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Aesth Plast Surg (2008) 32:1–10 DOI 10.1007/s00266-007-9040-7 REVIEW Aesthetic Surgery and Religion: Islamic Law Perspective Bishara S. Atiyeh Æ Mohamed Kadry Æ Shady N. Hayek Æ Ramzi S. Musharafieh Published online: 30 October 2007 Ó Springer Science+Business Media, LLC 2007 Abstract Background Plastic surgeons are called upon to perform aesthetic surgery on patients of every gender, race, lifestyle, and religion. Currently, it may seem natural that cosmetic surgery should be perceived as permissible, and in our modern liberal age, it seems strange to attempt justifying certain surgical acts in the light of a particular cultural or religious tradition. Yet every day, cruel realities demonstrate that although the foremost intention of any scripture or tradition has been mainly to promote religious and moral values, most religions, including Christianity, Islam, and Judaism, invariably affect human behavior and attitude deeply, dictating some rigid positions regarding critical health issues. Methods A Web search was conducted, and the literature was reviewed using the Medline search tool. Results Islamic law closely regulates and governs the life of every Muslim. Bioethical deliberation is inseparable from the religion itself, which emphasizes continuities between body and mind, between material and spiritual realms, and between ethics and jurisprudence. Conclusions The rule in Islam is that individuals should be satisfied with the way Allah has created them. Islam welcomes, however, the practice of plastic surgery as long as it is done for the benefit of patients. Even if it clearly considers ‘‘changing the creation of Allah’’ as unlawful, Islamic law is ambiguous regarding cosmetic surgery. Its objection to cosmetic surgery is not absolute. It is rather an objection to exaggeration and extremism. It has been mentioned that ‘‘Allah is beautiful and loves beauty.’’ This review was not supported financially by any organization, pharmaceutical company, or research board. The authors also do not have any financial or other interest from conducting it. Religion is a pathway to the practices and thoughts appropriate to the god(s) of a particular faith [1, 2]. It is not interchangeable with spirituality, which has a broader meaning and encompasses philosophical ideas about life, its meaning and purpose [1, 2]. Unfortunately, its role in health care seems to be increasing [3]. Incorporating religion with medicine necessarily raises serious questions of medical ethics [4]. Religious and medical perspectives are, of course, different and could come into conflict, although in general they need not be contradictory [5]. Throughout history, the relationship between religion and health care has cycled between cooperation and antagonism. Some of the most advanced civilizations of ancient times (Assyrian, Chinese, Egyptian, Mesopotamian, and Persian) equated physical illnesses with evil spirits and demonic possessions, and aimed B. S. Atiyeh (&) Division of Plastic and Reconstructive Surgery, American University of Beirut Medical Center, Beirut, Lebanon e-mail: aata@terra.net.lb M. Kadry Department of Plastic and Reconstructive Surgery, Cairo University, Cairo, Egypt S. N. Hayek Department of Plastic and Reconstructive Surgery, University of Minnesota, Minneapolis, MN, USA R. S. Musharafieh Department of Hand Microvascular and Reconstructive Surgery, St Georges University Hospital, Beirut, Lebanon Keywords Aesthetic surgery  Cosmetic surgery  Islamic law  Religion 123 2 treatment at banishing these spirits. Since then, physicians and other health care providers have been viewed by religious groups as everything from evil sorcerers to conduits of God’s healing powers. Similarly, the views of religion held by physicians, scientists, and health care providers have ranged from interest to disinterest to disdain [3]. Although the medical ethics guiding each surgeon currently remains influenced by his or her religious or cultural background [6], the surgeon still needs to be cognizant of the varying perceptions of health shared by people of different religious, sociocultural, and linguistic backgrounds [7–9]. Plastic surgeons in particular are increasingly called upon to perform surgery on patients of every gender, race, lifestyle, and religion. Today, it may seem natural that there should be little opposition to cosmetic surgery [10, 11], but up to the start of the 20th century, most religions as well as the medical establishment were opposed to any form of surgery for purely cosmetic reasons. Medical ills and physical disfigurement were considered forms of divine punishment. It was not permissible to correct what God had decreed [10]. Certainly, the bioethical problems occasioned by modern medicine have not been the exclusive concern of one religion or culture. Patients invariably present with diverse ethical decision-making models or religious/ spiritual preferences and may not hold Western bioethical views [12]. Moreover, studies have clearly shown that many patients are interested in integrating religion with their health care and consider religion to be very important. They would like their physicians to discuss religious issues with them [3]. The impact of religious beliefs on perceptions of health and illness is definitely important for the development of culturally sensitive and appropriate health care systems [7, 13]. However, it currently seems strange to attempt justifying certain surgical acts in light of a particular cultural or religious tradition. Nevertheless, the dogmas of most religions, including Christianity and Judaism, deeply affect human behavior and attitude [11] and dictate some rigid positions regarding critical health issues. Muslims as well as other religious communities today face a crisis of knowledge, or rather, a crisis in connecting knowledge and faith [14]. Much has been written about Jewish and Christian medical ethics. Islamic medical ethics, on the other hand, have not been specifically discussed widely as an independent field of ethics [6]. Paramount to this discussion must be an understanding of the various schools of Islamic thought and, most importantly, the mechanisms of jurisprudence and theological decision making that differ somewhat from what is customary in the Judeo-Christian tradition. 