padela_islamic medical ethics

COUNTRY REPORT

ISLAMIC MEDICAL ETHICS: A PRIMER

AASIM I. PADELA

KeywordsIslamic bioethics,Islamic Medical Ethics,Islamic law,Muslim ethics,transcultural ethics,Adab

ABSTRACTModern medical practice is becoming increasingly pluralistic anddiverse. Hence, cultural competency and awareness are given morefocus in physician training seminars and within medical school cur-ricula. A renewed interest in describing the varied ethical constructsof specific populations has taken place within medical literature. Thispaper aims to provide an overview of Islamic Medical Ethics. Begin-ning with a definition of Islamic Medical Ethics, the reader will beintroduced to the scope of Islamic Medical Ethics literature, from thataimed at developing moral character to writings grounded in Islamiclaw. In the latter form, there is an attempt to derive an Islamicperspective on bioethical issues such as abortion, gender relationswithin the patient-doctor relationship, end-of-life care and euthana-sia. It is hoped that the insights gained will aid both clinicians andethicists to better understand the Islamic paradigm of medical ethicsand thereby positively affect patient care.

With the increasing diversity in medicine, todayspracticing clinician, particularly in the United Statesand Europe, encounters patients from a wide spec-trum of socioeconomic and cultural backgrounds.The cultural background of both the clinician andthe patient influences the meanings attached to clini-cal encounters and interventions. Thus, culturalcompetency is given increased focus within medicaleducation programs. While no universally accepteddefinition of the culturally competent physicianexists, a common element is seen in the various for-mulations, that being a physician who possesses theknowledge-based skills to adjust his or her attitudesand behavior in order to provide effective clinical

care to patients from diverse backgrounds.1 Withinthe sphere of patient-doctor interaction bioethicalconflicts can arise due to religious and cultural dif-ferences between the practitioner and the patient,thus cultural competency has a place within medicalethics discourse. In this light Islamic Medical Ethicsis presented.

1 A. Misra-Hebert. Physician cultural competence: Cross-cultural com-munication improves care. Cleveland Clinic J Med 2003; 70(4): 289303;US Department of Health and Human Services-Bureau of Health Pro-fessions Other Definitions of Cultural Competency. Rockville, Mary-land: HRSA. Available at: http://bhpr.hrsa.gov/diversity/cultcomp.htm[Accessed 20 Nov 2006].

Address for correspondence: Aasim I. Padela, Box 655, Department of Emergency Medicine, University of Rochester Medical Center, StrongMemorial Hospital, 601 Elmwood Avenue, Rochester, NY 14642. e-mail: [email protected], phone: 585-305-7909

Bioethics ISSN 0269-9702 (print); 1467-8519 (online)Volume 21 Number 3 2007 pp 169178

2007 The Author. Journal compilation 2007 Blackwell Publishing Ltd., 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA.

ISLAMIC MEDICAL ETHICS

Ethics is classified as a sub-branch of applied phi-losophy that is intrinsically related to morality as itseeks to define the right and the wrong, the goodand the bad set of behaviors in a given circum-stance.2 Further, Medical Ethics is a subdivision ofethics that is concerned with moral principles asthey relate to biomedical science in the clinical andinvestigational arenas. As Western ethics has devel-oped into a philosophical science it has moved awayfrom a Christian conception of good and evil,readily seen in the writings of Kant and Augustine,to draw more upon human reason and experience asthe arbiter between right and wrong action. Thisdevelopment from religious ethics to philosophicalethics is not paralleled in Islamic intellectual dis-course. While Islamic ethics incorporates variousphilosophical traditions it still holds a religiousworldview and draws its resources mainly from,religious texts.

Ethics within Islamic intellectual discourse

In order to define Islamic Medical Ethics, it isimportant to note that Islamic ethics as a cohesivediscipline does not exist. Material on ethics is scat-tered throughout the Islamic sciences of Fiqh (juris-prudential understanding), Tafsir (Quranicexegenesis), and Kalam (scholastic theology).3 Onlyin modern writings, has consolidation beenattempted in order to allow for comparative study.Furthermore, when conducting such investigationsit is important to realize that there is no exact wordfor ethics in Arabic. Two Arabic terms that approxi-mate the meaning are Akhlaq and Adab. Akhlaq isderived from an Arabic root word meaning tocreate or to form thereby signifying innate quali-ties, and is used to mean morality or character.While in English the terms ethics and moralityhave different origins and connote different mean-ings, the former being what is appropriate andrational and the latter being more subjective andamenable to change over time, being what is com-

monly felt and done, in Islamic thought this distinc-tion is not so apparent as ilm-ul-Akhlaq, literally theknowledge of morality, is also the science of ethics.4

The term Adab has a wider range of meaningswithin Islamic intellectual thought, and has devel-oped into a specific genre within Arabic literature.Adab represents the linking of learning and knowl-edge to right and appropriate human conduct-. . . that is the foundation of the human

personality.5 Adab literature is related to characterethics, both in the personal and professional realm.The relation between Adab and Akhlaq in modernparlance is that Adab literature refines Akhlaq;works of Adab aim to refine character. There is asubstantial amount of writing from the classical eraon both Adab and Akhlaq as they relate to themedical field, the crowning achievement being thetreatise Adab al-Tabib (Practical Ethics of the Phy-sician) by Ishaq ibn Ali al-Ruhawi a ninth-centuryphysician residing under the Islamic caliphate inmodern-day Iraq.6 This genre is still prominenttoday as witnessed by the multitude of works relat-ing to Islamic codes of medical ethics. Thus, onetype of literature that falls within the purviewIslamic Medical Ethics discourse is Adab literature.

