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ISLAMIC MEDICAL EDUCATION RESOURCES 04

0208 - TOWARDS INTEGRATED MEDICAL AND HEALTH EDUCATION: AN ISLAMIC APPROACH

Keynote paper at the Second Islamic Medical Science Week, held at Dewan Utama, Kampus Kesihatan, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia on 18th August 2002 by Professor Omar Hasan Kasule, Sr. Deputy Dean for Research, Kulliyah of Medicine, International Islamic University, Kuantan, Malaysia. Fax 00 609 513 3615 and E-M omarkasule@yahoo.com

ABSTRACT

The purpose of medicine defines the system of medical education and student selection. From the Islamic perspective the purpose of medicine is to maintain or improve the quality of life and not to prevent or postpone death because that is in the hands of the Creator. Integration of the curriculum, deriving from the tauhidi paradigm, implies practice and teaching of medicine as a total holistic approach to the human in the social, psychological, material, & spiritual dimensions and not exclusively dealing with particular diseases or organs.

 

1.0 THE PURPOSE OF MEDICINE:

Two questions must be posed and answered before proceeding. There is no unanimity of answers to these 2 questions. The first question is: what is the aim of medicine and medical treatment? The second question is: what is the aim of medical education? What do medical schools try to achieve? These questions generate further disagreement. On one hand the answer to the second question depends on the answer to the first question. On the other hand, it could be argued equally logically that in practice medical schools and systems of medical education do not reflect the medical care delivery system.

 

Muslims have several disagreements with some basic paradigms that define the objectives of European medicine. From the Muslim’s point of view, European medicine suffers from four defects: it is disease-oriented and not health-oriented, it is very arrogant and claiming ability to cure any disease with no recognition of Allah’s involvement, It does not have sufficient humility to accept its failures and they are many, it sets itself the unrealistic goal of preventing or postponing death regardless of the quality of life that is lived.

 

Since health is the original state and illness is the exception, medicine must be health and not disease oriented. The main responsibility of the physician is to maintain health; cure of disease should be the exception rather than the rule. The ancient Chinese were nearer to our view of medicine and the role of the physician. They paid their physician as long as they were in good health. Payments would be suspended on falling sick. They would resume when the illness was cured. The disease model predominates in European medicine. The disease model involving a biological or physical insult to the tissues is the main causal mechanism recognized and other contributors to the final causal pathway are not emphasized. The bias to the disease model explains European medicine being more curative than preventive.

 

Illness to a Muslim has its positive aspects: it can be a blessing, a reason for expiation of sins, and the trial of illness is a source of much good for a believer[1]. An incident case of illness should not be looked at in isolation. When viewed in a larger context, illness or disease need not always be seen as bad. The Qur’an teaches that a human may like something that is bad for him or may hate something that is good for him[2]. Falling ill may save a person from going where he would be hurt or where he could commit a sin. Pathophysiologically the symptoms of ill health are useful even if people complain about them. Pain directs us to tissue injury so that corrective measures may be taken before the injury becomes more extensive. Exhaustion and collapsing may be the body’s way of forcing us to take a rest when we are over-stressed or overworked without adequate rest. Much of what manifests as disease are the body’s attempts to return to the natural or normal state. The ultimate cure of illness is from Allah[3]. The attending physician must realize that his efforts will succeed only if divine will intervenes and should therefore not be to arrogant. He should be aware that his efforts may fail or succeed. Physician arrogance and overuse of biomedical and technological interventions has sometimes led to the excesses of modern medicine in the form of side-effects (short and long-term) or iatrogenic diseases that are on the increase today.

 

Claims of European medicine to have reduced morbidity and mortality can be questioned. Mortality due to infectious diseases like tuberculosis and malaria fell dramatically in developed countries. Some infectious diseases like smallpox have been completely eradicated. However, new types of morbidity have appeared. Sexually transmitted diseases are on the increase. There is a lot of chronic fatigue and stress in industrialized society. Psychiatric morbidity (including depression, suicide, para-suicide, and substance abuse) is on the increase. Fetal wastage has actually increased with the rise in legal and illegal abortions and some forms of contraception. European medicine has had a marginal contribution to the falling mortality and morbidity over the past 2 centuries. Non-medical general improvements in nutrition, environmental sanitation, and personal hygiene have been responsible for the major changes. Mortality from diseases like tuberculosis was falling many decades before discovery of effective anti-infective agents. The prevalence of debilitating infectious diseases in the third world is more related to their low socio-economic development than to lack of scientific medicine. European medicine has reached or will soon reach a plateau in improving physical health at least in developed countries where infectious diseases that have plagued mankind for millennia are nearly being controlled. Any further improvements in health will not require biomedical interventions but changes in human behavior (nutrition, exercise, stress, psychological balance, substance abuse, violence). The most effective interventions will be non-medical. Changes of human behavior require will power to choose and stick to healthy lifestyles while avoiding unhealthy ones as well as self-care. The medical profession may have to change its whole orientation to support and enhance the will and ability of the people to take care of maintaining their health and lead healthy life-styles. The medical profession will have to know when to stop biomedical intervention and give room to non-medical interventions. Good results will be obtained only when equilibrium is established between the two. It is a paradox that medicine will remain busy in the next few decades trying to reverse iatrogenic problems it has caused this decade. Medical exposure to irradiation and steroids 20-30 years ago are responsible for cancers of today. Tonsillectomy, once a popular procedure is now thought to be the cause of Hodgkin’s disease. Oral contraceptives cause coagulation disorders. Other similar examples abound in medicine. Health problems due to environmental pollution will increase in the following decades. It is our contention that an Islamic paradigm emphasizing an integrated and balanced approach would have foreseen and prevented some of these problems.

