Obstetrics and Gynaecology
THE MALE GYNAECOLOGIST
MEDICAL EXAMINATION OF THE OTHER SEX
The Islamic revival witnessed recently has resulted in rekindling Islamic feelings and made many Muslims more sensitive and heedful to the teachings of Islam not only in the field of worship but in other areas of daily life. Practices and behaviours are subject to more scrutiny lest they might be objectionable to Islam, and new patterns and customs are prevailing amongst large sectors of Muslims. The question of whether a patient may be physically examined by a doctor of the opposite sex has been revisited, and many Muslims are naturally eager to get clear about the issue.
Islamic emotion is welcome. But when emotion is transformed into emotionalism there is a risk of going beyond the teachings of Islam in a desperate attempt to uphold them. Islam does not know ultra-Muslims, or uphold fiery fanaticism. To stop short of Islam, or to exceed beyond it, are both outside the spacious circle of Islam, and are both non-lslamic. Unless Islamic emotions are harnessed by proper knowledge of Islam and governed by it, they remain an enemy. More visible than the contemporary proper Islamic revival-which is indeed a fact-is its surrounding haze of overzeal and fanaticism which is not part of the revival but is even one of the hindrances it faces. Naturally it is more visible since it is the superficial and noisy crust. With heated emotion not reigned by proper knowledge the heirarchy of Islamic priorities becomes mixed up, peripheral trivial issues aquire more significance than basic ones, divisiveness amongst muslims for divergence of honest opinion are inevitable and the very roots of Islam are struck at in the process of preserving some twigs and offshoots. Islam’s totality and comprehensiveness becomes reduced to unending debate about rites, dress, food, drink and scattered other minutae.
It was perhaps symtpomatic of this climate then that upon starting the Faculty of Medicine in Kuwait, I was visited by a group of students of thefirst entering class, who were keen Muslims and therefore horrified with the idea of going into the dissecting room for their anatomy class and having to look at parts of female cadavres. Approving of me as a Muslim, they came to seek my views on that crisis. With the prospect of going to their clinical in the hospital wards two years later, when they would examine patients of both sexes, including thirteen weeks in obstetrics and gynaecology, the importance of alleviating their anxiety and upon solid Islamic grounds was obvious. Apart from that private visit, I made it a point to incorporate this and similar matters in their course on ‘History of Medicine’ in which I was co-teacher, and later on in ‘Islamic Aspects of Obstetrics & Gynaecology’ which has been part of our curriculum of obstetrics & gynaecology since the school started. But the general public also needed that education, and I had to step into the arena with a series of press articles and television and radio programs in a few countries wherever I could have access, as well as in various conferences and in my earlier book “Topics In Islamic Medicine” ( lst edition 1984, publ. Islamic Organization of Medical Sciences, Kuwait). Let us look at the subject in proper Islamic context.
The medical corps in the army of prophet Mohammad peace be upon him, was an all-woman corps. It comprised a group of Muslim ladies, with proper medical training according to the state of the art in those times. They were called the ‘asiyat’ or lady healers, and would join the army and strike camp at the margin of the battlefield, perhaps the prototype of what later became the field hospital. It was amongst their duties to go into the battle, carry the wounded soldiers back to their camp and attend to their treatment. The site of the wound on the body never paused a problem or raised an objection to their role in shouldering the medical responsibilities. Perhaps Muslims in those early days of Islam had more important pre-occupations than the fastidious splitting hairs that we sometimes see in our present day. It was thus established since the days of Badr and Uhud battles that the general rules governing the concealment of certain body parts from the sight of the others were waived for the purpose of medical treatment; as a legitimate exception from the general rule. Islam endorses ever a wider role for women. During the battle of Uhud, at a stage when the military situation became very critical to Muslims after an initial victory which lured some troops to disregard previous orders, one of the lady healers, by the name of Nussaiba threw away her medical kit and drew sword and shield and vigorously joined the battle. She was amongst the few who rallied to the prophet and fought in his defence. She was twice wounded and at the conclusion of the battle the prophet commended her, bravery and devotion and said: “Wherever I looked, to the right or to the left or ahead, there she was: fighting for me and defending me.”
Medical treatment, entailing the inspection of the body of the patient from the opposite sex is therefore legitimate according to the tradition of the prophet. Over the ages, jurists have upheld this statute. Under all other circumstances the ‘awra’ should be covered. The ‘awra’ is the part of the body that should be covered from strangers. In men it includes the genital region or, more restrictively, from the navel to knees. In women the body should be covered save for the face and the hands (some jurists allowed feet and ankles, and sleeves up to the elbows for the necessity of work or profession). The ‘awra’ is to be concealed even if the looker is from the same sex, although of course looking at the same sex is less provokative.”