Ethics within Islamic juridical discourse

While Adab literature calls to universal virtues andtimeless morals, the other type of Islamic medicalethics discourse is more distinct and is grounded inIslamic legal tradition. This is necessarily so sincemany Muslims when asked as to what is the sourceof their ethical code and where they turn whenfacing ethical dilemmas, would direct the questionertowards Islamic fiqh (jurisprudential understanding)and the Shariah (Islamic law). Similarly, ethicists inthe Muslim world may refer to the Shariah whendebating abortion, euthanasia, end-of-life care, andother biomedical issues. In Islam bioethical delib-eration is inseparable from the religion itself,which emphasizes continuity between ethics and

2 S. Aksoy & A. Elmali. The Core Concepts of the Four Principles ofBioethics as found in Islamic Tradition. Med Law 2002; 21: 211224.3 A. Siddiqui. Ethics in Islam: key concepts and contemporary chal-lenges. J Moral Education 1997; 26(4): 423431.

4 Ibid: 423.5 A. Nanji. Medical Ethics and the Islamic Tradition. J Med Phil 1988;13: 257275.6 M. Levey. Historical Notes. In Islamic Medicine. S. Athar, ed. onlinepublication available at http://islam-usa.com/im1.html [Accessed 20Nov 2006].

170 Aasim I. Padela

2007 The Author. Journal compilation 2007 Blackwell Publishing Ltd.

jurisprudence.7 Hence Islamic Medical Ethics is tiedto Islamic Law (Shariah), as Islamic Law not onlylegislates but also assigns moral values.8

It is important to understand the relationshipbetween two Arabic terms that are a source of muchconfusion: Fiqh and Shariah. Fiqh, often translatedas jurisprudence or law, has a much broader defini-tion. The term literally means, understanding ordiscerning, and connotes insight and comprehen-sion.9 Fiqh spans both theology and jurisprudence asthe objects of fiqh-understanding are either religion(its values or rulings) or sources of law and stat-utes.10 Thus fiqh represents the formulated legalruling on a subject matter and/or the moral valueassigned to a particular action. However, themechanism of fiqh-understanding, the process bywhich one arrives at the fiqh-law, is also called fiqh.This elliptic quality is a source of great misunder-standing to the unfamiliar reader. The science thatidentifies the sources of fiqh and also lays down rulesfor weighing these sources against each other incases of conflict is usul-ul-fiqh, literally the roots oflaw.

The Arabic term Shariah literally means the wayto the water and has two dimensions.11 The firstbeing physical as the corpus of legal rulings, prece-dents and statutes, (a collection of fiqh) and thesecond being intellectual, as the moral code ofIslam. Just as the root meaning of the Shariahpoints one to water, the source of all life, in Islamicteaching the Shariah is the source of Muslim exist-ence as it represents the correct path of action as

determined by God.12 A popular representation ofShariah is that of a highway along which to travelin order to lead the moral life.13 The Shariah, notonly separates actions into required and forbidden,but also the intermediate categories of recom-mended, discouraged and permitted. Consequently,Islamic law is both a legal and ethical system andany discussion of Islamic Medical Ethics mustincorporate the Shariah.

ISLAMIC MEDICAL ETHICS AS ADABLITERATURE

Classical Literature on Medical Adab

One of the forms that Islamic Medical Ethics dis-course takes is Adab literature. This genre withinIslamic literature advises to proper manners andseeks to inculcate practical morals. Within the pro-fessions, this type of writing was used to composemanuals of professional standards and ethics. Con-sequently, medieval Arabic literature is replete withworks on the ethics of judges, politicians, studentsand physicians.

Although Hellenistic writings on the practice ofmedical profession contained no explicit religiouscode they did call to general piety and sincerity.Similarly, since the medical art was closely related toreligion in ancient Egypt, India, and Persia, pietywas deemed a necessary professional characteris-tic.14 When these treatises came to be known in theIslamic civilization this ideal was accepted and aug-mented. As Nanji states, though medical traditionsand values from antiquity were sustained, many ofits details came to be set in Islamic contexts.15

Medical Adab literature therefore represents a syn-thesis of Islamic morals and standards infused intoolder healing traditions, the most significant beingGreek and Persian. Many of the most prominentphysicians of the classical Islamic civilization con-cerned themselves with professional ethics, amongthem were al-Ruhawi, and al-Razi (Rhazes). Each