123 Aesth Plast Surg (2008) 32:1–10 Islamic Schools of Thought and Mechanisms of Jurisprudence Islam is one of three monotheistic religions [15] and shares essentially the same code of morality as Judaism and Christianity despite some doctrinal differences [16, 17]. The most striking distinguishing feature in Islam, however, is the absence of an organized ‘‘church’’ and ordained ‘‘clergy’’ [6, 16]. In contrast to Christianity and Judaism, for which doctrinal authority is centralized and in the hands of one supreme figure or governing body, determination of valid religious practice and resolution of bioethical issues in Islam are left to qualified scholars (Ulema). These scholars are called upon to provide rulings (Fatwa) on whether a proposed action is forbidden, discouraged, neutral, recommended, or obligatory [6, 16] based on the four sources of law in Islam (Usul al-Fikh) [18]. A school of thought (Madhhab) is an Islamic term referring to the paths people follow to the Qur’an and the Prophet [19]. It is a method of interpreting religious material [18]. It also is a school of religious jurisprudence (Fiqh) within Sunni Islam [20]. Over the years, Islam has witnessed several learned Islamic scholars (Imams), but four of these became more known, and their teachings spread in different parts of the Islamic world [21], leading to the four currently recognized major schools: Hanafi, Hanbali, Maliki, and Shafi’i [20]. The Hanafi School, considered to be the most open to modern ideas [20], preserves many of the older Mesopotamian traditions, and its rulings are based largely on the personal opinion of the particular scholar [18]. The Hanbali School, predominant in the Arabian Peninsula, is the most conservative of the four schools [20]. The differences between the four schools of thought manifest in minor practical details. However, most Sunni Muslims consider them all fundamentally the same [20]. Currently, there is a strong growing movement against following the classical schools (anti-madhabist). The agenda of this movement is a return to the tradition of the Prophet’s companions (Sahaba), relying mainly on Hadith, which every individual can read for himself. In some aspects, this movement appears to represent a traditionalist new revival [18]. On the other hand, in Shi’a Islam, a fifth school of thought may be considered: the Ja’fari jurisprudence [19]. In addition to these major schools of thought, various sects and movements exist within each group. Wahhabism, for example, is a puritanical and legalistic Islamic movement under the Sunni umbrella often associated with the Hanbali school [20]. Salafis, on the other hand, advocate a puritanical and legalistic stance in matters of faith and religious practice. Salafism is in general opposed to Sufism and Shi’a Islam, which they regard as heresies [20]. Aesth Plast Surg (2008) 32:1–10 Twelvers (believers in 12 Imams) represent the largest Shi’a school of thought [20]. Usulis, for their part, are the largest group of Twelver Shi’a, and they follow the religious jurisprudence of Ayatollahs [20], considering that it is illegitimate to continue following the controversial rulings of a dead jurisprudent [22]. Thus Islam is not monolithic, and Muslims cannot be considered a homogeneous group because they have diverse cultures, customs, and sects, as well as various schools of jurisprudence. Diverse views in bioethical matters do therefore exist [1, 7, 16, 23] depending on whether the scholar making the ruling is a traditionalist following only the literal meanings of the Qur’an and Hadith (ahl al-hadith) or is basing his ruling on personal interpretation and opinion (ahl/ashab al-ra’y) [18]. Irrespective of this apparent distinction, liberal and progressive movements in Islam have in common a religious outlook that depends mainly on reinterpretations of scriptures (Ijtihad). Liberal Muslims believe in greater autonomy of the individual in interpretation, a critical examination of religious texts, gender equality, and a modern view of culture, tradition, and other ritualistic practices in Islam [20]. The Islamic point of view about any given issue can be presented from two different perspectives: first, by analyzing the work of various Muslim thinkers, and second, by attempting to assess the Qur’anic stance directly in the light of both verbal instructions and practices of the Prophet [24]. It is a misconception therefore that a Muslim should follow any given school of thought [21]. All the great scholars of Islam must be respected, but if any of their rulings or teachings contradict the Qur’an, they must be rejected without hesitation, and the Sunnah of the Prophet should be followed [21]. It is worth noting also that modern medical Fatwas demonstrate a clear continuity from medieval times. Companions of the Prophet and classical legal compendia are cited as easily and as cogently in the 20th century as in the 10th. Moreover, the mode of argument and classical terminology often are identical, although the specific issues have of course changed [25]. Scholars from Islamic universities such as Al-Azhar in Cairo often are charged with interpreting and contextualizing religious teachings for the wider community [26]. Some of the issues discussed are universal (e.g., abortions), whereas others are typically Islamic [6]. A proliferation of complex issues producing ethical dilemmas for health care professionals, patients, and society has resulted from recent scientific and technological advances requiring specialist knowledge and necessitating the somewhat novel