COVID-19: The Pandemic, the Muslim Physician and Authentic Reflection

by | Aug 26, 2020 | 0 comments


 

Abstract

Medicine and medical education have reduced reflection and its practice to a means of assessment and formalised it as an aspect of professionalism, which itself has become reduced and misunderstood in modern thinking. In doing so, this has led to a lack of engagement with authentic reflective practice for the healthcare worker. Muslim physicians, who belong to a faith that considers existential reflection a necessity, are also subject to the impacts of the reduction of reflection to an instrument or tool. However, when considering the true scope of reflection, it seems that the COVID-19 pandemic may provide a suitable environment for self-engagement and authentic reflection to prosper once more. In turn, particularly for the Muslim, physicians may see improved holistic practice and the betterment of patient-doctor relations. 

Introduction

“So, undoubtedly, along with hardship there is ease. Undoubtedly, along with the hardship there is ease.”1

Debate regarding the ontology of medicine, that is the identity to which it should depend upon and also therefore the manner of practice it should adopt, is a longstanding and well-discussed topic in medical literature2-7. The value of these discussions cannot be overstated, however it ought to be recognised that the pluralism that has consequentially developed has left the physician with a ‘fractured’ and arguably ‘impoverished’ identity8,9. Among the losses experienced by the physician, ‘reflection’ has been prominent. This piece aims to establish a working foundation with which to understand reflection for the Muslim physician, while outlining how the COVID-19 pandemic may allow for the individual to reflect more authentically.

In an increasingly reductive and instrumentalist field, the notion of reflection as well as the intention with which it is used has fallen victim to the capitalist sense of production that pervades many, if not all, aspects of healthcare10.  In a field now governed by targets and efficiency, reflective practice has become a means of assessment11, foregoing virtues and aspects of true holistic development such as ‘healing’ or ‘courage’. In response to challenges and moral dilemmas, the physician therefore no longer sees reflection as an end in itself and a means to navigate the troubling but rather operates in a manner that sees them “pinball from one moment of crisis to another”12, with little time for self-engagement.

Muslim healthcare workers, despite belonging to a tradition that promotes existential authenticity13, are no exception to this reality. In the light of the COVID-19 pandemic and the significant impact it has had on the physician, both as an individual but also as a doctor, discussion regarding reflective practice is warranted.

Authentic Reflection for the Muslim Physician

What then is ‘authentic reflection’? And why should it matter to the physician or Muslim? Though it is difficult to establish a definition that encapsulates the scope of this action, it may initially be considered an amalgamation of concepts such as Kant’s “reflektierende Urteilskraft”14 or Aristotle’s “phronesis” 15, denoting an active and practical wisdom. Kant (an eighteenth century German philosopher and rationalist), in describing reflection, states “it is a peculiar talent which can be practised only, and cannot be taught”14 and this presents a suitable foundation for building a framework within which to understand reflection. It is of interest to also note that Aristotelian phronesis encompasses cognitive, reflective and affective aspects of decision-making, highlighting the integral role reflection has in wise behaviour16.

For the Muslim, there are further complementary aspects from within the Quran and hadith as well the work of philosophers, past and present, that may be of benefit in beginning to comprehend the value and necessity of reflection. When considering the “pseudo-reflection”17 begotten by modern medicine, a stoic approach may seem to be a direct solution. While this approach, orientated in actions of ‘journaling’ and ‘rumination’, is indeed of value18, it ought to be considered removed from authentic reflection, particularly for the Muslim. Further, the value of such a stoic approach is restricted and reduced by the formalisation of the reflective process, which affects the physician’s willingness to engage fully with reflective practice as fears of repercussions and a perception regarding a lack of confidentiality prevent truthful reflection which is predicated upon vulnerability19. 

Authentic reflection may only take place when self-reflection is grounded in the subjective experience, distinct from the objective narrative approach stoicism advocates for, formulating “emotional movement”18. The engagement of one’s emotions and the allowance to feel sadness and other associated emotions was a practice that Muhammad (PBUH) himself did not shy away from. At the time of his son Ibrahim’s passing, the Prophet (PBUH) responds to questions regarding his emotional state as follows:

“Do you not hear, Allah does not punish for the shedding of tears or the grief of the heart but punishes or bestows mercy for the utterances of this (and he pointed to his tongue)”20

“This is mercy.” Then he wept more and said, “The eyes are shedding tears and the heart is grieved.”21

Thus, for the Muslim practitioner, it is evident that emotions are of value and worthy of attention, despite the unwritten rulings and culture of both healthcare and the communities within which Muslim healthcare workers exist which may otherwise deny ‘permission’ to feel to the physician. Medical education must also hold responsibility for this reality, as it promotes positivist objectivity at the expense of ‘soft skills’ – the term itself connoting the lesser importance and apparent ‘weakness’ of such skills. 

From these hadith, one may even argue that the necessity of engagement with emotions is of even greater value for the Muslim, as the Prophet (PBUH) suggests that working through the ‘grief of the heart’ is a necessity if one wishes to be able to behave in a holistic manner, at peace with themselves, and therefore find themselves a recipient of the mercy of their Lord. This is synonymous with the concept of ‘self-awareness’ that is proselytised in literature regarding medical professionalism22. Indeed, the mercy that is received may also account, in part, for the transformative and relieving properties included within the action of reflection.

