Religious Accommodation for Patients: A Review of Guidelines on Muslim Patient Care in Developed English- Speaking Countries

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Religious Accommodation for Patients: A Review of Guidelines on Muslim Patient Care in Developed English-

Speaking Countries

Salilah Saidun

Independent researcher, Kuala Nerus, Terengganu, Malaysia [email protected]

Keywords : Holistic patient care,

Diversity and inclusion, Spiritual and religious accommodation, Muslim patient care,

Culturally congruent care

Abstract

Concerns regarding spiritual and cultural issues have flourished over the years as part of the holistic patient care approach. Since then, health care providers have issued guidelines on providing care for patients with diverse cultural and religious backgrounds. This article reviews fifty-six guidelines on Muslim patient care in six developed countries namely Australia, New Zealand, the United Kingdom, the Republic of Ireland, the United States of America and Canada. The issues discussed include dietary, medication, fasting, hygiene, daily prayers, dress code, cross-gender interaction, maternity, sexual health, end of life and other related issues. The information provided in the guideline may be overwhelming for non-Muslim healthcare personnel to grasp due to the variances in rulings among different Muslim jurists and schools of thought (mazahib). This, in tandem with different levels of religious practice among Muslims, may complicate the delivery of service. Thus, from a practical point of view, it is imperative to ask patients how they would like their religious needs to be accommodated. The shift of paradigm in the current medical and ethical stance with spiritual and religious accommodation is a positive phenomenon not only for Muslims but for all religious believers. Whilst other Muslim-minority countries could emulate the initiatives to help healthcare personnel to better understand the religious and cultural needs of Muslim patients, Muslim-majority countries on the other hand could also adopt the initiatives for accommodating the religious needs of non-Muslim patients in their countries.

Kata Kunci : Penjagaan pesakit holistik Kepelbagaian dan

keterangkuman Akomodasi kerohanian dan keagamaan Penjagaan pesakit Muslim Penjagaan kesihatan mesra budaya

Abstrak

Keprihatinan terhadap isu kerohanian dan budaya telah berkembang sejak kebelakangan ini sebagai sebahagian daripada pendekatan penjagaan pesakit secara menyeluruh. Sejak itu, penyedia perkhidmatan kesihatan telah mengeluarkan garis panduan untuk berhadapan dengan pesakit dengan latar belakang budaya dan agama yang pelbagai. Artikel ini mengkaji lima puluh enam garis panduan penjagaan pesakit Muslim di enam negara maju iaitu Australia, New Zealand, United Kingdom, Republik Ireland, Amerika Syarikat dan Kanada. Isu-isu yang dibincangkan termasuk pemakanan, ubat-ubatan, puasa, kebersihan, solat, etika berpakaian, interaksi antara jantina, kesihatan seksual, akhir hayat dan isu-isu lain. Maklumat yang diberikan dalam garis panduan itu mungkin sukar untuk difahami oleh kakitangan bukan Islam kerana perbezaan tentang hukum di kalangan ahli perundangan Islam dalam mazhab yang berbeza. Fakto ini, ditambah pula dengan tahap amalan agama yang berbeza di kalangan individu, mungkin menyukarkan penyampaian perkhidmatan. Oleh itu, dari sudut praktikal, adalah penting untuk bertanya kepada pesakit bagaimana mereka ingin keperluan agama mereka ditampung. Anjakan paradigma dalam pendirian perubatan dan etika dengan memenuhi keperluan rohani dan keagamaan adalah fenomena positif bukan sahaja untuk umat Islam tetapi untuk semua penganut agama. Sementara negara-negara minoriti Islam yang lain boleh mencontohi inisiatif ini, negara majoriti Islam sebaliknya juga boleh menerima pakai inisiatif untuk menampung keperluan agama pesakit bukan Islam dalam negara mereka.

INTRODUCTION

Article 18 of the Universal Declaration of Human Rights proclaimed that everyone has the right to freedom of

religion, including the right to manifest his religion or belief in teaching, practice, worship and observance (United Nations, 1948). Religion plays an important part in a Muslim‟s life as Islam is not merely a

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aspect of life is regulated by the Shari’ah (Islamic law). Although culture and religion are closely aligned, Muslim cultural norms and religious obligations must be distinguished because compromise may still be made for norms that are merely culturally rooted, but not with Islamic religious obligations (Shabana, 2013), although levels of individual commitments vary.

Modern society has become increasingly diverse globally due to migration (due to social, political or economic factors), tourism and religious conversion. Policies formulated in response to this phenomenon fall under various spectrums of multiculturalism (which aims to foster harmonious coexistence by preserving and accommodating cultural diversity) and integration (which endeavors to assimilate and unite diverse minority groups with the majority population). The degree of cultural and religious accommodation depends on the national, state and institutional policies (Mohiuddin 2017, Saidun 2019).

Realizing the significance of religion to a person‟s life, healthcare providers in some English-speaking developed countries have taken the initiative to produce guidelines on

treating multi-faith patients, including Muslims. This article intends to review guidelines on Muslim patient care issued by public and private healthcare providers in six developed countries, where Muslims are a minority.

MATERIALS AND METHODS An online search for guidelines on Muslim patient care was conducted using online search engines. Various related keywords were used in the search such as

“cultural competency”, “intercultural guide”, “multi-faith guide”, “pastoral care”, “cultural care”, “religious need”,

“culture-specific care”, “culture-sensitive care”, “Muslim patient care” and

“Muslim chaplaincy”. The

acknowledgement and reference sections of some of the guidelines also provide information on the availability of other guidelines.

The scope is limited to developed countries as the issue of scarce resources is less apparent. The inclusion and exclusion criteria of the guidelines are provided in Table 1. The review focuses on issues of dietary and medication rules, fasting, hygiene practices, daily prayers, modesty, birth rites, sexual health, last offices, family and community relations and chaplaincy service.

Table 1. Inclusion and exclusion

Inclusion criteria Exclusion criteria

Guidelines issued by public and private healthcare providers in developed countries

Guidelines written in English

Guidelines can be accessed or downloaded online

Guidelines focusing on cultural groups per se (for example, Pakistani) as opposed to religious groups

Guidelines that only address one issue (for example, Last offices policy)

RESULTS AND DISCUSSION Fifty-six guidelines that meet the inclusion criteria from six developed countries were retrieved through the

online search, shown in Table 2. A majority of the guidelines retrieved originated from the United Kingdom [(42 guidelines, (75.0%)], followed by the

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(16.0%)] and Canada [2 guidelines (3.6%)]. There is one guideline (1.8%)

retrieved each from Australia, the Republic of Ireland and New Zealand.

