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 based on the thesis that epistemological reform is necessary for educational excellence. The paper starts by summarizing basic concepts and paradigms of Islamic epistemology and methodology of research. It then discusses the current crisis of knowledge and education in the ummat manifesting as low motivation for learning and love or respect for knowledge. The solution of the education crisis will start by epistemological reform in each of the disciplines of knowledge. Epistemological reform is defined as identifying biases in basic paradigms and research methodology that reflect a non-tauhidi world-view. This is followed by reformulating basic epistemological concepts and paradigms of various disciplines from a tauhidi paradigm characterized by objectivity, istiqamat al ma’arifat, and universality, ‘aalamiyyat al ma’arifat, of knowledge. The paper briefly describes the necessary curriculum for undergraduate medical education.. The conclusion of the paper is that excellence in learning and research will be achieved after epistemological reform that will motivate students and teachers to pursue knowledge within the tauhidi framework that conforms to their inner values and world-view.
1.0 BASIC EPISTEMOLOGICAL CONCEPTS
1.1 What is Islamic epistemology?, nadhariyat al ma’arifat al islamiyyat
Epistemology is the science of knowledge, ‘ilm al ‘ilm. It is the study of the origin, nature, and methods of knowledge with the aim of reaching certainty. Islamic epistemology, nadhariyyat ma’rifiyyat Islamiyyat, is based on the tauhidi paradigm. Its fixed parameters are from revelation, wahy. Its variable parameters are conditioned by varying spatio-temporal circumstances. Its sources are revelation (Qur’an and sunnat), empirical observation and experimentation, and human reason. Its main challenge today is achieving objectivity, al istiqamat, which is staying on the path of truth and not being swayed by whims and desires. Istiqamat comes only next to iman, as the Prophet said 'qul amantu bi al laahi thumma istaqim'.
1.2 Nature of knowledge, tabi’at al ma’arifat al insaniyyat
The Qur’anic terms for knowledge are: ‘ilm, ma’arifat, hikmat, basiirat, ra’ay, dhann, yaqeen, tadhkirat, shu’ur, lubb, naba’, burhan, dirayat, haqq, and tasawwur. The terms for lack of knowledge are: jahl, raib, shakk, dhann, and ghalabat al dhann. Grades of knowledge are ‘ilm al yaqeen, ‘ayn al yaqeen, and haqq al yaqeen. Knowledge is correlated with iman, ‘aql, qalb, and taqwah. The Qur’an emphasizes the evidential basis of knowledge, hujjiyat al burhan. The seat of knowledge is the ‘aql, and qalb. Allah’s knowledge is limitless but human knowledge is limited. Humans vary in knowledge. Knowledge is public property that cannot be hidden or monopolized. Humans, angels, jinn, and other living things have varying amounts of knowledge. Knowledge can be absolute for example revealed knowledge. Other types of knowledge are relative, nisbiyat al haqiqat. The probabilistic nature of knowledge arises out of limitations of human observation and interpretation of physical phenomena.
1.3 Sources of knowledge, masadir al ma’arifat:
Revelation, wahy, inference, ‘aql, and empirical observation of the universe, kaun, are major sources of acquired knowledge accepted by believers. In terms of quantity, empirical knowledge, ‘ilm tajriibi, comes first. In terms of quality revealed knowledge, ‘ilm al wahy, comes first. There is close interaction and inter-dependence between revelation, inference, and empirical observation. ‘Aql is needed to understand wahy and reach conclusions from empirical observations. Wahy protects ‘aql from mistakes and provides it with information about the unseen. ‘Aql cannot, unaided, fully understand the empirical world.
1.4 Classification of knowledge, tasnif al marifat
Knowledge can be innate or acquired. It can be ‘aqli or naqli. It can be knowledge of the seen, ‘ilm al shahadat, and knowledge of the unseen, ‘ilm al ghaib. The unseen can be absolute, ghaib mutlaq, or relative, ghaib nisbi. Acquisition of knowledge may be individually obligatory, fard ‘ain, whereas other knowledge is collectively obligatory, fard kifayat. Knowledge can be useful, ‘ilmu nafiu. Knowledge can be basic or applied. There are many different disciplines of knowledge. The disciplines keep changing with advance of knowledge and understanding. A discipline is defined and is limited by its methodology.
1.5 Limitations of human knowledge, mahdudiyat al marifat al bashariyyat
The Qur'an in many verses has reminded humans that their knowledge in all spheres and disciplines of knowledge is limited. Human senses can be easily deceived. Human intellect has limitations in interpreting correct sensory perceptions. Humans cannot know the unseen, ghaib. Humans can operate in limited time frames. The past and the future are unknowable with certainty. Humans operate in a limited speed frame at both the conceptual and sensory levels. Ideas can not be digested and processed if they are generated too slowly or too quickly. Humans cannot visually perceive very slow or very rapid events. Very slow events like the revolution of the earth or its rotation are perceived as if they are not happening. Human memory is limited. Knowledge acquired decays or may be lost altogether. Humans would have been more knowledgeable if they had perfect memory.
2.0 CRISIS OF KNOWLEDGE and EDUCATION, azmat al ma’arifat wa al ta’aliim
2.1 Manifestations of the crisis
There is pervasive ignorance of uluum al diin and uluum al dunia. There is little respect for scholarship. Wealth and power are considered more important than scholarship. There is neglect of the empirical sciences. There is a dichotomy in the education system: traditional Islamic vs. imported European, ulum al diin vs ulum al dunia. Integration of the 2 systems has failed or has been difficult because it has been mechanical and not conceptual. The process of secularization in education has removed the moral dimension from the education and violated the aim of Islamic education to produce an integrated and perfect individual, insan kaamil. The brain drain from Muslim countries has compounded the educational crisis.
