An overview of Islamic legal and bioethical considerations regarding termination of pregnancy

 A submission to the NICE call for evidence regarding termination of pregnancy guidelines currently under review

Guideline Scope

Draft Guideline

The UK is currently home to at least 3.4 million Muslims [1] who, to varying degrees, will refer to Islamic jurisprudential and ethical teachings to inform/guide their healthcare decisions, including that of termination of pregnancy (TOP). It is therefore pertinent for TOP providers to be aware of this system of ethics used by some of their patients, in order to effectively engage in patient-centred shared decision making with them.

TOP is not permitted in Islamic law, except under legal exception [2-5]. The applicability of such exceptions depends on the gestational age of the foetus, as the gestational age at which ensoulment is believed to occur dictates the foetus’ subsequent full legal status. There is a difference of opinion among contemporary Muslims jurists, of differing legal schools of thought, about when ensoulment occurs with two major opinions being at 120 days[1] gestation (or 19 weeks post-LMP [6]) and 40 days[2] gestation (or ~8 weeks post-LMP)[3].

Before ensoulment, TOP is permitted to avoid intolerable difficulty or severe loss/hardship associated with the pregnancy or rearing the child thereafter. Common examples would include TOP to prevent threat to the life of the mother, severe injury (or substantial risk thereof) to the physical/mental health of the mother, severe hardship associated with rearing a child with a congenital abnormality (judged on a case-by-case basis) and severe hardship associated with the social circumstances of the woman’s pregnancy (although financial difficulties are generally not acceptable in isolation). After ensoulment, some Islamic jurists may permit TOP under certain situations where the mother’s life is at risk. In any case, where a patient indicates Islamic law to be influential to their decision on TOP, consultation of that patient with a qualified and experienced Islamic scholar for the purposes of providing individualised, case-by-case guidance may be appropriate and helpful.

Furthemore, Islamic law does not permit Muslim healthcare professionals, even whilst living and working in the UK, to approve or conduct TOP procedures in patients (Muslim or otherwise) requesting TOP not fulfilling Islamic legal criteria.

Apart from Islamic jurisprudential teachings, Muslim patients’ TOP decision may also be influenced by ethical/theological beliefs [7, 8], including about the wrongness of abortion from day one, fate and acceptance of God’s will, how it is not their decision to interfere in God’s creation, the blessings of caring for a handicapped child, the reward associated with undergoing hardship in pregnancy and thereafter, the belief in hardship being a test from God, fear of God’s punishment for terminating a pregnancy due to putting one’s own interests before that of an unborn child, and, the importance of self-sacrifice to bring a child, albeit through difficulty or illness, into the world . These considerations may be influential for a Muslim patient in deciding to continue her pregnancy, despite Islamic jurisprudential edicts permitting TOP in her case.

Furthermore, cultural (non-religious) factors may also affect Muslim patients’ decisions for TOP. This may include a perceived stigma from their local community or pressure from their partner, spouse or family members (both in favour of or against TOP). It may also include secular beliefs about the immorality of bringing children into the world with severe foetal anomaly and subjecting them to suffering.

Apart from the above, Muslim patients’ decision to terminate a pregnancy will also, naturally, be influenced by factors that patients of other (or no) faith are also influenced by, including ease of access to TOP services, information about the procedure, concerns regarding safety, confidentiality and the care they will receive, their emotional/psychological health after the procedure, and the subsequent support available to guide their reproductive decision making, including the use of contraception.

Importantly, just because a patient appears Muslim, or admits to belonging to the Islamic faith, should not prompt healthcare professionals to assume that such patients will follow the letter of their faith. It is therefore paramount that healthcare professionals are sufficiently trained to sensitively gauge and appreciate the variety and interplay of factors that a Muslim patient will consider, including (but not limited to) the teachings of their faith, in order to discuss the various options available to them (including the continuation of pregnancy).

In the context of these various factors that influence Muslim patients (and Muslim doctors’) decisions to participate in TOP, the British Islamic Medical Association offers the following responses to the recent draft NICE guideline on Termination of Pregnancy, published 12 April 2019.

 

Information should be tailored specifically to account for the beliefs, values and concerns of Muslim patients, in a sensitive manner, to aid them (and those whom the patient freely chooses to accompany them, including their spouse/family members) to engage in a process of informed decision making, including the option of continuing pregnancy and its implications

In cases where a Muslim woman does choose TOP, prompt referral is essential due to the time limit of ensoulment under which the Islamic legal exception for TOP is likely to apply, should the patient see this as influential to her decision.

Muslim doctors and trainees (and other healthcare professionals, including students, nurses and midwives) may conscientiously object to refer, approve or participate in TOP procedures/services for both Muslim and non-Muslim patients, regardless of circumstances, gestational age or the fulfilment of Islamic legal criteria. Services should therefore be designed in a way which do not pressurise Muslim healthcare professionals against their right to conscientiously object, but also do not delay TOP service provision to women who will nonetheless seek an appointment/referral through another healthcare professional or, self-refer.

Muslim clinicians should however provide care for women suffering from complications due to TOP, whatever the reason or grounds for that TOP.