7 A. Daar & A. Khitamy. Bioethics for clinicians: 21. Islamic Bioethics.CMAJ 2001; 164(1): 6063.8 For the purposes of this paper, by Islamic law we mean Islamic

Sacred Law as derived from religious sources. The Shariah is IslamicSacred Law. Hence, the Shariah refers to legal stances and injunctionsderived from the science of Islamic jurisprudence (usul-ul-fiqh).However, law only becomes law when there is body that enforces it.There exists no state in the modern world that enforces the Shariahentirely nor one that considers it as the only source of law. Howeverimplementing the Shariah is an individual and collective duty in Islam,and it is both a source of law and a moral code. Accordingly on thepersonal and at some communal levels the Shariah is considered abinding guide to morality as well as the source of legal rulings. Thispoint will be explored further throughout the paper.9 Siddiqui, op. cit. note 3, p. 425; K. Reinhart. Islamic Law as Islamic

Ethics. J Rel Ethics 1983; 11(2): 186203.10 Reinhart, op. cite note 9, p. 188.11 Siddiqui, op. cit. note 3, p. 425.

12 J. Brockopp, ed. 2003. Islamic Ethics of Life: Abortion, War andEuthanasia. South Carolina: University of South Carolina Press.13 Reinhart, op. cit. note 9, p. 188.14 F. Rahman. 1998. Health and Medicine in the Islamic Tradition. ParkRidge Center, IL: ABC International Group, Inc: 91.15 Nanji, op. cit. note 5, p. 262.

Islamic Medical Ethics 171


of these physicians incorporated, and built upon,themes from the Hellenistic medical tradition.

One of the earliest and most thorough treatises onmedical ethics is entitled Adab al-Tabib (PracticalEthics of the Physician) by Ishaq ibn Ali al-Ruhawi.Al-Ruhawi lived sometime in the second-half of theninth century A.D. and practiced in the city ofRuha, which was part of the Islamic caliphate at thetime, located in an area of present-day northwesternIraq.16 Aside from his writings not much is knownabout al-Ruhawi. He was born a Christian, andthere is question as to whether he fully embracedIslam.17 His audience, however, was predominantlyMuslim and his writings contain a religious over-tone. He begins Adab al-Tabib by stating that hismotivation is to elevate the practice of medicine inorder to aid the ill and to enlist the aid of God in Hissupport vocationally and otherwise.18 In his bookal-Ruhawi calls medicine a Divine Art and considersbelief in the Abrahamic tradition to be a necessaryvirtue. Interestingly, however, he quotes AristotlesMetaphysics, Socrates in Platos Phaedo, GalensOn Ethics, and multiple works of Hippocrates tosupport this ideal. Importantly, the use of both theAbrahamic traditions and the Philosophers tofurther his points shows a distinctly Islamic para-digm; any knowledge that does not specifically con-tradict with Islam and is a part of the culture ofhumanity should be accepted as it is a mercy fromGod.19 This intellectual tolerance at Islamic centersof learning, and in Islamic discourse, was trulyexceptional given the prejudice against, and perse-cution of different ideologies present in Europe atthe time. In the first section of Adab al-Tabib, Onthe Loyalty and Faith Which a Physician MustHold, and the Ethics He Must Follow to Improve

His Soul and Moral Character, al-Ruhawidescribes three articles of faith that a physician musthave: that all in this world has only one ableCreator who performs all deeds wilfully, that hehave credence in the great Allah (Arabic term forGod) with a firm affection, and is devoted to Himwith all his reason, soul, and free will, and thatAllah sent his messengers to mankind to teach themwhat is good since the mind alone in not sufficient.20

He continues by stating that if one does not believein this, that one may find remedy for his blindnessin reading the books of the ancient wise men andthen references the works of Aristotle, Socrates andothers to show the necessity of, and prove, mono-theistic belief.21 For example he quotes AristotlesMetaphysics in defining God as that which occupiesno place is endless, and cannot be included in mate-rial like other things.22

Al-Ruhawis Adab al-Tabib contains twentychapters, the titles of which are listed in Table 1. Asthe chapter titles illustrate, Adab al-Tabib is not onlya manual of professional ethics, but contains signifi-cant material on personal hygiene, the patient-doctor relationship, and even comments on theprofession as it relates to the government. Thismonumental work demonstrates the integration ofancient medical principles into the moral frameworkof a vibrant Islamic culture. Al-Ruhawis workattests to the ability of Islamic thinkers to incorpo-rate seemingly disparate traditions and philosophiesinto an Islamic discourse.