concept of a ‘‘consensus edict’’ rather than classical Fatwa. For rulings pertaining to medicine, these consensus groups include in addition to a diverse representation of ‘‘Ulema,’’ 3 specialist clinicians from relevant disciplines responsible for providing necessary background information. The decision-making process is typically transparent, with members of the wider community able to scrutinize the arguments used and the textual material underpinning these edicts. Counterarguments may be presented, and it is not unusual for two or more seemingly contrasting opinions to coexist [26]. Instead of defining normative positions, broadly constructed bounds for discussion are set. The Fatwa literature is thus characterized by a spirit of lively debate legitimating many shades of opinion. In principle, individuals are free to choose whichever judgment they find most agreeable [25, 26]. Islamic Concepts of Health and Disease The treatment of illness is difficult enough without throwing in the added complications of religious and cultural differences [27]. Yet in any society, religion exerts powerful influences on personal perceptions, attitudes, and beliefs toward health care and shapes models of care that patients receive [1, 7, 28]. In recent years, interest in understanding the effects of religion on health has grown in the medical and scientific communities [29]. It is no surprise that health care workers in many countries face the problem of treating patients whose beliefs and behaviors about health and illness may be completely different from their own. Muslims are but one of many groups presenting such a challenge [27]. Islam is far more than a spiritual tradition, for it also has a societal dimension. Shari’a, or sacred law, is principally concerned with five objectives: protecting life, safeguarding the freedom to believe, maintaining the intellect, preserving human honor and dignity, and protecting property [30]. In Islam, all aspects of behavior are regulated by the precepts set in the Qur’an and the Sunnah [6, 14]. Sacred law is an entity embracing all aspects of human existence [26, 31]. Human beings are the crown of creation. They are endowed with reason, choice, and responsibilities, including stewardship of other creatures, the environment, and their own health [16, 32]. God plays a major role in health belief systems, which constitute a holistic framework meeting physical, spiritual, psychosocial, and environmental needs of individuals and communities [1, 7, 28]. Concepts about the origins, nature, cause, consequences, and interventions of health and disease appear heavily influenced by strong connections to Islam and its traditional culture. These affect as well the interplay between the surgeon and his practicing and deeply religious conservative patient [6, 7]. The world, including any advantages presented by nature or science, belongs to the bounties of God, which must 123 4 be shared so that no one goes hungry, no one suffers illness when there is a cure, and no one abuses the gifts that have been entrusted to us [1]. Historically, Islam teaches that God has decreed all things, good and evil, from eternity, all that happens, whether obedience or disobedience, faith or infidelity, sickness or health, riches or poverty, life or death [33]. Belief in predestination gives Muslims great courage in times of terrible hardship [33]. However, it is a crucial problem not only in Islam but also in Christianity. There has been a long and continuing discussion by theologians on both sides about whether man has power to act and free will to choose his action [34]. The conclusion that God has predetermined all things is what most Muslim theologians believe today [33]. Nevertheless, there are two opposing concepts in Islam: the concept of predestination and the concept of testing, which involves a notion concerning some sort of free will that essentially nullifies the former concept [35]. Muslims understand that illness, suffering, and dying are part of life and a test from God. A major illness is considered God’s will, and birth defects are regarded as a test of one’s patience and faith in him. It is a cleansing ordeal, not a curse or punishment or expression of God’s wrath [1, 15, 16, 32, 36]. With Islam, it is important to understand that opposites do not negate one another. Both concepts of predestination and free will are considered equally true [35]. Although the concept of ‘‘testing’’ is present, God’s will is never subservient to human will [35]. Thus the ‘‘testing’’ of the believer is reduced to a test of conformity to the creed rather than a test of the ability to discover what is right and true by oneself [35]. This explains why the Muslim so easily says, ‘‘Insha Allah,’’ meaning ‘‘if God wills.’’ It is the reason also why the illness, accident, death, or good fortune is said to be from God [33]. Educated Muslims who are trained in modern sciences, on the other hand, place more emphasis on human responsibility. They often believe that sickness or poverty is a simple result of man’s ignorance or laziness. They prefer to believe that it is God’s will for man to fight disease rather than simply accept it as one’s fate [37]. Although most Muslims appreciate modern medicine and seek health care, the belief in predestination may lead some patients not to follow treatment or not even to seek health care [23]. Moreover, older people, in particular, who have strong religious and sociocultural health beliefs, might be relatively resistant to acclimatizing to the ‘‘new’’ modern universal values and culture [7]. Muslims are expected to be moderate and balanced in all matters, including health. Health and illness are seen as part of the continuum of being. Illness is regarded as an event, a mechanism to purify and balance the person physically, emotionally, mentally, and spiritually. It is received with patience and prayers. Death is viewed as a 123 Aesth Plast Surg (2008) 32:1–10 journey to meet the creator [1, 16, 23, 31, 32]. Anger, therefore, is an inappropriate response [31]. However patients must avoid being fatalistic and are strongly encouraged, if not obliged, to seek treatment, which should not be regarded as a sign of conflict with reliance on God for cure [1, 16, 23, 32]. ‘‘Indeed, Allah has created the illness and its cure. So treat yourselves O Allah’s worshippers, but do not treat yourselves with something forbidden.’’ Medications therefore are permissible provided unlawful (haram) prohibited products (alcohol, pork) are not used [1]. Reported sayings of the Prophet are categorical in that regard [38]. However, for the exempted case of necessity, Islamic law has a different ruling [38–41]. Necessities overrule prohibitions [41]. Unlawful ingredients are allowed if they are lifesaving or prescribed by a trustworthy Muslim physician, and if lawful alternatives are not available [39, 40]. Others have even ruled that unlawful products may be allowed parenterally or for topical application [41]. Moreover, ‘‘transformation,’’ causing a material to change into another, with totally different properties and characteristics, turns prohibited substances into products permissible by law [41]. The Holy Qur’an achieves its healing and health-promoting effect by legal legislations prohibiting hazardous lifestyle and behavior, stressing behaviors that promote health (moderate eating; abstinence from consumption of alcohol, tobacco, and other psychoactive substances; regular exercise; prayers; fasting; ablution and bathing; breastfeeding; and many other injunctions). It provides general rules and regulations to guide individuals in conducting their daily lives. It also has direct healing powers; ‘‘a healing and a mercy to those who believe.’’ Anyway, prayer remains the salvation in both health and sickness [1]. Islamic Bioethics Ethics can be described as a subbranch of applied philosophy that seeks what is the right and the wrong, the good and the bad set of behaviors in a given circumstance. Bioethics, however, is a quasi-social science that offers solutions to the moral conflicts arising in medical and biological science practice [42]. The four ethical principles, namely, ‘‘respect to autonomy,’’ ‘‘justice,’’ ‘‘beneficence,’’ and ‘‘nonmaleficence,’’ have almost always existed and govern the ethical behavior of human societies. They are universal age-old commonsense principles applicable to any culture and society including Islamic traditional societies [42]. Irrespective of this generalization, appreciation of beliefs, perspectives, and conceptual frameworks are of Aesth Plast Surg (2008) 32:1–10 paramount importance and central to discussions concerning medical ethics. If secular Western bioethics has been described by some authors as rights based, with a strong emphasis on individual rights, Islamic bioethics is based on a combination of principles, duties, obligations, and rights as well as on virtue to a certain extent [6, 16, 26]. In Islam, Ijtihad (law of deductive logic) governs bioethical decision making carried out within a framework of values derived from revelation and tradition. Islamic bioethics is an extension of Islamic law (Sharia), which is based on the Qur’an (holy book) and the Hadith and Sunnah (Prophet’s words and acts) [16, 23, 26, 43]. The holy book is believed to be the eternal word of God revealed to the Prophet. The Hadith and Sunna also are accepted as truth [23]. The Shi’a branch of Islam has in some cases developed its own interpretations, methodology, and authority systems, but on the whole, its bioethical rulings do not differ fundamentally from the Sunni positions [16]. Bioethical deliberation is inseparable from the religion itself, emphasizing continuities between body and mind, material and spiritual, and ethics and jurisprudence [16]. The Qur’an, Hadith, and Sunnah have laid down detailed and specific ethical guidelines regarding various medical issues [16]. Islamic bioethics emphasizes prevention. However, when prevention fails, it provides guidance not only for the practicing physician, but also for the patient. It teaches also that the patient must be treated with respect and compassion and that the physical, mental, and spiritual dimensions of the illness experience must be taken into account [6, 16]. On the other hand, physicians must understand the duty to heal, acknowledging at the same time that God is the ultimate healer [16]. Islam recognizes that there is nothing in the creation that was created for naught. ‘‘And know that We have not created the heavens and the earth and all that in between them in mere idle play’’ (21:16) [14]. Moreover, one of the central emphases in the Qur’an is that God had faith in Adam and trusted that humankind can and will achieve goodness on earth. Furthermore, God gave man knowledge not imparted to other creatures to benefit humankind as a whole, regardless of race, color, or social status. The knowledge we acquire comes with God’s ‘‘help, guidance and will’’ [14]. God ‘‘knows all that lies open before men and all that is hidden from them, whereas they cannot attain any knowledge except that which He wills them to attain’’ (2:255). 