With the rapid growth of the field of medicine to the modern era, commercialization and consumerism gave rise to an unhappy patient population. Some physicians see their patients as customers, and medicine is sometimes, turning into a market place. A good patient-physician relationship is linked to patients’ satisfaction and treatment adherence, which ultimately leads to better outcomes.

Obtaining informed consent is the first step to proper communication respecting the patient’s values. Protecting confidentiality and breaking bad news are among the most challenging tasks facing physicians. When treating a Muslim female patient, recognizing and understanding her concerns about modesty is invaluable. The Muslim doctor should be fluent with the Islamic teachings on practical daily issues faced in his/her practice. Building a fruitful physician-patient relationship is a vital part of successful medical care, and one of the most complicated professional responsibilities of the physicians.


 Over the years, the patient-physician relationship (PPR) has dramatically changed due to commercialization, quality of healthcare services offered in the government set-up, and privatization of the health sector. Doctors may, nowadays, ask for unnecessary investigations or may give over-prescriptions, just to be safe. There is also a remarkable decline in human touch or empathy; and a significant rise in unhealthy competition among doctors.1

The ideal PPR has six components, namely voluntary choice, doctor’s competence, good communication, continuity, doctor’s empathy, and the absence of a conflict of interest. A poor PPR, on the other hand, has been proved to be a major hurdle for both doctors and patients. In the case of poor PPR, patients show poor compliance with doctor’s advice; they may practice doctor-shopping by frequently changing their doctors; remain anxious; may choose quacks or other non- scientific forms of treatment; and result in a significant increase in medical expense .2
The first consultation with a patient is the beginning of a doctor-patient relationship. Hence it is of major importance to conduct this in a proper way. In the hospital ward, the PPR is far more complex, since many other people are involved when somebody is sick. These include patient’s relatives and neighbours, nurses, technicians, social workers and administrators.3

Despite worldwide emphasis is on the responsibility of physicians, teaching the art of physician-patient relationship has not yet been incorporated into the curriculum of many medical schools.4

Factors like poor communication skills of the doctors, doctors not listening to their patient’s complaints, and a mismatch between the doctors’ objectives and patients’ expectations, have together created a wide gap in the PPR which caused a massive impact on the trust and bonding level between doctors and patients.5 Modern medical science is technology-base and there is investment behind the technology. Many doctors do not think of the low socioeconomic condition of their patients. The patients, therefore, think of the doctors as avaricious and hungry for money.6

Without a full understanding of the cultural background of the patient, it is impossible to build an effective relationship with the patient.The doctor must feel the distress of the patient and do his best to eradicate the disease the patient suffers from and not only the symptoms of the disease.

Over the years, the relationship between doctors and patients has evolved from a largely paternalistic model to a more interactive relationship. The principles of autonomy, beneficence, informed consent, patient’s access to medical information, and medico-legal concerns all now influence the doctor-patientrelationship.7 The UK General Medical Council published “What to expect from your doctor: a guide for patients”. The guide is a provisional step trying to patients getting the best outcome from the interaction with their physicians.8
Physician’s manners in Islam
Medical practice is considered a sacred duty in Islam, and the physician is rewarded by God for his good work. Al Izz ibn Abdul Salam, a renowned Islamic jurist (d 660H/1243 CE) in his book “Qawa’id al Ahkam (Basics of Rulings)”, said: “The aim of medicine, like the aim of Shari’ah (Islamic law), is to procure the maslaha (utility or benefit) of human beings, bringing safety and health to them and warding off the harm of injuries and ailments, as much as possible”. He also said: “The aim of medicine is to preserve health; restore it when it is lost; remove ailment or reduce its effects. To reach that goal it may be essential to accept the lesser harm, in order to ward off a greater one; or lose a certain benefit to procure a greater one”.9 This is a very pragmatic attitude, which is widely accepted, in Islamic jurisprudence, and it is frequently applied in daily practice in all fields including medicine.
The Quran and sayings of the Prophet Muhammad Peace Be Upon Him (PBUH) established morality and mode of conduct of physicians and surgeons. The Prophet gave many rules regarding seeking remedy, and the importance of consent. The Islamic jurisprudents required from the practitioner to be competent and obtain licensed to practice. He also should get the consent of the patient or his guardian if he is not competent, otherwise he would be liable.
The Quran and Sunna teach the Muslim physician the importance of possessing good “khuluq” (Manners) which incorporate mercy, patience, tolerance, kindness, and honesty, while avoiding pride, arrogance,and anger.10
One of the earliest and most thorough books on medical ethics is entitled “Adab al-Tabib” (Practical Ethics of the Physician) by Ishaq al-Ruhawi. Al-Ruhawi was a contemporary to Abu Bakr Al-Razi and lived in the second-half of the ninth century A.D.This book was translated to English by Martin Levey in 1967 (Transactions of the American Philosophical Society). Al-Ruhawi stated that the true physician is the one who fears God; the word fear here encloses love and respect. His conscience is his censor, and he is aware that God’s eye is ever watching.
Al-Razi has also written a book fully devoted to medical ethics called “Akhlaq al-Tabib” (Medical Ethics). To help establish such opinions in a well-organized book over a thousand years ago is quite significant. Besides, these ideas still maintain their validities nowadays and are laid down in several ethical codes of medicine.11,12

