0810-Professionalism: An Islamic Perspective
Paper presented by Professor Omar Hasan Kasule Sr. MB ChB (MUK), MPH (Harvard), DrPH (Harvard) Professor of Epidemiology and Islamic Medicine at the Institute of Medicine University of Brunei and Visiting Professor of Epidemiology at University Malaya EM and WEB: http://omarkasule.tripod.com at the Scientific and Islamic Medicine Seminar organized by the Students’ Executive Board Faculty of Medicine Deponegoro University held on Sunday 19th October 2008n at the Central Java Governors’ Hall Semarang Java Timur Indonesia
ABSTRACT
This paper presents the main elements of proper behavior and etiquette by a Muslim physician
1.0 PHYSICIAN ETIQUETTE, adab al tabiib
1.1 Good doctor etiquette with patients and their families’
Bed-side visits
The physician-patient interaction is both professional and social. The bedside visit fulfills the brotherhood obligation of visiting the sick. The human relationship with the patient comes before the professional technical relationship. It involves reassurance, psychological and social support, show of fraternal love, and sharing. A psychologically satisfied patient is more likely to be cooperative in taking medication, eating, or drinking. The following are recommended during a visit: greeting the patient, dua for the patient, good encouraging words, asking about the patient’s feelings, doing good/pleasing things for the patient, making the patient happy, and encouraging the patient to be patient, discouraging the patient from wishing for death, nasiihat for the patient, and reminding the patient about dhikr. Caregivers should seek permission, idhn, before getting to the patient. They should not engage in secret conversations that do not involve the patient.
Etiquette of the care-giver
The caregiver should respect the rights of the patient regarding advance directives on treatment, privacy, access to information, informed consent, and protection from nosocomial infections. Caregivers must be clean and dress appropriately to look serious, organized and disciplined. They must be cheerful, lenient, merciful, and kind. They must enjoin the good, have good thoughts about the patients and avoid evil or obscene words. They must observe the rules of lowering the gaze, and seclusion. Caregivers must have an attitude of humbleness. They cannot be emotionally-detached in the mistaken impression that they are being professional. They must be loving and empathetic and show mercifulness but the emotional involvement must not go to the extreme of being so engrossed that rational professional judgment is impaired. They must make dua for the patients because qadar can only be changed by dua. They can make ruqya for the patients by reciting the two mu’awadhatain or any other verses of the Qur’an.
Caregivers must seek permission when approaching or examining patients. Medical care must be professional, competent, and considerate. Medical decisions should consider the balance of benefits and risks. The general position of the Law is to give priority to minimizing risk over maximizing benefit. Any procedures carried out must be explained very well to the patient in advance. The caregiver must never promise cure or improvement. Every action of the caregiver must be preceded by basmalah. Everything should be predicated with the formula inshallah, if Allah wishes. The caregivers must listen to the felt needs and problems of the patients. They should ask about both medical and non-medical problems. Supportive care such as nursing care, cleanliness, physical comfort, nutrition, treatment of fever and pain are as important as the medical procedures themselves and are all what can be offered in terminal illness. Caregivers must reassure the patients not to give up hope. Measures should be taken to prevent nosocomial infections.
Etiquette of interaction between genders
Both the caregiver and patient must cover awrat as much as possible. However, the rules of covering are relaxed because of the necessity, dharurat, of medical examination and treatment. The benefit of medical care takes precedence over preventing the harm inherent in uncovering awrat. When it is necessary to uncover awrat, no more than what is absolutely necessary should be uncovered. To avoid any doubts, patients of the opposite gender should be examined and treated in the presence of others of the same gender. The caregivers should be sensitive to the psychological stress of patients, including children, when their awrat is uncovered. They should seek permission from the patient before they uncover their awrat. Caregivers who have never been patients may not realize the depth of the embarrassment of being naked in front of others.
