ACADEMIA Letters Medical Ethics form the Perspective of a Moslem Patient Abdulla Al Khader Al Sayyari, King Saud Bin Abdulaziz University for Health Sciences We are witnessing advanced and rapid medical development in many Moslem societies. These developments, inevitably, create more and more complicated medical ethical dilemmas. Moslem doctors have not kept abreast in developing suitable ethical discourses or frameworks to cope with, tackle and understand these ethical dilemmas from Moslem patients’ perceptive. They have not been able to adequately satisfy and respond to the questions, queries and concerns raised by Moslem patients and their relatives whenever medical decisions with ethical components and dimensions need to be made. Doctors dealing with Moslem patients, generally, resort to ethical standards and principles that are based on Western/secular ethical philosophy to reach ethical decision-making. They , particularly, utilize the Four Principles of bioethics, , the deontological ethics theory, the utilitarian ethics theory as well as the basic rights and duties theories as developed by secular ethics. They always use these theories as a backdrop to reach an ethical medical decision and indeed in order to argue, discuss and interact with their patients and the patients’ families in order for them to reach decision with their doctors. Such a secular approach often works because many moral beliefs and values are universally shared. However, it may not work for our patients as they look at ethics from different religious, societal and traditional prisms. We know, for example, that illness and cure perceptions have differing cultural influences on them. Moreover, in Islamic thoughts autonomy is not absolute and is restricted by some Islamic tenets and rules and “duties” are perhaps more stressed than are “rights”. Indeed, our patients are more likely to accept a given ethical decision if it were discussed with them using Islamic, social values and perceptions than if it were presented to them using Academia Letters, January 2021 ©2021 by the author — Open Access — Distributed under CC BY 4.0 Corresponding Author: Abdulla Al Khader Al Sayyari, aaalsayyari@gmail.com Citation: Al Sayyari, A.A.K. (2021). Medical Ethics form the Perspective of a Moslem Patient. Academia Letters, Article 150. https://doi.org/10.20935/AL150. 1 secular discourse despite many overlaps in such discussions. Writings on applied medical ethics concerning Muslim patients are rare. In those that are available, the writings are generally of theoretical nature, are not made by actively practicing physicians and do not address actual medical cases or how to answer specific questions often raised by Moslem patients and their relatives. Such questions are often religiously or societally loaded. Moreover, in my experience as an ethics teacher to medical students and medical residents in Saudi Arabia, it has been my consistent observation that virtually all the medical students view ethical issues through the prism of Islamic Shari’a of which they know quite a bit through school curricula , familial and societal interactions . As a result, they respond immediately in any discussion on bioethical vignettes or dilemmas by invoking what they think (rightly or wrongly) are the Islamic viewpoint on that dilemma. As such some lecturers may have a tendency or an inclination not to delve deeply into the moral arguments surrounding dilemmas at hand. We, however, never found this problematical and get the students to garner more moral insights by asking questions like “but why do think Islam has taken this particular viewpoint?” Or “can you think of any other genuinely Islamic view that might arrive at entirely different conclusions to the one you just mentioned?” Or “but you may, at some time in the future, be looking after a non-Moslem patient. Don’t you think that you ought to know about other ethical or secular approaches that will enhance your care of such a patient?” . We found that they, rather than objecting to such discussions, in fact, enjoy them and get deeply involved with them. Doctors dealing with Moslem patients need to reflect on the concerns and objections of the patients and their relatives and address them from the ethical and religious point of view: For example 1. How would you respond to relative who would say that he does not mind his father suffering – as,according to Islamic view, accepting suffering patiently will erase the father’s sins? 2. How would you respond to relative who would say that a relative should not be given bad news as according to the Prophet’s teaching sick people should be given comforting news? 3. How would you respond to relative who would insist on his relative getting a futile treatment since, there is always hope in Allah’s miraculous cure? 4. How would you respond - form Sharia point of view - to a relative who is not satisfied with prioritizing patients or in resource allocation when it negatively affects his relative? Academia Letters, January 2021 ©2021 by the author — Open Access — Distributed under CC BY 4.0 Corresponding Author: Abdulla Al Khader Al Sayyari, aaalsayyari@gmail.com Citation: Al Sayyari, A.A.K. (2021). Medical Ethics form the Perspective of a Moslem Patient. Academia Letters, Article 150. https://doi.org/10.20935/AL150. 