The Impact of Arab Culture on Psychiatric Ethics

Prof. Ahmed Okcrsha

Like most lads among my boyhood associates, I learned the Ten Com mandments. I was taught to reverence them because I was assured that

they came down from the skies into the hands of Moses. and that obedi
ence to them was, therefore, secretly incumbent upon me. l remember that whenever I fibbed, I found consolation in the fact that there was no commandment, Thou shalt not lie," and that the Decalogue forbade ly

ing only as a "false witness" giving testimony before the courts where it might damage ones neighbor. In later years, when I was much older, I be gan to be troubled by the fact that a code of morals which did not forbid lying seemed imperfect; but it was a long time before I raised the inter esting question: How has my own realization of this imperfection arisen? Where did I myself get the moral yardstick by which I discovered this shortcoming in the Decalogue? When that experience began, it was a dark day for my inherited respect for the theological dogma of "revela
tion." I had more disquieting experiences before me when, as a young orientalist, I found that the Egyptians had possessed a standard of morals

far superior to that of the Decalogue over a thousand years before the
Decalogue was written. (Breasted 1934, p. xi)

-l-he quotation of Breasted is giv

to show that the need for such codes dates back to ancient times. Since very

to show that ethical guidelines and values originated from ancient Egypt bu

early human interactions, relationships had to be regulated by means of et cal guidelines. Such codes are necessary to coordinate and control everyd

l:tIllL, \.uu.urc, cmu ray.u. y

interactions (These codes are generally laws.) The need for codes becomes more urgent when a hierarchy of power exists; the aim of these codes is to protect the less powerful from the control of the more powerful and to pro tect those with more power from claims of power abuse made by those with less power. Since early in history, the doctorpatient relationship has been one of the major power relationships. In fact, doctors have been believed to have super natural powers. Today, however, doctors are considered not half-gods but service providers whose primary tasks are to respond to the needs of their pa tients and to act in their patients best interest. Furthermore, in the last -lO years there has been an advance in medical technology and knowledge, an advance that carries major hopes for the management of previously incurable ailments. However, there are also possibilities of abuse. Psychiatry is one branch of medicine in which possibilities of abuse exist, and, indeed, actual abuse has occurred in this field. Because it involves inves tigation of the brain and its sometimes obscure functions, psychiatry has a mystique that not only is perceived by laypeople but may lead the psychia trist to have a false sense of omnipotence. Mental illness remains an obscure, frightening type of illness because it frequently affects an important human attribute, judgment. A situation in which a patient has distorted judgment can be a good opportunity for abuse by any of several power structures-po litical, industrial, administrative, or even familial. It is no wonder, therefore, that psychiatric associations all over the world have been trying hard to develop ethical codes with aims of protecting pa tients from possible abuse by members of the profession and preventing psy chiatrists from feeling omnipotent.

The Declaration of Madrid

The Declaration of Hawaii issued by the World Psychiatric Association in 1977 led to a long process of investigation and to concern within the domain of professional ethics; it also paved the way for the Declaration of Madrid [see the Appendix to this book), which was endorsed by the General Assem bly of the World Psychiatric Association in Madrid in 1996. In its final form, the Declaration of Madrid includes seven general guidelines that focus on the aims of psychiatrynamely, to treat mentally ill patients, prevent mental ill ness, promote mental health, and provide care and rehabilitation to mentally ill patients. The declaration prohibits abuse and prohibits the provision of treatment against a patients will unless such treatment is necessary for the

about confidentiality and the ethics of research. An appendix to tion includes guidelines on specific ethical issues in psychiat

welfare and safety of the patient and others. Emphasis is the patient or caregiver of all details of management and inf

gust l999namely, regarding genetic research and counseling,

sia, torture, the death penalty, sex selection, and organ trans well as a summary of the l99l United Nations resolutions tients with mental illness. Further ethical guidelines were end General Assembly of the World Psychiatric Association in H

consent and autonomy are addressed in the Declaration of Madrid

on ethnic or cultural grounds, and psychiatrists addressing issues currently in preparation by the Ethics Committee of the atric Association are the ethics of psychotherapy, the relation try with industry, the ethics of managed care, and the abuse o by third parties (eg., managed care, insurance companies].

