Year : 1995 | Volume
: 2 | Issue : 2 | Page : 21--26
Permanent diversion stomas: "Guidelines for Muslim physicians and patients "
Adnan A Albar
Family & Community Medicine Department, College of Medicine and Medical Sciences, King Faisal University, Dammam, Saudi Arabia
Adnan A Albar
P O. Box 2114, Dammam - 31451
Background: Ethical issues in medical practice are increasing in number, diversity and complexity and posing professional diemmas for physicians. It is the duty of Muslim physicians in collaboration with jurists, to resolve these issues.
Objectives: These guidelines aim at answering the following two questions:
1. On religious grounds to what extent is a Muslim patient bound ground to accept surgical treatment requiring permanent diversion of stool and urine?
2. What should be the role of medical staff in convincing the patient aril his relatives to accept diversion stomas.
Methods: 1. Identification of the consequences of diversion stomas. 2. Verification of the religious rule in relation to seeking treatment.
3. Identify the effect of carrying a stoma bag on the patient«SQ»s purity during worship.
4. Outline the role of the medical staff in convincing the patient vial his relatives to accept a needed stoma.
Results & Discussion: A Muslim patient needing a permanent diversion stoma has a religiously proven duty to listen to the instructions of a proficient physician in order to save himself if safety is most probable. Carrying a stoma bag does not interfere totally with patients purity. The exact role of medical staff in convincing the patient and his relatives to accept the procedure is discussed.
|How to cite this article:|
Albar AA. Permanent diversion stomas: "Guidelines for Muslim physicians and patients ".J Fam Community Med 1995;2:21-26
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Albar AA. Permanent diversion stomas: "Guidelines for Muslim physicians and patients ". J Fam Community Med [serial online] 1995 [cited 2020 Oct 23 ];2:21-26
Available from: https://www.jfcmonline.com/text.asp?1995/2/2/21/98613
Ethical issues in medical practice are increasing in number, diversity and complexity and posing professional dilemmas for physicians. It is the duty of Muslim physicians in collaboration with jurists, to resolve these issues. A worker searching through our great heritage of jurisprudence in the Holy Book (Quran) and the prophetic sayings and acts (Hadith) or the saying of our virtuous ancestors, will find pertinent guiding principles and rules to resolve such issues.
The Investigator had once the experience of trying to convince a female married patient suffering from malignant multiple polyposis to undergo permanent colostomy.
He plunged into deep discussions with the patient and her family. Questions were raised on procedure necessity, prospects of recovery, quality of life after the surgery and psychological, social and sexual effects of the surgery on the patient. Great efforts were made to convince the patient and her family yet they rejected the colostomy. The investigator questioned the validity of their stand from a religious point of view. This and the scarcity of published material on such issues urged the author to write these guidelines which aim at answering the following questions:
On religious grounds to what extent is a Muslim patient bound ground to accept surgical treatment requiring permanent diversion of stool and urine?What should he the role of medical staff in convincing the patient and his relatives to accept diversion stomas.
To achieve the stated objectives, the researcher adopted the following approach:
Identification of the psychological, sexual and social consequences of diversion stomas.Verification of the religious rule in relation to seeking treatment.Determining the effect of carrying a stoma bag on the patient's purity during worship.Discussing stomas acceptability in light of Islamic rules relating to preserving good health, and outline religious remedies for the psychological, sexual and social consequences of the procedure.Specifying the role of the medical staff in convincing the patient and his relatives to accept a needed stoma.
Results and Discussion
1. Identification of the psychological, sexual and social consequences of diversion stomas
Carrying permanent stomas is a well established surgical procedure, which has its legitimate indications. It's radical complications are relatively few and not dangerous such as herniation, obstruction, fractions, and skin erosion. However, its social impact is greater on the patient and his family. ,, Surgeons tend to look for alternative procedures such as low anal anastomosis, reservoirs surgeries. etc., yet, the different modalities arc not without organic and social side effects. ,,,,,,
Stoma patients have received much attention from medical boards in the western world. Special institutions and clubs have been established for such patients  . The local and regional health authorities in Britain have assigned qualified nurses for stoma patients both in hospitals and at home to ensure proper care, help and orientation for such patients. 
