An Islamic Bioethics Framework to Justify the At-risk Adolescents’ Regulations on Access to Key Reproductive Health Services

Abstract

Adolescent sexuality is one of the most important reproductive health issues that confronts healthcare professionals with moral dilemmas and legal issues. In this study, we aim to justify the at-risk adolescents’ regulations on access to key reproductive health services (KRHSs) based on principles of Islamic biomedical ethics and jurisprudence. Despite the illegitimacy and prohibition of sexuality for both girls and boys in Islamic communities, in this study, using 5 principles or universal rules of purpose; certainty, no-harm; necessity; and custom, we argue that first, applying these principles in the context of the no-harm principle can provide the best interests of at-risk adolescents; second, it is permissible to provide KRHSs to these adolescents with their own assent, as long as necessary, only with the intention of preventing or reducing harm. In this framework, while preventing harm, it tries to provide the best interests of at-risk adolescent. Thus, the principle of no-harm requires that the government, by designating the responsibility to healthcare professionals, protects at-risk adolescents from harm, and obliges these professionals to choose and implement the option that best suits adolescents’ interests.

Introduction

Protecting adolescents from injuries and diseases that depend on behavioral and sexual habits is a moral duty and a legal obligation (WHO 2003). The challenges of growing up in a rapidly changing world limit the opportunities and good prospects of millions of adolescents due to inequality. Living in a digital environment also exposes them to the threats of cyber space and social media. They face many threats such as violence, bullying, risky behaviors, and mental health problems. The prevalence of HIV- and AIDS-related deaths is increasing among older adolescents, while the death rate among other age groups is declining (WHO 2017).

The distinct stage of life and the intermediate age of adolescents indicate the need for specific responses in policy and practice. Transformational accountability for adolescents beyond survival pursues their enjoyment of physical, psychological, and social well-being. It also means civic engagement and participatory accountability mechanisms that put hearing the voice of boys and girls at the center of action framework (WHO 2017).

Studies in the countries of the Asia-Pacific region show the age of marriage increases and the age of adolescents’ sexuality decreases (Godwin et al. 2014). At-risk adolescents often struggle with their parents, who do not trust their children’s ability to make the right choices. These conflicts are especially severe in cases of adolescent sexuality and related care. Fear of disclosure may lead them to ignore seeking healthcare services. On the other hand, providing key reproductive health services (KRHSs) to the at-risk adolescents with the consent of their parents, due to conflict with cultural and religious beliefs, can endanger their mental or physical security (Koelch and Fegert 2010).

Sexuality in adolescence is one of the most important reproductive health issues, due to the need to use contraceptive methods to protect against sexually transmitted diseases (STDs) and illegitimate or unwanted pregnancy. Child and adolescent healthcare professionals confront moral dilemmas and legal issues surrounding consent and confidentiality that makes it difficult to decide for the best interests of the minors (Fouquier 2017; Hedayat and Pirzadeh 2001).

Decision-making capacity in the children grows with increasing their age. In addition to parental consent, obtaining the assent of minors to medical treatment is recommended. However, children may need to be examined and treated in an emergency situation or lack of access to a parent or legal guardian, in order to prevent serious and imminent harm. Given the evolving capacities of the child to make decision, some scholars have recommended the use of a flexible way of respecting their autonomy, depending on the severity of decision to be made, and request the participation of family members (Koelch and Fegert 2010). According to the Malaysian Children’s Bioethics Symposium, “the two principles of No-harm and Best interests are equally important and complementary in decision-making for children” (Khoo 2017). According to the policy statement of the American Committee on Pediatric Emergency Medicine and Committee on Bioethics, medical screening examinations and any necessary medical care to prevent imminent and significant harm to minors should generally not be delayed due to consent problems. The purpose of this statement is to provide a policy guidance in situations where parental consent is not readily available or necessary or exposes the child at the risk of serious harm (Committee on Pediatric Emergency Medicine 2003).

A systematic review reveals inconsistencies between adolescents’ reproductive health policies and regulations, in countries of the Asia-Pacific region (UNESCO 2013). Commitment to protecting at-risk adolescents requires life skill training to avoid unconventional sexual behaviors and the regulations on their access to KRHSs. The immigration of Muslims to European and American countries and the consideration of the rights and needs of their children have forced researchers to study the principles of Islamic biomedical ethics in this field. Given the current social changes and rising immigration rates, researchers and healthcare professionals need to investigate the bioethics issues on children and adolescents’ health and well-being. New knowledge and skills of healthcare professionals enable them to manage difficult and critical situations related to the minors (Khoo 2017).

