Medical Ethics According to Avicenna's Stance

GMJ.2017;6(4):261-7 www.gmj.ir

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

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 “Adab-al-Tabib” (mores of medical practice) is known as the first book on medical ethics edical ethics has been contemplat- in the era of Islam, written by Ali ibne Ishaq Med upon by practitioners since ancient al-Rahavi (9th century AD) [5]. Hakim Seyed times. Chinese ancient texts on medical ethics Mohammad Hussein Aghili Khorasani Shirazi have pointed indirectly to the four principles (18th century) has also discussed ethical is- of modern medical ethics [1]. In ancient Iran, sues in the medical practice in his manuscript too, medical ethics has had its own specific “Kholasat-Al-Hekmat [6]. Rhazes (854- 925 position of importance [2]. It is, however, CE), in his medical encyclopedia of Alhavi, noteworthy that among all medical schools in has discussed medical ethics in medical prac- antiquity, ancient Greece had the most famous tice and research. Numerous exact citations statements of medical ethics. The Hippo- to his predecessors’ works was a significant cratic Oath, the most renowned text of med- feature of Rhazes commitment to ethics in sci- ical ethics in the medical community, is still entific writing [7]. In view of the elimination being used and cited all over the world [3]. of many of ancient medical manuscripts— Medical ethics is also paid attention to in especially those of the Greeks—throughout the medical treatises of Islamic periods [4]. history, Rhazes’ exact citations from previ-

 Correspondence to: GMJ Mojtaba Heydari, Research Center for Traditional Medi- ©2017 Galen Medical Journal cine and History of Medicine, Shiraz University of Med- Tel/Fax: +98 71 36474503 ical Sciences, Shiraz, Iran PO Box 7193616563 Telephone Number: +989172051798 Email:[email protected] Email Address : [email protected] Azmand S, et al. Medical Ethics According to Avicenna’s Stance Medical Ethics According to Avicenna’s Stance Azmand S, et al.

ous works provided important access to the Results knowledge of his Greek predecessors. Even though Avicenna devoted no specific chapter Avicenna, in his overall recommendations, of his medical encyclopedia, Canon of Med- refers to several subjects that bear similar- icine, to Medical Ethics, he has frequently ities to new concepts of medical ethics. His mentioned the recommendations and concepts recommendations can be expressed in three related to medical ethics in the content [8]. main domains: considering patient interests, Sheikh Alrais Abu Ali Husain ibn Abdallah, communication skills, and adhering to the known as Avicenna is one of the most famous characteristics of professional excellence. scientists in Iran and in the world history [9]. He was born in the village of Afshane in Patient’s Interests Bukhara at Samanian era (980 CE) and died Adherence to the interests of the patient is one in Hamadan (1037 CE) [10, 11]. He has au- of the most important keywords in current thored 450 books in many various fields such medical ethics literature. In different parts of as medicine, philosophy, physics, music, his recommendations, Avicenna has advised mathematics etc., of which 240 are available physicians to care for the patients’ interest and today [12]. One hundred and fifty books are has highlighted this issue in differing orders. devoted to philosophy and forty to medicine. He considers confidentiality as one of the “Canon of medicine” (meaning: “rules of physician’s duties; he explicitly states that medicine”) and Shifa (meaning: “healing”) on “the physician ought to protect the patient’s philosophy are his most famous books [13]. secrets and should not express patient dis- Qutb al-Din Shirazi (1236-1311 CE) [4], one of eases such as hemorrhoids and diseases of the main commentators on Avicenna Canon of women except in the cases of necessity and Medicine (Figure-1), wrote multiple chapters (only) to the people who should know” [14]. on great medical scholar recommendations to In another section, Avicenna has discussed the physicians in his book “Fi Bayan al-hajat Ela physician-pharmacist relation. He considers al-Teb va al-Atteba va Vasayahom” (meaning: physician’s knowledge on different drugs as a “on needs to medicine and physicians and warranty for patient’s interest in dealing with their recommendations”) [14]. One of these pharmacist. He states that it is because of the chapters is on Avicenna’s recommendations. physician’s ability to inhibit the fraudulent ac- These recommendations mainly contain tivities of a pharmacist when the pharmacist topics that today are referred to as medi- offers expensive drugs to patients, considering cal ethics. Given the extreme importance his own profit without measuring the potential of Avicenna’s views on the history of sci- damages. In fact, Avicenna gives priority to ence, we have aimed at discussing these patient’s interests in the relationship among recommendations as “medical ethics from patient, physician and pharmacist. In this part, Avicenna’s stance” in this present article. Avicenna has indirectly mentioned the subject of health care provider’s conflict of interest. Search Strategies Another issue repeatedly cited in the rec- In this study, an overview of “Avicenna’s ommendation of Avicenna is consideration medical recommendations” in the third chap- of patient’s interests in diagnostic and ther- ter of the pistle “Fi Bayan al-hajat Ela al- apeutic function of physician. According to Teb va al-Atteba va Vasayahom” [14] was Avicenna’s view, a physician should consid- conducted. Medical ethical issues raised in er patient’s interests and conditions in all of these recommendations were extracted and his/her decisions about patient care. In the analyzed in three main aspects (Patient’s in- selection of specific treatment, he should terests, Communication Skills, Adherence start with the simplest and least aggressive to professional excellence). Similarities, treatments: he needs to avoid prescribing po- differences and conflicts between the - cur tentially harmful drugs as much as possible. rent theories on medical ethics and Avicen- Avicenna explicitly says that the choice of na’s viewpoints were discussed at the end. treatment by physician should be based on

