Alhassanain(p) Network for Heritage and Islamic Thought

Historical & Religious perspectives in Dealing with AIDS

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Acquired Immunodeficiency Syndrome is a serious medical and social problem that could be labeled as the plague of the century. But in many parts of the world still the subject of AIDS is considered as a taboo and HIV-positive people are mistreated. Such factors contribute to the fact that the number of AIDS cases may be underreported.
Although, ethics have long been recognized as an essential requirement in the making of a physician, there are particular ethical issues in dealing with AIDS patients. Even though AIDS has only recently been recognized, Islamic writings offered clear ethical guidance in dealing with similar problems. The ancient physician Ishaq Ibn Ali Al-Ruhawi wrote extensively about ethics in his book, Adab al-Tabib (Ethics of a Physician). Outline of this book showed that issues of responsibility, ethical dilemmas, and patients and community's rights are not new to medicine. Such ethical issues are originated from the principles guidelines of the holy Quran. Islamic medical ethics draw their essence from Islamic teachings, which call for honesty, sound performance, and consciousness of God in every act. They are based on the principles of the sanctity of human life, body, the soul and safeguarding its privacy. It is quoted in Quran that ” Whoever kills a human being not in lieu of another human being or because of mischief on earth is it as if he has killed all mankind; and whoever saves the life of a human being, it is as if he has saved the life of all mankind."   
An Islamic response to AIDS is directed mainly to prevent the disease by various measures; the most important of it is by having a sexual lifestyle that is prescribed by God. Muslim physicians have an obligation to continue caring for AIDS patients while taking the necessary precautions for themselves. They should also participate in preventive measures and education.
Historical & religious perspectives in dealing with AIDS
Medicine has always been considered as a very special profession. And those who want to practice it should acquire certain characteristics which include sense of responsibility, extensive knowledge, proper morals, dedication, self-denial, and mercy towards all people without discrimination.
One of the very important issues in medicine is the subject of medical ethics, and morality. And for thousands of years, ethics have been recognized as an essential requirement in the making of a physician (1). Hence medical ethics is defined as a discipline which evaluates the merits, risks, and social concerns of activities in the field of medicine considering the implications of new medical technologies and development. It ensures the principles of proper professional conduct, concerning the rights and duties of the physician, their patients and the fellow practitioners.  It sets guidelines for the physician's behavior and attitude, both at the personal and professional levels.
It is believed that physicians should be guided in their private life and while conducting their professional business by moral and ethical values. A person who lacks moral values in private life cannot be trusted in professional activities such as medicine, even with the highest professional and technical qualifications. Therefore it is impossible for a person to have two different ethical standards (2). The Almighty God says: "God has not made for any man two hearts in his body ...." Qur'an: 33/4

بسم الله الرحمن الرحيم
" مَّا جَعَلَ اللَّهُ لِرَجُلٍ مِّن قَلْبَيْنِ فِي جَوْفِهِ وَمَا جَعَلَ أَزْوَاجَكُمُ اللَّائِي تُظَاهِرُونَ مِنْهُنَّ أُمَّهَاتِكُمْ وَمَا جَعَلَ أَدْعِيَاءكُمْ أَبْنَاءكُمْ ذَلِكُمْ قَوْلُكُم بِأَفْوَاهِكُمْ وَاللَّهُ يَقُولُ الْحَقَّ وَهُوَ يَهْدِي السَّبِيلَ"
(334 سورة الاحزاب ( آية

