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Health Care in Islamic History and Experience

Author(s): Nayer Taheri, Dept. of Spiritual Care, Harborview Medical Center
Reviewer(s): Jamal Rahman, Muslim Sufi minister, co-minister at Interfaith Community Church in Seattle, Washington
Date Authored: May 01, 2008

Introduction

This article provides a short historical review about health care in Muslim experience, as well as current general information about Muslim people and their main observances and concerns in the Western health care system. Muslims in the U.S. come from many different cultures and schools of thought. A detailed explanation about differences is beyond this article's scope and purpose. This document focuses on similar beliefs and observances with regard to health care, illness, and death and dying among Muslims in the US.

Finally this document offers a list of suggested readings and resources available on the Internet.

Note
In the body of this article, common Islamic concepts or terms are linked to external websites that provide more information. These websites are noted, along with additional resources in the Suggested Resources at the end of this article.

General Information

The word “Islam” means peace and submission to the will of Allah (translated literally as “the God”); those who follow Islam are called Muslims. Islam is one of the three Abrahamic religions after Judaism and Christianity. In the 7 th century C.E. Islam emerged in the Arabian Peninsula, or present day Saudi Arabia. Muslims believe that there is only one God and that Muhammad was the last Prophet of God. They also believe that God revealed teachings to Muhammad, which are recorded in the Islamic Holy Scripture: the Qur'an.  The Qur'an advises Muslims on their religious duties, including the five pillars, or religious obligations, including confession of faith, prayer, fasting, charity, and pilgrimage.

Muslims consider the Prophet Muhammad as an exemplar and they try to emulate his deeds in their own lives by following his traditions and the Qur'anic instructions. Such teachings have historically influenced attitudes and practices toward different aspects of life including birth, illness, and death and dying, as well as the development of political, social and economic structures. These factors often impact policies on health care and shape Muslim sub-communities' attitudes about receiving medical treatment from the larger non-Muslim society.

During the early period of development, Islam was influenced by different factors including the cultural practices of newly conquered lands. Muslim rulers in these regions had to be rather flexible and they adopted and improvised many existing local practices; therefore, innovations in health care practice were accepted provided that they did not conflict with Islamic Law (Shari'ah).

Shari'ah considers Muslims as one community (Ummah) and prescribes their activity from birth to death. Measures for basic health care in Islamic Law include diet and personal hygiene. Due to differences between local personal habits, different interpretations of the Shari'ah developed during the early period of Islam. These interpretations resulted in the development of five distinct schools of Fiqh, or Islamic jurisprudence. Although these schools interpret the Shari'ah based on their own theological approach, they share nearly the same fundamental beliefs on the matter of death and dying.

Pre-Modern Medicine in Islamic Experience

There are no specific codes for medical treatment of physical illnesses in the Qur'an. In Islamic tradition the difference between health and illness was, and still is, perceived as balance and imbalance or the Humoral Theory. Muslims have historically sought the Qur'an as a healing source in times of psychological and spiritual distress. When experiencing physical illness, Muslims have also been open to the rituals and medicinal practices of different traditions, including those of non-Muslims. The following sayings of the Prophet are used to encourage patients to seek proper treatments in time of illness:

Historically, there has been a close relationship between religion and medicine and its practices. Muslims have been open to accept, use and improve non-Muslim as well as pre-Islamic healing rituals. They have adopted and improvised many practices such as home-made herbal and medicinal tonics, dietary restrictions, and amulets to ward off bad spirits. They also have adopted practices such as male circumcision, cupping, bloodletting, cauterization and ligaturing. During the pre-modern era, Islamic medical and other sciences leaned heavily upon local medical practices, as well as on works translated from Greek. These influences resulted in the further advancement of medical sciences, especially in the 11th and 12th century.

