Professional virtues and codes of conduct were historically associated with the philosophy and ethos of each community. The medical profession, in particular, was esteemed by all nations and cultures. Imam Shafi [1] (767–820 CE) said: “There are two kinds of persons who are indispensable for people. The scholars (of religion and law = ulema) for dealing with their matters of religion, and physicians for dealing with their bodies. Abubaker AlRhazi [2] (864–925 CE) said: “The physicians possess traits that are not found in others, among such is the unanimous view of the followers of religion and authority, of the preference of their occupation, and the acknowledgement of both kings and laymen for the exigent need for their services; for their everlasting strive to discover the unknown in the field of knowledge, of their pursuance to improve their profession, and of their persistent concern of introducing happiness and comfort to others.”

The medical profession should be practiced with efficiency and honesty. Prophet Muhammad (PBUH) said: “Allah likes when any one does a work, to do it with perfection” [3]. The physician should observe good conduct and fine character in both his acts and behavior. The manual guide for medical practitioners in Saudi Arabia [4] claims that: “The ethics of morals of profession mainly stem from the teachings of Islam which call for nobility of character, perfection of performance and fear of God in every act. The Prophet Muhammad said: “I have been sent to call for and complement high moral standards” [5].

Every nation and culture has its morals, mode of conduct, and ethics. The old Egyptians, Chinese, Indians, Persians, Babylonians, etc., had a mode of conduct for the medical profession, requirement for the priest physicians, and laws regulating the profession.

The Greeks were probably the most elaborate since the time of Hippocrates. The oath they promulgated and proclaimed became the cornerstone of medical ethics, which should be taken by anyone who contemplates to be involved in this noble profession.

The Hippocratic Oath: is part of a collection of writings known as the Hippocratic Corpus. The oath is generally believed to have been written a hundred years after the time of Hippocrates who lived in the Island of Cos in ancient Greek, in the fifth century B.C. (460–350) [6]. Ludwig Eldestein (1967) thinks that the Hippocratic tradition arose from the Pythagorean Cult, which was interested in Science, Philosophy, Medicine, and Religion [7].

The oath starts with a pledge to Greek gods and goddesses Apollo, Asclepius (a deified physician) the god of Medicine, and his two daughters Hygeia (from which hygiene is derived) and Panacea (the drug that cures all maladies). When the Muslim physicians adopted the Hippocrates Oath, they omitted these pledges and pledged to God [8]. Similarly, early Christians were at odds with these idol worshippers, and hence destroyed the Hippocrates temple in the Island of Cos [9].

The oath of Hippocrates then pledges loyalty to the teacher and his posterity, and to keep the profession of medicine secret except to those who deserve it by their character, or being the children of previous physicians.

The oath then applied dietetic measures for the benefit of the sick, in order to keep the patients from harm and injustice. “I will never give a deadly drug to anybody if asked for it, and will not give a woman an abortive drug. In purity and holiness I will guard my life and my art. I will not use the knife, not even on sufferers from stone (in the urinary bladder which was amenable to treatment), but withdraw in favor of such men as engaged in this work.”

The cause of abhorring surgery is religious, as holiness and purity implies not being contaminated by blood and waste products, which are religiously defiling [10].

Keeping Virtuous: The oath pledges: “Whatever houses I may visit, will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slave.”

Keeping Secrets: “What I may see or hear in the course of the treatment, or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself such things shameful to be spoken about.”

The Hippocratic Oath extolled the following principles:

Benevolence refers to the character trait or virtue of being disposed to benefit others.

The Principle of Beneficence: refers to moral obligation to act for the benefit of others.

Nonmaleficence

“Above all do no harm” or Primum non nocere is entwined with beneficence; it says: “I will use treatment to help the sick according to my ability and judgment, but I will never use it to injure or wrong them”.

It clearly guards life, “I will never give a deadly drug to anybody, and will not give a woman an abortive drug and even will not use the knife,” as surgery was hazardous at his time, and also for purity and religious reason avoiding blood and defiling religiously. The Hippocratic Oath is pro-life and vehemently against abortion, suicide, and any type of killing including Euthanasia. Doing harm in whatever way is abhorred, and should be avoided, even unintentionally. The physician should be careful in prescribing drugs and should take a detailed history of drug allergies, lest one of his drugs cause harm to his patient. More care will be needed in cases of surgery.