Although ethically the approach of harm prevention, at first glance, is a license to provide KRHSs to at-risk adolescents, the emergence of ethical and legal challenges in practice suggests the need for a bioethics guide to protect them. The aim of this study is to justify the regulations on at-risk adolescents’ access to KRHSs, based on the principles of Islamic biomedical ethics and jurisprudence. Given the existing restrictive laws, the proposed framework can be used as a policy guide for legislation and optimal action for the health and well-being of at-risk adolescents not only in Islamic communities, but also worldwide.

Adolescents and the Legitimacy of Sexuality

According to the World Health Organization, the adolescence period includes the ages 10 to 19, and people aged 10 to 24 are called young. About one in six people in the world are adolescent. 23.5% of the world’s population are young people and 16.4% are adolescents; 60% of the world’s young population lives in Asia (WHO 2014).

According to Article 1 of the Convention on the Rights of the Child, persons under the age of 18 are generally considered to be children, unless, in accordance with applicable law, the majority of the child is recognized (United Nations General Assembly 1989). The convention does not specify an age range for adolescence. According to Article 1 of the Iran Law on the Protection of Children and Adolescents (2020), as an example of the law of an Islamic country, a person who has not reached the age of juridical puberty is a child and a person who lies between the ages of juridical puberty to 18 full solar years is an adolescent (Islamic Parliament Research Centre of Iran 2020).

Maturity involves physical, mental and social growth. The age of physical puberty in Islam is defined as 9 and 15 full lunar years for the girls and boys, respectively, and implies taking on religious duties and responsibilities. But intellectual maturity is specified by the ability to function independently, which does not have a certain age. When a person is intellectually considered mature, he/she can make decisions for its own affairs. In practice, this decision is usually made temporarily and in special cases (Hedayat and Pirzadeh 2001).

Given the need to mental maturity, the age of majority for a variety affaire such as marriage, driving and voting, and even sexual activity varies according to the statutes of each state. Religious and especially Islamic communities and even some secular societies believe in abstaining from sexual activity for adolescents until marriage time. In Islamic communities, sexuality outside of marriage is forbidden for both girls and boys. For this reason, despite the declaration of the full age of 18 years by the Convention on the Rights of the Child, the reproductive health regulations vary in different countries (United Nations General Assembly 1989).

Bioethics and Deciding for the Best Interests of the Child

Ethicists have recommended harm and best interest standards for decision-making about pediatric medical care. People benefit from living in a healthy and safe society because they can experience health, productivity, and well-being. For example, the prevention and care of STDs and HIV are essential for the health and well-being of individuals and the public. The principle of harm makes the freedom of action of individuals conditional on their actions not harming others. According to the Mill’s philosophy, individuals are free as long as they do not interfere with the health, safety, and other legitimate interests and freedoms of the others. A clear example is the government’s power to intervene and prevent their risky behaviors to control infectious diseases and maintain public health (Gostin 2010).

Although the principle of harm has long been used to protect others, especially children and people with disabilities from harm in bioethics and health law (Gostin and Wiley 2015), for the past two decades it has been used as an ethical standard for decision making. Many ethicists have argued the use of harm standard to reinforce or even replace the best interest standard (Diekema 2004; Diekema 2011; Gillam 2016; Wilkinson and Nair 2016). Critics of the best interest standard argue that it is too vague and demanding and that it is not a sufficient standard restricting parental authority or determining the threshold for government intervention in parental decisions (Diekema 2004; Salter 2012). According to the principle of harm, if the decisions of parents of the children are exposed them to harm, the government must protect the children from the harm that result from these decisions. Diekema believes that a harm can neutralize or prevent one or more of the child’s essential interests, so it is serious (Diekema 2004).

It is morally acceptable to apply the principle of harm to describe the minimum threshold of parental decision, and beyond that, it requires intervention in parental decision to ensure the best interests of the child. This argument is almost like the domain of parental discretion based on the principle of harm from Gillam’s account (Bester 2018). Gillam (2016) proposed an ethical tool to be used in cases of disagreement between physicians and parents in deciding on medical interventions for children, which is called the ‘Gillam’s zone of parental discretion’. Any parental decision that is below the determined threshold based on the principle of harm is challenging and requires intervention and above that is placed in the parents’ discretion, where parents can make decisions for their child without intervention of the others (Gillam 2016). However, it is believed that although the application of the principle of harm is simple, but due to the ambiguity in its definition by changing the context, it alone cannot provide sufficient justification for a decision among the available options (Bester 2018; Birchley 2016). Applying the principle of harm in decision-making causes all moral requirements in preventing harm to be forgotten, because other related moral characteristics obscure the parent-child and physician-child relations; the result is a deviation from other moral requirements to promote the health and well-being of the child or to prioritize options that clearly benefit the child more than prevent harm alone (Bester 2019).

