MEDICAL CONFIDENTIALITY ETHICS IN LIGHT

OF THE ISLAMIC LEGAL MAXIM ―HARM MUST

BE ELIMINATED‖: A JURIDICAL ANALYSIS

BY

SAYYED MOHAMED MUHSIN

A dissertation submitted in fulfillment of the requirement for

the Degree of Doctor of Philosophy in Fiqh and Uṣūl al-Fiqh

Kulliyyah of Islamic Revealed Knowledge and

Human Sciences
International Islamic University Malaysia

DECEMBER 2018
 ABSTRACT

Medical confidentiality is a foundational tenet in the delivery of effective healthcare,

since the Hippocratic era. It is widely recognized that medical confidentiality can be
breached for the protection of the patient and/or others, if the maintenance of
confidentiality causes serious harm. However, the pot ential harms in the maintenance
and disclosure of patient confidentiality are yet to be systematically identified and
studied, particularly from a Sharīʿah perspective. Legal mandates, ethical codes and
professional guidelines have fallen short in explaining the procedures that doctors
must follow when encountering situations where conflicting interests arise; nor are
there clear directions in explaining procedures when faced with specific
circumstances. The current research aims to address this problem in theory and
provide practical solutions, subsequently adding value to existing research on the
application of Islamic legal maxims, as well as medical confidentiality from the
Sharīʿah perspective. Employing research methods – namely: exploratory analysis,
content analysis, critical analysis, thematic analysis and inferential analysis – this
research aims to: 1) critically identify potential harms in the protection and disclosure
of medical confidentiality, explored from the perspectives of patients, doctors and
third parties; 2) to analytically scrutinize ‗harm‘ in view of Islamic jurisprudence and
to methodically study the Islamic legal maxims related to harm elimination; and, 3) to
experiment with the implementation of a framework based on the Islamic legal
maxims, on issues related to medical confidentiality, in an attempt to eliminate or
effectively reduce harms. The major findings of the research are: 1) there are several
considerable harms – moral, physical, psychological, financial, familial, direct,
indirect, private and public – to th e patient, doctor and/or third party, in the protection
and disclosure of medical confidentiality; 2) Islamic jurisprudence deals with harm
extensively, to the extent that it includes all possible and considerable harms that may
be caused or suffered. Consequently, the Islamic legal maxims related to harm
elimination are decisively essential for prevention, elimination or minimization of
harm; and, 3) a harm elimination framework, based on the Islamic legal maxims, is
relevant in eliminating or effectively reducing potential harms in protection of medical
confidentiality and its disclosure.

ii
 ‫ملخص البحث‬

‫فقد ظظال ظ لامظظال ةظظا ل‬ ‫حفظظال سظظال ظ لملظظأل ألسظظي ل تقدقظظللعليةظظيصل اادفظظال م ظ عال ر‬
‫و ك ظ ظ لدّ ل رف لحفظ ظظال سظ ظظال ظ ظ لدالد ظ ظظديل ملظ ظظا ل ظ ظظأ لد ظ ظظد لت ظ ظ ل دفظ ظظال أل ظ ظاف ل‬
‫و آلخظاف لو ظظللّ ظنل ظظرال تحملظظا ل حفظ ظالعلحفظظال سظظال ظ ل ولد ظظد ملليظي سلف قظظال‬
‫ا ظعا القعرظدل ل أل ظظأ ل إلقظم ل لو ال ةظأ ال سعظالو خمهتعدوظدلو ألسظدفنل ألمل عظالمللي ظ ر ل‬
‫مجعلل إل اء تل أل أ ال يتلف س لل الفس كملدل سعبلا يليقد ضل ألمدحللواللفأ يليأ عظ ل‬
‫و حملحلا ي دلفأ ل سعظبلحظدالتلخد‪.‬ظا لوظيهلملظ ل ي قظالداليأحملظعحل أل ظك ال ظافظدل‬
‫ود ا لح أهلدلي سعةعد لوقفملعفل د سظدل مل اظظدل ي قظدتل ألأ ظأفمل عظظدلففق ظيل ف سعظيل ةأ اظيل‬
‫فةملع ظظا لو دهت ظظال س ظظال ظ ظ ل ظ ظ ل أل ظ ظظأ ل إلق ظظم ل ل ق ظظف ي ل سدح ظ ظ لعل ظ ظ ل أل ظ ظ مل ل‬
‫ف ع لل القفك دع لو حفأ ل ف ع ظ لول ف عظ ل ةظي لول ألأحملظأا لول القظف فد ل‬
‫ووظيهل ي قظالدال عظدال تحملظا ل حفظ ظالعلحفظال سظال ظ لود ظد ظ ل د ظبل ألظاف ل‬
‫ظ ظظدلوظظيهل ي ق ظظالدالل ع ظ ل فمل ظظأ ل ملظظا ل ظ ل ظظظأ ل فة ظ ل‬ ‫و سعظظب لو ظظاهل د‬
‫إلقظم ل للو ةأ اظظيل فةملعظال ألفق ةظظال ر ظظال ملظا لو ظظظدلفظاو لدالي سعظظيل إل ظظد ل ألسظيلا ظ‬
‫ةأ اظيل فةملعظال عظظدلففق ظي د سظال ظ لحدو ظالد ظال ملظا ل ولافعفملظد لويأ‪.‬ظ ل سدحظ لدال‬
‫س ظظعظال ظظممليفظ ظ لعل دحع ظظال فس ظظعا لو سي ع ظظا ل‬ ‫فظظد أ ل ارمل ظظد ل والنل المل ظظد ل حمل ظظا‬
‫و سظظعك أ عا لو ألد عظظا لو تق ظافال ألسدةظظام لوغظظمل ألسدةظظامل د‪.‬ظظالو قد ظظال ظظيتلي ظظيل ظظدألاف ل‬
‫و سعب لو اهل د لعلحد الحفال تقا ل سعالل ولعلحد الد د ملد لثد عدن دال فة ل‬
‫ففقد ظ ل ظلل فملظأ ل ملظا لا ظ ل ظديلو قظظلملت ظ لف ظظ لمجعظلل تحملظا ل حفظ ظا لو ال ةأ اظظيل‬
‫فةملع ظظال ألفق ة ظظال ر ظظال مل ظظا ل د ع ظظال ظظي لل مل ظظا ل ولية ع ظ لثد دند ظظدءل إل ظظد ل ألس ظظيلا ظ ظ ل‬
‫ةأ ايل فةملعال فعيل اي لعلد ال ملا ل ألفق يل فال سال ل ولد د‬