2.2 Ummatic malaise due to the knowledge crises
Knowledge deficiency and intellectual weakness are the most significant manifestation of ummat’s decadence. The intellectual crisis of the ummat is worsened by copying and using poorly digested alien ideas and concepts. The prophet warned the ummat about the lizard-hole phenomenon in which the ummat in later times would follow its enemies unquestionably like the lizard running into its hole. Among the manifestations of the ummatic malaise are action deficiency, political weakness, economic dependency, military weakness, dependence in science and technology, and erosion of the Islamic identity in life-style.
2.3 Historical background
The generation of the Prophet (PBUH) was the best generation. The best teacher met the best students and excellent results were obtained. Companions had excellent knowledge and understanding. Seeds of the current crisis appeared towards the end of the khilafat rashidat. New social and political forces overthrew the khilafat rashidat and the ideals it represented were distorted or abolished. Then the authentic ‘ulama and opinion leaders who remained faithful to the ideals of Islam were marginalized and persecuted. Intellectual stagnation then ensued. The process of secularization of the Muslim state progressed. Widespread ignorance and illiteracy became common. Many non-Islamic ideas and facts without valid proof have found their way into the intellectual and religious heritage of the ummat making the existing intellectual crisis even worse.
3.0 SOLUTION OF THE KNOWLEDGE CRISIS BY EPISTEMOLOGICAL AND CURRICULUM REFORM
3.1 The concept of reform:
Reform of knowledge is a process of recasting the corpus of human knowledge to conform to the basic tenets of ‘aqidat al tauhid. The process of reform does not call for re-invention of the wheel of knowledge but calls for reform, correction, and re-orientation. It is evolutionary and not revolutionary. It is corrective and reformative. It is the first step in the reform of the education system as a prelude to reform of society.
3.2 History of reform
The 2-3rd centuries H witnessed a failed effort at knowledge transfer. Greek scientific knowledge was transferred to Muslims together with Greek philosophy and ideas that caused confusions in ‘aqiidat. Greek science depended more on philosophical deduction than experimentally-based induction. It discouraged the scientific tarbiyat of the Qur’an which emphasized observation of nature as a basis for conclusions. The recent knowledge reform movement towards the close of the 14th century H aims at building an education system based on tauhid.
3.3 Reform of disciplines:
Reform has to start with reforming the epistemology, methodology, and corpus of knowledge of each discipline. It must be pro-active, academic, methodological, objective, and practical. Its vision is objective, universal, and beneficial knowledge in the context of a harmonious interaction of humans with their physical, social, and spiritual environment. Its practical mission is transformation of the paradigms, methodologies, and uses of disciplines of knowledge to conform to tauhid. Its immediate goals are: (a) reforming paradigms of existing disciplines to change them from parochiality to universal objectivity, (b) reconstruction of the paradigms using objective and universal guidelines, (c) re-classifying disciplines to reflect universal tauhidi values, (d) reforming research methodology to become objective, purposeful, and comprehensive (e) growth of knowledge by research, and (f) inculcating morally correct application of knowledge. The Qur’an gives general principles that establish objectivity and protect against biased research methodology. It creates a world-view that encourages research to extend the frontiers of knowledge and its use for the benefit of the whole universe. Scientists are encouraged to work within these Qur’anic parameters to expand the frontiers of knowledge through research, basic and applied.
3.4 Misunderstanding the reform process
Reform has been misunderstood as rejection of the corpus of existing human knowledge and disciplines. It has been misunderstood as creation of knowledge exclusive to Muslims. It has been misconstrued as rewriting existing text-books to reflect Islamic themes without deep thought about the paradigms and methodology. It has also been confined to spiritual reform of the student, scholar, or researcher. The following superficial approaches to reform have been tried and failed: ‘Insertion’ of Qur’anic verses and hadiths in an otherwise European piece of writing, searching for scientific facts in the Qur’an, searching for Qur’anic proof of scientific facts, establishing Qur’anic scientific miracles, searching for parallels between Islamic and European concepts, using Islamic in place of European terminologies, and adding supplementary ideas to the European corpus of knowledge.
3.5 Practical steps / tasks of the reform process:
The first step is a good grounding in Islamic methodological sciences of usul al fiqh, ‘uluum al Qur’an, ulum al hadith, and 'uluum al llughat. This is followed by reading the Qur’an and sunnat with understanding of the changing time-space dimensions. This is followed by clarification of basic epistemological issues and relations: wahy and aql, ghaib and shahada, ‘ilm and iman. This is followed by an Islamic critique of basic paradigms, basic assumptions, and basic concepts of various disciplines using criteria of Islamic methodology and Islamic epistemology. Islamic reviews of existing text-books and teaching materials are then undertaken to identify deviations from the tauhidi episteme and the Islamic methodology.
The initial output of the reform process will be Islamic introductions to disciplines, muqaddimat al ‘uluum, establishing basic Islamic principles and paradigms that determine and regulate the methodology, content, and teaching of disciplines. This parallels Ibn Khaldun’s Introduction to History, muqaddimat presented generalizing and methodological concepts on historical events. Publication and testing of new text-books and other teaching materials is a necessary step towards reform by putting into the hands of teachers and students reformed material. Developing applied knowledge in science and technology from basic knowledge will be the last stage of the reform process. This is because in the end it is science and technology that actually lead to changes in society.
4.0 OUTLINE OF AN UNDERGRADUATE MEDICAL CURRICULUM
INTEGRATING ISLAMIC VALUES
4.1 BACKGROUND PHILOSOPHY and CONCEPTS
4.1.1 RELIGIOUS BACKGROUND
Islam: The 3 fundamentals (Islam, Iman, & Ihsan), monotheism (Tauhid), Messengers and messages (risaalat), eschatology (aakhirat), Ithm (sinning), Dhulm (transgression). Pre-determinism: qadar / taqdiir (causality, human will, human responsibility and accountability for actions / choices, human rights and limits to individual freedom., health promotion, disease prevention, the concept of pre-determination in relation to disease: causation, prevention, and treatment). Reconciliation between pre-determination and probability theory.
