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Principles of Biomedical Ethics: Islamic Perspectives

CILE | 05/01/2013
During the period 5-7 January 2013, the Center for Islamic Legislation and Ethics (CILE) organized an international seminar on “Principles of Biomedical Ethics: Islamic Perspectives” in Doha, Qatar.The participants in this seminar included four Muslim religious scholars, two Muslim physicians and two bioethicists. The participating Muslim religious scholars were Shaykh Aḥmad al-Raysūnī (Morocco), Shaykh ʻAbd al-Sattār Abū Ghudda (Syria) Shaykh ʻAlī al-Qaradāghī (Qatar) and Shaykh ʻAbd Allāh Ben Bayya (Mauritania). The two Muslim physicians were Dr. Ḥassān Shamsī Bāshā (Syria) and Dr. Muḥammad ʻAlī al-Bār (Saudi Arabia). Finally, the two bioethicists were Tom Beauchamp from the USA and Annelien Bredenoord from the Netherlands.

Each of the Muslim religious scholars, except Shaykh Ben Bayya, submitted a paper to the seminar. Also Beauchamp, Bredenoord and al-Bār submitted papers but the paper of Bredenoord was written after the end of the seminar. Below the papers will be presented under two main headings:

(A)
Principles of biomedical ethics, which include the contributions of Beauchamp, Bredenoord and al-Bār and

(B)
Islamic perspectives, which include the papers submitted by the Muslim religious scholars; Raysūnī, Abū Ghudda and Qaradāghī.

(A)

PRINCIPLES OF BIOMEDICAL ETHICS 

In his paper “The principles of biomedical ethics as universal principles”, Tom Beauchamp elaborates the role that principles play in the so-called four-principles approach in the field of bioethics.The paper is divided into five sections.  In the first section, Beauchamp investigates the nature and sources of principles in recent biomedical ethics whose main features figured during the 1970s and early 1980s, especially through his book that he co-authored together with James F. Childress.

Beauchamp explains that a basic principle, in principlist theory, is an abstract moral norm. This abstractness means that practical judgments cannot be straightforwardly deduced from these basic principles. However, more specific rules for health care ethics can be formulated by reference to these principles.

The author adds that principles are context-bound rather than absolute or unconditional and thus no fixed priority for these principles can be claimed. The greater part of this section is dedicated to explaining the four principles proposed by Beauchamp and Childress, namely (1) respect for autonomy (a principle, not to be confused with individualism, requiring respect for the decision-making capacities of autonomous persons), (2) nonmaleficence (a principle requiring the avoidance of causing harm to others), (3) beneficence (a group of principles requiring both lessening of and prevention of harm as well as provision of benefits to others), and (4) justice (a group of principles requiring fair distribution of benefits, risks, and costs across all affected parties).

The second section of Beauchamp’s paper is devoted to the central role played in the four-principles account by the theory of common morality which, Beauchamp explains, is comprised of the full set of universal moral norms shared by all persons committed to a moral way of life. According to Beauchamp, one needs to distinguish between four types of norms for understanding the common morality, namely principles (and rules), virtues, ideals, and finally rights. Universal principles and rules of obligation in the common morality include, for instance, the following concrete rules: do not kill; do not cause pain or suffering to others; prevent evil or harm from occurring; and rescue persons in danger. As for universal virtues, Beauchamp gives examples like honesty, integrity and fidelity. Also universally praised ideals make an integral part of the common morality such as exceptional forgiveness, exceptional generosity and exceptional compassion. Finally, rights, Beauchamp argues, are universally valid moral claims and they have been so understood at least since early modern theories of rights were developed in the seventeenth century.

In the third section of his paper, Beauchamp addresses one of the persistent questions raised by his critics, namely are the four principles truly universal or just Western or American? In response, Beauchamp holds that clear distinction should be made between the common morality, with its abstract and content-thin universal norms, on one hand and particular moralities which present concrete, non-universal, and content-rich norms. Similar distinction should also be made between morality in the descriptive sense and morality in the normative sense. In the descriptive sense, Beauchamp explains, “morality” refers to groups’ codes of conduct and thus can produce justified multiple moralities. However, this descriptive sense has no implications for morality in the normative sense; how all persons should behave. Beauchamp concludes that all justified particular moralities share the norms of the common morality.

