Paper presented at a Workshop on The Integration of the Islamic Input in the Medical Curriculum with Competence-Based Curriculum In Muslim Medical Schools' with the theme 'Curriculum Reform of Medical Education in Medical Schools affiliated to the Federation of Islamic Medical Associations' held at Bumi Senyiur Hotel Samarinda East Kalimantan Province Indonesia 4-6 June 2010 by Dr Omar Hasan Kasule MB ChB (MUK), MPH (Harvard), DrPH (Harvard) Professor of Epidemiology and Bioethics Faculty of Medicine King Fahd Medical City Riyadh
ABSTRACT
The paper is divided into 3 parts: the Islamic basis for ethical theories and principles, ethical issues related to the educational process, and teaching medical ethico-legal-fiqhi issues. The ethical framework of Islam is based on the basic elements of the shari'at, the purposes of the sharia, and the principles of the sharia. The medical education process raises ethico-legal issues such as the etiquette of behavior in the healthcare team, interaction between genders, postmortem examination and cadaver dissection. The teaching of medical ethics requires analysis of actual situations using Islamic principles while comparing to alternative approaches available in society. The paper provides a framework of what should be included in the ethico-legal-fiqhi curriculum of a Muslim-based medical school.
1.0 THE SHARI'AT BASIS FOR MEDICAL JURISPUDENCE EDUCATION
1.1 EVOLUTION OF MEDICAL JURISPRUDENCE, tatawwur al fiqh al tibbi
1.1.1 First period
There are three stages in the evolution of fiqh tibbi. In the first period (0 to circa 1370H) it was derived directly from the Qur’an and sunnat.
1.1.2 The second period
In the second period (1370-1420) rulings on the many novel problems arising from drastic changes in medical technology were derived from secondary sources of the Law either transmitted (such as analogy, qiyaas, or scholarly consensus, ijma) or rational (such as istishaab, istihsaan, and istirsaal).
1.1.3 The modern period
The failure of the tools of qiyaas to deal with many new problems led to the modern era (1420H onwards) characterized by use of the Theory of Purposes of the Law, maqasid al shari’at, to derive robust and consistent rulings. Ijtihad maqasidi is becoming popular and will be more popular in the foreseeable future. The theory of maqasid al shari’at is not new but many people had not heard about it because its time had not yet come. By the 5-6th centuries of hijra the basic work on the closed part of the Law derived directly from primary sources was complete. Any further developments in the law required opening up new the flexible part of the law which necessitated discussion of the purposes of the law. It was at this time that al Ghazali and his teacher Imaam al Haramain al Juwayni introduced the ideas that underlie the concept of maqasid al shari’at. Other pioneers of the theory of maqasid al shari’at were Imaam an Haramain al Juwayni and his student Abu Hamid al Ghazzali (d. 505 H), Sheikh al Islam Ahmad Ibn Taymiyyah (d. 728H) and his student Ibn al Qayyim al Jawziyyat (d. 751H). The field of the purposes of the law witnessed little development until revived by the Abdalusian Maliki scholar Imaam Abu Ishaq al Shatibi in the 8th century AH who elaborated Ghazzali's theory. Our subsequent discussion of the purposes of the law is from al Shatibi's book al muwafaqaat fi usuul al shariat
1.1.4 Relation between law and ethics
Islamic Law is comprehensive being a combination of moral and positive laws. It can easily resolve ethical problems that secularized law, lacking a moral religious component, cannot solve. Many contemporary ethical issues in medicine are moral in nature and require moral guidance that can be provided only from religion. The Law is the expression and practical manifestation of morality. It automatically bans all immoral actions as haram and automatically permits all what is moral or is not specifically defined as haram. The approach to ethics is a mixture of the fixed absolute and the variable. The fixed and absolute sets parameters of what is moral. Within these parameters, consensus can be reached on specific moral issues. Ethical theories and principles are derived from the basic Law but the detailed applications require further ijtihad by physicians. Islam has a parsimonious and rigorously defined ethical theory of Islam based on the 5 purposes of the Law, maqasid al shari’at. The five purposes are preservation of ddiin, life, progeny, intellect, and wealth. Any medical action must fulfill one of the above purposes if it is to be considered ethical. Legal axioms or principles, qawa’id al shari’at, guide reasoning about specific ethico-legal issues and are listed as intention, qasd; certainty, yaqiin; injury, dharar; hardship, mashaqqat; and custom or precedent, ‘urf or ‘aadat.
