Citation for Codes of Medical Ethics

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MLA

Malik, Aisha . "Codes of Medical Ethics." In The Encyclopedia of Islamic Bioethics. Oxford Islamic Studies Online. Jan 27, 2022. <http://www.oxfordislamicstudies.com/article/opr/t9002/e0247>.

Chicago

Malik, Aisha . "Codes of Medical Ethics." In The Encyclopedia of Islamic Bioethics. Oxford Islamic Studies Online, http://www.oxfordislamicstudies.com/article/opr/t9002/e0247 (accessed Jan 27, 2022).

Codes of Medical Ethics

Codes aim to set standards for professionals to follow, and also to inform society of the conduct expected of professionals (Sohl and Bassford, 1986). The term “medical ethics” was not coined until 1803 when Thomas Percival wrote his eponymous book (Jonsen, 2009; Waddington, 1975). However, the foundation of medical morality (informed by culture, philosophy, and religion) was laid by oaths and treatises in the pre-modern era. It is therefore not unreasonable to speak of a long tradition of medical ethics prevailing in many places over many centuries and, although the language may differ from time to time and culture to culture (Jonsen, 2000), some features remain unchanged.

The purpose of this article is to trace the evolution of Islamic medical ethics’ codes and treatises from pre-modern to modern times, beginning with the akhlāq and adab treatises in the pre-modern period followed by the codes developed in the modern period by the Islamic Organization for Medical Sciences. In order to provide the framework within which the codes are written the article discusses, albeit briefly, the normative principles derived from Shariʿah.

Pre-modern Era

Greek medicine and philosophy influenced works of early Muslim physician-philosophers. Hippocrates in particular is praised for creating the basis for trust that is integral to the practice of medicine, and wrote seventy treatises. The oft-pledged deontological maxim “to help and not to harm,” appears in Epidemics 1. Oaths were prominent in Greek law and were “taken solemnly and observed stringently” [Jonsen, 2000, p. 4]. The injunction to refrain from “harm or intentional injustice” became a dominant deontological component of Greek medicine (p. 5) and later codes.

The Hippocratic Oath (400 BCE) shows the “interplay between Greek reverence for techne (craft/art) and doxa (reputation).” In this context, doxa goes beyond mere reputation—it is the reflection of the inner self to others, the external manifestation of moral virtue” (p. 7). It is claimed that the mastery of the techne sets apart a praiseworthy physician from a reprehensible one, for it not only obtains the desired therapeutic effects, it does so in a morally and professionally worthy manner. It is important to mention that there existed a dynamic interaction between philosophies of the East and Greek philosophical thought, and similarities between the Hippocratic Oath and pledges of ancient India and China can be seen perhaps via the Pythagorean School (Jonsen, 2000; Baltussen, 2015). Later, the normative values integrated into the Oath were adapted to fit various cultural contexts, be they Christian, Jewish, or Muslim (Waddington, 1975; Nutton, 1995).

Physicians’ Akhlāq and Adab

During the ninth to the thirteenth centuries Islam inspired great achievements in the arts, science, literature, and medicine, and it is during this period that many works of philosophy and Islamic law were written. Before examining this era, it is useful to discuss the ethical norms mentioned in the treatises written during this period.

The moral code to be followed by every Muslim is that of Shariʿah—based on the moral commandments stated in the Qurʾān together with the Sunnah. “Shariʿah is [therefore considered] equally law and morality, as well as religion and etiquette” (Carney, 1983, p. 162). This understanding of revealed norms (ʿilm al-fiqh) and the ethico-moral discourse (ʿilm al-akhlāq) can be said to shadow each other (Moosa and Mian, 2012; Nasr, 2004).