 

From an Islamic point of view, the aim of medicine is to maintain or improve the quality of remaining life. Medicine does not have as an aim the prevention of death or prolongation of life; the ajal is in the hands of the Almighty. Life on earth has a fixed and limited span and no one has the power to extend it even for a brief moment[4]. Importance of quality of life is recognized by some physicians trained in the European tradition but lacking an integrating tauhidi paradigm, they fail to define this quality in a holistic way. Islam can provide them with paradigms that enable them to pull everything together. The Islamic Quality of Life Index (IQLI) arises from the tauhidi integrative paradigm and is a comprehensive measure involving social, psychological, physical, spiritual, and environmental parameters. The quality of life is closely related to man’s understanding of the purpose of creation and the mission of humans on earth. Life becomes degraded, hayatan dhankan[5], in the absence of this understanding. The quality of life is also closely related to lifestyle. A good healthy lifestyle is associated with a higher quality of life. A bad unhealthy lifestyle is associated with a low quality of life. Lifestyle is directly related to the risk of physical and mental illness as well as the response or adjustment to that illness. A healthy lifestyle is characterized by: piety, generosity, charity, chastity, humility, trust, balance, moderation, patience, endurance, honor and dignity, integrity, moral courage, and wisdom. An unhealthy lifestyle is mainly a manifestation of one of the following diseases of the heart: shirk, kufr, takabbur, ujb, hiqd, hasad, ghadhab, ghurur, hypocrisy, miserliness, and suu al dhann. These diseases sooner or later lead to either physical or psychological transgression, dhulm, against self or others. Most human diseases can be traced to this transgression. Epidemiological studies if interpreted in an objective way provide sufficient data to relate ill-health to lifestyle and to quality of life.

 

2.0 PURPOSE OF MEDICAL EDUCATION:

The Islamic paradigmatic approach to defining the purpose of medical education can be derived from the paradigm of tauhid and the general theory of the purposes of the Law, maqasid al sharia. The majority of scholars concur that the following 5 purposes are protected by the law: (a) religion, diin (b) life, nafs (c) procreation, nasl (d) intellect, aql (e) wealth, maal.  Medical practice is intimately involved with all 5 of them but most so with nafs, nasl, and aql. Once the purposes of medical intervention are established, the aim of medical education should be to produce physicians who in their practice of medicine will fulfill that purpose or maqasid within a holistic context to ensure harmony and equilibrium. Thus the medical education system should aim at producing a physician who will be health and not disease oriented, who will have the humility to know that he will exert his best and trust in Allah to cure the disease. He will not have the arrogance to feel that he can prevent death but will strive to improve the quality of life for people knowing that the Islamic index of the quality of life is derived from the holistic tauhidi view: physical, spiritual, social, psychological aspects and proper balance between them. The physician should in addition have the following practical and conceptual skills: understanding of the society, epidemiological understanding of health problems, scientific capability, clinical expertise, and leadership. These qualities must be in a context of iman, tauhid and fulfillment of the general purposes of the sharia. Moosa[6] called for an Islamic ambience for medical education when he argued that ‘ the purpose of Islamic Medical Education is to produce men and women imbued with the Islamic spirit, who will serve mankind to improve and maintain the health and welfare of all peoples, undertake research and excel in whatsoever they do’

 

3.0 THE ISSUE OF FRAGMENTATION:

European medicine is characterized by narrow specialization and fragmentation. Physicians know more and more about less and less. The trend toward specialization in medical practice has strongly influenced medical educators to diminish the practical content of the crowded undergraduate program and transfer some of it to post-graduate or vocational training. A new graduate from medical school is therefore unable to treat a patient on his own until he becomes a specialist. Specialty practice however has the great disadvantage of fragmenting patient care among several specialists such that there is no one doctor to care for the whole patient. The fragmentation of medicine is reflected in the balkanization of administration (by department), stages of education (pre-medical, pre-clinical, and clinical) and by discipline or specialty. Separate curricular tracks for research and practice have even been suggested. In many cases each department teaches independently of others. Specialist physicians find it difficult to teach students who are just being introduced to medicine.

