A Primer for the Pediatrician



ABSTRACT 
The United States is becoming increasingly pluralistic. Pediatricians must become familiar with the factors that affect the emotional, physical, and spiritual health of their patients that are outside the ken of the traditionally dominant value system. Although many articles have addressed the cultural and ethnic factors, very few have considered the impact of religion. Islam, as the largest and fastest-growing religion in the world, has adherents throughout the world, including the United States, with 50% of US Muslims being indigenous converts. Islam presents a complete moral, ethical, and medical framework that, while it sometimes concurs, at times diverges or even conflicts with the US secular ethical framework. This article introduces the pediatrician to the Islamic principles of ethics within the field of pediatric care and child-rearing. It demonstrates how these principles may impact outpatient and inpatient care. Special attention is also given to adolescent and end-of-life issues. 
Key words: Islam, Muslim, ethics, pediatrics, child, child-rearing, human rights, adolescence, contraception, organ transplantation, death. 
Within the next 50 years, the majority of Americans will be of non-European descent,1 prompting the medical profession to broaden its understanding of cultural issues related to health care. Nowhere is this more crucial than in pediatrics. Pediatricians are often put in a position of advocating for the rights of patients. The majority of immigrants to the United States are <18 years old, and often their parents do not speak English sufficiently to communicate cultural and religious beliefs, potentially leading to misunderstanding or inappropriate intervention. The American Academy of Pediatrics has recently addressed this issue,2 but failed to address issues of religion and religious culture. 
Many works regarding Muslim patients have focused on cultural aspects of care particular to a certain country or region, often not distinguishing between folk customs and Islamic customs. Articles examining ethical dilemmas based on a Muslim patient's beliefs often fail to distinguish between idiosyncratic beliefs, cultural norms, and religious principles.3-6 Common beliefs have been incorrectly noted.a,1,7,8 
This article has 2 goals: to describe Islamic ethical and moral norms with regard to birth, child-rearing, reproduction, death, and patient care; and to delineate its practical implications in the clinical practice of the pediatrician. Throughout this article, the male pronoun is used for stylistic reasons, except when an issue applies only to women. Except where noted, all discussions using the male pronoun apply to men and women.

RELIGIOUS BACKGROUND
A Brief Overview of the Islamic Faith and Jurisprudence 

Islam has its roots in seventh century Arabia; however, it is not an "Arab" religion. In fact, out of the 1.5 billion Muslims in the world, <10% of Muslims are Arab.9 The majority of Muslims worldwide are Asian or African. More than 50% of North American Muslims are indigenous, usually black, with an increasing number of white and Latino converts as well.10 
Islam has a moral code as well as a civil law with a unifying ethical framework. A universal foundation of practices and beliefsb,2 creates a monotheistic culture, the aim of which is to create peace in one's self, family, and society by actively submitting to and implementing the will of God. This culture is further refined by various cultures based on their inclinations and sensitivities. Some differences among Muslims are attributable to differences of opinion by various schools of jurisprudence11 (of which there are 5 major ones: Ja'fari, Hanbali, Maleki, Hanefi, and Shafe'i). Others are not Islamic but ethnic, and may even violate Islamic norms.c 
The 4 main concerns of Islamic ethics are similar to that of other ethical systems: autonomy, beneficence, nonmaleficence, and justice.12 In distinction to Western secular ethics, more emphasis is placed on beneficence over autonomy, particularly at times of death. Because the Quran is seen as an eternal and immutable truth, the framework and principles of the law are seen as immutable. As the circumstances of the day change, the application and interpretation of the law changes with each age. Islamic law (shari'a), then, is in spirit dynamic and flexible, exemplified by the idea that "necessity renders the prohibited permissible."13

The Status of Children in Islam 
Children are valued and respected in Islam as individuals with inherent rights. The prophet Mohammad stated, "A child has three rights over his father: first, that he gives him a good name, second, that he teaches him reading and writing, and third, that he finds him a good spouse."14 In addition, a child has the right to be treated with respect and without violence (A. Aytatollahs Sistani and N. Makarem-Shirazi, personal communication, June 1999), to be treated when ill (A. Aytatollahs Sistani and N. Makarem-Shirazi, personal communication, June 1999), and not be forced into hard labor.15 

The Status and Role of Parents in Islam
The role of parents is highly regarded in Islam. Parents in Islam are legal agents, caretakers to whom the onus of child-rearing falls. However, they are also surrogates of the Divine and are expected to treat their children gently, fairly, and well. Parents who abuse and neglect their children can lose custody of them. In return, they are accorded a respect one degree below that owed to God. 
Although both parents have a responsibility to raise morally and physically sound children, the mother's role is considered more important in early childhood. The prophet Mohammad has stated, "The keys to heaven are beneath the feet of mothers,"14 and, "A child's character begins to be formed while still a fetus."14 The father is responsible for education, marriage, and all financial costs related to child-rearing, whereas the mother may contribute financially if she is able and wishes to. 