Moreover, within Islamic philosophy, reflection is considered a deep-rooted and contemplative endeavour. It is clear from the work of Al-Ghazali that reflection is a predicate to truly meaningful and content existence23. The Algazelian prescription of ‘muhasabah’, that is the active engagement of the self, provides the Muslim physician with a further tool with which to understand authentic reflection. Here, the individual both recognises turmoil and the associated emotions brought forth before journeying towards an acceptance of their struggle. In turn, this leads to a grounded reconciliation of an event and its associated troubles with one’s beliefs, leading to solace, comfort and the potential to flourish. Thus, reflection, especially for the Muslim, may be considered a liberating, transformative and enlightening experience. An experience which allows the agent to feel ‘whole’, allowing for the development of resilience, perseverance and passion. This growth may even allow the physician to have a more sustainable commitment and become more highly achieving within their field24,25.

COVID-19 and Reflection

Medicine and healthcare are tied to the politico-cultural and economic environment in which they operate26. The interaction and impact of these factors, alongside many others, is complex and discussed in-depth in medical literature. For the individual, the COVID-19 pandemic has affected all aspects of society. Ethical, political and cultural concerns have dominated headlines, while religious practice has also been greatly impacted as congregational prayers, pilgrimage (Hajj) and the month of Ramadhan have all required alterations, ranging from the withdrawal of prayers in the masjid to the cancellation of a once in a lifetime pilgrimage to Makkah for those outside of local borders. 

As societal axioms and customs are challenged and the spiritual homes of the Muslim are closed to them, an accumulative plethora of ethical and existential crises have ensued27-29. In addition to this, the physician must also face the difficulty of working within a healthcare system that has its own dilemmas. The ideals to which they treat patients seem distant as challenges arise in the current climate, such as healthcare rationing30 and the disproportionate impact of COVID-19 on BAME individuals31. These factors amount to a cumulative and additional existential taxation for the physician, particularly when considering their duty but also their identity as a human, as a Muslim and as a doctor. This “meaningless suffering”18 or anguish, as per Kierkegaard – a nineteenth century Christian philosopher considered the ‘father of existentialism’, seems overwhelming and paralysing in its description, even before the inclusion of wider concurrent global issues such as racial inequality, poverty and the climate crisis all of which have remained intensely discussed themes in everyday life. 

“That was a means of torture which Allah used to send upon whomsoever He wished, but He made it a source of mercy for the believers, for anyone who is residing in a town in which this disease is present, and remains there and does not leave that town, but has patience and hopes for Allah’s reward, and knows that nothing will befall him except what Allah has written for him, then he will get such reward as that of a martyr.”32

The above hadith has been heavily advertised in Muslim circles and recounts the words of the Prophet (PBUH) when asked for guidance regarding a pandemic. While many have focused on drawing their attention to the pragmatic nature of the allusion to aspects of quarantining and lockdown, the engagement with the Prophet’s (PBUH) call for patience has been oft overlooked or underappreciated.

Sabr or صَبْرٌ‎ (patience) is not merely the passive passage of time but an active endeavour, akin to persistence or perseverance. It is the nature of the Semitic languages for terms to hold layered and extensive meaning and this word holds within its semantic grasp aspects such as ‘resilience’33, ‘toughness’34 and ‘grit’19, all of which are regarded as invaluable characteristics formed under immense stress and stimuli. Authentic reflection is the necessary predicator to such a consistent approach or even the integral first step of such an approach, holding within its action the virtues of ‘moral courage’ and ‘wisdom’, which both relate to Aristotle’s conceptualisation of ‘phronesis’ or ‘practical wisdom’17.

In amidst the overwhelming nature of the pandemic and unable to escape from its grasp, the Muslim physician is placed in a unique position as they become an “agent-experient”35. In the face of increasing demands and stresses, the principles of ‘slow medicine’ somewhat paradoxically take hold, predisposing the individual to reflect authentically and conscientiously. The individual has little choice but to navigate through their feelings rather than dismiss or steer past them. In this process, the Muslim physician has the benefit of being able to look back at the examples of the Prophets and Sahabah themselves and aim to seek spiritual guidance from their Lord. 

The accessibility of these role models provides the Muslim with a favourable opportunity with which to develop their reflective practice and orientate oneself within the active practice of wisdom36. Moreover, a common theological concept in the Abrahamic tradition is that at man’s lowest point, when there seems to be no hope left, God may directly intervene and inspire man to raise him to a better standing than before. If this is to be believed, the Muslim can consider the opportunity afforded to them to begin a practice of authentic reflection the means by which to raise their station and character, allowing them find ease that verily comes following, if not during, hardship.

Conclusion

Self-care and self-actualisation may be considered an ethical obligation both within the Islamic faith and a healthcare setting. This pandemic has the potential to perpetuate the growth of this practice once more. Reflection, particularly for the Muslim physician, is a predicate to achieving such an outcome. In reference to social justice, Hamza Yusuf states that the Muslim is not responsible for the outcome of their efforts, rather they are accountable simply for the struggle itself37. This statement holds true when considering the issues Muslim physicians may face in facets of their healthcare practice but also in daily life. 

Within a secular framework, recent literature advocating for ‘slow medical education’ or ‘slow medicine’ indicates there is an alternative method to the journey and education of becoming a doctor. Proponents argue that actions such as reflection, among others, allow for the doctor-in-training to develop a holistic approach to healthcare – an approach centred in human understanding and dignity that allows for the most appropriate existential pace as a physician37. It follows that if the Muslim healthcare worker can more readily incorporate reflection into their spiritual daily practice, then the benefits that start within themselves could hold the key to a better standard of medical consultation and practice – one that recognises the humanity and suffering of both the doctor and the patient and allows for ‘healing’ to take hold once more.

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