Western and Islamic bioethics: How close is the gap?

Attitudes toward Medical Ethics among Obstetricians and Gynecologists in Saudi Arabia: An Exploratory Survey

Ethics is an important aspect of medical care. The purpose of this study was to investigate the attitudes of obstetricians and gynecologists towards various ethical issues and ethical principles, and their satisfaction with their knowledge, understanding, and problem-solving skills regarding ethical issues. Methods: A cross-sectional survey was conducted among the working OB/GYNs in Saudi Arabia from various hospitals in Saudi Arabia between May 2020 and August 2020. A link to the three-point Likert scale questionnaire was mailed to 1000 OB/GYNs working in various hospitals. The data were analyzed using inferential statistics. The quantitative data were expressed as absolute numbers and percentages. Results: A total of 391 out of 1000 OB/GYNs responded. Most of the respondents were female OB/GYNs (65%), most of them were working in tertiary government hospitals (63%), and most were educated in bioethics (62%). About 80.3% of the respondents considered ethics important, and there was a low satisfaction rate with their knowledge (26%), understanding (38.6%), and problem-solving skills (35.8%) related to ethical issues. Conclusions: The obstetricians and gynecologists considered ethics an important aspect of daily practice but lacked the skills and knowledge to deal with ethical issues. The level of satisfaction with practice ethics was very low. Despite the fact that most of them had undergone bioethics education, most of them expressed the need for ethics training. Theoretical ethics education seemingly did not increase competence in resolving ethical issues, whereas experience did. The workplace had a strong correlation with the employee's attitude toward ethical issues, principles, and satisfaction with their knowledge and skills in resolving ethical issues. The ethics curriculum needs to be structured in a more effective way to improve competence in dealing with ethical challenges in daily practice.

Development and validation of an instrument to measure physician awareness of bioethics and medical law in Oman

Background

A different ethos with respect to the perception of medical ethics prevails in societies in transition such as those in the Arabian Peninsula, which makes it difficult to apply international principles of bioethics in medical practice. This study aimed to develop and psychometrically test an instrument that measures physicians’ awareness of bioethics and medical law and their attitudes towards the practice of medical ethics. Additionally, it examined physician correlates influencing the awareness of bioethics.

Methods

Following a rigorous review of relevant literature by a panel of experts, a 13-item instrument, the Omani physicians’ bioethics and medical law awareness (OBMLA) questionnaire was developed with the aim of assessing physicians’ awareness of bioethics and medical law. The study tool’s construct validity and internal consistency reliability were examined by exploratory factor analysis (EFA) and Cronbach’s alpha. In a cross-sectional study, the questionnaire was distributed among a random sample of 200 physicians at a tertiary hospital in Muscat, Oman. Participant characteristics that may influence awareness of bioethics and medical law were explored.

Results

The EFA of the OBMLA questionnaire resulted in three well-loading factors: (1) Physicians’ bioethics practice subscale (2) incentive related bioethics subscale and (3) medical law awareness subscale. Internal consistency reliability ranged between Cronbach’s α: 0.73–0.8. Of the total 200 participants, 52% reported that teaching medical ethics during medical school was inadequate. The overall mean (standard deviation, SD) of the bioethics awareness score and Omani medical law awareness were 27.6 (3.5) and 10.1 (2.1) respectively. The majority of physicians (73%) reported that they frequently encountered ethical dilemmas in their practice and 24.5% endorsed the view that unethical decisions tended to occur in their practice.

Conclusion

The study provides an insight into the practice of bioethics, and the awareness of bioethics and medical law among physicians in a teaching hospital in Oman. The OBMLA questionnaire appears to be a valid and reliable tool to assess a physician’s awareness of bioethics and medical law. In this preliminary study, it appears that participants have suboptimal scores on the indices which measure practice and awareness of bioethics and medical law.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-021-00619-1.