Modern Period

One of the most significant changes in Islamic history occurred toward the end of the Ottoman period. During this transition the previously united Islamic world was fragmented into many newly independent Muslim countries due to the dissolution of the Ottoman Empire and the expansion of Western colonialism. These changes resulted in socio-political appropriation and adaptation of European influences, such as constitutional models and family law, as well as accepted medical treatments. As the result state-supported public and local health clinics were established and local therapeutic traditions experienced decline. By the end of the 19th to the beginning of the 20th centuries in many Muslim states/nations, the aim of state-sponsored health clinics was to eliminate local diseases and to provide education about reproduction.

While European medical practices were strong influences in early modern Muslim societies, it should also be noted that the sciences in Europe did not arise in a vacuum. Rather, they were historically based upon the Greco-Arabic medicinal sciences .

Contemporary Approach

Contemporary Muslims' approach to health care is still strongly based on preventative measures. In many cases, although Muslim patients seek a curative process through surgical or medical means, they still look to their religious and cultural heritage to address their spiritual, social and cultural needs. Preventative healthcare strategies in Muslim experience include: personal hygiene, dietary measures such as the restriction in eating specific ingredients (such as pork and its byproducts, and drinking alcohol), and the avoidance of addictive habits such as smoking tobacco or over-consumption of food.

The Muslim population in the US is very diverse and colorful. The cultural background of different Muslim groups might influence the way in which they respond to illness and other life crises. For example, some Muslims may perceive a sudden death or illness as a sign of punishment, or a test from God. Moreover, when an immigrant Muslim family moves to a larger non-Muslim society they may adopt certain elements of their new cultural environment. However, one aspect that is usually the same regardless of country of origin is in relation to the practices surrounding death and dying.

Life

In Islam, life is considered sacred and belongs to God. (002.164 ; 003:156). It is believed that all creatures die at a time determined by God (029:57 ; 003:185). Therefore, suicide (002:195) and euthanasia are forbidden. DNR orders are acceptable:

“The Islamic perspective on do-not-resuscitate orders has been described and is complex. A do-not-resuscitate order is consistent with the tenets of Islam. The withdrawal of support in the setting of a persistent vegetative state is less clear”. (Naughton and Davis, 2001).

Muslims believe in the after life. The Qur'an emphasizes that death is just a transition for the soul to depart the body and enter into another realm (002:28; 002:56). Muslims also believe in God's mercy and forgiveness (002:54; 004:96) . In times of illness Muslims find strength from prayer and meditation, and may find spiritual healing in reciting the Qur'an, particularly if they perceive their illness as a test or punishment from God (003:17). Therefore, it can be very helpful and comforting to provide Muslim patients and their families a copy of the Qur'an and access to a private space to perform their daily prayers.

Death

The definition of death in Islam is the departure of the soul from the body in order to enter the afterlife. The Qur'an does not provide any specific explanation of the signs of this departure. The common belief is that death is the termination of all organ functions. In 1986, at the third International Conference of Islamic Jurists in Amman, Jordan, a fatwa was issued that “equated brain death to cardiac and respiratory death.”  This ruling accelerates and facilitates the process for organ transplantation.

The Fatwa no. V: of this conference reads: “A person is considered legally dead and all the Shari'ah's principles can be applied when one of the following signs is established:

(i) Complete stoppage of the heart and breathing which are decided to be irreversible by doctors.

(ii) Complete stoppage of all vital functions of the brain which are decided to be irreversible by doctors and the brain has started to degenerate. Under these circumstances it is justified to disconnect life supporting systems even though some organs continue to function automatically (e.g. the heart) under the effect of the supporting devices” (Hassaballah,1996).

Since death is viewed as a process that bridges the soul's existence from one life to the next, it is acceptable to discontinue the use of life support equipment that prolongs the life of a patient. In medically-futile situations, in which life support equipment is used to prolong organ functions, the condition needs to be carefully explained to the family so they do not mistake DNR orders with euthanasia.

When death happens, Muslims believe that the soul returns to his or her creator (002:156). The family members of the deceased immediately prepare to perform the burial as soon as possible. If death occurs in a hospital or hospice, the face of the deceased person or his/her bed should be turned toward Mecca (in a northeast direction in the United States). The clothes are removed by same gender family members and the body will be covered by sheets. The family quickly prepares the arrangements for washing (ghusl) and Islamic burial .

