Islamic medical ethics is the methodology of analysing and resolving the ethical issues that arise in healthcare practice or research based, on the Islamic moral and legislative sources (primarily Quran and Sunna), and aims at achieving the goals of Islamic morality. Islamic ethics upholds “the four principles” of biomedical ethics. However, there are some differences in the applications of these principles. The aim of this paper is to briefly highlight the principles and characteristics of Islamic medical ethics.
Keywords: Bioethics, Islam, Medical Ethics, Morality.
Since the second half of the 20th century, “Bioethics” has become a relatively new topic for Islamic scholars resulting in engaging discussions throughout the Islamic world. In short, bioethics is a study that examines the moral basis of human behavior in medical fields. (1)
Islamic medical ethics is an extension of Shari’ah (Islamic law), which is itself based on 2 foundations: The Qur’an (the holy book of all Muslims), and the Sunna (The Tradition of Prophet Muhammad including his sayings, acts and approvals). When no clear rule is found in the Quran or Sunna, “Ijtihad” or “Qiya’s” is contemplated. This is analogical reasoning that allows the jurists to extrapolate fresh decisions from a case already known through the Qur’an or the Sunna which shared similarity with the new case for which the solution had to be found.).
National, as well as international Islamic organizations, have been conducting thorough examinations of contemporary issues in medical ethics. There are several universal principles in the field of ethics that are considered to be essential guidelines. Many of these principles have even published Fatwas (decrees) and in-depth studies to help clarify the many issues that have emerged.
The objectives and aims of Islamic rules (Shari’a) are: preservation of faith, preservation of Life, preservation of mind (intellect, reason), preservation of progeny (al-nasl), preservation of honor (al-irdh) and preservation of property. Given the wide range of ethical commands in Islam, Islamic ethical tradition devotes a special attention to the medical practice to ensure that such practice adheres to the Islamic Shari’a (Law).(3)
All nations have common principles in morality and ethics. (2) The source of these moral and ethical attitudes, from Islamic point of view, can be traced back to three main sources: Intuitive Reasoning or al-fitra (innate nature ), faculty of Reasoning or al-‘Aql and Divine Revelation or (Al-wahy, Tanzil). (1)
Pillars of Islamic Medical Ethics
The first pillar, Fitra, refers to the innate nature of a human being; encompassing the good and the bad qualities. Across different cultures, both past and present, humanity has common views on certain issues, which can be attributed to human nature. In every person, there is an innate intuition that can guide him/her to right or wrong in, at least, the basic morals. Without having to consult any religious beliefs or laws, it is a known fact that killing innocent human being is an abominable act.
The second pillar is “Aql” (Reason, Intellect): that is a guide used to think critically and distinguish right from wrong. God endowed humanity with the ability to use reason to differentiate between right and wrong, and to discern the proper course of action. Those who refuse to use their minds and follow their egotistic desires, and blind themselves with self-importance follow their instincts and hedonistic desires and deviate from the true path, becoming unable to minimally distinguish right from wrong. To be sure, even if they know the truth of the matter, they are inclined to follow their carnal desires and lust for material ends and tramp over whatever remains of their conscience. (1) In Islam, God tells people that Reason is what separates them from the behavior of animals, and is used to keep impulses at bay, should they arise.
The final pillar is “Wahy” (the revelations and guidance of God, carried by his prophets to the people). The ‘Oneness of God’ is the doctrine that states that there is one God, a singular divine being. In Islamic belief, revelation or inspiration is God’s Word delivered by his chosen individuals known as Messenger prophets. It is traditionally thought that God sends these prophets to people who carry revelations that are used to direct their lives. Historically, the first prophet was Adam, and the last one was Muhammad Peace Be Upon Him (PBUH). To truly understand Islamic traditions, one must realize that this is a means of guidance toward the true origin of humanity and the final return to God. All schools in the Sunni (majority sect of Muslims) Shari’ah (Islamic law ) are dedicated to the study of how “Wahy” guides the first two pillars and protects everyone from corruption. Wahy also focuses on the possibility of how to restore the masses to the way they existed before, in their prime unaltered form. (1)
Islamic medical ethics also upholds “the four principles” of biomedical ethics proposed by Beauchamp and Childress. According to this approach, the four general principles of biomedical ethics are: (1) Respect for autonomy, (2) Beneficence, (3) Non-maleficence, and (4) Justice.There is different emphasis, however, on the individual principles compared with the classical understanding of them in the Western Bioethics.(4, 5)
The need for Medical Ethics
Medical ethics is becoming an important part of the medical curriculum today. The clinical years of medical student education are an ideal time for students to learn, practice and develop ethical thinking and behavior. (6) Doctors’ ethical issues are usually seen in their communication with patients and about limited healthcare resources attempting to use in the most cost-effective way. Ethical issues arise far more frequently than most young doctors would have anticipated when they were medical students. During an average day of a doctor, there may be no ethical dilemmas at all about genetic testing, cloning, or end-of-life care. However, they are exposed to seeing patients misinformed about the purpose of the procedure, breaking bad news at times to their patients, maintain confidentiality or keeping proper relationship with their colleagues and other health care providers.(7)
Preservation of life
The first main principle of Islamic Medicine is the emphasis on the sanctity of human life which derives from the Qur’an: “whoever slays a soul, unless it is for manslaughter or for mischief in the land, it is as though he slew all men; and whoever keeps it alive, it is as though he kept alive all men ” (Qu´ran: 5: 32). According to this verse, saving life is an obligation and the unwarranted taking of life is a major crime.