‫‪iii‬‬
 APPROVAL PAGE

The thesis of Sayyed Mohamed Muhsin has been approved by the following:

_____________________________
Muhammad Amanullah
Supervisor

_____________________________
Luqman Zakariyah
Co-Supervisor

_____________________________
Sayyed Sikandar Shah
Internal Examiner

_____________________________
Raihanah Hj. Azhari
External Examiner

_____________________________
Naamane Djeghim
External Examiner

_____________________________
Akram M Z M Kheder
Chairman

iv
 DECLARATION

I hereby declare that this thesis is the result of my own investigation, except where

otherwise stated. I also declare that it has not been previously or concurrently

submitted as a whole for any other degrees at IIUM or other institutions.

Sayyed Mohamed Muhsin

Signature………..…………….……. Date …......................................

v
 INTERNATIONAL ISLAMIC UNIVERSITY MALAYSIA

DECLARATION OF COPYRIGHT AND AFFIRMATION OF FAIR USE OF

UNPUBLISHED RESEARCH

MEDICAL CONFIDENTIALITY ETHICS IN LIGHT OF THE ISLAMIC

LEGAL MAXIM “HARM MUST BE ELIMINATED”: A JURIDICAL
ANALYSIS

I declare that the copyright holder of this thesis is Sayyed Mohamed Muhsin

Copyright © 2018 Sayyed Mohamed Muhsin and International Islamic University Malaysia. All rights
reserved.

No part of this unpublished research may be reproduced, stored in a retrieval

system, or transmitted, in any form or by any means, electronic, mechanical,
photocopying, recording or otherwise without prior written permission of the
copyright holder except as provided below:

1. Any material contained in or derived from this unpublished research may

be used by others in their writing with due acknowledgement.

2. IIUM or its library will have the right to make and transmit copies (print
or electronic) for institutional and academic purposes.

3. The IIUM library will have the right to make, store in a retrieved system
and supply copies of this unpublished research if requested by other
universities and research libraries.

By signing this form, I acknowledged that I have read and understand the IIUM
Intellectual Property Right and Commercialization policy.

Affirmed by SAYYED MOHAMED MUHSIN

……..…………………….. ..…….……………………..
Signature Date

vi
 DEDICATION
Dedicated to

My Umma Sayyidat Fathimah Zahra,

Uppa Sayyid ʿAlavi Koya Thangal,
Wife Sayyidat Athika Beevi,

and
My late sister, Sayyidat Fathimah Mahboobah,
In memory of her departure to paradise at the age of three

vii
 ACKNOWLEDGEMENTS

All praise is due to Allah, ―who has taught man that which he knew not‖ (the Quran,
al-ʿAlaq: 5). May the blessings and salutations be upon the Prophet Muḥammad
Muṣṭafā (‫)ﷺ‬, his household and followers till the last day.

With my long cherished dreams now close to fruition, and through the
magnificent experiences I have had on this voyage of seeking knowledge, I am
overwhelmingly indebted to many wonderful people; undoubtedly this journey would
not have been possible if not for their immense care and invaluable guidance. I pray to
Allah that He rewards all of them with the best of this life and the hereafter.

Firstly, I would like to thank my supervisor, Prof. Dr. Muhammad Amanullah,

for giving me creative direction, continued guidance and thoughtful encouragement. I
am equally grateful to my co-supervisor, Assoc. Prof. Dr. Luqman Zakariyah, for his
constructive comments and critical insights. I record my gratitude to my examiners
Prof. Dr. Sayyed Sikandar Shah, Assoc. Prof. Dr. Raihanah Hj. Azhari and Assoc.
Prof. Dr. Naamane Djeghim for their valuable comments.

