Corona and the fatwa problem regarding the right to treatment when overcrowding

One of the sheikhs working in the purposes of Sharia law was asked who would have priority in treating people with the Coronavirus, if the patients crowded and the necessary equipment was not available to everyone. He only said: The former is offered, the first of whom is afraid of opening the door of manipulation and moods.

As for the European Council for Fatwa and Research, it answered - in its last meeting - that “Muslim doctors must adhere to the medical systems and regulations in the hospitals where they work. If they are entrusted to them, they must govern medical, ethical, and humanitarian standards. It is not permissible to remove devices from a patient who is treated in favor of If a doctor is confused between two patients so that he no longer has a choice but to choose one of them, he will offer the first, unless he is hopeless for his recovery, and [provides] who needs urgent medical assistance to whom his condition allows for delay, and who is requested to recover from whom Please, do not think so medical".

These two answers reflect the way the Mufti of today thinks about complex and highly sensitive issues, as some of them tend to general answers or easy and technical solutions, and are resolved in complex issues that need deep and detailed research and discussion befitting the issue itself, and seriously satisfy Islamic jurisprudence and ethics, far from such urgent answers And minor, because it relates to spirits on the one hand, and the complexities of the relationship with the state and its institutions, and the relationship of members of society with each other, and with specializations and details that the mufti himself may not be familiar with and then he should research and consult in it.

In this article, I will deal with the problem of the mufti in this matter, on the condition that I dedicate an upcoming article to explain how an Islamic position can be formulated in this regard.

The first answer does not only reflect lightness; it lacks a correct perception of the subject and its complexities that relate to other scientific fields: public health and medical ethics, as well as the rules of budgeting in Islamic jurisprudence that are absent here. Precedence here does not include a normative value, because the mufti confuses a competitive precedence in the act of good deeds, where the temporal factor has its value in the differentiation between individuals, and the precedence in the arrival of a patient to the hospital, which is a procedural matter that is not worth the value.

If we follow precedence at all, then this means that fatal issues will be the only ones critical; those who live near hospitals will be lucky, unlike those who live apart from them in the outskirts and villages; that is, filling the pretext of manipulation that constitutes the only concern for this mufti made him bias - unconsciously - against the poor and residents Parties, because hospitals are not distributed throughout the geography of each country; then what if they came together? What value do we seek to maintain here?

And when the European Council decides that it is not permissible to remove a person's breathing apparatus for the sake of a person who came after him, he will return to the same precedence criterion; but what if this patient will not dispense with the device for a long time while there is a need for it? What if the patient on the device is hopeless to treat and will never dispense with the device? Is removing the device in this case considered killing or not? What if removing the device in this case would save a number of patients versus one person? Is there a difference between whoever pays for the device itself and who receives treatment for free?

Many questions show the extent of the improvisation of the Council in deciding cases that did not meet its research, and did not seek the help of specialists in the field of medical ethics, and did not refer to the rules of jurisprudence and weighting and the balance between interests.

The other problem is that this issue is not subject to a fatwa fatwa only, because we are not talking about individual behavior or options in which the mufti is decided, but rather a topic that should be based on a general state policy that the hospitals implement, so that the issue is not subject to the choice of each hospital or doctor, and then The door to manipulation or personal judgment will be broad here.

The Fatwa of the European Fatwa Council evoked the organizational dimension, and therefore I began to instruct the doctor to follow the instructions and regulations followed in the hospital where he works, but apparently her obsession - seeking to introduce the criterion of integration in European reality over others, which is issued by a vague idea on the subject of the fatwa because it assumes There are stable regulations and legislations, and the matter is reduced to the regulations of each hospital that alone constitutes the doctor's reference.

If there are no regulations, the council refers the doctor to general medical and human principles; without realizing that there are no agreed principles in this regard; that we are facing a situation in which a set of principles is contradictory, and that the principles are always total, and their applications are subject to different interpretations and assessments, according to the complexities of reality and space Available to Ijtihad, who downloads these principles to cases; this means that the European Council refers the matter to the jurisprudence of the physician himself, because the Council deals with the matter procedurally, rather than values.

Moreover, this issue is not the prerogative of the hospital or the doctor; rather, it refers to the field of medical ethics, because we are faced with a normative issue and not procedural or organizational, and it also has legal dimensions, so its moral aspect is not only related to determining who is more deserving, but rather is related to ensuring the implementation of standards and directives. In an ethical and fair way, to avoid making individual decisions and preferences (from the doctor) or administrative (from the hospital); that is, the decision must be vested in a body other than the doctor and the hospital administration, and with the guidance of a higher authority, as long as we speak of saving lives.

The Council brings us back to the criterion of "precedence" in the event of confusion from the doctor, without clarifying the principles and criteria of weighting, nor the reason for the confusion, and are patients equal in every aspect until they resort to the former of them? Is precedence the same value criterion?

And if we go back to the original answer of the council - which is "following the regulations" - then we do not find - until now - agreed rules and principles in this case, so that they are complied with in hospitals; we are talking about an emergency that posed one of the most complex ethical dilemmas today, whether in terms of The development of modern technologies or in terms of advancing ethical debates and human rights discourse, as they lead us to seemingly primitive options and belong to the capabilities of pre-modern times.

