1. Home ISLAMIC MEDICAL EDUCATION RESOURCES029907-MEDICAL ETIQUETTE and CONFIDENTIALITYLecture for 3rd year medical students at the Kulliyah of Medicine, International Islamic University, Kuantan, Malaysia onSaturday 10th July 1999 by Prof Omar Hasan Kasule, Sr.OUTLINEBED-SIDE ETIQUETTEObligation to visit the patientEtiquette of visiting a patientAppearance of the caregiverMannerisms of the caregiverEmotional involvementCovering of awratMedical proceduresSupporting careManaging feverManaging painControl of infections DEALING WITH THE FAMILYSupportReassuranceInterferenceConflict INFORMED CONSENTChoice of physicianChoice of treatment, food, and drink CONFIDENTIALITYThe secretConcept of keeping secretsWritten RecordsBasis for medical confidentialityRelease of the information by the caregiver 1.0 BED-SIDE ETIQUETTEObligation to visit the patient, wujuub iyadat al mariidh: The ward rounds fulfil one of the social obligations of visiting the sick (KS 505). Visiting the sick has a lot of excellence, fadhl iyadat al mariidh, (KS 505). Care givers get a lot of reward from Allah for fulfilling this social obligation in addition to the rewards for their medical work The caregiver should interact with the patient as a fellow human. The human relation has priority over the professional patient-physician relation. Some bedside visits should therefore be purely social with no medical procedures or medical discussions. Etiquette of visiting a patient, adab ‘iyadat al mariidh: The prophet regularly visited his companions who fell sick (KS 505, MB #1956). His behavior at the bedside of the patient is good guidance for both the physician and the other visitors to the patient. The books of sirah have preserved for us memories of such visits such as what the prophet said during the visit (KS 505). The following are recommended actions during a visit to the patient: supplication, dua, for the patient (KS 505, MB #1961), reading Qur'an for the patient (KS 505), and asking the patient for supplication, dua. The Qur'an is a cure, al Qur'an dawa (KS p. 338). Dua is a cure, al dua dawau (KS p. 338). The Prophet gave us guidance on what can be said and what should not be said in the presence of the patient (KS 505). The following are enjoined: asking about the patient’s feelings, sua'al anhu, doing good/pleasing things for the patient, ihsaan, making the patient happy, tatyiib nafs al maiidh, andencouraging the patient to be patient, tashjiu al mariidh (KS 505). The patient should be discouraged from wishing for death wishing death, tamanni al mawt (KS 524). Appearance of the caregiver: The caregivers must make sure that they are clean and are dressed appropriately. The type and style of dress create impressions and convey messages. The dress, hair, and shoes of the caregiver must convey the impression of a serious, organized and disciplined person. The use of cosmetics should be limited to just covering up any defects and restoring the normal, average, and natural appearance. Excessive use of cosmetics conveys the impression of egoism and lack of seriousness. Perfumes should be used in moderation to suppress any unpleasant body odors. Excessive use, when the patient is aware that the caregiver is wearing perfume, is discouraged. Mannerisms of the caregiver: Caregivers must have a cheerful disposition, imbisaat (MB #2045). They must deal with patients with leniency, rifq (MB # 2025). They must strive to do good, ma'aruf (MB #2024). They must also have only good thoughts about their patients, husn al dhann. They must avoid evil or obscene words (MB #2026). It is important for the caregiver to have full interaction with the patient but must still observe the rules of lowering the gaze, ghadh al basar, except when medical necessity dictates otherwise. Caregivers must not be arrogant and show off (MB #2116). They must adopt an attitude of humbleness, tawadhu'u (MB #2117) all the time. Emotional involvement: It is very wrong for caregivers to adopt a detached emotionally-neutral disposition thinking that is the way of being professional. Caregivers must be loving and empathetic, tawadud & tarahum(MB #2018). They must show mercifulness, rahmat (MB #2020). The emotional involvement must however not go to the extreme of being so engrossed that rational professional judgment is impaired. Covering of awrat: Both the caregiver and patient must cover awrat as much as possible. However, the rules of covering are relaxed because of the necessity, dharurat, of medical examination and treatment. The benefit,maslahat, of medical care takes precedence over preventing the harm inherent in uncovering awrat. When it is necessary to uncover awrat, no more than what is absolutely necessary should be uncovered. To avoid any doubts, patients of the opposite gender should be examined and treated in the presence of others of the same gender. The caregivers should be sensitive to the psychological stress of patients, including children, when theirawrat is uncovered. They should seek permission from the patient before