1.0 ETIQUETTE WITH PATIENTS and FAMILIES
1.1 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 relation with the patient comes before the
professional technical relation. It is 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, 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.
1.2 ETIQUETTE OF THE PATIENT
The patient should express gratitude to the caregivers even
if there is no physical improvement. Patient complaints should be for drawing attention to problems that need attention and
not criticizing caregivers. The patient should be patient because illness is kaffaarat
and Allah rewards those who surrender and persevere. The patient should make dua
for himself, caregivers, visitors, and others because the dua of the patient has
a special position with Allah. When a patient sneezes he should praise Allah and the mouth to avoid spread of infections.
It is obligatory for the attendants to respond to the sneezer. The patient should try his best to eat and drink although the
appetite may be low. The caregivers can not force the patient to eat. They should try their best to provide the favorite food
of the patient. The believing patient should never lose hope from Allah. He should
never wish for death. The patient should try his best to avoid anger directed at himself or others. Getting angry is
a sign of losing patience.
1.3 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, husn al dhann, and avoid evil or obscene
words. They must observe the rules of lowering the gaze, ghadh al basar, and khalwat. Caregivers must have an attitude of humbleness, tawadhu'u, 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.
They must seek permission, isti' dhaan, 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.
1.4 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, maslahat,
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; Clinical skills laboratory: learning clinical skills by examining other students; 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.
1.5 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 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.
2.0 ETIQUETTE WITH THE DYING
Narcotics are given for severe pain. Drugs are used to allay anxiety
and fears. The caregivers should maintain as much communication as possible with the dying. They should attend to needs and
complaints and not give up in the supposition that the end was near. Attention should be paid to the patient's hygiene such
as cutting nails, shaving hair, dressing in clean clothes. As much as possible the dying patient should be in a state of rutual
purity, wudhu, all the time.
The dying patient should as far as is possible be helped to fulfill acts
of worship especially the 5 canonical prayers. Tayammum can be performed if wudhu is impossible. Physical movements of salat
should be restricted to what the patient's health condition will allow. The prophet gave guidelines on salat even for the
semi-conscious patient, salat al mughma ‘alayhi. The terminal patient is
exempted from saum because of the medical condition. It is wrong for a patient in terminal illness to start fasting on the
grounds that he will die anyway whether he ate enough food or not. lllness does not interefere with the payment of zakat since
it is a duty related to the wealth and not the person. The terminal patient is excused from the obligation of hajj. It is
also wrong for a patient in terminal illness to go for hajj with the intention of dying and being buried in Hejaz.
2.3 SPIRITUAL PREPARATION.
Spiritual preparation involves allaying anxiety,
presenting death as a positive event, thinking of Allah, and repentance. Caregivers should allay fear and anxiety about impending
death. Death of the believer is an easy process that should not be faced with fear or
apprehension. The process of death should be easier for the believer than the non-believer. The soul of the believer is removed
gently. Believers will look at death pleasantly as an opportunity to go to Allah. Allah loves to receive those who love going
to Him. The patient should be encouraged to look forward to death because death from some forms of disease confers martyrdom.
The patient should be told that Allah looks forward to meeting those who want to meet Him (KS525). Dying with Allah's pleasure
is the best of death and is a culmination of a life-time of good work. Thinking well of Allah is part of faith and is very
necessary in the last moments when the pain and anxiety of the terminal illness may distract the patient's thoughts away from
Allah. Having hope in Allah at the moment of death makes the process of dying
more acceptable. The dying patient should be encouraged to repent because Allah accepts repentance until the last moment.