1.2 SOURCES OF THE LAW, masadir al shariat
1.2.1 Qur’an as a primary source of law
The Qur'an is 'Allah’s words revealed to Muhammad (PBUH) in Arabic, transmitted to us in continuity, written in the mashaf, whose recitation is worship, commencing with surat al fatihat and ending with surat al nas. Verses of the Qur’an were revealed adhoc each associated with sabab al nuzuul. It was memorized and also written down immediately. Abubakar collected the written records and Othman issued one official version in the Quraishi dialect that is used all over the world.
The Qur’an is practical, rational, and miraculous. Its 3 themes are ‘aqidat, spiritual refinement, and practical guidance. Legal rulings, ayat al ahkaam, are a minority of its more than 6000 verses being distributed munakahaat 70, mu'amalat 70, jinayaat 30, iqtisaad 10 verses, qadha 13 verses, government 10 verses, and international law 25 verses. The Qur’an is comprehensive and complete but deals with issues in a generic and not specific way. Its verses are muhkamat or mutashabihat. It challenges the intellect, does not indoctrinate, and gives room for opposing views.
It is divided into 114 surats. Each surat starts with the basmalah except surat
The prophet read the Qur’an in 7 different ways, The Qur’an can be recited as tartiil or as tajwid. As a source of legislation the Qur’an provides general foundations and principles. Qur'anic evidence for legal rulings is either qatui, or dhanni. The Qur'an is the primary source of law. All other recognized sources are secondary to the Qur'an and are validated by it.
1.2.2 Sunnat as a primary source of law
Sunnat, a subgroup of hadith and part of wahy, is defined as words, actions, and tacit agreement of the Prophet. A hadith consists of a sanad, and matn. It can be hadith nabawi or hadith qudsi. Writing of hadith started late. Hadith collections are classified as sihaah, sunan, masanid, and muwatta’at. Hadith is described as mutawatir if narrated by many, mash'hur if reported by at least 2, and aahaad if reported by only 1 sahabi. It be tashri'i if legislative or ghayr tashri' if it is not. The grades of hadith authenticity in descending order are: sahiih, jayyid, and hasan. Muttafaq ‘alayhi is reported by both Bukhari and Muslim. Musnad has a chain of narrators to the prophet. Muttasil has an unbroken chain of narrators. The sanad stops at a sahabi in mawquf and at a tabi’e in a marfu’u hadith. In mursal the tabi’e reports directly from the prophet. Munqati’u has an incomplete sanad. Dha’if lacks the attributes of the sahiih and hasan. Sunnat can affirm, explain, or elaborate the Qur'an or bring up matters not mentioned in the Qur’an. Obedience of the prophet implies following his sunnat. The sunnat comes second to the Qur'an as a source of law. The daliil of the sunnat may be definitive, qatai, or probable, dhanni. The sunnat is interpreted in the light of general principles of the Qur'an, the social situation in the prophetic era, and the Arabic language.
1.2.3 Secondary sources of the Law
Ijma is agreement of all mujtahids existing at one time on a particular legal ruling based on nass. It can be ijma sariih or ijma sukuuti. Qiyas is use of a ruling of one matter for another matter when the two share the same illat. Pre-Islamic laws, shara'u man qablana, were either abrogated or confirmed by the Qur’an. The word of the companion, qawl al sahabi, is a source of law under specified conditions. Custom or precedent, ‘aadat or 'urf, is a source of law if it does not contradict nass, there is ijma on it, and is in the public interest, and closes the door to evil. Istishaab is continuation of an existing ruling until there is evidence to the contrary. Istihsaan is preference for one qiyaas by a mujtahid. Istislaah is assuring a benefit or preventing a harm used in mu’amalat but not ‘ibadat. Maslahat mursalat is public interest based on ra’ay when there is no nass. Sadd al dhari'at is prohibition of an act that is otherwise mubaah because it has a high probability of leading to haram.