All my teachers have been truly inspirational to me in my life and I am greatly

indebted to them. Among them I would particularly like to mention Prof. Dr. Arif Ali
Arif, Prof. Dr. Mumtaz Ali, Prof. Dr. Qais al-Mubarak and Prof. Dr. Bahauddeen
Nadwi who are and always will be my role models for wisdom, uprightness and
erudition.

In this academic pursuit, many friends have greatly supported and encouraged
me and I am unable to mention all of them here. However, I would like to mention
some of them who have provided intellectual conversations and companionship in the
period of writing this thesis; they are Jafar Paramboor, Muhammad Rasheed, Suhail
Hidaya, Muhammad Daqane and Junaid Mughal.

Several practitioners have helped me in understanding the areas relating to the

medical field and have guided me by reading my chapters; among them, Dr.
Muhammad Yousuf, Dr. Shafeeq Lone and Dr. Nazimuddeen deserve special mention
for their great support.

I am thankful to IIUM for awarding me the prestigious Rector Scholarship

(February to May 2017) and Dr. Ahmad Totonji from IIIT for their Scholarship
(September 2017 to June 2018). Both awards allowed me to dedicate time to my
research.

This humble achievement would not have been accomplished, had it not been
the infinite love, sacrifice and sincere prayers of my parents, Sayyid Alavi Koya
Thangal and Sayyidat Fathimah Zahra; words fail me if ever I try to express my
feelings towards them. My wife Sayyidat Athika Beevi took my dream as her dream
and accompanied me through each step of this research with selfless support; I owe

viii
her a great deal of gratitude. My son Sayyid Aban Ahmad‘s bright little smile
energized and cheered me along the way in the final stages of this thesis. My brothers
Sayyid Mahshuq Hudawi and Hafiz Sayyid Mashhoor and sister Sayyidat Fatimah
Mahmoodah were a constant source of encouragement and support. My gratitude also
extends to my in-laws, Father Sayyid Cheru Koya Thangal, Mother Sayyidat Ayisha,
Brother Sayyid Hashim and Sister Sayyidat Swalihah.

There are also many others that have not been mentioned here, who were
instrumental in the expeditious completion of this study. Jazākum Allāhu Khayrā.

ix
 TABLE OF CONTENTS

Abstract .................................................................................................................... ii
Abstract in Arabic .................................................................................................... iii
Approval Page .......................................................................................................... iv
Declaration ............................................................................................................... v
Acknowledgements .................................................................................................. viii
Table of Contents ..................................................................................................... x
Transliteration Table ................................................................................................ xiii
List of Tables ........................................................................................................... xiv

CHAPTER ONE: INTRODUCTION .................................................................. 1

Research Background ................................................................................... 1
Statement of the Problem ............................................................................. 4
Research Questions ...................................................................................... 7
Research Objectives ..................................................................................... 8
Significance of the Study ............................................................................. 9
Scope of the Study ....................................................................................... 10
Research Methodology................................................................................. 11
Literature Review ......................................................................................... 14

CHAPTER TWO: MEDICAL CONFIDENTIALITY ETHICS: POTENTIAL

HARMS IN THE PROTECTION AND BREACH OF PATIENT
CONFIDENTIALITY ........................................................................................... 26
Introduction .................................................................................................. 26
Brief Historical Background of Medical Confidentiality............................. 30
Medical Confidentiality from Conventional Perspective ............................. 32
Medical Ethics ....................................................................................... 32
Overview of Medical Confidentiality ................................................... 36
The Sharīʿah Perspective on Medical Confidentiality ................................. 38
Medical Confidentiality in light of the Quran and Sunnah ................... 38
Types of Confidentiality ....................................................................... 47
Conditions of Medical Confidentiality ................................................. 49
Potential Harm in the Protection and Disclosure of Medical Confidentiality
...................................................................................................................... 51
The Harm Elimination Principle in Medical Confidentiality Ethics ..... 56
Consent.................................................................................................. 63
Analysis of Potential Harms in the Protection and Breach of Patient
Confidentiality in Selected Areas ................................................................. 65
Serious Infectious Diseases ................................................................... 65
Psychiatric Diseases .............................................................................. 78
Domestic Violence and Child Abuse .................................................... 87
Situations Dealing with Crime .............................................................. 91
The Premarital Test ............................................................................... 101
Result of Genetic Screening .................................................................. 107
Conclusion.................................................................................................... 114