2.4 LEGAL PREPARATION
During the long period of hospitalization, the health care givers develop
a close rapport with the patient. A relationship of mutual trust can develop. It is therefore not surprising that the patient
turns to the care givers in confidential matters like drawing a will. The health care givers as witnesses to the will must
have some elementary knowledge of the law of wills and the conditions of a valid will, shuruut
al wasiyyat. One of these conditions is that the patient is mentally competent. The law accepts clear signs by nodding
or using any other sign language as valid expressions of the patient's wishes. The law allows bequeathing a maximum of one
third of the total estate to charitable trusts, waqf, or gifts. More than one third
of the estate can be bequeathed with consent of the inheritors. Debts must be paid before death or before the division of
the estate. A terminal patient can make living will regarding donation of his organs
for transplantation. The caregiver must explain all what is involved so that an informed decision is made. The caregiver may
be a witness. It is however preferable that in addition some members of the family witness the will to ensure that there will
be no disputes later. The caregiver may be a witness to pronouncement of divorce by a terminally ill patient. The pronouncement
has no legal effect if the patient is judged legally incompetent on account of his illness. If the patient is legally competent,
the divorce will be effective but the divorcee will not lose her inheritance rights. The caregiver should advise the terminal
patient to remember all his outstanding debts and to settle them. The prophet used to desist from offering the funeral prayer
for anyone who died leaving behind debts and no assets to settle them. He however would offer the prayer if someone undertook
to pay the debt. If the deceased has some property, the debts are settled before any distribution of the property among the
2.5 DEATH, BURIAL, and MOURNING
The last moments are very important. The patient should be instructed
such that the last words pronounced are the kalimat, the testament of the faith. Once death has occurred the body is placed
in such a way that it is facing the qiblat. Eyes are closed and the body is covered. Qur'an and dua are then recited. The
health care giver should take the initiative to inform the relatives and friends. They should be advised about the shariah
rules on mourning. Weeping and dropping tears are allowed. On receiving the news of death it suffices to say 'we are for Allah
and to Him we will return'. The following are not allowed: tearing garments, shaving the head, slapping the cheek, wailing,
and crying aloud. Relatives are comforted by telling them hadiths of the prophet about death. These hadiths talk about the
reward of the person who loses his beloved one and he is patient. The health care team should practice total care by being
involved and concerned about the processes of mourning, preparation for burial and the actual burial. They should participate
along with relatives as much as is possible. The preparation of the body for burial can be carried out in the hospital. The
body must be washed and shrouded before burial. Perfume can be put in the water used for washing the body. The washing should
start with the right. The organs normally washed in wudhu are washed first then the rest of the body is washed. Perfume can
be used except for those who died while in a state of ihram. Women's hair has to be undone. After washing the body is shrouded,
kafn, in 2 pieces of cloth preferably white in color. As many persons as possible
should participate in salat al janazat. Burial should be hastened. Following the procession is enjoined There is more reward
for accompanying the funeral procession and staying until burial is completed. The funeral bier is carried by men. Hurrying
in marching to the grave is recommended. The body should be buried in a deep grave facing Makka. After burial, the relatives
are consoled and food is made for them. Women in mourning should not touch any perfume. Only good things should be said about
3.0 ETIQUETTE IN THE HEALTH CARE TEAM
3.1 PRINCIPLES OF GROUP WORK
A group is several interdependent and interacting persons. Work is enjoined in groups
that are united, cooperative, open and trusting. Group members must be similar, empathetic, supportive, and sharing. Separation
from group is condemned. Group norms must be respected. Breaking norms, secretive behavior, concealment of information, and
secret talks destroy groups. Group membership has benefits of integration, stimulation, motivation, innovation, emotional
support, and endurance. Group performance is superior to individual performance. Group membership has the disadvantages of
arrogance, suppression of individual initiative, member mismatch, and intra-group conflict. Group formation has 4 stages:
forming (acquaintance and learning to accept one another), storming (emotions and tensions), initial integration (start of
normal functioning), total integration (full functioning), and dissolution. Mature groups have group identity, optimized feedback,
decision-making procedures, cohesion, flexibility of organization, resource utilization, communication, clear accepted goals,
interdependence, participation, and acceptance of minority views. Groups fail when constituted on the wrong basis, when members
cannot communicate, when there is no commonality (interests, attitudes, and goals), and when they have diseases of hasad, nifaq, namiimah, gaybah, kadhb, riyah, kibriyah, hubb al riyasa, tajassus, and dhun al soo. An effective
group follows the Qur'an and sunnat, members feel secure and not suppressed, members understand and practice sincere group
dynamics, members are competent and are committed to the group and the leadership.