Minimal delay in the provision of TOP for Muslim patients is essential, due to the legal time limit of ensoulment. Healthcare professionals should therefore enquire about whether a Muslim patient has any specific time limits in mind which would affect her TOP decision and ensure swift access to TOP services accordingly, including prioritisation.

It is a reality that the majority of TOPs in the England are carried out under the Royal College of Obstetricians and Gynaecologists (RCOG) Ground C during the first trimester, due to unwanted pregnancy, though not necessarily any real or foreseeable risk to the mental health of the pregnant woman [9]. Furthermore, the British Medical Association (BMA) also issued that “Given the risks associated with pregnancy and childbirth, and the risks of a woman having to continue a pregnancy against her wishes (compared with the minor risks associated with early medical abortion), there will always be medical grounds to justify termination in the first trimester”. On this, Islamic law requires the presence of intolerable difficult or severe hardship/loss regarding the mental/physical health of the pregnant woman to justify a TOP. Therefore, the technique of utilising relative risk does not hold legal weight in Islamic abortion law. For this reason, it is not unlikely that a proportion of Muslim clinicians would conscientiously object to partaking in TOP procedures in (the majority of) women requesting TOP on the grounds of unwanted pregnancy, even if it be integral to their speciality training curriculum. In this regard, NHS Trusts, higher educational institutions, Royal Colleges, and postgraduate deaneries involved in speciality training should provide clear information and guidance on the process of conscientious objection. Furthermore, an environment of tolerance for objecting trainees should prevail and under no circumstances should trainees perceive disadvantage in obtaining speciality training posts due to a foreseeable (or actual) decision to object to partake in TOP.

Muslim patients may freely and wilfully request the inclusion of their spouse or family members in their TOP (or continuation of pregnancy) decision. Healthcare professionals should respect and facilitate this, and not stigmatise women for their decision to include others in their reproductive choice. Healthcare professionals must also not apply pressure on Muslim women to partake in their decision alone, if that is not what they want. Similarly, healthcare professionals should be conscious of third parties seeking to influence the decision of a Muslim patient against her will and should provide adequate safeguarding in such a situation.

Healthcare professional should also not stigmatise or judge Muslim women for wanting to continue with their pregnancy based on underlying theological beliefs, even if they do not sit with the personal viewpoints of the healthcare professional involved in that shared-decision.

Information provision should not only be limited to the experiences of women who have had a TOP but should also include information about women considering TOP (for various reasons), as well as information on the experiences of women who chose to continue with their pregnancy despite initially considering/deciding on a TOP. This is in lieu of the fact that women should be aware of their freedom to change their decision at any time during the process. It is essential that information provision from all healthcare professionals involved in the TOP care pathway is holistic and includes information on the continuation of pregnancy, as opposed to being limited to the experiences and options of the type/time of TOP procedure, and the implications thereafter.

It is essential that healthcare professional involved in TOP-decisions with women first gauge the extent to which a woman wishes to be informed about the intricacies of the process.  This is to avoid undue distress to the patient, in what already may be a difficult and sensitive decision.

Muslim women may wish for foetal remains to be buried according to Islamic funeral rites. Healthcare professionals should therefore adequately explain the process of discharging foetal remains and do so in a manner sensitive of the status that a Muslim patient (and her family) may award to the deceased foetus.

It has been shown that there is a higher incidence of foetal anomalies in pregnancies borne to British Muslim women, thought to result from their higher incidence of cousin marriages amongst certain ethnic and cultural groups within the Muslim community [11, 12]. For this reason, consideration of TOP due to foetal anomaly may be more common among Muslim women than the general female population. In this regard, we recommend that:

·         Pre-natal screening for foetal anomalies should not be withheld from Muslim women, just because they are unsure about whether they would have a TOP. In this regard, all patients have the right to information about their pregnancy, so that they can make as well-informed choices as possible.

·         The provision of information about the nature of the anomaly, whether it directly causes risk to the health of the Muslim patient during her pregnancy, or the expected responsibility (i.e. hardship) associated with supporting a disabled child is essential. This is because such information forms the basis of the Islamic legal exception permitting TOP in the case of foetal anomaly, thus is likely to be influential to a Muslim patient’s decision on TOP due to foetal anomaly.

·         Muslim patients should be made aware of the support available to them should they wish to continue with a pregnancy involving a foetal anomaly. Healthcare professionals should also engage in discussion about the patient’s social support structures in this regard.

·         In cases of familial diseases, we recommend genetic/diagnostic tests be offered to at-risk, pregnant Muslim women as early as possible, allowing them to consider TOP in good time before the time of ensoulment.

In the case of a surgical TOP, Muslim women, due to various religious or cultural factors, may request a female doctor to carry out their procedure. Some Muslim patients may see this as more important than others. TOP services should therefore attempt, where possible, to facilitate this request, including referral to other TOP providers.

In the context of wanting to preserve (all parts of) foetal remains from a TOP for an Islamic burial, Muslim women may have specific sensitivities about how to handle said foetal remains during an at-home expulsion. In this regard, healthcare professionals should fully explain to the patient what to expect during an at-home expulsion, as well as the option of medical termination under hospital admission purely for the purposes of more sensitive handling of foetal remains and respectful discharge of said remains to the patient/family thereafter.