The doctrine teaches that no one has the right to kill an innocent soul. The belief that killing an innocent person is equal to killing the whole of humanity is deeply rooted in the religion. Islam oversees immense wealth used to compensate the victims of unintentional murder, also given the name Diyha (money payable in respect of unintentional homicide ). Years ago, the Diyha was worth 100 camels of different ages and specifications. In more modern times, the value of the 100 camels is determined by the Shari’ah Court. Medical treatment involving the usage of pork, blood, or alcohol is also prohibited. However, if there are no alternative means to preserve the life of human being, the usage of those substances will be allowed under the supervision of a trusted Muslim physician.
The second main principle is the emphasis on seeking a cure. This derives from a saying of
Prophet Muhammad (PBUH): There is no disease that God has created, except that He also has created its treatment.(8) The Prophet (PBUH), in another narration, is also reported to have said: “Seek treatment, for God the Exalted did not create a disease for which He did not create a treatment, except senility”.(9)
It is interesting to note here, that the Hadith is meant to give hope to patients and one should take any proper road to his/her recovery and do whatever can be done to move in a positive direction. One should keep fighting and not become unnoticed and cast aside. The Prophet Muhammad (PBUH) actually sought out clinicians to treat patients according their best knowledge. He also advised his followers to do the same to maintain their good health, which was seen as a gift from God. The prophet himself sought remedy and described medicaments of his time to his family and followers.
During recent years, the preservation of health has become a critical issue and some measures have been implemented in its promotion. Curative medicine is far more expensive than health preservation which cuts the amount of money given to medical companies.(10) In other not-such-controversial matters, it is agreed that one should always stay healthy, and seek out remedies should he gets ill, although disease is considered to be a natural phenomenon that expiates sins.
Seeking remedy in Islamic jurisprudence may be obligatory (mandatory) in certain lifesaving situations or may be preferred or encouraged (mandoob) in other situations. It may be facultative or optional and may be (makrooh), that is, discouraged, and in some situations or a certain type of treatment it may be (haram), that is, not allowed. Seeking remedy is facultative (optional) or (mobah) where the benefit is not proved or even doubtful and where ill effects of that mode of therapy are uncertain. It may be (makrooh) when therapy is unlikely to bring benefit and where harm or even inconvenience from the therapy may exceed its benefit. (11)
In Christianity, apart from the few that deviate, it was preferable not to treat illnesses. Instead, it was customary to depend on one’s faith in God’s omnipotence, which, in fact, directly contradicted the actions of Jesus who always helped the sick, injured, and the demented.
Rules of Medical Practice
Motive, an integral part of concept of morality, defines the inner impetuses of a person showing his/her true intentions to God. If they had good intentions, but in the end caused more harm than good; it would probably go unpunished. The Prophet (PBUH) said: “Actions are to be judged only by intention.”(12) The good intentions were the redeeming factor. Thus, the character of a person becomes particularly crucial in the entire sphere of the healthcare system. In the world of medicine, where, at times, logic can be flawed and unfair, specific rules and guidelines must be firmly established. For example, what actions are considered wrong and what deserves punishment or compensation must be determined in advance. To be trusted, the system must have some legitimacy to it. The legal boundaries will often clarify the most complicated situations since they are based on common sense and rational behavior. However, there will always be those gray areas that are set by cultures and religions. In Islam, the guidelines, legal or not, come from the Qur’an and Sunnah. These rules have specific criteria which carefully explain how to handle almost any situation. (5) The Prophet Muhammad (PBUH) said: “Whoever practices medicine when he is not known for that, he is liable”. (13) In the Islamic history, no one had the right to practice medicine without a certificate or approval provided by the Muhtasib (the controller of physicians ). The physician who is lacking sufficient knowledge in his/her field will be fully responsible for his acts, and often punished for his mistakes. If the physician, however, follows all the rules and procedures but harm occurred to the patient, the physician is not liable.