Keeping the secrets of the patient, his family and even his servants and slaves, whom the physician comes across while visiting the patient at his home, should be kept secret “I will keep to myself such things shameful to be spoken about.” This attitude is also part and parcel of benefiting the patient “Beneficence” and not doing any harm to him “Non Maleficence.” However, if divulging the secret may be of benefit to the patient, as considered by his physician, then it should be exposed, as far as it is beneficial to him or warding off harm thwarted against him.

The physician in the Hippocratic Oath is obviously paternalistic who is looking after his patient, as if he is his son or daughter, trying his best to benefit him, and prevent any harm that would befall him/her, and keeping all the secrets he comes across during his treatment of the patient, unless exposure is going to benefit the patient or ward off harm befalling him.

The Hippocratic Code endorsed the virtues of modesty, sobriety, patience, promptness, and piety. The physician must be upright and pure in character, diligent, and conscientious in caring for the sick.

The paternalistic attitude should be praiseworthy. But as changes occurred in the West, the enlightenment era approached and the liberal attitudes appeared, this attitude was disregarded and considered obsolete.

In the late eighteenth century an epidemic of typhus and typhoid fevers broke out in Manchester, England, and the Manchester infirmary staff were overworked. The medical practitioners were divided into dieticians, apothecaries (working with drugs), and surgeons and were blaming each other of negligence, as nobody exactly knew his duty in this epidemic. Percival, a well-educated retired physician wrote for them a medical code of conduct in 1803. It was in the Hippocratic tradition, which stressed the duty of the physician to benefit the patient, and placed no emphasis on the rights of patients in matters such as informed consent or open disclosure.

This duty to benefit the patient with absence of any recognition of the rights of patients is the hallmark of the Hippocratic tradition. It is one of the major differences between medical ethics that is Hippocratic and many of the other religious and secular ethics [10].

The American Medical Association (AMA) of 1847 turned to Percival’s Code, taking whole sections of it and incorporating in the 1847 Code of Ethics. Both Britain and USA have Codes of Ethics that are essentially Hippocratic. However, both mention the duties of physicians to benefit the society, which was never mentioned in Hippocratic Code of Ethics.

The American Medical Association (AMA) Code (1957–1980) endorsed the virtues that Hippocrates commended: modesty, sobriety, patience, promptness, and piety. However, in contrast to the first code in 1847, the AMA over the years has deemphasized virtues in its codes. In 1980, it eliminated all traces of virtues except in the admonition to expose those physicians deficient in character or competence [12].

The paternalistic virtues of benevolence, nonmaleficence, and compassion were extolled, while in recent attitudes of autonomy, these virtues are not called for; instead the virtue of respectfulness is more prominent and important. The contractual natures of medicine and health profession as a whole, became a business, ruled by contracts, mistrust, and litigations, which needed changes in medical codes, its by-laws and ethics.

However, the Hippocratic Oath remained with minor alteration in the World Medical Association Declaration of Geneva 1948 and 1956 [10].

Post-Soviet Russia constructed an oath for the Russian physician in 1993, which replaced the previous Marxist oath, and adopted the World Medical Association of 1956, which is Hippocratic [10].

But gradually the Hippocratic attitudes were replaced by autonomy and respect for the individual and his wishes. From 1970, the Hippocratic tradition started to collapse. The rights of the patient became more important, and the ethics of respect for persons (duty-based principles) were dominant. These included fidelity, autonomy, and veracity.

Not all the old codes of ethics were paternalistic like the Hippocratic Oath. Hinduism, Buddhism, various Chinese traditions, and Islamic teachings all differ from the paternalistic approach of the Hippocratic Oath.

Islam is considered as the religion of all the Prophets and Messengers of God. Islam means submission to God. Since monotheism is the true religion of Allah (God) from primordial times, as Adam, Noah, Abraham, Moses, Jesus, and all the Messengers of Allah were all of them monotheists, then Islam should be defended, expounded, and proclaimed. However, there is no compulsion in religion. “There shall be no compulsion in (the acceptance of) religion. The right course has become clear from the wrong” (Surah AlBaqarah 2/256).