Table 2. List of the guidelines retrieved

Guideline issuer Guideline title

1. ²gether NHS Foundation Trust, United Kingdom (2011) A religious and cultural guide for trust staff

2. 5 Boroughs Partnership NHS Trust, United Kingdom (2006) Meeting the needs of our multi-faith community

3. Alberta Health Services, Canada (2009) Health care and religious beliefs 4. Ashford and St. Peters‟ Hospital NHS Trust, United

Kingdom (n.d.) Caring for the Muslim patient

5. Basildon and Thurrock University Hospitals NHS

Foundation Trust, United Kingdom (2004) Caring for the human spirit: a resource for holistic and culturally appropriate care 6. Belfast Health and Social Care Trust, United Kingdom

(2012) Multi cultural and beliefs handbook

7. Blackpool, Fylde and Wyre Hospitals NHS Foundation

Trust, United Kingdom (2009) Religious and cultural beliefs 8. Bradford Teaching Hospital NHS Foundation Trust, United

Kingdom (n.d) Faith requirements information: Muslims

9. Calderdale and Huddersfield NHS Foundation Trust, United

Kingdom (n.d.) Chaplaincy: Islam

10. Cardiff and Vale University Health Board, United Kingdom

(n.d.) Faith and belief groups

11. Cleveland Clinic, United States of America (2012) Diversity tool kit 12. Coventry and Warwickshire NHS Partnership Trust, United

Kingdom (2011) Multi-cultural handbook: religious and

cultural resource

13. Crown Height Medical Centre, United Kingdom (2012) Cultural and religious policy for staff and patients

14. Dorset Healthcare NHS Foundation Trust, United Kingdom

(n.d.) Respect for cultural and religious needs

information resource

15. Ealing Hospital NHS Trust, United Kingdom (2006) Guide to ethnicity information when caring for patients

16. East Cheshire NHS Foundation Trust, United Kingdom

(n.d.) Privacy, dignity and respect for cultural

and religious beliefs: a guide for hospital staff to improve patient care

17. Hamilton Health Sciences, Canada (n.d.) Multi-faith guide for health care professionals

18. Health and Social Care, United Kingdom (2011) Multi cultural and beliefs handbook 19. Health Services Executive, Ireland (2009) Health Services Intercultural Guide 20. Hospital of the University of Pennsylvania and Penn

Presbyterian Medical Center, United States of America (2009)

Religious Diversity: Practical Points for Health Care Providers

21. Humber NHS Foundation Trust, United Kingdom (2011) Caring for people of different faith 22. Lancashire Teaching Hospitals NHS Foundation Trust,

United Kingdom (n.d.) Chaplaincy: embracing diversity, hope,

faith and spirituality within the hospital community

23. Leicestershire Partnership NHS Trust, United Kingdom

(2011) NHS staff multi-faith resource

24. Lincolnshire Community Health Services NHS Trust, United

Kingdom (n.d) A staff guide to the needs of ethnic-

religious minority communities 25. Loma Linda University Health System, United States of

America (n.d.) Health care and religious beliefs

26. London Borough of Redbridge, Redbridge Faith Forum, Saint Francis Hospice, Barts Health NHS Trust, North East London and the City NHS and Barking, Havering and Redbridge University Hospitals NHS Trust, United

To comfort always: an inter-cultural spiritual care directory for use by front line service providers

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27. Merseyside and Cheshire Cancer Network, United Kingdom

(n.d.) Religious needs resource

Table 2. continued

Guideline issuer Guideline title

28. Metropolitan Chicago Health Council, United States of

America (1999) Guideline for health care providers

interacting with Muslim patients and their families

29. New Zealand Ministry of Health, New Zealand (2001) Refugee health care: a handbook for health professionals

30. Newcastle upon Tyne Hospitals NHS Foundation Trust,

United Kingdom (n.d.) Respecting religious and cultural needs of

patients

31. NHS Education for Scotland, United Kingdom (n.d.) Spiritual care: a multi-faith resource for healthcare staff

32. NHS Grampian, United Kingdom (2009) Religions and cultures in Grampian 33. NHS Wales, United Kingdom (n.d.) Caring for a multi-faith community 34. North Middlesex University Hospital NHS Trust, United

Kingdom (n.d.) Spiritual and cultural care policy directory

35. Premier Health Partners, United States of America (n.d.) Cultural communications guide 36. Queen Elizabeth Hospital NHS Trust, United Kingdom

(2003) Policy for ensuring that religious beliefs

are respected 37. Queensland Health and Islamic Council of Queensland,

Australia (2010) Health care providers‟ handbook on

Muslim patients 38. Roswell Park Cancer Institute Pastoral Care Department,

United States of America (n.d.) Caring across cultures and belief systems 39. Rotherham Doncaster and South Humber Mental Health

NHS Foundation Trust, United Kingdom (2011) Chaplaincy service staff handbook 40. South Devon Healthcare NHS Foundation Trust Religious,

United Kingdom (2007) Spiritual, pastoral and cultural care

41. South Staffordshire and Shropshire Healthcare NHS

Foundation Trust, United Kingdom(n.d) A multi-faith resource for healthcare staff 42. South Warwickshire Combined Care NHS Trust, United

Kingdom (n.d.) Respecting religious and cultural beliefs: a

best practice guide for those involved in the welfare of patients

43. South Staffordshire and Shropshire Healthcare NHS

Foundation Trust, United Kingdom(n.d) A multi-faith resource for healthcare staff 44. St George's Healthcare NHS Trust, United Kingdom (n.d.) A guide to faith and culture

45. Stockport NHS Foundation Trust, United Kingdom (n.d.) Equality and diversity good practice toolkit

46. The Essex Cancer Network, United Kingdom (n.d.) Catching the concept of spiritual care 47. The Oakhill Trust in conjuction with Bromley Hospitals