x
CHAPTER THREE: HARM IN ISLAMIC JURISPRUDENCE: MEANING,
CRITERIA AND CATEGORIES ........................................................................ 116
Introduction .................................................................................................. 116
Definition of Harm (Ḍarar) ......................................................................... 118
Harm Elimination in the Quran .................................................................... 122
1. Harm to Heirs .................................................................................... 123
2. Harm to Wife..................................................................................... 124
3. Harm to Wife after divorce ............................................................... 125
4. Harm to the Husband, the Wife and the Child after Divorce ............ 126
5. Harms concerning Coercion of Scribes and Witnesses .................... 127
6. ―Harmful‖ Masjid.............................................................................. 128
Harm Elimination in the Prophetic Traditions ............................................. 130
Harm Elimination in View of Islamic Jurisprudence ................................... 133
Criteria of Considerable Harm ..................................................................... 139
1. The harm should be real. ................................................................... 139
2. The harm should be excessive (fāḥish). ............................................ 141
3. The infliction of harm should occur as a result of infringement or
arbitrariness or negligence. ................................................................... 144
4. Harm is inflicted on a valued possession owned by a legitimate owner.
............................................................................................................... 147
Categories Of Harm ..................................................................................... 149
1. According to the Role of Injurer ....................................................... 149
2. According to its Victim ..................................................................... 151
3. According to its Characteristics ........................................................ 151
4. According to its Infliction on Ḍarūriyyāt ......................................... 153
5. According to Intention of Injurer ...................................................... 160
Non-Maleficence: A Fundamental Principle in Medical Ethics .................. 162
Conclusion.................................................................................................... 171

CHAPTER FOUR: THE UNIVERSAL LEGAL MAXIM “HARM MUST BE

ELIMINATED”, ITS SUB-MAXIMS AND THEIR ETHICAL IMPLICATIONS
.................................................................................................................................. 173
Introduction .................................................................................................. 173
Definition and Major Features of Islamic Legal Maxim ............................. 176
Definition .............................................................................................. 176
Historical Development of Qawāʿid ..................................................... 179
Related Genres to Legal Maxims .......................................................... 181
Categories of Qawāʿid .......................................................................... 184
Five Universal Legal Maxims ............................................................... 186
Legal Maxim as Basis of Ruling ........................................................... 189
The Universal Legal Maxim ―Harm must be Eliminated‖........................... 191
Scope of the Maxim .............................................................................. 194
Objective of the Maxim ........................................................................ 195
Application Strategies ........................................................................... 196
Sub-Maxims of ―Harm must be Eliminated‖ ............................................... 198
Prevention of Harm before Occurrence ................................................ 198
Elimination of Harm after Occurrence .................................................. 205
Harm Elimination after Occurrence ...................................................... 208
1. Removal of harmful material: ........................................................... 209

xi
 2. Tort liability: ..................................................................................... 209
3. Legal punishments ............................................................................ 210
Minimization in Unavoidable Circumstances ....................................... 210
Other Relevant Sub-Maxims in the Elimination of Harm .................... 216
Fiqh al-Muwāzanah in Harm Elimination ................................................... 219
Methodology of Muwāzanah ................................................................ 223
The Ethical Implications of the Maxim on Harm Elimination .................... 226
Ethicality in Islam ................................................................................. 226
Ethical Aspects of Harm Elimination ................................................... 230
Conclusion.................................................................................................... 231

CHAPTER FIVE: HARM ELIMINATION FRAMEWORK AND ITS

APPLICATION TO MEDICAL CONFIDENTIALITY ................................... 237
Introduction .................................................................................................. 237
Harm Elimination Framework for Medical Confidentiality Practice .......... 238
Preamble ................................................................................................ 238
Phase One: Effective Maintenance of Confidentiality (Harm Prevention
Aspect) .................................................................................................. 240
Phase Two: Before the Disclosure (Harm Prevention Aspect) ............. 247
Phase Three: During the Disclosure (Harm Prevention and Elimination
Aspects): ................................................................................................ 251
Phase Four: Choosing Lesser Harm in Unavoidable Situation (Harm
Minimization Aspect): .......................................................................... 261
Application of Harm Elimination Framework to Selected Areas ................ 265
Application of the Framework to Serious Infectious Diseases ............. 266
Application of the Framework to Psychiatric Diseases ............................... 275
Application of the Framework to Cases Related to Domestic Violence and
Child Abuse........................................................................................... 285
Application of the Framework to Situations Dealing with Crime ........ 293
Application of the Framework to Results of Premarital Test ............... 301
Application of the Framework to Result of Genetic Screening ............ 306
Conclusion.................................................................................................... 312

CONCLUSION ...................................................................................................... 314

Major Findings ............................................................................................. 314
Recommendations ........................................................................................ 327

BIBLIOGRAPHY .................................................................................................. 331

xii
TRANSLITERATION TABLE

xiii
 LIST OF TABLES

Table 2.1 Principles that are mutually exclusive in medical 55

confidentiality cases

Table 2. 2 Harm elimination as a valid excuse for breaching medical 58

confidentiality in various ethical codes

Table 2. 3 Potential harm to the patient in concealment and disclosure 75

of infectious diseases

Table 2. 4 Potential harm to the doctor in the concealment and 76

disclosure of infectious diseases

Table 2. 5 Potential harm to a third party‘s/society‘s/public‘s interest in 76-77

the concealment and disclosure of infectious diseases

Table 2. 6 Potential harm to the patient in the concealment and 85

disclosure of psychiatric diseases

Table 2. 7 Potential harm to the doctor in the concealment and 86

disclosure of psychiatric diseases

Table 2. 8 Potential harm to the third party‘s/society‘s/public‘s interest 86

in the concealment and disclosure of psychiatric diseases

Table 2. 9 Potential harm to the patient in the concealment and 90

disclosure of abuse and violence

Table 2. 10 Potential harm to the doctor in the concealment and 90

disclosure of abuse and violence

Table 2. 11 Potential harm to the third party‘s/ society‘s/ public‘s 91

interest in concealing and disclosing abuse and violence.

