by Musa Mohd Nordin
*Published in International Journal of Human and Health Sciences (IJHHS)
In the annals of human history, the Western world has often referred to the millennium from 500-1500 C.E. as the Dark Ages. Synonymously known as the Middle Ages, it extends from the fall of the Roman Empire to the beginning of the Age of Discovery and Enlightenment, the Renaissance. The 1,000-year period was often described as being dark because it was perceived as being devoid of scientific, technological, philosophical, cultural and civilizational advancement.
To the student of history and research, this era was anything but dark. It was thus invariably described as:
“… And this civilization was driven more than anything by invention. Its architects designed building that defied gravity. Its mathematicians created the algebra and algorithms that would enable the building of computers, and the creation of encryption. Its doctors examined the human body, and found new cures for diseases. Its astronomers looked into the heavens, named the stars, and paved the way for space travel and exploration. Its writers created thousands of stories. Stories of courage, romance and magic. Its poets wrote of love, when others before them were too steeped in fear to think of such things. When other nations were afraid of ideas, this civilization thrived on them, and kept them alive…” (Carly Fiorina, 2001)
“… The medieval Islamic world, from Central Asia to the shores of the Atlantic, was a world where scholars and men of learning flourished …” (Prince Charles, 1993)
Abū Hurayrah (RA) narrated that the Prophet (ﷺ) said:
“There is no disease that Allah has created, except that He also has created its remedy”1.
In this and several other authentic traditions (Ahādīth), the Prophet (ﷺ) advocated research into the finding of cures for ailments, thus urging the believers to be at the frontiers of medical research.
This inspired the likes of physician, Al-Rāziī (854 – 925 C.E.) who carried out the earliest known example of a clinical research trial, investigating the effectiveness of venesection (bloodletting) in the treatment of patients with meningitis. He treated one group of patients with bloodletting but not the second group (control). This use of a control group is unprecedented and demonstrates Al-Rāzī’s commitment to medical science that is based on empirical evidence.
Ibn Sīnā (980 – 1037 C.E.) in his magnum opus, Al Qānūn Fī al-Tibb (The Canons of Medicine) outlined 7 principles before any medicine can be considered to be effective. Among others he emphasized that trials which were successful in animal models must be replicated in human subjects and that the results of the trials should be reproducible in other similar research.
The written works of both Al-Rāzī (Kitāb Al-Hāwī) and Ibn Sīnā (Al-Qānūn) were standard texts in the European medical curriculum in the16th century. Dr. William Osler, a Canadian physician, referred to Al-Qānūn as “a medical Bible for a longer time than any other work.”
Al-Zahrāwī (930-1013 C.E.), the father of modern surgery, used various forms of sutures to stitch abdominal wounds and was the first to use absorbable sutures, catgut, for his intestinal surgeries. His 30 chapters of medical writings in At-Tasrīf, was a major reference for doctors in Europe for many centuries. The 30th chapter illustrated many of his pioneering surgical instrumentations. His many surgical procedures and inventions were being used at a time when Europe was restricted by a religious edict in 1163 C.E which instructed as follows;
“All forms of surgery must be stopped in all medical schools by all surgeons.”
Whilst Europe and the rest of the world languished in the Dark Ages, scholars and scientists of various faiths and cultures converged in the Muslim world, where Arabic was the international language of science. They translated, transmitted and enhanced the knowledge and learning acquired from the ancient Romans and Greeks and made major scientific breakthroughs which among others unleashed the momentum towards the making of the European Renaissance.
Is it any wonder that Martin Kramer, an American historian, wrote:
“This supremely urbane civilization cultivated genius. Had there been Nobel Prizes in 1000, they would have gone almost exclusively to Moslems”2.
The early physicians who worked in the medieval Muslim hospitals were required to follow a strict code of ethical practices. Ishāq bin `Alī al-Rahāwī (854-931 C.E) authored Adab al-Tabib (The conduct of a physician), which is the earliest known Arabic treatise dedicated to medical ethics. Al- Rahāwīi considered physicians as “guardians of souls and bodies” and in this treatise he spells out all the deeds and acts a Muslim physician must observe.