lute commitment to patient welfare and condemnation of a

institutions or other parties are evident in the declaration and its

Universality of Human Rights Declarations

Unfortunately, the development ofdeclarations is not the e human rights conventions all over the world, there is the ass cial and political setup is present in which the individual bein

social attention. In the Declaration of Madrid, as in other declar

sumed that a social setup is present in which the individual is the fo charge. Wvhat if this is not the case everywhere in the world?

of a declaration, the more likely it is that all difficulties will be co

Although it is true that the more international input there

ples are highlighted. WVe believe that implementation of codes o quently difficult because of the zultural and social setups in wh

the declaration, in the end a document is needed in which

attempts at implementation are being made. These difficulties

from the social position of the medical doctor and the hierarchic

from interactions between individuals, families, and the co

of the medical profession vis-a-vis the rest of the commun other beliefs also have an effect on the lives and behavior o
Codes is to outline, address, and prevent malpractice. ln the

Malpractice is one of the main targets of ethical codes; an aim of

practice does exist, but the reaction of people to malprac

the final outcomeresponsibility for the outcome of me is determined by God a oamost saves people any ventions. psychiatricis even more the case with mosparticuarly This disorders.
Cultural Specificity

whatever the doctor decides is the right thing but also

aste Arab world to sue their doctors. This is due not only in many other regions of the world. For ex in

presses respect for and acceptance of local cultural and spiritu

with the patient and his or her family and the extent to

manitarian nature of this interaction depends on the way th

, if not more, than his or her technical ability or sci

ln Arab culture, the humanitarian interaction with a do

formation later communicated by verbal or nonverbal tion between patient and family different when the patie household?

g: Do patients who are not told the diagnosis u

These norms may face us sometimes with questions su

more natural and infirmity is less alien in these cultures. \V

ln Eastern cultures, social integration is emphasiz that is, the family, not the individual, is the unit of s

ered to indicate that the patient is "soft" or, worse, insane.'

vague complaint of psychological symptoms may be disre

more understood and acceptable and evoke a caring r

ln some cultures, and we argue that Arab culture is one

more important than achievement, how one appe anshame, rather than guilt, becomes a driving force. ln t r, physical illness and somatic manifestations of p

and norms of our target population? How ca srespect or disregard for local values? On the other hand, ho - sure that respect for the local culture rights? does ing eticaguidelines, to the detriment of our patients

to our ethical guidelines and at the same time not disregar

m- bers. Decisions are made notinterest. Ho at an in communalevel, in the best perceived collective

, lectivity of the community is valued rather than the i

Whether we like it or not, the encounters between psychiatry and law keep bringing us back to our conflicting conceptions of the value of health on the one hand and the value of liberty, integrity, and autonomy on the other. Cultural, ethnic, and sometimes sociodemographic data such as level of edu cation, age, and gender suggest different attitudes regarding patient auton omy and informed consent. l/Vhat is the perceived harm when members of the medical community violate cultural conventions and insist on telling the truth to patients? What are the disruptions of coping mechanisms of individ uals and families? ln what ways does acculturation change the beliefs of pa
tients of various ethnicities?

To answer those questions, it may be helpful to consider how individuals interact in Arab culture. We may then be able to understand the challenges and difficulties involved in implementing guidelines such as the Declaration
of Madrid.

One must first be familiar with the main characteristics that differentiate

the position of the individual within his or her community in a traditional so ciety from that in a Western society. Although societies should not to be con sidered stereotypically, general common attitudes can be assumed [Leff
1988).

Differences between the two types of societies are listed in Table 2-l. These differences are the mainstream norm and not an absolute description of a stereotyped behavior. Table 2-l shows that cultural diversity may influ ence the implementation of ethics in different societies. In traditional soci eties, the family is an extended one, decision making is group and family oriented, and the Western attitude regarding individual autonomy does not exist. The concept of external control, dependence on God with regard to health and disease, and attribution of illness and recovery to Gods will all maintain a healthy doctor-patient relationship, which makes trust, confi dence, and compliance characteristic in traditional societies. Arab culture includes traditional beliefs in devils, jirm, the evil eye, and so on [delusional cultural beliefs]. The family structure is characterized by af filiated behavior at the expense of differentiating behavior. Also, rearing is oriented toward accommodation, conformity, cooperation, affection. and in terdependence as opposed to individuation, intellectualization, independ ence, and compartmentalization. The extended family helps in managing intergenerational conflicts. Young individuals vacillate between tivo worlds, one following the values of Western societies and the other following the val
ues and beliefs of traditional societies.