5 ‘‘Verily, we did offer the trust to the heavens, and the earth, and the mountain; but they refused to bear it because they were afraid of it. Yet man took it up’’ (33:72) [14]. Thus there exists no conflict between science and Islam [14]. Anyway, a scientific medical approach does not preclude a religious perspective [5]. However, when science operates in an ethical vacuum, when it fails to assess whether its achievements are detrimental to the many or beneficial only to the few, a serious situation ensues [14]. Moreover, social organizations in general negate scientific and technological achievements by restricting their benefits to selected sectors of the community [14]. Anyway, Islam considers acquired scientific knowledge as a responsibility and a trust, given and accepted by the human, to be applied to the betterment of mankind, for doing good deeds, preventing evil, and addressing the misery and suffering of all [14]. Yet it must be accompanied by compassion, kindness, and generosity [14]. Attempting philosophical and theological justifications for certain surgical decisions, such as extensive skin grafting for severe burns, is one thing, but it is quite another thing to justify elective procedures [11]. Islam, however, has the flexibility to respond to new biomedical technologies, and because it shares many foundational values with Judaism and Christianity, the informed physician of Judeo-Christian background will find Islamic bioethics quite familiar [16]. Patient–Physician Relationship in Islam In this age of globalization, more and more members of different religions and cultures live in the same society. This situation tends to create many conflicts in different areas of life and not least in the health care system, a fact that raises a number of bioethical issues. The cultural and religious differences between patient and physician can be a cause of bioethical conflicts and therefore can represent a challenge for biomedical ethics [44]. Health professionals have a dual responsibility to their patients: to ‘‘do no harm’’ (nonmaleficence) and to act according to the best interests of each patient (beneficence) [4]. In an ethical conflict between two individuals who are members of different cultures, it is necessary to make sure that the ethical concept to be used for resolving the problem is relevant. In this particular case, both the Islamic legal responses (fatwa) and the classical theories of biomedical 123 6 ethics are often insufficient [44]. A minimum level of cultural awareness is a necessary prerequisite for the delivery of care that is culturally sensitive [45]. The long-standing aspect of modern medicine requires that health care professionals distance themselves from any purely religious issues that may arise in the context of their duties. This certainly demands that such professionals forbear from promoting or challenging religious beliefs, whatever their patients may want in the way of medicospiritual counseling [4]. The continuous developments in medicine and, consequently, in medical ethics, create new questions for Muslim physicians, medical jurists, and religious authorities [46]. At the center of medical morality is the healing relationship. In today’s pluralistic society, universal agreement on moral issues between physicians and patients is no longer possible. Nevertheless, a reconstruction of professional ethics based on a new appreciation of what makes for a true healing relationship between patient and physician is both possible and necessary [47]. Health care practitioners must actively support their patients’ diverse religious beliefs and practices without hypocrisy, without offending patients who do not subscribe to certain of such beliefs, and without offending atheists, agnostics, and religious nonaffiliates [4]. Muslim jurists over the ages have adopted a somewhat enlightened opinion with regard to the patient–physician relationship. They have acknowledged that religiously concealable body parts of both men and women should be concealed from men and women alike, a statute that is waived, however, only for the purpose of medical treatment. Therefore, medical examination entailing inspection of the body of the opposite sex is legitimate in Islam whenever it is considered a necessity [48]. Exceptions are rare, abnormal, and minimized still by the rules of Islamic medical ethics that make the presence of a third party (e.g., nurse) mandatory when a doctor examines a patient of the opposite sex [48]. Some, however, argue that a male physician may inspect the religiously coverable parts of a woman’s body that medical examination warrants, as long as no one else but a man is available to treat her, even if he has to look at her genital area. The same is true if a man is ill and only a female physician is available [48]. In the modern resurgence of Islam, some hardliners, however, still may feel uneasy even with the permissible exception on account of the ‘‘necessity’’ status of medical practice and seem to linger too much at phrases such as ‘‘only if necessary’’ or ‘‘if only a male doctor is available’’ [48]. Individuals who embrace the Islamic faith are likely to define a good physician as one who addresses issues of faith and spirituality as well as biologic needs in the clinical encounter [5, 49]. Not infrequently, a female patient may express her desire to be examined only by a female physician. It is understandable that every effort should be made to satisfy her wish, not because it is religiously 123 Aesth Plast Surg (2008) 32:1–10 forbidden for her to be examined by a man, but because it is a duty to respect patients’ personal beliefs and cater to their psychologic comfort [48]. Islam and Aesthetic Surgery There is a balance and perfection in the creation and in nature that must not be ignored: ‘‘He Who created the seven heavens one above another: No want of proportion wilt thou see in the Creation of Allah Most Gracious. So turn thy vision again, do you see any flaw?’’ (67:3) [14]. ‘‘We created Man in the most perfect form’’ (95:4) [26]. These dictums stress that each human life has its own inherent value and goodness but may theoretically render any further improvement in one’s appearance rather unconceivable. Not denying the capacity for autonomy and self-determination, in cases of absolute necessity wherein religiously lawful alternatives do not exist, Islamic teachings, as presented earlier, allow even for sacred law to be suspended, temporarily: ‘‘But if one is compelled by necessity, neither craving nor transgressing, there is on him no sin, for indeed Allah is Clement, Merciful’’ (2:173) [26]. It is imperative, however, that any alteration of creation be addressed with the utmost care. Moreover, one must remain vigilant so that the market for ‘‘altered creation,’’ be it genetically modified crops or aesthetic surgery, may remain mercy driven, not profit driven [14]. Aesthetic surgery is spreading fast in Muslim countries. Is it to be condemned as a futile luxury, or is it answering to a real physical and psychological need [50]? Well-informed scholars divide plastic surgery into two categories: 1. 