Abstract
The Ethics was not a separate discipline in the early Islamic era because all the oral values were already embedded in Islamic jurisprudence. Nevertheless, the importance of the manners, especially for physicians, prompted Ishāq ibn `Alī al-Ruhāwī t write Adab al-ṭabīb (Ethics of the Physician), t e earliest extant book that is fully dedicated to medical ethics. This and subsequent writings on the subject were devoted to the character of physicians and their relation to t e patients. This can be described as character ethics. In the modern era, medical ethics among Muslims became directed to dealing with the moral questions arising from ever- increasing new medical developments that challenged the old concepts in many ways, especially in the areas of reproduction, beginning and end of life and organ transplantation. While in the West, the resolution of these moral issues is based on secular reasons, Muslims should also consider whether a certain action is Islamically permissible. Muslim scholars are called upon to issue fatāwā (opinions), relying on scripture and reason guided by historically developed legal principles, regarding the permissibility of the actions in question. The study of these issues and their judicial status can be described as judicial ethics. This article discusses the evolution of Islamic medical ethics from its origin in character ethics to its incorporation of judicial ethics. It also discusses the judicial principles that form the bases of these fatāwā.
Introduction
Ethics is derived from the Greek word Ethikos, which is derived from the root word ethos, meaning customs, norms or manners. The closest Arabic word for ethics is akhlāq.
Ethics was initially limited to the personal character of the individual. As societies developed and individuals became grouped in professions, the concept of ethics developed to include certain codes of behaviour for the different professions, most notably the medical profession. Healthcare essentially entails direct and personal interaction with other individuals when they need help and are in emotional and physical distress. Physicians deal with human beings, the most honored of God’s creation, when they are most vulnerable due to sickness. Thus, they should have higher moral standards. In Islam, these good manners have been embedded in the culture as they were part and parcel of the Islamic teachings. Medical practice rules were simply dictated by the general rules of Islamic morals and conduct. Ethics discourse was thus not treated as a separate discipline. The Qur’an is replete with passages describing the character traits and morals that are pleasing to God and specifying which actions are permissible and which are prohibited.
God commands justice, doing of good and liberality with relatives and forbids all indecent deeds, evil and rebellion: He instructs you that may receive admonition. [Glorious Qur’an, 16:90]
When Allah wanted to praise His messenger, He chose to praise his character:
And you (stand) on an exalted standard of character. [Glorious Quran, 68: 4]
In addition, there are many aḥādīth, collectively called the Sunnah, that guide Muslims to a virtuous life. In one hadith, Prophet Mohammad said “The best among you are those who have the best manners and character” [1]. It is also narrated that Prophet Mohammad said, “I was sent to perfect good character” [2].
Qur’anic teachings and Prophetic sayings constitute the basis for the sharī`a (Islamic jurisprudence). Significantly, many of the Prophet’s aḥādīth discussed health and disease, encouraged seeking cure through spiritual and natural medications available at the time as well as by seeking the help of a qualified ḥakīm (physician).
Until the latter part of the twentieth century, ethics continued to be guided by these divine rules and prophetic guidance. With significant advances in medicine, many unprecedented modes of treatment and hitherto unknown techniques and procedures became available. In Islam, every human action can be characterized as ḥalāl (permissible) or haram (prohibited). Thus, these new procedures and treatments required judgments on which ones were acceptable from the Islamic point of view. These posed challenges to the Islamic scholars who could not find rulings that adequately fit them. Ethics thus had to evolve. In addition to the general moral principles applicable to all Muslims (character ethics), the discipline of ethics required the study of all new issues and deciding on its juristic implication (judicial ethics). Muslim scholars had to rely on ijtihād (personal judgment to reach a decision) to decide on matters not explicitly mentioned in either the Quran or Sunnah, the two main sources of Islamic law.
This article reviews the early writi gs of Muslims regarding ethics and medical ethics a d more recently their attempts to make judicial rulings and how they reach these rulings regarding the use of the new modalities. It also compares and contrasts the way they do that with how Western scholars deal with the same.