they uncover their awrat. Caregivers who have never been patients may not realize the depth of the embarrassment of being naked in front of others. An epileptic woman who was embarrassed at the uncovering of her awrat during an attack came to the prophet. He prayed for her and Allah answered the prayer (MB #1954). Medical procedures: Caregivers must be fully aware of their legal liabilities and responsibilities, mas'uliyat altabiib (Sunan Abu Daud Kitaab al diyaat baab 24, Ibn Majah Kitaab al Tibb baab 16). The rules of seeking permission, isti' dhaan, must be followed whenever caregivers approach a patient. The patient must be forewarned about the approach of the caregiver and should not be surprised. The privacy of the patient must be respected and he or she should be examined after getting permission. Medical care must be professional, competent, and considerate. Medical decisions should consider the balance of benefits and risks. The general position of the Law is to give priority to minimizing risk over maximizing benefit, dar'u al mafsadat muqaddamu ala jalbi al maslahat. Any procedures carried out must be explained very well to the patient in advance. Supporting care: The caregivers must listen to the felt needs and problems of the patients. They should ask about both medical and non-medical problems. Supportive care such as nursing care, nutrition, cleanliness, and ensuring physical comfort are as important as the medical procedures themselves. In terminal cases it is only the supporting care that can be given. Managing fever: Fever is a generalized often non-specific patho-physiological response. It is a cause of much discomfort. Caregivers should detect it early and treat it effectively. The prophet described fever as a blow of hot wind from hell-fire. He recommended using cold water to cool the body during fever (MB #1972). Any additional methods of reducing body temperature should be used. Managing pain: The caregiver should comfort the patient in pain. He can explain that there is reward, ajr, for being patient when suffering (MB #1953). The patient should persevere and not wish for death, tamanni al mawt, because of extreme pain (MB #1958, 1959, 1960). The patient should be reassured that there is eventually a cure for every ailment, dawa li kulli dai (MB #1962) so that there is no loss of hope. Control of infections: The prophet forbade a sick person visiting the healthy (KS 504) to prevent spread of infection. Precautions against spread of contagion were also recommended (MB #1969). Caregivers are obliged to make sure they have all their infectious diseases treated so that they are not a risk to their patients. 2.0 DEALING WITH THE FAMILYSupport: The family is also a victim when any member falls sick. The caregiver must provide psychological support to them. Sometimes even material support may be necessary. It should be remembered that part of the well being of the patient is to know that the family left behind is not suffering. Reassurance: Illness is a cause of much anxiety for the family. The caregiver must take time to reassure the family by explaining what is going and assuring them that the best care is being given. They must be told not to give up hope because Allah in His power can reverse the most serious or critical conditions. In communicating with the family caregivers must make sure they do not violate medical confidentiality except where it is necessary, dharurat. Involvement: Caregivers should similarly realise the importance of visits by relatives and friends and should plan their ward routines to maximize such visits. The family can be involved in some aspects of supportive care. This is helping them fulfil kindred obligations, silat al rahim. It uplifts the patient's morale to see that the family care and are around being involved. Interference: Caregivers should be on the guard to make sure that the eagerness of the family to be of assistance and to be involved does not step beyond the limits. The family may interfere with medical care causing disturbance of the medical routines. This should be resisted with firmness. Conflict: Illness is a stressful condition that generates anxiety in the family. It may initiate conflicts or aggravate existing ones. Caregivers may unwittingly find themselves in the middle of such conflicts. They should have the clarity of mind to understand that it is none of their business solving family conflicts. If they do they may regret it since they may become party to the conflict and are considered by some members of the family to favor other members. 