Other creeds (milal): The academic definition of religion (an object of worship, a prophet, theology, scriptures, doctrines & dogmas, rites, rituals, & ceremonies, icons or symbols, holidays, ethics and social teachings). Dogmas with medical implications in Buddhism, Hinduism, Nasraniyyat, Confucianism, Yahudiyyat, Shintoism, and Taoism, and others
4.1.2. HISTORICAL BACKGROUND
Civilization: Start of human civilization (khilafat, taskhiir, ‘omraan). Cycle of civilizations: World & Muslim history (phases of civilizational growth, factors or rise and fall of civilizations, achievements and failures, renewal and reform)
History of medicine: Ancient medicine; Concept of Islamic Medicine (definition as values and ethics and not specific therapeutic procedures). Prophetic Medicine (definition, sources, classification, examples, modern applications); European TCM (naturopathy, homeopathy, osteopathy, chiropractic), Chinese TCM (theory and philosophy, history, diagnostic techniques, treatments, efficacy and safety, modernization), Ayurdevic TCM (history, diagnosis, treatmemts, present status, scientific study). Unani TCM (historical background, humors, present status), Borneo TCM. Critique of biomedicine vs holistic medicine (depersonalization, atomistic vs holistic).
4.1.3 EPISTEMOLOGICAL BACKROUND
Theory Of Knowledge (epistemology): Knowledge (philosophy, history, sources, classification, methodology, objectivity vs bias, limitations). The duality/dichotomy crisis (traditional vs European knowledge / education systems). The empirical methodology / scientific method (strengths, limitations, weaknesses), Integration of knowledge (the spiritual-matter duality and relation to medicine).
4.1.4 BASIC SCIENCES BACKROUND
Creation (cosmogenesis / genesis) and afterlife (eschatology): Creation of the universe (ultimate questions, start of the universe). Cosmology (signs of creation; will and power; physical laws, order, change and permanence). Creation of the human being (creationist vs evolution views), nature of the human (matter-spirit duality, strengths & weaknesses). Superiority of humans (intellect and moral values). Mission
Transitions in the status of life and health: Life (definition, nature, criteria, quality, worth/value). Death (definition, nature, process, criteria, and attitudes). Health (definition, quality, determinants, individual, family, community, protection, and promotion). Disease / illness (definition, classification, causes, positive and negative attributes and consequences). Treatment of disease (cure vs prevention, curability of all disease, complementation between prevention and cure, modalities of treatment, doa, slaughtering, superstition).
The human life cycle (growth and senescence): Intrauterine period (conception, stages, external and internal environments, ethico-legal implication of the start of life, disorders). Infancy and childhood (parenthood, physical, social, and psychosocial growth, disorders). Adolescence (definition, physical changes, problems of transition, mismatch between biology and wisdom / experience). Youth (definition, stress career vs family, cognition vs emotion, idealism vs pragmatism, morality vs hedonism). Middle age (definition, biological, social, psychological changes in men and women, the midlife crisis, menopausal problems: physical, psycho-social-sexual). Old age (definition, theories og aging, homeostasis vs homeostenosis, ageing vs disease, characteristics, physical decline, psychosocial functions, care for the elderly: home vs institution, research on the elderly, common health disorders, exemption of the elderly from social and religious obligations), after life (linear vs cyclic concepts).
The Biological Miracle: The human organism (perfection, optimality, incomparability). Interaction of the external and internal environments (homeostasis, equilibrium, balance, central tendency, ecology, pathological repair & restoration). Functional unity of the organism (control, command, and communication systems of DNA, the nervous, endocrine, sensory, and immunological systems, negative vs positive feedback). Correlation of structure and function by organ systems: input-output (alimentary and urinary), transport (cardiovascular and respiratory), command, control, aned coordination (sensory, nervous, endocrine, immunological systems), locomotor, support, and protective (musculoskeletal and connective systems).
4.2 ETHICO-LEGAL-FIQH CONCEPTS & PRINCIPLES
4.2.1 BASICS OF LAWS
Fundamentals of the Law: Sources of Islamic Law (Qur’an, sunnat, ijma, qiyaas etc). Sources of European Law (statute, case law). Purposes of the Law: maqasid al shari’at (morality, life, progeny, intellect, resources). Principles of the Law: qawa’id al shari’at (intention, certainty, injury, hardship, custom). Types of legal rulings (halal, haram, mubaah, makruh, aziimat & rukhsat), Relation of ethics to law (the Islamic vs European perspectives). The law and human rights (Islamic vs the European perspectives). Equality before the law (non discrimination on grounds of race/ethnicity, national origin, creed, political affiliation, gender, age, and disability status).
Practical: visits to Mufti Office and Attorney General’s Chambers
4.2.2 THEORIES AND PRINCIPLES OF MEDICAL ETHICS
Theories of medical and biomedical ethics: Islamic theory: maqasid al shari’at (morality, life, progeny, intellect, and resources). European theories (deontology vs. teleology, consequentialism / utilitarianism, principlism, Kantian, virtue, relationship, and casuistry, communitarian ethics, feminist ethics, empirical).