Ancient physicians not only have had a great role in the development of modern medicine but for example Al-Razi (841-926 A.D.) (figure-1) and Ibn Sina (Avicenna,
980-1036 A.D.) (figure-2) set principles for practicing physicians. They described Medicine as the art which is concerned with the preservation of good health, fighting disease, and regaining the health of sick people. More over Al-Razi in an effort to maintain ethics in medicine introduced code of practice. For example he attacked quackery and trick in order to obtain money or advantage from the patients. He warned doctors from roaming around to sell medicine whose efficacy is questionable and whose ingredients are usually kept secret. At the same time, he warned that even a highly educated doctor may not have answers to all medical problems and could not cure all sicknesses or heal every disease. Therefore he stressed on continuous medical education to keep up with advanced knowledge, and made distinctions between curable and incurable diseases (3).
"Fardous AL Hikma" is considered a treasure book that illustrates the doctors' code of conduct. It is written by Ali Ibn Sahl Ibn Rabban Altabari (Abu Alhassan) who is a Muslim scholar from Tabiristan (838-870 A.D.). Altabari studied in Iraq, Syria, and Egypt, but spent most of his life in Baghdad teaching and writing. He stresses in his book on good personal characters of the physician and physicians obligation towards his patients, community and colleagues. Altabari was concerned much with issues related to patient's confidentiality and instructs physicians on that issue as quoted in his book "physician should not divulge the secrets of his patients" (4).
As medical field continues to expand and advance, more ethical questions develop. It is important to note that almost many problems faced by physicians and patients today are not very much different from the problems faced in earlier periods of history.
Prophet Mohammed (pbuh) said "A person, who practices art of healing when he is not acquainted with medicine, will be responsible for his actions."
Therefore the  ultimate goal of Islamic medical ethics when practiced by physicians is sanctity of human life and safeguarding of its values.  Shahid Athar who is an American scholar writing extensively in Islamic Medicine stated that "Life, though short as it may look on this planet, is still a precious gift from God. For our soul and spirit to live in our body for a certain period can be compared to living in a beautiful, leased apartment or house. The only thing which the landlord would like the tenant to do is to live with certain rules and regulations and do things to improve upon the apartment or house rather than destroy it (5). Hence we have a responsibility to preserve our life
 Therefore Medical ethics draw their essence from Islamic teachings, which call for honesty, sound performance, and God consciousness in every act.
 Sharif Kaf Al-Ghazal, a UK plastic surgeon believes that the doctor–patient relationship is stronger in Islam than it is in modern medicine because Muslim physicians have responsibilities which they will be asked about them by God in the Day of Judgment (4).
Therefore ethical guidelines in Islam are obtained from a combination of principles, duties and rights. And Muslim physicians derives their conclusion from rules of Islamic laws (Shari‘ah) and Islamic medical ethics (6). So when ethical decisions are to be made it will only be done through depending on broad ethical values derived from the holly Quran and Prophet Mohammed's instructions.  Although it  is well known that Islamic ethics emphasizes on disease prevention, physicians education on how to deal with patients it stresses on the fact that patient must be treated with respect and compassion and that the physical, mental and spiritual dimensions of the illness experience be taken into account (7). Also Islam looks at human life with respect and instruct us to take all measures to protect it (8). The
saving of a life is considered one of the highest merits and imperatives in Islam (9). In the Quran it is said: "And if anyone saved a life, it would be as if saved the life to all mankind". {Al Maidah (32)}.

بسم الله الرحمن الرحيم
"مِنْ أَجْلِ ذَلِكَ كَتَبْنَا عَلَى بَنِي إِسْرَائِيلَ أَنَّهُ مَن قَتَلَ نَفْسًا بِغَيْرِ نَفْسٍ أَوْ فَسَادٍ فِي الأَرْضِ فَكَأَنَّمَا قَتَلَ النَّاسَ جَمِيعًا وَمَنْ أَحْيَاهَا فَكَأَنَّمَا أَحْيَا النَّاسَ جَمِيعًا وَلَقَدْ جَاءتْهُمْ رُسُلُنَا بِالبَيِّنَاتِ ثُمَّ إِنَّ كَثِيرًا مِّنْهُم بَعْدَ ذَلِكَ فِي الأَرْضِ لَمُسْرِفُونَ "