Beauchamp dedicates the fourth section of his paper to the key concept of specification which means, in the context of morality, adding action-guiding content to the general principles. This is because principles are generally abstract and thin in content and thus must be made specific if they are to become practical. Beauchamp concedes that people will always be confronted with competing specifications, especially when it concerns controversial issues such as abortion, animal research and euthanasia even if specification is done by reasonable and fair-minded parties committed to the common morality. At the end, Beauchamp argues, a specification will be justified only if it is consistent with the norms of common morality and maximizes the coherence of the overall set of relevant, justified beliefs of the party doing the specification.

In the fifth and final section of his paper, Beauchamp demonstrates the relevance of the four-principles approach for discussions on human rights, multiculturalism, and cultural imperialism. In his view, the alleged East-versus-West dichotomy concerning moral traditions of liberty, rights, respect for autonomy, and respect for families is ungrounded. However, Beauchamp concedes, some understandable and justifiable differences from one country to another still do exist. For instance, one cannot claim that a principle such as respect for individual autonomy is given precisely the same status and prized to the same extent in Eastern traditions as it might be in some Western cultures.

In her paper “The principles of biomedical ethics revisited”, Annelien Bredenoord reconsiders the four-principles approach. The paper is divided into two main sections. In the first section, Bredenoord presents an overall overview of the four principles of biomedical ethics, as proposed by Beauchamp and Childress, and the main challenges of each principle espoused with her own response to these challenges. Concerning the principle of respect for autonomy, the author discusses three main criticisms the first of which is that this principle is too individualistic because autonomy at the end of the day cannot exist independent from relationships. The second criticism concerns the scope of autonomy because some people are temporarily or permanently not considered to be autonomous agents, such as minors, mentally ill and comatose or people who are unconscious.

The third criticism leveled against the principle of respect for autonomy is that giving a central place to autonomy leaves little room for competing societal interests. According to Bredenoord, these and may be also other criticisms are partly due to a mistaken, too one-dimensional interpretation of the concept of autonomy. Unlike autonomy, non-maleficence seems to be the least contested principle. One possible criticism, Bredenoord explains, could be that the demarcation between non-maleficence and beneficence is sometimes difficult to draw.

Concerning the principle of beneficence, one of the main challenges discussed by the author has to do with demarcating the scope and limits of this principle. For instance, unrestricted use of this principle by physicians may lead to unjustified paternalism. As for the principle of justice, Bredenoord argues that despite its significance, this principle remains ‘empty’ if taken alone and thus always needs filling in by a theory of justice. The real moral work, the author adds, is in choosing and justifying a theory of justice and to subsequently argue for what constitutes morally justified discrimination.

The second section of Bredenoord’s paper is dedicated to identifying three main debates regarding principlism, as a bioethical theory and method. The first topic of ongoing debate is whether a pluralist or eclectic approach is an appropriate one and if so, whether general principles are sufficiently sophisticated to function as a bioethical theory. On one hand, the four-principles approach is acclaimed for being an accessible educational tool and an applicable framework for the analysis of every-day bioethical issues. On the other hand, this approach is criticized for missing one single moral theory that ties the four principles together and thus there is no practical guide which generates clear and coherent rules for action nor justification of those rules.

According to Bredenoord, this debate is part of a broader epistemological debate in ethics about what moral theory is or should be. On one hand, the foundationalists demand that an ethical theory should be well-developed and should provide a clear directive for the morally right action. On the other hand, the principlists, including Beauchamp and Childress, are less demanding in this regards and more willing to accept a loose framework for normative deliberation.

The second topic of debate is the possible hierarchy of the four principles or how they (should) relate to each other. The position taken by Beauchamp and Childress is that no single principle should override all other moral considerations. However, Bredenoord argues for prioritizing the principle of respect for autonomy within a specific understanding of the concept of autonomy. Finally, the third topic of debate on the four-principles approach relate to the issue of specification or how to arrive from general ethical principles to concrete moral judgments. Unlike the general principles that may be embraced by all people, specified moral judgments can legitimately vary between persons but this requires continuous refinement and adjustment when relevant data gives cause to do so.

