 Hello, I'm Mildred Solomon. I'm a professor here in the Center for Bioethics at Harvard Medical School where I have the privilege of directing the Center's Fellowship in Bioethics. I'm also the president of the Hastings Center, which is an independent research institute in Garrison, New York. The fellowship program here at Harvard Medical School is 25 years old. It was founded by Dr. Ezekiel Emanuel and Dr. Robert Trug. Bob Trug is now the director of the Center where the fellowship is based. Our purpose is to build the bioethics capacity of the Harvard Affiliated Teaching Hospitals. But we also encourage participation and accept fellows from a wide array of medical schools and hospitals from around the world. And I'm delighted that we also often encourage people to come to us from very distant places. And today, I have the privilege of chatting with a fellow in our 2016-2017 cohort, Dr. Abdullah Al-Judhi, who is a family medicine and community medicine physician from Saudi Arabia. Welcome, Dr. Al-Judhi. Thank you so much for talking with me. Thank you very much for having me. Dr. Al-Judhi chairs the Ethics Committee, is head of the research unit, and is assistant director of academic affairs at King Fod Hospital of the University in Saudi Arabia. You received your medical degree from King Faisal University. And I understand that you also hold a diploma in epidemiology from King Saud University, and as I said, a board certificate in community medicine. You've published in peer-reviewed journals, including The Lancet. And I understand that you are contributing to a publication that all of us are really looking forward to a new publication, The Encyclopedia of Islamic Bioethics. And that's really what I wanted to talk to you about today. I thought you could share perspectives with us about what it's been like being a Muslim physician in our secular bioethics program in the fellowship here at Harvard. So I thought I'd sort of, with through that lens, ask you some questions about your year here. Well, that's a big question. Yeah, it's big. I'll try to break it down a little bit. Yeah, right. I mean, let's start, actually, back in Saudi Arabia. Tell me what first interested you in bioethics to begin with. Well, the first encounter with bioethical issue was in my internship year when I was rotating in the Department of Neurosurgery. I was instructed by my resident to examine a patient in the ICU who is suspected to be a brain death case. I went to the ICU as an intern. And I found myself standing in front of the patient, having no clue what to do. And in the middle of my thinking, the nurse shouted, the hidden nurse shouted, said, are you going to examine the patient or just call your senior? So I called my senior. And I was thinking of that case, what does brain death mean? What are the criteria used? How can we be sure or not sure about the death? What's the rule of Muslim scholars in deciding the criteria? But after the internship, I was actually deviated from that field. I went to epidemiology and public health. And then I came back to the field in 2009 when I joined for the first time in my life, the ethics committee in one of the hospitals in the eastern province where I'm living. And I got experience and get deviated. And then I moved to my university and established the ethics committee in the hospital and learned a lot from the books I read and the lectures I heard. And eventually, I sought a continuous medical education opportunity and attended the Harvard Medical School Center for Bioethics course on bioethics in Switzerland. Oh, I didn't know that. So that's the beginning of the connection. Yes, that's the beginning. So I enjoyed the course and I decided to continue learning from Harvard. And here I am. So we're lucky enough to have you in our fellowship program this year. And you bring so many perspectives that we wouldn't otherwise have represented. So I've been really enjoying having you be part of our group. Thank you, ma'am. I've learned a lot. I'm looking forward to learn more. Can you? This maybe isn't fair. It is a big question and I can narrow it down. But do you have observations about the relationship between Islamic bioethics and the secular kind of program and the secular training that you're experiencing this year? Well, actually, there are similarities. And of course, there are differences. But let's start with the similarities. The bioethics field is a multidisciplinary field interprofessional field where people come from different profession with different perspectives in a forum to discuss the cases raised in the forum. So for example, in bioethics, you have philosophers, you have physicians, you have public representatives, community members, you have lawyers. They come together and discuss these cases. It is similar in the Islamic bioethics with the addition of the Muslim scholars, the jurists, the theologians, et cetera. So it's a multidisciplinary interprofessional. Another similarity is that human being is in the center of the attention. And it is very valued, the human being is very valued in the field of bioethics. This is another similarity. A third similarity is that in bioethics, in the secular bioethics, there is no authority in discussing the cases. It's like in Islam, there is no authority. So there are lots of scholars and jurists discussing the cases and coming up with different interpretations. But the main difference is that in Islamic bioethics, it has a divine reference. So God will establish in the Islamic bioethics while in the secular bioethics, basically, there is no place for God. So that is the major, the main difference. And that is in the epistemological level. But when we come to the applications, it's very