2. Essential surgery genuinely needed to correct congenital or acquired defects. Such surgery is permissible because it is not meant to change the creation of God [51–53]. Many hold the opinion, however, that this provision allows the improvement of an ugly appearance causing physical and psychological suffering [52]. Surgery performed for beautification. Such surgery is unnecessary and is therefore unlawful (haram) and not permissible. The body given to us is a trust and ‘‘changing Aesth Plast Surg (2008) 32:1–10 the nature created by Allah’’ is a sin inspired by Satan (Shaytan) [51, 52, 54]. Moreover, when a person follows Islam both in letter and in spirit, he must thank God for what he has been blessed to receive and must not complain about what he does not have. More recently, it has been ruled that beautification used to reshape a deformed part of the body is generally recommended in Islam, as long as it is used for a valid reason [51]. Some scholars, on the other hand, report that surgeries for beautification are the result of the materialistic pattern followed by Western civilization, whose main focus is the body and its desires. Standards set by Hollywood, sports stars, and the media are the main driving force behind their increasing popularity. Men and women more preoccupied with form than with substance, with body than with soul, indulge in excessive beautification and reshaping of their bodies, unnecessarily changing what God has created and subjecting themselves to torture, pain, and waste of money [50, 51, 55]. Mutilation of one’s body also is clearly prohibited in Islam. Cosmetic surgery may be considered as deliberate selfmutilation, which indeed some failed cosmetic surgeries may be. It also may be considered a form of oppression that can be damaging to women’s freedom and potential for development [52, 55, 56]. Conservative scholars have even ruled that medical students are allowed to learn cosmetic surgery, but that they should not perform it in unlawful cases. They should rather advise patients against it. Perhaps their advice may have a stronger effect [51]. Moreover, surgeries meant to disguise criminals are impermissible. Sex change operations and giving in to stray whims also are definitely prohibited. However, operations to decide the sex in cases of pseudohermaphroditism are allowed [54]. On the other hand, it has been ruled that because there is no explicit directive forbidding plastic or cosmetic surgery, nobody has the right to forbid what God (and his Prophet) has not forbidden. It has been ruled as well that in the case of an unusual physical defect attracting the attention of others and causing physical and psychological pain, a person may seek treatment to alleviate his embarrassment. ‘‘Allah, the Most Merciful, has imposed no hardship on us in religion . . . .’’ If the surgery is needed to eliminate pain or distress or offers a better quality of life, it cannot be considered unlawful and must be allowed [5]. It is reported as well that the Prophet has said that ‘‘Allah is beautiful and loves beauty’’ although theological interpretation of this saying may give it a different meaning than what is apparent [57]. Conclusion Many health care providers and many hospitals have an overtly religious perspective or mission, yet they deliver 7 evidence-based medical care [5] irrespective of their patients’ religious affiliation. Nevertheless, many physicians seem to agree that spiritual well-being is an important component of health and that it should be addressed with patients. However, only a minority do so with any regularity [58, 59]. Surveyed physicians blame lack of time, inadequate training, discomfort in addressing the topics, and difficulty in identifying patients who want to discuss spiritual issues for this discrepancy [3, 60]. Moreover, there is considerable debate over how religion should be integrated with health care and who should be responsible, especially when health care providers are atheists or belong to a different religious group [3, 61]. Achieving cultural competence in caring for a patient who is a member of a different religious, ethnic, or racial minority is a multifaceted project involving specific cultural knowledge as well as more general skills and attitude adjustments to advance cross-cultural communication in the clinical encounter [5]. One approach to improving the cultural competence of physicians focuses on general, attitudinal, and organizational shifts as well as on the application of general methods for communicating across different cultures [5, 62, 63]. However, establishing an understanding and acceptance of each patient as an individual helps to create an environment in which the patient can receive culturally acceptable care and treatment [64, 65]. In general, it should not be difficult for physicians and other care providers to show courtesy to patients’ religious beliefs without compromising evidence-based health care. In rare circumstances of extreme belief, there may be direct conflict between evidence-based medicine and religious belief, and this should be approached with tact and with community resources [5]. Religious and moral consensus, however, even within the same culture, is neither easily achievable nor applicable [11]. Furthermore, religious belief and practices may vary widely among individuals, even within the same religion or specific denomination [5]. Highly organized religions or beliefs with a centralized governing body can collectively express their stance on any arising issue