TOP providers should provide the option of in-house counselling or psychological interventions, as opposed to referring to community mental health services, in the interest of maintaining a woman’s confidentiality and providing prompt support.

Apart from counselling, Muslim women may request access to Muslim chaplaincy services to provide support before, during and after TOP. We recommend that TOP service providers explore links with approved local hospital and community Muslim chaplains and establish a referral pathway for women who request it.

It is also essential that both male and female Muslim chaplains are there to listen and offer spiritual and pastoral care without judgment and in a confidential manner, whatever the reason for the TOP, or the week of gestation that the TOP was carried out at.

We, the British Islamic Medical Association, recommend the commissioning of research into the development of culturally and religiously sensitive TOP care pathways for Muslim women. This could include, but is not limited to:

·         What factors affect a British Muslim woman’s decision to terminate her pregnancy?

·         What barriers, if any, exist to British Muslim women accessing TOP services?

·         Do British Muslim women’s experience of TOP services evidence that they are provided in a way which reflects and accounts for their concerns, beliefs and values?

·         To what extent would the sensitivity of the 18-21 week foetal anomaly scan be affected, were it to be offered earlier at 14-16 weeks to Muslim women, allowing them time to consider TOP (before 19 weeks post-LMP) for other foetal anomalies not screened for during the early pregnancy (10-14 week) scan?

[1] Hanafi, Shafi’I and Ja’fari schools.

[2] Maliki and Hanbali schools

[3] Although some other jurists have also argued 80 days or 5 months.

References

1.     Ons.gov.uk. (2019). Muslim population in the UK 2018 – Office for National Statistics. [online] Available at: https://www.ons.gov.uk/aboutus/transparencyandgovernance/freedomofinformationfoi/muslimpopulationintheuk/ [Accessed 21st May 2019].

2.     Sekaleshfar F. Abortion Perspectives of Shiah Islam. Studies in Ethics, Law, and Technology. 2008. 2(3): Article 4.

3.     Ekmekci P. Abortion in Islamic Ethics, and How it is Perceived in Turkey: A Secular, Muslim Country. J Relig Health. 2017. 56(3): 884–895.

4.     Al-Matary A. et al Controversies and considerations regarding the termination of pregnancy for Foetal Anomalies in Islam. BMC Med Ethics. 2014. 15:10.

5.     Asmen O. Abortion in Islamic Countries – Legal and Religious Aspects. Medicine and Law. 2004. 23:73-89

6.     Lmo.ir (2016). Mu’āyināt Siqt-i-Darmāni. Available at: http://lmo.ir/web_directory/54768-مشاهده-یک-خدمت.html?id=54&cnt_id=54&sisOp=view [Accessed 21st May 2019]

7.     Ahmed S. et al. Attitudes towards prenatal diagnosis and termination of pregnancy for thalassaemia in pregnant Pakistani women in the North of England. Prenatal Diagnosis. 2006. 26 (3): 248-257

8.        Ahmed S. et al. The influence of faith and religion and the role of religious and community leaders in prenatal decisions for sickle cell disorders and thalassaemia major. Prenatal Diagnosis. 2006. 26 (9): 801-809

9. www.abortionreview.org (2019). Statistics briefing (3): Grounds for abortion. Available at: http://web.archive.org/web/20180808011334/http:/www.abortionreview.org/index.php/site/article/963/ [Accessed on 21st May 2019].

10.     BMA, The Law and Ethics of Abortion, November 2014

11.   Sheridan E. et al. Risk factors for congenital anomaly in a multiethnic birth cohort: an analysis of the Born in Bradford study. Lancet. 2013. 382(9901):1350-9

12.   Corry P. C. Consanguinity and Prevalence Patterns of Inherited Disease in the UK Pakistani Community. Hum Hered. 2014. 77:207-216

Eid Mubarak

Assalamo Alaikom

Eid-ul-Fitr is here, and may Allah bless you and your families with a wonderful Eid.

Although there may be a tinge of sadness as we approach the end of Ramadan, this sadness should not prevail. We should be grateful that we have been able to participate in this blessed month, we should count our blessing that we have managed to fast, offer Sadaqah and pray taraweeh and qiyam. It should not be a farewell however as we should keep up all the good works we do in Ramadan during the rest of the year.

Ramadan is not merely a month, it is a way of life and the beginning of a new journey. Let us now say farewell and let us allow Ramadan to live within us so we can keep living it long after it has ended.

Fasting is not exclusive to Ramadan. The Qur’an should not be sent back to the bookshelves after Ramadan. The mosque is not only open during Ramadan.

I am hoping that our good deeds during this month are all accepted inshaAllah and that we can build on them during the upcoming year. Ramadan should offer us the opportunity to recharge our spiritual batteries and face the challenges ahead inshaAllah.

Eid Mubarak

Sharif Kaf Al-Ghazal

Ramadan Mubarak

“O you who have believed, decreed upon you is fasting as it was decreed upon those before you that you may become righteous.” (2:183)

Ramadan is upon us and what a delightful guest it is. A holy month in which Allah offers us the biggest opportunity for redemption. It is imperative we make the most of this chance.