NHS Trust, United Kingdom (2004) To comfort always: inter-cultural spiritual care directory for use in the health services 48. The Whittington Hospital NHS Trust, United Kingdom

(2002) Respect for privacy, dignity, religious and

cultural belief 49. University of Pittsburgh Medical Center, United States of

America (2009) Interfaith guide: meeting the religious and

spiritual needs of patients and families 50. University of Virginia Health System, United States of

America (2010) Religious beliefs and practices affecting

health care 51. West London Mental Health, NHS Trust, United Kingdom

(2011) Cultural competency toolkit

52. West Suffolk NHS Foundation Trust, United Kingdom

(2010) Directory of Information on faiths and

cultures: Islam 53. Western Cheshire Black and Minority Ethnic Health

Advisory Network, United Kingdom (2010) Western Cheshire culture and belief resource and information file

54. Weston area health NHS Trust, United Kingdom (n.d.) Faith and culture: Islam 55. Wirral Ethnic Health Advisory Group, United Kingdom

(2009) Information and resource file

56. York Hospitals NHS Trust, United Kingdom (2009) The concise guide to the customs of

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Ensuring correct information on the Islamic faith in the guidelines is crucial as they are targeted at non-Muslim healthcare providers who may have little or no knowledge about Islam and would perceive all the information as true. Therefore, the involvement of any knowledgeable Muslim representative during the guideline formulation process is essential to validate the information. Nineteen¹ guidelines (33.9%) on treating Muslim patients were published in collaboration or consultations with local Islamic councils or Muslim believers. Other guidelines do not state whether or not there is any Muslim representative involvement during guideline formulation.

It is important to note that there are different juridical schools in Islam which share the same fundamental principles regarding the faith itself but may differ in their positions on some rituals and rulings on certain issues. All except eleven² guidelines remind that individual practices varies due to various factors such as variances in rulings among scholars of different Muslim sects, personal level of adherence and cultural influence. Hence, it is important to ask the patients themselves regarding their stance and practice on each issue.

Dietary, Medication and Common Medical Procedures

Islam prohibits the consumption of intoxicating substances and porcine-based foods (Qaradawi, 2011a, 84-126). Smoking is ruled forbidden by some scholars while others stated that it is highly discouraged

1 Guideline 1, 3, 4, 5, 19, 23, 24, 25, 28, 29, 30, 31, 32, 37, 38, 43, 49, 50 and 55.

2 Guideline 5, 9, 11, 16, 27, 28, 39, 46, 48, 49 and 55.

(makruh tahrim) (Al-Qaradawi, 2011b, 342).

Permissible animals are slaughtered in a specific way to make them halal (permissible) for consumption (Al- Qaradawi, 2011b, 342). If halal food is unavailable, Kosher (Al-Qaradawi, 2011b, 342), seafood or vegetarian meal may be the alternatives, provided that alcohol and non- halal animal-based ingredients are not used and the food is not prepared or served using utensils contaminated with non-halal substances (Al-Zuhayli, 2002, 162). If utensils previously used to prepare pork dishes are intended to be used, they must be washed cleanly with any cleaning agent according to Hanbali scholars, while Shafii scholars opined that they could only be purified using soil and water (Al-Zuhayli, 2002, 162). Although a majority of Muslim scholars rule that all seafood is permissible, Hanafi scholars opined that only fish is permissible (Al-Zuhayli, 2002, 782). The same rule also applies to any medication.

Alcohol and non-halal animal-based medications are impermissible, unless no other alternative medication is present for the severe illness as this falls under darurah (threatening) circumstances (Al-Zuhayli, 1999, 596-600). Alcohol-containing preparations can be utilized for local applications (Al-Qaradawi, 1995, 517). The whole list of non-halal animals may be long and perplexing to non-Muslims due to variances of opinions among scholars.

Instead, healthcare personnel should inform the ingredients of the meals or medications and ask if the patients are permitted to consume them. The initiatives of providing halal food in hospitals are convenient for Muslim patients but the halal status of the meal provided must be certified (for

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Allowing relatives to bring food for the patients is convenient for the institution and enables patients to have their preferred food. Healthcare personnel ought to know that it is forbidden to use medications containing non-halal substances except in threatening circumstances and this information should be included in all guidelines. Thus, the availability of lists of medication contents is helpful for healthcare personnel dealing with Muslim patients.

Muslim special dietary requirements are emphasized in all the guidelines. Eight³ guidelines assert that Kosher meal is permissible. Two⁴ guidelines do not specifically mention the word Kosher but state that consumption of animal meat

“slaughtered by a Muslim, Jew or Christian with active expulsion of blood” is allowed. The permissibility to consume vegetarian meals and eggs is mentioned in eighteen⁵ and twelve⁶ guidelines respectively. Muslim acceptance of seafood are stated in five⁷ guidelines while the other fifteen⁸ guidelines only mention fish and three⁹ guidelines specify fish with scale. One¹⁰ guideline lists prawns as permissible food. One¹¹ guideline states that shellfish is permissible while another¹² guideline says the opposite. One¹³ of the guideline mentions that hare and predatory birds as haram while another

3 Guideline 1, 17, 23, 35, 38, 49, 52 and 53

4 Guideline 3 and 25.

5 Guideline 2, 6, 7, 8, 10, 17, 18, 20, 22, 24, 28, 30, 31, 35, 37, 49, 52 and 54.

6 Guideline 22, 30, 31, 32, 35, 37, 39, 40, 41, 34, 54 and 56

7 Guideline 17, 19, 23, 35 and 37.

8 Guideline 2, 8, 10, 21, 22, 30, 31, 32, 34, 39, 40, 41, 52, 54, and 56.

9 Guideline 1, 24 and 55.

10 Guideline 52.

11 Guideline 50.

12 Guideline 43

13 Guideline 1.

one¹⁴ lists carnivorous animals and some birds as haram for consumption. All except two¹⁵ guidelines mention prohibitions of porcine-based foods. Only eight¹⁶ guidelines do not state that alcohol is forbidden. Six¹⁷ guidelines (one¹⁸ of which does not specifically mention alcohol) include ingesting all intoxicants, three¹⁹ guidelines include using narcotics, one²⁰ guideline mentions using drugs, and four²¹ guidelines include smoking in the forbidden list. The prohibition of blood products is cited by twelve²² guidelines while the prohibition of carrion is quoted by seven²³ guidelines.