whenever it is required. For Muslims, however, there can be no collective unified stance, other than a few declarations issued by Ulamas of certain countries. These are simple ‘‘prohibited’’ or ‘‘allowed’’ (haram or halal) declarations for given products or technologies without explicit information or justification. Muslims’ attitudes toward ethical issues, contrary to what may be assumed, are pragmatic, seeking a compromise between Islamic heritage and achievements of modern medicine, as long as basic Islamic dogma is not violated [6]. Whatever the tradition and its specific and implied teachings, the basic questions remain what it 123 8 means to be human and to perform surgically moral acts. Various religious traditions definitely rate physical appearance differently, affecting perceptions about the moral rightness or wrongness of types of surgical procedures. However, it is very clear from developments in technology and its global expansion that we cannot survive the 21st century with 20th-century ethics [65, 66]. Islam welcomes plastic surgery as long as it is performed for the patient’s benefit. Unfortunately, certain scholars consider some forms of cosmetic surgery as performed for luxurious purposes and not for sound legitimate reasons [51]. In Islam, instead of being preoccupied with the body, the individual should be satisfied with the way God has created him or her and should give time to worshipping and doing righteous and charitable acts [55]. Islamic law regarding cosmetic surgery, however, is ambiguous. Objection is not absolute. It is rather objection to exaggeration and extremism. Whenever there is genuine need, there may be a dispensation of permissibility. In the opinion of many, not more than 5% to 10% of cosmetic surgery is irrevocably unlawful [51, 52]. We have personally operated on a large number of Muslim patients, some very conservative, even royalties in countries with strict Islamic laws. Their wishes, desires, and requirements did not differ in any way from those of non-Muslims. As long as the patient is willingly, rightfully, and legitimately requesting cosmetic surgery, it is the duty of the surgeon to fulfill this request to the best of his or her abilities. Naturally, the surgeon must be aware of certain cultural restrictions. Moreover, because women generally make up the majority of any cosmetic surgery practice, plastic surgeons need to be overly cautious when examining a Muslim woman. The issue of women in Muslim culture is a complex one, and it is important that health care professionals be nonjudgmental and respectful of their traditions and customs [67]. A physician’s comfort level with his or her spiritual beliefs should not dictate competency of knowledge on various spiritual and religious practices. With very little effort, families’ and patients’ wishes, culture, and customs may be respected at all times, and one may be supportive by respecting culturally or religiously motivated rights and rituals [12]. Several ethical dilemmas regarding case selection, allocation within the law, medical problems, and economic sources must be confronted [68]. The basic question remains, however, how to enforce international, universal human rights standards while protecting cultural diversity and respecting and supporting cultural, spiritual, or religious preferences [12, 69]. On the whole, 21st-century biomedical issues are very complex. It is hence important to understand fully the technological, economical, political, and spiritual issues surrounding the life science controversies instead of issuing 123 Aesth Plast Surg (2008) 32:1–10 mere statements of ‘‘halal’’ or ‘‘haram’’ [53]. Anyway, one cultural tradition cannot be said to be better than another. With further education and knowledge, cultural and religious smoke screens around the real reasons for maintaining certain positions or practices can be overcome in all societies no matter what their cultural background [70]. In Islam, there is a duty to work for decisions that can ease the suffering in the world without harming humankind and the world humans inhabit [14]. Moreover, a comforting aspect of Islam is its general respect for logic providing the framework for the notion that there is a range of logical approaches available to different people, each of which is appropriate to different levels of society [71]. References 1. Rassool GH (2000) The crescent and Islam: Healing, nursing, and the spiritual dimension: Some considerations towards an understanding of the Islamic perspectives on caring. J Adv Nurs 32:1476 2. Wright S (1999) How to be happy at work. Nurs Times 95:26 3. Lee BY, Newberg AB (2005) Religion and health: A review and critical analysis. Zygon 40:443 4. Aksoy S, Elmai A (2002) The core concepts of the ‘‘four principles’’ of bioethics as found in Islamic tradition. Med Law 21:211 5. Betancourt JR, Green AR, Carillo JE (2003) Defining cultural competence: A practical framework for addressing racial/ethnic disparities in health and healthcare. Public Health Rep 118:293 6. Rispler-Chaim V (1989) Islamic medical ethics in the 20th century. J Med Ethics 15:203 7. Ypinazar VA, Margolis SA (2006) Delivering culturally sensitive care: The perceptions of older Arabian Gulf Arabs concerning religion, health, and disease. Qual Health Res 16:773 8. Daly J, Davidson P, Chang E, et al. (2002) Cultural aspects of adjustment to coronary heart disease in Chinese-Australians: A review of the literature. J Adv Nurs 39:391 9. Maher P (1999) A review of ‘‘traditional’’ aboriginal health beliefs. Aust J Rural Health 7:229 10. Westreich M (1998) Orthodox Jewish law (Halachah) and plastic surgery. Plast Reconstr Surg 102:908 11. Carey JS (1989) Cosmetic surgery: A theological comment. Plast Reconstr Surg 83:139 12. Quest TE, Franks NM (2006) Vulnerable populations: Cultural and spiritual direction. Emerg Med Clin North Am 24:687 13. Gesler W, Arcury TA, Koenig HG (2000) An introduction to three studies