The prevailing pattern in bioethics for many years in decision-making for children has been to consider the best interest of the child. The best interest is morally and legally the first consideration in the decision-making process for children, which is enshrined in law and serves as both a guiding and limiting standard for parental authority (Pope 2011). This standard guides parents in deciding and choosing the optimal treatment option, and if the parents’ decision is not reasonable, it requires the intervention of government officials (Diekema 2011). In this case, healthcare professionals shall choose the option that best promotes the best interests of the child by balancing the various options. However, decision-making based on the best interest standard is difficult because of the need to identify the interests of the child and to choose the best one from the available options (Pope 2011).

Principles of Jurisprudence and Islamic Bioethics

Even with the belief that God has revealed the right way of life within the framework of the Shari’a through revelation, the inference of a statute and its application is due to the rational reasons used in ethical thought. The Shari’a recognizes the independence of other moral systems within their sphere of influence, without imposing its views on others with different cultural beliefs and experiences. More importantly, due to different interpretations of the Islamic system in society, different traditions have been created with specific jurisprudential thoughts and practices. In the absence of a formal and organized religious institution, as well as a formal theological body that has full authority to express religious beliefs to all members of society, Islam has inherently and permanently retained its pluralistic nature in thinking and justifying moral actions. Therefore, when it comes to the specific application of principles to new ethical issues such as women’s right to abortion resulting from rape, it is possible to see different jurisprudential views. However, jurists of different traditions have identified several principles that are often, but not always the same. Since the language of Shari’a is the language of duty, the principles and maxims of jurisprudence in Islamic bioethics are interpreted as duties and its derivatives (Sachedina 2009).

Social changes have necessitated the inevitable change of some statutes. In the account of sachedina, Maslaha and No-harm are two major Islamic principles of social moralities which have been considered as the reasons of statutes of biomedical issues in the last two decades, in comparison to known bioethics principles in secular systems. This important moral development has achieved through adoption of Islamic bioethics with secular bioethics and thus centrality of moral reasoning in public policy domain (Sachedina 2009).

The legitimacy of applying the principles derived from reason depends on the validity that comes from religious sources. ‘Maslaha’ (public interest) is a secondary rational source in Islamic jurisprudence as well as a framework in traditional Islamic law to interpret Shari’a considerations to the jurisprudential maxims. According to Imam al-Ghazali, Maslaha, indicates on providing common good and avoiding harm and serves to protect Maqasid al-Shari’a (Shari’a purposes). Those that protect five Shari’a purposes (preservation of religion, life, intellect/reason, lineage, and property) are considered as Maslaha and those that destroy these purposes are considered as “Mafsadeh” (detriment or evil) (Al-Ghāzalī 1994).

‘Istislah’ is related to the Maslaha and means guaranteeing benefits and preventing harm in public domains, which represents the independent jurisprudence statutes based on the public interests (Abouey Mehrizy 2010). Providing common good and protecting minors’ interests in relation of influencing issues on their health and well-being in Muslim communities requires to consider Shari’a issues in framing public policies. Although some of the statutes are individual, but when individual aspects expand to the extent that to be communal, enacting the principle of Maslaha (public interest) is essential. When enacting the principle of Maslaha, disputes arise due to the closeness of the good and evil aspects. In these cases, analyzing and balancing of all goods and evils is critically important and can be accurately done using maxims and subsidiary rules (Sachedina 2009).

In the framework of the principle of Maslaha, the jurisprudential maxims are derived from Islamic jurisprudence. These maxims clarify the background and patterns of the statutes that have been deducted from legal literature accumulated by Islamic scholars, among which, 5 principles or maxims of intent, certainty, no-harm, necessity, and custom is used in Islamic biomedical ethics (Sachedina 2009). Mustafa believes that the principles of Islamic biomedical ethics support the four principles and these universal rules play a decisive role in policy-making in Islamic communities (Mustafa 2014). In following, while brief explaining these maxims, we use them to justify the regulations on at-risk adolescents’ access to KRHSs.