Deceased Organ Transplantation in Bangladesh: The Dynamics of Bioethics, Religion and Culture

Organ transplantation from living related donors in Bangladesh first began in October 1982, and became commonplace in 1988. Cornea transplantation from posthumous donors began in 1984 and living related liver and bone marrow donor transplantation began in 2010 and 2014 respectively. The Human Organ Transplantation Act officially came into effect in Bangladesh on 13th April 1999, allowing organ donation from both brain-dead and related living donors for transplantation. Before the legislation, religious leaders issued fatwa, or religious rulings, in favor of organ transplantation. The Act was amended by the Parliament on 8th January, 2018 with the changes coming into effect shortly afterwards on 28th January. However, aside from a few posthumous corneal donations, transplantation of vital organs, such as the kidney, liver, heart, pancreas, and other body parts or organs from deceased donors, has remained absent in Bangladesh. The major question addressed in this article is why the transplantation of vital organs from deceased donors is absent in Bangladesh. In addition to the collection of secondary documents, interviews were conducted with senior transplant physicians, patients and their relatives, and the public, to learn about posthumous organ donation for transplantation. Interviews were also conducted with a medical student and two grief counselors to understand the process of counseling the families and obtaining consent to obtain posthumous cornea donations from brain-dead patients. An interview was conducted with a professional anatomist to understand the processes behind body donation for the purposes of medical study and research. Their narrative reveals that transplant physicians may be reticent to declare brain death as the stipulations of the 1999 act were unclear and vague. This study finds that Bangladeshis have strong family ties and experience anxiety around permitting separating body parts of dead relatives for organ donation for transplantation, or donating the dead body for medical study and research purposes. Posthumous organ donation for transplantation is commonly viewed as a wrong deed from a religious point of view. Religious scholars who have been consulted by the government have approved posthumous organ donation for transplantation on the grounds of necessity to save lives even though violating the human body is generally forbidden in Islam. An assessment of the dynamics of biomedicine, religion and culture leads to the conclusion that barriers to posthumous organ donation for transplantation that are perceived to be religious may actually stem from cultural attitudes. The interplay of faith, belief, religion, social norms, rituals and wider cultural attitudes with biomedicine and posthumous organ donation and transplantation is very complex. Although overcoming the barriers to organ donation for transplantation is challenging, initiation of transplantation of vital organs from deceased donors is necessary within Bangladesh. This will ensure improved healthcare outcomes, prevent poor people from being coerced into selling their organs to rich recipients, and protect the solidarity and progeny of Bangladeshi families.

Maqasid al-Shariah Based Islamic Bioethics: A Comprehensive Approach

Maqasid al-Shariah based Islamic bioethics is an Islamic bioethics concept which uses the objectives of the Shariah (maqasid al-Shariah) as its approach in analysing and assessing bioethical issues. Analysis based on maqasid al-Shariah based Islamic bioethics will examine any bioethical issues from three main aspects namely intention, method, and output or final goal of the studied issues. Then, the evaluation will be analysed from human interest hierarchy, inclusivity, and degree of certainty. The Islamic bioethics concept is a manifestation of dynamic Islamic jurisprudence which can overcome new complex and complicated bioethical issues such as tri-parent baby technology issues. Therefore, this article will introduce and explain the concept of maqasid al-Shariah based Islamic bioethics and outline a general guidance of maqasid al-Shariah based Islamic bioethics to determine a maqṣad (objective) based on standards of human good or well-being (maslahah) and harm (mafsadah).

Using the Maqāṣid al-Sharī'ah to Furnish an Islamic Bioethics: Conceptual and Practical Issues

The field of Islamic bioethics is currently in development as thinkers delineate its normative content, ethical scope and research methods. Some scholars have offered Islamic bioethical frameworks based on the maqāṣid al-Sharī'ah, the higher objectives of Islamic law, to help advance the field. Accordingly, a recent JBI paper by Ibrahim and colleagues describes a method for using the maqāṣid al-Sharī'ah to provide moral end-goals and deliberative mechanisms for an Islamic bioethics. Herein I highlight critical conceptual and practical gaps in the model with the hopes of fostering greater discussion about how maqāṣid al-Sharī'ah frameworks may fit within Islamic bioethics deliberation.

