Moving on from a Patient-Centred to a God-Centred Ethics
- Siti Nurani Mohamed Nor, Ph.D.
Department of Science and Technology Studies
Faculty of Science
Universiti of Malaya
Kuala Lumpur, Malaysia
Eubios Journal of Asian and International Bioethics 11 (2001), 52-54.
The ethics and the quality of the health-care system has come under scrutiny within the Malaysian scene. Every nation whether rich or poor is struggling to make sure that its citizens have easy access to equitable healthcare. There has been public displeasure at the unreasonably high charges imposed by private hospitals. There have also been reports of private clinics insisting on deposits before treatment and patients being moved to public hospitals because of their inability to pay the bills. The noblest profession in the world has lost its charm; doctors have become aloof and uncaring.
The public was also recently shaken by media coverage of what was alleged to be an inhuman act by a medical practitioner. A gynecologist had been reported to have "kidnapped' a patient for failing to pay the medical bills. A Minister from the Health Department, expressed concern over the incident and quickly relayed the Hippocratic Oath said to be "The Law' by which physicians were supposed to abide and follow in going about their practice.
Yet another worrying incident happened whereby a physician was arrested for causing the death of his patient when performing an abortion. A member of the local Medical Association reacted by voicing disappointment at policy makers for drafting "unclear policies' on abortion. He pointed out that while the common people knew that abortion is "immoral', unwanted pregnancies were increasing by the number everyday. This has resulted in abortive procedures done secretly and dangerously, resulting in unnecessary deaths. He suggested that elective abortion laws might help to curb abortion related deaths. What seemed evident here is a spokesman from among physicians who believed that doctors ought to be allowed freedom to conduct abortions if and when necessary. It also revealed an attempt to distance themselves from the Hippocratic Oath. "To do no harm' is the Hippocratic maxim that has long been a fundamental principle in medical ethics. It emphasizes respect for the sanctity of the human life. It is strange that the Oath is still referred to in this day and age, whenever a misconduct involving a medical professional occurs. It is also awkward that the Oath is still addressed given the fact that Malaysia is a country that professes Islam as the official religion. The resurgence and assimilation of Islamic values has brought on the mushrooming of several Islamic hospitals and clinics across the country, and these establishments have offered an alternative approach in discharging their service to the community.
A common deontological dimension holds the chief place in both western and Islamic medical ethics. This is to say that there must be a determination of the rightness or the wrongness of the action, and not only of the good to be gain from medical care or from medical research.
The medical profession has long subscribed to a body of ethical statements developed primarily for the benefit of the patient. Codes of Medical ethics are quasi-legal but self-legislative documents. The medical profession is not bound strictly to it unless the profession chooses to attribute to them. The codes submit three universal ethical principles, namely, justice, beneficence and autonomy.
A comparison of the Hippocratic Oath and the Geneva Physician's Oath reveal striking differences in emphasis. For example, The Hippocratic Oath is pledged with a reference to a multiplicity of Gods. In The Declaration of Geneva of the World Medical Association, the pledges are made in the name of man. It is made as a decree in his capacity as a person. The last line reads "I make these promises solemnly, freely and upon my honor'. It is done with the recognition that doctors can act freely in their own capacity. The Declaration has stated the physician will maintain by all means in his power, the honor and the traditions of the medical profession and will not exploit his or her position. "A physician shall be dedicated to providing competent medical service with compassion and respect for human dignity" and "A physician shall respect the rights of patients, of colleagues and of other health professionals, and shall safeguard patient confidences within the constraints of the law."
McCullough elaborates how the first texts on medical ethics by John Gregory and Thomas Percival prescribed certain "intellectual and moral standards' for physicians and that they should put the patient's interests ahead of their own. The physicians should further "not exhibit any social-class differences in their care of patients'. However, in a physician-patient relationship, patients can become vulnerable to the authority and power of physicians'. Physicians become arrogant after achieving a successful reputation.
Gregory has observed physicians taking "a most ungenerous advantage of the confidence and trust which people have in their ability once they have experienced success and recognition. He noticed that, "in the beginning he is affable, polite, humane, and assiduously attentive … but he has reaped the fruits of such a behavior…. He becomes haughty, rapacious, careless and often brutal in his manner'.