Fasting is obviously a crucial part of the holy month. But fasting goes beyond simply hunger and thirst. Amongst the benefits of fasting and the hunger that it causes is the motivation to do more for others who are less fortunate than yourself. Fasting itself is a detox for us – a chance for our bodies to flush away the toxins and rid ourselves of habits of excessive consumption. As healthcare professionals we understand the need to take great care of what we place into our body and Ramadan offers the opportunity to reflect on that. 

Beyond fasting, additional forms of worship are strongly encouraged. Work on your relationship with Allah (SWT). Pray the extra sunnah prayers. Take time to reflect and read the Quran and evaluate its connection to your life. 

Furthermore, worship to Allah isn’t necessarily a solitary affair. Giving to charity (Sadaqa), serving others for the sake of Allah (SWT), engaging in voluntary work are all opportunities to gain good deeds.   

Ramadan is a good opportunity to reflect and evaluate yourself and your relationship with Allah. Strive to organise your life to minimise waste, over-consumption and the ills that come with this. 

Some people these days are too inflexible and intolerant towards others. We, as health care professionals and students should go out of our way to display the best of character to our patients and colleagues when interacting with them, following in the example of our beloved prophet (PBUH) when interacting with the people. In Ramadan it is even more crucial to do this and it is also worth reflecting more on how we can improve our levels of compassion towards patients and colleagues.

Moreover, we need to show that fasting is not affecting our work efficiency and that we are just as productive as we are when not fasting. Fasting helps concentrate our mind and soul so should help us physically too. We cannot allow our hunger and thirst to become distractions. And any hunger cannot turn into frustration or anger either.

Fasting teaches endurance, empathy, and sacrifice — three qualities all great healthcare professionals recognise and share. Let us focus on these qualities and look to embed them in our daily lives.

May Allah accept all our good deeds inshaAllah.

Sharif Kaf Al-Ghazal, President, BIMA

Medicines, Healthcare and the Holy Month of Ramadan

By Amira Shaikh, Deputy Senior Clinical Pharmacist; NHS 111 pharmacist advisor; Royal Pharmaceutical Society Ambassador

Providing tools and resources related to understanding different cultures is essential for pharmacists’ competency to provide optimal care. While serving Muslim patients who observe fasting during the holy month of Ramadan, patient autonomy should be taken into account. Where the patient chooses to continue to fast despite contrary advice they must be given the support and tools to retain their engagement in case of an emergency.

In order to advise patients and counsel clinicians on healthcare management during the month, it is very important to understand the basic physiological changes the body goes through. Understanding these changes at their most basic level will aid in better understanding on the pharmacological impact medicines may or may not have.

Early fasting is characterised by a high breakdown of blood glucose. As fasting continues, progressive ketosis develops because of the mobilisation and oxidation of fatty acids. Several hormonal changes occur during fasting, including a fall in insulin and changes in thyroid levels. Other changes to the body during fasting include a slight decrease in core body temperature.

Categorising a patient’s underlying health

1 – Stable Long Term Condition (LTC)

The advice given to patients needs to be specific to their chronic LTC and how a fasting regime may or may not have an effect. The following are common LTC’s encountered in primary care (which by no means is an exhaustive list). Clinical judgement should always be exercised to ensure that the information given relates to the patient and their condition.

Diabetes – The most obvious medical condition clinicians become concerned about during Ramadan is diabetes and the dangerous issue of erratic blood sugar control and risk of constant high blood glucose levels. The advice for diabetic patients will vary depending on whether they are taking insulin or taking hypoglycaemic drugs such as sulphonylureas. If they are taking insulin, the following should be considered:

. Regular check of their blood sugar levels to preempt action before  entering into a full hypoglyceamic state

.To use less insulin before starting fast

. Possibly change the type of insulin being used as pre-mixed insulin are not recommended

. To break their fast with healthy option meals that are slow releasing, high energy meals and drink plenty of fluids

Diabetes UK have plenty of material to share with patients that can be useful to help consolidate the message.

Heart Failure (HF)- Patients have a limited daily intake of fluid to less than two litres and sodium to less than 2500 mg. Medications include angiotensin converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs), beta blockers, diuretics and digoxin. Research has started to emerge supporting HF patients fasting as long as adhere to fluid and salt restrictions and ensure compliance with their medication schedule. For those who are two daily dose, would be advised to take each dose during their non fasting hours with as big a gap as possible. Where possible, to change the drug to modified release preparations. However, due to the narrow gap we will experience this year, it must be discussed with relevant consultant physicians.

Chronic Kidney Disease – For patients with kidney disease, discussions should always be sought with their consultants. There have been several studies that have confirmed safety in fasting for CKD patients, however, limitation with these studies is that they have been carried out in Ramadan during the cold seasons. As Ramadan is in the summer season with longer fasting hours, management will be deemed more complex.

Asthma/COPD There is limited evidence available for a direct link between fasting and asthma exacerbation. There is however, physiological evidence that dehydration, can lead to drying up of airways which may induce acute exacerbations. The ruling of asthma inhaler use is mixed amongst scholars, which makes it difficult to direct patients. However, patients need to be made aware that they need to use their relievers during acute periods in order to avoid deterioration or hospital admissions.

2 – Unstable Long Term Condition

General advice may be provided to patients or clinicians. However, due to complexity of certain drug regimens for unstable patients generally, the safer advice would be to avoid fasting if it is likely to make their condition worse in the short or long term. This may also apply to patients who are on specific medicines, such as insulin for diabetes or where they are on multiple dosing (due to small gap between fasting and non-fasting hours) it would not manage their condition or increase risk.

3 – Acute illnesses

The Shariah (Islamic ruling) does allow exemption from fasting for patients with severe or acute medical conditions who are either at risk of getting worse or if fasting would directly impede their health in any way. This is particularly important for patients who require immediate antibiotics for acute infections.

Creams, ointments, and eye drops are permitted by many people, although there are differences of opinion and understanding regarding inhalers and nose sprays. Oral tablets, capsules, or liquids are almost always considered to be breaking the fast. Patients should be advised to consult with their local imams to confirm their theological standing especially for patients suffering from asthma.

References:

  1. Nicola Luigi Bragazzi. Ramadan fasting and chronic kidney disease: A systematic review.  [PMCID]
  2. Kelly Grindrod, BScPharm, ACPR, PharmD, MSc and Wasem Alsabbagh, BScPharm, PhD. Managing medications during Ramadan fasting. [PMCID]
  3. Fasting and asthma [online] Available at: https://www.asthma.org.uk/advice/living-with-asthma/fasting/ [Accessed April 2019]
  4. Berbari AE, Daouk NA, Mallat SG, Jurjus AR. Ramadan fasting in health and disease. In: Berbari AE, Mancia G, editors. Special Issues in Hypertension. Milan, Italy: Springer-Verlag; 2012.

Cancer screening awareness – importance and impact

By Dr Lubna Salim, GP


Photo by Miguel Á. Padriñán from Pexels

وَأَنْ لَيْسَ لِلْإِنْسَانِ إِلَّا مَا سَعَىٰ

And that man shall have nothing but what he strives for (Surah An-Najm 53:39). It is interesting to note that Allah says that man shall have in accordance to his efforts rather than just his actions. Striving is what is essential. All thanks to the Almighty and kudos to BIMA for providing us with the platform for holding cancer screening awareness talks. I was part of two of these talks in Peterborough, targeting female audiences.

Participation on the day

If someone had asked me on the day of the talks, how I rated their success, I would have admitted to a smidgen of disappointment. There was a lukewarm response to the first talk with a turnout of just 15 sisters. The second event was relatively better attended by double the number of audiences, and we had a more interactive session. The attendance of men, however, was a lot more and I had this disquieting feeling that we had not managed to reach out to all the sisters for whom this message is of paramount importance. Within a week after the talks, I had revised my opinion.

Positive impact and survival stories

In the successive week, I saw three ladies who came with concerns regarding some breast symptoms based on the information they had acquired during the talks. A 56-year-old sister wanted to refer herself for the screening bowel scope, the invitation to which she had failed to respond to last year. Another sister contacted me regarding her smear result. I would always be grateful to the sister who asked questions regarding the safety of the HPV vaccine. After listening to our discussion, another sister asked me about primary immunisations and their safety. She expressed her intention to get her three children immunised for whom she had refused vaccination in the past. In all, I had come across six sisters personally who felt empowered to make better decisions for themselves and their children as a result of our efforts.

During the talk, there were tears in the eyes of a lady with a close family member who has cancer. There was a sister, who as a breast cancer survivor, had made a special effort to attend this event and another sister, who asked several questions and wanted to know if we could hold talks for people who undergo cancer treatment. Not surprisingly, she herself was a cancer survivor. Although they were not the target audience, our message resonated even more strongly with these brave sisters and helped others to understand the reality of this dreaded condition and that it could be overcome.

I had started my talk by asking my audience what they thought was the cause of different Cervical Cancer prevalence rates in the UK and some other countries. It is the 14th most prevalent cancer in women in the UK  as compared to most common in Kenya, the second most common in Romania and the third most frequent in Pakistan.

There was a prolonged silence before someone asked in a hesitant voice: “Is it due to screening?”.

By the end of our talk, the answer was clear to all, that countries with low screening coverage have higher cancer incidence and mortality. Many of the attendees came up to personally confirm their commitment to attend all screening programmes. May Allah keep them firm in their intention.

From ripples to waves

The process of improvement in health care is also a highly social one, driven not just by organisational, but also individual initiative. We had witnessed the impact of a single pebble in the form of a few ripples. Imagine, our hundreds of other brothers and sisters who attended these events in mosques all over the country, and the waves they would create. Therefore, no matter how small the steps,  let us continue to strive Inshallah. May Allah bless our efforts to spread our message and help our communities to attain better health.

Jazakallah!

Talks were held at the Faizan-e-Madina and the Ghousia Mosques with colleagues, Dr Nausheen Anwar and Dr Shabina Asad Qayum. Dr Azhar Chaudhry presented to the male participants.

3

Hijab and Bare Below the Elbows – a reflection…

Stock image of Muslim HCP in half-sleeved uniform

Every healthcare student and professional starts their journey starry-eyed and keen to make a good impression on colleagues. Potential conflict with supervisors or disciplinary procedures would definitely be on the list of things to dread! So what do we do when a hospital policy is at odds with our religious identity and faith that we hold so dear?

This is a dilemma almost all hijabi healthcare professionals working in a hospital environment face due to the Bare Below the Elbows (BBE) policy and lack of consistent policies on head coverings in theatre from hospital to hospital.

New research…

Research published in the BMJ Open recently found that 51.5% of respondents had experienced problems wearing a headscarf in NHS theatres. Some women felt embarrassed (23.4%), anxious (37.1%) or bullied (36.5%). Of the respondents, 56.3% felt their requirement to cover their arms was not respected by their Trust.

The BBE policy arguably has little evidence to prove it has reduced the spread of infection. Yet it has become part of hospital culture and enforced almost in a military manner by infection control nurses, especially when Care and Quality Commission (CQC) inspections loom! As an extension of this culture, many female healthcare professionals can be asked to remove their head coverings in theatre, even though there is no evidence to show head coverings are harmful. If healthcare professionals refuse to roll up their sleeves or remove their head coverings, they risk being seen as belligerent and disobedient – especially if others of the same faith have complied! 

Under the spotlight…

Most at risk of being intimidated into compliance are the students and junior healthcare professionals new to the hospitals or theatres. Regarded as ‘the bottom of the chain’, they are less likely to speak up for themselves and may be scared to challenge policies in the same way as registrars and consultants.

However, the premise of the BIMA Hijab and Bare Below Elbows (HBBE) project is that all these feelings of intimidation and harassment that Muslim female healthcare professionals experience are unnecessary, and the project exists to try to encourage a change in culture at both the policy and grassroots level. 

Solutions…

What are the solutions to the HBBE policy we advocate?

• As per Appendix B of the 2010 Uniform and Workwear policy, Muslim women should be either provided with disposable oversleeves or should be allowed to keep their sleeves down when not engaged in direct patient care activities.

• Muslim women should be allowed to bring in their own freshly washed hijab at 60 degrees.

• Orthopaedic hoods that cover the neck fully should be made available or be purchased.

• Muslim women should be allowed to use 3/4 length sleeves and single use disposable head coverings

Join our campaign!

We urge everyone to get behind our work in the following ways:

1. Share our research, published in BMJ Open. This research, which has taken 4 years to plan, conduct and write up, provides evidence that dress code policies and implementation in hospitals is a problem that needs to be taken seriously by policy makers and hospital managers.

2. If you are a student or junior healthcare professional working in hospitals, download our online toolkits that provide a step by step guide on how to proactively deal with the BBE policy and the hijab in theatre issue before you are reprimanded by ward staff!

Let’s change hospital policy and culture, hospital by hospital, and make sure disposable oversleeves and suitable head coverings in theatre are readily provided and not questioned.

None of our junior sisters should be forced to make career choices on the basis of feeling they have to compromise their deen if they pursue a hospital specialty.

Join us in this campaign, even if you are male or an established senior female clinician. Get in touch with us at [email protected]

BIMA Statement on the RCP Assisted Suicide Poll

We at the British Islamic Medical Association (BIMA) recognise there are challenging dilemmas facing patients, their families, and their physicians at the end of life. However, we are opposed to the concept of assisted suicide. The recent efforts to change the Royal College of Physician’s stance from one of opposition to one of neutrality are troubling, and we are concerned about the many implications that this will have on doctors, their patients, and a relationship that has always been predicated on “first do no harm.”

As Muslims, we inherently believe in the sanctity of life. Even in the most difficult of circumstances, we feel that the focus should be on better pain relief, communities coming together and supporting the sick, investing in research for cures, and supporting our world-leading palliative care services. As God says in the Quran: “Do not kill yourselves, for verily God has been to you most merciful” (Quran 4:29). The opposition to assisted suicide is a position that has unanimous consensus from Islamic scholars and jurists across the globe.

Any shift away from the current stance of professional opposition to assisted suicide may have far-reaching consequences for patients and healthcare professionals, especially those who are opposed to it on the grounds of their faith or conscience. Questions remain as to what neutrality actually means in practice, and how patient trust in physicians who may ‘treat’ them with death will be maintained. In an increasingly austere environment, we are concerned that the narrative will paint those who are made vulnerable by ill health as burdens on their families and taxpayers, pressurising them to take this route.

For these reasons and many more, we strongly and respectfully oppose attempts by professional associations to change their current stance of opposition to assisted suicide.

It is our duty as professionals to speak in the interests of our patients, even if it goes against prevailing and evolving norms. We must continue to safeguard the interests of patients, healthcare professionals and the community as a whole. BIMA is working with an alliance of faith and civic bodies to articulate our strength of feeling on this issue, and lobby our representatives to this end.

ENDS

—

Notes

[1] The Royal College of Physicians (RCP) recently held a poll for its 35,000 members on assisted dying. It was framed in an unusual way, requiring a supra-majority vote of 60% – an unprecedented move from the RCP Council which was a marked changed from previous polls on the issue.

[2] The RCP defines assisted dying as: “The supply by a doctor of a lethal dose of drugs to a patient who is terminally ill, meets certain criteria that will be defined by law, and who requests those drugs in order that they might be used by the person concerned to end their life.”

[3] The British Islamic Medical Association (BIMA) is the national organisation for Muslim healthcare professionals in Britain, aiming to unite and inspire members to serve patients and professions. Visit www.britishima.org for more information or see their social media channels at www.facebook.com/britishima or www.twitter.com/britishima.

BIMA statement on the Government’s proposed “opt-out” system for organ donation after death in the United Kingdom

 

Opinions within the Muslim community

There are a range of opinions present within the Muslim community as to the permissibility of organ donation after death. While there is evidence that a majority of Islamic scholars and Muslim health care professionals are proponents for it (with varying conditions needing to be satisfied), there is unfortunately relatively little clear evidence on how an “opt-out” system would influence or change these views.

The reality is that the Muslim scholarly, Muslim healthcare and general Muslim community are not homogenous. Therefore, we are likely to encounter a range of opinions for a variety of reasons. For example, there are those who are in favour of organ donation after death, but are concerned by the lack of express consent inherent in an opt-out system. Also, we cannot overstate the desire to expedite burial as a perceived practical reason to opt out of organ donation. Finally, it is likely that personal and non-religious cultural factors will be as influential as religious motivation when it comes to this sensitive issue for the bereaved.

BIMA has previously and is also currently running various seminars and workshops to address and facilitate this discussion. There is certainly an appetite within the Muslim community to engage with this process. This will require sustained engagement in order to achieve whatever outcome the community feels is correct.

 

In summary:

The Government should be commended for taking proactive steps to increase the number of available organs available to those who need it most. We are acutely aware that ethnic minorities tend to be under-represented when it comes to donation but are over-represented when it comes to needing organ donation. However, there is concern that legislating an opt-out system without education and engagement may have adverse and unintended consequences. We would recommend taking the following measures to help mitigate for these potentialities.

 

Recommendations for:

 

The Government:

1. To help launch an education and awareness campaign for the Muslim community in their places of congregation (e.g. mosques) and in their native languages (e.g. Bengali, Somali, etc.).

2. To allow flexibility for those who object to their relatives organs being donated on religious grounds.

3. To engage with Muslim healthcare professionals and Islamic scholars to help address caveats/concerns around organ donation.

4. To ensure a holistic and sensitive approach to this matter and prevent vilification of any particular community.

 

The Medical community:

1. To organise and participate in more “outreach” sessions and public health campaigns on organ donation, particularly within ethnic minority communities where there may be a shortage of organ donors.

2. To highlight the possibility of organ donation to patients / family members at an early stage so that they can make an informed choice.

3. To respect the views of those who still refuse to donate their / their relatives’ organs.

 

The Muslim community:

1. For the range of Islamic scholars, Islamic organisations and Islamic medical associations to provide clear guidance on this to the Muslim public.

2. To invite healthcare professionals to their mosques / places of congregation to speak to them about organ donation and its benefits as well as address any concerns.

3. To make an informed and documented choice at an early stage to prevent difficulties later on.

 

BIMA statement regarding the erasure of Dr Bawa-Garba from the Medical Register

 

The British Islamic Medical Association (BIMA) is compelled to add its voice to the growing body of concern regarding the prosecution and erasure of Dr Hadiza Bawa-Garba, following the tragic death of Jack Adcock in 2011.

We extend our heartfelt sympathies to Jack’s parents who have suffered an unimaginable loss and we respect the legal process and the General Medical Council’s (GMC) role in protecting the public. However, the process of reducing a series of complex, systemic failures involving many institutions and individuals to a single trainee is concerning.

We are concerned that the entire case will have unintended consequences that will adversely impact patient safety, healthcare training and morale. We call on our members and all stakeholders to engage with the British Medical Association (BMA), Health Education England (HEE), the GMC and others to address the many concerns raised by this case.

[Ends]

Reflection – Salah

Working in healthcare is hectic. Patients and administrative tasks, among other things, occupy a substantial amount of our time. At times these duties seem to be never-ending, and as a result we may miss praying our Salah (prayers) in the appropriate time.

Salah is an important part of a Muslim’s daily routine. It helps us take a break from what can seem like a rat race, and allows us to remember Allah, the ultimate bestower of all our successes. As His creation we have a duty to remember and praise Him, and to realise that Salah acts as a medium to directly communicate with our Creator, seeking His forgiveness and asking for His blessings.

“Take care to do your prayers, praying in the best way, and stand before God in devotion.” [2:238]

As our lives become busier, it can appear difficult to juggle our duties to our Lord as well our patients, but it is of the utmost importance as Muslims to tend to, alongside our patients and administrative tasks, our spiritual needs and the purification of our hearts.

August News & Views

An article this month in the journal Developing World Bioethics argues against the prohibition of surrogacy by many Islamic scholars, challenging the arguments against surrogacy which include concerns over gene mixing and the involvement of a third party.

Read “Reexamining the Prohibition of Gestational Surrogacy in Sunni Islam” here

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A study in the journal Religions exploring the problem of OCD washing subtype (repeating Wudu several times) suggests an increase in awareness by Imams of OCD symptoms and signposting for professional psychiatric help, since the patients interviewed for the study recognised the importance of the Imam being the first point of contact in dealing with religious obsessions.

Read “Exploring Professional Help Seeking in Practicing Muslim Women with Obsessive Compulsive Disorder Washing Subtype in Australia” here

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We are always looking for relevant articles and news to include in our monthly newsletter. Please send any items to [email protected]

August Events Roundup

1. In preparation for Lifesavers 2017, regional training days were held in 8 locations around the country, with an attendance of over 120 mosque leads & volunteers. More on the list of 60+ mosques involved in delivering Lifesavers involved here.

2. BIMA East Midlands held a well-received social in Leicester, giving local Muslim healthcare professionals a chance to network and enjoy some fantastic Turkish food.

July News & Views

Firstly this month, a study in the Journal of Religion and Health identifies the different trust issues among American Muslims regarding their attitudes and behaviours towards healthcare, which could help healthcare professionals (and others involved in designing health intervention programs) gain the trust of the Muslim patient population.

Read “The Types of Trust Involved in American Muslim Healthcare Decisions” here

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A review paper in the Annals of General Psychiatry outlines the history of psychiatry in the Islamic world (both in the past and the present) and summarises different aspects of forensic psychiatry in the Shari’a and compares them with ancient Greek and modern European law.

Read “Islam, mental health and law: a general overview” here

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We are always looking for relevant articles and news to include in our monthly newsletter. Please send any items to [email protected]

July Events Roundup

1. BIMA Trainees organised the the national FY1 Induction event took place on Saturday 22nd July nationwide in 4 locations- London, Birmingham, Leicester and for the first time in Leeds, Yorkshire. The event was a huge success with over 150 signups nationwide.

2. BIMA sent 12 delegates from all over the UK to attend the Federation of Islamic Medical Association’s (FIMA) Youth Summer Camp 2017 in Istanbul, a week-long program of camp activities, educational seminars, project development sessions, networking, and a tour of Istanbul. BIMA’s President also attended the FIMA Annual Congress and Council Meeting, and the main headline was an address by President Erdogan of Turkey.

3. BIMA North East organised a talk with Dr Arif Moothadeth, consultant in occupational medicine, in association with Newcastle Central Mosque on coping with traumatic eventsafter the recent freak accident outside the mosque on Eid day, during which local healthcare professionals helped look after those injured.

4. BIMA Professional Development organised a webinar with Dr Deen Mirza, a GP and self-help author for GPs, on avoiding diagnostic errors and medical mistakes in general practice.

 

BIMA delegates at FIMA’s Youth Summer Camp 2017  (above) and attendees at the BIMA FY1 Induction (below)

June News & Views

Firstly this month, a study in the journal Aging & Mental Health examining the association between refugee mental health, past traumatic experiences, and religious observance found that refugees with a higher level of religiousness did not show higher levels of PTSD after exposure to war trauma compared to those with a lower level. The authors argue that religious observance provides a buffering effect to refugees’ mental health from severe war trauma.

Read “Mental health among older refugees: the role of trauma, discrimination, and religiousness” here

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The Born In Bradford cohort study is an ongoing study following 12,500 pregnant women and their children recruited over a 3 year period from 2007 to 2010 at Bradford Royal Infirmary. A study this month in the Journal of Epidemiology and Community Health used the data from this study found that infants conceived by Muslim mothers fasting during Ramadan were not significantly smaller than infants conceived by Muslim mothers outside of Ramadan.

Similarly, there was no difference between the two groups in premature birth rates. From the results, the authors conclude that “Muslim women and their partners can be advised by doctors that Ramadan fasting around the time of conception appears unlikely to have a detrimental effect on the size of their infant at birth or result in premature birth.”

Read “Are babies conceived during Ramadan born smaller and sooner than babies conceived at other times of the year?” here

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And finally, a review published in the Journal of Obstetrics and Gynaecology Canadaexplored the preference of female obstetricians/gynaecologists among immigrant women.

The identified reasons for preference of female providers include religious beliefs, modesty, and comfort. The review also briefly discusses the Islamic factors Muslim patients consider when preferring gender-concordant care such as ‘awrah (modesty) and khalwah (close proximity).

Read “Gender of Provider – Barrier to Immigrant Women’s Obstetrical Care” here

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We are always looking for relevant articles and news to include in our monthly newsletter. Please send any items to [email protected]

June Events Roundup

1. Shaykh Dr. Rafaqat Rashid hosted a Ramadan webinar discussing the medical and spiritual benefits of Ramadan, while Mufti Abdur-Rahman Mangera hosted another webinar later in Ramadan on maximising one’s time in Ramadan.

2. Our team in the North East hosted an iftaar in Newcastle. Attendees had the opportunity to network with fellow Muslim healthcare professionals and students, and we look forward to bringing more of our activities to the North East.

 

Attendees at our North East iftaar