Principles of Islamic Biomedical Ethics

The Principle of Intention

Medical actions are judged primarily on their intentions to be benevolence and profitable. The intent of a medical procedure must be evaluated before performing it. The other subsidiary rule of this principle, is that, the purpose does not justify the mean. Therefore, the use of immoral methods for beneficial medical purposes is not allowed (Mustafa 2014). According to this principle, the provision of KRHSs to at-risk adolescents by healthcare professionals, in order to protect them from serious and imminent harm as well as to ensure public health provides the appropriate ethical justification.

The Principle of No-harm

This principle is consistent with the principle of non-maleficence in biomedical ethics and harm principle in health law, and in addition to religious documents, it has strong rational reasons (Hedayat and Pirzadeh 2001; Mustafa 2014). This principle justifies medical interventions to prevent harm and acknowledges that the minimal harm of the interventions can only be justified if more valuable benefits are achieved (Khoo 2017).

The likelihood of harm is the first determining principle in making health decisions. The first step in ethically justifying adolescents’ access to KRHSs is to identify the potential for serious and imminent harm. The important point is that the definition of harm varies in different contexts; in the cases that we cannot recognize the harm, we refer to the custom (Hedayat and Pirzadeh, 2001). Because sexuality or substance abuse by adolescents in Islamic communities is considered as a harm, the first step is to educate and counsel them to avoid these harms.

Second, according to this maxim, in case of the simultaneity of two harms, to prevent further harm, the action should be chosen which is less harmful (sometimes the action can be to leave the intervention). Principles of evolving capacities of the child, harm, and best interests limit parents’ power to consent. Informing parents to consent for providing the services such as HIV counseling and testing or prescribing emergency pill to the at-risk adolescents can be life-threatening. Given the purpose of preventing harm, not choosing the best therapeutic intervention with parental permission which requires disclosure of information and sufficient justification for informed consent, in such critical situations, the interest of the adolescent requires to provide these health services with the adolescent’s assent.

Some scholars believe that the patient assent is sufficient for routine, simple, and low-risk actions. Assent requires that healthcare professionals only provide specific recommendations based on the patient’s condition while providing education and a brief list of care options (Hedayat and Pirzadeh, 2001). Adolescents 14 years of age and older are considered to have the capacity to make informed decisions about treatment interventions and participation in nonprofit researches (Fouquier 2017; Khoo 2017). In the case of serious and imminent harm, the principle of no-harm, while restricts the parents’ discretion to consent, obliges healthcare professionals to protect the adolescent from harm. Therefore, it can be inferred that in critical situations, it is necessary to provide KRHSs to the adolescents to prevent or reduce the harm with their assent. Post-test counseling is an essential action in advising to avoid sexual relations and high-risk behaviors by the adolescents with negative test results, as well as to care for and treat those with positive test results, and also to prevent the spread of HIV infection in the community (Smith et al., 2005).

Third, according to the principle of no-harm, the minimal harm of these interventions can only be justified if more valuable benefits are achieved. Side effects should always weigh less than the benefits, in other words, avoiding harm takes precedence over achieving benefits with the equal or less value. Therefore, healthcare providers should make any decision for at-risk adolescents by balancing the burdens and benefits of each action with taking into account their best interests.

The Principle of Certainty

This maxim basically supports what we now call evidence-based medicine and implies that most medical decisions are relative. A subsidiary rule is that certainty is not cancelled by doubt, and a proven scientific truth can only be modified or disproved by convincing evidence. Another subsidiary rule is that all medical procedures are permissible unless their prohibition is definitive, although there are exceptions to those related to reproductive and childbearing functions (Mustafa 2014).

Preventive interventions such as educating and counseling, using contraceptive methods such as condom, screening, and diagnostic tests are used to prevent harm at the population level and due to their non-invasive nature do not lead to harm. Failure to apply these interventions entails serious harm, and individual and social consequences. Based on scientific evidence, KRHSs, due to the nature of prevention as opposed to therapeutic interventions, not only have no harmful side effects but, conversely, failure to provide these services can cause serious harms or outcomes. The use of condom protects people against STDs and HIV, and HIV counseling and testing are necessary actions in people with high-risk sexual behaviors. Also, taking emergency contraceptive pills within 72 h of unprotected intercourse, to prevent unwanted or illegitimate pregnancy, has no abortive mechanism and access to it is recommended in scientific guidelines.