Akhlāq and adab approximate the meaning of ethics. Akhlāq (singular khulq) refers to one’s character (Moosa and Mian, 2012), while adab literally means civility or etiquette and refers to norms of right conduct, which is often understood as “one’s disposition as formed by habit” (Moosa and Mian, 2012). The Prophet regarded ḥusn al-khuluq (good manners) an admirable attribute (Sahīh Muslim, vol. 4, n.d., p. 3436). In Islam, the inner disposition and its outward expression are inextricably linked in a “cyclical relationship” (Sartell and Padela, 2015, p. 1)—in other words, being kind and acting kindly, as mirrored in the Prophet’s virtuous character. The Qurʾān emphasizes this aspect by saying of the Prophet, “truly thou art of an exalted character” (68:4) and commanding: “but do good, for God loves those who do good” (2:195).

As part of its moral directive to attain a virtuous character, the Qurʾān emphasizes justice (ʿadl), equity, benevolence (ihsān), truth (ḥaqq), humility, moderation (iʿtidāl), forgiveness, kindness, tolerance (including of nonbelievers), musāwāh (equality among believers). At the same time, the Qurʾān cautions against lewdness (fawāḥish), evil (munkar), deception, arrogance (takabbur), and rebelliousness (baghy) (Ghamdi, 2015). Thus the concept of adab parallels Hippocrates’ humanitas and Aristotle’s virtue ethics.

Though an official code of ethics was absent in the early years of Islam, a small group of conscientious physicians, concerned with the quality of medical care and the reputation of their profession, provided guidelines for individual physician’s professional behavior (Weisser, 2009). Three examples discussed below are Adab al-ţabīb (The Practical Ethics of the Physician), Akhlāq-al-ţabīb (Medical Ethics), and al-Qānūn fī al-ṭibb (Canon of Medicine).

Adab al-Ţabīb (The Practical Ethics of the Physician)

Isḥaq ibn ʿAlī al-Ruhāwī’s (850–899 CE) Adab al-tabīb is the first treatise devoted to medical ethics in the Islamic tradition and is pivotal in the genre of akhlāq literature for Muslim physicians (Aksoy, 2004; Levey, 1967). Many works, including those of Aristotle, Plato, and in particular works of Hippocrates and Galen were a source of inspiration. Martin Levey writes that “the contents of this work [Adab al-ţabīb] are remarkable in their delineation of the manner in which Muslim (and to a lesser extent, Christian) religious ideas were made to harmonize with the older science and ethics of the Greeks in particular” (Levey, 1967, p. 3).

In the opening paragraphs, al-Ruhāwī declares that his purpose is “to collect material about the ethics which the physician must cultivate, and the manner in which the physician must strengthen his moral character.” Al-Ruhāwī, exhorts physicians to be truthful and have trust in God’s help and support (Levey, 1967, p. 18). He stresses that “the highest type of humanity…is to attain man’s oneness with God” (Levey, 1967, p. 9). From Galen’s On the Passions of the Soul, al-Ruhāwī borrowed the Aristotelian notion that virtue is embodied in the “just mean” between the two extremes on the virtue continuum (as iʿtidāl), which requires moderation and temperance from physicians (Weisser, 2009, p. 366; Levey, 1967). The concept conforms with “muʿtadil” (moderate/the middle between two extremes) in Islam, for in the Qurʾān Muslims are described as ummah wasaṭ (literally a “middle nation,” “community of the middle way” (2:143), signifying a people who follow the path of balance and moderation, justice and equity. From Galen, al-Ruhāwī also explored the concept of liberation from passions through training and practice, along with compassion for the sick (Weisser, 2009).