Principles of medical and biomedical ethics: Islamic (intention, certainty, harm, hardship, custom) and secular European (autonomy, beneficence, nonmalefacence, justice), Christian, Buddhist, Jewish, and empirical. International ethical codes (Hippocratic, Nurenberg, Helsinki
Practical: visit to Brunei Medical Board offices
4.2.3 ISSUES OF CONSENT
Medical consent for competent patients: Patient autonomy (definition, legal and conceptual basis, significance in health care, limitations, patient autonomy vs physician paternalism, second opinion, conflict between human rights and requirements of medical treatment). Physician autonomy (forcing a procedure on a physician). Competence / capacity (definition, conditions, testing). Informed consent (definition, process, who asks?). Scope of consent (physician choice, physician of a different gender, treatment, refusal). Conditions for validity of consent (understanding, disclosure, weigh info, voluntary, aware can refuse). Information for informed consent (diagnosis, prognosis, treatment alternatives, risks and benefits). Capacity to consent (global vs specific, tests for capacity, enhancing capacity). Consent / refusal for the competent (process).
Practical: Visit to the emergency room in the evening.
Medical consent for incompetent patients: Consent / refusal for the incompetent (young children, older children, the mentally ill, the unconscious). Consent in emergencies (competent patient but no time for consent, incapacitated patients, resuscitation after attempted suicide, carrying out an unauthorized /unfamiliar procedure to save life, refusal of emergency treatment by a competent / incompetent person, advance refusal, forensic search of unconscious patients, off duty doctor in an emergency, disclosure of emergency room information to the police, forensic searches of emergency patients: blood alcohol levels, domestic violence and child abuse in ER, admission of relatives into ER). Physician assessment of best interests of the patient. Proxy decisions (parents, relatives, designated person). Advance statements (definition, scope, format, witnesses, advantages, and disadvantages). Consent by the court. Treatment options (economic and other considerations).
Practical: consent procedures in surgical and obstetric wards.
4.2.4 PRIVACY, CONFIDENTIALITY AND DISCLOSURE
Privacy and confidentiality: Privacy (definition, relation to patient autonomy). Confidentiality (definition, what information is considered confidential, anonymized information, violation with / without consent, disclosure about the deceased). Basis/ rationale / justification of confidentiality (clinical care. Autonomy and privacy, fidelity, social basis, legal basis). Truthfulness (obligation to tell the truth, information patient does not need/want to know, partial disclosure / white / technical lies, giving bad news, the physician’s body language).
Disclosure: Disclosure (by the patient, with consent for education, research, and insurance; without consent to other healthcare professionals and in the public interest). Conflict of duties regarding confidentiality and disclosure to: insurance, employer, HIV, witness in litigation (with consent, without consent). Disclosure of family history / genetic information (by the patient vs by the physician, request by the employer, request by the police).Generation and handling of medical records (SOAPIE, various forms of records, ideal record, omitting or removing information, legal ownership of records, ensuring record security, period of retention of records, patient access to records, access to records of the incompetent, issues in storage and retrieval of records). Disclosure to the mass media (public vs individual interest). Disclosure by doctors with dual obligations: occupational, army, police, prisons, sports, hospital manager (with consent, without consent). Physician in court: as a witness of facts vs expert witness (duty to patient vs public duty to justice, testifying for vs testifying against the patient).
Practical: visit to hospital medical records department.
4.2.5 RESEARCH
Research policies and procedures: Composition of Institutional research committee. Functions of an Institutional research committee / basis for ethical approval (scientific merit, competence of researchers, social value, risks vs benefits, informed consent, confidentiality, conflict or interests / roles, transparency, disclosure, publication / funding bias). Types of fraud in research (not following GCP guidelines, no consent, data falsification, plagiarism, including names that did not participate, researchers not trained, falsifying authorship). Avoiding research fraud / malpractice (training in GCP, ethical and scientific review of research proposal, detailed recording of all research activities, researchers must be personally involved, quality assurance and audit, encourage whistle blowing.
Practical: visit to the Ministry of Health research ethics committee
Animal research: Handling animals before, during, and after research (kindness and good treatment, forbidding cruelty, nutrition, minimize pain, respect even in death). Purposes of animal research (spare humans from risk, the doctrine of taskhiir). Purposes and principles of the Law in animal research. Relevance to humans (similar physiology, findings not definitive human research still needed). Choice of animals for research (edible vs non-edible, pets, wild vs domestic, big vs small, dangerous vs innocuous).
Practical: visit to the animal house.
Human research: History (historical evolution, historical ethical violations). Phases of clinical trials (1,2,3, and 4). Therapeutic vs non-therapeutic research. Good clinical practice guidelines. Autonomy / informed consent (research on humans, research on records, postmortem research). Information given to patients before consent (the treatment, available information, missing information necessitating research, difference between the new and the standard treatments, alternative treatments, risks and benefits, measures to ensure safety). Freedom to withdraw. Material inducements. Confidentiality (anonymized data, personal details disclosed with consent). Research in emergency rooms. Inclusion of women and minorities. Research on the mentally incompetent. Record based research. Research on cadavers. Research on Children (consent by competent children endorsed by parents, parental consent for incompetent children, children’s physiological vulnerability, parental consent for research in child’s interest. Parental consent for research not in the child’s interests, benefits > risks, child overriding parental consent). Research on the elderly. Research on the mentally incapacitated. Research on prisoners. Research on students and employees. Research on members of uniformed services, army and police (consent vs obeying chain of command). Research on biological samples, organs, and tissues from living donors (informed consent if not anonymous, storage of material, benefits and risks, confidentiality). Research on organs and tissues from dead donors (consent by family, storage, confidentiality). Research on embryos (sources of embryos, types of disease that benefit). Research on fetal tissues (spontaneous abortions, induced abortions, financial inducements). Biomedical research. Public health research. Health services research.
Practical: visit to a clinical trials operations office
4.3 ISSUES AT THE BEGINNING AND END OF LIFE
4.3.1 Beginning of life issues: Prenatal / pre-implantation gender testing in IVF. Induced abortion (maternal disease, unwanted pregnancy, gender selection, congenital anomalies).