He also described the process of licensing physicians, when he wrote:
“…the physician was not allowed to sit for treating patients until after he passes the generally aforementioned tests and examinations…”
This was later enforced into law during the Abbasid Caliphate whereby all doctors were required to pass an examination before being allowed to practice medicine. This physician licensure became mandatory after the Caliph Al-Muqtadīr, in 931 C.E., was informed of the death of one of his subjects due to a physician’s error.
All of these early medical practices during the Glorious Era of Islamic civilisation, represented various aspects of contemporary clinical governance, and were undertaken by the early Muslim scholars, in response to the call of Allah in several chapters of the Glorious Quran:
“إِنَّ اللَّهَ يَأْمُرُ بِالْعَدْلِ وَالإِحْسَانِ وَإِيتَاء ذِي الْقُرْبَى وَيَنْهَى عَنِ الْفَحْشَاء وَالْمُنكَرِ وَالْبَغْيِ يَعِظُكُمْ لَعَلَّكُمْ تَذَكَّرُونَ”
“Allah commands doing justice, doing good to others, and giving to near relatives, and He forbids indecency, wickedness, and rebellion. He admonishes you so that you may take heed”3.
This represents the aspirations of the higher objectives of Islamic jurisprudence (Maqāsid al-Sharī`ah), which is the promotion and preservation of the common good and benefit (jalb al- masālih) and the avoidance and protection from harm (dar’ al-mafāsid), the preservation of public interest (maslahah `āmmah) and the transformation towards justice.
Founded in the early 9th century, the House of Wisdom (Bayt al-Hikmah), in Baghdad, was an academy of knowledge, learning and research that attracted scholars from all over the world. Caliph Hārūn al-Rashīd filled the world-class library with a vast collection of manuscripts. His son Caliph Al-Mā’mūn extended the academy to host various disciplines of knowledge and commissioned the translation of the ancient texts into Arabic. This knowledge transfer was replicated in 12th century Spain at Toledo where the manuscripts were translated from Arabic to Latin and other European languages which contributed towards the European Renaissance.
Intrinsically, the early Muslim scholars were inspired by the exhortations from the verses of the Glorious Qur’ān, the teachings of the Prophet (ﷺ) and a cultural ambience of learning and teaching, experimentation and discovery. Extrinsically, this passion and quest for new knowledge and learning were well reciprocated by the Muslim caliphate, who supported them with the appropriate infrastructure and resources in the Muslim lands. A renaissance of these research values in both the Muslim scientists and the Muslim political leaders is indispensable if we are ever to realize the golden age of the Islamic civilization.
Research is considered by the Muslim clinician and scientist as a religious duty, a trust and an obligation to recognize and unravel the beauty and complexity of Allah’s (ﷻ) creations, to discover the cures and treatment of diseases for the health and general betterment of mankind.
“إِنَّ فِي خَلْقِ السَّمَاوَاتِ وَالأَرْضِ وَاخْتِلافِ اللَّيْلِ وَالنَّهَارِ لَآيَاتٍ لِّأُولِي الأَلْبَابِ”
“الَّذِينَ يَذْكُرُونَ اللَّهَ قِيَامًا وَقُعُودًا وَعَلَىَ جُنُوبِهِمْ وَيَتَفَكَّرُونَ فِي خَلْقِ السَّمَاوَاتِ وَالأَرْضِ رَبَّنَا مَا خَلَقْتَ هَذَا بَاطِلاً سُبْحَانَكَ فَقِنَا عَذَابَ النَّارِ”
“Surely in the creation of the heavens and the earth, and in the alternation of night and day, there are signs for men of understanding. Those who remember Allah while standing, sitting or (reclining) on their backs, and reflect in the creation of the heavens and the earth, (saying): ‘Our Lord! You have not created this in vain. Glory to You! Save us, then, from the chastisement of the Fire”4.
The authentic narrations of the Prophet (PBUH) emphasised:
“There is no disease that Allah (SWT) has created, except that He has also created its remedy”1.
It is therefore the obligation and quest of the Muslim physician, to discover the cures for diseases, through research and experimentation.
Islamic bioethics is based on and guided by the Islamic Shari’ah. It dates back to 14 centruies ago. It cannot be separated from “doing the right thing”, from morality, as it is firmly entrenched in the Islamic Law.