One of the truths of the medical profession, seems to be beyond the comprehension of some critics outside the profession. In medical practice the human body ceases to exhibit its attraction as a focus of seductive temptation. What the doctor sees in the patient is a system of integrated and interrelated structure and function. The doctor checks it as a mechanic checks an engine, trying to locate what went wrong and why. Doctors undergo a process of professionalization starting from the day they entered medical school. A nonmedical person might lack this feeling but should not deny it. We go down to the clinic, the bed side and the operation theatre not as men or women but as doctors. The language of anatomy, physiology, pathology and therapy absolutely displaces that of beauty and sex. Exceptions are rare and are abnormal, and are minimized even more by the rules of professional ethics that make the presence of a third party (usually the nurse) mandatory during clinical examination.
Some critical persons are especially conditioned against the practice of obstetrics & gynaecology with respect to the male doctor. Completely lost to their (myopic) views is the fact that the body of the patient is also exposed to the doctor in other specialities, whether physician, surgeon, neurologist, dermatologist, orthopaedist to name but a few. An operation for haemorrhoids exposes the same operation field as for gynaecological operation. Pelvic examination might have to be performed to palpate the lower reaches of the body cavity even in nongynaecological conditions. The cry against one field of medicine therefore does not seem to be well founded.
The enlightened outlook of old jurists many centuries ago should have closed the door against our latter day overzealots, but the real crisis is lack of knowldge. Old writings remain to our day the model of broad mindedness, progressiveness and maturity in both Islamic sincerity and Islamic intellect. In his book “Al-Mughni” written in the eighth century Ibn Quadama, an authority of the Hanbali sect wrote: ‘ ‘It is,permissible for the man doctor to Inspect whatever parts of the woman s body that, the medical examination warrants for this is considered a necessity and this was written over seven centuries ago. ‘Al-Adab Al-Shariyya’ written by Ibn-Muflih also of the Hanbali school-relates an interesting account: “Marwathi asked Abu Abdullah about a woman who had incurred a fracture and the bone-setter found it necessary to lay his hands on her to manipulate the fracture. The answer was a clear consent since that was a medical necessity. So he went a step further and told that the bone-setter who wanted to apply a splint, wanted to expose her chest and lay his hands over it during the treatment, and again the answer was a straightforward approval. “The same page in the same book bears the clear statement: A man doctor may inspect the ‘awra’ of a woman ‘s body as far as the medical examination warrants, if only a male doctor is available to treat her, even if he has to look to her private parts. This same would be true if a man is ill and there is but the woman doctor to treat him. she may inspect his body even his private parts.” The same is reaffirmed by other authorities such as judge Abu- Yaala of the Hanbali and Ibn Abdeen of the Hanafi schools.
Some contemporary hardliners linger a bit too much at statements like ‘if only a man doctor is available mentioned in the previous text. Not long ago, a member of parliament in a Middle Eastern country expressed disquiet during a parliamentary session at the practice of obstetrics & gynaecology by male doctors, and officially made the proposal that only women doctors should conduct obstetrics, and summon the help of the man doctor only when complications arise and the situation becomes one of “compelling necessity”, to use his terminology. We can perhaps respect his opinion, but since he based his arguments upon ‘the teachings of Islam’ , we find it inevitable to disagree. If his views were Islamically correct, and the male master doctor is to be invited only when the situation is really bad, one cannot help enquiring: and how was this male super specialist made? Had he been sent as a student to the medical school only to be taught the management of complicated and desperate situations? Could he have mastered the difficult without vast experience of the easy? Could he have reached the top without diligently climbing from bottom to top?
Beginning at the beginning, there is unanimity, including even the ultraradical, that society should have doctors of both sexes, whatever the duties later to be assigned them. It does not take much thinking to know that in the preparation of the young man or young woman to become a doctor , it is imperative for them to examine the body of both sexes. If we delete the male body from the curriculum of women medical students it will not be possible to make women doctors out of them. Similarly it will not be possible to make men doctors if we delete the study of the female body from the curriculum of male students. The nature of medical studies has no room for such ideas. The making of the doctor starts with the making of the generalist. At a later stage specialization will entail the in-depth study of a certain discipline, retaining full awareness of relations and interactions with other body functions and systems, otherwise key-hole medicine is produced, where concentration on a minute aspect overlooks very relevant and operating interactions.
That society should make its doctors is a religious duty on society, of the type called ‘Fardh Kifaya’ ie that which can be carried out by some members of society on behalf of the community at large. Another Islamic dictum proclaims that whatever is necessary to uphold a religious duty becomes of itself a duty. Applying this to making doctors, it becomes clear that from the time of going into medical school, a legitimate exception from the rules of concealing the ‘awra’ immediately operates.