Fifteen²⁴ guidelines recognize that medications containing forbidden substances are problematic for Muslims but seven²⁵ guidelines elaborate that they may be used if no permissible alternative is present for life-threatening or severe illnesses. One²⁶ guideline mentioned that although the use of alcohol-containing hand scrubs is questionable, the use is permissible but healthcare personnel may need an imam to convince the patients. Two guidelines suggested members of staff to refer to the available medicines information for the contents of the medication²⁷ or consult ward pharmacists²⁸.

14 Guideline 55.

16 Guideline 8, 16, 22, 23, 36, 43, 51 and 56.

17 Guideline 3, 17, 23, 25, 35 and 53.

18 Guideline 23.

20 Guideline 1.

21 Guideline 3, 14, 25 and 35.

22 Guideline 2, 6, 17, 18, 19, 22, 31, 36, 37, 41, 54 and 56.

23 Guideline 13, 22, 31, 36, 41, 54 and 56.

24 Guideline 1, 3, 7, 11, 12, 13, 17, 19, 20, 29, 35, 37, 38, 48 and 49.

25 Guideline 3, 17, 19, 20, 29, 37 and 38.

26 Guideline 20.

28 Guideline 1.

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meal is available in some hospitals, while one³⁰ guideline suggests providers to consult the local Islamic council for sources of halal food. Five³¹ guidelines recommend permitting relatives to bring food for the patient. Twelve³² guidelines emphasize that utensils used to prepare or serve non-halal meals should not be used to prepare halal meals. Four³³ guidelines state that halal meals should not be placed or cooked near pork or non-halal food. One³⁴ guideline recommends members of staff to offer disposable dishes and cutleries without giving any explanation to the recommendation. Three³⁵ guidelines state that there is no need to use different utensils but the utensils have to be washed.

The preference for using the right hand when feeding or giving something to the patients is written in nine³⁶ guidelines.

Six³⁷ guidelines assert that Muslims use different hands for eating and toileting purposes. One³⁸ guideline informs that Muslims prefer to eat with their hands (not using for, spoon and knife) and hence, prefer cannulation in the arm. Eight³⁹ guidelines state hand-washing preferences before and after meals.

Twenty-one⁴⁰ guidelines inform that transfusion is acceptable but one⁴¹ guideline states that there are variances in rulings.

29 Guideline 1, 5. 6, 7, 8, 18, 28, 33, 35, 37, 46, 48, 51 and 55.

30 Guideline 19.

31 Guideline 6, 8, 18, 28 and 30.

32 Guideline 2, 8, 10, 13, 22, 31, 36, 37, 45, 51, 52 and 55.

33 Guideline 34, 39, 40 and 41.

34 Guideline 33.

36 Guideline 8, 10, 12, 14, 15, 16, 37, 49 and 55.

37 Guideline 22, 23, 31, 32, 41 and 54.

38 Guideline 33.

39 Guideline 1, 19, 20, 30, 37, 39, 40 and 43.

40 Guideline 3, 5, 10, 11, 12, 13, 15, 19, 22, 25, 28, 32, 36, 38, 39, 41, 42, 44, 46, 54 and 55.

41 Guideline 45.

Three⁴² guidelines assert that personal preference regarding transfusion varies.

Sixteen⁴³ guidelines affirm that organ donation is acceptable in Islam but five⁴⁴ guidelines assert that there are differences in rulings among scholars regarding the procedure. However, ten⁴⁵ guidelines state that it is a personal choice to accept or decline the procedure. Sixteen⁴⁶ guidelines state that organ transplantation is allowed.

One⁴⁷ guideline states that organ transplant is allowed with restriction such as not using porcine products. One⁴⁸ guideline informs that there is differences in ruling of the procedure while another⁴⁹ guideline specifies that there are variances in rulings regarding organ transplantation between two living persons. However, four⁵⁰ stated that it is a personal choice. Explanation on the presence of variances in rulings by Muslim scholars may be useful to prevent confusion among non-Muslim healthcare personnel.

Fasting Obligation

During the holy month of Ramadan, Muslims fast from dawn to dusk, abstaining orally (including smoking) and sexually (Al- Zuhayli, 1995, 715-756). Menstruating and women with post-partum bleed are exempted from fasting while pregnant, lactating women, the sick and travelers may be excused from fasting (Al-Zuhayli, 1995, 715-756). Like other Islamic obligations, fasting is non-obligatory for children before reaching puberty, although many start

43 Guideline 3, 4, 5, 27, 6, 17, 18, 23, 25, 28, 32, 36, 41, 44, 48, 50, 54 and 55.

44 Guideline 8, 12, 20, 42 and 45.

45 Guideline 6, 12, 18, 27, 39, 41, 48, 49, 54 and 55.

46 Guideline 3, 11, 13, 15, 19, 23, 28, 32, 36, 41, 44, 38, 39, 46, 54 and 55.

47 Guideline 28.

48 Guideline 37.

49 Guideline 14.

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injectable, sublingual, transdermal, eye drop, eardrop, inhaled medications, per rectal and per vaginal procedures do not impair fasting unless a nutritious substance is given (Islamic Fiqh Academy, 2000, 205-207), they are not preferred, hence, are recommended to be postponed until the breaking of fast.

Muslim obligation to fast is written in all except two⁵¹ guidelines. Among all the guidelines that address this issue, only five⁵² guidelines do not explain that the period of fasting is from dawn to dusk. All except thirteen⁵³ guidelines elucidate that a sick person is exempted from fasting. Six⁵⁴ guidelines only state that pregnancy grants exemption from fasting, seven⁵⁵ other guidelines only mention breastfeeding as a permissible excuse not to fast, while thirteen⁵⁶ other guidelines include both.

Sixteen⁵⁷ guidelines inform that menstruation grants an excuse not to fast.