Abu Bakr Muhammad ibn Zakiriyya al-Razi wasundoubtedly the greatest physician of the Islamicworld and one of the great physicians of all time.23

He hailed from the Iranian city of Rayy, born some-time between 841 and 865 AD. and passing awaythere in 924 or 925 AD.24 Initially, he was interestedin music but later learnt medicine, mathematics,astronomy, chemistry, pharmacy, and philosophyand wrote numerous books relating to these

16 Rahman, op. cit. note 14, p. 92.17 M. Levey. Medical Ethics of Medieval Islam with Special Referenceto Al-Ruhawis Practical Ethics of the Physician. Transactions of theAmerican Philosophical Society 1967; 57(3): 199; Levey, op. cit. note 6.Even though al-Ruhawi might not have become a Muslim his writingsdo show the influence of the Islamic environment he was in. His intel-lectual tolerance and reference to Abrahamic tradition are illustrative ofclassical Islamic ethical discourse.18 Ibid: 8.19 The terms Abrahamic traditions and Abrahamic religions are used incomparative religious discourse to mainly refer to Judaism, Christianityand Islam. The term denotes a religion derived from the ancient tradi-tion attributed to the Prophet Abraham, the great patriarch described inthe Torah, Bible and Quran.

20 Levey, op. cit. note 17, p. 19.21 Levey, op. cit. note 17, p. 20.22 Ibid.23 A. Arberry (trans.). 1950. The Spiritual Physick of Rhazes. London.Butler & Tanner Ltd: preface.24 Ibid: preface; E. Abouleish. Contributions of Islam to Medicine. InIslamic Medicine. S. Athar, ed. online publication available at http://islam-usa.com/im1.html [Accessed on 20 Nov 2006].

172 Aasim I. Padela


sciences. He served as chief physician for majorhospitals in Baghdad and Rayy and is famous forthe criterion by which he decided the best place tobuild a hospital in Baghdad. He is said to havechosen its position by hanging pieces of meatthroughout the city, deciding that the ideal locationfor the hospital is where the putrefaction of meat isslowest. His most renowned works on medicinewhere Kitab al-Hawi fi al-tibb (The ComprehensiveBook onMedicine) and Kitab al-Mansuri (The Bookfor Mansour), which was dedicated to his patron the

Iranian Prince Abu Salih al-Mansur ibn Ishaq.25

This work became one of the most widely read medi-eval medical manuals in Europe for hundreds ofyears. He wrote a companion to Kitab al-Mansuri,dedicated to the reformation of the character, andentitled it Tibb al-Ruhani (Spiritual Medicine). Inthis work he details how one can elevate his charac-ter by controlling his passions and casting awayvices. He makes numerous references to God, butdoes not base his arguments on Islamic theology.Rather he refers to a common monotheistic under-standing of God and honors the Philosophers. Hesummarizes Platos advices when discussing the sup-pression of passions, and when speaking about thevirtuous life states it consists of treating all menjustly as did all the great philosophers.26 Whileal-Razi did disagree with Hellenistic thought oncertain matters, it is clear from his works that he didnot completely reject the Greeks. His works attest tothe general thrust of the Islamic civilization in refin-ing and building upon ancient traditions and addingits own color to the tapestry of intellectual thought.

Modern Medical Adab Literature

The contemporary Adab literature pertaining to themedical profession follows a similar pattern. Thesewritings call to universal virtues while packagingthem in an Islamic vocabulary. For example in Dr.Arafas Ethics of the Medical Profession from theIslamic Viewpoint, six personal qualities are consid-ered necessary to ethical practice: sincerity, honesty,truthfulness, compassion and sympathy, patienceand tolerance, and humility.27 While these qualitiesare universal virtues, Dr. Arafa quotes verses of theHoly Quran and sayings of the Prophet Muham-mad (peace and blessings be upon him) to empha-size that these virtues are an integral part of theIslamic character.

A modern attempt to synthesize a code of medicalethics from the Islamic perspective was undertakenat the International Conference on Islamic Medicine

25 Ibid: preface.26 Ibid.27 H. Arafa. Ethics of the Medical Profession from the Islamic View-point. Doha, Qatar. Available at http://www.islamonline.net/iol-english/dowalia/techng-2000-August-22/techng7.asp [Accessed 20 Nov2006].

Table 1. The Chapters in Adab al-Tabib byal-Ruhawi

1. On the loyalty and faith in which a physician must believe,and on the ethics he must follow

2. On the means and measures by which a physician treats hisown body and limbs.

3. On things of which a physician must beware4. On the directions which a physician must give to patients and

servants5. On the behavior of the patients visitors6. On simple and compound drugs which a physician must

consider and on his remedial directions which may becorrupted by the pharmacist and others

7. On matters of which a physician must question the patients orothers

8. On the necessity for ill and healthy people to have faith in thephysician in times of illness and health

9. On the agreement that the patient must follow the directionsof the physicians and the outcome when it is annulled

10. On the behavior of the patient with his people and servants11. On the behaviour of the patient in regard to his visitors12. On the dignity of the medical profession13. On that people must respect a physician according to his skill

but kings and other honorable men must respect him more14. Peculiar incidents concerning physicians, that is, those already

known, so that the physician may be forewarned. Some arefunny and may help him to discover uncooperative personsbefore the consultation lest he be held responsible for anyharm that may occur

15. On the subject that not everyone may practice the professionof medicine but that is must be practiced by those who havea suitable nature and moral character

16. On examination of physicians17. On ways by which kings may remove corruption of physicians

and guide the people in regard to medicine, and how it wasin ancient times

18. On the necessity of warning against quacks who callthemselves physicians and the difference between theirdeceit and the true medical art