The notion of patient autonomy came to be given greater emphasis and became a genre in the medical enterprise. According to Veatch it was the trump card to counter the argument that doctors knew best what was in the patient's interest. The patients should be treated with dignity as autonomous agents, and an autonomous person is an individual capable of deliberation about personal goals and of acting under the direction of such deliberation. To respect autonomy is to give weight to autonomous persons' considered opinion and choices while refraining from obstructing their actions unless they are clearly detrimental to him/herself. To repudiate that person's considered judgment, to deny the individual the freedom to act on those considered judgment, or to withhold information necessary to make a considered judgment is regarded as a lack of respect for an autonomous agent. The American Patient's Bill of Rights is an outstanding example of a catalogue of rights that pushes for greater autonomy for the patient. The document affirms that "the patient has the right to considerate and respectful care' and "the right to reasonable continuity of care'. It has even been said that the bill gives patients an upper hand in developing a social policy that will shape the very practice of medicine.
In most cases the principle of informed consent is rarely justified. Patients not only are so ill that they lose adequate voluntary judgments but the complexity of the disease may them incapable of grasping important information about their disease. Illness and the depression that follows it increase the patient's vulnerability.
Tristram Engelhart observes that "One of the most pervading consequences of modern technological society is the social distribution of knowledge which prevents fully informed individual and to some extent societal, decisions and consent concerning the directions of medicine. The accrual of a special stock of skills and knowledge by a particular group of individuals, with consequent peculiar social duties, rights, powers and expectations, in part defines medicine as a profession and distinguishes the physician from the layman. It establishes not only divisions of labor but of power due to the possession of special knowledge bearing on the life and death of laymen. It also establishes a social subgroup defined by its interest in the observation and maintenance of its skills and knowledge, and thus by special interests and goals.
Ahmed Elkadi in his article on Professional Ethics claims that an ethical system that is man-made would be more likely to encounter errors than a system that draws upon the Quran. In 1981, the Islamic Code of Medical Ethics was first drafted based on the teachings of the Quran and the Hadith. On this principle aspect, this oath is recommended for Muslim doctors in place of the Hippocratic Oath. The Islamic Code upholds the doctrine of Unity or tawhid. Also referred to as the Oath of Muslim Doctors the name of Allah s.w.t. is incorporated and a pledge to abide by its principle is made in His name.
A code of medical ethics that is formulated in awareness that there is a Divine God who supervise all things, would mean that it is likely to engender greater humility in doctors, and hence a more ethical practice.
It has been claimed that Western medicine sees patients as "merely an aggregate of persons gathered together by chance, or indeed, bad luck. Diseases, however, not only places patients at a disadvantage, creating a need for the service of another, it also makes the patient dependent upon the physician for continued care.
In Islam, illness is not perceived in a negative way. On the contrary, disease is believed to come from god. Having disease does not throw a person in "a state of bad luck' or into unfortunate circumstances. Having disease brings a person closer to God, it enhances and brings him up, and if he is patient (or sabar) to a higher level of faith. The discomfort to the one afflicted is not seen as a curse, wrath or punishment from God. The trial of an illness is believed to be a blessing and a reason for expiation of sins. As narrated by the wife of the Prophet, Aisha (radiallahu anha): The Prophet (peace be upon him) once spoke: "No calamity befalls a Muslim but that Allah expiates some of his sins because of it, even though it were the prick from a thorn."
Another hadith reported that Abdullah bin Masud had visited the Prophet (pbuh) when he was suffering from a high fever. "I touched him with my hand and said, "O Allah's Apostle. You have a high fever.' The Prophet (pbuh) replied, "Yes I have as much fever as two men have.' I asked, "Is it because you will get a double reward?' He answered, "Yes, no Muslim is afflicted with harm because of sickness or some other inconvenience, but that Allah will remove his sins the way a tree sheds its leaves.'"
Muslims also believe that the ultimate cure for all diseases would come from God. A particular verse in the Holy Quran states, "And when I am sick, He (Allah s.w.t.) provides the cure." Another hadith of the Prophet recounted that, "No disease is created whereby He has not also created the cure. There is cure for all diseases except death."
Such perception regarding diseases would make a Muslim physician approach patients with humility and with no trace of arrogance. The Oath of the Muslim Doctor defines the physician "as an instrument of God's mercy. He is to regard God in carrying out his profession. He is also to live his faith in private and in public, avoiding any blemishes in the eyes of God, and his Prophet (pbuh). A God-centered disposition would imply total submission to God for the ultimate success in discharging their duties. Patients also do not become highly dependent on their doctors when they are asked to accept disability and disease as God's way of controlling human behavior. The sick is unable to go about his ordinary duties and to a certain extent, it is believed that it protects the person from events and circumstances that may be adverse.