The basic principle in Islamic Law stipulates in the Glorious Quran:
“وَلَقَدْ كَرَّمْنَا بَنِي آدَمَ وَحَمَلْنَاهُمْ فِي الْبَرِّ وَالْبَحْرِ وَرَزَقْنَاهُم مِّنَ الطَّيِّبَاتِ وَفَضَّلْنَاهُمْ عَلَى كَثِيرٍ مِّمَّنْ خَلَقْنَا تَفْضِيلاً”
“We have honoured the progeny of Adam” 5
Respect for the patient’s dignity and his informed consent to make his own choices and decisions is mandatory in Islamic bioethics. Informed consent policies should be universally available to all including people in developing countries, indigenous people, and incarcerated subjects so that justice prevails where the poor and vulnerable are treated fairly.
The respect for autonomy even extends to the issue of belief, where there must not be compulsion in religion.
“لاَ إِكْرَاهَ فِي الدِّينِ قَد تَّبَيَّنَ الرُّشْدُ مِنَ الْغَيِّ فَمَنْ يَكْفُرْ بِالطَّاغُوتِ وَيُؤْمِن بِاللَّهِ فَقَدِ اسْتَمْسَكَ بِالْعُرْوَةِ الْوُثْقَىَ لاَ انفِصَامَ لَهَا وَاللَّهُ سَمِيعٌ عَلِيمٌ”
“Let there be no compulsion in religion”6.
Islamic Law confirms this basic human right in it’s rulings:
“No one is entitled to dispose of the right of a human being without his permission”7.
Islamic bioethics vis a vis bomedical research is readily accessible in the “International Islamic Code for Medical and Health Ethics” in December 20048.
Contemporary research ethics has evolved over the past 70 years, following the cruel experiments on prisoners of war (POW), without consent, by the Germans and Japanese in World War 2 (1939-1945).
The Nazi doctors were tried in Nuremberg, Germany, which led to the 10 principles of human research in the Nurember Declaration, which among others included the importance of free and informed consent. These were further updated at the 59th World Medical Associations’ (WMA) Helsinki Declaration in 19649.
The broad principles of autonomy, beneficience, non-maleficence and justice is shared with the current international codes of biomedical research. However, the ideological and philosophical foundations of Islamic bioethics is firmly grounded on the transcendental, spiritual and the moral aspects of health related issues, unlike contemporary bioethics.
Banked biospecimens and biodata are invaluable sources for “secondary” biomedical research consequent upon the explosive technological advances in health research, and massive amounts of information in big databanks. The classical informed consent process may no longer be suitable nor applicable to the emerging issue of research related to biospecimens or big biodata. This issue has yet to be addressed by Islamic jurisprudence councils. In the absence of a fatwa (edict), the author opines that with the minimal risk exposed to the individual, with potentially large benefits to the society, the current bioethical codes are in harmony with the objectives of the Islamic Law (Maqāsid Sharī`ah).
The back to basics principles of ethics which is harmonious with Islamic teachings, namely respect for persons, beneficence, non-maleficence and justice is preserved and protected in all forms of research involving human subjects. The Institutional Review Board (IRB), has the fiduciary duty as the regulator of bio-medical research. The primary objective of the IRB is to protect the research subjects from physical or psychological harm. It reviews the research protocols and related material within the framework of institutional regulations, legal mandates, professional conduct and research ethics including considerations of faith and culture. The IRB works closely with researchers to establish sound ethical research for the enhancement of health whilst safeguarding the safety of the individual and the larger community10.
In the design of the clinical trials, the researcher is among others guided by the core maxims of Islamic jurisprudence known as al-Qawā’id al-Fiqhiyyah al-Asliyyah. These five guiding principles of Fiqh (core maxims) represent the essence of the Sharī`ah as a whole, and the other maxims further elaborates on these five core principles. They are:
- Harm must be eliminated.
- Matter will be judged by their purposes.
- Certainty is not overruled by doubt.
- Hardship begets facility and
- Custom is a basis of judgment.
The safety culture in every research protocol is reinforced by the legal rule, “Prevention of harm takes precedence over the attraction of benefit” 11.
Ibn Taimiyah emphasises, “The principle of the Law is that if an action involves harm, it is prohibited, unless this harm is in conflict with a weightier benefit, as in the case of permitting a person to eat the flesh of an animal corpse when he has to. The greater of two harms is warded off by tolerating the lesser one”
Apart from the Muslim physician’s ethical responsibility, it is also his religious obligation to respect, protect and preserve his patients’ confidentiality.