3.0 INFORMED CONSENTChoice of physician: As long as patients are conscious and are in full control of their mental faculties, they should be consulted about choice of physicians. Minors, unconscious patients, and those who have lost legal competence can not choose physicians. Their legal representative, waliy, will have to make the decisions. The caregiver must realise that choice of a physician is a continuing resolution and must make sure that there has been no change of mind on the part of the patient or the legal guardian. Permission to treat must be sought at every visit though not necessarily in a formal way. It is illegal to treat a patient against their will unless provided for otherwise by the Law in defined exceptional circumstances. As guidance to the patient in physician selection, the following order of priority is followed: Muslim of the same gender, non-Muslim of the same gender, and Muslim of the opposite gender. Choice of treatment, food, and drink: The sunnah has given us guidance about forced feeding and forced treatment (KS 505: Sunan al Tirmidhi Kitaab al Tibb Chapter 3). The patient retains freedom to accept treatment or to reject it. The patient can not be forced to take any medication or undergoes any medical procedures. Treatment with new/experimental drugs or procedures requires informed consent. If the patient has lost legal capacity, ahliyat, by being unconscious or by losing mental capacity, the guardian, waliy, will take binding decisions on behalf of the patient. Illogical refusal of treatment or food could be grounds for finding a patient intellectually and legally incompetent making it necessary for the guardian to make the necessary decisions. Some situations of refusal of treatment are not issues of freedom of choice but have criminal implications. For example a patient with pulmonary tuberculosis who refuses treatment is committing the crime of endangering the lives of other members of the community. A parent who refuses immunization of a child is endangering the health of that child and other children in the community. 4.0 CONFIDENTIALITYThe secret, al sirr: The Qur'an mentioned the term secret in many verses (p. 570 2:77, 2:235, 2:274, 5:52, 6:3, 9:78, 10:54, 11:5, 12:19, 12:77, 13:10, 13:22, 14:30, 16:23, 16:75, 20:7, 20:62, 21:3, 25:6, 34:33, 35:29, 36:76, 43:80, 47:26, 60:1, 64:4, 66:3, 67:13, 71:9, 86:9). The term secret is relative. What may be a secret for one person may not be for another. What may be a secret in one place and at a particular time may no longer be a secret when time and place change. Secrets are of various degrees of importance. Revelation of some secrets could hurt an individual. Others can hurt the whole community or the whole ummat. Some secret information could be harmful if it is related directly to one individual but could be harmless if it is generalised. Concept of keeping secrets, kitman al sirr: Humans are capable of deliberately hiding and sitting on information (p. 986 3:72, 2:228, 2:271, 3:167, 4:42, 4:149, 5:61, 5:99, 6:28, 14:38, 21:110, 24:29, 27:25, 33:54, 60:1). Allah knows all what humans hide and reveal (p. 986 2:33). The natural default situation is for humans to divulge and share information during conversations even without being obliged or expecting any benefits. Keeping a secret therefore requires effort and discipline. Hiding information may be praiseworthy for example if a person does not reveal is iman infront of enemies, kitman al iman (p. 986 40:28). Keeping a secret, hifdh al sirr, entrusted to you in confidence is a sign of good Islamic character ( ). You may keep your own secrets from people who are potential enemies. The Prophet taught us to rely on keeping secrets in managing our affairs, al I'itimad ala al kitman fi qadhai al hajat ( ). Secrecy could be negative if it involves hiding the truth that should have been spread to others, kitman al haqq (p? 2:42, 2:146, 2:159, 2:173, 3:71, 3:187, 4:37, 5:15, 6:19). It is also negative to hide evidence, kitman al shahadat (p. ? 2:140, 2:283, 5:106). The basic position is to keep secrets and information and not reveal them even if there is no foreseeable harm. It is part of good Islamic character not to reveal all what a person knows. The Prophet taught that people should listen more and speak less. Written Records: Secrets are kept within the person, al kitman fi al nafs (p. 987 2:235, 2:284, 3:29, 3:118, 3:154, 27:74, 28:69, 33:37, 40:19). With development of writing and electronic technology, we now have other ways of keeping secret information. The Qur'an mentioned the tools for producing written records as paper,sahifat (p 979 20:133, 52:2-3) and the pen, qalam (p 979 68:1, 96:4). The Qur'an used the term kitaab to refer to written records such as scriptures (p. 977 4:153, 6:7, 17:93, 21:103, 29:48, 34:44, 35:40, 37:157, 34:21, 62:5), the Qur'an ( ), the record of pre-destination, kitaab al qadr (p. 978 3;145… 57:22), the record of values,kitaab al qiyam (p. 979 98:3), the record of knowledge, kitaab al ilm (p. 979 27:40)., and correspondence letters (P. 979 27:28-29). He process of writing was mentioned about evidence, kitabat al shahadat (p 979 43:19) and contracts, kitabat al uquud (p. 979 2:235, 2:282-283). Writing of false records was severely condemned (p 979 2:79). The prophet gave guidance about writing and writers (KS p. 452). In a modern medical environment, many records are generated about each patient. These prove a challenge as far as keeping of secrets is