Eight⁵⁸ guidelines state that fasting is not mandatory for children while three⁵⁹ other guidelines specify that the rule applies to pre-pubertal children, five⁶⁰ guidelines state below twelve and two guidelines state below ten⁶¹ years old. Old age and travelers are listed as individual groups granted fasting exemption in fourteen⁶² and twelve⁶³

52 Guideline 18, 33, 35, 44 and 50.

53 Guideline 2, 3, 12, 21, 23, 25, 27, 33, 35, 41, 42, 49 and 50.

54 Guideline 19, 28, 44, 45, 47 and 55.

55 Guideline 13, 22, 31, 36, 41 and 54.

56 Guideline 4, 5, 8, 10, 11, 14, 16, 23, 29, 32, 37, 46 and 51.

57 Guideline 1, 4, 10, 11, 13, 14, 22, 29, 31, 32, 36, 37, 41, 53, 54 and 55.

58 Guideline 4, 8, 16, 19, 33, 37, 44 and 52.

60 Guideline 4, 15, 30, 46 and 52.

62 Guideline 4, 5, 8, 14, 15, 16, 22, 31, 37, 41, 46, 51 and 54.

guidelines respectively. Eleven⁶⁴ guidelines also highlighted that although people in those categories are exempted, the individuals may still decide to fast. The obligation to fast the missed fasting days at a later time is also explained by twenty⁶⁵ guidelines. Twenty-five⁶⁶ guidelines advise providers to arrange pre-dawn and post- dusk meal for hospitalized fasting patients.

Abstinence from food and drink during fasting is cited by twenty-eight guidelines⁶⁷. Eight⁶⁸ guidelines include smoking and twelve⁶⁹ guidelines list sex in the fasting abstinence list. Three⁷⁰ guidelines claim that those who fast are forbidden to indulge in pleasurable activities – this statement may be untrue as only pleasurable activities related to eating, drinking, smoking and sexual activities would invalidate fasting.

Five⁷¹ guidelines state that essential drugs and medicine could be administered during Ramadan. One⁷² guideline affirms that injections invalidate fast. Seven⁷³ guidelines state that injections do not annul fasting but two⁷⁴ of them clarify that intravenous injections of nutritious substances nullify fast. Four⁷⁵ guidelines mention that eye drop application does not affect fast.

63 Guideline 4, 14, 15, 22, 30, 31, 32, 37, 41,53, 54 and 55.

64 Guideline 1, 4, 5, 8, 14, 15, 20, 22, 29, 31, 40, 41, 46, 51, 52, 54 and 55.

65 Guideline 8, 14, 15, 16, 30, 32, 36, 37, 46, 51, 52 , 53 and 55.

66 Guideline 1, 4, 5, 6, 9, 14, 18, 19, 20, 22, 24, 26, 30, 31, 33, 34, 39, 40, 41, 46, 47, 48, 51, 52 and 54.

67 Guideline 2, 4, 5, 8, 9, 11, 15, 16, 19, 20, 21, 22, 24, 27, 29, 31, 32, 37, 41, 43, 44, 46, 48, 51, 52, 53, 54 and 55.

68 Guideline 2, 4, 8, 16, 29, 51 and 53.

69 Guideline 2, 4, 5, 8, 9, 11, 16, 32, 46, 44, 51 and 53.

71 Guideline 1, 6, 18, 39 and 40.

72 Guideline 52.

73 Guideline 4, 5, 14, 15, 37, 46 and 51.

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rectal pessaries negate fasting and another guideline⁷⁷ advises practitioners not to obtain cervical smears. One⁷⁸ guideline asserts that the application of ear drops nullifies fast but another guideline states the opposite. Two⁷⁹ guidelines add that intravenous dye does not break fast. Two⁸⁰ guidelines state that nose drops nullify fasting. One⁸¹ guideline also added that inhaled medications nullify fasting but using medications absorbed through skin and gargling without swallowing do not. It is stated in the one guideline that “for some Muslims, participation in invasive medical procedures may be prohibited”⁸². Twelve⁸³ guidelines suggest providers to accommodate medication schedules and appointments.

Hygiene Practices

Hygiene is another important entity in Islam. One‟s private parts are preferably cleaned with water after urination and defecation (Al-Zuhayli, 2002, 175). A Muslim is also required to clean himself at least five times daily during ablution before each prayer (Al-Zuhayli, 2002, 188). In certain conditions such as after menstruation, post-partum bleeding and seminal discharge, a full ablution bath (ghusl) is required (Al-Zuhayli, 2002, 332-340). If it is impossible for patients to use water for ablution purposes due to various clinical reasons, tayammum (dry purification) may be performed using clean earthy dust (Al- Zuhayli, 2002, 395-396).

77 Guideline 51.

78 Guideline 4.

79 Guideline 5 and 46.l

81 Guideline 37.

82 Guideline 29.

83 Guideline 5, 12, 22, 24, 29, 31, 32, 41, 46, 51 and 54.

All except twenty⁸⁴ guidelines acknowledge the need for water for cleaning purposes after urination and defecation, while one⁸⁵ guideline suggests the use of wet towels if water is absent.

Preference for shower over bath or sponge bath is stated by twenty-five⁸⁶ guidelines.

Two⁸⁷ guidelines assert that a full bath is mandatory after seminal discharge, twenty- one⁸⁸ guidelines state after menstruation, one⁸⁹ guideline mentions after childbirth and one⁹⁰ guideline mentions after sex and one⁹¹ guideline lists after the post-natal bleed. Two⁹² guidelines only mentioned menstruation as a reason for a full bath.

The need for washing specific parts before prayer (ablution) is also mentioned in all except seven⁹³ guidelines. Six⁹⁴ guidelines state that dry ablution (tayammum) is alternative to using water if it is medically advisable.

Six⁹⁵ guidelines mention the preference for the left hand for washing the private parts after toileting while one⁹⁶ guideline only stated that private parts are washed with hand without stating preferences. As stated previously, six⁹⁷ guidelines do not specifically inform preference of using the right or left hand for eating; instead, both guidelines assert that Muslim use different hands for eating

84 Guideline 3, 4, 6, 11, 15, 18, 21, 24, 25, 26, 28, 30, 34, 38, 44, 45, 47, 49, 50 and 53.

85 Guideline 17.

86 Guideline 1, 2, 5, 7, 8, 10, 12, 22, 23, 27, 31, 32, 33, 39, 41, 42, 43, 45, 46, 51, 52, 54, 55 and 56.

88 Guideline 5, 7, 8, 9, 12, 13, 22, 27, 31, 32, 36, 37, 41, 42, 45, 46, 48, 52, 54, 55 and 56. 54.

89 Guideline 45.

90 Guideline 52.

91 Guideline 37.

93 Guideline 17, 25, 28, 30, 35 and 38

94 Guideline 6, 7, 18, 19, 37, 45 and 50.

95 Guideline 8, 12, 15, 14, 16, 19 and 52.

96 Guideline 33.

97 Guideline 22, 23, 31, 32, 41 and 54.

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specify that due to the reason, many prefer to have lines on the right hand but individual preference should be clarified.

