Medical Etiquette And Confidentiality

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ISLAMIC MEDICAL EDUCATION
RESOURCES02
9907-MEDICAL ETIQUETTE and
CONFIDENTIALITY


Lecture for 3
rd
year medical students at the Kulliyah of Medicine, International Islamic
University, Kuantan, Malaysia onSaturday 10
th
July 1999 by Prof Omar Hasan Kasule, Sr.

OUTLINE
BED-SIDE ETIQUETTE
Obligation to visit the patient
Etiquette of visiting a patient
Appearance of the caregiver
Mannerisms of the caregiver
Emotional involvement
Covering of awrat
Medical procedures
Supporting care
Managing fever
Managing pain
Control of infections


DEALING WITH THE FAMILY

2. Support
Reassurance
Interference
Conflict


INFORMED CONSENT
Choice of physician
Choice of treatment, food, and drink

CONFIDENTIALITY

The secret
Concept of keeping secrets
Written Records
Basis for medical confidentiality
Release of the information by the caregiver


1.0 BED-SIDE ETIQUETTE
Obligation 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

3. 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

4. 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.

5. 2.0 DEALING WITH THE FAMILY
Support: 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 CONSENT
Choice 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

6. 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 CONFIDENTIALITY
The 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

7. 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.

8. 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