The American College of Obstetricians and Gynecologists (ACOG) while notifying the differences in the statutes regarding the consent of minors to receive healthcare services by each state, and the need that obstetricians and gynecologists be familiar with these regulations (Committee on Adolescent Health Care 2017a), allows adolescents access to all contraceptive methods approved by the Food and Drug Administration. In addition, the college recommends dual use of condom and an effective contraceptive method as the ideal way to prevent STDs and unwanted pregnancy (Committee on Adolescent Health Care 2017b). However, using long-acting contraceptives by adolescents, while leading them to continue having illicit sex without follow-up visits and medical assessments, it can cause some side effects.

Thus, as long as the adolescent exposes to the serious harm, the provision of these services in accordance with the situation and the extent of harm is permitted according to scientific evidence. In addition, setting criteria for the type and frequency of available services, without exerting negative effects such as stigma and discrimination can prevent high-risk sexual behaviors and reduce their harm, and have a deterrent effect on the repetition or intensification of these behaviors.

The Principle of Necessity

According to this principle, a prohibited illegal act could be allowed in the case of necessity, although the level of difficulty or necessity should be considered for the appropriateness of action. A good example of this principle includes allowing abortion in the event of a threat to the life of pregnant mother. The limitation of this principle is that if the necessity is removed, the default prohibition will be resumed (Mustafa 2014). Therefore, an unauthorized medical or healthcare service with a scientifically proven effect and minimal side effects can be considered permissible with the right intent as long as needed. It is inferred that although any sexual relation outside of marriage is forbidden in the Shari’a, according to the principle of necessity, immediate intervention in perilous circumstances is necessary. Therefore, as long as effective counseling can empower the adolescent to avoid unconventional sexual behaviors and healthy choices and also eliminate the need, providing KRHSs to at-risk adolescents with the intention of preventing or reducing harm is permitted. For example, HIV counseling and testing or prescribing emergency pill to prevent an illegitimate pregnancy in adolescents who have experienced or been a victim of sexual intercourse may be permissible due to the known scientific effect and minimal side effects.

The Principle of Custom

Since Shari’a is applicable in different times and places, local custom has power as long as it is not contrary to Islamic law. Customary action can be considered valid if that be the dominant and widespread method or practice of medicine. Local custom is also a reference for determining the occurrence of a harm; in cases which we cannot recognize the harm, we refer to the custom (Mustafa 2014). It should be taken into consideration when making relevant rulings (Sachedina 2009). As we have mentioned, extramarital sex and the free access to contraceptive methods for adolescents are not only not common in Islamic communities, but also prohibited. According to this principle, and in a harm prevention approach, the regulations on at-risk adolescents’ access to KRHSs is ethically justifiable when it is accompanied with the de-normalization of unconventional sexual behaviors, without enacting stigma and discrimination.

Conclusion

Despite the illegitimacy of unconventional sex for both girls and boys in Islamic communities, in this study, we used the principles of Islamic biomedical ethics and jurisprudence to argue that first, applying these maxims in the context of the no-harm principle can provide for the best interests of at-risk adolescents. Second, at-risk adolescents’ access to KRHSs with their own assent and the intention of preventing or reducing harm is allowed as long as necessary. In this framework, while preventing harm, it tries to provide for the best interests of the at-risk adolescent.

The no-harm principle requires the government to protect at-risk adolescents from harm by assigning responsibility to healthcare professionals. Also, the justifiability of the minimal harm of these preventive interventions, only if more valuable benefits are achieved, obliges these professionals to balance the burdens and benefits of available options, and to choose the option that best promotes the interests of the adolescent.

In this study, we did not aim to argue the age of consent or self-determination of at-risk adolescents to receive KRHSs. However, the principles of evolving capacities of the child, no-harm, and best interests, restrict the parents’ power to consent. In such risky situations where obtaining parental consent is not possible and the adolescent is exposed to the risk of serious and imminent harm, the interest of the adolescent requires that these services be provided with her/his own assent.

Author Contributions

FA conceived the research idea, searched the literature, made arguments, and wrote the manuscript; AZ and MA made arguments, critically supervised the research, and reviewed and approved the manuscript.

Funding

This research was granted by UNAIDS, Iran (Project AIRSCl802618; Award 68578; Task 2.5)

Declarations

Conflict of Interest

The authors declare that they have no competing interests.

Ethics Approval

Not applicable.