1.3 CLASSIFICATION OF REGAL RULINGS: MEDICAL APPLICATIONS
1.3.1 Obligatory, waajib
Waajib is the most important legal ruling. The shafi’e school considers waajib the same as faradh. Individual obligations, fardh aini, cannot be delegated. Performance of a collective obligation, fardh kifai, by any member of the community absolves the rest from sin. However only those with the necessary competence can perform the collective obligations. The rest are not obliged even if they are members of the community.
1.3.2 Recommended, manduub
Recommended, manduub, is also called sunnat or masnuun, nafilat, mustahabb, tatawu'u, ihsaan, fadhiilat. It is ordained without compulsion. The manduub has got the following levels of excellence: confirmed, sunnat muakkada; and not confirmed, sunnat ghayr muakkadat. The sunnat muakkadat is what the Prophet used to carry out continuously and left it only on rare occasions.
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1.3.3 Prohibited, haraam
Prohibited/unlawful, haraam is defined as omission of the waajib or commission of the haraam. The original position for all human acts is permission and prohibition is the exception. Thus textual evidence is required to prove prohibition but is not required to prove permission. The situation is reversed in sexual matters in which the original position is haraam and permission is the exception requiring textual evidence. Only Allah can make something haraam. Haraam is prohibited because it is impure and harmful. An act that aggravates disease is haraam. An act that leads to haraam is also haraam. An act that cures disease is waajib. A general principle is that the halaal is clear and the haraam is clear and between the two are inconclusive matters, mutashaabihaat For inconclusive matters what leads to bad or evil is makruuh and what leads to good is manduub.
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1.3.4 Offensive, makruuuh
Offensive/reprehensible/disaaproved, makruuh, is an act that is discouraged by the Law giver without compulsion. It is better to avoid the makruh. The makruh is an introduction to the haram and must therefore be avoided.
2.0 THE MAQASIDI AL SHARI'AT AS A MEDICAL ETHICS EDUCATION
2.1 THE 5 MAQASID AS THE ISLAMIC THEORY OF ETHICS
2.1.1 Protection of ddiin, hifdh al ddiin, 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. A sick or a weak body cannot perform physical ‘ibadat properly. Balanced mental health is necessary for understanding ‘aqidat and avoiding false ideas that violate true ‘aqidat.
2.1.2 Protection of life, hifdh al nafs: The primary purpose of medicine is to fulfill the second purpose of the Law, 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. Medicine contributes to the preservation and continuation of life by making sure that physiological functions are maintained. Medical knowledge is used in the prevention of disease that impairs human health. Disease treatment and rehabilitation lead to better quality health.
2.1.3 Protection of progeny, hifdh al nasl: Medicine contributes to the fulfillment of the progeny 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, peri-natal 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.
2.1.4 Protection of the mind, hifdh al ‘aql: Medical 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.
2.1.5 Protection of wealth, hifdh al mal: The wealth 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 healthy vibrant communities. 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.
2.2 THE 5 QAWA'ID AL SHARI'AT AS THE PRINCIPLES OF ETHICS
2.2.1 The principle of intention, qa’idat al qasd: The Principle of intention comprises several sub principles. The sub principle ‘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 ‘means are judged with the same criteria as the intentions’ implies that no useful medical purpose should be achieved by using immoral methods.