Along with the philosophical content, the twenty chapters of Adab al-ţabīb provide a detailed exposition of the akhlāq and adab within the medical context. A physician’s daily routine, espoused by al-Ruhāwī is that: “after finishing his morning toilet and prayer, his [physician’s] first activity will be the study of books, first religious ones to improve his character, than [sic] medical ones to improve his learning” (Weisser, 2009, p. 367). A virtuous physician, according to al-Ruhāwī, shows “mercy, conscientious attention, patience and firmness. He should be chaste, keep secrets, and bestow the benefits of his science on all people without distinguishing them as friends or foes, in agreement or disagreement” (Jonsen, 2009, p. 19). More importantly a physician, as a guardian of soul and body, should interrelate spiritual health and physical health. This is in light of the view that a virtuous physician, in imitating the acts of God, can improve a patient’s soul and body (Jonsen, 2009, p. 20; Levey, 1967, p. 9; Ilkilic, 2009).

Akhlāq-al-Ţabīb (Medical Ethics)

Abū Bakr Muḥammad ibn Zakariyyā al-Rāzī, (Rhazes) (865–925 CE) wrote Akhlāq-al-ţabīb (Medical Ethics), in addition to his philosophical works: al-Ţībb al-ruhānī (Spiritual Medicine) and al-Sīrah al-falsafiyah. Al-Rāzī, a pure rationalist (Badawi, 2002), emphasized that reason rather than blind submission (taqlīd) guaranteed progress and improvement (Goodman, 1999). Although al-Rāzī emulated Socrates in philosophy and Hippocrates in medicine, he challenged them as well (Modanlou, 2008). Specifically, al-Rāzī argued that a strong relationship between the health of the body and the health of the spirit exists—such that troubles with the latter can lead to problems with the former. Thus the physician of the body ought to be a physician of the spirit as well.

Akhlāq al-ţabīb stresses that ethical responsibility is a triad—between the physician and patient, the patient and his physician, and the physician to himself (Karaman, 2011). Al-Rāzī considered it the physician’s duty to improve his techne (by maintaining a commitment to medical education), lead a virtuous life, and treat all people justly (Karaman, 2011). Addressing his students, al-Rāzī urged them to be gentle, honor the trust that patients expect, thereby maintaining confidentiality and professionalism.

Al-Qānūn fī al-Ţibb (Canon of Medicine)

Abū ʿAlī al-Ḥusayn ibn ʿAbd Allāh ibn Sīnā (Avicenna, 980–1037) was influenced by Aristotle and sought to and tried to reconcile ancient Greek philosophy with God as the creator of the universe (Goichon, 1999; Avicenna, 2012). Avicenna’s synthesis of Greek philosophy and theology was later adopted by medieval Christian and Jewish philosophers such as Thomas Aquinas and Maimonides, respectively (Goichon, 1999; UNESCO, 2004).

Although no specific chapter is devoted to medical ethics in Canon of Medicine, it can be said that the book “has come to represent many humanistic ideas” relevant to the medical field (Heidari, 2012). Avicenna wrote of medicine as a devotional practice to a human in need and, ultimately, a devotion to God, for which the physician earns a living, cultivates gratitude, and acquires insights into the realities of nature (Jonsen, 2000, p. 20). Much like al-Ruhāwī and al-Rāzī, Avicenna emphasized a non-disjunction between mind and body and developed a holistic approach in the practice of medicine (UNESCO, 2004).

Although Muslim medical ethics in the ninth century were influenced by Greek, Indian, Syrian, and Persian traditions (Haleem, 1993, p. 2), the God-centered ethical discourse of al-Ruhāwī, al-Rāzī and Ibn Sīnā was based on philosophical ethics and religious faith. These physician-philosophers considered sensitivity toward the sick irrespective of the patient’s social status as a virtuous requirement for physicians.

During the centuries that followed, other notable physicians likewise studied the Hippocratic and Galenic texts and wrote on medical ethics though with an emphasis on Islamic religious thought (Hamarneh, 1971).