Instead of singling out obstetrics & gynaecology for attack, it would have been more logic-illogic as it is to shout the cry of “Women doctors for women and men doctors for men’, whether in general practice or in anyone of the specialities. Is it possible? Is it feasible? Is it the right step to take?
Women are half of the society are women doctors one half of the medical force? Would they ever be? Can women doctors assume half the number of the members of every specialty? Some health authorities have tried to compel women graduates to take up obstetrics & gynaecology in the way of military. drafting. It did not work. It would be against legitimate personal choices. Many a woman doctor would prefer to take up a specialty devoid of hard work and very uncomfortable hours with emergency calls during day or night. To do that at the expense of home, husband and children is acceptable only to the few and shunned by the many. The few women who opt to specialize in obstetrics & gynaecology find it distasteful to be regarded as’ ‘woman’, and not as doctor, and in public (government) hospitals, employing salaried full time doctors, an overdemand of over-religious women patients for women doctors caused the women doctors to counter demand not to be discriminated against on the basis of their sex. To the majority of the patients, however, the priority is given to their faith in the doctor and ability to treat or operate on them irrespective of the doctor’s sex.
What if a woman patient requests to be examined by a woman doctor? The Islamic answer is of course to answer her request as far as it is possible. We should not judge people for their opinions, and it is part of good medical care to make our patient content. Some women have inherent shyness to expose their body to a doctor of the opposite sex. Some have their religious views and these should also be respected but without in any way compromising the educative role of the Muslim doctor, be it to the public or to the individual patient. In this and in other issues, the Muslim doctor is not one who takes off his Islam as he puts on the white coat. In tolerance of opposing views, and in a most graceful way of talk, we have seen the simple presentation of the truth about Islam alleviate ” much anxiety, and relieve many a fellow Muslim from burdens that God never intended to impose on them.
Volume 1 Number 7
Man Shall not Live By Science Alone
01 March 1988
An old patient of mine and her husband sought my help to make peace with their 20-year-old son.
By DR HASSAN HATHOUT
A view from Kuwait
In my part of the world the medical doctor is still called `the wise man’, a title he has held for centuries. Once you earn the community’s confidence you are sure to be consulted on matters completely outside the sphere of medicine.
One of the features of my life is what I call my `telephone clinic’. People ring me up – many wanting to remain anonymous – to explain their problems and seek my views about them. Although sometimes inconvenient, it is a source of happiness for me. It is a pleasure to be able to solve problems and it gives me satisfaction to feel I am trusted.
On one of these occasions an old patient of mine and her husband sought my help to make peace with their 20-year-old son. He was quite a religious young man, so I reminded him of God’s words in the Qur’an: `Your Lord decrees that you worship none but him… and that you be kind to your parents.’ The son retorted: `No. I owe them nothing, doctor.’ Noticing my shock he explained: `When they married they made up their minds to have two children only. It was sheer chance that I was number two after my elder sister. Had I been conceived later, they would have killed me through abortion as they did the five that came after me.’
This took me by surprise, as it brought me face to face with a dimension of the issue of abortion that had not previously crossed my mind -that the victim of abortion is not only the aborted baby but can well be the relationship with unaborted children.
Yet we live in the age of the crime of massed abortion. Innocent lives are sacrificed just because they are unwanted or inconvenient. The sanctity of human life has been progressively undermined, hand in hand with progress in science and technology.
Medical science has contributed by standing neutral and making this crime something praiseworthy and safe – a clinical killing under aseptic conditions using a spectrum of scientific methods including dilatation evacuation, vacuum aspiration, intrauterine injection or pharmacological uterine stimulation.
Medical science has accepted the argument that the freedom of a woman over her body could be extended to the killing, by the hand of the doctor, of an innocent foetus which, scientifically, is not a part of her body, and whose presence in her uterus is of her own doing and not the baby’s.
It is my conviction – and that of my religion – that human life is a value in its own right, and its sanctity covers all phases, including the foetal. Without values to guide science people take the status of `things’, and foetuses become tiny little `things’. Once the value of human life is compromised, the logical consequences for society are that one has a right to die (clinically) if ill beyond cure, and then, later perhaps, that one has a duty to die if by reason of age, infirmity or nonproductivity one’s life becomes a financial liability.
This value-less appraisal of human life is not a fiction in today’s world. The euthanasia movement is actively gathering momentum in some countries. A new tune in modern socio-economic literature preaches that when the human machine has outlasted its productive span so that its maintenance costs more than its productivity, it should be disposed of. Such clinical disposal is being sweetened by calling it `death with dignity’.