BIRTH TO ONE YEAR OF AGE 
Felicitations: Is It a Boy or a Girl?

In Islam there is no preference for a boy over a girl, contrary to the customs of some Muslim countries. The sexes are seen as spiritually equal, and equally valuable. In the Quran we read, "Oh people, be careful of your duty to your Lord, who created you all from a single soul, and his mate of the same ..." (4:1). Whenever a child was born to him, the prophet Mohammad would not ask the sex of the child, but ask if it were healthy or not.16

Postnatal Ceremonies and Customs 
There are many customs associated with the birth of a child, the majority of which are not mandated by the religion and, in some cases, may be discouraged or prohibited. For example, the Ladakhi of Kashmir hide the birth of the boy for the first few years, dressing him like a girl to avoid the evil eye and jealousy of neighbors.17 Muslims may have idiosyncratic or culturally influenced explanations for legitimate customs that are incorrect (cf below). 
The following are Islamic customs, none of which are mandatory. Shortly after birth, the calls to prayer are whispered into the ears of the child. On the seventh day, in addition to circumcision (for boys), a sheep is slaughtered with the meat distributed to the needy (done for boys and girls).d Finally, the head is shaved with the weight of the hair given in silver or gold as alms to the poor (done for boys and girls).18 

Circumcision 
The circumcision of boys is an obligatory custom, similar to Jewish traditions.18,19 It is preferable for it to be performed on or after the seventh day of life, but it is not a problem if it is performed sooner.20 It is not necessary for the circumcisor to be Muslim.21 Analgesia and the safest methods available should be used. Whenever circumcision is contraindicated, such as known cases of bleeding disorders, it should not be performed at any time.22 
Female circumcision is a controversial issue and is beyond the scope of this article. The majority of Muslim countries (except in parts of sub-Saharan Africa) do not practice it.23 It is considered to be a pre-Islamic custom and is not exclusive to Islam, but is indicative of certain regions. People indigenous to all parts of the world, of all beliefs and religions still practice it, including Jews, Christians, Buddhists, and Animists living in Asia, Africa, and even Mexico.24 
Diet Islam is the only religion in which breastfeeding is addressed in the sacred scripture.25 "And the mothers should suckle their children for two whole years for him who desires to make complete the time of suckling ..."36 (2:233). Although not mandatory, breastfeeding is highly encouraged, for up to 30 months.27 A woman and her husband may mutually decide to not breastfeed at all, or to stop nursing before the recommended time. Often for Muslim women, breastfeeding is more than an act of feeding, but a great religious deed, hence they may initially be resistant to advice of early weaning, even if medically indicated. If medically indicated, it should be stopped. The prophet Mohammad has stated, "Any woman who breastfeeds her child, for each time that she puts the infant to the breast, God will grant her the divine reward of freeing a slave. And when she has weaned him, [the Angel Gabriel] will alight down and with a hand on her shoulder say, "Live your life anew, for God has forgiven your past sins.'"14 
There is no specific ruling on the introduction of solid foods, it is influenced by local customs. In general, Islam emphasizes eating healthy foods, in moderate amounts.