 

The following attempts have been suggested to overcome the problem of fragmentation: interdepartmental or inter-disciplinary programs, integration of clinical and basic sciences, generalist and not specialist medical practice, vertical integration (linking early with later years in the same discipline), horizontal integration (linkage between different disciplines), teaching by organ systems, and using the problem-centered approach.

 

The concept of integration has been well accepted and propagated but not understood well when it came to practical application. Attempts at integration are a response to a felt problem and are certainly a step in the right direction however they have not solved all the problems; they even succeeded in creating a few new ones. Uncoordinated integration has succeeded in producing a hypertrophic curriculum. There is pressure from each discipline to ‘integrate’ its material into the curriculum. New disciplines such as genetics, statistics, epidemiology, demography, anthropology, and sociology are at the door claiming their share of the undergraduate curriculum. New disciplines have been created to ‘integrate’ or bridge the gap between pre-clinical and clinical disciplines e.g. clinical biochemistry, clinical pathology, and clinical epidemiology. Interdisciplinary teams have been used as a tool of ‘integration’ in community medicine.

 

If each of these demands and approaches to integration were to be fulfilled, the undergraduate medical curriculum will require a life-time to complete! There are, however, defenders of a crowded undergraduate curriculum. They argue that students should be exposed to all disciplines to enable them be informed choices about their future specialties. This reminds us of the story of an ’accomplished’ lawyer who knew a bit about every subject including law. The process of continuous additions to and pruning from the curriculum is going on and has been dramatically described as integration, re-integration, and disintegration.

 

Fragmentation is a reflection of an underlying European world-view and did not come about in medical education by accident. This world-view started with the renaissance when religion was separated from public life and science. This set in motion centripetal forces that continually separate, fragment and sub-divide. The body was separated from the soul. The mind was separated from the body. Science was separated from art in medical practice. Each disease or organ was isolated and was dealt with in isolation. It must however be recognized that specialization has been responsible for much of the progress in scientific medicine because of the concentration of the researcher’s energy on a narrow focused issue. It is not surprising that in a context of increasing fragmentation, the concepts of ‘total health’, ‘total disease’ are not easily accepted. It is not the ‘total human’ who gets sick but his organs or tissues. It is however very surprising that Claude Bernard’s concept of a harmonious ‘milieu interieur’ and the appreciation of the biochemical unity of all life did not motivate practice of ‘total medicine’. Many physicians in the west have recognized that fragmentation is a major problem and have set about attempting to achieve integration in medical treatment and medical education. Some of these attempts were described above.  Their limited success is due to lack of a guiding vision.

 

Integration is not just putting two or more disciplines together. It is a fundamental philosophical attitude based on a vision and a guiding paradigm. Only Islam can provide this paradigm. Criticism of the fragmented medical curriculum is actually criticism of the underlying European non-tauhid world-view. The fundamental reason for failure of integration efforts is that the European world-view is atomistic; it is good at analysis and not synthesis. It is incapable of synthesis because it lacks an integrating paradigm like tauhid.

 

4.0 THE ISSUE OF LACK OF BALANCE:

Lack of equilibrium is a secondary manifestation of lack of integration. A lot of human illness is due to lack of balance and equilibrium; for example excessive intake of some foods leads to disease just as inadequate intake leads to ill-health. The Qur’an calls for observing the equilibrium, al wastiyyat. Violating the rule of the golden middle is associated with many problems and lack of balance is condemned.

 

Ancient Muslim, Indian, Chinese, Greek medical systems understood the concept of equilibrium. Modern European medicine lacks the concept of equilibrium or balance. It is replete with examples of overdoing a good thing beyond the equilibrium point and creating even bigger problems. Some therapies are worse than the disease they are supposed to cure. The quality of life of terminal cancer patients is made worse by chemotherapy and radiotherapy than the original disease perhaps they could have been left to die in dignity. Pesticides were used to eradicate malaria but they led to human disease. The best treatments of yesterday are known causes of malignancies today. Some physicians trained in the European tradition recognize the problems of balance and integration but they can not propose a comprehensive solution because of lack of an underlying paradigm. A European symposium called for balance between technological development and social change within an integrated system, education and skill acquisition, general and specialized training, science and behavioral disciplines. The conference did not however have a comprehensive solution or paradigm.