Medical co-education involves intense interaction between genders: Teacher-student, student-student, and teacher-teacher. Interacting with colleagues of the opposite gender raises special problems: norms of dress, speaking, and general conduct; class-room etiquette; social interaction; laboratory experiments on fellow students; learning clinical skills by examining other students; and the operation theatre. Medical personnel of opposite genders should wear gender-specific garments during surgical operations because Islam frowns on any attempt to look like the opposite gender. Shari’at guidelines on interaction with patients of the opposite gender should be followed. Taking history, physical examination, diagnostic procedures, and operations should preferably be by a physician of the same gender. In conditions of necessity a physician of the opposite gender can be used and may have to look at the ‘awrat or touch a patient. The conditions that are accepted as constituting dharuurat are: skills and availability. The preference between a Muslim of opposite gender vs non-Muslim of same gender depends on the local situation.
Dealing with the family
Visits by the family fulfill the social obligation of joining the kindred and should be encouraged. The family are honored guests of the hospital with all the shari’at rights of a guest. The caregiver must provide psychological support to family because they are also victims of the illness because they are anxious and worried. They need reassurance about the condition of the patient within the limits allowed by the rules of confidentiality. The family can be involved in some aspects of supportive care so that they feel they are helping and are involved. They should however not be allowed to interrupt medical procedures. Caregivers must be careful not to be involved in family conflicts that arise from the stresses of illness.
1.2 Good doctor etiquette in the health care team
Etiquette of teaching & learning in the health care team
The hospital health care team is complex and multi-disciplinary with complementary and inter-dependent roles. Members have dual functions of teaching and delivering health care. Most teaching is passive learning of attitudes, skills, and facts by observation. Teachers must be humble. They must make the learning process easy and interesting. Their actions, attitudes, and words can be emulated. They should have appropriate emotional expression, encourage student questions, repeat to ensure understanding, and not hide knowledge. The student should respect the teacher for the knowledge they have. They should listen quietly and respectfully, teach one another, ask questions to clarify, and take notes for understanding and retention. They should stay around in the hospital and with their teachers all the time to maximize learning.
Etiquette of care delivery in the health care team
Each member of the team carries personal responsibility with leaders carrying more responsibility. Leaders must be obeyed except in illegal acts, corruption, or oppression. Rufaidah, the first Muslim nurse, was a good model of etiquette. She was kind, empathetic, a capable leader and organizer, clinically competent, and a trainer of others. Besides clinical activities, she was a public health nurse and a social worker assisting all in need. The human touch is unfortunately being forgotten in modern medicine as the balance is increasingly tilted in favor of technology.
The health care team: general group dynamics
Basic duties of brotherhood and best of manners must be observed. Encouraged are positive behaviors (mutual love, empathy, caring for one another; leniency, generosity, patience, modesty, a cheerful disposition, calling others by their favorite names, recognizing the rights of the older members, and self control in anger. Discouraged are negative attributes (harshness in speech, rumor mongering, excessive praise, mutual jealousy, turning away from other for more than 3 days, and spying on the privacy of others).
The health care team: special group dynamics
Gender-specific identity should be maintained in dress, walking, and speaking. Free mixing of the genders is forbidden but professional contact within the limits of necessity is allowed. Patients of the opposite gender are examined in the presence of a chaperone. The gaze should be lowered. Modest covering must be observed. Display of adornments that enhance natural beauty must be minimized.
1.3 Doctor misconduct’
Abuse of professional privileges
Un-ethical research on patients is abuse of professional privileges. Abuse of treatment privileges consists of unnecessary treatment, iatrogenic infection, and allowing or abetting an unlicensed practitioner. Abuse of prescription privileges is manufacturing, possessing, and supplying a controlled drug without a license, prescription of controlled drugs not following procedures, diverting or giving away controlled substances, dispensing harmful drugs, sale of poisons, and writing prescriptions using secret formulas.
Financial fraud may be pharmacy fraud (billing for medicine not supplied), billing fraud (billing for services not performed), equipment fraud (using equipment that is really not needed or using equipment of poorer quality), or supplies fraud. It is also illegal to get financial advantage from prescriptions to be filled by pharmacies owned by the physician. Kick-backs are unethical and illegal. False or inaccurate documentation is a breach of the law and includes issuing a false medical certificate of illness, false death certification, and false injury reports.
