[32] mercy, rahmat[33] and kindness, hilm.[34] Allah desires kindness in everything, al llaahu yuhibbu al rifq fi kulli shay.[35] They must strive to do enjoin virtue, ma'aruf.[36] They must also have only good thoughts about their patients, husn al dhann.[37] They must avoid evil or obscene words.[38] It is important for the caregiver to have full interaction with the patient but must still observe the rules of lowering the gaze, ghadh al basar, except when medical necessity dictates otherwise. Caregivers should also avoid being alone with a patient of the opposite gender which could constitute khalwat. Caregivers must not be arrogant and show off.[39] They must adopt an attitude of humbleness, tawadhu'u[40] all the time.
Emotional Involvement
It is very wrong for caregivers to adopt a detached emotionally-neutral disposition thinking that is the way of being professional. Caregivers must be loving and empathetic, tawadud & tarahum.[41] They must show mercifulness, rahmat.[42] The emotional involvement must however not go to the extreme of being so engrossed that rational professional judgment is impaired.
3.2 Spiritual Approach to Care
Role of Dua in Medical Care
Pre-determination, qadr, can only be changed by dua, la yuraddu al qadar illa bi al dua.[43] The prophet made dua when he felt the approach of his death, dua al nabiy ‘indama ahassa bi dunuwi ajalihi.[44] Dua has a lot of merit, fadhl al dua.[45] It is also a cure, al du’a shafaa’u and is a medicine, al dua dawaau.[46] The Qur’an is the best medicine, khayru al dawa al Qur’an.[47] Supplication should be serious, ‘azm al mas’alat.[48] Allah will respond if the supplicator is not in haste, yustajaab ma lam yasta’jal.[49] A general dua for the patient is to pray for relief from fever and pain, al dua min al humma wa al awjaau.[50] Otherwise one of the general dua is said because the prophet preferred them, kaana al nabiy yastahibbu al jawwamiu min al dua.[51] The physician and other caregivers can make dua for the patient, al dua li al mariidh.[52]
Role of Ruqya
The physician can make ruqya for the patient in addition to the medical care being given. Ruqya is allowed, tarkhiis al ruqya.[53] It can be by reciting the two mu’awadhatain which are surat al falaq and surat al naas, al istirqaau bi al mu’awadhatain[54] or any other verses from the Qur’an, ma yustaraqqu bihi min al qur’an.[55]
3.3 Medical Procedures
Caregivers must be fully aware of their legal liabilities and responsibilities, mas'uliyat al tabiib.[56] The rules of seeking permission, isti' dhaan, must be followed whenever caregivers approach a patient. The patient must be forewarned about the approach of the caregiver and should not be surprised. The privacy of the patient must be respected and he or she should be examined after getting permission. Medical care must be professional, competent, and considerate. For example the prophet taught leniency when carrying out a circumcision, al rifq fi al khitaan.[57] 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, dar'u al mafsadat muqaddamu ala jalbi al maslahat. 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, al tasmiyat ‘ala kulli haal.[58] Everything should be predicated with the formula inshallah, if Allah wishes.[59] All measures of resuscitation available should be used when the patient collapses. It is wrong to assume that this is the last moment. The prophet recommended pouring cold water on the unconscious patient, sabb al maa ‘ala raas al maughshi ‘alayihi.[60]
3.4 Supportive care
Hygiene:
A patient need not bathe, la ghusl fi haalat al maradh, tayammum will be a sufficient substitute, al tayammum niyabat ‘an al ghusl.[61] Cutting nails, taqliim al adhfaar, is a general hygienic measure[62] recommended by the prophet for patients.[63] It makes the patient comfortable and helps prevent infection. Urination in a vessel, al bawl fi inaa,[64] is allowed.
Nutrition:
The nutritional status of patients deteriorates due to loss of appetite and the original disease condition. Maintaining a good nutritional status may prove difficult especially if the patient is not cooperative. The prophet made recommendations on what to feed the sick, ma yuti’am al mariidh.[65] The prophet recommended milk as the last drink on earth.[66]
Managing Fever:
Fever is a generalized often non-specific patho-physiological response. It is a cause of much discomfort. Caregivers should detect it early and treat it effectively. The prophet described fever as a blow of hot wind from hell-fire.[67] He recommended using cold water to cool the body during fever.[68] Any additional methods of reducing body temperature should be used.
Managing Pain:
The caregiver should comfort the patient in pain. He can explain that there is reward, ajr, for being patient when suffering.[69] The patient should persevere and not wish for death, tamanni al mawt, because of extreme pain.[70] The patient should be reassured that there is eventually a cure for every ailment, dawa li kulli dai[71] so that there is no loss of hope.
Control of Infections:
The prophet forbade a sick person visiting the healthy[72] to prevent spread of infection. He recommended placing the hand over the mouth when yawning, al yad ‘ala al famm ‘inda al tathaaub.[73] Precautions against spread of contagion were also recommended.[74] Caregivers are obliged to make sure they have all their infectious diseases treated so that they are not a risk to their patients.