3.2 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.
3.3 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. Rafidah was good model
of etiquette. She a kind, empathetic, a capable leader and organizer, clinically competent, and a trainer of others. Besides
clinical activities, she was 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.
3.4 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).
3.5 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 are
examined in the presence of a chaperone. The gaze should be lowered. Modest and covering must be observed. Display of adornments
that enhance natural beauty must be minimized.
4.0 USE OF ANIMALS IN RESEARCH
4.1 ENJOINING KINDNESS TO ANIMALS
The prophet enjoined kindness to animals. Saving animals from danger is a noble act. There is reward for kindness to
4.2 PROHIBITING CRUELTY TO ANIMALS
Cruelty and physical abuse of animals are prohibited. There is severe punishment is reserved for cruel treatment
if animals. Face branding, beating, cursing, sexual abuse, sexual abuse, and wanton killing of animals were forbidden.
4.3 ANIMAL RESEARCH: PURPOSE and RELEVANCE
The purpose of animal research is to spare humans from risk. Findings in animals are relevant to humans because of
similarities in physiology and biochemistry. However findings in animals cannot be directly transferred to humans; research
on humans is still necessary for a definitive conclusion. Animal research is exploratory and not definitive.
4.4 THE LAW AND ANIMAL EXPERIMENTATION
The position of the Law is that animal experiments are allowed if a prima facie case can be established that
the result of the research is a necessity, dharuurat. Dharuurat under the Law is what is necessary for human
life. The regulations of necessity require that no more than the absolute minimum necessary should be done, al dharurat
tuqaddar bi qadiriha. Animal research has definite risks for the animals that are not balanced by any benefits: pain,
suffering, permanent injury, inhumane treatment and operations, and being killed (sacrificed). Thus use of animals in justifiable
on the basis of taskhiir and not any benefits that accrue to the animals. The risks to humans from animal research
are minimal in the short term; long-term effects are difficult to fathom. The purposes and principles of the Law can be used
to analyze all legal aspects of animal experimentation.
4.5 OUTSTANDING ETHICO-LEGAL ISSUES
There are limits to taskhiir. Humans were not given a carte blanche to exploit animals in any way they liked.
They have to conform to the Law and moral guidelines. If the results of animal experimentation will lead to protection of
human life, then research is allowed to proceed because then it is a necessity. This is similar to killing animals for food,
a necessity for human life. If research is for general scientific curiosity unrelated to any tangible human benefit, then
it is beyond the authorization of taskhiir. There are differences among animals. Animals considered dangerous and must
be killed. Use of such animals for research should therefore raise fewer ethical objections than other animals. All types
of animals used in research cannot be subjected to unnecessary pain and suffering. Animals whose flesh is edible are preferably
used in research. Use of animals that are haram like the pig should be avoided as much as possible and should be considered
only in cases of dharurat. Animals, like humans, have rights to enjoyment of life and good health. The researcher must therefore
follow Islamic etiquette to minimize animal suffering. The basmalah is said at the start of an animal experiment, similar
to slaughter of animals for food, in recognition of the fact that the experiment is carried out with the permission of the
creator under the requirements of taskhiir. The animals must be shown kindness and respect. They should not be subjected
to the psychological pain of seeing other animals in pain or being sacrificed. Pain must be minimized both during the experiment
and when the animal is being terminally sacrificed. This is based on the legal requirement of slaughtering animals using a
sharp knife and as quickly as possible to prevent pain and suffering. The long-term effects of the experiment on the animal
must be considered and efforts made to decrease suffering and pain. The nutritional and medical needs of the animal must be
taken care of before, during, and after the research.