Table 2. 12 Potential harm to the patient in the concealment and 99

disclosure of crimes and plans for crimes

Table 2. 13 Potential harm to the doctor in the concealment and 010

disclosure of crimes and plans for crimes

Table 2. 14 Potential harm to the third party‘s/ society‘s/ public‘s 100-101

interest in concealing and disclosing crimes and plans for
crimes

Table 2. 15 Potential harm to the patient in the concealment or 106

disclosure of premarital test results

xiv
Table 2. 16 Potential harm to the doctor in the concealment and 106
disclosure of premarital test results

Table 2. 17 Potential harm to the third party‘s/society‘s/ public‘s interest 107

in the concealment and disclosure of premarital test results

Table 2. 18 Potential harms to the patient in the concealment or 112

disclosure of genetic test results

Table 2. 19 Potential harms to the doctor in the concealment and 103

diclosure of genetic test results

Table 2. 20 Potential harm to the third party‘s/ society‘s/ public‘s 103

interest in concealing and disclosing genetic test results

Table 3. 1 Usage of word ḍarar and its derivatives in the Quran and its 122
number of times

Table 4. 1 Criteria and categories of maxims 184

Table 4. 2 Situations where the benefits and evils are mixed and their 212
rulings

Table 4.3 Various forms of removal of harms and their rulings 205

Table 5. 1 Potential victims and types of harms 251

Table 5. 2 Four possible ways of harm elimination and rulings upon 253
them

Table 5. 3 Various ways of disclosure and their legal rulings 257-258

Table 5. 4 Hierarchy of preference in eliminating one among two or 264

more mutually exclusive harms

Table 6. 1 Categorization of harm from various considerations 320

xv
 CHAPTER ONE

INTRODUCTION

RESEARCH BACKGROUND

Medical confidentiality (also known as patient confidentiality) has been a foundational

tenet in the delivery of effective healthcare since the early period of Hippocrates 1 (460

–370 BC).2 Medical confidentiality implies that the physician3 acknowledges the

patient‘s need for privacy vis-à-vis the medical care he4 is receiving. This aspect of

the doctor-patient relationship is about building trust and protecting the patient‘s

dignity.5 However, with time, the connotations around medical confidentiality have

changed and no longer reflect the absolute secrecy that it referred to in ancient times.

Codes of medical practice, such as the International Code of Medical Ethics of the

World Medical Association (WMA), do not consider confidentiality as being

compromised, if disclosure of patient privacy is necessitated due to risk of harms to

the patient or others likely to be affected.6

A significant factor that can impinge on medical confidentiality is the

disclosure of patient information to individuals or groups, such as the police, social

1
Hippocrates is an exceptional figure in the field of medicine, who is widely known as the "father of
modern medicine". He was a Greek physician who lived in the age of Pericles and founded the
Hippocratic School of Medicine. For more details, refer to: Farrington B, Greek Science: Its Meaning
for Us (Nottingham: Spokesman Publications, 2000); Edelstein L, Ancient Medicine (USA: Johns
Hopkins University Press, 1967).
2
Higgins, G. L, ―The history of confidentiality in medicine‖, Canadian Family Physician, 35, (1989):
921.
3
In this research, the terms – doctor, physician, practitioner, health professional, healthcare
professional, health staff and health worker – are used interchangeably for convenience and to avoid
repetition of the same word. However, all terms refer to employees in the healthcare sector who deal
with patient privacy.
4
‗Or she‘ is understood henceforth.
5
Mark Siegler, ―Confidentiality in Medicine: A Decrepit Concept‖, in Taking Sides in Clashing Views
on Controversial Bioethical Issues, edited by Carol Levine (USA: The Dushkin Publishing Group, Inc.,
6th edn., 1995), 150.
6
John R. Williams, Medical Ethics Manual, (France: World Medical Association, 3rd edn., 2015), 51;
Post, S. G. Encyclopedia of bioethics, (Michigan: Macmillan reference. 3rd edn., 2004), 495.

1
workers or companies dealing with occupational health. Likewise, healthcare

professionals may encounter complicated situations, whereby the divulgence of

patient privacy may pose a threat to one party, whereas the concealment of such

information may cause harm to another. Physicians often encounter ethical dilemmas

between maintaining patient confidentiality versus the disclosure of confidential

information to fulfil their responsibility of protecting third parties or the general public

from danger. By and large, health professionals come across the problem of having to

breach patient privacy of individuals affected by psychiatric diseases, contagious

diseases, venereal diseases, criminal or abusive cases and genetic testing.