3.5 Dealing With the Family
Rights of Visitation for the Family
Some caregivers restrict family visits for some very good reasons: disturbing hospital routines, not giving the patient time to rest, and spread of infection. These however should be compared to the psychological benefits to the patient and family of visits to the hospital. Family visits contribute to joining kindred relations which has a lot of rewards, ajr silat al rahim.[75] The physician should not prevent family interactions because of medical needs but must try to look for a compromise such as restricting visits to certain hours of the day. The physicians should look at the family visiting as guests of the hospital. It is obligatory to honor the guest, wujuub ikraam al dhaif.[76] The rights of the guest, huqquq al dhaif,[77] should be extended to the family.
Support
The family is also a victim when any member falls sick. The caregiver must provide psychological support to them. Sometimes even material support may be necessary. It should be remembered that part of the well being of the patient is to know that the family left behind is not suffering.
Reassurance:
Illness is a cause of much anxiety for the family. The caregiver must take time to reassure the family by explaining what is going and assuring them that the best care is being given. They must be told not to give up hope because Allah in His power can reverse the most serious or critical conditions. In communicating with the family caregivers must make sure they do not violate medical confidentiality except where it is necessary, dharurat.
Involvement
Caregivers should similarly realize the importance of visits by relatives and friends and should plan their ward routines to maximize such visits. The family can be involved in some aspects of supportive care. This is helping them fulfill kindred obligations, silat al rahim. It uplifts the patient's morale to see that the family care and are around being involved.
Interference:
Caregivers should be on the guard to make sure that the eagerness of the family to be of assistance and to be involved does not step beyond the limits. The family may interfere with medical care causing disturbance of the medical routines. This should be resisted with firmness.
Conflict:
Illness is a stressful condition that generates anxiety in the family. It may initiate conflicts or aggravate existing ones. Caregivers may unwittingly find themselves in the middle of such conflicts. They should have the clarity of mind to understand that it is none of their business solving family conflicts. If they do they may regret it since they may become party to the conflict and are considered by some members of the family to favor other members.
NOTES
[1] Qur’an 28:70
[2] Qur’an 4:1
[3] Qur’an 49:13
[4] Qur’an 25:54
[5] Qur’an 29:60-62
[6] From an article by the author ‘A Critique of The Biomedical Model from an Islamic Perspective. International Medical Journal Vol. 2 No. 2, 2004
[7] Bukhari K23 B2
[8] Muslim K45 H40
[9] Abudaud K37 B211
[10] Bukhari K2 B7
[11] Muslim K11 H12
[12] Ahmad 3:138
[13] Abudaud K29 B1
[14] Tirmidhi K40 B11
[15] Bukhari K79 B4
[16] Abudaud K20 B7
[17] Tirmidhi K45 B36
[18] Ahmad 4:105
[19] Bukhari K61 B25
[20] Ibn Majah K31 B28
[21] Ahmad 2:446
[22] Bukhari K75 B10
[23] Ahmad 2:312
[24] Tirmidhi K26 B35
[25] Bukhari K75 B19
[26] Abudaud K40 B59
[27] Muslim K3 H115
[28] Qur’an 24:27-29, 24:58-59
[29] Qur’an 58:9
[30] Bukhari K81 B1
[31] Mukhtasar al Bukhari H2045
[32] Bukhari 8:53
[33] Tirmidhi K25 B16
[34] Tirmidhi K25 B66
[35] Bukhari K78 B35
[36] Bukhari 8:53
[37] Abudaud K40 B81
[38] Bukhari 8:55
[39] Bukhari 8:506
[40] Bukhari 5:509
[41] Bukhari 8:40
[42] Bukhari 8:42)
[43] Tirmidhi K30 B6
[44] Ibn Sa’ad
[45] Tirmidhi K45 B101
[46] Ahmad 2:446
[47] Ibn Majah K31 B28
[48] Bukhari K80 B21
[49] Bukhari K80 B22
[50] Tirmidhi K45 B36
[51] Abudaud K8 B23
[52] Tirmidhi K45 B37
[53] Muwatta K50 H3
[54] Tayalisi H396
[55] Bukhari K66 B9
[56] Ibn Majah Kitaab al Tibb baab 16
[57] (KS214 Abudaud K40 B161)
[58] Bukhari K77 B63
[59] Bukhari K56 B23
[60] Bukhari K11 B29
[61] Bukhari K7 B7
[62] Bukhari K77 B63
[63] Abudaud K20 B11
[64] Abudaud K1 B13
[65] Tirmidhi K26 B3
[66] Ahmad 4:219
[67] Bukhari K76 B28
[68] Bukhari K76 B28
[69] Bukhari 7:550
[70] Bukhari 7:575
[71] Bukhari 5:582
[72] Bukhari K76 B53
[73] Bukhari K78 B128
[74] (MB1969 Bukhari 7:608)
[75] Bukhari K78 B12
[76] Bukhari K78 B28
[77] Bukhari K46 B18
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© Professor Omar Hasan Kasule December 2006
© Professor Omar Hasan Kasule December 2006