Abdulmalik ibn Habib (al-Andalusi) (d:238H/853G) wrote one of the first books on Al-Tibb Al-Nabawy (Prophet Medicine) that discussed the ethics of medicine. He stated that physicians should not only be liable if they make a mistake, but must be liable if they practice medicine at all without the sufficient teaching and training. (14)
Medical practitioners must be sufficiently qualified to inform the patients of their conditions and options. It is the job of the physician to have empathy for their patients and to care for their recovery and mental well-being. This is true even if the methods of help are futile; the medical team is responsible to help their patients to come to terms with the onset of death and make peace with that expected outcome. (15)
Medical Ethics Principles
If a medical practice is to be considered “ethical,” it must include all these principles: autonomy, justice, beneficence, and non-maleficence. These premises are deeply rooted in the Islamic verses. (4,5)
The oath of Hippocrates’ is used to guide a physician to do only what is in the best interest of the patient. It is stated that the medical professional should be treated as if he/she was a family member; only acting on what needs to be done; not what the patient wants to be done. This philosophy was rejected by an increasingly liberal system in the West during the 1970’s. They opted to give the patient the liberty to choose his course of action.
Autonomy literally means self-rule. The Qur’an clearly declared that “there is no compulsion in religion”. (Quran 2:256) and that each person has the full will to accept Islam or refuse it. Van Bommel also says: “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) Consequently, personal choices are only accepted if they are the “right” ones.(4)
The patient has the right to be well informed to make decisions about his/her treatment. The informed consent should be obtained with free will without coercion. In modern Islamic bioethics, the family plays an essential role in the decision- making process as does the patient. It is similar to the methods used in other eastern cultures like India and Japan, much to the opposition of more liberal communities who value autonomy above all else. This is especially true in the case of major operations that may cause death. The decisions about resuscitation, organ transplantion, or abortion are clear examples where the family of the patient deserves to be included in the decisions. (15) This is especially true in the Islamic culture. If the patient is deemed to have a mental deficiency or when a guardian refuses the treatment; it is the responsibility of a magistrate of the government to make medical decisions. Except in cases when there is a life or death situation, the consent of the person being treated or his/her guardian, if the patient is incompetent, must be obtained. (17)
Non-maleficence is an essential part of morality and bioethics. If an action results in both good and harm, it is preferable to prevent causing harm. Furthermore, if a good outcome outweighs the harm in a situation, the action can be completed and accepted. The Prophet Muhammad said, “La Dharar wa la Dhirar” (There should be neither harming nor reciprocating harm). (18) In his book, “Qawa’id Al Ahkam” “Basics of Rulings,” Al Izz ibn Abdul Salam (d:660H/1262G), an Islamic jurist, stated that the aim of medicine is to preserve health and to provide a cure when it is needed. At times, in order to reach this goal, the lesser harm must be accepted to avoid greater damage. The eventual goal is for the patient to benefit from the treatment. (19) As a result, prohibited treatments can be permitted when they are deemed necessary and when there is no alternative. This rule applies to taking medicine containing porcine material or alcohol. If there is no alternative, the safer treatment is the best choice.
There are five major maxims of particular significance to medical practice and to the field of Islamic medical ethics. (20) One of them is Al-Mashaqqatu Tajlibu Al Taiseer (Hardship begets facility). Several legal principles were derived from this maxim, especially those, which relate to the concepts of darurah (necessity) and hajah (need). Among them is the rule “Al-daruratu tubihu al-mahzurat (necessity makes the unlawful lawful). However, committing the otherwise prohibited action should not extend beyond the limits needed to preserve the purpose. For example, the use of morphine or similar drugs is allowed in the cases of chronic pain if no alternatives prove to be effective. (20)
Beneficence is so intimate to the principle of non-maleficence. The term beneficence implies acts of mercy, kindness, charity, altruism, love, and humanity. There are many verses in the Qur’an that orders Muslims to “enjoin the right and forbid the wrong” when considering that the true nature of man (al-fitra) is to be good.
Justice is often regarded as being synonymous with fairness. A great importance is paid to justice by the Holy Qur’an. The main purpose of sending the prophets was to establish justice in the world. The Qur’an says: “Indeed We have sent Our Messengers with clear proofs, and revealed with them the Scripture and the Balance (justice) that mankind may keep up justice.”( Quran 57:25). Justice is not only a supreme virtue but also a command from God. Qur’an says very openly that “God commands justice (principle of Justice), doing of good (principle of beneficence), and giving to kith and kin, and forbids all indecent deeds, and evil (principle of non-maleficence) and rebellion: He instructs you that may receive admonition” (Quran 16:90).