Another point worth mentioning is that the phenomenon of homeless mentally ill patients, common in the United States and Europe [especially af

TABLE 2-1. Differences between traditional and \Vestern soeieties

regarding relationships and medical treatment
Traditional societies
Western societies

Family and group oriented

lndividual oriented

Extended family (less geographical than previously, but conceptual] Status determined by age, position in family, and care of elderly

Nuclear family
Status achieved bv own efforts

Relationship between kin obligatory Relationship between kin a matter of

individual choice

Arranged marriage, with an element Choice of marital partner; determined b of choice dependent on interfamilial interpersonal relationship
relationship
relatives lives

Extensive knowledge about distant Knowledge about close relatives lives o

Family decisionmaking
External locus of control

Individual autonomy
Internal locus of control

considered holy Rare suing for malpractice

Deference to Crocls will

Physicians decision respected and Doubt in doctor-patient relationship

Common suing for malpractice
Self-determination

Healthy doctor-patient relationship Mistrust in doctorpatient relationship Individual can be replaced; family Individual is irreplaceable, pride is in self
should continue and pride is in
family tie

Pride in family care of mentally ill Community care of mentally ill patient
patient

Dependence on God regarding health Selfdetermined recovery

and disease; illness and recoverv
attributed to God

ter mental health reform and the closing of psychiatric hospitals], is rare the Arab world. When it does occur, it is because of poverty and not bec
if it is discovered that a mentally ill family member is homeless.

of mental illness. Families in some traditional societies take pride in after their mentally ill relatives. In these societies, it is shameful to th

Traditional Versus Modern Heal ing

There are a number of important lessons to be learned from the examination of beliefs and practices relating to psychiatric illnesses that exist in various

cultures throughout the world. ln many non\/Vestern cultures, native practitio ners, to whom modern psychiatry is completely unknown, treat emotionally disturbed persons. Examination of the emotional attitude and interpersonal elements in these various forms of psychological treatments gives the psychia trist a broad perspective from which to study the basic components of pres ent-day psychiatry and the ethics that guide it. Traditional forms of mental health care contain important elements and are sometimes effective. Such treatments are frequently the only methods available in some cultures, a fact that requires better understanding to clarify the complex ways in which mental illness interacts with culture. Traditional treatments are characterized as culturally compatible (healers are familiar with the cultural value systems of the patients] and holistic (physical, psy chological, social, and spiritual aspects of healing are integrated] and are usu ally carried out by charismatic healersindividuals who promise to he in charge and indeed are, almost to the point of bearing the responsibility for the results of their decisions. The therapeutic process also frequently incor porates the family, tribe, or group and involves the social manipulation of the patients immediate environment. Traditional and religious healers in primary psychiatric care deal with mi nor neurotic, psychosomatic, and transient psychotic states using religious and group therapies (eg., the Zar ceremony), suggestion, devices, amulets, and incantations. National health priorities and health care services are not geared toward mental health and mentally ill patients. Furthermore, 75%-30% of Egyptian psychiatric patients, for example, present with so matic symptoms, and 60%-70% of these patients with somatic symptoms present to traditional healers and general practitioners (Okasha and Karam 1998). In Arab culture, the patients learning the diagnosis, prognosis, and lines of treatment is not viewed as empowering. In traditional societies, the fam ily-centered model is valued. A higher value may be placed on harmonious functioning and the family rather than on autonomy of the individual family
member.

The Role of Religion

Religion plays an :mportant role in symptom phenomenology, attribution [Gods will), and management. Psychological symptoms are attributed to weakness of personality, lack of faith, lack of conformity, laziness, or other factors, hardly factors that entitle an individual to a right of choice. State

ments such as "if God is willing, " I seek refuge in God from the accu

that the final decision is made where no human has control and, therefo that human choice is a marginal variable in the determination of the
outcome,

tan," "God is the healer" are widespread in the Arab world, ind

Islam is the religion of the majority in the Arab region. Fundamen lam is the essentially theocratic society, in which the state is of value the servant of revealed religion. This principle is explicitly stated in th stitutions of Morocco, Tunisia, Syria, Mauritania, Sudan, Egypt, and Y
{David and Brierly IQSS].

