1.0 OBLIGATION AND EXEMPTION FROM PUASA: a medical perspective

Puasa in Ramadhan is obligatory and is one of the pillars of Islam. It is obligatory for adult, sane, and healthy Muslims. All these three conditions involve medical considerations.

Because of the physiological stress involved, puasa is obligatory on adults who have reached the age of puberty or the age of 15. They are the ones able to withstand the physiological stress involved. Fasting of children above the age of 7 is for training but is not obligatory. Their physiological preparedness for puasa should be monitored carefully to make sure there are is no physiological harm especially micro or macro-nutrient malnutrition. As part of training, children may not have to observe puasa for the whole day or for the whole of Ramadhan. Puasa of children below the age of 7 is offensive and may cause health problems.

Those who have mental conditions that are associated with lack or deficiency of legal capacity, ahliyyat, are not obliged to observe puasa because there is no takliif. Medical criteria for mental / intellectual competence have to be satisfied before they are relieved of the obligation.

Various conditions of ill health and physiological weakness are a reason for exemption from the obligation of puasa. In some conditions the exemption is temporary and the missed puasa will have to be made later. In other conditions the exemption is permanent. The exemption may be accompanied by kafaarat or not. The details of these should be sought from local jurists in accordance with the dominant school of fiqh in the area.

2.0 HEALTH BENEFITS OF PUASA

The merits of puasa, fadhl al siyaam, are many and are varied but all of them have medical or health implications.

Puasa breaks the normal routines of life that revolve around meals. It creates a different psychological milieu that liberates the mind from the routines of life and gives it an opportunity to reflect on the bigger issues of the creator, the good and the bad. Puasa in this way leads to psychological satisfaction because of the liberation from the dominating and sometimes constraining daily routines of life.

The medical merits are appetite and weight control. Puasa teaches a person to control the food appetite during the day for 30 days every year. Avoiding food or drink for a hungry and thirsty person requires self discipline and self control that are empowering. This empowerment can be transferred to other life activities. The training is repeated every year.

3.0 MEASURES TO PREVENT PHYSIOLOGICAL HARM IN PUASA:

The prophet (PBUH) taught measures to ensure that puasa does not cause physiologic damage. Puasa continuously from day to day, wisaal, was forbidden[1]. Early iftaar was recommended[2]. Delaying suhuur was recommended[3].

There are medical guidelines on diet in puasa. The aim should be maintaining normal body weight or actually reducing it if overweight. Over-eating at iftaar and suhuur should be avoided. It will cause weight gain and indigestion. The diet should contain sufficient fiber to prevent constipation. Fiber and slowly digested foods with a long stomach transit times are preferred because they delay the feeling of hunger. Enough water should be taken at night both for preventing dehydration and preventing constipation. Adequate fluid and salt intake prevents lethargy in the afternoon caused by low blood pressure.  

Inadequate sleep is a cause of headaches. Intake of adequate calcium, magnesium, and potassium will prevent muscle cramps. Hot places should be avoided because they aggravate the dehydration. Cooling the body such as tepid sponging, tabarrud, is allowed[4] during puasa.

4.0 PUASA WITH PHYSIOLOGICAL IMPAIRMENTS

4.1 Old age

Old age is considered an excuse from puasa[5] because of physiological fragility and delicate nutritional requirements.

4.2 Diabetes mellitus

Diabetes has special consideration in puasa because of its direct relationship with food intake.  Insulin-dependent diabetics have to reduce their insulin dose because of reduced food intake during the day. In some cases this is not possible and they have to be exempted from puasa altogether especially if their diabetic control is brittle. Insulin-dependent diabetics should be monitored very carefully because hypoglycemia may arise due to insulin injections with inadequate dietary intake. Non-insulin diabetics can undertake puasa under medical supervision. This will generally require changing times of medication, close monitoring of blood sugar levels, and being alert to any hyperglycemic or hypoglycemic crises. Pregnant diabetics are exempted from fasting because diabetic control is more difficult in pregnant women making fasting doubly hazardous for both the mother and the fetus.