In Islam, the body is sacred and belongs to God; therefore, autopsy examinations are only allowed when legal requirements demand it. Embalming and cremation are forbidden in Islam; therefore, the families try to bury their loved ones before the body decays. At the time of death of a loved one, Muslims usually are supported by their community of affiliation and mosques. When an unexpected or sudden death occurs, hospitals may receive a large number of visitors and community members to support the patient and family.

(See also in EthnoMed cultural information about Somali Muslims, including information about funeral traditions, beliefs surrounding death and encounters with the medical examiner:  Somali Cultural Profile)

Important Religious and Cultural Facts in Providing Care

In caring for hospitalized Muslim patients, the following information will help to provide a more comfortable stay for patients, and will facilitate communication between staff and their patients and families.

Scripture

To support psychological and spiritual health and healing, it is widely believed that reading and reciting the Qur'an brings blessings to those who are spiritually and psychologically distressed; therefore, providing a copy of the Qur'an to Muslim patients is helpful.

Muslim Women

Muslim women prefer to have same gender doctors and nurses in order to follow rules of modesty in regard to the opposite sex. Related to this, Muslim women cover their head and body in various Islamic coverings (Hijab), according to the custom of their country of origin. To show respect, healthcare workers should ask a Muslim woman for permission to uncover parts of her body for injection, or for any other medical reasons.

It is helpful to have a sign on female Muslim patients' door asking the staff to knock first before entering. This will provide them a few seconds to put on their Hijab. Additionally, it is helpful to provide a sign requesting that medical staff return in a few minutes in order to give female patients enough time and privacy to perform their daily prayers.

Diet and Food Restriction

Muslims follow dietary requirements that may affect compliance with prescriptions. Muslims avoid eating pork or drinking alcohol, and are proscribed from taking medicines that contain alcohol or pork byproducts unless they are life-saving drugs and no substitute is available. Usually at a time of necessity Muslims follow the general rule that “necessity dictates exception” (016:115 ; 012:068 ; 006:145 ):

“Porcine heparin, for example, contains gelatin from pork products, and is the only heparin universally used. That was thought to cause a potential problem for Jewish, Muslim, and Seventh-day Adventist patients at this institution," says Doha Hamza, the coordinator of Muslim volunteers at the spiritual care service department at Stanford (CA) University Medical Center. "We investigated the issue with an Imam and a Muslim doctor who concurred that the use of porcine heparin is lawful because of the chemical modification the product undergoes and the urgent need involved. Also the amount is so small, it doesn't fit the definition of consumption." Similar solutions might be found for insulin products* derived from pork and porcine heart valves” (Pennachio, 2005).

* Since January 2006, pork insulin for human use has no longer been manufactured or marketed in the U.S.
( http://www.fda.gov/CDER/drug/beefandporkinsulin/default.htm)

In hospices it is helpful to pay attention to pork product usage in the daily food menu for Muslim patients. It is also recommended to inform the patient about medications that contain alcohol.

Another dietary sensitivity occurs during the month of Ramadan (9th month of Arabo-Islamic Lunar calendar ) when all healthy and physically able adult Muslims fast (002-183). Those who are ill, menstruating, lactating or pregnant or those who are traveling are not expected to fast. Those who miss the Ramadan fast may fast once they become healthy, or once they have returned to their homes. Alternately, those who missed the fast may pay alms in order to make up for the days they missed (002-184). Since many Muslims approach illness as a test or punishment, they may wish to fast to receive spiritual or physical healing. In these cases, a Muslim chaplain or an Imam may be helpful to encourage and negotiate an almsgiving alternative that reduces potential physical weakening. (See other information in EthnoMed about Ramadan: Ramadan 2007 Reminder to Health Care Practitioners; Pearls of Cross Cultural Care: Ramadan 2000; Breastfeeding in Ramadan for Somali Diet; Report on Somali Diet; Food and Fasting in Somali Culture)

Important Dates

Eid Fitr and Eid Adha are two of the most important holidays which all Muslims recognize. On these two days, Muslims visit hospitals to visit their communities' patients, as well as cemeteries. Eid Fitr celebrates the final day of Ramadan. On the Eid Fitr, the fast is broken and all Muslims gather in community to celebrate with a celebratory community meal. On that day the head of each household pays their annual alms to a charity of their choice. Eid Adha occurs during the Hajj (pilgrimage) which celebrates the willingness of Abraham to sacrifice his son Ismael (Ishmael). On these important dates, healthcare workers may see an increase in visitors for their Muslim patients.