Studies showed that the actual location of the stoma (colostomy, ileostomy or ureterostomy) has no effect as to the patient's attitude towards the surgery or to the extent of his acceptance or rejection of it  . Appropriate pre-operative patient counselling and morbid suffering prior to surgery such as faecal or urinary incontinence would strengthen the patient's conviction to undergo the operation in the hope that he would get rid of this distressing symptom. , After surgery on average 30% of stoma patients suffer from depression, and in some reports the rate was as high as 70%  . Most of the patients develop problems with their body image  . Some patients, particularly the elderly, tend to be socially withdrawn, and the patient would lose confidence in his ability to lead a normal Iife , Yet in a review of 1,033 cases of ileostomy, it was found that more than 90% were able to resume work without problem  . A significant number of patients suffer from sexual deficiency and stool irregularity. ,,
Studies have shown that the time and effort dedicated to prepare the patient for the surgery were very useful, particularly in helping him to overcome some of his pre-existing worries and anxieties. The roles of the family physicians, surgeon, spouse or supporter, stoma nurse and the social worker are all required  . There is no relationship between the seriousness of the disease which necessitates the stoma (such as cancer) and the prospects of psychological disturbances and social problems associated with it. This suggests that the patients' rejection of stomas arises from the nature of the surgery and the stoma, and not from the pathological morbidity  . Although diversive stomas have psychological and social complications, other studies have shown that alluding to the surgery is associated with psychological and social problems which may not be less effective than those occuring as a result of the surgery  .
Based on the above, one may conclude that the psychological, social and sexual consequences of diversive stomas appear to be greater than they really are. They would become even less significant as the patient and his relatives adapt to the new situation and new body image.
2. The Religious Rule in Seeking Treatment
Man's life and health are the seignory of the Creator, entrusted to man's custody, and he has a duty to preserve them. Therefore, Islam urged for seeking medical treatment as stated in many Quranic verses and Prophetic sayings. Examples are "And make not your own hands contribute to (your) destruction"  and "Nor kill (or destroy) yourself: for verily God hash been the most merciful"  . And, in the prophetic tradition we find: "For each morbidity there is a cure and if the cure strikes the morbidity, it will cure with the help of God Almighty." 
Prophetic traditions which call for appropriate treatment are too numerous to be discussed in detail in this study. Scholars are unanimously agreed on the permissibility of seeking treatment, however in relation to its dutifulness they are split into two groups , . The majority view it as a must and support their point of view with explicit verses and authentic traditions relevant to the question. The other group says that treatment is permissible, but not a must, unless the treatment is proved effective and lifesaving. They base their jurisprudence on an authentic prophetic saying narrated by both Bukhari and Moslem, quoting Ibn Abbas that a black woman came to the Prophet Peace and Prayer Be Upon Him (PPBUH) and said: "I suffer frequent fits and uncover my body, please pray to God for me". He said: "If opt to stand the illness, you will go to Heaven. And, if you wish I will pray to God Almighty to cure you". She said "I chose patience", and added: "I uncover my body. Please pray to God for me not to do so". The Prophet prayed for her"  . Another prophetic saying included in "Sahib Al Bukhari" about the Prophet's description of the seventy thousand from his followers who will go to Heaven without reckoning, says: "They are those who do not believe in pessimism, who do not practice treatment with fire or incantation and they trust in God." 
Therefore, we conclude that receiving treatment is a duty of Muslims whenever treatment is proved effective and life-saving, and in infectious disease where there is danger to the community, but it can be relinquished in certain cases.
3. The effect of carrying a stoma bag on patients purity during worship.
Knowledge of religious rules related to stoma patients is very important for both the physician and the patient. The patient will ask, before and after the operation, about rules of purity and prayer associated with an operation which requires him to permanently carry a bag for his body wastes viz. urine or faeces. Here, it can be stated that Islam has called for patients to be excused. God Almighty says: "It is not fault of the blind nor of the born lame, nor of one afflicted with illness"  . He also says" "And God has imposed no difficulties on you in religion"  .
Religion defines specific rules for those excusable followers in accordance with the type of the excuse. Muslim jurists have compared the case of carrying the waste bag for urine or faeces with the case of a patient with urinary or fecal incontinence. They consequently deducted permissibility of prayer for such patients while carrying such bags, and to enter mosques  . Most of the jurists impose a pre-condition that the patient should perform ablution before each prayer, while some of them see no need to repeat ablution for each prayer as long as the patient is maintaining his purity. The first view point is more cautious. As to washing out impurity, the existence of the bag has no effect at all on the perfectness of the ritual washing.