Patients and students of medicine frequently complain about attending physicians who want to spend the minimal time with them and lack patience in answering their worries or queries. The physician should always be honest, benefit his or her patients, and speak kind words to others. The Sunnah warns against pride and arrogance, two major transgressions that have marked modern medicine. The Prophet (PBUH) said: “Allah will not look, on the Day of Resurrection, at a person who drags his izār (garment) [behind him] out of pride and arrogance.13
With the advancement of diagnostic medical technology, many modern physicians refer their patients for sophisticated investigations without even performing a physical examination, thus failing to treat the patient as human and instead treating the patient as a number or a disease to be dealt with as rapidly as possible. Many medical codes of ethics request that physicians waive their fees for poor patients. In reality, waivers are often granted to rich and powerful patients who could provide physicians with societal benefits.10 The Prophet (PBUH) said: “Feed the hungry, visit the sick and set free the captives”.14 The medical profession is unique in that the client should not be denied the service even if he cannot afford the fee.
Empathy is the ability to understand an individual’s subjective experience. It plays a major role in establishing a good physician-patient relationship.15 Enhancing a physician’s empathy may be the key to attending to health-related religion and spirituality needs of the patients.16
The doctor should always honor the high standards of his profession and hold it in the highest regard, never prescribing to activities of propaganda, or receiving a commission or similar misdoings. It is imperative for a Muslim doctor to always remember the Prophet Muhammad saying: “The best among you are those who have the best manners and character”.17
The Holy Qur’an and Hadiths of the Prophet Muhammad are full of verses and sayings of the Prophet enjoining doing good and refraining from doing harm.18 The Qur’an says: “So whosoever does good equal to the weight of an atom (or a small ant), shall see it. And whosoever does evil equal to the weight of an atom (or a small ant), shall see it.” 19
If medical necessity or emergency puts a needy person under his care, the Doctor should be considerate and kind, and avoid his fees if any being a further burden atop of the ailment. For as you give the poor it is God you are giving and alms giving is not only due on material possessions but on knowledge and skills too. The sphere of a Doctor’s charity, nicety, patience and tolerance should be large enough to encompass the patient’s relatives, friends and those who care for or worry about him but without of course compromising the dictates of “Professional Secrecy”.20,21He should avoid wrongdoing, not abusing his/her stat for monetary gain, and not misleading his/her patient because God does not love the liars and wrongdoers.22 The Prophet (PBUH) said: “Those who have a perfect faith are those who have the best character”.23Islamic ethics instructs human beings not only to be virtuous, but also to contribute to the moral health of society. The Qur’an says “You enjoin what is right and forbid what is wrong”.24 The character of the Muslim is exemplified in a verse of the Holy Qur’an saying: (“Indeed, Allah orders justice and good conduct” … and “forbids immorality and bad conduct and oppression”).25 The characteristic features of a virtuous physician are firmly rooted in the Qur’an and the Sunna.
Patient’s family
One major factor that must be considered in the care of Muslim patients is the importance of the family. Visiting family and friends in the hospital is extremely important in Islam. Muslims are required to visit those who are sick or injured and provide patients and their families with comfort and support. The teachings of Islam dictate that Muslims not only meet with those who are ill but also converse with them, provide words of encouragement, and pray for their well-being and prompt recovery. This important obligation is vital to the care of Muslim patients, and measures should be taken to accommodate these visitations.26,27
However, it is important to recognize that these events may provide additional stress to the nursing staff or adjacent patients sharing semiprivate rooms.21