The Prophet (ﷺ) said: “Matters discussed in a meeting are confidential and must not be disclosed beyond hat meeting”12.
And for his act of not disclosing his patient’s secrets, he has been promised bountiful rewards in the hereafter.
The Prophet (ﷺ) said: “The one who keeps te secrets (confidentiality) of a Muslim brother, Allah will keep his secrets (sins) on the Day of Judgement”13.
Only under very exceptional circumstances is the health care professional allowed to reveal his patient’s information to select and relevant authorities.
A placebo (from the Latin, I shall please) effect occurs when an inert substance causes a beneficial effect. While a nocebo (from the Latin, I shall harm) effect is when it causes a harmful effect to the research subject.
It is difficult to dissociate placebo and nocebo responses from the natural course of an illness of the true effects of a new drug/intervention in a clinical trial. The undelying mechanism in placebo and nocebo effects are expectancy and classical conditioning. Clinicians and researchers need to be aware of both these phenomena which may improve or worsen psychosomatc symptoms in the conduct of the research study.
The placebo and nocebo phenomenon was summarized succinctly with a reference to Ibn Sīnā’s counsel to his patient: “Look! You, I and disease are “three”. If you help me and stand beside me, we become “two”, and the disease will be left alone; then we will overcome it and compel your illness. But if you stand beside the disease, you will become “two” and I will be alone, then you will overcome me, and I will not be able to cure you”14.
Bias as a source of error in medical research can only be mitigated by a genuine sense of accountability, transparency and resolute quest for the truth. The Glorious Quran instructs all of the believers, researchers included to be just fair and truthful even agaist our own enemies or those whom we hate:
“يَا أَيُّهَا الَّذِينَ آمَنُواْ كُونُواْ قَوَّامِينَ لِلَّهِ شُهَدَاء بِالْقِسْطِ وَلاَ يَجْرِمَنَّكُمْ شَنَآنُ قَوْمٍ عَلَى أَلاَّ تَعْدِلُواْ اعْدِلُواْ هُوَ أَقْرَبُ لِلتَّقْوَى وَاتَّقُواْ اللَّهَ إِنَّ اللَّهَ خَبِيرٌ بِمَا تَعْمَلُونَ”
“O you who believe! Stand out firmly for Allah and be just witnesses and let not the enmity and hatred of others make you avoid justice. Be just, that is nearer to piety, and fear Allah. Verily, Allah is well acquainted with what you do”15.
Bias is an occult source of error in biomedical research, which would undermine the validity and applicability of the conclusions of the research study. A Muslim researcher who undertakes research as an act of `ibādah (worship), therefore has the double duty to be both aware of the potetial mecahnism of research errors and to prevent, correct and overcome bias.
Plagiarism is intellectual dishonesty and is a mounting problem in biomedical research. It is strongly condemned in Islamic laws and Islamic bio-ethical codes. In the Glorious Qur’ān it is explicitly stated that:
“إِنَّ اللَّهَ يَأْمُرُكُمْ أَن تُؤَدُّواْ الأَمَانَاتِ إِلَى أَهْلِهَا وَإِذَا حَكَمْتُم بَيْنَ النَّاسِ أَن تَحْكُمُواْ بِالْعَدْلِ إِنَّ اللَّهَ نِعِمَّا يَعِظُكُم بِهِ إِنَّ اللَّهَ كَانَ سَمِيعًا بَصِيرًا”
“Allah commands you to render trusts to their owners”16.
The Prophet (ﷺ) said: “He who acts dishonestly towards us is not of us”17.
The domain of clinical research has much been affected, even tainted by the influence of “big pharma” on physicians and medical institutions. Potential conflicts of interest can be mitgated and kept in check if all researchers comply with the ethical and scientific guidelines as detailed by the International Conference of Harmonisation on Good Clinical Practice (ICH-GCP). The International Islamic Code for Medical and Health Ethics outlines in much detail the ethical professional behaviours with regards to physician-industry relationships to safeguard the nobility of the medical profession and the authenticity of the research output18.
Among the primary end points of biomedical research is to improve the wellbeing of mankind and specifically to enhance the healthcare conditions of fellow human beings. Despite the challenges of paucity of research infrastructure, human resources and fiscal funding in Low and Middle Income Countries (LMIC), international agencies like the WHO has sponsored various international collaborative research projects to improve global health.