concerned because many people can access them. Besides their use in medical care, the records ca be used for medical education, medical research, and for legal purposes. Prevention of access to records for educational purposes may fall under the prohibition of hiding knowledge, kitman al ilm. Basis for medical confidentiality: Medical confidentiality has psychological, social, and legal bases. The psychological basis is the private and privileged relationship of trust between the patient and the caregiver. Revealing secrets that occurred to a third party is a violation of the trust. Such violation destroys future co-operation because the patient will hold back some information from the caregiver thus impairing correct diagnosis and appropriate management. The social basis lies in the prohibition of spreading rumors, namiimat(MB #2032) and backbiting. The legal basis is three Principles of the Law, qawaid al sharia, and the Law of Property. The Principle of Injury, dharar, states that an individual should not harm others or be harmed by others, la dharara wa la dhirar. The Principle of Hardship, mashaqqa, states that hardship mitigates easing of the sharia rules and obligations, al mashaqqa tajlibu al tayseer. Necessity legalizes the otherwise prohibited,al dharuraat tubiihu al mahdhuuraat. Necessity is defined as what is required to preserve the five Purposes of the Law (religion, life progeny, property, and intellect). If any of these five is at risk, permission is given to commit an otherwise legally prohibited action. The ownership of the records is not clear. Do they belong to the patient, the caregiver that wrote them, or the institution?. Using the law of property, a product belongs to the person who made it. In this case, the patient is the 'maker' of all the medical facts that are written and should be the acknowledged owner of the records. The patient is also the only person involved who has most to lose if records are misused. Thus, the contents of the medical records can not be revealed without the express permission of the owner. The general position regarding medical records is that they are a secret that can not be revealed without specific necessity, dharurat, as defined by the law. Release of information by the patient: The patient should consider any injurious information as a secret and can not reveal it. If it is about his sins or dishonorable shameful things, fahishat, he is forbidden. The prophet condemned al mujahir. A Muslim should repent and conceal his sins (MB #2037). Release of the information by the caregiver: It is prohibited for the caregiver to use the privileged medical information he has for any personal gain. For example, he can not use his knowledge of the health of a businessperson to buy shares in a certain company. He can not advise his relatives about marrying or not marrying a certain person because of what he knows about their health. Release of information in the public interest is a more complicated situation. The question arises whether a caregiver is obliged to reveal disease in a leader or airline pilot that could endanger the public? What should the caregiver do if he knows of a patient with a contagious disease that is in the community and is endangering others? Is it a violation of privacy for the caregiver to share medical information with other caregivers caring for the same patient? What about using the data for medical research or medical education? How much can the caregiver tell the relatives of the patient without compromising the regulation of keeping secrets? What should the caregiver do if approached by law enforcement agencies asking for specific medical information that can help them solve a crime? Can a caregiver testify in court against his patient using information obtained during the medical examination? All these are questions for which no easy answers can be given most of the time. The simplest situation is when the patient, the owner of the records, consents to their release provided no other individual is directly hurt by such a release. There are situations in which over-riding public interest will require refusing to release information even if the patient consents. If the patient or his guardian do not consent, the caregiver can not release information except in situations of legal necessity, dharurat, as defined above. Education, research, and crime investigations do not fall under the category of necessity. In cases of court litigation. The caregiver could testify in criminal cases that involve dhulm. The Qur'an forbids the revelation of the shameful unless there is dhulm (p 308 4:148, 24:19). The caregiver can not give false testimony (MB #1176). One of the ways for the caregiver to decrease his risk of revealing secret information is to have only the minimum needed for his work. This means that during history taking only those questions directly related to the medical problem should be asked. There should be no probing or digging for unrelated facts. © professor Omar Hasan Kasule July 1999