Ethicists, law professionals, members of healthcare, and society at large are

close to reaching a consensus about the rightfulness of confidentiality breaches for the

protection of patients and others from serious harm.7 However, to the best of the

researcher‘s knowledge, the potential harms in the protection and disclosure of patient

confidentiality are yet to be systematically identified and studied, especially from the

Sharīʿah perspective. Likewise, legal mandates, ethical codes and professional

guidelines fall short in explaining the procedures doctors have to follow when they

encounter situations in which conflicting interests arise; rather they are left at the

discretion of the health worker.

Having recognized the ambiguities regarding the potential harms in medical

confidentiality practice and the lack of effective steps in addressing them, the

researcher aims to utilise the Islamic legal maxims for dealing with harms in the

maintenance and disclosure of patient privacy. The Islamic legal maxims contain

7
The Islamic Fiqh Academy, Resolutions And Recommendations, Eight Session in Bandar Seri
Begawan, Brunei Darussalam, 1-7 Muharram 1414 AH ( 21-27 June 1993). Resolution No: 79/10/8;
GMC, ―Disclosing patients‘ personal information: a framework‖, Confidentiality: good practice in
handling patient information, www.gmc-uk.org/guidance . (Accessed 23 December, 2017), 13; John R.
Williams, Medical Ethics Manual, (France: World Medical Association, 3rd edn., 2015), 28.

2
principles and precepts of Islamic law, including higher objectives of the Sharīʿah

(maqāṣid al-Sharīʿah8). They are meant, among others, to provide the necessary scope

for jurists to handle ethical issues and to revive the exercise of ijtihād (independent

legal reasoning) in the modern era.9 With steady synthesis between the text and

context, Islamic legal maxims (al-qawāʿid al-fiqhiyyah) are operative and vital in the

lives of people, as they allow for problems to be readily solved.10 The phrase ―harm

must be eliminated‖, is one among five universal legal maxims, and in the view of

some scholars, it encompasses half of fiqh (Islamic jurisprudence), as all legal rulings

it has provided are either for beneficence or non-maleficence.11 This maxim was

formulated to be used primarily as the guiding principle to protect the welfare of

people, both at the societal and individual levels.12 In the healthcare system, this

maxim is central as demonstrated by its congruity with the idea of Hippocrates, which

is, ―strive to help, but above all, do not harm‖.13 Moreover, the legal maxims on

elimination of harm encompass the crux of four foundational principles in modern

medical ethics, namely respect for autonomy, non-maleficence, beneficence and

justice.

8
Abū Ḥāmid al-Ghazālī, al-Mustaṣfā fī ʿIlm al-Uṣūl, (Beirut: Dār al-Kutub al-Ilmiyyah, 1413H), 1:
174. Maqāṣid are also consensually perceived as the five universal legal purposes, namely the
protection of religion, body, intellect, progeny and wealth. Noticeably, all nations and communities
have acknowledged the importance of these five foundational objectives. Maqāṣid is defined as
‗modalities intended by the Sharīʿah for people to achieve beneficial purposes, or to save the interests
of the public in their specific actions‘. Al-ʿAllāl al-Fāṣī, Maqāṣid al-Sharīʿah, 7. Concisely, maqāṣid
are ‗underlying values and purposes of the Islamic law‘. Jasser Auda, Maqasid al-Sharīʿah as
Philosophy of Islamic Law; A Systems Approach, (London, Washington: IIIT, 2008), xxiv.
9
Al-Suyūṭī, al-Ashbāh wa al-Naẓā‟ir, 6; Intisar Rabb, ―Islamic Legal Maxims as Substantive Canons
of Construction: Ḥudūd-Avoidance in Cases of Doubt‖, Islamic Law and Society, Vol. 17, No. 1
(2010): 63.
10
Aḥmad bin Idrīs al-Qarrāfī, Anwār al-Burūq fī Anwā‟ al-Furūq (Beirut: Dār al-Kutub al-ʿIlmiyyah,
1998) 1:3; Muṣṭafā al-Zarqā, al-Madkhal al-Fiqhī ʿᾹmm (Damascus: Dār al-Qalam, 1998), 2:974.
11
ʿAlā‘ al-Dīn Abū al-Ḥasan al-Mardāwī, al-Taḥbīr Sharḥ al-Taḥrīr (Riyadh: Maktabat Rushd, 2000),
8: 2846.
12
Aḥmad Futūḥī, Sharḥ al-Kawkab al-Munīr (Cairo: Maṭbaʿat al-Sunnah al-Muḥammadiyyah), 390.
13
William, ―Medical Ethics‖.