In his extended paper, “The 4 Principles of Biomedical Ethics”, al-Bār discusses much more than four principles introduced by Beauchamp and Childress. The paper is divided into six main sections. In the first section, al-Bār reviews the ideas of Greek and Muslim philosophers, in additional to a number of modern philosophers and thinkers, about the nature of morality and if it is innate or something that can be cultivated by education and training.

The author further elaborates on the significance of having moral motives to judge specific act as virtuous and quotes statements attributed to the Prophet of Islam together with quotations from Beauchamp and Childress to argue for his thesis. Again through quotations from Muslim and non-Muslim philosophers conflated with prophetic traditions, al-Bār argues that the main virtues in medicine and nursing are compassion, discernment, trustworthiness, integrity and conscientiousness. In the second section, the author gives a detailed review of the codes of ethics for the profession of medicine throughout history.

In this section, Al-Bār pays special attention to the Hippocratic Oath and its significant position in the history of medical ethics. The author also gives detailed information about the religion of Islam and its main teachings concerning medical treatment and the physician-patient relationship. A great deal of this this section is dedicated to the codes of ethics drafted in modern history such as the Nuremberg Code of (1946 and 1947) and the Declaration of Helsinki (1964).

In this context, the author also quotes a fatwa issued in December 2003 by the Islamic Fiqh Academy in Mecca on stem cell therapy. Under the subtitle, “Bioethics Research without Control Despite Ethical Codes”, the author concludes this section with an extended list of cases (during the period 1915-2012) that have flagrantly violated the basics of the biomedical research ethics. Each of the remaining four sections is dedicated to one of the four principles, respectively, autonomy, non-maleficence, beneficence and justice.

The author maintains a uniform method for addressing the four principles; quotations from Principles of Biomedical Ethics authored by Beauchamp and Childress espoused with recalling relevant references in the Qur’ān, the Sunna and opinions expressed by early and contemporary Muslim jurists.

(B)

 ISLAMIC PERSPECTIVES 

The paper of Shaykh al-Raysūnī is entitled, “Al-akhlāq fī al-ṭibb: ta’sīs maqāṣidī (Ethics in medicine: a founding approach in light of Sharia objectives)”. The main premise of al-Raysūnī’s paper is that ethics is an indivisible whole and thus cannot be divided into various segments each of which may fit within a specific aspect of life such as medicine, politics, finance or social relations. However, al-Raysūnī adds, specific principles and values can be more highlighted in particular fields because they will work more efficiently and be more productive than other clusters of values and principles. Against this backdrop, al-Raysūnī divides his paper into two main sections.The first section elaborates on the position of ethics in Sharia and its objectives. In this section, the author argues that life in its totality must be based on ethics. The second section focuses on ethics in the field of medicine. In this section, the author argues that if all walks of life are in need of ethics to be meaningful, the medical field in particular cannot survive unless it is based on ethics.

Shaykh al-Raysūnī also notes that there is overlap between the objectives of Sharia and those of medicine. The man objectives of Sharia are protecting (ḥifẓ) the so-called five necessities (al-ḍarūriyyāt al-khams), namely religion, life, offspring, intellect and property. Three of these five represent the main objectives of medicine, viz., protecting life, offspring and intellect.

As far as ethics is concerned, the author holds that two main ethics-related objectives are more associated with the field of medicine and they both constitute two major principles of Islamic ethics as well, to wit, God-consciousness (taqwā) and mercy (raḥma). The author defines taqwā from a Sharia perspective as “a moral and spiritual state of a person who is highly responsible, self-disciplined and considerate of the consequences of his acts.

He behaves accordingly toward himself, God, any person, or anything on earth.” Activating taqwā in the field of medicine, the author argues, can be very effective because it arises from inside oneself as a result of self-censorship and it exists in oneself all the time. A person may manage to avoid others’ control, reproach and pressure but he will never succeed deceiving his self-censorship as long as he cultivates taqwā. Thus, taqwā for the physician will be a source of internal uprightness.

The integrity of this physician will not be dependent upon just taking a medical oath. On the other hand, those who lack the virtue of taqwā and self-questioning, no oath they take, whether it is Greek or Islamic, will be useful. Concerning mercy, the author states that it is integral to both Sharia and medicine. At the end of the paper, Shaykh al-Raysūnī comments on Euthanasia or mercy-killing and argues that claiming a link between euthanasia on one hand and the virtue of mercy on the other hand is a baseless claim for two main reasons.