Therefore, both the funder and the investigator in LMIC, should be responsive to the health needs and priorities of their community with limited resources and ensure their research is relevant to these important and urgent needs. The Prophet (ﷺ) said: “The best from among you is he who is beneficial to his fellow mankind” 19.
There have been increasing calls over the past 20 years to improve the quality and safety of healthcare deliverables, in the midst of escalating healthcare costs. And how best to promptly integarate best practises from clinical research into the healthcare ecosystem. This enhances a continuous learning and research culture into the helathcare system. This transformation of the “traditional” health care into a “Learning” health care system (LHS) is still in it’s infancy.
At the individual level, it aims to minimise complications or errors of care, and avoiding un-needed or harmful interventions. At the societal lelevl, LHS aims at the establishment of a just health care, high quality care based on the strongest evidence from clinical research, and delivered with the highest achievable safety, with eventual reduction in healthcare costs.
When research and practice are integrated, the obligations of research ethics must be fulfilled but the ethical framework is more flexible, less complicated, more practical and timely20.
The Glorious Qur’ān and Ahādīth are very explicit in their call for the unity of the Muslims and its working together as a cohesive jama`ah (team). Unfortunately, there is a paucity of teamwork among Muslim academics in biomedical research which is largely due to the hierarchal mindset that is prevalent among our academics. It is both important and urgent for Muslim scientists involved in biomedical research to relearn, embrace and apply teamwork dynamics if they hope to increase the quality and quantity of their research output21.
Physicians, medical and surgical organisations and medical schools should continue to endevour to restore and uplift the professionalism and integrity of biomedical research and medical practice.
For Muslim healthcare professionals, the Islamic Shari’ah is the bedrock of biomedical research ethics, and commands us to act justly and with integrity as the fiduciary guardians of th best interests and well being of the individual patient and the larger society.
References
- Al-Bukhārī 7:582
- Martin Kramer, Jerusalem Post, December 31, 1999
- The Glorious Quran: Surah an-Nahl 16:90.
- The Glorious Quran: Surah Al-Imran 3:190-191.
- The Glorious Qur’an: Surah Al-Isra’ 17:70.
- Al-Quran, Surah Al-Baqarah 2:256.
- Ibn Qudduma, al Mughni, IV: 552.
- Islamic Organization for Medical Sciences. International ethical guidelines for biomedical research involving human subjects “an Islamic perspective.” In El-Gendy AR, Al-Awadi ARA, editors. The international Islamic code for medical and health ethics. Kuwait: Islamic Organization for Medical Sciences; 2005:Vol 2, 121-276.
- Informed Consent in Biomedical Research: Contemporary Standards And Islamic Perspectives. Hassan Chamsi Pasha and Mohammed Ali Albar. FIMA Yearbook 2017, 16-25.
- The Role of Institutional Review Boards and Ethical Committees In Basic and Clinical Biomedical Research. M. Iqbal Khan and Hania Iqbal. FIMA Yearbook 2017. 33-40.
- Shairah Intelligence manual, 150-166.
- Sunan Abu Dawud. Vol 5 Hadith No. 4869.
- Al Sunan Kubar Lil Nisaee. Beirut, Lebanon 2001, Hadith No. 7241.
- Placebo and Nocebo Effects in Clinical Trails Majed Pasha, Hassan Chamsi Pasha and Mohammed Ali Albar. FIMA Yearbook 2017. 114-121.
- The Glorious Qur’an: Surah Al-Ma’idah 5:8.
- The Glorious Qur’an: Surah An-Nisa’ 4:58.
- Sahih Muslim, 1:181.
- Role of Sponsors in Biomedical Research. Abdul Rashid Abdul Rahman. FIMA Yearbook 2017, 66-72.
- Ahmad, ath-Thabrani, ad-Daruqutni. Quoted by al-Albani in Sahihul Jami, No. 3289.
- Learning Health Care System: Integrating Healthcare and Research Aly A. Mishal. FIMA Yearbook 2017, 122-130.
- Teamwork Ethics in Biomedical Research Among Muslim Academia. Afshan H. Khattak. FIMA Yearbook 2017, 89-103.
