Dr Wasim Mir MBBS BSc MRCP(UK) PGCert Ed
Core Trainee in Anaesthesia and Intensive Care Medicine
Warwickshire School of Anaesthesia, UK
The author is currently working as a trainee at Worcestershire Acute Hospitals NHS Trust in Anaesthesia and Intensive Care and has a special interest in the areas of Medical Education, having completed postgraduate studies at the University of Birmingham, as well as Islamic Medical Ethics and Islamic Sciences, being a part-time student at As-Suffa Institute, Birmingham.
Correspondence to: Dr Wasim Mir, Department of Anaesthesia, Alexandra Hospital, Woodrow Drive, Redditch, United Kingdom B98 7UB, [email protected]
Treating a critically ill patient presents a unique challenge to a physician working in the NHS. Added to that, as a Muslim, one is faced with interesting ethical scenarios that test both our innate and learned ability to make “correct” and authentic decisions. So how do we, as Muslim physicians in the current NHS dynamic, arrive at sound and grounded decisions in areas such as end-of-life care, the withdrawal of treatment, and organ donation? Better yet, are we well equipped to deal with the growing complexity surrounding such sensitive issues for ourselves as Muslim physicians and Muslim patients?
Despite the large corpus of work analysing medical bioethics in Western medicine, and a substantial Muslim population in the United Kingdom of 2.8 million (1), there is still little in the way of comprehensive guidance produced for those from a religious background, such as Islam, working in a Western setting. This, however, is changing. With a substantial number of Muslim health professionals involved in various domains and specialties in the NHS workforce, advocacy groups have developed on an unprecedented scale, reflecting the demand for such institutions. Leading the way on this is the British Islamic Medical Association or BIMA, which now has a membership of over 2000 health professionals. Its members commonly seek guidance and clarification on day to day ethical dilemmas faced in the workplace, including, but not limited to; end of life care, euthanasia and organ donation.
As this issue has been identified, Islamic scholarship has also sought to bridge the divide between religious academia and the health profession by engaging Muslim doctors and health professionals in the study of Islamic medical jurispudence – a field commonly known as fiqh.
Islamic scholarship has always had a rich history in the field of medicinal sciences, including notable figures such as ibn Sina (Avicenna) and Razi. As well as the copious medical literature of these historic figures, Muslims transfer guidance primarily from sources such as the Quran and Ahadith (sayings of the Prophet Muhammad). In particular, a book called Kitab at-Tibb (the Chapter of Medicine) contains 58 chapters and 105 ahadith. It is therefore a subject far from alien to the Islamic sciences since the very early years of Islamic thought.
There has now been a concerted movement to close the gap between Islamic scholarship and the medical profession in the UK, with online and face-to-face courses developing advanced curricula in the subject of medical fiqh, such as those run by Al-Balagh Academy, based in Nottingham, but with an international following – Al Balagh recently hosted their first international conference in London earlier this year. This has led to an interface between two movements who both serve large communities, yet have the potential to feed off each other to the benefit of contemporary medical ethics in a diverse setting such as the United Kingdom.
As a lifelong student of both medicine and Islam, I firmly believe this is an area that needs strong development, not just at a superficial level between academics, but at the heart of inculcating Muslim medical students with a sound knowledge base. Muslim physicians can underpin their practice with a firm understanding in what their faith deems appropriate, which in many cases is more lenient and diverse than what is anticipated in the field of end-of-life care, family planning and organ donation. This information can also then be disseminated to the wider Muslim population, who may be devoid of the opportunity of access to such information.
As Mahdi et al.(2) postulated in a recent survey of American physicians, there may be a link between the level of engagement one has with their religion, in this case Islam, and the basis for their medical decision-making. Albeit a small study, and focussing on a rather distant populous, it does highlight an interesting question regarding where we derive our medical decision-making guidance from, and what role religion plays, if any, in something so important such as our profession. If one were to use, for example, a basic set of Islamic shar’i (legal) principles from a Hanafi (major school of Islamic thought) perspective (Table 1) as the basis for much of the decision-making in a hospital or primary care setting, one could argue that this provides quite a simple foundation to underpin how we can both practise medicine and explain to Muslim patients our basis for decision making, within the boundaries and rules set by respective regulatory bodies.
It is generally acknowledged that the field of preventative medicine (Tibb al-wiqa’i) is a superior branch of Islamic medicine since it is primarily concerned with the prevention and preservation of health rather than with cure/therapeutics – known as Tibb al-ilaj (3). Often, in practice, I have found many Muslim physicians and patients are convinced that Islam has a “do-everything” attitude to the preservation of life in scenarios often encountered in hospital medicine, especially in a critical care unit. Yet ironically, few have had any formal Islamic education in the field of fiqh or medicine. This has had, I believe, detrimental effects to fields such as palliative medicine, blood and organ donation, and, more worryingly, the perception and interface between non-Muslim healthcare professionals and Muslim patients and their relatives.