19. On faulty habits to which people are accustomed but whichmay injure both the sick and health and cause physicians tobe blamed

20. On matters which a physician must observe and be carefulabout during periods of health in order to prepare forperiods of illness, and at the time of youth for old age

Source: M. Levey. Medical Ethics of Medieval Islam with Special Reference toAl-Ruhawis Practical Ethics of the Physician. Transactions of the AmericanPhilosophical Society 1967; 57(3): 199.



held in Kuwait in 1981. The proceedings of the con-ference yielded the Declaration of Kuwait entitledthe Islamic Code of Medical Ethics. Although thispaper is shorter than Adab al-Tabib, it is similar inscope, aiming to set ethical guidelines for the physi-cian in multiple spheres of interaction. It is dividedinto eleven parts as shown in Table 2. The documentconcludes with The Physicians Oath, which hasbeen adopted by many Muslim medical schools andorganizations for ceremonial purposes.28 It too callsto universal ideals within the framework of Islamicdiscourse.

As has been demonstrated one vein within IslamicMedical Ethics discourse is Adab literature. Thisliterature not only serves as a quasi-codification ofprofessional ethics, it also speaks to the personalmorality of both physician and patient. The reasonfor this dual emphasis is two-fold. The first being abelief in the ethical responsibility of the physicianhaving two dimensions: one being the care and com-passion that must mark the doctors behaviortowards the patient, and the other being that a phy-sician must be righteous for his treatment to be effi-cacious. The second reason is that according to theIslamic paradigm ethical health is part of generalhealth thus good character leads to physicalhealth.29

ISLAMIC MEDICAL ETHICS AS RELATEDTO ISLAMIC LAW (SHARIAH)

The distinction of Islamic medical ethics vis--visprincipilism-based medical ethics lies in it giving areligious basis to morality. Philosophical or secularethics starts with the psychological constitution ofmans nature and the obligation laid on him (like thefour principles [of Beauchamp and Childress]) asa social being, but in Islamic Ethics the basicassumption is faith in Allah (with other pillars ofIslam) and morality is the attempt of each individualas well as society to approach Him as far as pos-sible.30 This approach to Allah is made through theShariah. Collectively state authorities may give theShariah supreme legal authority as the only sourceof law (which no country does today), while indi-viduals may apply Islamic law in their personal life.In this latter realm the Shariah as a moral code forMuslims is fully functional and is better understoodas the collective ethical subconscious of theMuslim community.31 With this definition as a start-ing point it follows that any discussion of IslamicMedical Ethics must include analysis of theShariah. Muslim patients may refer to the Shariahwhen discussing treatment options or seek assis-tance from an expert in Islamic law when faced witha difficult decision during the course of care. Theobjective of the Shariah in finding the possibleDivine law is to protect five essentials of the person:life, religion, intellect, honor and integrity and prop-erty.32 Furthermore, scholars have enumeratedprinciples that aid in the formative process of legis-lation. Of these, five are known as the cardinal rules:

1. Intent is all-important in action;2. Do no harm: harm must be removed (by a lesser

harm) or compensated;3. The doctrine of legal presumption of continu-

ance;

28 The Islamic Code of Medical Ethics. World Medical Journal 1982;29(5): 7880; The Kuwait Declaration: Ethics of medicine in the light ofIslamic Constitution. Medical times XVI 1981; 32(6).29 Rahman, op. cit. note 14, p. 96.

30 Aksoy & Elmali. op. cit. note 2, p. 216.31 A. van Bommel. Medical Ethics from the Muslim perspective. ActaNeurochir 1999; [Suppl] 74: 1727.32 A. Gatrad & A. Sheikh. Medical ethics and Islam: principles andpractice. Arch Dis Child 2001; 84: 7275; M. Abdel Haleem. 1993.Medical ethics in Islam. In Choices and Decisions in Health Care. A.Grubb, ed. John Wiley & Sons Ltd: 120.

Table 2. The Eleven Sections in the Islamic Code ofMedical Ethics as put together by the First Interna-tional Conference on Islamic Medicine in 1981

1. Definition of the Medical Profession2. Characteristics of the Physician3. The Physician and his Brother Physicians4. The Physician and his Patient5. Professional Secrecy6. The Physicians Role in Time of War7. The Sanctity of Human Life8. Responsibility and Liability9. The Physician and Society

10. The Physician and Modern Biomedical Advances11. On Medical Education

Source: The Islamic Code of Medical Ethics. World Medical Journal 1982; 29(5):7880.