3
 The rubric of harm given in the maxim includes public and private harms, as

well as moral and material harms, which may have both direct and indirect effects on

physicians, patients and/or third parties. The maintenance and disclosure of the

privacy of individual patients may result in physical and/or psychological harm, as

well as potential damage to factors such as the wealth, profession, family, and dignity

of patients or others. Notably, the prevention and elimination of these potential harms

and damages are deemed as one of the higher objectives of the Sharīʿah.14

The current research analyses medical confidentiality from a Sharīʿah

perspective, followed by a detailed scrutiny of harms in the maintenance and

disclosure of patient privacy. Examining how and when an act is characterized as

harmful from a fiqh perspective, this research conducts a thorough study of the Islamic

legal maxim, ―harm must be eliminated‖, and its derivatives. Finally, by designing a

harm elimination framework for medical confidentiality practice, this research strives

to situate the principles and implications imbued in the Islamic legal maxims in larger

contexts of medical confidentiality ethics. The researcher presupposes that an active

incorporation of the legal maxim ―harm must be eliminated‖ and its derivatives, and

current issues surrounding medical confidentiality could significantly assist in the

elimination of the underlying predicaments that exist.

STATEMENT OF THE PROBLEM

Although medical confidentiality is widely recognized as an essential principle in

therapeutic relationship, its systematic and coherent practice has been an arduous duty

upon healthcare providers due to various concerns such as clinical, moral, social,

14
Abū Ḥāmid al-Ghazālī, al-Mustaṣfā min ʿIlm al-Usūl, ed. Muḥammad Ḥasan Ḥito (Beirut: Dār al-
Kutub al-ʿIlmiyyah) 1:172.

4
ethical and legal.15 Beauchamp and Childress assert that, ―the obligations of medical

confidentiality are not, at present, well-delineated and need restructuring‖,16 because

this principle is observed as compromised in several ways in everyday clinical

practice. Based on recent studies, these concerns surrounding medical confidentiality

have seen an increase at present.17 Noticeably, professionals have a vague

understanding when it comes to making appropriate decisions in the face of ethical

dilemmas regarding medical confidentiality, especially when they have to balance

confidentiality principles against those related to public safety, law enforcement,

national security, protection of a third party, etc.

A frequent phrase articulated in discussions surrounding the validity in

disclosure of confidential medical information is ‗prevention of serious harm‘.18 In

other words, protection of patients or others from serious harm is generally deemed as

15
Beauchamp and Childress, Principles of Biomedical Ethics (New York: Oxford University Press, 5 th
edn., 2001), 304; HA Clegg, ―Professional Ethics‖, in Medical Ethics: A Guide to Students and
Practitioners, edited by M Davidson (London: Lloyd-Luke, 1957), 44; Angus H Ferguson, ―Should a
doctor tell?: medical confidentiality in interwar England and Scotland‖, (Scotland: University of
Glasgow, 2005), 2; Hippocratic Oath, reprinted in J.K. Mason & Alexander McCall Smith, Law and
Medical Ethics, (UK: Butterworths, 1994), 429.
16
Ibid., 312.
17
Sade, R. M., ―Breaches of health information: Are electronic records different from paper records?‖,
40.
18
The Islamic Fiqh Academy, Resolutions And Recommendations, Resolution No: 79/10/8; GMC,
―Disclosing patients‘ personal information: a framework, 13; John R. Williams, Medical Ethics
Manual, 28; Singapore Medical Council, ―Medical confidentiality‖ in Ethical Code and Ethical
Guidelines 2016, www.smc.gov.sg (Accessed October 1, 2017), 40; American Medical Association,
―Chapter 3: Opinions on Privacy, Confidentiality & Medical Records‖, AMA Code of Medical Ethics
Opinions on Privacy, Confidentiality and Medical Records, https://www.ama-
assn.org/sites/default/files/media-browser/code-of-medical-ethics-chapter-3.pdf, (Accessed on January
16, 2018), 5; MMC Guidelines 2011, at Provision 3; UN General Assembly, "Universal Declaration of
Human Rights," Article 8, (Paris, 1948), http://www.un.org/en/universal-declaration-human-rights/,
(Accessed December 22, 2017); The Saudi Commission for Health Specialties, Department of Medical
Education & Postgraduate, Code of Ethics for Healthcare Practitioners Studies.
https://www.iau.edu.sa/sites/default/files/resources/5039864724.pdf (Accessed March 6, 2018), 20;
Pakistan Medical and Dental Council, Code of Ethics of Practice for Medical and Dental Practitioners,
http://www.pmdc.org.pk/LinkClick.aspx?, p 11-12; Dubai Health Authority, Code of Ethics and
Professional Conduct of Dubai Health Authority,
https://www.dha.gov.ae/Documents/HRD/RegulationsandStandards/guidelines/Code, (Accessed March
7, 2018), p.23.

5
a justified warrant to breach confidentiality.19 However, according to the best of the

researcher‘s knowledge, the nature and sorts of potential harms as well as the different

categories in which they may fall are poorly explained and barely explored within the

medical field, especially in light of the Sharīʿah principles. Arguably, identification of

potential harms will help practitioners categorize them according to their magnitude

and potential consequences, and thus prevent, eliminate or at least minimize the

harm.20 As a result, this research is meant, among other objectives, to explore the

potential harms in medical confidentiality practice, from patient‘s, physician‘s and

third party‘s perspectives.