Firstly, real mercy means protecting life, which is one of the main objectives of both Sharia and medicine and thus no pain should be relieved at the cost of a human soul. Secondly, mercy is not only a worldly concept but it is also closely associated with the hereafter. In the Islamic tradition, it is recognized that enduring pains and difficulties in life is a source of great rewards in the hereafter, which is also a kind of mercy.

The title of the paper submitted by Shaykh Abū Ghudda is “Al-mabādi’ al-ḥākima li al-khlāq al-Islāmiyya fī al-ṭibb (The governing principles of Islamic ethics in medicine)”. The paper is divided into three main sections and appended by documents issued by the Islamic organization for Medical Sciences (IOMS) in Kuwait and the International Islamic Fiqh Academy (IIFA) in Jeddah, Saudi Arabia. In the first section of the paper, the author explains the great attention paid by the Islamic Sharia to ethics in general. According to the author, law schools outside the Islamic tradition are usually exclusively concerned with rights and obligations from a judiciary perspective. However, Islamic Sharia used to integrate these rights and obligations within a broader scheme in which ethics and moral conduct were always central.

That is why Islamic legal manuals, whose main task was to elucidate the rulings of what is permissible and prohibited in Islam, also contain frequent references to issues related to moral conduct. Some Muslim jurists dedicated a distinct chapter, whereas others dedicated a whole book, to these ethical issues usually bearing the title of al-jāmiʻ (the comprehensive).

This integral part of ethics within the Islamic Sharia, the author argues, has to do with the overall philosophy of this Sharia, namely achieving specific higher objectives some of which can be realized in this life and others only in the hereafter. Thus, basic moral values are to be observed and maintained even if they may cause some accidental harm to people in this life as long as this harm will be abundantly compensated by God in the hereafter.

The second section of Abū Ghudda’s paper is dedicated to terminology where the author explains key terms such as ethics, morals and values. In this section, the author also differentiates between two types of ethics, namely philosophy-based ethics and religion-based ethics. Philosophy-based ethics exclusively depends on reason and on philosophical underpinnings to analyze ethical issues. On the other hand, religion-based ethics depends mainly, but not exclusively, on revelation and ethical principles are usually extracted from religion.

However, the author adds, the religious nature of this type of ethics does not eliminate the role of reason and human thinking, which remain functioning but as means rather than ends. In this section, the author also refers to the four principles of biomedical ethics developed by Beauchamp and Childress, however, without mentioning their names. Abū Ghudda just quotes these principles from an Arabic source whose author holds that these principles are now shared by most countries all over the world. Besides these four principles (autonomy, beneficence, nonmalficence and justice), Abū Ghudda refers to four ethical instructions, mentioned by an early Muslim scholar, that the physician should abide by, viz., giving advice, being kind and compassionate and nicely referring the terminally-ill patient to write his/her testament.

In the third section, the author introduces a list of the basic Islamic ethics in medicine. According to the author, this list is extracted from Islamic sources including the Qur’ān, the Sunna and the writings of early Muslim physicians, especially the work of Abū Bakr al-Rāzī Akhlāq al-ṭabīb (the ethics of the physician).

The list consists of nine items:

1.     Obtaining medical experience
2.     The conformity of the physician’s practices with the professional standards
3.     Having knowledge of Sharia-based rulings related to practicing medicine
4.     God-consciousness (taqwā) and fear of Him
5.     Sincerity and dedication to work
6.     Modesty towards Allah and compassion towards the patients
7.     Truthfulness and honesty
8.     Practicing medicine within the limits of medical specializations
9.     Confidentiality

The paper of Shaykh al-Qaradāghī is entitled “Ṣiyāghat al-mabādi’ al-akhlāqiyya fī ḍaw’ maqāṣid al-Sharīʻa wa ḍawābiṭiha (Drafting the ethical principles in the light of the objectives of Sharia and their criteria)”. The paper is divided into three main sections preceded by an introductory part. In the introductory part, the author holds that ethics in Islam is not a means but an end in itself and it is not one of the branches of Islam but one of its core-components. This fact, the author argues, is attested by a great number of scriptural texts whether those addressing issues related to belief or the texts that tackle practical questions in society. All these texts underscore the significance of cultivating ethics and moral conduct in society so that people can lead a good life. Shaykh Qaradāghī also explains that ethics, values and virtues in Islam can be divided into three main categories. The first category includes those morals and values whose observance and maintenance are made obligatory by God who also prescribed specific penal procedures for those who neglect these morals and values. The second category is composed of those values and morals whose observance was made obligatory but God did not specify any particular punishment for their negligence. The third category includes the morals and values whose observance was made supererogatory such as giving other people’s interests a higher priority to one’s own interests.