In other parts of Asia, in particular, Taiwan and Japan, there are calls pressing for a revision in the attitudes, conduct and management of the medical enterprise. There are suggestions for a more humanistic face of the medical profession. There is a need for a holistic understanding of personhood as in Chinese and Ayurvedic medicine. There are calls to promote a consciousness of physician's responsibility.
There are further criticisms that modern medicine does not incorporate an element of moral and spiritual guidance. Medicine is said to heal a man physically, socially and mentally but it does so without any acknowledgement of the spiritual well being of the person. For instance, The World Health Organization defines health as that of physical, social and mental well being without any element of spirituality.
Nizami "Aruzi stressed the importance of the power of intuition:
A physician should be of kindly disposition, characterized by a rational thought and possessed of excellent intuitive power. Intuition is the movement of the mind whereby it hits at correct opinion, that is, a quick passage from the known to the unknown … Now a physician who does not recognized the nobility of man cannot have a kindly disposition, one who is not well-versed in logic cannot have rational thinking, and one who does not have God's support cannot possess an excellent intuitive power. Without the gift of intuitive power, a person cannot know the correct cause [of an ailment], …
It has further been proposed that hospitals built to integrate Islamic spiritual values should not only put emphasis on the conduct of the health care givers but that rooms and wards should specifically be designed with easily accessible and suitable corners for ablution and prayers. Such atmosphere is thought to be conducive for the healing of patients as well as efficient facilitation of tasks.
In the Western world there has been dissatisfaction that modern scientific medicine has advanced technical skill at the cost of personal warmth. Medical laboratories dramatic discoveries increasingly appear to diminish the doctor's inclination to use his senses and intuition. As early as 1931, the American physician, James Herrick argued that there was good reason to ask questions such as, "Should we no longer feel for an enlarged spleen, a pre-systolic thrill. Are we to give up the attempt to locate by percussion an infiltrated area in the lung or fluid in the pleural cavity? Are we to discard the stethoscope and cardiac murmurs and bronchial breathing and rely on the X-ray and the electrocardiograph?' He added that medical teachers were unknowingly leading undergraduates "to place emphasis on the instrument of precision rather than on the eye, ear, hand of the physical examiner.'
George Pickering, Regius Professor of Medicine at Oxford in 1955 also lamented about the apparent over dependence of doctors upon machine diagnosis. "To rely on data, the nature of which one does not understand, is the first step in losing intellectual honesty…The use of diagnostic technology can enlarge the doctor's knowledge of disease but it can also erode his confidence in his ability to make independent judgments. … If the doctor develops mistrust for his non-technical judgments, he risks becoming merely an intermediary between the patient and the medical judgments rendered by technical experts and machines.
The peculiarity of the Islamic ethics of medicine in Malaysia is exemplified in the problem of abortion. Islam like any other religions upholds the sanctity of life as attested in several verses in the Quran. A number of verses in the Quran would testify to the importance of life. "If anyone slays a human being unless it be (in punishment) for murder or for the spreading corruption on earth ― it shall be as if he had slain the whole of mankind; whereas if anyone saves a life, it shall be as if he had saved the lives of the whole of mankind.' And, "Hence do not kill your children for fear of want or poverty; it is We who shall provide sustenance for them as well as for you. Verily, killing them is a great sin.'
When the Indonesian Islamic Council of Jakarta, conveyed a fatwa contemplating that it is not wrong to terminate a pregnancy before 120 days because the soul is only present after this period, it created ripples within the Muslim community in Malaysia. The fatwa was rejected by the local Muslim authorities declaring that life begins at the moment of conception. This declaration is an indication of the Islamic medical policy of the country ― it is made with public interest in mind. The good of society or the ummah is of utmost importance. There is too much attention on patient-centeredness in western ethics that strong proponents have suggested that "persons are to be respected as individuals with rights and interests that take precedence over the greater good of the society'. On the contrary, in a Muslim society the goals of the society would otherwise take precedence.
