17.4.1 VALUES, COMPETENCE, AND RESPONSIBILITY
The physician-patient is based on brotherhood. The physician must maintain the highest standards of
justice. He should also follow the following guidelines from the sunnat: good intentions, avoiding doubtful things, leaving
alone matters that do not concern him, loving for others, causing no harm, giving sincere advice, avoiding the prohibited,
doing the enjoined acts, , renouncing greed, avoiding sterile arguments, respect for life, basing decisions and actions on
evidence, following the dictates of conscience, righteous acts, quality work, guarding the tongue, avoiding anger and rage,
respecting transgressing Allah’s limits, consciousness of Allah in all circumstances, performing good acts to wipe out
bad ones, treating people with the best of manners, restraint and modesty, maintaining objectivity, seeking help from Allah,
and avoiding oppression or transgression against others. The physician should be professionally competent (itiqan & ihsaan), balanced (tawazun), have responsibility
(amanat) and accountability (muhasabat).
He must work for the benefit of the patients and the community (maslahat).
17.4.2 MEDICAL DECISIONS
No medical procedures can be carried out without informed consent of the patient except in cases of
legal incompetence. The patient has the purest intentions in decisions in the best interests of his or her life. Others may
have bias their decision-making. The patient must be free and capable of giving informed consent. Informed consent requires
disclosure by the physician, understanding by the patient, voluntariness of the decision, legal competence of the patient,
recommendation of the physician on the best course of action, decision by the patient, and authorization by the patient to
carry out the procedures. The patient is free to male decisions regarding choice of physicians and choice of treatments. Consent
can be by proxy in the form of the patient delegating decision making or by means of a living will.
Valid consent must be voluntary, informed, and by a person with capacity to consent. It involves explaining
the procedure contemplated, making sure the patient understands, and offering the patient a choice. Consent is limited to
what was explained to the patient except in an emergency. Refusal to consent must be an informed refusal (patient understands
what he is doing). Refusal to consent by a competent adult even if irrational is conclusive and treatment can only be given
by permission of the court. Doubts about consent are resolved in favor of preserving life. Spouses and family members do not
have an automatic right to consent. A spouse cannot overrule the patient’s choice. Advance directives, proxy informed
consent by the family are made for the unconscious terminal patient on withholding or withdrawal of treatment. Physician assisted
suicide, active euthanasia, and voluntary euthanasia are illegal. A do not resuscitate order (DNR) by a physician could create
legal complications. The living will has the following advantages: (a) reassuring the patient that terminal care will be carried
out as he or she desires (b) providing guidance and legal protection and thus relieving the physicians of the burden of decision
making and legal liabilities (c) relieving the family of the mental stress involved in making decisions about terminal care.
The disadvantage of a living will is that it may not anticipate all developments of the future thus limiting the options available
to the physicians and the family. The device of the power of attorney can be used instead of the living will or advance directive.
Decision by a proxy can work in two ways: (a) decide what the patient would have decided if able (b) decide in the best interests
of the patient. Informed consent is still required for physicians in special practices such as a ship’s doctor, prison
doctor, doctors in armed forces. Police surgeons may have to carry out examinations on suspects without informed consent.
CONSENT OF THE INCOMPETENT
Competent children can consent to treatment but cannot refuse treatment. The consent of one parent
is sufficient if the 2 disagree. Parental choice takes precedence over the child’s choice. Courts can overrule parents.
Life-saving treatment of minors is given even if parents refuse. Parental choice is final in therapeutic or non-therapeutic
research on children. Mental patients cannot consent to treatment, research, or sterilization because of their intellectual
incompetence. They are admitted, detained, and treated voluntarily or involuntarily for their own benefit, in emergencies,
for purposes of assessment, if they are a danger to themselves, or on a court order. Suicidal patients tend to refuse treatment
because they want to die. Nutrition, hydration, and treatment can be withdrawn in a persistent vegetative state since the
chance of recovery is low. There is no moral difference between withholding and withdrawing futile treatment. Labor and delivery
are emergencies that require immediate decisions but the woman may not be competent and proxies are used. Forced medical intervention
and ceserian section may be ordered in the fetal interest. Birth plans can be treated as an advance directive.
17.4.3 DISCLOSURE AND TRUTHFULNESS
As part of the professional contract between the physician and the patient, the physician must tell
the whole truth. Patients have the right to know the risks and benefits of medical procedure in order for them to make an
autonomous informed consent. Deception violates fidelity. If disclosure will cause harm it is not obligatory. Partial disclosure
and white or technical lies are permissible under necessity. Disclosure to the family and other professionals is allowed if
it is necessary for treatment purposes. Physicians must use their judgment in disclosure of bad news to the patient.
17.4.4 PRIVACY AND CONFIDENTIALITY
Privacy and confidentiality are often confused. Privacy is the right to make decisions about personal
or private matters and blocking access to private information. The patient voluntarily allows the physician access to private
information in the trust that it will not be disclosed to others. This confidentiality must be maintained within the confines
of the Law even after death of the patient. In routine hospital practice many persons have access to confidential information
but all are enjoined to keep such information confidential. Confidentiality includes medical records of any form. The patient
should not make unnecessary revelation of negative things about himself or herself. The physician can not disclose confidential
information to a third party without the consent of the patient. Information can be released without the consent of the patient
for purposes of medical care, for criminal investigations, and in the public interest. Release is not justified without patient
consent for the following purposes: education, research, medical audit, employment ofr insurance.
The principle of fidelity requires that physicians be faithful to their patients. It includes: acting
in faith, fulfilling agreements, maintaining relations, and fiduciary responsibilities (trust and confidence). It is not based
on a written contract. Abandoning the patient at any stage of treatment without alternative arrangements is a violation of
fidelity. The fidelity obligation may conflict with the obligation to protect third parties by disclosing contagious disease
or dangerous behavior of the patient. The physician may find himself in a situation of divided loyalty between the interests
of the patient and the interests of the institution. The conflict may be between two patients of the physician such as when
maternal and fetal interests conflict. Physicians involved in clinical trials have conflicting dual roles of physicians and