In the first section of this paper, the author explains how the main objectives of Sharia, as outlined in a great number of books throughout the Islamic history, can be utilized to draft an Islamic version of biomedical ethics. Besides the well-known six objectives (viz., protecting religion, life, intellect, property, offspring and honor), the author adds two other objectives, namely preserving the integrity of the legitimate state and the integrity of the society. According to the author, each of these eight objectives, within the context of health and medical care, can build up a solid ground for a cluster of medical ethics. The objective of protecting religion can be used to safeguard the patient’s religious beliefs. Hence, prescribing any religiously prohibited material as medicine, without any compelling necessity, will be considered unethical. Within the context of medical ethics, the objective of protecting life means not only protecting the whole physical body from harms but it also includes maintaining mental health. Protecting life is not only the right of the patient but it is also a duty from an Islamic perspective. That is why euthanasia is forbidden even if the patient gives clear permission. The objective of protecting intellect means that the physician is under obligation not to prescribe medications that affect the mental health of the patient. Also according to this objective, the patient should be able to use his/her discretion to make decisions concerning medical treatment and experimentation. By applying the objective of protecting property in the field of medical care, the physician or the medical institution will not be able to impose unreasonable fees on the patient because such practice contradicts this overall objective. Even the patient himself will not be allowed to extravagantly spend money on unnecessary medication. Concerning the objective of protecting lineage, the author argues that abortion will be seen as an unethical act in principle except in exceptional cases such as avoiding a life-threat situation for the mother. The objective of protecting honor will mean in the biomedical context that the patients’ secrets, especially those that may harm his/her honor and reputation, cannot be disclosed. The last two objectives related to protecting the integrity of the state and that of society will have, for instance, a clear bearing on the question of justice and resource allocation. Shaykh Qaradāghī argues that this objective-based approach for drafting the principles of biomedical ethics already accommodates the four principles proposed by Beauchamp and Childress. The two principles of beneficence and nonmalficence, the author explains, are already included in each objective because they all aim at achieving benefit and avoiding harm. Respecting autonomy comes under the two objectives of religion and life and justice is included within the objective of protecting the integrity of society.
The second section of Qaradāghī’s paper is dedicated to a number of legal maxims and rules by which the objective-based approach for the principles of biomedical ethics can be specified and applied with a considerable degree of exactness. In this context, reference is made to legal maxims like “No harming and no counter-harming” and “certainty cannot be overruled by doubt”. The author also makes reference to the so-called “jurisprudence of balances (fiqh al-muwāzanāt)” by which the possible clash between benefits and harms in specific cases can be avoided or resolved. Concerning the issue of certainty and doubt, the author holds that decisions in the field of medical care cannot always be based on certainty. That is why Islam, Shaykh Qaradāghī holds, recognizes the concept of “dominant probability (ẓann ghālib)” as an acceptable ground for making decisions in the field of medicine.
In the third section of this paper, the author enlists a number of virtues and etiquettes that physicians should stick to. According to Shaykh Qaradāghī, most of these virtues can be summed up into two, namely professionalism (ikhtiṣāṣ) and sincere devotion (ikhlāṣ). The author also holds that physicians need to be aware of the Islamic religious rulings related to the field medicine and medical care. At the very end of the paper, the author underscores the percept of confidentiality and the duty to keep all information between physician and patient private.

About the Research Center for Islamic Legislation and Ethics (CILE):

CILE aims to contribute to the reform and renew the Islamic thought by developing a contemporary vision guided by the fundamental principles of the Holy Qur’an, Sunnah and the higher objectives of Islamic Shariah. For more information, please contact: CILE Office.

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