2.2.2 The principle of certainty, qa’idat al yaqeen: Medical diagnosis cannot reach the legal standard of absolute certainty, yaqeen. Treatment decisions are based on a balance of probabilities. The most probable diagnosis is treated as the working while those with lower probabilities are kept in mind as alternatives. Each diagnosis is treated as a working diagnosis that is changed and refined as new information emerges. This provides for stability and a situation of quasi-certainty without which practical procedures will be taken reluctantly and inefficiently. The principle of certainty asserts that uncertainty cannot abrogate an existing certainty. 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.
2.2.3 The principle of injury, qa’idat al dharar: Medical 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 an injury has priority over pursuit of a benefit of equal worth. If the benefit has far more importance and worth than the injury, 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 injurious and there is no way but to choose one of them, the lesser injury is committed. A lesser injury is committed in order to prevent a bigger injury. In the same way medical interventions that are in the public interest have priority over consideration of individual interest. The individual may have to sustain an injury in order to protect public interest. In many situations, the line between benefit and injury is very fine.
2.2.4 The principle of hardship, qaidat al mashaqqat: Medical interventions that would otherwise be prohibited actions are permitted under the principle of hardship if there is a necessity. Necessities legalize the prohibited, al daruuraat tubiihu al mahdhuuraat, and mitigate easing of legal rules and obligations. In the medical setting a hardship is defined as any condition that will seriously impair physical and mental health if not relieved promptly. 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. The temporary legalization of prohibited medical action ends with the end of the necessity that justified it in the first place.
2.2.5 The principle of custom or precedent, qaidat al urf: The standard 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 ETHICO-LEGAL-FIQHI ISSUES IN THE MEDICAL EDUCATION PROCESS
3.1 THE ETIQUETTE / ETHICS OF THE TEACHER, adab al mu'allim
3.1.1 Characteristics of the teacher
Teachers should take their task very seriously. The education process, involving giving and receiving knowledge is noble[i]. Teachers should have the humility to know that their knowledge is limited and that they can always learn more. Arrogance because of knowledge is condemned[ii].
3.1.2 The learning process
Teachers must make the learning process interesting and avoid boredom[iii]. They should make the atmosphere and circumstances of learning easy for the students[iv]. Teachers must be careful in their actions, attitudes, and words at all times because being models and leaders they are seen and are emulated. They must be aware that sometimes they can teach using body language without saying anything[v]; they have to be careful about their public dispositions They should be ready to carry out their function at all times and at any opportunity[vi].
3.1.3 Communication with the students
They should have an appropriate emotional expression. They can raise the voice to emphasize an important point[vii]. They can show anger or displeasure when a mistake is committed[viii]. Asking students questions to ascertain their level of knowledge is part of the teaching process and is not in any way a humiliation for them[ix]. Teachers should make sure that the students understand by constant repetition[x]. Teachers should strive to pass on to the students as much knowledge as they can. Hiding knowledge is a cause of punishment, uqubat man katama ‘ilma[xi].
3.2 THE ETIQUETTE / ETHICS OF THE STUDENT, adab al muata'allim
3.2.1 Respect for the teacher
The Islamic etiquette of the relation between the student and the teacher should be followed. In general the student should respect the teacher. This is respect to knowledge and not the individual. The prophet taught admiration and emulation of the knowledgeable[xii].
3.2.2 The learning process
Students should be quiet and respectfully listen to the teacher all the time[xiii]. Students should cooperage such that one who attends a teaching session will inform the others of what was learned[xiv]. Students can learn a lot from one another. The student who hears a fact from a colleague who attended the lecture may even understand and benefit more[xv]. Students should ask questions to clarify points that they did not understand or which seem to contradict previous knowledge and experience[xvi]. Taking notes helps understanding and retention of facts[xvii]. Study of medicine is a full-time occupation; students should endeavour to stay around the hospital and their teachers all the time so that they may learn more and all the time. They should avoid being involved in many other activities outside their studies[xviii].
3.3 UNCOVERING AWRAT IN MEDICAL EDUCATION
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 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.
3.4 GENDER ISSUES IN MEDICAL EDUCATION
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; learning clinical skills by examining other students; and the 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.