interesting to see the similarities between different rules. OK, well, then let's go to some of the applications and get more specific. As we've talked many times in the fellowship, there's a great emphasis on individual decision making in Western bioethics. And I'm wondering how that plays out in Muslim bioethics. And in particular, how it may play out in making decisions about the use of life-sustaining technologies near the end of life. Well, there was a study conducted in the United States about Muslims who are facing their end-of-life decision. And they found that Muslims who were born in USA and raised in USA, they are more prone to respect their autonomy in comparison to those who were born and raised outside USA. But they came to USA after that. They still have the family bond. And they believe that families should be part of their decisions. So the more assimilated or longer people that were here longer? See it more as the patient's decision rather than the family's decision? Yes, that's the difference. All of them are Americans living in America. But those who lived and were born and raised in America, they believe on the autonomy more than those who were born and raised outside America. But because of the family, it's very central in Islamic bioethics in the Muslim community. Family is very essential. And the family could be involved in the decision sometimes if the decision is like, for example, the end-of-life care. But according to the guidance of the Muslim scholars, according to the resources in Islamic bioethics. So patients who can speak for themselves have the right to refuse treatment. And if somebody's unconscious, let's say, and being supported on a ventilator, they're not going to be recovering consciousness. You're saying in Saudi Arabia, families could make the decision? Or would doctors make that decision? How would that work? Well, in this case, if the patient is unconscious and there is a diagnosis by a committee of physicians, three physicians at least, deciding that the intervention is brutal and useless and there is no hope, then they will discuss the case with the family. If there is any indication of the patient's preference or patient decision, it will be taken. But in addition to that, family has very influential role in deciding of stopping the treatment. And there is a landmark FATWA. We call it FATWA. It's a religious ruling by the committee form of religious scholars in addition to physicians. And they came up with the FATWA that if the three physicians or the committee decided that the patient cannot come back, then they have the right to stop the ventilators and to let the death process take its natural course. And if families object, do families object? Well, yes, sometimes families object. And in this case, they have the right to transfer the patient or they have the right also or they have the ability to come up with compromisation with the hospitals. But it depends on the availability of resources in that hospital and the availability of beds in other hospitals. You've started an ethics committee. Is our end of life cases the preponderance of the kinds of cases that you get? Or if not, what would characterize the sorts of cases that make their way to your ethics committee? Well, the ethics committee actually received many cases, different cases. But we have a habit of developing policy and procedures whenever we have a good number of cases. So if we find that there, for example, we have found that end of life care is a very common decision that intensivist and physician needs to take. So we develop the policy and procedures, detailed policy and procedures based on the Islamic bioethics, rulings by the Mufti and the scholars, and based on the Saudi society of intensive care unit, intensive care and intensivist. So at the end, we develop the policy and procedures. And we educate physicians. So at the end of the day, physicians are able to take the decision with the family. If they have trouble, then they will consult the ethics committee or consult me personally. And I will try to help in finding, to facilitate and alleviate if there is anything can be elevated and facilitated to find the, to reach the final decision. I'm just curious how much, to what extent end of life cases are conflictual in Saudi Arabia. If you were going to rank the kinds of cases in terms of frequency of what comes up on American ethics committees, I would say that end of life care, of course, there's many types of ethics conflicts. But conflicts regarding the use or foregoing of life sustaining treatments is probably number one or right up near the top. Where would you rank that in Saudi culture? How often are there conflicts around that? You're right. I have noticed that when I'm attending the ethics committee meetings here, here in Mass General Hospital, and so it's the most common cases. So as I said, in our country, we have a clear cut policy and procedures regarding the end of life care based on the fatwa or the religious rulings. But I'm asking you about the incidence of the conflict around that. Like how often do family members say, no, that's not how we want to proceed. And so it ends up as something that has to be discussed at the ethics committee. Well, it depends on the communication skills of the treating teams. And also depending on the family members. So most of the time, if the family is very well, they come together and the physicians, they know the physician because he or she is taking care of their mother or father for a long time. So it's rarely to have such a. It's rare. Is that what you said? It's rare. As far as I know, it's not common. So that's a difference. It's not common to be resolved. But maybe there is conflict