The Islamic faith and best interests

SummaryThis article reviews a 2017 Court of Protection case which assessed and decided issues relating to the Islamic faith and the Mental Capacity Act 2005. The case involved a 39-year-old Muslim man with learning difficulties. It centred on his ability to make decisions about two specific aspects of his faith - capacity for fasting and for the removal of pubic and axillary hair. The judgment describes how s.4 of the Act was applied in deciding these decisions under the doctrine of best interests. In doing so, it elucidates key principles which can be applied to similar cases of this and other faiths.Declaration of interestNone.

Assessing Relationships Between Muslim Physicians’ Religiosity and End-of-Life Health-Care Attitudes and Treatment Recommendations: An Exploratory National Survey

Background:

Research demonstrates that the attitudes of religious physicians toward end-of-life care treatment can differ substantially from their nonreligious colleagues. While there are various religious perspectives regarding treatment near the end of life, the attitudes of Muslim physicians in this area are largely unknown.

Objective:

This article attempts to fill in this gap by presenting American Muslim physician attitudes toward end-of-life care decision-making and by examining associations between physician religiosity and these attitudes.

Methods:

A randomized national sample of 626 Muslim physicians completed a mailed questionnaire assessing religiosity and end-of-life care attitudes. Religiosity, religious practice, and bioethics resource utilization were analyzed as predictors of quality-of-life considerations, attitudes regarding withholding and withdrawing life-sustaining treatment, and end-of-life treatment recommendations at the bivariate and multivariable level.

Results:

Two-hundred fifty-five (41% response rate) respondents completed surveys. Most physicians reported that religion was either very or the most important part of their life (89%). Physicians who reported consulting Islamic bioethics literature more often had higher odds of recommending active treatment over hospice care in an end-of-life case vignette. Physicians who were more religious had higher odds of viewing withdrawal of life-sustaining treatment more ethically and psychologically challenging than withholding it and had lower odds of agreeing that one should always comply with a competent patient’s request to withdraw life-sustaining treatment.

Discussion:

Religiosity appears to impact Muslim physician attitudes toward various aspects of end-of-life health-care decision-making. Greater research is needed to evaluate how this relationship manifests itself in patient care conversations and shared clinical decision-making in the hospital.

Therapeutic abortion and ectopic pregnancy: alternative sources for fetal stem cell research and therapy in Iran as an Islamic country

Regenerative medicine as a background of stem cell research and therapy has a long history. A wide variety of diseases including Parkinson's disease, heart diseases, multiple sclerosis, spinal cord injury, diabetes mellitus and etc. are candidate to be treated using different types of stem cells. There are several sources of stem cells such as bone marrow, umbilical cord, peripheral blood, germ cells and the embryo/fetus tissues. Fetal stem cells (FSCs) and embryonic stem cells (ESCs) have been described as the most potent stem cell source. Although their pluri- or multipotent properties leads to promising reports for their clinical applications, owning to some ethical and legal obstacles in different communities such as Muslim countries, care should be taken for therapeutic applications of FSCs and ESCs. Derivation of these cell types needs termination of pregnancy and embryo or fetus life that is prohibited according to almost all rules and teaches in Muslim communities. Abortion and termination of pregnancy under a normal condition for the procurement of stem cell materials is forbidden by nearly all the major world religions such as Islam. Legislated laws in the most of Muslim countries permit termination of pregnancy and abortion only when the life of the mother is severely threatened or when continuing pregnancy may lead to the birth of a mentally retarded, genetically or anatomically malformed child. Based on the rules and conditions in Islamic countries, finding an alternative and biologically normal source for embryonic or fetal stem cell isolation will be too difficult. On the one hand, Muslim scientists have the feasibility for finding of genetically and anatomically normal embryonic or fetal stem cell sources for research or therapy, but on the other hand they should adhere to the law and related regional and local rules in all parts of their investigation. The authors suggest that the utilization of ectopic pregnancy (EP) conceptus, extra-embryonic tissues, and therapeutic abortion materials as a valuable source of stem cells for research and medical purposes can overcome limitations associated with finding the appropriate stem cell source. Pregnancy termination because of the mentioned subjects is accepted by almost all Islamic laws because of maternal lifesaving. Also, there are no ethical or legal obstacles in the use of extra-embryonic or EP derived tissues which lead to candidate FSCs as a valuable source for stem cell researches and therapeutic applications.