3.4 POSTMORTEM EXAMINATION IN MEDICAL EDUCATION
3.4.1 Definition: The term autopsy or necropsy is used to refer to dissection and examination of a dead body to determine the cause(s) of death. It may be carried out for legal or for educational purposes.
3.4.2 Purposes of autopsy: Post-mortem examination serves several purposes. It can be done for scientific research to understand the natural history, complications, and treatment of a disease condition. It can be done for further education of physicians and medical students especially when they compare their clinical diagnosis with the evidence from autopsy a process usually referred to as clinico-pathological correlation. The lessons learned will improve their diagnostic and treatment skills in the future and decrease the incidence of clinical mistakes.
3.4.3 Permissibility of autopsy for educational purposes under the principle of necessity, qa’idat dharuurat: Dissection of cadavers has been very important for medical education over the past decades when there was really no alternatives to dissection. Cadaver dissection was therefore permissible under the legal principle of necessity, dharuurat. The reasoning is that cadaver dissection enables future doctors to be trained well to treat patients which fulfils the second purpose of the Law, preservation of life or hifdh al nafs. The situation of necessity explained above takes precedence over considerations of violating human dignity by dissecting the body under the general principle of the Law that necessities legalize what would otherwise be prohibited, al dharuuraat tubiihu al mahdhuuraat. However this can only be carried out if there is informed consent from the family members who have the authority to consent as prescribed by the Law. As far as possible this consent should take into consideration the will of the deceased on this matter if it was known before death. However human dignity cannot be violated more than necessary. The body should still be handled with respect and consideration. All tissues cut away should be buried properly and the remaining skeleton should also be buried in a respectful way.
3.4.4 Alternative ways of achieving the educational objectives of autopsy: The following arguments cast doubt on the degree of necessity for cadaver dissection in medical education. The cadaver is treated before dissection and does not truly represent the structure or appearance of tissues in a living person. Secondly with availability of computer graphics and anatomical models, medical students can learn human anatomy very conveniently and more efficiently. The necessity of educational autopsies can be reduced by modern endoscopic and imaging technology that can enable inspecting internal structures of a corpse without the making an incision to inspect internal tissues. If the educational objective can be achieved fully using such technology then the rational for the necessity will disappear and educational autopsies will be considered repugnant to the Law.
3.4.4 Research on dead corpse
There are several types of research on the recently dead that can be permitted under the principle of necessity if they will result in better health care that fulfills the second purpose of the Law, preservation of life or hifdh al nafs. Forensic pathologists may carry out research to study the process of decomposition of the body. They then can use that information to estimate time since death in cases of criminal homicide.
4.0 TEACHING ETHICAL ISSUES FROM AN ISLAMIC PERSPECTIVE
4.1 Contents of the ethico-legal-fiqhi curriculum
4.1.1 Theories and principles of medical ethics
- Purposes and Principles of Medicine and ethics, maqasid wa qawa’id al tibaabat
- Regulations of Medical Procedures, dhawaabit al tatbiib
- Regulations of Research Procedures, dhawaabit al bahath
- Regulations of Physician Conduct, dhawaabit al tabiib
- Regulations about Professional Misconduct, dhawaabit al inhiraaf al mihani
4.1.2 Ibadat for the patient, ibadat pesakit
- Taharat for the sick, taharat al mariidh
- Haidh
- Salat of the sick, salat al maridh
- Saum for the patient, saum al mariidh
- Medical guidelines on diet in saum
- Saum in difficult weather
- Saum in pregnancy, menstruation, and the post partum period:
- Medical examination and investigations in Ramadhan
- Medical treatments in Ramadhan
- Pilgrimage of the sick, hajj al mariidh
4.1.3 The etiquette of the physician, adab al tabiib
- Etiquette with Patients and Families
- Etiquette with the Dying
- Etiquette with the Health Care Team
- Etiquette of Research on Humans