Practical: visit IVF / fertility clinic
4.3.2 Stem cell technology: Stem cells (definition, methods, use in disease therapy, use in research, sources of stem cells and ethical controversies).
4.3.3 Embryo/fetal research: Sources of embryos. Types of research that uses embryos (contraception, sterilization, reproductive cloning). Ethical guidelines and controversies.
4.3.4 Genetic technology: Genetic therapy. Genetic banks and patenting issues. Human-animal hybrids. The Human genome project. Genetic testing. Genetic screening. Pre-implantation diagnosis. Genetic engineering and therapy.
4.3.5 End of life issues: Terminal illness (definition). Palliative care (definition, content, organization, institutional vs home, modalities, ethical and legal issues). Diagnosis of brain death (whole brain & higher brain). Initiating / withdrawing artificial life support (principles of saving life, certainty, resource conservation, autonomy). Euthanasia (definition, purpose of life, difference between legal withdrawal and euthanasia, acts of omission and commission). Physician assisted suicide. Solid organ transplantation (living and cadaver donor, xenotransplantation, use of anencephalic donor, neural transplantation, fetal transplantation). Post-mortem examination (purposes, process, ethico-legal controversies). Cadavers (research on cadavers, display and teaching on cadavers, dissection of cadavers, storage and use of human tissues).
4.4 ETHICO-LEGAL-FIQH ISSUES IN MEDICAL PRACTICE
4.4.1 NORMAL PHYSIOLOGICAL CONDITIONS
Issues in normal reproduction: Menstruation (salat, puasa, recitation, use of hormones to delay menses in Ramadhan and hajj, activities allowed/prohibited during menstruation). Pre-menstrual tension (impact on social and religious obligations). Irregular menstruations in the climacteric period (impact on salat, puasa, sexual life). Prolonged menstruation (puasa, salat, coitus). Dysmenorrhea (salat). Menopause (definition, early induction medically or surgically, artificial delay, HRT). Human sexuality & sexual behavior (forms sexual expression and behavior, regulation of human sexuality, guidelines on coitus, moral/cultural relativism regarding sexual behavior). Contraception (legal permissibility, autonomy decisions: individual choice vs public policy, disagreement between spouses, risks and benefits of various methods, allowed and prohibited methods, contraception for the unmarried, sterilization of the mentally retarded, relation to sexual promiscuity, demographic impact, parental consent for minors). Pregnancy (legal minimum and maximum duration). Prenatal screening & diagnosis genetic/non-genetic (benefits & risks, non-therapeutic abortion, human rights of the embryo). Labor (puasa and salat). Delivery (autonomy in choice of method, refusal of CS, request for CS, maternal-fetal conflict). Postnatal care (iqamat and adhan at birth, naming, aqiiqat). Breast-feeding (duration, foster feeding).
Practical: visits to gynecological and ante-natal clinics.
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Issues in activities of normal living: Physiological secretions and wudhu / salat (skin and integuments, hair, ear, nose, throat, mouth, urogenital, intravascular, interstitial, pathological secretions, & intubation, and catheterization). Environmental hygiene (bad odors in mosque and public gatherings). Foods & drinks (sources, halal & haram, etiquette of meals, food hygiene, control of the appetite, waste of food, hunger and thirst). Physical activity (difference between physical activity and physical exercise, health, recreational, and other benefits). Standing, sitting, walking and running (purposes, bipedal locomotion, upright posture, dynamic and static balance, postural hypotension in prolonged salat). Sports (traditional, violent, participatory & non-participatory), sleep and rest (definition, a form of death, purposes, etiquette, dreams, disorders, legal competence of the sleeping person).
4.4.2 MEDICAL PROCEDURES
Diagnostic procedures: History (consent, scope, lifestyle questions, confidentiality, nasiha). Physical examination (consent, uncovering awrat, physician of opposite gender). Radiological examination (consent, confidentiality of images). Laboratory tests (consent, confidentiality, disclosure). Esophagoscopy and colonoscopy (wudhu, salat, puasa). Aggressive investigation of common symptoms (cost vs risk of missed diagnosis, legal liability for missed diagnosis). HIV testing (compulsory mass testing, compulsory testing of a suspect, targeted testing of high risk groups, testing at the workplace, pre-marital testing, anonymous testing for epidemiological purposes, disclosure to the employer and the spouse).
Practical: visit to outpatient clinic, laboratory and radiology departments.