The physician must help everyone without consideration of faith, skin color, or social status.
Islamic medical-ethical Code
The Islamic medical-ethical code that is used today is primarily based on Galen’s work and the Hippocrates oath (16). Necessary changes were made to fit with the ethos of Islam today and coincide with the Qur’an and Sunnah. The original Greek code had many facets that coincided with Islamic sources, especially in the case of juridical matters. It often mirrored what is seen in the Qur’an and Sunnah today, such as the accountability of physicians regardless of their expertise or status. The code also includes a religious statement that one must always be conscious of his/her duty to God and His Prophet. A physician, it states, should follow the rules of Islam in private and in public: “O Allah, grant me the strength, patience, and dedication to adhere to this Oath at all times”. This whole process started during the time of Abbasid Caliphate (Al-Muktader) when the high physician took the Hippocrates oath. After altering it to fit his religion, he was able to keep the same premise of its original meaning (1, 16).
Because of the interconnections between Islamic law and Islamic ethics, Islamic medical ethics has to consider requirements of the Islamic law (Shari‘ah) in addition to moral considerations. Islamic medical ethics empower and support Muslim physicians when they encounter health care
dilemmas. When facing a medical problem, a physician has to decide for his /her patient in light of available knowledge, experience of his/her peers and consensus of the medical community. In addition, a Muslim physician derives his /her conclusion from rules of Islamic laws (Shari`ah) and Islamic medical ethics.
- Al-Bar MA, Chamsi-Pasha H. Contemporary Bioethics: Islamic perspective. New York: Springer Publishing; 2015.
- Beauchamp T, Childress JF. Principles of biomedical ethics. 7th edition. New York: Oxford University Press; 2013.
- Shabana A. Religious and cultural legitimacy of bioethics: lessons from Islamic bioethics. Med Health Care Philos 2013; 16: 671-7
- Mustafa Y. Islam and the four principles of medical ethics. J Med Ethics. 2014 Jul;40(7):479-83.
- Chamsi-Pasha H, Albar MA. Western and Islamic bioethics: How close is the gap? Avicenna J Med. 2013 Jan; 3(1): 8-14
- Chamsi-Pasha H, Albar MA. Islamic medical jurisprudence syllabus: A Review in Saudi Arabia. Med J Malaysia. 2017 Oct;72(5):278-281
- Chamsi-Pasha H, Chamsi-Pasha M, Albar MA. Pragmatic message to junior doctors. Postgrad Med J 2016; 92(1089): 418-20.
- Sahih al-Bukhari, Book 79, Kitaab al-Tibb, Chapter 1, Hadith 5354.
- Sunan Abi Dawuud. Vol. 2, Book 27, Kitaab al-Tibb, Chapter 1, Hadith 3855
- Miller G, Daly M,Roehrig C.Tradeoffs in cardiovascular disease prevention, treatment, and research. Health Care Manag Sci. 2013 Jun; 16(2): 87–100
- Chamsi-Pasha H, Albar MA. Ethical Dilemmas at the End of Life: Islamic Perspective. J Relig Health 2017 56(2): 400-10
- Sahih al-Bukhari. Book of Revelation. Hadith 1, vol. 1.
- Sunan an-Nasa’i, Book 45, Hadith 125.
- Al-Bar MA. Comments on: Abdulmalik ibn Habib. AlIlbeiri Tibbi Nabawi. Damascus: Dar alQalam; 2017 ( 3rd edition).
- Chamsi-Pasha H, Al-Bar MA. Doctor-patient relationship. Islamic perspective. Saudi Medical J 2016. 37(2): 121-26.
- Van Bommel A. Medical ethics from the Muslim perspective. Acta Neurochirurgica Supplement. 1999; 74: 17–27.
- The International Islamic Jurisprudence Council, OIA. 1992-2009. Fatwas and Decisions: Fatwa No. 7/5/67 on Consent of the Patient. The 7th session, 1992. Fatwa No. 171/10/18. The 18th Session, 2007. Fatwa on Consent in urgently needed operative intervention. Decision No. 184/10/19. The 19th Session. Jeddah: Book of Decisions; 2009.
- Sunan Ibn Majah Vol. 3, Book 13, Hadith 2341.
- Al Izz ibn Abdul Salam. Qawa’id Al Ahkam. [commented by Nazih Hammad and Othman Dhamariyah] Damascus: Dar al Qalam; 2012 ( 2 volumes).
- Chamsi-Pasha H, Al-Bar MA. Principles of Islamic Medical Ethics. JBIMA. 2019 April, Vol. 1 – No. 1.( www.jbima.com)