4.1.4 Issues in disease conditions, fiqh al amraadh
- Uro-Genital System, jihaaz bawli & jihaaz tanaasuli
- Cardio-Respiratory System, qalb & jihaaz al tanaffus
- Connective Tissue System,
- Alimentary System, jihaaz al ma idat
- Sensory Systems, al hawaas
- Patho-physiological Disturbances
- General Systemic Conditions
- Psychiatric conditions, amraadh nafsiyyat
- Neurological conditions, amraadh al a’asaab
- Age-Related Conditions, amraadh al ‘umr
4.1.5 Issues in modern medicine fiqh mustajiddaat al tibb
- Assisted Reproduction, taqniyat al injaab
- Contraception, mani’u al haml
- Reproductive Cloning, al istinsaakh
- Abortion, isqaat al haml
- Genetic Technology, taqniyat wiraathiyyat
- Artificial Life Support, ajhizat al in’aash
- Euthanasia, qatl al rahmat
- Solid Organ Transplantation, naql al a’adha
- Stem Cell Transplantation, naql al khalaayat
- Change of Fitra, taghyiir al fitrat
4.2 Method of teaching ethics
Apart from basic lectures on theoretical issues, most of the teaching should be in the form of discussing case studies. These are cases of actual ethical problems that are encountered in hospital practice. Source material should be provided in advance of any session. Students should be encouraged to look for relevant evidence in the Qur'an and sunnat. Each session will be opened by a short introduction from the facilitator. Then the participants will be divided into discussion groups each dealing with a group of related cases. Groups will present their findings in the plenary session followed by a general discussion. The facilitator will summarize the principles learned as well as correct any misunderstandings.
4.3 Source material
Resource material will be provided as required. Additional material can be obtained from http://omarkasule.tripod.com.
4.4 Examples of case studies
4.4.1 Privacy and confidentiality
A neurologist informed his wife over dinner about an elderly school bus driver who had Parkinson disease and had to take an unusually high dose of medication to suppress the tremors. The medication made the patient sleepy all day. The wife asked for the name and realized that the patient was a driver for her school transport company who had been coming to work late in the past 2 weeks. She dismissed him the next morning.
4.4.2 Disclosure
The manager of a national airline was worried about the erratic behavior and mistakes of one of the senior pilots. He asked around and found out the name and address of the pilot’s family doctor who was in private practice. He wrote to the private practitioner to provide records about treatment of the pilot for vision and psychological problems. He asked specifically for information on drug abuse. The private practitioner called and gave the information but told the manager that he could not put it down in writing since he had not discussed the matter with the patient. Two weeks later the private practitioner received an offer of a free ticket for himself and his wife to a holiday resort. The letter from the airline public relations office said that the airline was carrying out a promotion and that names of beneficiaries had been selected at random from the telephone directory. The doctor subsequently went on the trip with his wife.
4.4.3 Consent to treatment
A patient was brought to the emergency room by the police after attempting to kill himself by hanging. He was unconscious when first brought in and had a signed suicide note in his shirt pocket saying that he wanted to die. The doctors ignored the note and started resuscitation measures. The patient became conscious after 30 minutes and protested at the medical treatment arguing that he wanted to die. The doctor was thinking of stopping resuscitation measures when the patient’s father and wife arrived and instructed the doctor to continue resuscitation.
4.4.4 Refusal of treatment
A 40-year old policeman refused surgery to drain a pyomyositis abscess. He still refused surgery after the abscess burst spontaneously. The surgeons sedated him and carried out the surgery without his consent.
4.4.5 Negligence & malpractice
A patient with no obvious injury after a minor accident was discharged without X-ray investigations. He developed back problems 3 months later leading to leg paralysis. He sued the hospital for negligence.
4.4.6 Life support in terminal illness
A patient with brain stem death is kept on artificial life support at the insistence of the family because announcing the death immediately will have an adverse effect on the values of the family business on the stock exchange.