Court action could be brought against a physician for the following crimes against the person: manslaughter (voluntary & involuntary); euthanasia (active and passive): battery for forced feeding or treatment; criminal liability for patient death; induced non-therapeutic abortion; iatrogenic death; abusive therapy involving torture; intimate therapy; rape and child molestation; and sexual advances to patients or sexual involvement. The physician-patient relation requires that the physician keeps all information about the patient confidential. Breach of confidentiality can be done only in the following situations: court order, statutory duty to report notifiable diseases, statutory duty to report drug use, abortions, births, deaths, accidents at work, disclosure to relatives in the interest of the patient, disclosure in the public interest, sharing information with other health professionals, disclosure for the purposes of teaching and research, and disclosure for the purposes of health management.
Private mis-conduct derogatory to reputation, kharq al muru’at
Breach of trust is a cause for censure because a physician must be a respected and trusted member of the community. Sexual misbehavior such as zina and liwaat are condemned. Fraudulent procurement of a medical license, sale of medical licenses, and covering an unqualified practitioner indicate bad character. Physicians can abuse their position by abuse of trust (eg harmful or inappropriate personal and sexual relations with patients and their families), abuse of confidence (eg disclosure of secrets), abuse of power/influence (eg undue influence on patients for personal gain), and conflict of interest (when the physician puts personal selfish interests before the interests of the patient). Other forms of misconduct are in-humane behavior such as participation in torture or cruel punishment, abuse of alcohol and drugs, behavior unbecoming, indecent behavior, violence, and conviction for a felony.
Public professional mis-conduct
Physicians in private practice must adopt good business practices. Halal transactions are praised[i]. An honest businessman is held in high regard[ii]. Leniency in transactions is encouraged[iii]. Full disclosure is needed in any transaction[iv]. Measures and scales must be fulfilled[v]. Bad business practices are condemned. There is no blessing in immoral earnings[vi]. Selling over another’s sale is prohibited[vii]. Cheating is condemned[viii]. Also condemned are financial fraud including criminal breach of trust, riba on bills, fee splitting, and bribery[ix]. Sale of goodwill of a practice is allowed. Also allowed is agreement among partners that they will not set up a rival practice on leaving the partnership. Entering into a compact with pharmacists or laboratories involving fee splitting and unnecessary referrals is not moral. Treatment regimens can not be patented as an intellectual property. Physicians are entitled to a reasonable fee[x]. Medical fees cannot be fixed by government because the Prophet refused to fix prices[xi].
1.4 Medical malpractice / negligence
Description and definitions
Malpractice is failure to fulfill the duties of the trust put on the physician. The term malpractice includes the legal concept of medical negligence. Negligence is breach of duty owed by the physician to the patient resulting in damage or injury. Negligence is defined according to the customary standards of care that are established by the profession.
There are 4 elements in medical negligence: discharge of duty, breach of duty, injury, and burden of proof. Medical negligence may be breach of duty resulting in causation of injury which calls for damages.
Negligence may also arise as battery which is injury due to intentional tort (a civil wrong in which liability is based on unreasonable conduct). The intentional torts are assault, battery, treatment without informed consent, false imprisonment or confinement, intentional infliction of emotional distress, and defamation (slander if verbal and libel if written).
Negligence also arises from abandonment of a patient or breach of confidentiality. Negligence also arises in liability for drugs and devices and as vicarious liability. A physician is also found negligent for negligent referrals, failure to warn about risks, and failure to report a notifiable disease. Negligence also covers professional errors. The errors may be ordinary or extraordinary. They may be harmful or non-harmful.
Types of liability
The following are types of liability: physician liability, professional errors, neglect of duty, vicarious liability, liability for defective products, and special types of causation. Physician liabilities include lack of informed consent, errors, and neglect of duty. Professional errors may be ordinary or extra ordinary. They may be harmful or non-harmful. Informed consent or expressed instruction of the patient does not relieve the physician of liability for errors. The physician is liable for discontinuing treatment without justification. Vicarious liability is when someone is made liable for a negligence they did not personally perform for example the employer. The supplier is liable for defective products.
Basis of liability
Liability is based on breach of contract, the tort of negligence, and breach of confidence. The physician-patient relationship establishes a contractual relationship that can be breached. The tort of negligence is invoked when there is breach of duty that leads to injury of either the patient or a third party. Three ingredients must be proved: (a) the physician owed a duty of care (b) the physician failed in that duty (c) the failure resulted in damage. The physician may also be liable for breach of confidence. The physician-patient relationship is based on confidence.