Often physicians forget that they have responsibilities that extend beyond rights per se to their patients but that they have civil duties to society and to their profession. For example, physicians have a duty to society to report of potential outbreak of diseases. In the same way, physicians have a duty to respect the goals of the society and their country. Unwanted pregnancies or rather, pregnancies conceived out of wedlock, is a phenomena in society that taxes not only concerned parents or teachers but also the general public and the government. Doctors should ask themselves by aiding such abortions whether they are more obliged as befrienders of the misfits or the misbehaves, or should they more appropriately assume roles as protectors or guardians of a civil society. The competent physician should not only be responsible to himself and his patient but also to the whole society. He/she must not stand indifferent to the social ills that erode the path of development towards a civil society but is committed to contribute to it. A physician may see himself as responding to his patient's needs but may fail to foresee the repercussions of his actions towards society. Therefore, the responsibility of the Muslim doctor extends beyond purely medical issues. In this respect a Muslim doctor can refuse a patient that approaches him for an abortion for a reason other than to save the life of the mother.
A curriculum consisting of six credits of Islamic Civilization course has been incorporated into the medical curriculum of undergraduates in a number of local universities. Dawson wrote in his book The History of Medicine about the period of excellence between the ninth and the thirteenth century when the world witnessed the original contribution of great names in medicine such as Al-Razi, Ibn Rushd, Ibn Sina and Ibn Maimon. "The Germanic invaders of the Roman Empire took 1000 years to outgrow their savagery and welcome a revival of learning whilst the Arabs achieved a high standard of culture in 100 years.'
Students are made to understand that the Holy Quran provided the motivation and the guidance in achieving the overwhelming abundance of knowledge. Mankind is challenged to study the universe, "Behold! In the creation of the heavens and the earth, and the alternation of night and day, there are indeed signs for men of understanding.'
It is also to be noted that several academic activities in the form of a series of lectures, seminars and dialogues on the subject of Islamic Science and Civilization have been implemented since 1986 to 1992 in schools and institutions of tertiary education. The setting up of such institutions such as the International Islamic University, Institute for Islamic Understanding, The Academy for Islamic Scientists and the Islamic Center of Malaysia all established for the main purpose of inculcating an awareness of Islamic heritage during the Golden Era. It was contended that "An understanding and appreciation of Islam, the main religion of Malaysia, is important for the practice of medicine ― to help understand patient's perception, behavior and reaction in illness and death'.
The five year medical programme at medical schools involve an intricate process of molding and cultivating young school leavers into a decent group of medical professionals. They have to be equipped with good public relations skills, ethics, professional decorum, appropriate mannerisms and attitude. A part of the students programme includes a three weeks stay living with adoptive parents in remote rural areas, and at spastic centers, old folks home and orphanages. These activities are felt essential in inculcating care and compassion among the interns.
On graduation day, students are required to pledge an oath of practitioner, which starts with "In the name of God, we seek from you qualities such as truthfulness, modesty, mercifulness and objectivity.' They also pledge to admit their mistakes, amend and forgive. They seek God's wisdom to attend to the well being of their patients regardless of social status, race and religion. Most importantly, is the acknowledgment that the medical profession is sacred because it deals with God's precious gift of life and intellect.
As cited in McCullough LB, "Authority Power and Trust", J. Medicine & Philosophy, 24 (1), (Feb. 1999).
Robert M Veatch, "Autonomy's temporary triumph" Hasting's Center Report 14(5), 38-40.
Beauchamp TL & Walters L (ed), Contemporary Issues in Bioethics-2nd Ed, Wadsworth, California, 1982, 127.
Tristram Engelhart, in: Md Bayles and DM High (eds.), Medical Treatment of the Dying, Moral Issues, Schenkman Pub Co, Cambridge, Mass., 1978, 9-28.
Ahmed Elkadi, "Professional Ethics" J. of the Islamic Medical Association (Sep 1976), Indiana, 27.
Kuwait document: International Conference on Islamic Medicine, January 1981, p. 93.
Fazlur Rahman, Health and Medicine in the Islamic Tradition
James B. Herrick, "The importance of the history and physical examination in diagnosis," J. Indiana State Med Assoc. 24 (1931), 71.
Stanley J. Reiser, Medicine and the Reign of Technology . Cambridge: Cambridge University Press, 1978.
Surah Al Maidah: 32
Surah Al Israa: 31.
RMVeatch, "The National Commission to IRBs: an evolutionary approach', Hastings Center Report, vol 9(1), 1979, 27.
Surah Al Imran:190.
Go back to EJAIB 11 (2)March 2001
Go back to EJAIB
The Eubios Ethics Institute is on the world wide web of Internet: