ED physician highlights Muslim bioethics
Focus of paper is cross-gender interactions
As a way of addressing the potential for disparities in the delivery of health care services, U.S. physicians would do well to approach each patient individually, focusing on that particular patient's religious and cultural values, according to a paper published in November.
This is particularly true of American Muslim patients, whose religion informs their attitudes both toward health care in general and toward the physician-provider interaction, according to a paper published in the Nov. 1, 2010, online issue of the Journal of Medical Ethics.1
The author of the paper is Aasim I. Padela, MD, an emergency department physician and instructor in the Department of Emergency Medicine at the University of Michigan in Ann Arbor. Padela also is a Robert Wood Johnson Foundation Clinical Scholar at the University of Michigan Health System.
"I do think that there are commonalities between Islam and any other religion or any other group that has strong values, and how it affects the [physician-patient] encounter," he says. "Or people who have beliefs about disease causation, like how a disease comes about or how a cure comes about, might affect how they interact with the healthcare system . . . Obviously, I'm looking at American Muslims, so the value system I look at is how Islamic values and how Islamic ethics might play a role in the health care behaviors."
In Islam, however, there "might be a heightened sensitivity of gender or modesty through the gender boundaries line, which might not be the same for other groups. . . So, I think there is a variance within every tradition, but there are commonalities and there are things that are specific to Muslims," he says.
In the paper, Padela writes: "Medical practice is becoming increasingly racially, ethnically and culturally diverse, resulting in a plurality of value systems at play in the clinical arena. These multiple value system may present obstacles to quality care when clinicians and patients fail to understand one another or to agree on modes of health care delivery and therapeutics.
"Further, ethical dilemmas may arise when the culture, or legal considerations of medicine, are in conflict with patient values," Padela writes.1
U.S. social context for Muslims
The reason for focusing attention on American Muslims and cross-gender interactions is actually "the context, I would say, of what's occurring with post-9/11 discrimination and abuse, and in the social context where we live, this group is marginalized," Padela tells Medical Ethics Advisor. "So, it's even more important that we kind of understand what's going on, because there are implications for how there might be misinterpretation on both sides," including "distrust on the patient side."
Cultural competency movement
While Padela says the cultural competency movement that has evolved over the last 15-20 years is needed, it had its beginnings in approaches "where people were saying, 'We need to learn about the values of some of [our] patients from some ethnic community here; here are the 10 things that they do. Or, for some patients from Ghana, here are the 10 things you should know."
The approach was one of compiling a checklist by facilities and then having staff operate from that checklist.
"Now, we've moved to [where] the idea isn't the first view, you know, everybody's the same and you can figure out this box, but rather, you learn cross-culture communication skills where you are able to listen to concerns . . . of the patient," he says.
So, essentially, physicians learn about some of the needs that particular ethnic or cultural groups have, but then "you have the tools with which can then figure out, 'Does this apply to this patient or not,'" he says.
The primary approach should be to listen to the patient under the model of patient-centered care so that the physician can learn from the patient something about his or her religious or cultural values, such that they can then be addressed, Padela says.
However, if, for example, a physician works in an area where there are large groups of Somali refugees, then that physician should "learn about their culture and their value systems a little bit," he says.
"So, we're trying to immerse people with [the] understanding that culture is part of someone's value system; it's how they negotiate their identity," Padela explains. "There's also medical culture, so we have to come and negotiate and have a participatory decision-making [encounter] and be cognizant of how our culture influences our [physician] values."
Muslim religious laws and values
Padela's paper focuses specifically on Muslim patients and cross-gender interactions, presenting Islamic "ethicolegal regulations" that pertain to this, using these regulations "to derive bioethical regulations in three area of clinical relevance: dress code, seclusion of unrelated or unmarried members of the opposite sex, and physical contact."
According to Padela's paper, there are nearly 7 million American Muslims in the United States, where Muslims are the "fastest-growing religious group, with nearly equal numbers of African-Americans, South Asians, and Arabs."
Due to the diverse composition of American Muslims, study of this population group presents challenges, and any studies conducted "often overlook the connection between cultural expression and religious dictates."
In the paper, Padela explains that Muslims can be "divided into two main branches: Sunni and Shiite. While these two groups share "beliefs, religious practices and legal structures," they vary on "issues related to religious authority and prophetic succession."
There are also "two dominant genres" of writing on Islamic medical ethics: Adab and Shariah. According to the paper, Adab is "literature which aims to promote virtues and righteous conduct couched within Islamic terms. Shariah is an Islamic ethicolegal structure with writings that "aim to expound the legal permissibility of medical interactions, procedures, and therapeutics."
Padela also discusses fatwa, or "non-binding legal opinions rendered by jurisconsults."
"This work shows this value system is based on the religion, Islam, and [is] coming from the religious text, and teachings, and the law itself," Padela tells MEA. "So, while it might be a variable in terms of how patients practice or adopt this, or for some it might not be a concern at all," it is the religion itself that dictates behavior, including in the health care setting.
One example of how a physician might respond to a Muslim patient might be, Padela says, if that patient wants to fast for Ramadan. A physician evaluating this situation from a health care culture might determine it is not a good idea for someone who has diabetes or a mild heart condition to fast for 12 hours in the summer, "because it has health effects, potentially."
"As the health care provider, that's my value system, but for the patient, it is a religious requirement it's something that I think has value to me spiritually, and I want to do it," Padela explains.
"Making those two value systems meet in the middle so that you can optimize their health, so that they can also do the things that they feel are important spiritually for their spiritual health, is something we have to be attuned to," Padela says.
Padela says that his work has suggested that "even if sometimes you can't meet the needs of a patient . . . communicating in a way that makes them feel valued and understood," is a fundamental aspect of providing care.
Reference
- Padela AI, Rodriguez del Pozo P. Muslim patients and cross-gender interactions in medicine: an Islamic bioethical perspective. J Med Ethics published online November 1, 2010. doi: 10.1136/jme.2010.037614.
Source
- Aasim I. Padela, MD, Emergency Physician, Instructor in the Department of Emergency Medicine and Robert Wood Johnson Foundation Clinical Scholar at the University of Michigan Health System, Ann Arbor, MI.
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