Informed Consent
Obtaining patient’s permission prior to delivering medical treatment is obligatory in Islam if the patient has full legal capacity, or their legal guardian if the patient is a minor. This is only if the treatment prescribed is permissible. However, according to the International Fiqh Academy (1992), consent is not required if the treatment and the medical procedures are needed in emergency to save a life, or organs, when the patient is unconscious or a minor, and no guardian is available, or in cases of contagious diseases and preventive immunizations ordered by the health authorities. Similarly, consent is not required if a minor’s legal guardian refuses to give permission and it is clearly detrimental to the patient under his/ her guardianship. While this may be different to the conventional law in medical practices, it is derived from the principles of fiqh (Islamic Law), “harm should not be inflicted nor reciprocated” (laadhararawalaadhiraar), and “public interest should be prioritized over personal interest” (al- maslahah al-‘am tuqaddam‘alaa al-maslahah al-khassah).
Hence, refraining from treatment is an act of misconduct if the treatment is obligated, and preventing misconduct is an obligation upon all Muslims.28,29
Dress Code
The Qur’an tells both men and women to ‘lower their gaze and guard their modesty’ and further addresses women to ‘not display their beauty and ornaments except what (must ordinarily) appear thereof.30 Muslim women often choose to cover their hair with a scarf called a hijab, and it is essential that physicians respect this decision and allow them to do so whenever possible. For example, even when going to the operating room for surgery, it is preferable to allow a Muslim woman to wear her hijab in addition to the hospital gown. If this is room Hospital staff could offer to keep the curtains drawn, or the door closed. Another effective way is a ‘knock, wait, enter’ policy by which staff knock, wait for permission and then enter patient rooms. It must be stressed that the clinician uncover only that part of the body that needs to be examined, and cover those that are not part of the exam or have been examined already.31
Avoiding unnecessary exposure is an important priority. Muslim women are encouraged to wear loose fitting clothing that can be stretched to allow adequate exposure for examination while maintaining as much coverage as possible. Although a patient may be unconscious, covering the genital area in the operating room with a surgical towel during skin preparation is also encouraged and conveys an additional element of trust between the patient and the surgeon.21,26
Physical Contact between the sexes
“Khalwah” is defined as the situation where a ‘man and a woman are both located in a closed place alone and where sexual intercourse between them can occur’. This situation is prohibited between non-mahram (a very relative or husband) adult members of opposite sexes in order to prevent the accusation, and committal of, illicit relations.
Most Islamic scholars believe that a patient seeking non urgent treatment should choose a physician according to the following order of decreasing preference: Muslim of the same gender, non-Muslim of the same gender, Muslim of the opposite gender, non-Muslim of the opposite gender. For a Muslim woman, it could be very stressful to expose her body in front of a male physician, or even to discuss with him sensitive issues related to her health. It is quite common for the husband to ask to stay with his wife during a physical examination. Having a female nurse available for examinations may help a Muslim woman to feel more comfortable, and is mandatory in all countries in the world.21,29
Islamic law does allow for deviation from normal regulations in cases of need and emergency. All Muslim scholars state that necessity allows things that are ordinarily forbidden to be permissible. Ibn Qudama, a renowned Hanbali scholar, writes: ‘‘It is permissible for the male doctor to inspect whatever parts not permitted, using a surgical head and neck covering can allow a woman to maintain her sense of comfort and dignity without compromising hospital and operating policy.26 of the woman’s body that the medical examination warrants.’’ Ibn Muflih, also of the Hanbali school state: ‘‘if a woman is sick and no female doctor is available, a male doctor may treat her. In such a case, the doctor is permitted to examine her, including her genitals.’’ Scholars are also clear that female doctors may fully examine male patients in cases of necessity. In all cases, a third party of the same gender as the patient is required to be present for the examination.29,32 Physical contact outside of the examination should always be approached with caution. Understanding a Muslim woman concerns about modesty is invaluable in developing appropriate physician-patient relationship.
Breach of confidentiality under certain conditions is justifiable in Islam. Examples include reporting, to the assigned authorities, probable criminal acts (such as domestic violence or child abuse), serious communicable diseases or circumstances, which pose a threat to others’ lives (such as an epileptic patient working as a driver), notification of births and deaths, medical errors, and drug side effects. If the patient agrees to disclose the close complexity of his medical condition to the family, then there is no breaking of confidentiality. If a consort has an HIV infection, then the physician’s duty is to inform the other consort of the true diagnosis. The doctor should take the permission from the infected person, or ask him to tell his consort, in his presence, the true diagnosis.29 In a fatwa issued by the International Islamic Fiqh Academy in 1993, jurists affirmed that a breach of confidentiality can be acceptable only if the harm of maintaining confidentiality overrides its benefits. The fatwa describes some situations in which breaching confidentiality is allowed, or mandatory.33 “Such cases are of 2 categories: a) Cases where confidentiality must be broken on grounds of the rational of committing a lesser evil and obviating the greater one, and the rational of seeing to a public interest, which favor enduring individual harm so as to prevent public harm if needed. These include 2 sets: Those which involve protecting society against some prejudice, and those which involve protecting an individual against some prejudice. b) Cases where confidentiality may be broken: 1) To ensure a public interest. 2) To prevent a public damage. In all such cases the objectives and priorities are set out by Shari’ah (Islamic law) regarding preserving the faith, human life, reason, descendants, and wealth”.34,35
Breaking Bad News
Healthcare workers in Muslim communities are to modify the Western-based recommendations to match the culture of their patients and their families.36 Several problems arise when physicians break bad news; some of which are specific to Muslim countries. Breaking bad news would ideally require lengthy preparation and adequate time. However, due to patient overload, time is a luxury many physicians in Muslim countries do not possess. Besides, physicians in Muslim countries require culture-specific training to break bad news and this is not currently incorporated in the medical curriculum in the majority of developing countries.37Junior doctors usually spend more time with their patients than their senior colleagues. Because of their limited clinical experience, junior doctors may have an unjustifiable level of conviction about a patient’s imminent death. They have not seen yet the patients recovering from a situation where death seemed to be inevitable.38
Physicians working in Muslim communities are required to balance between the patient’s rights to be informed (autonomy) and the relative’s request to avoid emotional distress to the patient, and thus define the magnitude of bad news that the patient desires to know and act accordingly.37