174 Aasim I. Padela


4. Hardship calls for license;5. Custom is the rule (is the absence of a ruling).33

Lastly, in order to facilitate comparison with otherethical systems and legal structures two broad ten-dencies that shape Islamic ethical reflection shouldbe stated. The first being a tendency toward theo-logical voluntarism, i.e. that God alone defines thestandard of right and wrong, hence the corollarythat good deeds are good only because God com-mands them, and evil is evil because God forbidsit.34 Following this assumption would lead toheavy dependence upon revelation and no role forhuman deduction. However, there exists a counter-balancing tendency, Gods commands are purpose-ful and as such His will extends to all areas of lifeand every field of action. Since Gods will is pur-poseful human reason in dependence upon revela-tion can discern rules and apply them.35 These twotendencies or assumptions gave birth to the richnessof Islamic legal thought and ethical reflection inthe development of usul-ul-fiqh. Usul-ul-fiqh is thescience that identifies the sources of fiqh-law andalso lays down rules for weighing these sourcesagainst each other in cases of conflict. The word usulin Arabic means root and in the ethical/legallexicon the fiqh-process . . . (is) a movement fromthe bases or roots (usul) of revelation to specificdeterminations that constitute the actual dictates ofDivine Law.36

Sources of Islamic law (Usul ul-Fiqh)

The sources of Islamic fiqh-law can be divided intomaterial sources and formal sources. The materialsources as the Quran and the Sunnah. The Quran isthe Muslim holy book and held to be the literalword of God transmitted through the angel Gabrielto the Prophet Muhammad (pbuh) over a period of23 years. The Quran contains 6326 verses of whichapproximately 500 are explicitly concerned withlegal rulings mostly pertaining to worship and reli-gious duties. However, many principles of behavior

are laid out within the text.37 The Quran, as Burtonstates, is a source of knowledge in the way that theentire corpus of legal precedent is for the commonlaw tradition: not as much as an index of possiblerulings (rather) as a quarry in which the astuteinquirer can hope to find the building blocks for amorally valid, and therefore, true system of ethics.38

The Sunnah is the second source of binding lawand encompasses collections of sayings, actionsand silent affirmations of the Prophet Muhammad(pbuh). For Muslims the Prophet Muhammad(pbuh) represents the ideal model of human behav-ior and multiple Quranic injunctions order believ-ers to emulate and obey him. However, the sunnah,is not just a mere catalog of moral behavior; it is acollection of data that requires assessment andapplication. Since the Prophet Muhammad (pbuh)represents a life lived totally in accord with themoral/legal code of Islam he is the normative case39

as well as the explainer of the code.40 The Sunnah hasbeen complied in book form in collections calledhadith.

The formal sources are the product of juristicendeavors to find the fiqh-law. These are ijma andqiyas. Ijma refers to consensus agreement about themoral and/or legal assessment of an act or practice.Its scope can include how a particular hadith orQuranic injunction should be applied and inter-preted, as well a record of agreement on an issuethat may not be explicitly covered by the two mate-rial sources. Thus, ijma can be seen as a materialsource itself. As for the question the consensus ofwhom, differences exist within the different schoolsof law.41 The dominant opinion is that ijma is the

33 A.A.A. Yacoub. 2001. The Fiqh of Medicine. London. Ta-Ha Pub-lishers Ltd: 43.34 D. Brown. Islamic Ethics in Comparative Perspective. The MuslimWorld 1999; 89(2): 181192.35 Ibid: 187.36 Reinhart, op. cit. note 9, p. 189.

37 Yacoub, op. cit. note 29, p. 16.38 J. Burton. 1977. The Collection of the Quran. London: CambridgeUniversity Press: et passim.39 In Islamic theology all of the Prophets are considered protected byGod from sin. They were fully human and subject to the same tenden-cies as all other humans but they lived their life in total accordance tothe commandments of God. Their errors in judgement are consideredto be Divinely decreed for the purposes of teaching the rest of mankind.Thus they serve as examples of humans who are in perfect harmony andexemplars of perfect human conduct. Therefore there is no concept oforiginal sin in Islam.40 Reinhart, op. cit. note 9, p. 190.41 Ijma (consensus agreement) is considered a source of Islamic law bythe four major Sunni schools of law- Hanafi, Shafii, Maliki andHanbali. The Hanafi and Hanbali pose no restrictions on consensus interms of time and place. The Malikis prefer to restrict consensus to the



agreement of Muslim learned persons at a time,after the death of the Prophet (pbuh) on a legalmatter.42 Qiyas literally means to compare or tomeasure, and in practice is juristic reasoning byanalogy.43 In application it stands for applying acertain ruling from an established case if the predis-posing conditions, which led to the ruling in the firstcase, apply to a second case. These four sources indescending order of importance, albeit with slightmodifications in scope, the Quran, Sunnah, Ijmaand Qiyas, are agreed upon by the four majorschools of law in Sunni Islam.44 The four schools Hanafi, Shafii, Maliki and Hanbali are namedafter famed jurists who developed systems forweighing evidences in the Shariah and promulgatedtheir views.