The Arabic word majnotm (insane"] appears five times in the Kor however, there it alludes not to insanity but rather to how people per

ceived prophets when they first attempted to guide the people

enment with beliefs not conforming with the traditions of their societies.

During the dark ages of Islam, majnoun referred to possession the proper Arabic meaning of the word is that of a shield or
mind.

In Islamic jurisprudence, it is emphasized that criminal responsib be attributed only to sane adults capable of good reasoning (Dols 19 responsibility is attributed to children, psychotic adults, or sleepi
state.

porous persons. In Islam, the welfare and care of an individu

illness are clearly the responsibility of the family, and not of the soc

Muslim law, down to its finest details, is an integral part of the Islam

ligion and to the revelation that it represents. Consequently, no

Islam.

the world is qualified to change it. Not to obey Muslim law is a si

punishment as a heretic and, thereby, excludes one from the

In Mediterranean countries, many peopleespecially those living in Is lamic societieshave an external locus of control and all events are c ered God's will. Islam is centered on the idea of humans obligation or du

rather than on any rights they may have. In that context, issues such sent, autonomy, and decision making become complex matters. In addition to the concept that the mentally ill individual is posse there is the concept that a person with mental illness is one who da

innovative, original, or creative or attempts to find alternatives t stagnant mode of living. This concept is evident in attitudes tow mystics. For example, the expansion of self and consciousness
been taken as a rationale to label some Sufis as psychotic. The autobiogra

phies of some Sufis reveal the occurrence of psychotic sympto

mental sufferings in their paths to self-salvation [M. Rakhawy, personal com munication, August I 989}. The third concept is that mental illness is the consequence of clisharrnony or constriction of consciousness, to which nonbelievers are susceptible. It is related to denaturing of one's basic structure [Al Fimzh] and disruption of harmonious existence by egoism, detachment, or alienation, partly due to loss of integrative insight. Which concept of mental illness prevails in the Islamic world depends on whether development or deterioration of genuine Islamic issues is oc curring. For instance, during deterioration, the concept that the mentally ill individual is possessed by evil spirits dominates, whereas during periods of enlightenment and creative epochs, the disharmony concept domi
nates.

In Islam, the unity of body and psyche is also recognized. The psyche [Elnrifs] is mentioned 185 times in the Koran, with the word referring vari ously to the body, behavior, affect, and conduct. The teaching of the great clinician Rhazes had a profound influence on Arab as well as European medicine. The two most important books of Rhazes
are El Mansuri and /ll-Hnwi. The first work includes the definition and na

ture of temperaments and is the predominant comprehensive guide to physi ognomy. AZHawi is considered the greatest medical encyclopedia produced by a Muslim physician. Translated into Latin in 1279 and published in 1486, it was the first clinical book that presented complaints, signs, and differential diagnoses of and effective treatments for illness. Avicenna's "El-Canoon was published IOO years later and is a monumental educational and scientific
book with better classification.

It is believed that the first Islamic hospital was established by the early ninth century in Baghdad and was modeled on Eastern Christian institu tions, apparently mainly monastic infirmaries. Of the hospitals that appeared throughout the Islamic world, perhaps the most famous was that created in Cairo by the Egyptian sultan al-Mansour Kalaoon in IZS4 [Dols l992). The first psychiatric hospital in Europe was established in Spain, in the medieval Moorish kingdom of Granada, through Arab influence. The fourteenth-century Kalaoon Hospital in Cairo had sections for sur gery, ophthalmology, and treatment of medical and mental illnesses. Contri butions by wealthy residents of Cairo made possible a high standard of medical care and periods of convalescence for patients until they could be gainfully employed. The care of mentally ill patients in a general hospital and the involvement of the community in the welfare of patients foreshadowed modern trends by six centuries [Baasher 1975].