Undoubtedly, the Quran is explicit in its statements underpinning the sanctity and preservation of life; “And whoever saves one – it is as if he had saved mankind entirely – Surah 5:32) yet in the current climate of healthcare, whereby the Royal College of Physicians is debating with its membership whether active euthanasia is to be considered as a viable option in palliative care for example (4), these matters must be addressed from an informed and knowledgeable workforce.
As a trainee in Anaesthesia and Critical Care, how does this translate to working in a critical care unit on a day-to-day basis as a Muslim? In the context of a highly diverse community in the UK, both in the population served and the clinicians who serve, one must first abide by national regulatory bodies such as the General Medical Council (GMC) and often adhere to guidelines, from a national level such as those from NICE, to local and departmental strategies. These often run in unison with many Islamic Shar’i principles, such as the endeavour to preserve life and serve society as a whole, fairly. With limited resources in Intensive Care, one often has to make judgments as to which patients are suitable for both admission and advanced forms of treatment to give a fair and just opportunity to the wider patient population. This can be challenging at the best of times and nigh on impossible at the hardest.
From a personal perspective, I seek support and guidance from those with greater knowledge in both the medical field and Islamic sciences. Having a sound knowledge of medical ethics and Intensive Care medicine is essential to give credence to making appropriate decisions to maintain congruity with the environment within which we work. Indeed, I find that Islamic shar’i principles and guidance learnt through the study of Fiqh and Usul-al-Fiqh help solidify my decision making and make me content and at ease with my practice.
I find an apt analogy of an approach to critical care is that of Ibn Ahmad al-Ayni (d.855), a classical scholar and analyst, who asserted that the field of Tibb al –ilaj, or therapeutic medicine, was motivated by the desire to support the body to retain its natural healthy state, analogous to the “premorbid” state oft-quoted in health settings (5) . It is this notion that describes the supportive and restorative component that intensive care medicine offers. In essence, intensive organ “support” treatments are merely temporising measures to ensure actual treatment of underlying conditions, to help patients regain their health during periods of critical illness. This has helped contextualise treatments when discussing with both Muslim and non-Muslim patients and their families.
It is often a difficult decision to withdraw treatment from a patient, regardless of their religious background; by and large these decisions are made in a multi-disciplinary setting (including patients’ relatives) and with some evidence base. Often patients come with unrealistic expectations of what intensive care units can offer in the treatment of patients. Anecdotally, there have been several occasions whereby clinicians have felt intimidated by the passion and sheer number of relatives of patients from Muslim backgrounds. However, I believe that a responsibility we must convey to both junior and senior Muslim clinicians is to be assertive with themselves in what their religion advocates, just as much as they are with what their local and national regulatory bodies do. This, I believe, is the key to the Muslim workforce flourishing in areas such as the treatment of critically ill and dying patients, as well as educating our community at large, including our fellow clinicians.
|Mutayaqqin||Certainty of cure or recovery||Nutrition and hydration||Sinful if such means not taken|
|Maznun||Probable/expected >50% chance||Most evidence based medical treatment||Not sinful, potentially rewarding if taken with intention of being the Sunnah (way) of the Prophet Muhammad – peace be upon him|
|Mawhum||Imagined/illusive <50% chance||Therapies with little/no evidence base to their effectiveness i.e. some herbal/home therapy||Permissible. Better to rely on the will of Allah|
Table 1 – Principles of Shari’ obligations in seeking medical treatment, adapted from Withdrawal of Treatment and Brain Death: Advanced Cases, Dr Shaykh Rafaqat Rashid, Al Balagh Academy, 2017.
1-Office for National Statistics. 2011 Census: Population Estimates for the United Kingdom, 27 March 2011.
2-Mahdi, S et al. Predictors of Physician Recommendation for Ethically Controversial Medical Procedures: Findings from an Exploratory National Survey of American Muslim Physicians. J Relig Health 2016 Apr;55(2):403-21. doi: 10.1007/s10943-015-0154-y.
3-Deuraseh, N. Health And Medicine In The Islamic Tradition Based On The Book Of Medicine (Kitab Al-Tibb) Of Sahih Al-Bukhari. JISHIM, 2006: pp.2-14.
4- No majority view on assisted dying moves RCP position to neutral, RCP 29th March 2019 https://www.rcplondon.ac.uk/news/no-majority-view-assisted-dying-moves-rcp-position-neutral
5-Al-`Ayni. Umdah al-Qari Sharh Sahih al-Bukhari, 25 vols. (Beirut: Dar Ihya’ al-turath al-`Arabi, n.d); 21: 229