Maqasid al-Shariah as a Complementary Framework for Conventional Bioethics: Application in Malaysian Assisted Reproductive Technology (ART) Fatwa

Rapid development in the area of assisted reproductive technology (ART), has benefited mankind by addressing reproductive problems. However, the emergence of new technologies and techniques raises various issues and discussions among physicians and the masses, especially on issues related to bioethics. Apart from solutions provided using conventional bioethics framework, solutions can also be derived via a complementary framework of bioethics based on the Higher Objectives of the Divine Law (Maqasid al-Shariah) in tackling these problems. This approach in the Islamic World has been applied and localised in the Malaysian context. Thus, this paper highlights a conceptual theoretical framework for solving current bioethical issues, with a special focus on ART in the Malaysian context, and compares this theory with conventional theories of bioethics.

General approaches to ethical reasoning in Islamic biomedical ethics discourse

Islamic and non-religious ethics discourses have similarities and differences at the levels of meta-, normative, and applied ethics (e.g. biomedical ethics). Mainstream biomedical ethics (MBME) uses the language of contemporary, non-religious, Western ethics. Significant effort has been dedicated to comparing Islamic biomedical ethics (IBME) and MBME in terms of meta- and normative ethical positions, and final decisions on practical ethical issues have been reached. However, less attention has been given to comparing the general approaches of the two aforementioned discourses to ethical reasoning. Furthermore, IBME uses different languages to approach ethical reasoning, but identification and conceptualization of these approaches are among the important gaps in the literature. The aim of this study was to conceptualize general approaches to ethical reasoning in IBME. Through review and content analysis of the existing literature and the comparison between the languages employed by IBME and MBME, an inductive distinction have been made. The languages used in conceptualized approaches include the followings: (i) a language in common with the one employed by MBME; (ii) MBME language adjusted to the basic, common beliefs of Muslims; (iii) a language based on fatwas; and (iv) a language based on IBME principles. In the authors' opinion, major challenges of the above-mentioned four approaches include, respectively: identifying the lack of religious sensitivity or Islamic considerations regarding an issue; acknowledging specific beliefs as the basic, common beliefs of Muslims; diverse fatwas and relations between juridical soundness and ethical soundness; and agreement on the same principles and rules as well as who should apply them.

Diabetes, driving and fasting during Ramadan: the interplay between secular and religious law

A large proportion of the Muslim population fasts during Ramadan. The risk of hypoglycemia is increased with fasting during Ramadan in people with diabetes who are on insulin and insulin secretagogues. Therefore, the combination of fasting with diabetes and driving presents a challenging situation, with legal implications for such individuals and their healthcare professionals. This novel, narrative, non-systematic review discusses the importance of addressing hypoglycemia in fasting with reference to secular legal guidance on driving with diabetes. We discuss religious aspects relating to fasting and driving in Islam. While there is no clear guidance or legal position on diabetes and driving for individuals who are fasting, Islamic law provides a logical framework to address this. Healthcare professionals need to raise and facilitate discussions on this often-overlooked topic with people with diabetes who are planning on fasting to minimize the potential for public harm. For some individuals fasting perhaps should be avoided when driving and that this religiously compatible position would best be adopted when one is dependent on driving for livelihood. Ultimately further research on glycemic control and management when fasting and driving, as well as a formal legal guidance on this topic, is required to safeguard healthcare professionals and the public from the potential dangers of driving with diabetes and fasting.