of rural elderly people: Effects of religion to culture on health. J Cross-Cultural Gerontol 15:1 14. Agha Al-Hayani F (2007) Biomedical ethics: Muslim perspectives on genetic modification. Zygon 42:153 15. Hammoud MM, White CB, Fetters MD (2005) Opening cultural doors: Providing culturally sensitive health care to Arab American and American Muslim patients. Am J Obstet Gynecol 193:1307 16. Daar AS, Al Khitamy B (2001) Bioethics for clinicians: Islamic bioethics. Can Med Assoc J 164:60 17. Hathout H (1995) Why an Islamic perspective? In: El-Gindy AR (ed) Health policy, ethics, and human values: Islamic perspective. Islamic Organization of Medical Sciences: Kuwait, pp. 81–85 18. Tripod. On the Islamic schools of law. Retrieved May 2, 2007 at http://www.members.tripod.com/*SuzyAshraf/index.html_ essays Aesth Plast Surg (2008) 32:1–10 19. Ahlul Bayt Digital Islamic Library Project. The five schools of Islamic thought. Retrieved May 2, 2007 at http://www.al-islam. org/shiism/3.htm 20. Wikipedia. Divisions of Islam. 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McAuley J, Pecchioni L, Grant J (2000) Personal accounts of the role of God in health and illness among older rural African American and White residents. J Cross-Cultural Gerontol 15:13 29. Levin JS (1996) How religion influences morbidity and health: Reflections on natural history, salutogenesis, and host resistance. Soc Sci Med 43:849 30. Aksoy S, Elmai A (2002) The core concepts of the ‘‘four principles’’ of bioethics as found in Islamic tradition. Med Law 21:211 31. Ali N (1996) Providing culturally sensitive care to Egyptians with cancer. Cancer Pract 212 32. Al Khayat MH (1995) Health and Islamic behaviour. In: El Gindy AR (ed) Health policy, ethics, and human values: Islamic perspective. Islamic Organization of Medical Sciences: Kuwait, pp. 447–450 33. Abrahamic faith. Predestination in Islam. Retrieved May 2, 2007 at http://www.abrahamic-faith.com/shamoun/Predestination%20 in%20Islam.html 34. Mohamed I (2000) Concept of predestination in Islam and Christianity: Special reference to Averroes and Aquinas. Islamic Q 44:393 35. New English Review. Predestination and free will. Bynum R. Islam (2006 November). Retrieved May 3, 2007 at http://www.newenglishreview.org/custpage.cfm?frm=4557&sec_ id=4557 36. Zahr L, Hattar-Pollara M (1998) Nursing care of Arab children: Consideration of cultural factors. J Pediatr Nurs 13:349 37. Answering Islam. In: Emory VanGerpen (ed) Notes on Islam. Retrieved May 3, 2007 at http://www.answering-islam.org/Index/ P/predestination.html 38. Dartmouth. In: Yusuf al-Qaradawi (ed) The lawful and prohibited in Islam. Retrieved May 6, 2007 at http://www.dartmouth.edu/ *dcare/pdfs/yusuf.pdf 39. Islam awareness. In: Mohamed El-Moctar El-Shinqiti (ed) Fatwa: Alcohol-based medication. Retrieved May 3, 2007 at http://www.islamawareness.net/Alcohol/fatwa_alcohol002.html 40. Islam Online. 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The Islamic vision of some medical practices. Retrieved May 2, 2007 at http://www.islamnet.com 55. Al Ghazal S. In: Al-Awadi ARA, Al-Mazkur K, Al-Saif A, et al (ed) Is cosmetic surgery allowed? Retrieved May 2, 2007 at http://www.islamicmedicine.org 56. Studying Islam. In: Mobin-Uddin (ed) A head scarf is far more than a symbol for Muslim women. May 2, 2007 at http://www.studying-islam.org/articletext.aspx?id=918 57. For all the Muslims. In: Imaam ibn al-Qayyim al-Jawziyyah (ed) Allaah is beautiful and loves beauty. Retrieved May 5, 2007 at http://www.sunnahonline.com/ilm/purification/0005.htm 58. McLane S, Lox CL, Butki B, Stern L (2003) An investigation of the relation between religion and exercise motivation. Percept Motor Skills 97:1043 59. Monroe MH, Bynum D, Susi B, Phifer N, Schultz L, et al. (2003) Primary care physician preferences regarding spiritual behavior in medical practice. Arch Intern Med 163:2751 60. 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Ozgen C (2006) Ethics in the use of new medical technologies for neurosurgery: ‘‘Islamic viewpoint.’’ Acta Neurochir Suppl 98:13 67. Galanti GA (2000) American health care professionals should respect the traditions of other cultures. West J Med 173:356 68. Mousavi SR (2006) Ethical considerations related to organ transplantation and Islamic law. Intern J Surg 4:91 69. James SA (1994) Reconciling international human rights and cultural relativism: The case of female circumcision. Bioethics 8:1 123 Aesth Plast Surg (2008) 32:1–10 70. Hellsten SK (2004) Rationalising circumcision: From tradition to fashion, from public health to individual freedom: Critical notes on cultural persistence of the practice of genital mutilation. J Med Ethics 30:248 71. Leaman O: Islamic philosophy. In: E. Craig (ed) Routledge encyclopedia of philosophy. Routledge: London, 1998. Retrieved March 30, 2007 at http://www.rep.routledge.com/article/H057
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My Opinion on Middle East Culture
Thesis statement: In my view, religious beliefs such as Islam indeed help in making
individual behave in ethical ways but should not be incorporated in the healthcare setting.
1. Introduction
2. My opinion
3. Conclusion


Running head: MY OPINION ON MIDDLE EAST CULTRUE

My Opinion on Middle East Culture
Institution Affiliation
Date

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MY OPINION ON MIDDLE EAST CULTRUE

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Introduction
Religion is a very important aspect of human life because of the role it plays in guiding
how individuals behave and act. It usually does not really matter the religion, either it is
Christianity, Judaism, Hinduism or Islam, all religions tend to affect the way human beings
behave. Unlike other religions, Islam is usually one of the strongest religions because of the
fact that Islamic law tends to closely govern and regulate the life of every Muslim. Apart fr...


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