One⁹⁹ guideline states cannulation preference in arms for Muslims.

Daily Prayers

Five daily prayers facing Mecca is one of the five pillars of Islam. It is mandatory for every adult Muslim except during menstruation or when women are having bloody discharge postpartum (Al-Zuhayli, 2002, 579-98). Prayers could be performed anywhere on a clean surface (Al-Zuhayli, 2002, 579-98). Each prayer takes about five to fifteen minutes. Those who could not stand are given relaxation to perform prayers in a sitting or even a lying position (Al-Zuhayli, 2002, 660-68). Some scholars also opined that sickness allows someone to combine the second prayer with the third prayer and the fourth prayer with the fifth prayer (jama’) (Al-Zuhayli, 1995, 372-81).

Weekly Friday prayer is also obligatory for all Muslim men (Al-Zuhayli, 1995, 284). If he is fit to leave the health care facility for an hour, then he should be allowed to do so unless no mosque is available nearby.

All except two¹⁰⁰ guidelines mention the obligation to perform five daily prayers.

One¹⁰¹ guideline does not specifically mention the number of prayers. One of the guidelines stated that Muslims need to pray

“not less than three times a day”¹⁰². Another¹⁰³ guideline presented this in a better way in their guideline by saying that allowed to combine noon and afternoon, and sunset

99 Guideline 33.

101 Guideline 23.

102 Guideline 21.

103 Guideline 50.

and evening prayer. Twelve¹⁰⁴ guidelines state that congregational prayer is held on Friday. Although one¹⁰⁵ guideline mentions special prayer on Friday, it did not mention the nature of the prayer (congregational prayer done at mosques). Four¹⁰⁶ guidelines state that prayers are not offered during menstruation while one¹⁰⁷ guideline mentions two other exempted situations which are mentally incapacitated and during post-natal discharge. One¹⁰⁸ guideline adds a few other exempted situations including being mentally incapacitated, ill and for forty days after giving birth while another guideline states that post-partum patients are exempted from praying for ten days¹⁰⁹.

Five¹¹⁰ guidelines explain the movement involved while praying which include standing, bowing, prostrating and sitting. One¹¹¹ guideline only mentions kneeling and bending, another¹¹² guideline mentions kneeling and prostrating, one¹¹³ guideline only mentions kneeling, while another¹¹⁴ guideline only mentions prostrate. Prayer relaxation (rukhsah) for the ill is mentioned in a few guidelines: ten¹¹⁵ guidelines mention sitting while four¹¹⁶ guidelines state lying down and six¹¹⁷ guidelines state on the bed. One¹¹⁸ guideline states that advice should be encouraged by an imam for those who cannot pray normally.

104 Guideline 1, 2, 7, 8, 15, 17, 28, 30, 32, 38, 44 and 45.

105 Guideline 37.

106 Guideline 1, 14, 50 and 51.

107 Guideline 37.

108 Guideline 51.

109 Guideline 50.

110 Guideline 7. 16, 37, 49 and 52.

111 Guideline 20.

112 Guideline 15.

113 Guideline 19.

114 Guideline 32.

115 Guideline 6, 8, 13, 16, 17, 18, 19, 24, 37 and 55.

116 Guideline 6, 16, 19 and 55

117 Guideline 7, 8, 13, 17, 37 and 49.

118 Guideline 20.

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direction of qiblah (Makkah) for prayer at their locations. Two¹²⁰ guidelines encourage permanent signs to be displayed while another¹²¹ guideline mentions that qiblah finders can be purchased. Regarding prayer area criteria, twenty-one¹²² guidelines mention clean, eleven¹²³ guidelines state quiet, thirteen¹²⁴ guidelines cite privacy- friendly (such as drawing curtain and secluded area) and three¹²⁵ guidelines assert free from religious icons. Three¹²⁶ guidelines explain that “privacy is appreciated but not essential”. One¹²⁷ guideline states that a prayer room with an ablution facility is preferred. Twenty-one¹²⁸ guidelines recommend offering prayer mats, clean sheets or clean towels for patients to pray.

One¹²⁹ guideline states that the mat should not be touched by anyone ritually unclean.

Modesty

Modesty is an important element in the Islamic faith. Muslim men have a religious obligation to cover from the navel to the knee while women are responsible to cover the whole body except the face and hands (and feet according to some scholars) with loose clothes to obscure one‟s figure (Al-Zuhayli, 2002, 598-616). Allowing patients to wear their clothes (if the gowns

119 Guideline 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 15, 16, 19, 22, 24, 25, 26, 27, 31, 32, 33, 34, 35, 36, 37, 39, 41, 42, 43, 46, 47, 48, 50, 52, 53, 54, 55 and 56.

121 Guideline 14.

122 Guideline 2, 7, 8, 10, 14, 15, 16, 24, 25, 28, 32, 33, 35, 37, 43, 48, 49, 52, 53 and 55.

123 Guideline 4, 8, 14, 22, 28, 29, 31, 32, 35, 37 and 54.

124 Guideline 2, 4, 5, 8, 16, 22, 24, 31, 32, 37, 49, 50 and 54.

125 Guideline 19, 28 and 37

127 Guideline 19

128 Guideline 2, 3, 6, 7, 8, 10, 15, 16, 18, 24, 25, 29, 33, 37, 44, 46, 48, 49, 51, 52 and 55.

129 Guideline 50

do not provide adequate coverage) would reduce uneasiness among patients. Limiting cross-gender interaction (including eye contact and physical contact) is prescribed unless for pressing needs. Medical staff are advised to announce themselves before entering the room and give the patients some time to be decent.