During the meeting he should pay special attention to the body language of the patient and his/her family. Is the patient afraid, stressed, or at ease? Does the patient have a religious background? In patients who have strong religious views, physicians should stress the positive and optimistic religious statements such as, “Everything is in the hands of God”.
Asking for Advice
Sometimes the patient may say to his doctor: “What is your advice in my condition? What would you do if your parent was in my situation? The physician may feel embarrassed, but he/she should be honest and give the sincere advice. The matter may be more complicated when the patient relegates the decision-making to the doctor saying: “Look I have trust in you, and whatever you decide I will accept.” The physician should be tactful and try to explain the situation and give information to the patient and/or his family, and reach with them the course to be taken. As far as he can make it, the physician should explain that the decision should be in the hands of the patient and his family. He might help by giving all the required data, and give his personal advice.21
In cases where the patient does not want to know the required diagnosis, the physician should discuss the condition fully with the family, and let them try to persuade the patient, at least to take part in the decision-making .In patients who prefer a non-disclosure approach, physicians are encouraged to stress a paternalistic approach such as; “Don’t worry, I will do everything possible to improve your health” or “You’re in good hands.”.36

The question of confidentiality will crop up here, if the family gets to know the details of the ailment and its management. If the patient agrees to divulge the intricacies of his medical condition to the family or proxy, then there is no breaking of confidentiality, as it is done after getting the consent of the patient himself.29
Medical practice is considered a sacred duty in Islam and the physician is rewarded by God for his proper work. Despite the efforts of many medical universities to reform their medical curriculums and implement communication skills, it seems that many doctors do not appear to build effective relationships with their patients. Some doctors are reluctant to improve communication,
which is one of the crucial elements of treatment. The only and sole interest the doctor should consider, is the best interest of his/her patient. The importance of the have intimate personal relationship between the physician and the patient cannot be over emphasized.

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