2 5. How would you respond to relatives who might say: (a) You are telling me that you want my father to have “good death”. I do not know what that means and it means nothing to me” (b) “You are telling me that you want my father to “die with dignity” ”. I do not know what that means and it means nothing to me” (c) “You are telling me that you do not want my father to suffer, but suffering – according to Hadith- will erase his sins?” (d) “You are telling me that you think that further treatment for my father will be futile. How do you know this without trying it first? (e) “you are telling me that you think that further treatment for my father will be futile but as you know , Allah is kind and can do anything” (f) “You are telling me that you think that doing CPR on my father has only 5% to succeed. Well, 5% chance is better than nothing” (g) “ I know you doctors, you want to save money for the hospital by not getting my father to the ICU. Sorry but my father deserves to be treated regardless of the cost. If you want me to pay for him to go to the ICU, I will “ Is it time that we develop a protocol of delivering bad news to Moslem patients and their as opposed to suing the Western approach? I believe the answer should be yes. Such an approach should take into account things like 1. Based on Islamic teaching (a) The meaning of illness and suffering in Islam (b) The perception of cause and cure of illnesses in Islam (c) The concept of miraculous curesin Islam (d) Every disease has a cure concept in Islam (e) What is the Islamic view about “futility” concept in secular ethics (f) Islamic guideline 1: i. Simplify matters; do not make them hard or difficult. Tell the good tidings; do not convey frightening ones,“ (g) Islamic guideline 2 Academia Letters, January 2021 ©2021 by the author — Open Access — Distributed under CC BY 4.0 Corresponding Author: Abdulla Al Khader Al Sayyari, aaalsayyari@gmail.com Citation: Al Sayyari, A.A.K. (2021). Medical Ethics form the Perspective of a Moslem Patient. Academia Letters, Article 150. https://doi.org/10.20935/AL150. 3 i. “He who visits a patient whose moment of death has not yet come, and says seven times “I pray to Allah the great, Lord of the Supreme Throne to heal you”, Allah shall heal him of his disease” (h) Islamic guideline 3 regarding conveying bad news to a Moslem patient i. In an article titled “ To convey a sense of a hopelessness to a patient in his prognosis is a mistake that requires accountability” that appeared in the “Journal of Contemporary Jurisprudence Research Issue 109; 1438, the authors concluded that to be kind to the patient and not cause despair in him about his prognosis is a moral duty of the doctor and to cause hopelessness in the patient is a grave and infringement of the doctor’s duty 2. Based on societal outlook (a) Relatives not wanting the patient to know (b) Impact on and by families (c) Expectations versus reality (d) “Familial autonomy” versus “personal autonomy” approach 3. Emphasizing spiritual aspects (a) Should we have an Islamic scholar in the team delivering bad news. When a new medical advancement leads to an ethical dilemma, often a fatwa ( religious opinion) is sought from prominent religious scholars. A fatwa may state that the situation in question is permissible (”halal”), impermissible and sinful (”haram”), or improper but not haram (”makrouh”). Also, a basic tenet of Islam is that actions are considered halal unless stated as otherwise in Islamic Sharia. The primary source of reference for reaching a fatwa is the holy Quran. The next most valuable source is the “hadith,” which describes the sayings and actions of the Prophet Mohammed. If neither of these contains a reference to the issue in question, the scholar looks for precedence in the actions of the prophet’s companions (”sahabah”). Failing this, the scholar uses “ijtihad,” meaning he passes his own opinion as a best guess based on intuition. For ijtihad, most conservative scholars use “naql” (following previous thoughts and ideas almost literally) whereas more open-mind-ed scholars use “aql” (logic, commonsense. Another aspect of reaching a fatwa is the use of “qayas,” or comparative inference. As an example, Islamic scholars based their fatwa that permitted organ transplantation on the following considerations: Academia Letters, January 2021 ©2021 by the author — Open Access — Distributed under CC BY 4.0 Corresponding Author: Abdulla Al Khader Al Sayyari, aaalsayyari@gmail.com Citation: Al Sayyari, A.A.K. (2021). Medical Ethics form the Perspective of a Moslem Patient. Academia Letters, Article 150. https://doi.org/10.20935/AL150. 4 • Altruism: Like other major religions, Islam advocates and encourages altruism. Organ donation is one of the clearest examples of altruism; • The concept that avoiding harm transcends attaining good; • The belief that human life is sublime, as expressed clearly in Surah Al-Maeda, the chapter of the Quran entitled “The Feast.” “When one saves a life it is as one has saved all mankind”; • Need is considered the same as necessity. Therefore the need for an organ equals a necessity; • Necessity permits the doing of forbidden things. Academia Letters, January 2021 ©2021 by the author — Open Access — Distributed under CC BY 4.0 Corresponding Author: Abdulla Al Khader Al Sayyari, aaalsayyari@gmail.com Citation: Al Sayyari, A.A.K. (2021). Medical Ethics form the Perspective of a Moslem Patient. Academia Letters, Article 150. https://doi.org/10.20935/AL150. 5