Prayer

Devout Muslims pray (salaat) 5 times a day. Daily salaat is mandatory and performed at dawn, noon, mid afternoon, sunset, and late night. It is helpful to direct the bed of a terminally ill Muslim patient toward Mecca (in a northeast direction in the United States) for spiritual reasons. Also it should be noted that Muslims ritually wash (Wuzu) before their daily prayers. This ritual includes washing the arms, face, mouth, ears, and feet each time before prayers. Therefore, if a patient desires to engage in this practice, extra effort will be needed from the medical team and nurses to help the patient meet this requirement.

Transplants

Since there are no specific codes on transplant and organ donation in the Shari'ah, there are different approaches to treatment. Most Muslim jurists and their followers accept organ donations because it is in harmony with the Islamic principle of saving lives. (5:32)

“The following requirements should be met before transplantation: (1) a transplant is the only form of treatment available; (2) the likelihood of success is high; (3) the consent of the donor or next of kin is obtained; (4) the death of the donor has been established by a Muslim doctor; (5) there is no imminent danger to the life of a living donor; and (6) the recipient has been informed of the operation and its arrangement for ritual body wash” (Sarhill, N., LeGrand, S., Islambouli, R., Davis, M. P., & Walsh, D. (2001).

Cited References

Hassaballah, A. M. (1996). Minisymposium. definition of death, organ donation and interruption of treatment of islam. Nephrology, Dialysis, Transplantation: Official Publication of the European Dialysis and Transplant Association - European Renal Association, 11 (6), 964-965.

Naughton, M., & Davis, M. (2001). Discussing do-not-resuscitate status: Furthering the discourse. Journal of Clinical Oncology : Official Journal of the American Society of Clinical Oncology, 19 (13), 3301-3302.

Pennachio, D. L. (2005). Cultural competence: Caring for your Muslim patients. Medical Economics. Retrieved 5/10/2008, 2008, from http://medicaleconomics.modernmedicine.com/memag/content/printContentPopup.jsp?id=158977

Sarhill, N., LeGrand, S., Islambouli, R., Davis, M. P., & Walsh, D. (2001). The terminally ill muslim: Death and dying from the muslim perspective. The American Journal of Hospice & Palliative Care, 18 (4), 251-255.

Suggested Journal Articles

Ahmed, Q. A., Memish, Z. A., Allegranzi, B., Pittet, D., & WHO Global Patient Safety Challenge. (2006). Muslim health-care workers and alcohol-based handrubs. Lancet, 367 (9515), 1025-1027. doi:10.1016/S0140-6736(06)68431-6.

Ali, O. M., Milstein, G., & Marzuk, P. M. (2005). The imam's role in meeting the counseling needs of muslim communities in the united states. Psychiatric Services (Washington, D.C.), 56 (2), 202-205. doi:10.1176/appi.ps.56.2.202.

al-Shahri, M. Z., & al-Khenaizan, A. (2005). Palliative care for muslim patients. The Journal of Supportive Oncology, 3 (6), 432-436.

Carter, D. J., & Rashidi, A. (2003). Theoretical model of psychotherapy: Eastern asian-islamic women with mental illness. Health Care for Women International, 24 (5), 399-413.

Carter, D. J., & Rashidi, A. (2004). East meets west: Integrating psychotherapy approaches for muslim women. Holistic Nursing Practice, 18 (3), 152-159.

Daneshpour, M. (1998). Muslim families and family therapy. Journal of Marital and Family Therapy, 24 (3), 355-368.