4.4.7 Reproductive issues
A couple married for 10 years without a child decided to have IVF. Before the procedure was completed, the husband died. The wife insisted on using the stored semen of her dead husband. The relatives of the husband objected. The first wife who had been divorced 15 years earlier with one girl also asked for the semen for an IVF procedure that she hoped would enable her have another baby to act as a bone marrow donor for her daughter who had leukemia and had failed to find a matching donor.
4.4.8 Organ donation
A father of a child with end-stage renal disease got tired of taking her for dialysis every week. He had failed to find a live or a cadaveric donor for her in his country. He considered traveling to a nearby country where kidneys could be bought but he was not sure. He also considered marrying a young wife (his first wife had died) and hopefully produce a child who could be a donor.
4.4.9 Drug abuse and suicide
A patient, whose engagement had been called off in the week that he failed his university entry examinations, started smoking, drinking alcohol, and using illicit drugs to forget his problems but to no avail. He was admitted to the medical ward after suffering a nervous breakdown. He was violent and abusive on the ward and refused to take his medication. Two weeks from his admission he left the ward without telling anyone and went and killed his former fiancée at her home. He later became very agitated and depressed and within 10 hours he also committed suicide. His parents and the parents of his ex-fiancee jointly sued the hospital.
4.4.10 Doctor etiquette
A physician prescribed a new unlicensed drug donated to him by a pharmaceutical company. The physician had shares in the company. He had no previous personal knowledge of the drug. The patient developed an immediate allergic reaction. The physician blamed the nurse for not asking about drug allergies before injecting the drug.
4.4.11 Resources
A 65-year old man whose brother had just died from coronary heart disease walked into the health center and asked for examination because he was afraid that his heart may also have problems. The triage nurse asked him if he had any specific complaints. He replied that he has none and that he was in perfect health. The nurse rebuked him for wasting her time. ‘Don’t you the see line of 120 really ill people waiting to see a doctor? How can we waste time in someone healthy like you?’. The man left but was admitted to the ICU 5 days later with myocardial infarction and he died after 2 days.
4.4.12 Physicians with dual obligations
A national football team physician examined a player and found that he had a chronic shoulder dislocation and advised that he should not play again until it was treated. The player protested because he had always played with that condition since he was young. The team manager threatened to dismiss the physician if he did not certify the player as fit to play because that star player was the only hope of the team to win in an international match the next day.
4.4.13 Postmortem
A police officer died a few minutes after admission from what was suspected injuries sustained in the course of his duty. The police department insisted on a postmortem to determine the cause of death in order to make decisions about compensation. The family was divided. Some were opposed to postmortem and others wanted to go ahead.
Notes
[i] (MB70 Bukhari 1:79)
[ii] (MB102 Bukhari 1:124)
[iii] (MB62 Bukhatri 1:68)
[iv] (MB63 Bukhari 1:69)
[v] (MB75 Bukhari 1:85 and MB76 Bukhari 1:86)
[vi] (MB74 Bukhari 1:83)
[vii] (MB55 Bukhari 1:57)
[viii] (MB79 Bukhari Bukhari 1:90, MB80 Bukhari 1:91, and MB81 Bukhari 1:92)
[ix] (MB56 Bukhari 1:59)
[x] (MB82 Bukhari 1:95)
[xi] (KS390 Abudaud K24 B9, Tirmidhi K39 B3, Ibn Majah Intr B24, Ibn Sa’ad J4 Q2 p56, Ahmad 2:263, Ahmad 2:296, Ahmad 2:305, Ahmad 2:344, Ahmad 2:352, Ahmad 2:495, Ahmad 2:499, Ahmad 2:508, Tayalisi H2534)
[xii] (MB66 Bukhari 1:73)
[xiii] (MB101 Bukhari 1:122)
[xiv] (MB78 Bukhari 1:89)
[xv] (MB61 Bukhari 1:67)
[xvi] (MB88 Bukhari 1:103)
[xvii] (MB93 Bukhari 1:112)
[xviii] (MB98 Bukhari 1:118)