between the treating team and the patient's family. But eventually, it will be resolved with the discussion. And actually, most Muslims, when they are confronted with the Muslim scores, opinion, and the Quran and the Hadith saying the prophet of the Quran verses, they are always accept that. And this is very helpful in discussing the end of life care with families. Even though the scholars differ on how they interpret things, the fact that there is an authority there makes it less conflictual. Yeah, but we are lucky because this issue has major, majority of scores agrees on the process of the end of life care. On the right to refuse. On the right to refuse. And the right to draw with draw or withhold the treatment. OK, that's great to know. Well, we've just been talking about differences and similarities in the context of end of life decision making. You know that Harvard and the Hastings Center cosponsored a conference recently on the ethics of making babies on reproductive ethics. And I'm wondering in that domain how Muslim perspectives and Western secular perspectives on the range of issues related to reproduction stand up. Well, first of all, making babies, this expression may be problematic for some Muslims because they believe God is the one who makes babies. But I'll take it as a metaphor. So I accept it. So yes, there are differences and there are similarities between Islamic bioethics and Western secular bioethics in the reproductive area. For example, IVF in vitro virtualization, it's widely practiced in Muslim countries because Islam encouraged Muslims to treat fertility because kids in Islam is a source of policing in this life and the life after. So Muslims actually not only permitted to seek treatment or cure for infertility, but they are encouraged. So IVF is very wide. And the third issue is the surrogacy issue. As you know, the IVF is encouraged in Islam. But sometimes the woman cannot carry the baby. So they look for the third party, second woman, who is going to carry the baby for nine months, give birth, and then leave the baby with the couples and walk away. Those who are against the surrogacy believe that this is unfair for the woman and at the same time for the surrogate. And at the same time, the mother in Islamic literature and culture and sources is known as Walida. So Walida is the mother. Walada is giving birth. So actually the mother who gave birth is a Walida, is a mother. So in this case, how come you deprive her of her rights to be a mother? But at the same time, the eggs and the sperm are coming from the couples. So who's going to be the mother? And this is a dilemma. And this actually will violate the higher principle or higher objective of protecting lineage or protecting lineage or protecting offspring. So to avoid violating the higher principle of protecting lineage, then this is prohibited. You've also talked about it, though, as violating the rights of the surrogate mother, which is a different issue than the lineage issue. Are both issues discussed? Both issues are discussed. And as part of the process of developing discussion in Islamic bioethics, there is more than aspect to be discussed. One of them is the right of that woman. And actually, what will be her position in the family? Is she's going to be a mother or not? And is she going to be allowed to see that baby or not? What's the relation of that baby to her? So this kind of issue led to the prohibition of surrogacy in Islam. So it's prohibited worldwide? Well, if we talk about Muslim country, there is a kind of very minor scholar, minority opinion of some scholars, in fact, one scholar who supported the surrogacy. And this scholar was actually opposed by some scholar from his school of thought. So that was interesting, because the consensus was built by all schools of thought. That's a. And yet, he was disagreed? And yet, he disagreed? Only by someone inside his particular perspective. Yeah, absolutely. So those are scholarly commentaries, moral commentaries. What's the state of the law in Muslim countries? Is there something consistent from Muslim country to Muslim country legally? That is a very important question. Thank you for asking this, Mali, because the fatwa is technically non-binding religious opinion. But the fatwa is needed sometimes in a Muslim country who is applying Islam, like Saudi Arabia. They will base the law on the fatwa. Now, in our time, the fatwa is coming from a collective fatwa, collective scholars. It's not anymore one scholar or two scholars. So the fatwa, despite the fact that it is non-binding, now it gained more strength than before. So probably, the fatwa of the councils, for example, we have in Saudi Arabia three councils. One council is a Saudi council for supreme scholars. But we have two important councils in Saudi Arabia. One represents all Muslim countries. That is the International Tech Academy. The other one represents the Muslim scholars of all Muslim countries, of most Muslim countries. That is the Muslim League. Muslim League is non-governmental. The other council is governmental. And both of them, they are very active in this issue. Both of them, they build a consensus against surrogacy. They did. They did. And is that now reflected in law? That is reflected in law in most countries in the Muslim world. Interesting. So we've talked about end-of-life care. And we've talked about reproductive ethics. Are there any other domains where you think it's interesting to compare or contrast secular and Muslim bioethics? Well, there are many areas that were discussed in the Islamic bioethics. Let's take, for example, the organ transplantation. This is one of the early issues that was discussed among Muslim scholars and physicians. And