Therapeutic procedures: Balance of benefit and injury (benefit>injury, benefit<injury, benefit=injury, choice between 2 evils, choice between legality and benefit, individual vs public interest, prohibited vs necessary, double effect). Prescriptions and administration of medications (ethico-legal issues, financial violations, conflict of interests, pharmacogenetics, regulations of drug administration, request for lifestyle drugs, porcine derived anticoagulants). Medication and wudhu (oral and rectal routes, vomiting after medication). Medication and puasa (oral, rectal, intramuscular, intravenous, sublingual). Surgical procedures (disclosure of surgical risk, consent). Anesthesia (consent, wudhu, salat). Blood transfusion (safety, cross matching errors, consent/refusal, selling/buying, unwilling donors, donation by relatives, prisoners, and drug addicts). Resuscitation (without consent, principle of certainty about nett benefit, doctrine of futility). Cosmetic / reconstructive surgery (concept of changing Allah’s creation, beautification, prostheses, gender change, results less than desired, injury). Solid organ transplantation (indications, preventive transplantation, sale of organs, informed consent for donor and recipient, friend and family donors, living will on organ donation, issues of organ harvesting and determination of death, minor donors and recipients, ownership of organs, decision to donate for incompetent terminally ill and the dead, condemned prisoners as donors, opt-in and opt-out systems, organ donor card, organ donor register). Doctrine of double effect. The slippery slope. Ordinary vs heroic means in treatment. Acts of omission vs acts of commission. Use of drugs in sports. HIV treatment (compulsory treatment of pregnant HIV+ve, free retroviral drugs for HIV +ve)
Practical: visit to a hospital emergency room
4.4.3 CONDITIONS OF ILLNESS
Physical Acts Of Worship For The Sick: Toilet hygiene (istinjau, colostomy, urinal, discharging fistula). Wudhu (conditions that do/do not nullfy wudhu, wudhu with skin conditions, wounds, bleeding, urinary, and fecal incontinence; wudhu for immobilized patient, wudhu for hemiplegics, wudhu with extreme sensitivity to cold or heat, wudhu with dysfunctional bleeding). Tayammum (definition, conditions of recommendation: skin and cold, etiquette, soil / sand in the hospital), Ghus for the sick., salat (salat with musculoskeletal and neurological disability, joining and shortening salat for a reason; salat for immobilized patient, salat for the blind and deaf, salat in extreme cold/hot weather, salat with extreme thirst or hunger, salat with hemiplegia, vestibular disorders, postural disorders, dysfunctional bleeding). Puasa (diabetes, ulcers, vomiting, diarrhea), zakat, and hajj (muscoskeletal and neurological disability, hajj for the blind and deaf, vestibular disorders, postural disorders)
Practical ibadat pesakit: video, simulated patients, real patients.
Input/output systems: alimentary and urinary: Upper GIT conditions: nausea, vomiting /hemetamesis, peptic ulcer (wudhu, salat, pausa). Lower GIT conditions: rectal bleeding, incontinence, fistulae (wudhu, salat, puasa, and hajj). Urinary symptoms and signs: dysuria, pyuria, urgency, incontinence, hesitancy, strangury, terminal dribbling, tenesmus, urethral discharge, colored urine, hematuria (wudhu, salat, haj, coitus). Chronic renal failure (dialysis, renal transplantation). Urinary fistulae and catheters (wudhu, salat, and hajj). Renal colic (salat, hajj). Prostate disease: symptoms and signs, screening: PSA, treatment options: watch, bilateral orchidectomy, chemical orchidectomy wioth LHRH agonist, non-steroidal anti-androgen, radiotherapy +/- adjuvant LHRH, chemotherapy, .
Transport systems: cardiovascular & respiratory: Dyspnea due to cardiovascular causes: (salat, hajj, puasa). Dyspnea due to respiratory causes: pneumothorax, pulmonary embolism, chronic bronchitis, emphysema (salat, hajj, puasa). Congestive cardiac failure (puasa).
Reproductive system: Menopausal disorders (artificial menopause, osteoporosis, benefits and risks of HRT, preventive hysterectomy +/1 ovariectomy). Dysfunctional uterine bleeding: peri-menopausal, pre-menopausal, post-menopausal, malignancy (salat, puasa, hajj, coitus, hysterectomy +/1 ovariectomy). Erectile dysfunction: definition, causes, treatment (marital dissolution). Sexually transmitted disease (pre-marital screening, condoms for sexually active teenagers, confidentiality in treatment, partner tracing and notification). Pre-natal diagnosis / screening / genetic testing/treatment (indications, methods, test performance, counseling pre and post, informed consent, risks and benefits, relation to abortion, human rights of the embryo/fetus). Assisted reproduction for infertility: in vivo and in vitro insemination (basic permissibility for a married couple, prohibition of ovum or sperm donation, premarital disclosure of infertility, postmortem IVF, masturbation, paternity and maternity disputes, disposal/use of unused fertilized ova, pre-implantation sex selection and diagnosis, selective fetal reduction, developing embryos for non reproductive purposes, IVF for sibling benefit, using fertilized embryos for cloning).
Locomotion, support, and connective system: Orthopedic problems: sprains & fractures, orthopedic fixation, osteomyelitis, osteoporosis, malignant bone neoplasms (salat, hajj, work-related injury, workmen compensation, factory work with tremors, physical activity, rest, and sleep). Limb disorders (salat and hajj), Gait disorders (salat and hajj). Involuntary movements:chorea, athetosis, spasciticity etc (salat, hajj, work with moving machinery, driving, accidents in activities of normal living). Myasthenia gravis (salat, puasa, hajj). Joint disorders with restricted/painful movements: osteoarthritis and rheumatoid arthritis (tayammum if cold exercabates the pain, salat, hajj, risk-benefit analysis of chronic pain medication, addiction to analgesics and opiates). Vertebral column pain: spondylosis, intervertebral disease, sponylolidthesis, ankylosing spondylitis, root compression, etc (salat, hajj). Laryngeal, pharyngeal, or oral disease (recitation of Qur’an, public duties like judging, leadership, and court testimony).
Practical: visit to the orthopedic department.
Sensory system: Blindness and deafness (salat, hajj, court testimony, marital contracts, civil contracts, financial contracts, leadership, judgeship, employment). Olfactory disorders (wudhu, salat, halitosis in puasa, use of perfume in public). Taste disorders (selling and buying food). Tactile disorders (work accidents). Temperature disorders (heat stroke in hajj, salat and puasa in extreme temperatures, work accidents). Pain disorders: headache (salat in extreme pain, dyspareunia and marital stress). Hunger and thirst (delay of salat for hunger, puasa with extreme hunger/thirst).
Practical: visits to the eye, ENT, and pain clinics.