Ishaq Ibn Ali Al-Ruhawi is another famous physician scholar who wrote an important book that deals with medical ethics called Adab Al-Tabib. Al-Ruhawi who lived around 1200 A.D.  was born in Ruha, a city in northwestern Iraq, today known as Urfa (10).
Adab Al-Tabib describes the responsibilities of physicians in relation to medical practice and the ethical issues related to it. Al- Ruhawi, thinks that patient has equal responsibility in the relationship between the physician and the patient. Similarly, the society has to realize the nature of demands placed on a physician and afford him the support that he may need at times (10).
The following are few guidelines about physicians' conduct as stated in Adab Al-Tabib. It recommends that physician should be;    
1.A good listener
2.Respecting the patient's views
3.Treating the patient equally without any discrimination
4.Avoid arrogance
5.Examining the patient gently
6.Requesting only the needed investigation
7.Restricting the prescription of medication
8.Abstaining from any practices that may harm the patient
9.Striving to be open and truthful in advising the patient
10.Resorting to his humane judgment in deciding the merit of either telling a terminally ill patient
11.Exerting utmost care in writing medical reports
12.Abstaining from committing infringements of religious rules, such as staying alone with a woman behind closed doors
13.Referring the patient to another physician who can provide specialized treatment
14.Furnishing the necessary information needed for the treatment
15.Helping the patient in obtaining the necessary reports and information
16.Allowing the patient to consult an alternative physician
17.Prescribing continuous, quality medical care to patients
18.Ensuring that the patient receives the necessary medical care even during his absence