Modern Era

At the end of World War II, the two most important developments in the field of medical ethics were the formulation of the Nuremberg Code (1948) and the establishment of the World Medical Association (WMA, 1947). The WMA issued a physician’s oath as well as the Declaration of Geneva (1948), which specifies a set of duties of physicians toward patients, the profession, and society. In 1949 the WMA issued the International Code of Medical Ethics, a declaration that provides ethical principles for medical research involving human subjects. The Declaration of Helsinki (1964) and the Declaration of Lisbon (1981) focused on the rights of the patient, and were written in response to the exploitative research practices involving vulnerable people that shook the conscience of the global medical community. The deontological principles laid down in these oaths, declarations, and codes are accepted internationally as the cornerstone of ethical guidance in the medical field. They are amended regularly in tandem with emerging developments around the world. In its 2004 International Islamic Code for Medical and Health Ethics, the Islamic Organization for Medical Sciences (IOMS) included the 2000 revision of the Declaration of Helsinki in its appendix, but it used the guidelines of the Council for International Organizations of Medical Sciences (CIOMS) as a foundation of its Code.

The Belmont Principles

In 1979 the US National Commission for the Protection of Human Subjects in Biomedical and Behavioural Research published the Belmont Report as a response to the Tuskegee Syphilis study. It provides a “principled moral framework” that is not tied to a particular region (Beauchamp, 2005). The principles set out in the Belmont Report form the foundation of research ethics guidelines and they are ubiquitously applied in the clinical context as well (Cassell, 2000). Within this report three main principles are emphasized:

Respect for persons. Social evolution toward a rights-based society gave rise to the principle of respect for human beings as autonomous persons who have the ability to determine what can and cannot be done to them. Although self-determination had found expression in the Nuremberg Code, prior to the Belmont Report physicians often unilaterally decided what to tell patients and how to treat them. Respect for persons includes two ethical convictions. The first is to treat individuals as autonomous agents, capable of deliberation about personal goals and acting under the direction of such deliberations (Belmont Report, 1979). After being provided adequate information, an autonomous person’s choice should be respected and not overridden or obstructed, unless it proved to be detrimental to others. The second is that persons with diminished autonomy should be protected. The imperative is that respect does not vary according to the ability to act autonomously, it is owed to all human beings by virtue of their intrinsic worth.

Beneficence requires making efforts to secure the well-being of patients. It encompasses a moral obligation to do no harm, and to prevent and remove harm and to do good. The dual responsibility of doing good and avoiding harm stems from physicians’ medical knowledge and their virtuous character (Cassell, 2000).

Justice, interpreted as fair, equitable and appropriate treatment (“what is deserved”) and reflects fairness in distribution based on the Aristotelian principle: “equals ought to be treated equally.” That is, all patients qua patients, ought to be treated fairly, irrespective of race, ethnicity, and social status. Distributive justice along with a competent patients’ right to self-determination guard against exploitative practices.

Islamic Organization for Medical Sciences (IOMS)

As stated earlier, Muslims are required to develop a virtuous character and adhere to Islamic values in every field, and medicine is no exception. Medicine has advanced immensely, but so has the potential for its misuse, either intentional or unintentional. Society is constantly catching up to provide an ethico-legal framework for the application of the new interventions. It is within this context that scholars of Islamic jurisprudence (fiqh) and medical scientists in the Islamic world convened meetings to revive Islamic values and commit to ethical standards in the field of medicine (El-Gendy, 2005).

Islamic Code of Medical Ethics

The First International Conference on Islamic Medicine, held in Kuwait in January 1981, issued the Islamic Code of Medical Ethics (IOMS 1981), which urged a Muslim doctor to maintain his “professional behavior within the boundaries of Islamic teachings.”

IOMS 1981 heralded the beginning of medical ethics codification in the Islamic world. The Code defines the medical profession and affirms its devotional character—a doctor is “an instrument of God in alleviating peoples’ illness.” He/she “is a catalyst through whom God, the creator works to preserve life and health.”

The IOMS document is divided into sections that, in addition to addressing physicians’ duty toward the profession, patients, and society, addresses physician’s interaction with modern medical advances, medical education, and physicians’ duties during war.