Historical emphasis on physicians character and conduct
The importance of good character of physicians has been expressed from antiquity. Hippocrates wrote about the moral character of the physicians, but early Muslim scholars were the first to dedicate complete books on the subject. Al-Rāzī“ wrote a companion to Kitāb al-Mansūrī dedicated to the ‘reformation of the character’ and entitled it al-Tibb al-rūḥānī(Spiritual Medicine). In this work, he details how one can elevate his character by controlling his passions and casting away vices [3].”Yuhannā ibn Māsaweh wrote a book on the same subject, called Miḥna al-ṭabīb (“The Challenge of the Physician”). Both of these early books are lost [3]. The first book that survived is that of Isḥāq ibn `Alī al- Ruhāwī, entitled Adab al-ṭabīb (“The Ethics of the Physician”) [4]. Al-Ruhāwīwas born in Ruhā (Urfa
today) in north western Iraq in 854 A.D. and passed away in 931 A.D. An English translation of a manuscript found in Istanbul by Martin Levey has been published [5] Adab al-ṭabīb is divided into 20 chapters. The significance al-Ruhāwī’s book was also discussed in recent publications [3,6].
A later book that addresses morals was written by Abū `Alī Aḥmad ibn Muḥammad known as ibn Maskaweh (940 – 1030 AD) almost a century after al-Ruhāwī. The book is titled Tahthīb al-akhlāq wataṭhīr al-a`rāq (“Refinement of morals and purification of lineage”) [7]. Although this book is not specific to physicians, it shows the importance Islamic scholars gave to akhlāq.He states that, if the actions of the human being are less than what he is created for by not adopting the morals outlined in the sharī`a, he will be undermining his honored status among other creations of God. He then discusses in detail the virtues that one should acquire and the vices and bad characters one must avoid. The moral person does what he does not for worldly benefit but for God’s love. He advises each person to investigate himself to detect deficiencies and work hard to correct them.
The following section contains highlights of al-Ruhawi’s Adab al-ṭabīb, based on the edition edited by Marīzī Sa`īd Marīzī`Asīrī [4]. Page numbers are italicized in brackets.
Highlights from Adab al-ab b
The medical profession is the most noble of professions.The physician who seeks the profession should do so for its sake, not just for earning a living. Such a physician will get lasting satisfaction and joy, in addition to a good living. He will have an excellent reputation, people will respect him, and he would be close to Allah and His Pleasure. [208]
Not everyone can be taught to be a physician. Only those who are of good character and ability to endure long studies and continued learning should enter this profession. Physicians are very responsible people. In other professions, if a mistake is done, it can be corrected. However, with physicians’ mistakes, the patient’s health or even life can be lost, and the damage often cannot be corrected. Physicians must be tested before they are allowed to practice, with emphasis on both the theoretical (basic sciences) and practical aspects (technical skills). [242-4]
The physician should be skilled in eliciting symptoms and in looking for signs of diseases[184]. He should use a pharmacist that he trusts for making the medications he uses. Yet, he should be familiar with the preparation of the medications whether simple or complex and whether the medications whether simple or complex and whether they deteriorate in efficacy or become harmful over time. [174-6]
The physician should encourage the patient or his helpers to be frank with him. They need to tell the physician whether mishaps occur, be they errors in the use of the medications, in the preparation of foods or in following his instructions so the physician can try to fix what went wrong in time to avoid complications. Physicians should consult with each other if needed.[198]
Al-Ruhāwī stressed the importance of the good moral character of the physician. He should not be envious, hateful, greedy or arrogant. He should be forgiving, kind, humble and thankful. He should take pleasure at well- deserved praise he has earned from grateful patients. Al- Ruhāwī cautions physicians against praise given by evil people. He urges them to ignore criticism as long as they are doing the right thing. [164-5]