19.Reporting any practice, which conflicts with law or ethics.
Al-Ruhawi also recommends that the physician must guard all his five senses and not use them except for a beneficial purpose and to repel harm. For example, to use speech sensibly so that no offensive words or language are produced. Also avoid his vision from sighting illegal seen and his ears from allowing it to hear bad words spoken about others. His conscious and feeling should be full of mercy; which is not possible except by the fear of God.
With this background of information we will now highlight in brief about the problem of AIDS and discuss the religious codes of conduct towards patients affected with this problem.
 Acquired Immunodeficiency Syndrome (AIDS) has become a major medical and social problem in recent years. It is estimated that world wide there are 40 million persons that are infected with HIV, of whom 200000 of them are in USA alone (11). And 70% of such cases occur in sub-Saharan Africa where less than one US Dollar per year is spent for the treatment of AIDS in African countries such as Kenya. It is reported that more than 95% of new cases happen in low and middle
income countries. The high prevalence of the disease in Africa is considered by some health organizations as a threat to the world stability.
 Out of those affected, 2.5 million are children under the age of 15 years. World Health Organization reported that there are 5 million new cases appearing per year, around 14,000 are infected daily or 11 new patients per minute. Of these new cases that occur every day 2000 occur in children under 15 years of age and 12,000 in ages between15-49.
 The fatality rate due to AIDS is high. It has been reported that three million deaths occurred due to AIDS in the year 2003. In addition to its fatality, 14 million of children become orphaned each year due to the death of their primary care takers from AIDS.
 Caring and providing medical management for AIDS take a very big part of the health care budget. In the USA the medical care, research, education and screening services provided for AIDS has risen sharply from US$ 7 Billion in 1986 to US$ 55.6 Billion in 1991 (11). The introduction of newer technology in medicine in areas of care of AIDS patients has posed physicians and patients some new questions of ethics. Pinching et al, 2000 highlighted the effect of AIDS on medical ethics by stating “The impact of AIDS on medical ethics perhaps can be compared to the impact of war on medicine itself” (12).
An Islamic Approach to the Prevention of the Spread of AIDS
 Since human life is much appreciated and respected in Islam, Islamic religion when dealing with mankind, it puts into consideration the following points;
Preservation of Human life, preservation of the constituents of Human life, preservation of Human Dignity, life-related legislative controls, and preservation of human-related factors of equality and preference.
 Therefore prevention of AIDS in Islam is directed at different level, firstly, to prevent the disease by taking proper and ethical precautions through having a sexual lifestyle that is advised by God (13). Also by avoidance of indulging in promiscuous sexual relationships.
 Therefore as a preventative measure Of AIDS three recommendations are indicated:
 This practice with no doubt provides protection against sexually acquired AIDS. Almost most of the literatures about the spread of AIDS indicate that unethical and illegal sexual practices among homosexuals and heterosexuals play a major role in the spread of AIDS virus infection.
Prophet Mohammad in promoting marriage urges Muslims to make marriage affordable and easy for all members of society. He said: "When a man comes to you seeking marriage, and you are happy with his religious and moral integrity and honesty, give him your daughter; otherwise immorality and corruption would spread among you all."
2. Prevention of promiscuity:
Islam instructs both men and women to control their sexual urge and prevent themselves from going into promiscuity.
3- Circumcision:
Circumcision is an ancient practice which was believed by may societies and religions across the history. Various tools were used for its implantation. Figure-3 shows the circumcision kit used in the eighteenth century (14).
Figure 3. Seixas Family circumcision set and trunk, ca. eighteenth century.Wooden box covered in cow hide with silver implements: silver trays, clip, pointer, silver flask, spice vessel.
Male circumcision is another Islamic recommendation which is inhibitive to HIV infection. Studies from around the world have shown that uncircumcised men are   
at a greater risk of contracting AIDS and other STDs, than circumcised men. In AIDS the virus will find its way into the victim's bloodstream through any tiny break or abrasion in the penis (15-17). The inner lining of the erect penis in an uncircumcised male can represent as much as 50% of the surface of the shaft. "This will indeed increase the chances of a break in the exposed soft skin, and augment the risk of infection" (quoted by Daniel, 1986 cited in the AIDS Crisis (15)). Researches have indicated that the tissue of the mucosal surface of the internal foreskin of the penis absorbs HIV up to nine times more efficiently than other genital tissue. In fact this mucosal surface is very susceptible to tears and abrasions, and, consequently, infection by HIV and other STDs (18-19).
Numerous studies have noted that the risk of HIV infection and its prevalence in circumcised men is decreased. Randomized controlled trial in South Africa has found that such reduction can reach up to 60%-75% in circumcised male (20).
Also circumcision has been shown to reduce male-to-female HIV transmission by 60% to 75%. A study from South Africa reported that male circumcision might reduce the risk of men contracting HIV through sexual intercourse with women by about 60% (20).
HIV rates among those who are not circumcised are two to eight times higher than in those groups who do practice circumcision (21).
Promoting male circumcision and loyalty to one partner seems to be more effective at curbing the spread of HIV than promoting abstinence and condom use.
Ronald Gray and his colleagues of Johns Hopkins University, after examining records of more than 300 couples in Uganda, in which the female partner was HIV negative and the male was HIV positive, provided solid documentation of the protective effects of male circumcision in reducing the risk of infection among women. They found that male circumcision reduced by 30 percent the likelihood that the female partner would become infected with the AIDS virus (22).
Male circumcision is also reported to reduce the risk of penile cancer and other sexually transmitted diseases such as chancroid, herpes, and syphilis (18-19).
Although many datas indicate that circumcision is correlated with reduced risks of HIV transfer, we should be careful to avoid the miss believe of some that they will
be protected against HIV through circumcision and see circumcision as a safe alternative to other forms of protection, such as condoms (23).
In conclusion, religion and ancient physicians' manuscripts provide comprehensive ethical and protective guidelines for people against various illnesses especially sexually transmitted diseases that include AIDS. Sickness drives patient closer to God and during such illnesses, many patients go through spiritual growth to strengthen their self esteem and wellbeing. Therefore if we understand the religion of our patients, we can help them to take proper preventative measures against illnesses.

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14-  Circumcision.
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17- Dam Johannes van, Anastasi Marie-Christine.  Male circumcision and HIV prevention. Direction for future Research. Population Council, USA June.2000. Horizons Project.
18-  Halperin DT, Bailey RC. Male circumcision and HIV infection : 10 years and counting. Lancet 1999; 354:1813-1815
19- Patterson BK, Landay A, Siegel JN, et al. Susceptibility to human immunodeficiency virus-1 infection of human foreskin and cervical tissue grown in explant culture. Am J Pathol 2002; 161:867-873.
20- Auvert B. Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. Randomized, controlled intervention trial of maile circumcision for reducion of HIV infection ris: the ANRS 1265 Trial.  PloS Med. November 2005.
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22-  Conference on Retroviruses and Opportunistic Infections (CROI), FEB. 5-9, 2006, Denver, Colorado. releases/2006/02_0806. html.
23-  Circumcision 'reduces HIV risk'. BBC News (October 25, 2005). Retrieved on 2006-07-20.

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