5.0 ETIQUETTE OF RESEARCH ON HUMANS
5.1 HISTORICAL BACKGROUND
Early humans experimented with several plants and by trial and error found some to be useful as medicines and others
to be poisonous. These early experiments were not planned in a systematic way neither were they documented. Galen founded
experimental medicine before 200 CE. Historical experiments were carried out by James Lind In 1747 on scurvy, Dr Edward Jenner
in 1798 on small pox, and Goldberger in 1914 on pellagra. Community trials were carried out on vitamin C, the Salk and HBV
vaccines, cardiac disease risk factors, and water fluoridation for dental caries. Clinical trials were on streptomycin in
TB 1948, aspirin and vitamin C for cancer prevention, alpha-tocopherol and beta-carotene in lung cancer prevention in smokers.
Unethical experiments without informed consent were carried out in the 1940s, 1950s, and 1960s. The Nuremberg
code of 1946 laid down rules on voluntary informed consent, unnecessary experiments, animal before human experimentation,
physical and mental suffering, scientific qualification of researchers, freedom of subjects to withdraw, and stopping the
investigation if patient are in danger. The Helsinki Declaration of 1964 incorporated the Nurenberg code. Its basic principles
were: conformity generally accepted scientific principles, qualified researchers, risk benefit assessment, research subject
welfare, and full disclosure before informed consent. The Nuremberg and Helsinki
codes on experimentation did not stop all unethical research. They lack were neither laws enforceable by the state nor moral
standards enforced by conscience. They are an unsuccessful attempt at bridging the secular divide between morality and public
life. Islam on the other hand looks at problems of human experimentation as purely legal issues. The Law provides adequate
guidelines and safeguards. Islamic Law, unlike western law, incorporates morality in its fabric. There is therefore no need
to have special ethical codes outside the Law.
5.2 PURPOSES OF THE LAW IN HUMAN EXPERIMENTATION
The Islamic ethical theory on research is based on the 5 purposes of the Law, maqasid al shari’at,
religion, life, progeny, the mind, and wealth. If any of the 5 necessitiesis at risk permission is given to undertake human
experiments that would otherwise be legally prohibited. Therapeutic research fulfills the purpose of protecting health and
life. Infertility research fulfils the purpose of protecting progeny. Psychiatric research fulfills the purpose of protecting
the mind. The search for cheaper treatments fulfills the purpose of protecting wealth.
5.3 PRINCIPLES OF THE LAW IN HUMAN EXPERIMENTATION
The 5 principles of the Law guide research. Research is judged by its underlying and not expressed intentions.
Research is prohibited if certainty exists about beneficial existing treatment. Research is allowed if benefit outweighs the
risk or if public interest outweighs individual interest. If the risk is equal to the benefit, prevention of a harm has priority
over pursuit of a benefit of equal worth. The Law chooses the lesser of the two evils, injury due to disease or risk of experimentation.
The principle of custom is used to define standards of good clinical practice as what the majority of reasonable physicians
consider as reasonable. Under the doctrine of istishaab, an existing treatment is continued until there is evidence to the contrary. Under the doctrine of istihsaan a physician can ignore results of a new experiment
because of some inclination in his mind. Under the doctrine of istislaah preventing a harm has priority over obtaining a benefit.
5.4 INFORMED CONSENT
Informed consent by a legally competent research subject is mandatory. Informed consent does not legalize risky
non-therapeutic research with no potential benefit. It is illegal to force participation of the weak (prisoners, children,
the ignorant, mentally incapacitated, and the poor) in clinical trials even if they sign informed consent forms.
5.5 OUTSTANDING ETHICO-LEGAL ISSUESResearch on fetal human tissues may encourage abortion. Cadaver dissection and post mortem examination are permitted
under necessity. Use of human bodies in auto crass experiments violates human dignity. Genetic experiments may cause diseases
hitherto unknown. The Law allows research on ageing as long as the aim is not prolongation of life or preventing death because
those aspects are under Allah’s control.