Eighteen¹³⁰ guidelines explain the obligation for Muslim women to cover the whole body except the hands and face but six¹³¹ guidelines state that covering body parts is a personal choice. However, only twelve¹³² guidelines mention that men also have mandatory parts to be covered (navel to knee). Two¹³³ guidelines add that clothes should not be tight or transparent. Three¹³⁴ guidelines reiterate that the definition of modest dressing may vary among individuals. Four¹³⁵ guidelines also highlight that if long-sleeved long gowns are unavailable, then Muslim women should be allowed to wear their own. The importance of minimizing exposure during examination is addressed by ten¹³⁶ guidelines.

Preference for same-gender practitioners is mentioned in twenty-four¹³⁷ guidelines with five¹³⁸ of the guidelines emphasizing that it is even more important for female patients. The other twenty-one¹³⁹ guidelines specifically state that female patients prefer females without extending the same-gender generalization to males.

130 Guideline 6, 10, 11, 18, 33, 38, 43, 49, 52 and 53.

131 Guideline 6, 18, 22, 23, 31 and 32.

132 Guideline 7, 8, 10, 11, 16, 17, 33, 37, 51, 52, 53 and 56.

135 Guideline 19, 28, 35 and 51.

136 Guideline 8, 19, 20, 23, 28, 29, 35, 51 and 53.

137 Guideline 1, 2, 3, 4, 7, 8, 10, 11, 12, 16, 17, 19, 20, 21, 25, 29, 35, 37, 42, 49, 51, 52, 53 and 56.

138 Guideline 3, 25, 28, 37 and 49.

139 Guideline 13, 14, 15, 22, 23, 27, 24, 31, 32, 33, 36, 38, 39, 40, 41, 43, 44, 45, 50, 54 and 55.

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labor. One¹⁴¹ guideline encourages providers to explain the need and importance of more invasive examination or procedure, more importantly when same-gender providers are unavailable.

Seventeen¹⁴² guidelines address Muslims‟

discomfort in sharing the same space (for example, ward, and swimming pool) with the opposite genders. Four¹⁴³ guidelines mention the etiquette of limiting eye contact. Eighteen¹⁴⁴ guidelines affirm that female patients may prefer family members such as husbands or female relatives to be present during consultation or procedure.

Twenty-four¹⁴⁵ guidelines inform that unnecessary physical contact (including handshake) is forbidden. Six¹⁴⁶guidelines recommend arrival announcements and providing some time before entering the patients‟ spaces to allow patients to dress appropriately. One¹⁴⁷ guideline enunciates the importance of complete curtain screening during physical examination or ward procedures to safeguard patient privacy.

Sexual Health and Birth Rites

Temporary reversible contraceptions are allowed in Islam for married couples but not permanent irreversible contraception techniques and emergency contraception, without any absolute contraindication to pregnancy (Al-Zuhayli, 1999, 639-40).

Abortion is only allowed on solid medical grounds such as a threat to the mother‟s

140 Guideline 6, 18, 30, 32 41 and 54.

141 Guideline 37.

142 Guideline 1, 2, 4, 7, 8, 13, 14, 16, 22, 23, 31, 32, 33, 36, 45, 53 and 54.

143 Guideline 6, 20, 28 and 35

144 Guideline 4, 6, 8, 18, 20, 22, 23, 24, 26, 28, 31, 32, 37, 41, 48, 51, 53 and 54.

145 Guideline 6, 7, 11, 14, 18, 20, 21, 22, 23, 27, 28, 31, 32, 33, 35, 38, 39, 41, 43, 44, 51, 53, 54 and 55.

146 Guideline 3, 20, 25, 28, 29 and 44.

147 Guideline 29.

life. Having fetal anomalies incompatible with life is a sound medical reason for abortion according to some scholars (Al- Qaradawi, 1995, 384). Companionship during labor is strictly female-or-mahram only (mahram is the husband or family members who are unlawful to marry that person). The number of staff must be minimized even if they are all women. Soon after delivery, prayers (adhan) might be whispered to the baby‟s ears (Al-Zuhayli, 1999, 733-37). Some sweet foodstuff such as honey is rubbed on the lips and palate, a prophetic tradition called tahniq (Al-Zuhayli, 1999, 733-37). The head is encouraged to be shaved and according to some scholars it is recommended to do it on the seventh day (Al-Zuhayli, 1999, 733-37). There are different opinions among scholars regarding male and female circumcision (Al-Zuhayli, 1999, 733-37). Other rituals are mostly cultural and not religious. Mothers are encouraged to breastfeed their babies until two years of age (Al-Zuhayli, 2001, 871-74).

However, the milk bank practice is unacceptable because the baby and the milk donor will become a family, hence he cannot marry any of her children (Islamic Fiqh Academy, 2000, 9-10). Aborted fetuses of more than four months and stillborn babies must be buried according to the Islamic rituals (Al-Zuhayli, 1995, 489).

Six¹⁴⁸ guidelines state that contraception is forbidden, one¹⁴⁹ guideline affirms that there are differences in opinion and two¹⁵⁰ guidelines mention that contraception is discouraged. Ten¹⁵¹ guidelines reiterate that individual practices regarding contraception vary while ten¹⁵²

148 Guideline 22, 31, 34, 40, 41 and 54.

149 Guideline 32.

151 Guideline 6, 17, 18, 22, 31, 32, 34, 41, 42 and 54

152 Guideline 13, 14, 15, 23, 24, 36, 37, 40, 44 and 50.

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certain conditions. Two¹⁵³ guidelines specify that post-coital contraception is forbidden.

Three¹⁵⁴ guidelines mention that assisted reproduction is only permitted for married couples during the span of their marriage while one guideline only states that it is permissible¹⁵⁵. One¹⁵⁶ guideline asserts that surrogacy is forbidden and two¹⁵⁷ guidelines state that genetic testing and gene manipulation is acceptable for therapeutic purposes. Four¹⁵⁸ guidelines state that abortion is impermissible. Nineteen¹⁵⁹ guidelines assert that abortion is only acceptable for sound medical reasons such as endangering the mother‟s life (stated by sixteen¹⁶⁰), fetal anomalies¹⁶¹, rape conception¹⁶². Two¹⁶³ guidelines state that Muslims are reluctant to abort even if fetal anomalies are detected. One¹⁶⁴ guideline adds that it is permissible if the mother stopped lactating for another child and the pregnancy is before 120 days. One¹⁶⁵ guideline reminds that individual practices regarding abortion vary. Two¹⁶⁶ guidelines say that an aborted product of conception before 130 days is treated as discarded tissue; after 130 days, as a human being, without mentioning funeral requirements.