The most scientific arguments are used to promote these ideas, but unfortunately they emanate from purely materialistic concepts. They ignore the fact that it is value and not matter that makes Man more than just another animal; master of his environment, founder of civilization and – if you believe in God as I do – the bearer of God’s Spirit, the shedder of his light and the trustee of his guidance on earth.
But what is the meaning of God’s spirit, light and guidance in scientific terms? Practically nothing… for science concerns itself with the study of the tangible and is, as yet, unequipped to handle `values’. This would not have mattered if scientists did not deny the existence of whatever lies beyond the realm of science.
Unfortunately many have fallen into this trap. A new scientific `religion’ called `secular humanism’ maintains that human values are to be laid down by human beings without reference to any outside or supernatural source. This denies God and makes Man his own god. The source of Man’s godlike authority is his mind, the creator of his science.
No sooner does Man assume the role of a god than he faces a critical impasse. For the human mind admits its own limitations. Every new discovery today proves our ignorance yesterday, and every new discovery tomorrow reveals our ignorance today.
Had the human mind claimed the completeness worthy of a god, then research would be stopped and research budgets cancelled. The more we know, the more aware we become of our ignorance.
In its tendency to self-worship, science fell into another trap: that whatever can be done should be done – if for no other reason than that it is possible. In my field of medicine, test-tube baby technology was soon followed by the technology of surrogacy, where a woman carries through a full pregnancy the foetus of another couple, and gives it away when she delivers it. For the first time in human history the human female is willing and able to mother a foetus with the prior intention of giving it away. As this is in most cases done for a certain amount of money, `motherhood’, as a value, is reduced by having a price put on it.
The right of the baby to have and know a legitimate father and a legitimate mother is ignored. Indeed, the concept of `legitimacy’ does not seem to be very scientific in modern times. If `motherhood leasing’ and `,infant selling’ become widespread and a new generation knows that it is common practice that a mother carries, delivers, cashes and gives away… what effect would this have on the bond that ties consecutive generations in love and compassion?
We live in the age of the sexual revolution. When Freud formulated his views (a great scientific leap in his days although later dead and buried) people put sex into the domain of science, freeing it from the unscientific constraints that confined it to marital life.
Similarly, when the American Psychiatric Association ceased to consider homosexuality as an aberration to be treated, the public thought it was scientifically acceptable. This not only encouraged homosexual activity amongst suppressed homosexuals, but also considerably spread homosexuality itself.
The result of these and other moves is the current epidemic of exploitation, venereal disease and enslavement to sexuality and pleasure-seeking. We count the cost not only in terms of health but also in loss of selfrespect, mutual respect and self-restraint, without which we lose our humanity.
Medical and biological science is by no means the only illustration of the possible hazards of science unguided by values, but it is the latest member of the club. Since the dawn of history, medicine has confined its efforts to the service of life. Nowadays it has started to be a double-edged weapon – sometimes for life and sometimes against it.
Here I am not referring to abortion and euthanasia – but it is no secret today that preparations for biological warfare have been making significant headway over the past decades. Top military secrets probably reside now more in biology laboratories than in those of chemistry, physics or mechanics. When the first atomic bomb was dropped over Hiroshima, Oppenheimer the father of the atomic bomb – said: `Today physicists have known sin.’ Will the day come when the same will be said about biologists?
I am a firm believer in science and a strong advocate of scientific advancement. But I am fully aware that if science stands neutral between morality and immorality, good and evil, what is useful and what is harmful, then, at least, people – including scientists – should refrain from such neutrality. Science is subject to Man, and not Man to science. The freedom of scientific pursuit is sacred but its products are not necessarily so. The bridge between science on the one hand and technology and mass production on the other should be heavily guarded by a value system. In other words science must have a conscience.
But from where do we derive our values? If Man is too fallible, then what about God? Does God exist?
Imagine being told that the order of the words in a dictionary was the result of an explosion in a printer’s shop. Would your scientific mind swallow it? Look around you, thoroughly and scientifically, from atom to galaxy. All has been planned, arranged and set to function according to immutable scientific laws. A creation immensely more sophisticated than the words in a dictionary.
If you think God is there, is it logical that he uniquely endowed Man with concepts of responsibility and accountability and yet left him without the possibility of divine guidance?
Hassan Hathout is Professor of Obstetrics & Gynaecology at the University of Kuwait, a member o f the Board of Trustees of the Islamic Organization of Medical Sciences and a member of the FIGO (International Federation of Gynaecology & Obstetrics) Committee for the study of Ethical Aspects of Human Reproduction.
Obstetrics and Gynaecology