El-Hazmi, M. A. (2004). Ethics of genetic counseling--basic concepts and relevance to islamic communities. Annals of Saudi Medicine, 24 (2), 84-92.

El-Sendiony, M. F., & Al-Hussain, Z. (1983). Sharia in islamic therapies for the aged. Current Psychiatric Therapies, 22 , 249-251.

Gatrad, A. R., & Sheikh, A. (2001). Muslim birth customs. Archives of Disease in Childhood.Fetal and Neonatal Edition, 84 (1), F6-8.

Gatrad, R., & Sheikh, A. (2002). Palliative care for muslims and issues after death. International Journal of Palliative Nursing, 8 (12), 594-597.

Hassouneh-Phillips, D. (2003). Strength and vulnerability: Spirituality in abused american muslim women's lives. Issues in Mental Health Nursing, 24 (6-7), 681-694.

Hathout, H. (2006). An islamic perspective on human genetic and reproductive technologies. Eastern Mediterranean Health Journal = La Revue De Sante De La Mediterranee Orientale = Al-Majallah Al-Sihhiyah Li-Sharq Al-Mutawassit, 12 Suppl 2 , S22-8.

Hedayat, K. (2006). When the spirit leaves: Childhood death, grieving, and bereavement in islam. Journal of Palliative Medicine, 9 (6), 1282-1291. doi:10.1089/jpm.2006.9.1282

Hedayat, K. M., & Pirzadeh, R. (2001). Issues in islamic biomedical ethics: A primer for the pediatrician. Pediatrics, 108 (4), 965-971.

Hodge, D. R. (2005). Social work and the house of islam: Orienting practitioners to the beliefs and values of muslims in the united states. Social Work, 50 (2), 162-173.

Laird, L. D., Amer, M. M., Barnett, E. D., & Barnes, L. L. (2007). Muslim patients and health disparities in the UK and the US. Archives of Disease in Childhood, 92 (10), 922-926. doi:10.1136/adc.2006.104364

Lester, D. (2006). Suicide and islam. Archives of Suicide Research : Official Journal of the International Academy for Suicide Research, 10 (1), 77-97. doi:10.1080/13811110500318489

Miklancie, M. A. (2007). Caring for patients of diverse religious traditions: Islam, a way of life for muslims. Home Healthcare Nurse, 25 (6), 413-417. doi:10.1097/01.NHH.0000277692.11916.f3

Padela, A. I. (2007). Islamic medical ethics: A primer. Bioethics, 21 (3), 169-178. doi:10.1111/j.1467-8519.2007.00540.x

Porter, B. (2001). The muslim festival of eid ul-fitr at L'arche daybreak: A pattern and principles for common worship services in solidarity with those not of the majority faith. Journal of Pastoral Care, 55 (2), 197-200.

Pridmore, S., & Pasha, M. I. (2004). Psychiatry and islam. Australasian Psychiatry : Bulletin of Royal Australian and New Zealand College of Psychiatrists, 12 (4), 380-385. doi:10.1111/j.1440-1665.2004.02131.x

Quadri, K. H. (2004). Ethics of organ transplantation: An islamic perspective. Saudi Journal of Kidney Diseases and Transplantation : An Official Publication of the Saudi Center for Organ Transplantation, Saudi Arabia, 15 (4), 429-432.

Saha, N. (2007). The attitudes and practice of muslim patients using guttae medication during ramadan. Eye (London, England), 21 (6), 878-879. doi:10.1038/sj.eye.6702753

Sarhill, N., LeGrand, S., Islambouli, R., Davis, M. P., & Walsh, D. (2001). The terminally ill muslim: Death and dying from the muslim perspective. The American Journal of Hospice & Palliative Care, 18 (4), 251-255.

Simpson, J. L., & Carter, K. (2008). Muslim women's experiences with health care providers in a rural area of the united states. Journal of Transcultural Nursing : Official Journal of the Transcultural Nursing Society / Transcultural Nursing Society, 19 (1), 16-23. doi:10.1177/1043659607309146

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( Note:  online access limited; subscription required)

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