in Saudi Arabia, for example, very early, the scholars produce a fetwa that permits organ transplantation. And I think I remember that in the early 90s, the first heart transplantation was done. It is based on the concept of preserving or protecting life. So as we all know in the first Quran that says, if one saves one life, it's like if he says, the whole humanity. So this is another one. The organ transplantation is a very important field in which Islamic bioethics contribute to the discussion of bioethics in the world. Is there both donation after cardiac death as well as donation after brain death in Saudi Arabia? That's an interesting question. There are actually controversy on this issue because of the different fetwa. One fetwa stated that the organs can be taken from the patient when the physicians decided that the patient is in brain death case. While the other fetwa said they can take it until the patient, until they stop the life-supporting machine and the patient come to death. So the announcement of death is after the stopping the life-saving machine. So in this case, as we know, the only organ that can be transplanted or can be used is the kidney. While in the other case, many organs can be used because it's perfused. So there is no ischemia in that case. And this is actually is a kind of hot debate right now. And there is revisiting discussion. And hopefully they will reach to the decision that will help promote. I think that even with donation after cardiac death we can use other organs besides kidneys because we begin that process very quickly within a few minutes of cessation. Do you have any other, I think the last questions I wanted to ask you have to do with advice you might have for Western physicians who are here in the States caring for patients, Muslim patients and their families. Is there anything you think would help create greater sensitivity or responsiveness to clinical decision making for those patients or for their health that Western physicians should keep in mind? Well, I think the Western physicians have been involved in discussing Islamic bioethics in the last few years. I have come across many articles published in the United States about Muslim's patient and their needs. In fact, in 2010, the New York Times published an article. It's entitled, The Needs for Muslim Patients. And they cited an article, a reflection by one of the emergency medicine physicians in New York and he wrote a reflection on a case that was published in the Journal of American Academy of Emergency Medicine. And then he actually elaborated more on it and published it in the Journal of Medical Ethics. And it's about understanding the needs of a patient, a female Muslim patient, understanding her needs for modesty, understanding her needs for being respected and not exposed, her dignity. Sometimes we don't understand why she took that decision but when we become more aware of her background, her beliefs, her rituals, et cetera, we will be, let's say that more sensitive towards that issue and we can find answers to their questions and it's not necessarily to refuse providing them with care but we can provide the care that is actually culture sensitive, so to say, to that patient. This will help the patient to be engaged in the healthcare and in the management of her physician. So I would like to urge all Muslim and non-Muslim physicians who are taking care of Muslim patients in the United States to read about the topic. And interestingly, many articles, very good articles were published in nursing journals, more than the physician journals. Thank you for bringing that up. Yes, and I think this is because nursing profession is built on the compassion and the care and the spirit of care among nursing population is very obvious and I don't want to compare but it's very clear that nursing are more understanding when it comes to the special needs of patients. Their professional ethic requires a real attention to patients' needs and patients' cultural beliefs. And actually, I was not surprised when I came to know that many chairs of ethics committees are nurses. That's true here in Boston, for sure, yeah. Maybe this is a harder question, but are there any cultural beliefs or, I don't know, desires or behaviors that Muslim patients might make requests of physicians that maybe physicians would not be willing or desire to comply with? Absolutely. Muslim patients, regardless of their level of observance because we don't want to assume that all Muslims are observant, but some Muslims who are very religious, very observant, for example, they want to perform their prayers on time. And if the physician aware of that, they can arrange a way to reschedule the doses or the treatment or whatever, so they cannot violate that, right? On the other hand, sometimes, for example, in fasting month of Ramadan, if the physician can come to an agreement with the patient on a special rearrangement of the treatment, they can, the patient, they can fast Ramadan and take their medication at night, for example. Without understanding that needs, without asking the patient to open up and to say what she wants, we will not be able to understand her needs. So that is very important. Another issue, maybe it's not common here, but in our country, the visitors who comes to visit the patient, who come to visit the patient, sometimes are overwhelming and people cannot understand in the Western country why? Because the family and the friends and the neighbors, they are like a one family. So this is maybe disturbing the nursing or the physicians. So this is need to be understood. And especially when a patient comes to the United States with a difference in the culture and beliefs. I'd like