While it is beyond the scope of this paper, thereexist other formal sources of law within each schoolthat carry lesser importance than the above men-tioned four, these are isthisan, which is the principlewhere equitable considerations may override strictqiyas; maslahah, which is the consideration of publicwelfare or interest; urf, which is customary practice;istishsab, which is the presumption in the laws ofevidence that a given state of affairs known to betrue in the past still continues to exist until the con-trary is proved. It is also important to note that in

the Shiite sects of Islam, which represent between1015% of Muslim population have a similar systemof usul-ul-fiqh. For example, the Jafari sect of ShiiteIslam, also maintain the Quran, Sunnah, Ijma assources of law but add aql, or human intellect, asthe fourth source instead of qiyas.45

While this system may seem complicated andlabor-intensive, in practice the sources are seen asliving harmoniously with one another and thus ajurist may consult an important handbook of law asreadily as the hadith literature in his quest to find themoral value and/or ruling on an action. The entireprocess of determining the fiqh-law is called ijtihad.The end result of this process can yield three types ofrulings: judicial fact or law (hukm al-qadi), a deter-mination of validity (hukm wadi) and a determina-tion of moral status (hukm taklifi).46 This lastcategory is what makes the Shariah a moral andlegal code. The moral status of an action is dividedinto five different categories with obligations in thisworld and a consequence in the hereafter, as seen inTable 3.

Legal opinions (Fatawa) as a window intoIslamic ethics

A final point that must be made is that the applica-tion of the Shariah, is both an individual and col-lective duty in Islam. Centers for learning theIslamic sciences have existed since classical timeswithin, and in modern times even outside of,Muslim countries. After completion of years ofstudy the graduate of such an institution may come

agreement of the immediate companions of the Prophet (pbuh) andgeneration immediately following them, while the Shafii require theconsensus of the entire Muslim community. M.A.H. Sheikh. 1999.Islamic Principles on Family Planning. Karachi, Pakistan. Darul-Ishaat:20.42 Yacoub, op. cit. note 29, p. 25.43 Ibid: 25.44 Ibid. p. 15; H. Hathout. 1989. Talking to Each Other. In HealthPolicy, Ethics And Human Values, An Islamic Perspective. Geneva:Council for International Organization of Medical Sciences: 26.

45 Yacoub, op. cit. note 32, p. 41.46 Reinhart, op. cit. note 9, pp. 193194.

Table 3. Moral Status of Actions in Shariah

Status Meaning in this life Consequence in Hereafter

Wajib or Fardh Obligatory Minimum actions needed to be performed to beconsidered part of the Islamic community

Reward for performancePunishment for neglect

Mandub or Mustahabb Recommended Commendable actions Reward for performanceNo consequence for neglect

Mubah Permitted Indifferent No reward or punishmentMakruh Discouraged Should be avoided as a way to piety No punishment for performance

Reward if avoidedHaram Prohibited Performance of certain of these acts or

legitimacy of performing them takes one outof Islamic community

Punishment for performanceReward for avoidance

Source: K. Reinhart. Islamic Law as Islamic Ethics. J Rel Ethics 1983; 11(2): 186203.

176 Aasim I. Padela


to be employed within the Islamic legal system as aqadi or judge. This, however, necessitates a func-tional Islamic legal system, which exists only in alimited form today. The other career option for thegraduate is to be employed by communities or otherinstitutions as a mufti. A Mufti, literally someonewho can render a fatwa (legal opinion), is a scholar-in-residence who is specialized in the Shariah andhas been conferred this title through study andexamination. The difference between the ruling of aMufti and that of the qadi is that the former is notbinding, but the latter is, since it is backed by a statesystem. This twofold system still functions in manyparts of the Islamic world as the mufti serves as alegal consult before bringing a case to the formalcourt.47 In Western countries, the mufti is morepopularized as a communal and personal resource,who can offer moral guidance on specific issues anddilemmas. The fatwa, or legal opinion of the Mufti,functions as an informal religious document uponwhich to base action. Today one can readily findpublished fatawa (sing. fatwa), in books, newspa-pers and on the various websites. Some scholarseven host call-in radio and television shows, as wellas Internet chat forums, where the seeker might beable ask a Mufti for a fatwa. There are two essentialaspects of a fatwa: it is founded on the juridicalsources and principles of the Shariah, and it is for-mulated with consideration of the context that moti-vated the questioner to seek the opinion.48 Thus, thecompilations of fatwa serve as a window into themoral code of the Islamic community on particularissues.

Islam does not have a singular developed clergysystem. A diversity of views on any particularmatter exists and is apparent within the fatawa col-lections. For the one who is seeking the fatwa, themultiplicity of opinions allows one to explore andmake a personal choice as to which fatwa has thestronger argument; which fatwa sets the seekersheart at ease. In practice however the seeker oftenonly consults the particular Mufti whose opinion hetrusts, and will consider binding, on the particularsubject. This choice of a particular Mufti could be

based on adherence to a particular school of juris-prudence, on similarities in cultural background, oron preferential scholarship.

With regard to Islamic Medical Ethics in particu-lar the fatwa literature is a fertile ground whensearching for an Islamic opinion on a variety ofissues ranging from abortion to assisted reproduc-tive technologies. Furthermore, patients may referto specific fatwa when encountering an ethicaldilemma. In the medical field there has been a trendto develop consensus position papers through jointconferences between medical specialists and schol-ars of Shariah. Increasing scientific and techno-logical advances have forced the Muftis to consultmedical scientists in order to better understand thescience behind the technology or issue that they areasked to find an Islamic position on. This coopera-tion has been deemed an obligation upon themedical scientist as the Islamic Code of MedicalEthics states the medical profession has the rightand owes the duty of effective participation in theformulation and issuing of religious verdicts(fatwa) concerning the lawfulness or otherwise ofthe unprecedented outcomes of current and futureadvances in biological science.49 The cooperation isstill in its infancy, but the numerous Islamic medicalconferences occurring each year, and the inclusionof both scholars of the Shariah and of medicinewithin them, is an encouraging sign.