The Code emphasizes “no harm or harming,” akin to the Hippocratic dictum, and urges that a physician’s comportment should instill respect, trust and dignity. Confidentiality and truthfulness are essential as they bear directly on the trust in the medical profession. Based on the Prophetic reports listing the good deeds that benefit an individual even after death, it considered teaching the art of medicine as a form of continuing charity.

In order that physicians are able to advise patients when asked about religious rulings regarding their predicament, much like the Muslim physician-philosophers of the ninth century, IOMS also requires that physicians ought to be knowledgeable about fiqh, while at the same time pursuing advances in medicine and sciences since it will bear directly on the well-being of their patients.

Respecting patients’ dignity, privacy, and emotions is essential. Because Islam emphasizes modesty, physicians ought to show respect befitting a human body, living or dead. However the maxims “actions depend on intentions” and “necessities override prohibition” (Haleem, 1993) allow the physician to look at the private parts of the body for the purpose of medical treatment, under certain guidelines.

The International Islamic Code for Medical and Health Ethics (IOMS 2004)

In light of the developments in medicine in the modern era, the IOMS convened a series of meetings and seminars culminating in a 2004 conference in Cairo, which resulted in the compilation of The International Islamic Code for Medical and Health Ethics. The Code reaffirms the role of virtue as the middle position between two extremes. It then goes on to reiterate the characteristics of a well-mannered person:

He (the physician) tends more toward bashfulness and humility and less toward hostility, he is righteous and pious. When he talks he tells only the truth; he is short on words but long on actions; he seldom slips into error or pries into people’s affairs; he is reverent and devoted, friendly and communicative, dignified and patient; he is grateful and content, mild–tempered and tolerant, tender and chaste, compassionate and affectionate. He does not swear, insult, gossip, or slander; he is not impatient, rancorous, parsimonious, or envious; he displays a friendly mien and wears a cheerful smile. In loving, approving, or getting exasperated, he only seeks God’s pleasure (El-Gendy, 2005, p. 32).

The Code has four parts. Three enumerate relevant principles, while the fourth contains two appendices. Part one discusses medical behavior and physician rights and duties in 107 articles. They reflect the contractual basis of physicians’ professional ethics in relation to patients, colleagues, society, and themselves. The articles are supported by Qurʾānic injunctions and related Prophetic traditions.

Part two discusses international ethical guidelines for biomedical research involving human subjects from an Islamic perspective. This section uses CIOMS guidelines as the foundation and presents the Islamic viewpoint regarding each guideline. It also has three appendices which detail the items to be included in a research protocol, the Declaration of Helsinki (2000 version), and the phases of clinical trials for vaccine development.

Part three presents the arguments of Islamic law rulings on recent medical issues, such as human cloning, IVF, the human genome project, genetic engineering, and counseling, the use of aborted fetuses and surplus zygotes, and the medical definition of death. It presents the viewpoint of the Islamic Fiqh Academy on each issue before presenting the legal position adopted by IOMS (El-Gendy, 2005).

The guidelines indicated are based on the three principles of the Belmont Report: respect for persons, beneficence, and justice and adds to these the principle of charity as a supererogatory act. However, while the Belmont Report grounds these principles in the Enlightenment moral philosophies, the IOMS grounds each principle in Shariʿah. Thus respect for persons deriving from “We have honored the Children of Adam” (Qurʾān 17:70) permits legally competent persons to determine for themselves (El-Gendy, 2005, p. 43). The same respect is owed to an incapacitated person, though it plays out differently. The rule that “whoever is incompetent in action shall consequently be considered incompetent in words,” requires that a guardian (in matters of healthcare this could be the physician) acts in the patient’s best interest (El-Gendy, 2005, p. 44). This requirement is congruent with Kant’s Categorical Imperative: “always treat humanity whether in yourself or another as an end [in itself], never solely as a means.”