 

5.0 THE TAUHIDI PARADIGM, INTEGRATION AND BALANCE:

Tauhidi is the main paradigm in Islamic civilization that forms a backbone of all intellectual discussion of medical education. Tauhid al rububiyyat motivates the appreciation that there is only one creator and that thee is unity, harmony and useful interconnections among different forms of life and the physical environment. Tauhid al uluhiyyat motivates the appreciation that the creator has definite purposes from creation and that human life must fulfill those purposes. This implies that there are certain laws that lead to a fulfilling life. Obeying those laws is associated with a healthy high-quality life-style. The tauhidi paradigm implies integration and harmony of matter and soul, body and mind, parts and the whole.

 

The physician should be trained to practice medicine as a total holistic approach to the human in the social, psychological, material, & spiritual dimensions and not an attack on particular diseases or organs. The example of the early Muslim physicians is worth emulating. They were well rounded in their education and their practice of medicine. They were also integrated in the sense that their medical practice fitted in well with other social activities. Al Qadhi Abd al Razaaq used to teach medicine and mathematics in the mosque in Bukhara until his death. Muwaffaq al Ddiin Abd al Latiif al Baghdadi taught medicine in the Azhar mosque during his stay in Egypt. Thus the context and the environment in which the teaching was carried out was integrative. It integrated medicine with the mosque and worship.

 

Al Faruqi[7] described tauhid as the source of truth, cosmic and social order. It ensures unity of truth and therefore prevents contradictions between different disciplines of knowledge. Tauhid is a world wide view that can guide not only medical education but also all endeavors of building a civilization. The Islamic social order is totalistic and Islam is relevant to every aspect of human endeavor. The tauhidi approach to integration is putting medical knowledge, teaching and practice in a larger context to making sure it is in harmony and is well coordinated with other related medical or non-medical phenomena. It is therefore possible to envision a very ‘integrated’ doctor who at the same time is very specialized. Such a doctor will approach the patient as a whole human and not just as organs or tissues.

 

 

 

 

 

 

 

 

 

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[1] Muslim vol 4, page 1364 hadiths # 6235 : Narrated Abdullah bin Mas’ud: I visited Allah’s Apostle (s.a.w) while he was suffering from a high fever. I touched him with my hand and said, “O Allah’s Apostle! You have a high fever.” Allah’s Apostle (s.a.w) said “Yes I have as much fever as two men of you have.” I said, “is it because you will get a double reward?” Allah’s Apostle (s.a.w) said, “Yes, no Muslim is afflicted with harm because of sickness or some other inconvenience, but that Allah will remove his sins for him as a tree sheds its leaves.”

 

 Narrated Abu Said Al-Khudri and Abu Huraira: The prophet (s.a.w) said, “No fatigue, nor disease, nor sorrow, nor sadness, nor hurt, nor distress befalls a Muslim, even if it were the prick he receives from a thorn, but that Allah expiates some of his sins for that.

 

Narrated Abu Hurairah:  Allah’s Apostle (s.a.w) said, “Allah wants to do good to somebody, He afflicts him with trials.” Sahih al Bukhari and sahih Muslim

 

[2] Fighting is prescribed upon you, and you dislike it but it is possible That Ye you dislike a thing which is good for you And that Ye love a thing which is bad for you. But Allah knoweth, and ye know not. Qur’an 2:216

 

O ye who believe! Ye are forbidden to inherit Women against their will Nor Should ye treat them with harshness, that ye may take away part of the dower ye have given them -except where they have been guilty of open lewdness: On the contrary live with them on a footing of kindness and equity. If ye take a dislike to them it may be that ye dislike a thing, and Allah brings about through it a great deal of good. (Qur’an 4:19)  

 

[3] “And when I am ill, It is He who cures me; ” (Q26:80)

 

Narrated Aisha: Whenever Allah’s Apostle (s.a.w) paid a visit to a patient, or a patent was brought to him, he used to invoke Allah, saying, “Take a way the disease, O the Lord of the people! Cure him as you are the one who cures. There is no cure but yours, a cure that leaves no diseases.” (Bukhari).

 

 Aisha reported : When any person amongst us fell ill, Allah’s Messenger (S.A.W) used to rub him with his right hand and then say : O Lord of the people, grant him health, heal him , for Thou art a great healer . There is no healer; but with Thy healing power one is healed and illness is removed.

 

[4] Surat Al Imran: ayat 145: Nor can a soul die Except by Allah’s leave, the term being fixed as by writing. If any do desire a reward on this life, we shall give it to him; and if any do desire a reward in the Hereafter, We shall give it to him. And swiftly shall we reward those that (serve us with) gratitude.

 

[5] “But whosoever turns away from My Message, verily for him is a life narrowed down, and we shall raise Him up blind on the Day of Judgment.” Surat Taha: ayat 124

 

[6] Moosa. Allie. Islamic Medical Education. in: The Second International Islamic Medicine Conference (abstracts) Kuwait 1982

 

[7] al Faruqi, Raji Ismail. Islamization of Knowledge. IIIT Reston VA 1982

Omar Hasan Kasule, Sr. August 2002