Consent
The primary purpose of highlighting consent as a core element in psychiatric eth ics is to promote individual autonomy and to permit rational decision-making. Consent is not the mere signing of a piece of paper by a patient to protect the treating physician or institution from future malpractice complaints. The risks and benefits of the proposed treatment and alternative treatments should be ex plained to the patient. Also, the patient should be informed about the risks and benefits of refusal of treatment, and it should be deterrnined that the patient is not under any sort of undue influence and that the environment is not coercive.
The basic elements of informed consent are competence [this involves the capac ity for decision making; affective incompetence is not usually recognized by the

law], information (there should be a fiduciary relationship in which there is re spect for the dignity and autonomy of the patient), and noncoercion (there is a
subtle difference between coercion and persuasion). In common law, consent is not required in cases of necessity-when the doctor is of the opinion that treatment is in the patient's best interest and the patient is not competent to give valid consent to that treatmentand in emergency situations-when treatment is required in order to prevent im mediate serious harm to a patient or to others.

Competence
Patients are considered legally competent unless legally judged incompetent or temporarily incapacitated by a medical emergency. ln a l94B ruling, the civil court held that persons are competent to make treatment decisions if they are of "sufficient mind to reasonably understand the conditions, the nature and the ef fect of the proposed treatment, [and the] attendant risks in pursuing the treat ment and in not pursuing the treatment" (Egyptian Civil Law 1948, p. 44). Common law states that competent adults have a right to refuse medical treatment even if refusal may result in death or permanent injury. Further more, competence can apply to different things; one may be competent to consent to treatment, to admit oneself to a hospital, or to agree to a do not
resuscitate" order.

Decision Making
What if the decision-making process is not an individual one? ln Arab culture, issues of illness are dealt with as family matters. Whether a patient is hospital ized, for example, or subject to electroconvulsive therapy or discharged from

the hospital is dependent not on what the patient wants himself or herself but on the estimation, need, or wish of the extended family. Patients may wish at times not to be burdened with the extra load of making decisions that may de termine the patterns of the rest of their lives. The concept of shared responsibil ity is central in Arab culture, and most people in the Arab world would not like to be responsible for the outcomes of decisions made on their own. The decisionmaking style in Arab culture might be best described as family centered. The moral, social, and psychological support for which extended fami lies in developing countries are so well known is the result of collectivity of deci sion making, that is, decision making by consensus. An individual decision that
differs from the collective decision leaves the decision maker to bear the respon

sibility of the outcome alone and may deprive him or her of familial support. On the other hand, when a collective decision is acted on, negative consequences of the decision are not the patients fault alone and he or she does not have to bear the guilt of making a wrong decision. One illustrative example of the issue of consent and decision making is hospital admission. In the United States, 73% of patients in psychiatric facili ties are voluntarily admitted, whereas in Egypt, the rate is 90%. ln reality, the distinction between voluntary and involuntary admission is not as clear as is stated in law. Patients are often pressured into agreeing to voluntary admis sion. If voluntary admission were always strictly voluntary, the rate of invol untary admission would likely increase. The family plays a strong role in the rate of voluntary admission. In the Arab world, respect for and compliance with family decisions is more important than autonomy of the individual, es pecially if responsibility for the outpatient rests with the family because there are no community social support systems. It is the responsibility of the family to learn the patients diagnosis and prognosis and to make the difficult decisions needed. Studies in Italy, Greece, Spain, and Egypt showed that a patients learning of his or her diag nosis of cancer is not viewed as empowering. Rather, this knowledge is seen as isolating and burdensome to the patient, who 1s suffering too much and is too ignorant about his or her condition to be able to make meaningful choices. Knowledge of a diagnosis harms the patient by causing him or her to lose hope.

Affiliation Versus Autonomy

The idea of patient autonomy is not universal, nor has the level of patient au tonomy remained constant. In 1961, 90% of physicians in the United States

did not inform their patients of a diagnosis of cancer (Blackhall et al. l995). ln l979, however, 97% of American physicians made it their policy to inform
patients with cancer of their diagnosis. ln most of the literature on this

change, the view is that this is the result of the progress from physician pater nalism, in which the patient remains uninformed, to a more enlightened and respectful attitude toward the patient. The same change has occurred in the area of mental illness in some parts of the world. Cultural, ethnic, and probably sociodemographic factors affect attitudes regarding patient autonomy and informed consent.
ln family-centered cultures, a higher value may be placed on the harmoni

ous functioning of the family than on the autonomy of individual family members. Mthough it is true that the patient-autonomy model is founded on the idea of respect for persons, people live, become ill, and die in the context of family and culture and exist not simply as individuals but in a web of rela tionships (Blackhall et al. l995]. insisting on the patient-autonomy model of medical decision-making when that model runs counter to the deepest values of the patient may be an other form of physician paternalism. In the Arab region, a person may actu ally change doctors because of the way the first doctor conveys information to him or her or if the doctor persists in considering the patient the only deci
sion maker.