In addition to his professional skill and good behavior, the physician should take care of his own hygiene and physical appearance. He should always be clean and be sure he has no mouth or body Odor. He must observe his dietary habits. He should be cutting his nails and excessive hair on his head and face. It is not polite of him to expectorate, yawn or stretch himself in public. The physician must take care of his clothes. They must be clean and be garments of beauty, especially, when he is near people of status. The physician must guard his five senses. No foul word should be heard from him. He must guard his sight, not beholding anything vile unless it is necessary. He should not be listening to uneducated people or to statements of the wicked. He should instead frequent assemblies of the virtuous, lettered and learned. [157-9]
The physician should follow a strict schedule in his daily activities including a limited amount of sleep. He divides his day between prayer, remembrance and thanking of Allah, studying and visiting the patients both at their homes and in his office. [159-60] The physician must be just and merciful to the weak and the poor. As he provides good care and consideration for the rich and powerful, he should do the same for the poor, even if they cannot compensate him financially. [287] It is not correct for the physician to earn property by trade since that holds him back from the further pursuit of knowledge. [240] It is not in the best interest of the physician to occupy himself with play and playthings which may make him weak-minded and silly. Flattery is not fitting for the physician since it is of the morals of the common people. Envy is not good for the physician since it causes him to fall from his high position. [277-8]
The physician must be thankful to God that He bestowed on him these bounties. He should be sincere in his worship of Allah. Similarly, people should honor and give due respect to physicians. It is bad if a patient asks for help from God and fro a physician and then, once he is cured, that patient fails to thank God appropriately and treats the physician with disdain. Some patients hate their physicians because they tend to advise against indulgence in vices and other pleasures. [191-2]
Physicians have to prepare themselves for getting old, weak or incapacitated by paying attention to proper diet and exercise so that, as they age, they remain capable of taking care of their patients. Al-Ruhāwī advises the physician to be careful with his money so as to save some for old age. [282-3]
While many of these recommendations and advice seem quite sensible and obvious to us at present, it is noteworthy they were state and combined in a detailed way in a book written about eleven hundred years ago.
Adab literature as the vehicle for universal virtues
The genre of writings in the Islamic world dedicated to akhlāq has been called adab literature. Adab literature calls to universal virtues in the medical profession while using Islamic terms and do trines.[3] Al-Ruhāwī’s Adab al-ṭabīb is the earliest extant example of this. A more recent example of adab literature is a medical code of behavior from the Islamic perspective that was synthesized byan international conference on Islamic Medicine held in Kuwait in 1981.
This Kuwait Declaration consists of eleven parts. It incorporates these universal ideas but expresses them through Islamic principles and texts. Another, more recent example of adab literature is Arafa’s “Ethics of the Medical Profession from the Islamic viewpoint.” It lists personal qualities: “sincerity, honesty, truthfulness, compassion and sympathy, patience and tolerance, and humility [3]”. In this paper, I refer to the aspects of medical ethics adab literature addresses as character ethics.
Islamic Medical Ethics
Islamic Medical ethics with its two branches, character ethics and judicial ethics, comprises a set of moral rules and principles which guide a member of the medical profession as to how to discharge his/ her professional responsibilities, and to what procedures he/she can perform. In Western societies, these rules are based only on human thought and intellect with no role for religion. On the other hand, in Islamic societies, these rules and morals draw their legitimacy from divine guidance. Muslim jurists consider actions permissible or impermissible. They further classify the permissible into the subcategories of obligatory, recommended, neutral (mubāḥ) and discouraged.
