Received 2016-12-01
Revised 2016-12-02
Accepted 2017-05-30
Medical Ethics According to Avicenna’s Stance:
A Synopsis
Sajad Azmand1, Mojtaba Heydari2
1Department of Medical Ethics and Philosophy of Health, Shiraz University of Medical Sciences, Shiraz, Iran
2Research Center for Traditional Medicine and History of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
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Abstract Medical ethics has been contemplated upon by practitioners since ancient times. Avicenna’s notes on medical ethics are presented in the third chapter of the manuscript “Fi Bayan al-hajat Ela al-Teb va al-Atteba va Vasayahom” (meaning: “on needs to medicine and physicians and their recommendations”) by Qutb al-Din Shirazi’s (1236-1311 CE), one of the main commentators on Avicenna Canon of Medicine. Avicenna refers to several ethical subjects which can be expressed in three main domains: considering patient interests, communication skills, and adhering to the characteristics of professional excellence. Although there are similarities between the classical medical ethics recommendations and ethics recommendations raised by Avicenna, significant moral differences can be considered between the two views. [GMJ.2017;6(4):261-7] DOI: 10.22086/gmj.v6i4.768 Keywords: Medical Ethics; History of Medicine; Persian Medicine |
Introduction
Medical ethics has been contemplated upon by practitioners since ancient times. Chinese ancient texts on medical ethics have pointed indirectly to the four principles of modern medical ethics [1]. In ancient Iran, too, medical ethics has had its own specific position of importance [2]. It is, however, noteworthy that among all medical schools in antiquity, ancient Greece had the most famous statements of medical ethics. The Hippocratic Oath, the most renowned text of medical ethics in the medical community, is still being used and cited all over the world [3].
Medical ethics is also paid attention to in the medical treatises of Islamic periods [4]. “Adab-al-Tabib” (mores of medical practice) is known as the first book on medical ethics in the era of Islam, written by Ali ibne Ishaq al-Rahavi (9th century AD) [5]. Hakim Seyed Mohammad Hussein Aghili Khorasani Shirazi (18th century) has also discussed ethical issues in the medical practice in his manuscript “Kholasat-Al-Hekmat [6]. Rhazes (854- 925 CE), in his medical encyclopedia of Alhavi, has discussed medical ethics in medical practice and research. Numerous exact citations to his predecessors’ works was a significant feature of Rhazes commitment to ethics in scientific writing [7]. In view of the elimination of many of ancient medical manuscripts—especially those of the Greeks—throughout history, Rhazes’ exact citations from previous works provided important access to the knowledge of his Greek predecessors. Even though Avicenna devoted no specific chapter of his medical encyclopedia, Canon of Medicine, to Medical Ethics, he has frequently mentioned the recommendations and concepts related to medical ethics in the content [8].
Sheikh Alrais Abu Ali Husain ibn Abdallah, known as Avicenna is one of the most famous scientists in Iran and in the world history [9]. He was born in the village of Afshane in Bukhara at Samanian era (980 CE) and died in Hamadan (1037 CE) [10, 11]. He has authored 450 books in many various fields such as medicine, philosophy, physics, music, mathematics etc., of which 240 are available today [12]. One hundred and fifty books are devoted to philosophy and forty to medicine. “Canon of medicine” (meaning: “rules of medicine”) and Shifa (meaning: “healing”) on philosophy are his most famous books [13].
Qutb al-Din Shirazi (1236-1311 CE) [4], one of the main commentators on Avicenna Canon of Medicine (Figure-1), wrote multiple chapters on great medical scholar recommendations to physicians in his book “Fi Bayan al-hajat Ela al-Teb va al-Atteba va Vasayahom” (meaning: “on needs to medicine and physicians and their recommendations”) [14]. One of these chapters is on Avicenna’s recommendations.
These recommendations mainly contain topics that today are referred to as medical ethics. Given the extreme importance of Avicenna’s views on the history of science, we have aimed at discussing these recommendations as “medical ethics from Avicenna’s stance” in this present article.
Search Strategies
In this study, an overview of “Avicenna’s medical recommendations” in the third chapter of the pistle “Fi Bayan al-hajat Ela al-Teb va al-Atteba va Vasayahom” [14] was conducted. Medical ethical issues raised in these recommendations were extracted and analyzed in three main aspects (Patient’s interests, Communication Skills, Adherence to professional excellence). Similarities, differences and conflicts between the current theories on medical ethics and Avicenna’s viewpoints were discussed at the end.
Results
Avicenna, in his overall recommendations, refers to several subjects that bear similarities to new concepts of medical ethics. His recommendations can be expressed in three main domains: considering patient interests, communication skills, and adhering to the characteristics of professional excellence.