you to just reflect a little bit. You've been here now several months and I know that you've been embedded, so to speak, inside several of our major hospitals, participating and observing on ethics committees and ethics consults, maybe even on an IRB, I'm not sure. But you've had a lot of wonderful walking around and being integrated into the health systems of Boston. What surprised you the most as you've observed us? You know, Mellie, one of the fundamental issue that surprised me is the issue of autonomy before coming to United States and through my readings in the different books, Western circular bioethics. I had the perception of absolute autonomy. But when I come here, I found that it's not that absolute that I have imagined. It actually have more kind of context oriented autonomy in the discussion with the patient and the family here. So family are involved. It's not like I imagined. The different views about what type of autonomy we want or what time of autonomy a patient's needs, the issue of the difference between respecting person and autonomy. So respecting person is actually wider than autonomy. So sometimes the autonomy is not to just overwhelm the patient with information and leaving the patient to decide and leading the patient to have an anxiety about that, but actually to provide him with an autonomy, not to impose autonomy on it. So this is actually one of the aha moment in this fellowship. Well, we've tended, we've focused so much on autonomy as the way to implement respect for persons that sometimes it's been over-learned and or there's been a very thin notion of autonomy and a knee jerk response to kind of just give information to patients and say, okay, you decide, you're autonomous. And I don't think that's at all what's meant. As you say, it's a much deeper understanding of the importance of respecting a person and their values, but that doesn't mean throwing information and saying you decide. It means helping and offering recommendations and shepherding. It's a much more of a give and take and a shared decision-making model. So I'm glad that you, I'm glad that coming in in person was a qualifier for what you were reading about. Yeah, that was actually, and actually the physician role here, I don't want to say that, but probably there is some compromisation or some of restriction on physician autonomy. Actually, the physician sometimes is just an information provider, but in my country, actually in the literature, in the Islamic literature, in the Islamic heritage, in the Islamic history, physician is seen as a wise guide. So it's not only an information provider. He or she is expected to guide the patient to give the advices whenever needed, being sensitive and giving advices. Of course, the patient has the autonomy and has to decide, but the physician has more things to do than to watch and to wait for the answer from the patient. Yes, offering guidance. Offering guidance. Very important. So what are you planning to do when you complete your year with us later this spring and you go back to Saudi Arabia? How do you imagine using your experiences here? Well, first of all, I'd like to thank you for the opportunity and I learned a lot and I hope when I go back to Saudi Arabia, I will be able to contribute to the ongoing discussion and activities on bioethics in Saudi Arabia. Actually, bioethics in Saudi Arabia started long time ago in the early 80s. If we can go back, if we talk about public health ethics, we can talk about the 30s. The first time published the policy and procedures for quarantine and for epidemics was in the early 30s in Saudi Arabia. So in the early 80s, physicians and doctors and scholars started to meet and discuss issue about bioethics and actually most of our university established courses in the undergraduate in the medical schools in Saudi Arabia. And the research ethics committees are well established in Saudi Arabia. The National Bioethics Committee makes it mandatory. They published the law in 2010 and they revise it two or three times. But the clinical ethics committee is the one that needs to be developed. So far it's a kind of, it depends on the hospital, it depends on the people. So what I would like to do, and I hope I can have the power and the support to do it, is to establish a clinical ethics committee or clinical ethics consultation service in my hospital and to be a model for the rest of the kingdom. Well, I wish you lots of luck and I have every reason to believe this is going to be very successful. Thank you very much. Thank you. It's been wonderful having you in the fellowship this year. All of us have learned so much. You bring so much to our sessions. It's been a thrill. And we've also been very happy that we've been able to find ways for you to become integrated into the Harvard affiliated hospitals. I know that you are sitting on ethics committees, observing research ethics committees, case consultation. So you've really become a member of our community. We're gonna be sad to see you go, but I know that you're gonna be doing incredible things when you go back to Saudi Arabia. They're gonna be very lucky to have you, so as we have been. Thank you very much, Mellie. I have enjoyed being here and hope to come back again and again. And I will be always ready to contribute to the discussion in bioethics. Thank you very much. Thank you, Mellie, for having me. I'd like to encourage you to check out our online journal, which you can find on our website. And there you will also see many other things that the Center for Bioethics here at Harvard is doing, our master's program, our fellowship program, our conferences. And I hope that you will engage again on the next issue of this journal. Thank you.