Beneficence is based on the principle “neither harming nor reciprocating harm,” such that benefit is maximized, deliberate harm neutralized, and unavoidable damage minimized. The priority then is “the attainment of what is beneficial to people by protecting what is essential to them and promoting what is needed and what is commendable” (Haleem, 1993, p. 4).

The document also emphasizes justice in the sense that each person ought to be given their due, similar to the principle: “equals ought to be treated equally.” Administering justice is regarded by Islamic scholars as the common purpose for which all the prophets and messengers were sent, as stated in Qurʾān 57:25: “We sent down the Book and the Balance with them, that the people would uphold justice.”

Islamic Code of Medical and Health Ethics (ICMHE 2005)

In September 2005 the World Health Organization’s Regional Committee for the Eastern Mediterranean (EM/RC), in its fifty-second session, issued the Islamic Code of Medical and Health Ethics, which indicates that humanity’s dignity, extending from the honor bestowed by God, ought to be respected. The committee declared that “ethical values flow from one source, and follow a clear path that extends to every part of the world [maintaining] life, freedom, preservation of property, health and sufficiency, throughout man’s life” (EMRO, 2005, p. 1).

Many of the principles reiterate the ideas given in previous documents and treatises. The first emphasizes that autonomy and confidentiality of patients ought to be respected (EMRO, 2005). That is, since God has “honored the children of Adam,” physicians should show respect for persons (patients) by allowing, in fact enabling, legally competent persons to make informed voluntary decisions.

The second principle stipulates that every human being has a right to life that ought to be respected and protected, quoting the Qurʾān “…and when he saves [a life] it is as if he saved the lives of all people” (5:32). The code states that any aggression against the life of a human being, even if it is a fetus or an old or disabled person, is an aggression against all people. Just as harm can be physical, psychological, social, or spiritual so can the acts of saving (EMRO, 2005).

The third principle of equity/justice is founded on the Qurʾānic verse: “God commands justice and the doing of good….and forbids all indecent deeds, and evil and rebellion” (16:90), which endorses justice as one of the characteristics of faith: “to decide justly even if it is against you.” The fourth principle of doing well (doing good/beneficence), which has been translated from the Arabic word iḥsān, could mean “right action/good deeds/goodness/sincerity/perfection/benevolence (Ibn Mājah, n.d., p. 3170; Şaḥīḥ Muslim, vol. 8a, n.d., p. 1; Şaḥīḥ al-Bukhārī, vol. 6, p. 300). The fifth principle reiterates the principle of “no harm and no causing harm, which cautions against bringing harm to oneself (physician included) or to others or to society in any form.

Conclusion

There has and continues to be cross-pollination of ethico-moral norms. The physician-philosophers of the ninth century reconciled the philosophical underpinnings of medical ethics constructed in the pre-modern era with Islamic religious beliefs, as an individual enterprise. The complexity of the issues during the modern era require the efforts of multiple actors from the fields of medicine, fiqh, anthropology, and medical research to formulate codes that interpret secularly derived principles using Shariʿah as a frame of reference. IOMS undertook this task and produced an elaborate system of guidance both for clinicians and researchers.

The overarching normative principles that form a common thread between the treatises of pre-modern and modern codes are indicative of the “preference of a middle course”/moderation (iʿtidāl), justice (ʿadl), benevolence (Iḥsān), and respect for life. A physician’s adab and akhlāq are meant to guide him or her so that the right actions and results are produced for the right reasons; that is, their intentions and actions are appropriately aligned. As seen in the treatises above physicians are expected to develop their techne through continuous professional development and revere doxa, emphasized since the pre-modern era, creating the trust that has always been the bedrock of the medical profession.

The imperative among modern medical professionals is to turn the contemporary Islamic codes (such as those developed by IOMS) into “living” documents, which in tandem with scientific innovations should evolve to protect participants’ rights and facilitate research (Malik and Foster, 2016).

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