Patient’s Interests
Adherence to the interests of the patient is one of the most important keywords in current medical ethics literature. In different parts of his recommendations, Avicenna has advised physicians to care for the patients’ interest and has highlighted this issue in differing orders.
He considers confidentiality as one of the physician’s duties; he explicitly states that “the physician ought to protect the patient’s secrets and should not express patient diseases such as hemorrhoids and diseases of women except in the cases of necessity and (only) to the people who should know” [14].
In another section, Avicenna has discussed the physician-pharmacist relation. He considers physician’s knowledge on different drugs as a warranty for patient’s interest in dealing with pharmacist. He states that it is because of the physician’s ability to inhibit the fraudulent activities of a pharmacist when the pharmacist offers expensive drugs to patients, considering his own profit without measuring the potential damages. In fact, Avicenna gives priority to patient’s interests in the relationship among patient, physician and pharmacist. In this part, Avicenna has indirectly mentioned the subject of health care provider’s conflict of interest.
Another issue repeatedly cited in the recommendation of Avicenna is consideration of patient’s interests in diagnostic and therapeutic function of physician. According to Avicenna’s view, a physician should consider patient’s interests and conditions in all of his/her decisions about patient care. In the selection of specific treatment, he should start with the simplest and least aggressive treatments: he needs to avoid prescribing potentially harmful drugs as much as possible.
Avicenna explicitly says that the choice of treatment by physician should be based on patient’s interest: “He should not prescribe therapeutics unaffordable for patient.” He believes that all physicians’ behaviors must be based on patient’s interests, and this must not be excluded even in regards with examination.
One of the outstanding points of Avicenna recommendations is the strong emphasis on avoiding any action that may cause harm to the patient: “Physicians should not recommend the use of poison, lethal drugs and abortive medications; they are not to talk about these materials except when they want to prevent harm or when it benefits the patient”. He also states that if the physician causes any harm to the patient or happens to miss one of his/her interests, he should compensate.
To summarize, from the viewpoint of Avicenna, respecting patient’s interest should dominate all aspects of physicians’ relations and decisions.
Communication Skills
In various parts of his recommendations, Avicenna refers to patient-physician relationship. He believes that physician’s professional behavior must be eligible for moderation, and be “away from extremes of intimacy or arrogance; because excessive intimacy and jesting harm the dignity of physician while arrogance or any harshness could harm the patient-physician relationship”.
He also describes in detail how to communicate with patient, when Avicenna says:
“… upon visiting of a patient, the physician should sit next to him in a way that is in front of him so that he could see his face and listen to him well. He should only ask the questions that provide necessary information for his diagnosis and treatment: the physician ought to avoid extraneous and unnecessary questions. Moreover, the physicians should avoid prolonging the time of his visit even if the patient wants his companion. The physician should limit the visiting time to the required length in a compassionate and respectful manner.”
According to Avicenna’s view, one of the duties of a physician is to increase the patient’s hope to the good prognosis of his disease, but he should condition it to complete compliance with the physician’s recommendations:
“The physician should also be calm and dignified in his behavior, associated with patience, gentleness and tolerance; he must listen well to the patient’s complaints, explain the information he needs according to the patient’s understanding, and avoid using difficult words in the conversation with the patient”[14].
Adherence to Professional Excellence
Another feature of professional ethics that Avicenna has greatly emphasized is physician’s adherence to continuous improvement in knowledge, behavior, and ethics. Today, this feature is named professional excellence. In many parts of his recommendations, Avicenna mentions important features and states various examples. At the beginning of his recommendations, Avicenna has explained different branches of knowledge that a physician should master in addition to his/her specialized knowledge. These comprise logic, anatomy, mathematics, astronomy, geometry, and music. In fact, Avicenna emphasizes the point that physicians can improve the quality of their services if they learn and apply all the information they need.
From Avicenna’s point of view, a physician should exploit every opportunity to improve his/her knowledge level. A physician must travel for the knowledge he needs so that he might meet medical scientists; he is not to neglect science acquisition, as well as enthusiasm for collecting books and resources that help medical diagnosis and treatment. He also has the duty to make every effort to upgrade his/her studies –to be serious in understanding them. He must even not be afraid of reviewing the previous knowledge: he must not consider himself protected from forgetfulness. Avicenna believes that despite the fact that the performance of the physician should be based on existing conditions and his/her local patients, he is obliged to have information of the global issues and affairs, and also put them into good use.