When the judicial status of an action is unclear, Muslim jurists practice individual and collective rational, logical reasoning (ijtihād) within the universal sharī`aguidelines and in fulfillment of one or more of its maqāsid (objectives) to opine on if it is permissible or not, and whether there are some conditions that are necessary to make it permissible, or on the other hand, circumstances which render the impermissible permissible. These opinions are called fatāwā. The objectives of the sharī`a are preservation of religion, life (and health), intellect, progeny and resources. This ijtihād in the context of medicine can be called judicial medical ethics. Kasule called it medical jurisprudence (al-fiqh al-tibbi)[8] and described three stages of its evolution. “During the first period (0 to circa 1370 AH[1951 CE]), it was derived directly from the Qur’an and the Sunnah. In the second period (1370-1420 AH[1951-1999 CE]), rulings on the many novel problems arising from the significant changes in medical technology were derived from secondary sources of Islamic law, either transmitted as analogy (qiyās), scholarly consensus (ijmā`) or reason (istiḥsān, istisḥāb, oristslāḥ).” Reason was formalized into istiḥsān (judicial preference between two or more values), istisḥāb(presumption of continuity) and istslāḥ(consideration of public interest). These tools, specifically qiyās, frequently failed to adjudicate in cases with drastic medical advances on which there were no precedents to draw. This led to the modern era (1420 AH / 1999 CE onwards), characterized by use of the theory of maqāsid al-sharī’a (purposes of the law) to derive the opinions. Kasule called this method ijtihad maqāsidi (independent judgement based on the purposes of the law).[8]. Kasule stated that this theory has to be supplemented by five major principles of Islamic jurisprudence:
- Intention: It requires pure and sincere intention in all medical decisions and procedures.
- Certainty: decisions are to be evidence-based and not based on subjective feelings. Or at least the evidence is preponderant
- Injury: requires careful balancing of the benefits of an intervention versus its side effects
- Hardship: allows medical procedures and therapies that are normally prohibited if there is a necessity such as saving a life
- Custom (`urf) or precedent: using generally accepted protocols and procedures [8].
The four principles of bioethics and the Islamic judicial ethics
The significant medical and technological advances of today brought us face to face with new challenging ethical and moral issues. In the secular West, ethicists depend on their individual r collective rational to make the moral judgement concerning these challenges. The most accepted principles used in this regard are those developed by Beauchamp and Childress[9]
These are autonomy, beneficence, non-maleficence, and distributive justice. Autonomy means that a person makes his own decisions about treatment, etc. as long as he understands the different options, benefits and risks.
In effect, he must give informed consent for any test, procedure or treatment. Beneficence means that, whatever the health provider does, its intent must be the benefit of the patient. Non-maleficence is the prohibition of doing harm to others. Distributive justice requires a fair distribution of benefits and burdens. This includes allocations of healthcare resources.
These principles are in general agreement with Islamic principles.These four principles are implied in the Qur’an and aḥādīth. Allah says:
We have honored Adam’s children. [Glorious Qur’an, 17:70]
A person’s divinely enshrined honor bestows the right to make his or her own decisions and choices (principle of autonomy)
Prophet Muhammad is reported to have said, “The most loved of people in the sight of Allah are those who are the most beneficial to others” [10]. This is termed beneficence in our lexicon of today.
A ḥadīth says: “No harm or reciprocating harm” [11].“Even in the case of being harmed, Islam advises not to reciprocate harm for vengeance [12].”An Islamic principle states that “every action that leads to harm or that prevents a benefit is forbidden”. One of the Islamic jurisprudence axioms is: “Avoiding harm takes precedence over bringing good.” If one expects an action to result in a similar amount of benefit and harm, one should avoid the action. If, however, the expected benefit outweighs considerably the expected harm, then one could proceed [12]. These instructions represent non- maleficence.
Muslims consider justice to be a foundational principle. Allah says:
If you judge among people, judge with justice. [Glorious Qur’an, 4:58]
In a ḥadīth, Prophet Muhammad quotes his Lord:
Verily I have made oppression unlawful for Me and for My servants too, so do not commit oppression [13].
In fact, three of the four principles developed by Beauchamp and Childress [9] are found in one passage of the Qur’an [16:90] cited above. “Commands justice” may be compared to distributive justice. “Liberality with relatives” connotes beneficence, and forbidding “evil” connotes non-maleficence.