Minimizing nocebo effect: Pragmatic approach

The nocebo effect, the inverse of the placebo effect, is a well-established phenomenon, yet under-appreciated. It refers to nonpharmacological, harmful, or undesirable effects occurring after active or inactive therapy. The frequency of adverse events can dramatically increase by informing patients about the possible side effects of the treatment, and by negative expectations on the part of the patient. Patients who were told that they might experience sexual side effects after treatment with β-blocker drugs reported these symptoms between three and four times more often than patients in a control group who were not informed about these symptoms. Nocebo effect has been reported in several neurological diseases such as migraine, epilepsy, multiple sclerosis, Parkinson's disease and neuropathic pain, and in patients with depression. The investigation of the biological and theoretical underpinning of the nocebo phenomenon is at an early stage, and more research is required. Physicians need to be aware of the influence of nocebo phenomenon and be able to recognize it and minimize its effects.

Beyond a Western Bioethics in Asia and Its Implication on Autonomy

Despite flourishing as a multidisciplinary subject, the predominant view in bioethics today is based on Anglo-American thought. This has serious implications for a global bioethics that needs to be contextualized to local cultures and circumstances in order to be relevant. Being the largest continent on the earth, Asia is home to a variety of cultures, religions and countries of different economic statuses. While the practice of medicine in the East and West may be similar, its ethical practices do differ. Thus, the Western understanding of autonomy may not be wholly applicable in the Asian setting, especially in the setting of breaking bad news, giving consent, determining best interests and deciding on end-of-life care. This article explores these topics in depth, attempting to find shared integrating factors, but at the same time arguing for a modified ethical application of autonomy, based on Asian beliefs.

A Bicultural Researcher's Reflections on Ethical Research Practices With Muslim Immigrant Women: Merging Boundaries and Challenging Binaries

Bicultural researchers are well positioned to identify tensions, disrupt binaries of positions, and reconcile differences across cultural contexts to ensure ethical research practices. This article focuses on a bicultural researcher's experiences of ethically important moments in research activities with Muslim immigrant women. Three ethical principles of respect, justice, and concern for welfare are highlighted, revealing the implications of binary constructions of identity, the value of situated knowledge in creating ethical research practices, and the need to recognize agency as a counterforce to oppressive narratives about Muslim women.

Ethical Dilemmas at the End of Life: Islamic Perspective

Many Muslim patients and families are often reluctant to accept fatal diagnoses and prognoses. Not infrequently, aggressive therapy is sought by the patient or his/her family, to prolong the life of the patient at all costs. A series of searches were conducted of Medline databases published in English between January 2000 and January 2015 with the following Keywords: End-of-life, Ethics and Islam. Islamic law permits the withdrawal of futile treatment, including all kinds of life support, from terminally ill patients leaving death to take its natural course. However, such decision should only take place when the physicians are confident that death is inevitable. All interventions ensuring patient's comfort and dignity should be maintained. This topic is quite challenging for the health care providers of Muslim patients in the Western World.

Doctor-patient relationship. Islamic perspective

The doctor-patient relationship is an intricate concept in which patients voluntarily approach a doctor and become part of a contract by which they tend to abide by doctor’s instructions. Over recent decades, this relationship has changed dramatically due to privatization and commercialization of the health sector. A review of the relevant literature in the database of MEDLINE published in English between 1966 and August 2015 was performed with the following keywords: doctor-patient relationship, physician-patient relationship, ethics, and Islam. The Muslim doctor should be familiar with the Islamic teachings on the daily issues faced in his/her practice and the relationship with his/her patients.