Although the concept of elimination of harm embodies half of the deliberations

of Islamic jurisprudence, the researcher has found an obvious need for profound and

systematic studies that extend beyond the definition of harm (ḍarar), criteria of

considerable harm, as well as its various categories from a fiqhī perspective,

particularly in the English language. This research gap is filled by the current

research. Based on the data gathered by the researcher, it is clear that though there are

many works on the application of Islamic legal maxims in criminal law and financial

transactions, so far no significant study has been undertaken to discuss the application

of the legal maxims in order to eliminate underlying harms when dealing with patient

confidentiality. The current research is among the first to deal exclusively with the

legal maxims related to harm elimination with an urge to streamline them for utilizing

in decision-making processes vis-à-vis medical confidentiality.

The main part of this research discusses the potential harms in the protection

and disclosure of medical confidentiality, followed by a comprehensive analysis of

19
The Nursing and Midwifery Council, Code of Professional Conduct (UK: NMC, 2002), 5: 3; General
Medical Council, Confidentiality: good practice in handling patient information (UK: GMC, 2017), 10.
20
Mohammed Nabhan, ―What is preventable harm in healthcare? A systematic review of definitions‖,
BMC Health Services Research 2012. 1.

6
considerable harm in Islamic jurisprudence and legal maxims related to harm

elimination. As such, this research attempts to design a framework, benefitting from

the maxim ―harm must be eliminated‖ and its derivatives, that eliminates or

significantly reduces the potential harms in the protection and disclosure of medical

confidentiality.

RESEARCH QUESTIONS

Bearing in mind the issues mentioned in the statement of the problem, this research

aims to address the following questions:

1. How does the Sharīʿah perceive and analyse confidentiality in the doctor-

patient relationship? In what circumstances do doctors have the right to

breach medical confidentiality on account of harm elimination, and what

are the potential harms likely to be posed by the disclosure or concealment

of confidential information, against a patient, doctor, and/or third party?

2. What is ‗harm‘ in Islamic jurisprudence? On what legal grounds do

Islamic jurists determine a considerable harm that needs to be removed,

and how do they classify harm into various categories? What is the

relevance of non-maleficence principle in medical ethics?

3. What are the decisive Islamic legal maxims related to eliminating harm?

How do these maxims help influence the decision-making process? What

are the ethical implications imbued in legal maxims related to harm

elimination?

4. In applying the Islamic legal maxims, is there a way to design an effective

and paradigmatic framework that can eliminate the potential harms in

medical confidentiality practice? Can the framework be implemented to

7
 significantly reduce and/or eradicate the harms involved in the selected

categories (i.e. infectious diseases, psychiatric diseases and domestic

violence cases, etc.)?

RESEARCH OBJECTIVES

Based on the questions above, this research attempts to achieve the following

objectives:

1. To analyse medical confidentiality from the Sharīʿah perspective, while

exploring situations that legally demand confidentiality breaches in order

to preserve the principle of harm elimination. It also seeks to scrutinize

various potential harms, resulting from protection and disclosure of

medical confidentiality that may pose a threat to patients, doctors and/or

third party.

2. To explore the meaning, criteria and classifications of considerable harm

that need to be significantly reduced and ultimately removed from an

Islamic jurisprudence perspective. It also aims to discuss the relevance of

principle of non-maleficence in medical ethics.

3. To highlight the importance of Islamic legal maxims related to harm

elimination and to analyse their significance and role in the decision-

making process followed by an analysis of ethical implications imbued in

the legal maxims of harm elimination.

4. To formulate and design a paradigmatic framework that can effectively

operate in eliminating potential harms in medical confidentiality practice

and to ensure its applicability to cases selected in this study.

8
SIGNIFICANCE OF THE STUDY

The factors below discuss the significance of the study:

1. Harm elimination is a globally appreciated notion, for the language of pain

and suffering is universal. In Sharīʿah, elimination of harm is a

fundamental requirement upon every capable human being.21 Remarkably,

Islamic legal maxims and medical ethics share several common features,

with the concept of harm elimination being a central value in both.

2. This topic has merit in academic milieu and clinical applications. This

research is meant, among other aims, to facilitate health workers in

discharging their legal and ethical duties vis-à-vis medical confidentiality

in a way where protection of the patient, the potential victim(s) and the

society in general is paramount. This will be particularly important in the

current context in which legal mandates and ethical codes give vague

directions when dealing with confidentiality concerns and issues relating

to a conflict of interest in medical confidentiality practice.

3. The problems in medical confidentiality have caused a ripple effect that

becomes increasingly difficult over time. The current research aims to

address this problem in theory as well as it provides practical solutions, so

as to add value to research done on the application of Islamic legal

maxims as well as medical confidentiality from the Sharīʿah perspective.

4. This study is highly important for healthcare professionals, due to the

following reasons: (1) the inappropriate usage of confidential information

of a patient may pose a threat to the physique, psyche, wealth, dignity and

family of a patient, doctor, third party or society at large. The Sharīʿah

21
Muḥammad bin Ismāʿīl al-Bukhārī, al-Jāmiʿ al-Ṣaḥīḥ (Cairo: Dār al-Shaʿb, 1987), 2: 143.