The requirement for proper burial ceremonies for dead fetuses is described by

155 Guideline 11.

156 Guideline 37.

159 Guideline 3, 6, 7, 14, 15, 17, 18, 23, 24, 25, 28, 29, 33, 37, 38, 40, 44, 48 and 50.

160 Guideline 3, 6, 7, 14, 17, 18, 23, 24, 25, 28, 29, 33, 37, 38, 44, 48 and 50.

164 Guideline 50.

165 Guideline 28.

two¹⁶⁷ guidelines, while other guidelines specify the gestation period of dead fetuses requiring proper burial: one¹⁶⁸ guideline writes “more than 120 days”, another¹⁶⁹ guideline states “more than thirteen weeks”, five¹⁷⁰ guidelines assert “more than four months” and eight¹⁷¹ guidelines mention

“more than 130 days”. One¹⁷² guideline states that there is no funeral requirement for still born or non-viable fetus.

Four¹⁷³ guidelines assert that husband is not usually present during labor. This may be cultural norms as there is no such prohibition in Islam. One¹⁷⁴ guideline writes the contrary that husbands may request to be present. Four¹⁷⁵ guidelines suggest female relatives or friends accompany patients if their husbands cannot be present. Seven¹⁷⁶ guidelines mention that internal examination may be refused. One¹⁷⁷ guideline addresses maternity and sexual health issues under the culture segment instead of the Islamic religious segment, hence many of the items are culturally based such as special food preparation, warm clothing, bad luck following baby praising, colostrums not good for children and the exact recording of the time of birth for astrological purposes. One¹⁷⁸ guideline states that “mothers who just given birth are given a special diet of nutritious concentrated chicken soup which the family may bring in daily”: a cultural practice that is not religiously rooted.

Two¹⁷⁹ guidelines write about proper

168 Guideline 37.

169 Guideline 36.

170 Guideline 22, 31, 32, 41 and 54.

171 Guideline 5, 9, 13, 23, 27, 46, 50 and 55.

172 Guideline 48.

173 Guideline 3, 25, 29 and 30.

174 Guideline 14.

175 Guideline 3, 17, 25 and 44.

176 Guideline 6, 18, 22, 30, 31, 32 and 41.

177 Guideline 29.

178 Guideline 30.

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is cleaned and buried but this practice is not mandatory. Six¹⁸⁰ guidelines mention that baby is washed soon after birth. Seven¹⁸¹ guidelines state that shaving off the head is preferably on the seventh day, two¹⁸² guidelines write that on the sixth or seventh day while another¹⁸³ guideline mentions within six weeks. Seven¹⁸⁴ guidelines explain about tahniq with chewed dated, honey or anything sweet. One¹⁸⁵ guideline recommends practitioners warn the risk of botulism infection following the feeding of honey to infants under one year old.

Twenty-eight¹⁸⁶ guidelines write only on prayer recitation after birth. Five¹⁸⁷ guidelines assert that Islam encourages breastfeeding up to two years old. One¹⁸⁸ guideline affirms that nursing others‟ babies lead to the formation of relationship similar to the biological relationship. Male circumcision practice is addressed in fifteen guidelines¹⁸⁹. Twelve¹⁹⁰ guidelines write that male circumcision is to be done as soon as possible, five¹⁹¹ guidelines state on the seventh day, three¹⁹² guidelines assert within the first month, six¹⁹³ guidelines write before puberty and another six¹⁹⁴ guidelines do not mention the timeframe for

180 Guideline 7, 8, 16, 50, 52 and 56.

181 Guideline 7, 8, 16, 37 and 53.

183 Guideline 30.

184 Guideline 8, 16, 23, 32, 37 and 53.

185 Guideline 37.

186 Guideline 6, 7, 8, 11, 13, 14, 16, 17, 18, 19, 20, 23, 24, 28, 30, 31, 32, 33, 36, 37, 41, 44, 50, 51, 53, 54 and 56.

187 Guideline 3, 24, 25, 37 and 55.

188 Guideline 37.

189 Guideline 3, 8, 12, 13, 14, 15, 16, 17, 28, 36, 37, 41, 42, 44 and 54.

190 Guideline 6, 12, 13, 18, 21, 22, 30, 31, 36, 41, 42 and 54.

191 Guideline 7, 8, 16, 50 and 53.

193 Guideline 14, 15, 29, 37, 50 and 53.

194 Guideline 3, 17, 25, 33, 44 and 56.

circumcision. Seven¹⁹⁵ guidelines affirm that female circumcision is not religiously mandatory and two¹⁹⁶ guidelines assert that male circumcision is only strongly encouraged.

Family and community relation

Two¹⁹⁷ guidelines recognize the need to involve the family in decision making while the other six¹⁹⁸ specifically recognized the need to involve the head of the family.

Frequently, Muslim patients have many visitors because visiting the sick is an obligation (Al-Zuhayli, 1995, 468).

Eighteen¹⁹⁹ guidelines explain this obligation and the high probability of Muslim patients receiving high number of visitors.

End of life

Relatives and friends will gather around the dying one to recite Quran and teach him to say the syahadatayn, the declaration of faith where there is only one God and Muhammad is the last messenger (Al-Zuhayli, 1995, 476-81). If no one is around the patient, the local imam may be helpful. Muslims are encouraged to turn the dying person‟s face or the whole body towards qiblah (Al-Zuhayli, 1995, 476-81).

The deceased must be treated with respect and gentle care. The rules regarding gender segregation and body parts required to be covered, which also apply to the dead have been discussed above. Post-mortem procedures must be avoided and minimized unless necessary (Al-Zuhayli, 1999, 603- 604). Burial is done as soon as possible (Al- Zuhayli, 1995, 479), preferably within 24 hours. Withdrawal of treatment for

195 Guideline 8, 15, 22, 31, 32, 41 and 54.

198 Guideline 1, 11, 14, 35, 49 and 50.

199 Guideline 1, 2, 6, 8, 11, 16, 18, 19, 22, 28, 31, 33, 37, 38, 39, 43, 54 and 55.