Modesty, Conscience, and What it Takes to be a Doctor (with a bit of Comedy)

Two apparently unrelated new and new-ish papers in the JME have caught my eye over the last few days.  One of them is this one: Salilah Saidun’s “Photographing Human Subjects in Biomedical Disciplines: An Islamic Perspective”.  We’ll come to the other in a little while.

There’s a couple of puzzling things about the paper.  One is that I’m not sure what the tone is supposed to be.

It could be a descriptive piece, along the lines of “Look, here’s what Muslims might think about medical photography, and if you’re going to take or use medical photographs, you might want to keep it in mind.”  Of course, it’s by no means certain that all Muslims think alike, or that if (mirabile dictu) they do, it has anything much to do with Islam – but we’ll put that to one side.  Similarly, the fact that some people do think this won’t tell us much about what practical implications there ought to be, beyond keeping it in mind.  It won’t tell us that we ought to adhere to those opinions.  Islamic rules might provide a reason to behave in a certain way; but there might be other reasons to behave in a certain other way – and they might sometimes be more compelling.  I’ll put that to one side, too, though.  As a descriptive paper, it might very well be the sort of thing that’s useful on the wards.

But a descriptive reading won’t explain the passages that appear to have a more normative dimension:

In contrast, recording of images that involve awrah* are unethical, as is storing, using and viewing them, even if the patient gives their consent.  The only exception is when a trustworthy Muslim specialist certifies that there is a threat to the patient, where circumstances dictate that such practices are essential in order to avoid greater detriments and no permissible alternative is available. These rules, which apply to both living and deceased subjects, must not contradict Islamic teaching to be deemed ethical from an Islamic perspective. [emphasis mine]

Note the phrase “are unethical”, rather than “are (sometimes) believed to be unethical”, and that the patient’s own preferences come at a discount.

Nor will it explain the passages outlining what various commentators have said about what is required: after all, if the paper is simply explaining what some people actually think, the appeals to scholarship seem otiose.  They make more sense – and really only seem worth including – if you’re talking about what Muslims should think.

So there appears to be a normative aspect to the paper as well as a descriptive one.  But then several questions arise; and an important one has to do with precisely whose business it is to regulate these things.  I’m not, I’ll admit, entirely certain how these things work, but if a doctor sees a patient and thinks that there’d be an interesting case study there, isn’t it between the doctor raise the request and the patient to decide what can be recorded and what can be done with those recordings?  There’ll be constraints that mean that the patient gets the final say; but if the patient is happy for images to be stored and viewed, then why isn’t that the end of it?  Why should “a trustworthy Muslim specialist” have to OK it, and what would give him (and, let’s face it, it’s almost certainly going to be a bloke) the right to OK or veto it to begin with?  Why does modesty require rules and approval from someone else?

Indeed, in the final paragraph of the paper, we find the claim that “an individual Muslim’s perception of the rules and associated practice may vary” – which sort of prompts the question of why it’s necessary to go into such depth about the rules to begin with: why not just say that some people might be happy to be photographed, and others not, and leave it at that?  We’d be back to the non-normative aspect of the paper.

So I’m not sure how the paper is supposed to be read, or how we’re supposed to respond.

(Incidentally, my bedtime reading over the last few days has been this collection of annotated Stewart Lee transcrips; I only mention it because I read this paper at about the same time as I read the “I’m failing to lose weight as a result of Islam” routine from 41st Best Stand-Up Ever, and though the link is a little tenuous… well, I drew it anyway.  And we might need a little light relief.)

And then I read this: Card’s “Is there no Alternative?: Conscientious Objection by Medical Students”, and there’s a passage there that, I think, speaks to some of the stuff in the photography paper.  It refers to stories about Muslim medical students attempting to opt out of physical examinations of members of the opposite sex.

By refusing to perform examinations on members of the opposite sex, such students are failing to engage the question of what constitutes a touch that is professional and non-sexual done that exemplifies a ‘cool intimacy’ that is still compatible with closeness to a patient.  The matter here is not one of the mechanics of touch; it is instead an emotional and psychological investigation whereby one learns how to cognitively distinguish clinical touching from touch that might otherwise signify erotic or romantic affection.

That’s it, isn’t it?  It’s one thing for a patient to be uncomfortable undressing in front of a stranger, especially a stranger of the opposite sex; and it might be that Islamic culture has a load of anxieties about sexuality that – from an outsider’s perspective at least – are not too well-founded (I mean: I’m pretty sure that it is possible for a man and a woman to be alone in a room without any sexual impropriety at all).

But you can put those considerations aside, because the more important point is that if a medic or would-be medic can’t distinguish between professional touching and sexual touching, something has already gone very wrong, irrespective of the culture, even before the consulting-room door has opened.  Even before the graduation robes have been ordered.

And what goes for touching also goes for photography.  There’s a world of difference between photography for medical purposes, and salacious photography.  It’s a difference that matters, and it’s a difference that any medic should understand.

That is to say: modesty might be a concern for the patient; but – as Card says – the idea that students or medics might be able to use something like that appeal and so not achieve a core competency in medicine increases the chance not only that they’ll be a bad doctor, in the sense of being incompetent to deal with at least some conditions, but a bad doctor in the sense of lacking a virtue of medicine – an ability to treat the patient well as a person while, at the same time, treating their body as just a body: an ability to talk to the patient’s eyes even while looking at their arse.  Or maybe even lacking a basic virtue of all adults – an ability to interact with other persons without immediately sexualising them.  After all: when Saidun articulates the idea that

[w]hen two non-mahram* are together in an enclosed space, a chaperone is necessary to avoid impropriety – actual or alleged,

one response is simply to say No it isn’t.  Adults should be able to behave properly towards each other without a chaperone; the idea that a chaperone is necessary to avoid allegations of impropriety tells us more about the people making the allegations (and believing them) than the two people left alone in a room, and it shouldn’t be up to those two people to demonstrate propriety… as if it’s anyone else’s business in the first place.  Besides: if someone’s hell bent on alleging impropriety, no number of chaperones will stop them: after all, if you’re going to go to the lengths of inventing impropriety, inventing the circumstances in which it happened as well isn’t going to be too much extra effort.

Look: it comes to this.  If you don’t want to undress and be photographed by your doctor, you don’t have to; that’s fine, and there’s no need to appeal to religion.  If you’re a doctor and you don’t want to see or touch undressed people, though, that’s not fine.  Even if you appeal to religion.



*”The awrah of a man in circumstances where he can be seen by other humans is between navel and knee.  A woman’s awrah is the whole body except the hands and face, and some scholars also include the feet when she can be seen by non mahram (marriageable individuals of the opposite sex).

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