ONE TO SIX YEARS
Discipline, Play, Safety 

The guardianship of parents in Islam is provisional. Physical and sexual abuse, as well as acts of omission, are all grounds for temporary or permanent removal of parental guardianship in Islam, as in secular law (A. Aytatollahs Sistani and N. Makarem-Shirazi, personal communication, June 1999). To this end, the prophet Mohammad has said, "Parents are equally obliged to discharge their responsibilities toward their children and are accountable in case of failure."14 
During the first 6 years of life, parenting should be more permissive, allowing children to explore and ask questions, children being considered more trainable than teachable. In this regard, the prophet Mohammad has said, "For the first seven years, leave them alone (ie, do not be too strict in manners, discipline, and formal education)", and, "Whoever asks questions in childhood will answer them as an adult."14 Furthermore, he emphasized the importance of play when he said to his companions, "Let [the children] play, for this is how they grow (in intellect)."14 
In Islamic jurisprudence, discipline should be brief, mild, and commensurate to the severity of the act committed. A light tap as a form of stern disapproval is permitted, nothing more. It is not permissible to hit a child in the face, neck, abdomen, or back even lightly (A. Aytatollahs Sistani and N. Makarem-Shirazi, personal communication, June 1999). The pediatrician cannot condone child abuse as a religiously acceptable practice. Although it is the pediatrician's legal obligation to report cases of child abuse, it is preferred to arrange for religious social agencies to help place the child in foster care when available and appropriate (A. Aytatollahs Sistani and N. Makarem-Shirazi, personal communication, June 1999). There have been numerous cases where Muslim children have been placed in the care of non-Muslim families, some of whom have attempted to change the child's religion.28-31
Day Care, Working Mothers, and Divorce
Women are free to work outside the house and hold any profession in Islam as long as the sanctity of the family remains intact and a woman's honor is not compromised.32 The decision to place children in day care is a personal matter. Muslims who come from more traditional cultures tend to prefer care at home by the mother or by a relative, if possible. 
Divorce is permissible in Islam, although traditionally, there has been a low rate of divorce (<10. Among US-born or married Muslims, there has been a trend toward higher divorce rates, averaging 31% (vs 49% for the US population), according to an ongoing US Department of Education study.33 The pediatrician will encounter Muslim children with divorced parents. Anticipatory guidance should be given with regard to emotional and school disturbances that may arise during and after a divorce. 

SEVEN TO FOURTEEN YEARS
Responsibility
This is the most sensitive period of child-rearing, where etiquette, discipline, education, and religious teachings are begun and solidified. The prophet Mohammad has said, "For the next seven years (ie, 7-14 years of age) teach them." It is encouraged to have children perform chores and have responsibilities commensurate to their abilities and level of maturity, education, however, takes precedence, and hard labor is not permitted. 

FIFTEEN YEARS AND BEYOND
Rites of Passage
There are no formal rites of passage in Islam. There may be local customs based on the country of origin. When a Muslim reaches the age of maturity, the rituals, obligations and duties of Islam become incumbent on him, such as daily prayer and fasting. 
Maturity and Modesty
Maturity, is defined in 2 ways: the onset of spiritual awakening (bulugh) and the attainment of intellectual maturity (`aql). The first is generally an arbitrary age, 9 for girls, and, 15 for boys, and heralds the aforementioned noted religious responsibilities. The second is determined by a person's ability to live and function independently, which has no specific age. Once a person is considered intellectually mature (`aaqil), then they are considered to be adults, with regard to medical and legal decisions. Practically speaking, in Muslim countries, this is usually decided on an ad hoc basis. However, there is a move in some Islamic countries to base maturity on a somewhat arbitrary and uniform age of 15 (for boys and girls), for legal considerations such as voting, marriage, and property ownership.34,35 
This dichotomy of minor and adult status is an area of potential conflict with secular law in that a Muslim patient may be 18, thus "free" (by secular law) to decide his own course of action in treatment, but meet objection from his parents if not considered intellectually mature. Islamic law requires Muslims to respect and obey the laws of the host country unless they violate Islamic law. The pediatrician in such circumstances should try to clarify what the basis of objection of both the parents and their child are and try to resolve them while maintaining family harmony. It may be helpful to consult with an Islamic scholar (ie, Imam, Sheikh, etc.) of a local mosque to determine if the patient is considered "aaqil. 
Modest dress is incumbent on all Muslims on reaching the onset of maturity (bulugh). Both boys and girls are expected to wear clothing that does not reveal the curves of the bosom, hips, or behind. Girls, in addition, begin to wear a head covering (hejab) that only reveals their face. It may be taken off for an examination by a male examiner if absolutely necessary (cf below). The form of dress for girls is determined by cultural preferences and is not specified in Islam. 
Before the onset of bulugh, it is not problematic for boys or girls to be seen by a male or female physician. After bulugh, except for emergencies or necessity, the preference, in descending order, is as follows: same sex Muslim physician, same sex non-Muslim physician, opposite sex Muslim physician, opposite sex non-Muslim physician.36 



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