According to Avicenna, thinking in terms of conditions and affairs of patients and planning on their therapeutic process can lead to promotion of physicians’ professional excellence. Avicenna has also emphasized the presence of physician in clinical environments to gain experience on what he has learned from books or on what is not mentioned in books.
Avicenna, additionally, recommends physicians to pay enough attention to their own physical health: if they become ill, it forms a question in the minds of people as to whether he is unable to prevent himself from disease and/or treat himself. A physician’s malady may abate the public trust in him or in the medical profession; it also reduces the dignity and position of the physician for people. With regard to the subject expressed, we can perceive that from the stand point of Avicenna, ethical and behavioral features of a physician are so important.
Discussion
Many of the mentioned expected features of physicians have remained valid today in medical and professional ethics. Focusing on patient’s interests and preventing any damage to the patient are the important goals of medical ethics reflected in principles, such as respect for patient autonomy, beneficence, non-malfeasance, confidentiality and patient privacy [15].
Conflict of interest in relationships among physician, patient and other health care providers is another subject that has been considered by Avicenna. Conflict of interest refers to” a set of conditions in which professional judgment concerning a primary interest (such as a patient’s welfare or the validity of research) is unduly influenced by a secondary interest (such as financial gain) [16]. Avicenna’s emphasis on avoiding damage to patients, evoke one of the famous principles of medical ethics, nonmaleficence [15].
Explanation of communication skills in physician-patient relationship in detail is another strength of these recommendations. The ability to communicate well with others, especially with patients, is an important professional competency that medical students should obtain and be evaluated on in different levels. Various professional organizations in the field of medicine have emphasized the importance of communication skills for physicians [17, 18]. Different parameters such as good communication skills and efficient relationship with patients are essential to provide good care for patients. The establishment of these types of relationships and communication skills has many benefits, including the proper understanding of patient as well as his/her condition and problems, more cooperation with physician in the process of diagnosis and treatment, reducing the stress, and in general, increased level of patient satisfaction. [19, 20].
The subject of excellence is another concern that is mentioned repeatedly in Avicenna’s recommendations. Physician and other medical professionals should create excellence within themselves to upgrade skills continuously. They must attend continual educational processes to improve their communication skills with patients and improve the quality of care at various levels, including individual, corporate and public levels. Furthermore, discovering new relevant scientific and technological advancements and their appropriate usages are examples of adhering to professional excellence [21].
Despite the mentioned similarities between Avicenna’s and modern medical ethics recommendations, coming deeper into these recommendations reveals important differences in the philosophical background of their recommendations. Avicenna acknowledged divine and religious rationale for his recommendations. In contrast, modern medical ethics more focuses on other philosophical schools such as deontology, utilitarianism and consequentialism. For example, having expanded on physicians’ moral personality traits, Avicenna states that these traits are subject to God’s grace and attention. Or Avicenna warns the physician who prescribes harmful and deadly drugs of divine punishment. However, modern medical ethics has different rationale and philosophical perspective on these issues. For instance, James Rachels in justification of privacy says: “Privacy is sometimes necessary to protect people’s interests in competitive situations.” [22]
The justification of confidentiality by the consequentialist approach in the book of “principles of biomedical ethics” is another example for the mentioned difference of philosophical perspectives. [15]
This study just focused on a text remained from Avicenna as his recommendations to physicians, which mainly contains ethical recommendations. As this study has not considered other remained manuscripts from Avicenna like”Canon of Medicine” and “Shifa”, it can be considered as an important limitation of the study. On the other hand, this is the first study which has discussed the ethical recommendations form Avicenna, who is known as the most important medical scholar from the Islamic golden age.
Conclusion
Medical ethical recommendations from Avicenna can be divided into three groups: interests of the patient, communication skills, and adhering to professional excellence. Despite the similarities between Avicenna’s and modern recommendations, there are fundamental differences in the philosophy of ethics in these two approaches.
Contrastive analysis of new and old ideas in the field of medical ethics in addition to familiarizing medical ethics professionals with the strengths and weaknesses of old and new theories, can provide a background for developing new promoting ideas in these fields. There is, of course, further room for elucidating Avicenna’s viewpoints on medical ethics and its various ramifications. Comparative analogy also has its own prospects for more explanation.
Conflict of Interest
The authors report that there is no conflict of interest.
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Correspondence to: Mojtaba Heydari, Research Center for Traditional Medicine and History of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran Telephone Number: +989172051798 Email Address : mheydari@sums.ac.ir |
Figure 1. First page of Al-Tuhfat al-sadiyah, a comprehensive commentary in five volumes on the Canon of Avicenna by Qutb al-Din al-Shirazi (1236-1311 CE).
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