Confidential ity
A third major element of psychiatric ethics is confidentiality and disclosure of information, another universal principle of the Declaration of Madrid and

other professional declarations. Although there is no consistently accepted set

of information to be disclosed for any given medical or psychiatric situation,

five pieces of information are generally provided: diagnosis; nature and pur pose of the proposed treatment; consequences, risks, and benefits of the pro posed treatment; viable alternatives to the proposed treatment; and prognosis
(projected outcomes of treatment and no treatment]. Nurses, residents, social workers, psychologists, medical secretaries, in surance companies, and accreditation bodies already have access to this information and are entitled to see the patients records. The issue of con fidentiality therefore relates to people outside the medical profession and its accessoriesthe patients family, for example. Telling the patient the truth about his or her condition, especially when the prognosis is poor or a major decision should be made, is not considered Ei

virtue in Arab culture. In fact, althogh Arab families praise the technological advances of Western medicine, they always comment about the harshness of \rVestern doctors, who tell their patierrts the truth regardless of the associated emotional trauma to the patient. In Arab culture, the norm is to convey the

information to the family first and th2n leave it up almost entirely to the fam
ilv to decide whether to inform the :>atient.

Frequently, an Arab family will s;eak of a cousin who "feels" that he or she may have cancer and who does not really want to know for sure. There is a strong conviction among Arab patants that not knowing the truth allows the patient to have the hope that th ngs may become better. Issues such as writing a will or making other economic arrangements arc hardly matters of concern, probably because Islamic la.v leaves little room for interference by the patient in such practical matter:. Preparation for death, too, is not of great concern, because it is mainly aspiritual matter, with few practical im plications. In the field of psychiatry, nn Arab patient and his or her family al ways like to hear that the patients t;:ndition will improve. The patient and the patients family would rather seea psychiatrist who will insist that things will get bettereven if the condition does not in fact improve or improves only for short periodsthan a psycl iatrist who will relate the outcome in statistical, scientific terms. Arabs ter:1 to believe that recovery is Gods will and lack of recovery may be due to failure on the part of the doctor.

Conclusions
An ethical foundation is necessary in asychiatric practice so that patients are

not left at the mercy of the good intent of the practitioner. However, ethical codes must be implemented with tact and understanding of local constraints so that the image of the psychiatrist and psychiatry is not further jeopardized. We could, for example, suggest that physicians ask patients whether they
wish to be informed about their illnes es and be involved in making decisions about their care or whether they preiar that their families be informed and

handle such matters. In any case, the patients wishes should be respected and the patient should be allowed to choose a family-centered decisionmaking style. In permitting this form of decis:>n making, we are not abandoning our commitment to individual autonomy < r its legal expression in informed con sent. Rather, we are broadening our view of autonomy so that respect for per sons includes respect for the cultura values they bring with them to the decisionmaking process.

EIIIILDI kuuul vc, cnn r ayuuruu y

References
Baasher T: The Arab countries, in World History of Psychia ry. Edited by Howels TG. New York, Churchill Livingstone, 1975, pp 97-123 Blackhall L, Murphy S, Frank G, et al: Ethnicity and attitudes toward patient auton omy. JAMA 274:8ZO8Z5, 1995
Breasted JH: The Dawn of Conscience. New York, Sc:ibner's 1934

David R, Brierly J: Major Legal Systems in the `World Today. _.ondon, Stevens, 1985 Dols MW: Majnun: The Madman in Medieval Islamic Socie y. Edited by lmmisch
DE. Oxford, Clarendon, 1992

Egyptian Civil Law: Article 45,46, Vol 131, p 44. Egyptian Official Documents.
Cairo, Ameria Press, 1948

Leif J: Psychiatry Around the Globe: A Transcultural View Kjraslcell Psychiatry Se

ries]. London, Royal College of Psychiatrists, 1988, p 79

Okasha A, Karam E: Mental health services and research ir the Arab world. Acta

Psychiatr Scand 98:406-413, 1998

Declaration of Hawaii. World Psychiatric Association, 1977