4. Stomas acceptability in light of Islamic rules relating to preserving good health.
We should look at the issue from two different angles. First, a diversion stoma involves the displacement of a body part and the impedance of its function. Secondly one has to deal with its psychological, sexual and social consequences and their associated religious rules.
As to the first point, Islam is based on the general principle of prevention of harm and bringing about benefits. Proper attention is given to maintaining the five necessities of life namely: religion, life (soul), mind (essential body parts), honesty and money respectfully  . One of Islam's rules stipulates that preserving the whole has priority over preserving the part, and that the less harmful should be chosen in order to prevent a greater evil , . Therefore, if it is not possible to preserve both the life and the body part, then, preserving the life as a whole should be given priority over preserving the body part. This means that it is a duty to excise the body part for the sake of saving a life. Ibn Abdul-Salam one of the religion scholars says: "Therefore, the infected arm is to be cut although this means the end of its function because of the possibility of achieving the greater advantage of saving the soul, if safety is more probable"  .
Based on the above , it can be said that the permissibility of agreement to undergo diversion stomas or similar therapeutic modalities is represented in the patients right to that option if safety in saving a life is a more probable outcome. The degree of probability is determined by the natural history of the disease, and patient's tolerance. The physician is required to adopt all necessary medical remedies, and to leave the outcome to God "And say: Work (righteousness): soon will God observe your work, and his apostle, and the believers"  . "God controls all movements of death, when their term is reached, not an hour can they cause delay, nor an hour can they advance it in anticipation." 
The second point is dealing with the resultant psychological, sexual and social effects. The Islamic view of illness is consolation, comfort and ease of the patient's calamity. Illness is the most effective case for men's repentance, faith, expiation of sins and superiority of rank. Prophet Mohammad (PPBUH) said: "A believer would not suffer hardship, fatigue, illness, sadness, even have solicitude worried him or even a thorn pricked him without receiving God's forgiveness for some of his sins"  . He also said: "Those who are most apt to hardship are prophets, virtuous and exemplary men. Man's suffering its comparable with his faith. Hardhip would continue until man walks around clean of sins"  .
Strong family relation, characterizing the Islamic society in accordance with its principles and commandments, is a stimulus for the care and assistance extended to needy relatives to raise their morale and give them the feeling that their emotional and spiritual stature have not changed, particularly in the husband-wife relationship. God Almighty says: "And do not forget liberality (generosity) between yourselves"  . The prophet (PPBUH) said "The best of you are those best to their families, and I am the best of any of you to his family"  . Islamic society calls upon its subjects to cooperate and help each other, particularly at times of hardship. "Believers in their love and kindness to each other are like the human body; if a part suffers pains, the rest of the body would falter by fever and insomnia"  . The patient has a right to be visited, prayed for and helped in managing his life.
5. Role of the Medical Staff in Convincing the Patient and His Relatives to Accept a needed Stoma.
The Muslim medical staff mainly the surgeon, the family physician, and the social worker must give advice and orientation to the patient and encourage him to receive all necessary treatment without coercion. Generally, the extent of insistence by the medical staff on the patient for treatment is determined by many factors including the type of treatment, the need for it, its effectiveness and consequences. Their role towards patients requiring diversion stomas can be summed up as follows:
provide detailed explanation of causing illness and risks involved, as required.explain the operation to be carried out, and indicate misconceptions the patient may have about it.indicate adverse consequences of the procedure and of not undergoing it, taking into account the psychological condition of the individual patient.describe prospects of cure and the quality of life afterwards. The side effects should not be concealed.emphasise the significance of operation from the religious point of view and that it does not contradict with reliance on God's will for cure.convince the patients' relatives, the supporters in particular, of the necessity of the treatment using the above approach and ask for their assistance in convincing the patient and helping him.provide booklet, pamphlets, audio & video cassettes prior to the surgery containing the illness, the surgery, and stoma care.since muslims tend to listen to and be content with the religious point of view, religious leaders particularly Mosque leaders (Imams) can be involved in convincing the patient and his family, and alleviating their fears and worries.
From the previous discussion one concludes that a Muslim patient needing a permanent diversion stoma has a religiously proven duty to listen to the instructions of a proficient physician in order to save himself if safety is most probable. Medical staff must make all efforts to convince the patient and his family of the necessity to undergo the surgery when the need for it is proven and the desired consequences are most probable. Suitable mechanisms may be thought of to involve religious leaders particularly Mosque Imams in dealing with such cases.
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