262 GMJ.2017;6(4):261-7 www.gmj.ir Medical Ethics According to Avicenna’s Stance Azmand S, et al.

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).

262 GMJ.2017;6(4):261-7 GMJ.2017;6(4):261-7 263 www.gmj.ir www.gmj.ir Azmand S, et al. Medical Ethics According to Avicenna’s Stance Medical Ethics According to Avicenna’s Stance Azmand S, et al.

patient’s interest: “He should not prescribe gentleness and tolerance; he must listen well therapeutics unaffordable for patient.” He be- to the patient’s complaints, explain the infor- lieves that all physicians’ behaviors must be mation he needs according to the patient’s un- based on patient’s interests, and this must not derstanding, and avoid using difficult words be excluded even in regards with examination. in the conversation with the patient”[14]. One of the outstanding points of Avicenna recommendations is the strong emphasis on Adherence to Professional Excellence avoiding any action that may cause harm to Another feature of professional ethics that the patient: “Physicians should not recom- Avicenna has greatly emphasized is physi- mend the use of poison, lethal drugs and abor- cian’s adherence to continuous improvement tive medications; they are not to talk about in knowledge, behavior, and ethics. Today, these materials except when they want to this feature is named professional excel- prevent harm or when it benefits the patient”. lence. In many parts of his recommenda- He also states that if the physician causes any tions, Avicenna mentions important features harm to the patient or happens to miss one and states various examples. At the begin- of his/her interests, he should compensate. ning of his recommendations, Avicenna has To summarize, from the viewpoint of Avicenna, explained different branches of knowledge respecting patient’s interest should dominate all that a physician should master in addition to aspects of physicians’ relations and decisions. his/her specialized knowledge. These com- prise logic, anatomy, mathematics, astron- Communication Skills omy, geometry, and music. In fact, Avicen- In various parts of his recommendations, na emphasizes the point that physicians can Avicenna refers to patient-physician rela- improve the quality of their services if they tionship. He believes that physician’s pro- learn and apply all the information they need. fessional behavior must be eligible for From Avicenna’s point of view, a physician moderation, and be “away from extremes of should exploit every opportunity to improve intimacy or arrogance; because excessive in- his/her knowledge level. A physician must timacy and jesting harm the dignity of physi- travel for the knowledge he needs so that he cian while arrogance or any harshness could might meet medical scientists; he is not to harm the patient-physician relationship”. neglect science acquisition, as well as en- He also describes in detail how to commu- thusiasm for collecting books and resources nicate with patient, when Avicenna says: that help medical diagnosis and treatment. “… upon visiting of a patient, the physician He also has the duty to make every effort should sit next to him in a way that is in front to upgrade his/her studies –to be serious in of him so that he could see his face and listen understanding them. He must even not be to him well. He should only ask the questions afraid of reviewing the previous knowledge: that provide necessary information for his di- he must not consider himself protected from agnosis and treatment: the physician ought to forgetfulness. Avicenna believes that despite avoid extraneous and unnecessary questions. the fact that the performance of the physi- Moreover, the physicians should avoid pro- cian should be based on existing conditions longing the time of his visit even if the patient and his/her local patients, he is obliged to wants his companion. The physician should have information of the global issues and limit the visiting time to the required length affairs, and also put them into good use. in a compassionate and respectful manner.” According to Avicenna, thinking in terms of According to Avicenna’s view, one of the du- conditions and affairs of patients and plan- ties of a physician is to increase the patient’s ning on their therapeutic process can lead to hope to the good prognosis of his disease, but promotion of physicians’ professional excel- he should condition it to complete compli- lence. Avicenna has also emphasized the pres- ance with the physician’s recommendations: ence of physician in clinical environments to “The physician should also be calm and digni- gain experience on what he has learned from fied in his behavior, associated with patience, books or on what is not mentioned in books.