Neurological disorders: Stroke (salat, puasa, hajj, civil transactions). Epilepsy (salat, hajj, driving, factory work, job discrimination, injury due to inadequate anti-convulsive therapy). Parkinson disease (salat, hajj, employment). Dementias (salat, puasa, hajj, legal competence, civil and financial transactions, court testimony, tests of capacity). Brain tumors. Brain /skull trauma. Spinal cord injury: lower motor vs upper motor, hemiplegia/hemiparesis, paraplegia/paraparesis (salat, hajj, marriage). Aphasia/dysphasia (marriage and contracts, evidence, public leadership). Vestibular disturbances (salat, hajj). Peripheral neuropathies: diabetic neiropathy.
Practical: visit to neurology clinic.
Psycho-social conditions: Legal impact of loss of competence (salat, hajj, zakat, marriage contract, divorce, wills and testament, financial transactions, legal proceedings). Human drives and the genesis of emotions positive and negative. Anxiety disorders (unbalanced drives, classification of anxiety: normal and pathological, anxiety vs fear and depression, normal and pathological anxiety, spiritual malady and cognitive impairment as causes of anxiety, salat in extreme anxiety, wudhu/salat with compulsive/obsessive disorders, prevention of anxiety by renewal of aqidat, ibadat, doa, and removal of stressors, socialization). Stress (competence, spiritual treatment of stress, salat with stress, prevention of stress, salat as cure of stress). Loss of consciousness: sleep, forgetfulness, anesthesia, coma (salat, puasa, zakat, civil, financial, and judicial transactions, proxy decisions by the guardian, wali). Personality disorders (salat, puasa, hajj, marriage). Psychiatric conditions /psychosis/schizophrenia (salat, zakat, hajj,stigmatization, compulsion:, Brunei Lunacy Act 1984, psychosurgery, ECT, confidentiality). Depression and suicide / para-suicide / harm to self and others (compulsory detention and treatment, process of mental committal, liability of physician who fails to identify potential suicide, conflict on suicide religious prohibition vs autonomy rights). Psychogenic sexual disorders (definition: lack of libido, sexual dysfunction, sexual deviation, treatment, impact on marriage and divorce: divorce or khulu’u). Neurotic / anxiety / compulsive-obsessive disorders (salat, marriage and divorce, civil and judicial transactions).
Practical: visit to psychiatry clinic
Other conditions: Patho-physiological disturbances: fever, dehydration, infecrtions, (wudhu, salat, hajj, civil and financial transactions). Hematological disorders: anemia, leukemia, lymphoma, coagulation disorders. Skin disorders: eczema, psoriasis, SLE, etc. Diabetes mellitus (ouasa).
Issues of special age and gender groups: Women and maternal conditions. Neonatal and infant conditions. Congenitally abnormal fetii / infants: anencephaly, spina bifida, hydrocephalus (delivery time: before or at term?, delivery method: vaginal or Ceserean?, CPR at birth, long-term life support). Child conditions. Geriatric physical dysfunction: musculoskeletal, falls, fractures, senses, nutrition (taharat, wudhu, salat, puasa, hajj). Geriatric psychoneurological conditions and dementias (civil and financial transactions, salat, puasa, hajj). Geriatric psychosocial dysfunction (depression, dependency/loss of self esteem, sexual dysfunction, quality of life, civil transactions). Disabilities: rights and obligations. Research on the elderly. Drug prescriptions for the elderly.
4.5 ETHICO-LEGAL-FIQH ISSUES IN PSYCHO-SOCIAL APPLICATIONS
4.5.1 The Family Institution: Gender. Family as a natural social unit. Marriage. Parents and relatives. Child protection (definition of child protection, limits to parental rights, state intervention to protect children)
4.5.2 Community Problems: Description of culture (definition, relativism, relation to personality, ethnocentrism). Trans-cultural ethics. Life-style (essentials of life, dress and ornamentation, entertainment, social failure). Sexual perversions (background, antecedents, adverse effects, prostitution, abnormal coital behaviors, sexual paraphilias, and criminal sexual aggression, abnormal marital arrangements). Unwanted pregnancy (determinants and causes, adverse effects, relation to abortion, alternatives to abortion, prevention and mitigation). Addiction and substance abuse: nicotine, drugs, alcohol (causes, prevention and treatment, rehabilitation). Poverty. Violence. Child abuse & neglect (definition and classification of abuse, sexual exploitation, child protection, best interests, physician reporting /non-reporting of abuse to authorities: benefits and risks). Issues of women (discrimination)
4.5.3 Community Action: enjoining the good and forbidding the bad, health promotion, social change, professional and occupational organizations, social welfare, disaster relief, refugees,
4.5.4 Civil Transactions: Health-related ethico-legal issues in marital contracts (selection of a spouse, forbidden spouses, marriage contract conditions, conjugal rights and responsibilities). Divorce & annulment (divorce in menstruation and pregnancy, purposes of post-dicorce waiting period). Inheritance. Endowments & gifts,
4.5.5 Occupational health issues: Pre-employment testing (infectious disease, addiction to drugs and alcohol, genetic, psychological). Testing during employment (purposes, disclosure to employer, sick leave, random test for drugs, removal of hazards).
4.5.6 Judicial transactions: legal competence: ahliyyat
4.5.7 Public health ethics: Public health measures in an epidemic without consent (quarantine, isolation, mass immunization, mass treatment). Disease screening and surveillance. Control of infectious disease (control and eradication, infectious disease control Act). HIV (premarital testing, voluntary testing, counseling, confidentiality), HIV prevention (free condoms in schools, sterile needles for IV drug users). HIV: discrimination in employment, immigration, and healthcare. Vaccination / immunization (cost benefit analysis)
4.6 PROFESSIONALISM
4.6.1 Professional physician etiquette / conduct with patients: Physician competence, responsibility, and accountability. Doctor-patient relationship (compassion, competence, disclosure & truthfulness, confidentiality, etiquette of the patient, bedside visit, uncovering awrat, interaction with the opposite gender, interaction with the family). Fidelity obligations (patient-doctor contract, dual obligations: army, police, prisons, sports, factory, school & university, conflict of duties and conflict of interests). The disabled patient.