In Italy, for example, the age criterion was adopted to give priority to young people, and in Germany, the comparison between patients on the basis of age and marital status was rejected. But if the options are absent and only the option of choice - which is an "inevitable evil" due to insufficient equipment and the large number of patients who need intensive care - remains, the German document provides three conditions here to stop providing superior or focused treatment, namely: that the patient enter It is physically in the stage of death, that it is hopeless to be cured, and that survival is only guaranteed by staying in intensive care. The patient's condition is evaluated according to five criteria that you have identified that relate to the nature of the danger that threatens him: the degree of consciousness, blood loss, temperature, duration of illness, and the amount of pain.

In an article published by The New York Times, Sherry Fink indicated that the US federal government has not yet provided guidelines for legalization in light of the outbreak of the virus, while discussions are taking place between officials from different states, medical societies, and hospitals about their own plans, That is, the field will be open to very different decisions in this regard.

Some US states - where the virus has spread, such as Alabama, Utah, and Tennessee, have seen a suggestion that certain people be left without a respirator; when all patients are not satisfied, the list of leftovers includes patients with cerebral palsy, autism, and advanced dementia.

The third problem is that it was absent from these fatwas that the debate is about a “state of emergency”, which is not a stable or fixed case. The spread of the epidemic occurs suddenly and is open to daily variables as we see in the Corona virus, which means that it can be talked about here to reassess the level of availability of devices Available on a daily basis to restrict recourse to the option of depriving some patients of due care as much as possible and based on accurate calculations. And if the previous fatwas discussed the values ​​and how to download them and differentiate between them, then they would give way to this part, instead of talking about general, undisciplined directives.

The fourth problem is that the theoretical framework was absent from previous fatwas, as was the setting of disciplined standards required for evaluating a specific application case. The mufti is partially responsible for the applications of his fatwa, which is different from discussing an abstract or total issue in the field of theoretical ethics.

By the theoretical framework here we mean discussing the governing values ​​of this topic and the ways of differentiating between them, and providing the necessary explanations ethically and juristically, and this framework is necessary to evaluate the applied cases so that they are downloaded and built, and the necessary explanations that make it ethical or immoral, and not being satisfied with general and vague phrases such as (should not be permitted) Because these muftis are not streets, and their sayings themselves are not a normative authority; rather, their arguments and explanations are the ones that acquire the authentic and normative characteristic, or that they do not acquire, and this is a methodical point that will be difficult for those who are passionate about the personalization of words and fatwas.

The mufti could have formulated a more serious position if he had specified the central values ​​that are balanced here, namely: life preservation, justice and equality, because the choice among patients would be violated by this, and then he would resort to exhausting the effort to achieve the highest interests of the largest possible number of people, then ensure Implement this fairly and transparently, and then discuss whether this or that criterion is the most appropriate to achieve this value.

Calendar and redress will be possible later according to the course of applications and the new information that it will reveal, because the value is present and is the criterion, not the person or judgment (may or may not), and this is within the meaning of "pay and approach", which is a continuous ethical process that seeks to achieve the value of payment and the value of approach as much Payment is possible; if not fully achieved.

It is also important here to say that discussing the value of life includes a distinction between saving life itself and prolonging the life of an expected period, and the trade-off between whether life itself is a value, or that the value is constant for the quality of life; and this discussion will take us to difficult paths, perhaps the closest: who determines the quality A life that deserves respect? How is it determined?

Based on this, the discussion referred to earlier regarding delaying patients with paralysis, autism, dementia, and others is presented, because this proposal adopts an assessment of the quality of life, not life itself. On the other hand, there is no doubt that defenders of the rights of persons with disabilities will take sides with this group, because it is a vulnerable group who need increased attention.

The mufti was busy here with a partial question: "Who is entitled to apply for treatment?", But it was missed that the discussion is about "intensive care" only because of the small number of devices or beds, but this does not mean neglecting these patients completely; rather, other forms of Possible care, even for those who are hopeless or doomed, is a recent topic that is receiving attention and called palliative care, and the Mufti is one of the first people to talk about this type of care.

The first option for the European Council was to follow the hospital’s regulations and instructions, although its function is not to guide people to their duty legally or professionally (we call it an industrial duty), but rather to show the religious and moral duty in this regard, because it is based on determining the will of the street that entails sin and reward, It is not only about following laws and administrative regulations that revolve around safety from punishment, or maintaining a job inside the hospital by not violating its regulations.

This does not mean neglecting reality and laws and regulations, but criticism of unilateral consideration in this way, especially in this case that is shrouded in ambiguity and difference as before, without this means that the separation between legal and moral is a complete separation, but may overlap and may separate.

We can refer here to two important models in dealing with this issue, which the European Council could have sought at least with them; the first model is the directives issued by the British Medical Association when urging doctors - in the event of scarcity of resources - to observe three criteria: 1 Severe disease severity; 2. co-morbidity; 3. fragility due to aging. But - at the same time - she made it clear that just getting a corona does not require treatment priority over other serious diseases.

The second most important model here is the article published by one of the most prestigious scientific journals in the world and is the magazine (The New England Journal of Medicine); and although it consists of a few pages, it was written by ten specialized professors from different universities, and the comparison between this article and the answer that opened There is a lot of frying pan here!

The article talked about four basic ruling values ​​here: maximizing interests despite a lack of devices, treating people as equals, estimating available devices as valuable, and therefore must be used ethically as well, giving priority to those who are worse off. The state's duty to develop a rational policy to secure adequate emergency equipment was not neglected.

Finally, adherence to preventive instructions, such as voluntary social isolation, quarantine, hand washing, etc., and if its peremptory benefit does not appear in the infallibility of the virus, it has another benefit related to this discussion, which is that it gives more time to avoid reaching this emergency when we face difficult choices due to Lack of equipment, thus narrowing the gap between medical need and available treatment.