SUMMARY AND FINAL REMARKS

A certain level of cultural awareness is necessary todeliver culturally sensitive medical care. Our societ-ies are becoming increasingly multicultural with aplurality of value systems that may come into con-flict with one another. Cultural and religious differ-ences can lead to bioethical conflicts in the clinicalrealm and in order to bridge these differences eachparty must understand the ethical constructs thatinform each others opinions. Thus, not only iscultural competence necessary, but competence indealing with divergent ethical codes is as well. Thefield of medical ethics is a growing one, and increas-ing importance has been placed upon it within47 Brockopp, op. cit. note 12, p. 9.

48 T. Ramadan. 2004. Western Muslims and the Future of Islam. NewYork, NY: Oxford University Press: 48. 49 Siddiqui, op. cit. note 3, p. 430.



medical curricula. It is hoped that within theseeducational programs diverse systems of, andapproaches to, medical ethics are presented in orderto facilitate greater competence in the clinical realm.

Islamic Medical Ethics discourse can be dividedinto two distinct forms of literature. The first beingof practical ethics and advice literature; Adab litera-ture. Prominent physicians in the golden age of theIslamic civilization authored numerous works onthe ethics of the medical professional. These trea-tises incorporate ideals from the ancient healing tra-ditions into a distinctly Islamic discourse relyingon morals derived from sayings of the ProphetMuhammad (pbuh) and verses from the Quran.Modern committees have also undertaken the taskto develop comprehensive manuals on IslamicMedical Ethics highlighting universal morals justi-fied through Islamic vocabulary.

The other type of discourse in Islamic MedicalEthics relates to Islamic law, Shariah. The Shariahis not only a source of law but assigns moral valuesto actions in Islam. Hence any discussion on medicalethics in the light of Islam must refer to it. Thissecond type of literature aims to define the Islamicstance on biomedical issues ranging from abortionand reproductive technologies to gender relationsand end-of-life issues. One can find these topics dis-cussed in books of fiqh, in collections of fatawa, andin consensus position papers of Islamic medical con-ferences. Studying these works allows for compari-son between Islamic medical ethics and other ethicalcodes.

It is encouraging that there have already beenmultiple papers examining the relationship betweenthe Four Principles of medical ethics as describedby Beauchamp and Childress and Islamic MedicalEthics.50 It is hoped that this paper lays the founda-

tion for moving beyond stereotyped and genericinteraction when dealing with the Muslim patient toone marked by experiential learning and mutualrespect. Furthermore it is hoped this paper servesthe ethicist as a starting point for in-depth analysisof Islamic Medical Ethics literature vis--vis SecularMedical Ethics.

Acknowledgments

Prof. Madelon Finkel for her endless support and the Office of Inter-national Medical Education at WMC and its donors for funding thetravel, Deans Alger and Alonzo at WCMC-Q for allowing for the use offacilities in Qatar, Prof. Rodriguez del Pozo at WCMC-Q for his men-torship and invaluable comments, the library staff at WCMC-Q fortextual aid, and MRP for support, editing and comments.

GLOSSARYAdab a type of Arabic advice literature aimed at

inculcating moral valuesAkhlaq Morality, Ethics, CharacterAql Human intellectFatwa (pl. fatawa) a legal opinion about a matter in the light of

Islamic lawFiqh jurisprudential understanding, also can be used

to denote legal rulings concerning a particularissue, i.e. Fiqh of prayer

Ijma Consensus agreement, third source of Islamiclaw

Ijtihad the process by which one derives an Islamicruling when one is not explicit in the sources

Isthisan the principle by which equitable considerationsoverride strict qiyas

Kalam Scholastic TheologyMaslahah public welfareMufti a title conferred upon a scholar of Islamic lawQadi judgeQiyas juristic reasoning by analogy, fourth source of

Islamic lawShariah Islamic sacred LawSunnah the corpus of sayings, actions, and silent consent

to the performance of certain deeds by theProphet Muhammad (pbuh), the secondsource of Islamic law

Tafsir Quranic exegenesisUrf customary practiceUsul-ul-fiqh a system developed within Islamic jurisprudence

to assign sources of law and how to weighthese sources against one another to find theproper ruling in cases on conflict

50 Aksoy & Elmali. op. cit. note 2, pp. 211224; van Bommel, op. cit.note 27, pp. 1721; I. Ilkilic. Bioethical Conflicts Between MuslimPatients And German Physicians And The Principles of BiomedicalEthics. Med Law 2002; 21: 243256.

178 Aasim I. Padela


padela_islamic medical ethics

Documents