4.6.2 Professional etiquette with the terminally ill/dying: palliative care. The terminally ill / dying (comfort, hygiene, alleviation of pain, acts of worship, legal preparation, spiritual preparation). Death. Burial (customs, mourning,). Bereavement.
4.6.3 Collegial relations / etiquette in a health team: principles of successful group work. General and special group dynamics. Student-teacher relation. Mutual respect and cooperation. Conflict resolution. Whistle blowing on unethical behavior. Cooperation with traditional healers.
4.6.4 Professional misconduct: Abuse of privileges (unethical research, unnecessary treatment, iatrogenic infection, misuse of controlled drugs, false documentation). Private misconduct derogatory to the profession (sexual transgression, abuse of trust, violence and felonies). Financial misconduct (kick-backs and fee splitting, conflict of interest). Un-ethical business practices. Felonies. Dealing with the pharmaceutical industry. Conflict of financial interests (physician as a manager, occupational physician employed by the company, sports physician). Licensing and registration (specialist practice without certification). Promises of wonder cures.
4.6.5 Malpractice & negligence. Definition of negligence/malpractice. Ingredients of a negligence suite. Avoiding negligence suits. Bolam principle as modified by Bolitho. Patient complaint / grievance system as a tool to prevent malpractice.
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4.7 PERSONAL DEVELOPMENT (5%)
4.7.1 INDIVIDUAL DEVELOPMENT
Success as a medical student: Etiquette of the student and the teacher. Time management (concepts of time, planning and prioritization, balance, problems, meetings). Study techniques and strategies (lectures and note taking). Speed reading. Group study and teamwork (types of groups, group dynamics, factors of group success, etiquette of a healthcare team). Motivation (concepts & theories, methods, relation to performance and responsibility, motivation in the medical profession). Management of student stress. Conflict resolution. Cheating and plagiarism. The nature of medical education (purpose, integration, balance, service, and leadership). Physician rights (renumeration, professional independence, continuing medical education, refusal to undertake unethical procedures). Physician responsibility (to self and family, to society, to science).
Towards developing a scientific culture: Understanding. Thinking. Description. Analysis. Objectivity. Rationality. Prudence. Respecting the other opinion.
Character and behavior: Character, habits, and behavior. Positive personality traits (integrity, responsibility, courage, wisdom, patience, humility, self-restraint, modesty, simplicity, moderation, good acts, good company, principled life, positive image).
Self Development and personality enhancement: Self improvement (commitment, effort, learning from experience, interdependence, creativity, needs vs wants, positive attitude, futuristic outlook, assertiveness, self confidence, self reliance, contentment). Intellectual development. Social development. Skill development. Professional development (postgraduate training, apprenticeship, mentoring, goal setting, quality results, financial security, professional networking). Personal beliefs and conscience in health care especially abortion,
4.7.2 SKILL DEVELOPMENT
Communication: Concepts and theory of communication (definition, functions, channels, process, modes, elements of success, perception, styles, barriers). Communication in small groups (advantages of face to face communication, on first meeting, continuing in the group, factors of success, active listening, barriers to effective listening, etiquette of telephone and online communication). Purposes and types of written communication (letters, office memos, papers, reports, and manuals). Characteristics of good writing (precision, simple language, logic, believable, purposive, draft and review). Special characteristics of medical/technical writing. Publishing a paper. Problems in writing (blank page/writer’s block, writing to difficult persons, conveying unpleasant information). Public speaking (purposes, elements, the message, delivery, the audience). Dealing effectively with the mass media (strengths and weaknesses of various media, impact of media on health-related KAP).
Negotiation skills: Nature and purpose of win-win negotiation (purpose, elements of success, conducive circumstances, interests and concessions, multi-issue negotiation, alternatives to win-win). Negotiation strategies (winning strategy, negotiation power). Negotiation tactics (aggressive, friendly, evasive, provocative, risk taking, incremental approach, brinkmanship). Management of a negotiation session (commitment, personal relations, self discipline and self control, learn the other side, planning a strategy, phases and agenda setting, demands and offers, narrow differences, final bargaining, persuasion, implementation and follow up). Difficult negotiations (win-lose, deadlock).
Leadership Skills: Basic characteristics of effective leadership. Personal Attributes of leaders. Conceptual leadership skills. Technical leadership skills (communication, decision making, planning and execution, team leadership, motivation, conflict resolution, maintaining relations). Human skills of leaders (concern, respect, compassion etc). Diseases of leaders (personality, and poor human relations). Diseases of followers (hypocrisy, insincerity, bad advice for leader, flattery). Model leaders in medicine;
Management Skills for health services: Strategy, planning, and implantation. Control and evaluation. Quality assurance/quality improvement. Decision-making (principles, process, and steps of rational decision making). Problem-solving (principles, process, and steps of rational problem solving. Crisis management (definition, stages, identification, isolation, and intervention). Economic analysis in health (terminology, CBA, CEA, and CUA). Health policy (allocation of health resources, preventive vs curative medicine, justice). Health finance (reasons for high cost of medical care, managed care, waste control, cost control). Health services delivery (barriers, access and poverty). Basics of organizational management (organizational design, structure, culture, and development; recruitment, placement, and maintenance of personnel; job design, description, and assignment; advantages & disadvantages of specialization; training process, advantages and disadvantages of delegation, worker appraisal). Basics of organizational financial management. Health information management systems (definition of MIS, types and structure of databases, information dissemination, privacy and confidentiality).