And say: The truth is from your Lord, so whoever wills let him believe; and whoever wills let him disbelieve (Sura AlKahf 18/29).

Are you going (O Mohammed) to compel the people to believe (Sura Yunus 10/99).

You are not in control of them (Sura AlGhashiya 88/22).

The Qur’an is replete with such verses, which orders freedom of faith and human personal responsibility.

Verily God does not change men’s condition unless they change their inner selves (Sura Ar-Rad/The Thunder 13/11).

Every soul will be held responsible for what it had done (Sura AlMuda’ththir/The Cloaked One 74/38).

If there is no compulsion in accepting religion (which is the most important thing for humans), then there is no compulsion in accepting medicine by drugs or surgery.

The consent of the person to be treated should be obtained if he/she is adult and competent. If he is a minor (a child) or mentally incapacitated then the consent of the guardian should be obtained. Only in life saving situations that consent may be ignored. Otherwise, it is imperative to obtain the consent prior to any medical or surgical intervention. If the guardian refuses to give consent for the child or incompetent person under his guardianship, and the physicians think it is very important to operate or give kidney dialysis or whatever medical intervention, then the magistrate can appoint another guardian who will give consent. There are many ways in implementing this treatment immediately, and in cases of emergency and life saving situations there will be no need for the consent.

The Islamic jurisprudence considers seeking remedy depends on the situation.

Seeking remedy in Islamic jurisprudence may be obligatory (mandatory) in certain life saving situations or may be preferred or encouraged (Mandoob) in other situations. It may be facultative or optional and may be Makrooh, i.e., not preferred and in some situations and with certain type of treatment may be Haram, i.e., not allowed.

Ibn Taimyiah said: “seeking remedy may be Haram (not allowed) or Makrooh (not preferred), may be facultative i.e. optional (Mubaah), it may be preferred (Mandoob) or may be obligatory when it is life saving” [13]. He also said: “seeking remedy is not obligatory in the opinion of majority of Ulema (religious law experts), they however differed which is better: to seek remedy or not, for those stoics who can forebear” [14]. During that time, almost all modes of therapy were of doubtful results and many involved certain dangers, especially when surgery was contemplated.

It is incumbent that everyone should seek remedy in life saving situations. In such cases, if the person is unconscious or he is a minor, there is no need to wait for obtaining consent from proxy or guardian. The physician (or nurse) should do his/her best to save the life, organ, or limb without waiting for due consent. He/she would be liable otherwise. In case of infectious diseases that will endanger the health of the community, the government has the power to enforce treatment on a patient, irrespective of his will [15]. However, in cases like appendicitis, the doctor cannot enforce treatment if the patient refuses, except in case of a minor; then the court will appoint another guardian to give consent for treatment [16].

If the patient requires a caesarian section, the consent of the lady is sufficient and there is no need for consent of her husband, a practice common in many Arab countries where the consent of the husband is thought imperative [17].

In case where the life of the fetus is endangered, e.g., prolapsed cord, many jurists would advise caesarian section even without the consent of both parents [18].

The governments impose mandatory immunization schemes for children and in case of epidemics such as meningitis; vaccination is required for many Hajj seasons. Such actions have been supported and encouraged by many Fatwas (decision 67/5/7 of Islamic (jurisprudence 7th meeting) [15].

Seeking Remedy: Encouraged and Preferred

Prophet Muhammad (PBUH) said: “O servants of Allah seek remedy, for Allah has not put an ailment except that he puts its remedy except one ailment. They asked: what ailment? He said: old age”. And in another Hadith he said: death.

Seeking Remedy: Facultative (optional)

Seeking remedy may be Makrooh (not preferred) in the following conditions:

Some jurists from the Hanbali School thought that abstaining from remedy is the better option in the following conditions:

There are two hadiths of Prophet Muhammad (PBUH), which encourage abstaining from remedy. They are:

She had attacks but never got exposed after that incident. (Narrated by AlBukhari) [21].

Many companions refused therapy in their last illness, as they felt it would be futile e.g. Abubaker Assidiq-The First Caliph, Muath ibn Jabal and Abu Darda’a.