264 GMJ.2017;6(4):261-7 www.gmj.ir Medical Ethics According to Avicenna’s Stance Azmand S, et al.

Avicenna, additionally, recommends phy- skills has many benefits, including the prop- sicians to pay enough attention to their er understanding of patient as well as his/her own physical health: if they become ill, it condition and problems, more cooperation forms a question in the minds of people as with physician in the process of diagnosis and to whether he is unable to prevent himself treatment, reducing the stress, and in general, from disease and/or treat himself. A physi- increased level of patient satisfaction. [19, 20]. cian’s malady may abate the public trust in The subject of excellence is another con- him or in the medical profession; it also re- cern that is mentioned repeatedly in Avicen- duces the dignity and position of the physi- na’s recommendations. Physician and other cian for people. With regard to the subject medical professionals should create excel- expressed, we can perceive that from the lence within themselves to upgrade skills stand point of Avicenna, ethical and behav- continuously. They must attend continual ioral features of a physician are so important. educational processes to improve their communication skills with patients and improve Discussion the quality of care at various levels, including individual, corporate and public lev- Many of the mentioned expected features of els. Furthermore, discovering new relevant physicians have remained valid today in med- scientific and technological advancements ical and professional ethics. Focusing on pa- and their appropriate usages are examples tient’s interests and preventing any damage to of adhering to professional excellence [21]. the patient are the important goals of medical Despite the mentioned similarities between ethics reflected in principles, such as respect for Avicenna’s and modern medical ethics recom- patient autonomy, beneficence, non-malfea- mendations, coming deeper into these recom- sance, confidentiality and patient privacy [15]. mendations reveals important differences in Conflict of interest in relationships among the philosophical background of their recom- physician, patient and other health care pro- mendations. Avicenna acknowledged divine viders is another subject that has been consid- and religious rationale for his recommenda- ered by Avicenna. Conflict of interest refers tions. In contrast, modern medical ethics more to” a set of conditions in which profession- focuses on other philosophical schools such al judgment concerning a primary interest as deontology, utilitarianism and consequen- (such as a patient’s welfare or the validity tialism. For example, having expanded on of research) is unduly influenced by a -sec physicians’ moral personality traits, Avicen- ondary interest (such as financial gain) [16]. na states that these traits are subject to God’s Avicenna’s emphasis on avoiding damage grace and attention. Or Avicenna warns the to patients, evoke one of the famous princi- physician who prescribes harmful and deadly ples of medical ethics, nonmaleficence [15]. drugs of divine punishment. However, mod- Explanation of communication skills in phy- ern medical ethics has different rationale and sician-patient relationship in detail is another philosophical perspective on these issues. For strength of these recommendations. The abili- instance, James Rachels in justification of pri- ty to communicate well with others, especial- vacy says: “Privacy is sometimes necessary to ly with patients, is an important professional protect people’s interests in competitive situa- competency that medical students should ob- tions.” [22] tain and be evaluated on in different levels. The justification of confidentiality by the Various professional organizations in the field consequentialist approach in the book of of medicine have emphasized the importance “principles of biomedical ethics” is an- of communication skills for physicians [17, other example for the mentioned differ- 18]. Different parameters such as good com- ence of philosophical perspectives. [15] munication skills and efficient relationship This study just focused on a text remained with patients are essential to provide good from Avicenna as his recommendations to care for patients. The establishment of these physicians, which mainly contains ethical types of relationships and communication recommendations. As this study has not con-

264 GMJ.2017;6(4):261-7 GMJ.2017;6(4):261-7 265 www.gmj.ir www.gmj.ir Azmand S, et al. Medical Ethics According to Avicenna’s Stance Medical Ethics According to Avicenna’s Stance Azmand S, et al.

sidered other remained manuscripts from are fundamental differences in the philos- Avicenna like”Canon of Medicine” and “Shi- ophy of ethics in these two approaches. fa”, it can be considered as an important lim- Contrastive analysis of new and old ideas in itation of the study. On the other hand, this the field of medical ethics in addition to famil- is the first study which has discussed the iarizing medical ethics professionals with the ethical recommendations form Avicenna, strengths and weaknesses of old and new theo- who is known as the most important med- ries, can provide a background for developing ical scholar from the Islamic golden age. new promoting ideas in these fields. There is, of course, further room for elucidating Avicen- Conclusion na’s viewpoints on medical ethics and its various ramifications. Comparative analogy also Medical ethical recommendations from Avi- has its own prospects for more explanation. cenna can be divided into three groups: interests of the patient, communication skills, Conflict of Interest and adhering to professional excellence. Despite the similarities between Avicen- The authors report that there is no conflict of na’s and modern recommendations, there interest.

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