Based on the above, it appears that these four principles of Beauchamp and Childress are in general agreement with Islamic principles. In fact, Askoy and Elmali state that these principles “are being ap lied in Islamic traditional and cultural societies” [14].
However, there are differences in interpretation and application of autonomy in particular. In Islam, it is permissible to override a patient’s refusal of critical treatment that could sav his life, such as blood transfusion in the face of uncontrollable hemorrahage. Saving a life is a more important goal than respecting autonomy.
On the other hand, it may be possible to abide by the patient’s choice even if it is not in his best interest. For example, the patient may choose a treatment that the physician thinks is inferior to the treatment the physician recommended.
Also, respect for autonomy (of the patients) is overruled by a beneficent action in situations where the public safety (health) is jeopardized. One can prefer the beneficial effects of a decision within a community over the autonomy of an individual(s) such as preventing the spread of an infectious disease by imposing restrictions on the individual(s).
Muslim patients like to and should be allowed to consult with their family members or religious leaders regarding their treatment and follow t eir advice. “In the context of research, women around childbearing age are oftentimes encouraged to consult with and obtain consent from their spouses and family before participating in research as subjects, given the priority of the familial unit over the individual self [15].”
Van Bommel stated that “For a Muslim patient, absolute autonomy is very rare, there will be a feeling of responsibility towards God, and he or she lives in social coherence, in which influences of the relatives play their roles. [16]”
A Muslim physician, out of concern for the patient, will sometimes advise avoiding behavior detrimental to health and well-being [12], in effect negating his autonomy.
In a recent paper, Mustafa wrote “although the underlying essence of an individual’s autonomy is something which can be said to be intrinsic to the Islamic faith, the practical outward manifestations with relation to public interest, and the ultimate view of the human being’s subservience to God contrast significantly with the Western philosophical model” [17]. Several publications provide a more detailed discussion of the place of autonomy in Islamic discourse [12,14-8]
Recent Activity in the Field of Islamic Medical Ethics
Muslims can reach answers relating to the acceptability and utilization of the new medical advances based on Islamic teachings through the methods described above [8]. There have been many attempts to resolve these questions through plural fatwas. Conferences of physicians, scientists and religious scholars from different countries and schools of thought have been organized to achieve that goal. Examples of these are meetings organized by al-Azhar University, Cairo, Egypt [19], The Society of the Islamic Medical Sciences, Amman, Jordan[20], and the Islamic Organization of Medical Sciences (IOMS), Kuwait [21,22]. The proceedings of many of these conferences have been published. Similar conferences have been arranged in USA by the Islamic Medical Association of North America (IMANA) [23] and the Initiative on Islam and Medicine [24]. The Federation of Islamic Medical Associations (FIMA) has published yearbooks in a series entitled “Encyclopedia of Islamic Ethics” since 2011 [25].In addition to such conferences, several books have been recently published such as Islamic Perspectives in Medicine [26], Islamic Biomedical Ethics: Principles and Application by Abdulaziz Sachedina [27],Islamic Bioethics: Problems and Perspectives by Dariusch Atighetchi [28],Medical Ethics: An Islamic Perspective by Mohammad Iqbal Khan[29] and Medicine and Shariah: A Dialogue in Islamic Bioethics, a collection of articles edited by Aasim Padela [30] .Presentations were made, and papers were published [31-6].
Discussion of these modern ethical issues is beyond the scope of this paper, but examples of the issues discussed includebrain death, beginning and end of life, living wills, organ donation and transplantation, euthanasia, termination of pregnancy, assisted reproductive technologies, stem cell research and cloning [31-3,35-6].
Muslim physicians are getting more involved in clinical research. Past experience of abuse of humans included in medical research has prompted many international organizations including Islamic medical organizations to establish ethical guidelines for clinical research. The evolution of this subset of medical ethics has been described elsewhere [37].
Acknowledgements
The author declares that he has no competing interests and there was no funding to support the work.
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