4.3 Other conditions of Illness

The sick are allowed to break puasa[6] if trusted physicians fear that puasa will be deleterious to good health. The missed puasa is made up later[7]. If the illness is chronic, maradh muzmin, then there will be no opportunity for making up. The puasa of a sick person is valid but is makruh. The heirs can perform make-up fasting, qadha al saum, for days missed by a deceased disabled by disease in terminal illness[8].

Peptic ulcers are aggravated by raised acid levels and could be a reason for exemption from puasa. Low fluid intake could encourage growth of kidney stones and joint problems due to deposition of excess solutes.

4.4 Puasa in travel:

The prophet observed puasa on a journey[9] and also broke it on another journey[10]. A Muslim may or may not observe puasa on a journey[11]. It is however preferable to take the exemption and break puasa during a journey. This is understandable because traveling is both a psychological and physiological stress. It may also not be easy for a traveler to find the necessary food for iftaar and suhuur. The traveler has to make up the missed days at the end of the travel and before the next Ramadhan. The puasa of a traveler who chooses not to take the exemption is valid but it is preferable for him to make the rukhsat.

4.5 Puasa in difficult weather:

Puasa in conditions of extreme heat leads to dehydration. Care should be taken to take enough fluids at suhuur and not to expose oneself to extreme environmental temperatures. In very cold areas, the metabolic rate is raised to be able to generate sufficient heat for maintaining body temperature. In such conditions extra care should be taken to consume enough food and to cover oneself properly to minimize heat loss. Regions of the world near the two poles may have extremely long days in summer and very short ones in winter. It is recommended that the times of suhuur and iftaar of the nearest temperate region should be followed rather than following local sun-rise and sunset.

4.6 Puasa in pregnancy, menstruation, and the post partum period

The pregnant woman, al hublah, is allowed to break puasa[12] if puasa is a health risk. The breast-feeding woman or nursing woman, al murdhi'[13], is allowed to break puasa if there is health risk. The exemption from fasting is obligatory for the menstruating woman, al haidh[14], and for a woman in the post partum period, nifaas[15]. Any fasting undertaken in haidh and nifaas is invalid.

5.0 NULLIFICATION OF SAUM, mubtilaat al saum: a medical perspective

5.1 Concept of jawf

Any potentially nutritious substance that enters and stays the inside cavity of the body, al jawf, nullifies puasa. The term jawf has to be reinterpreted in view of modern anatomical and physiological knowledge. In my understanding jawf means the alimentary canal from the mouth to the anus.  

5.2 Oral intake

Deliberate eating and drinking and eating nullify puasa. Smelling food or any other pleasant odor does not nullify puasa Use of snuff or tobacco in the nose nullifies puasa. Deliberate smelling of tobacco or any other type of smoking material nullifies puasa. If the smelling is non intentional it does not nullify the puasa. 

Madhmadhat and istinshaaq in wudhu are permitted during puasa[16]It is however offensive to exaggerate them[17].  The decision of what is normal and what is excessive requires more discussion. More discussion is needed on swallowing saliva and swallowing phlegm during puasa.

The mouth can be rinsed with pure water without nullifying puasa. Care must be taken to avoid swallowing Siwaak is permitted all through the day of puasa[18]. Use of a tooth brush with toothpaste is allowed if care is taken to rinse out the mouth fully such that none of the toothpaste remains in the mouth.

The ear-drum was traditionally considered a nullifier of puasa but unless the eardrum is perforated there is no direct connection between the ear and the jawf.

Eye drops enter the nostrils and may eventually reach the pharynx probably reaching the jawf.. Kohl applied to the eye does not nullify puasa if its smell is not felt in the mouth.

5.3 Medical examination and investigations

Taking blood, urine, and stool samples for investigation does not nullify puasa. Diagnostic enemas and barium meal examinations nullify puasa. Esophagoscopes, gastroscopes, and sigmoidoscopes that have lubricants or other substances that will remain in the jawf nullify puasa. Digital rectal examination involves inserting substances into the jawf and may nullify puasa. Vaginal examination may nullify puasa but the reasoning involved is more complicated. Examination of the external auditory canal, endoscopy and catheterization of the urethra and the urinary bladder should in normal circumstances not nullify puasa because they do not involve entry into the jawf.  Imaging that does not involve using contrast media in the jawf does not nullify puasa. IVP uses contract media injected in the blood stream and not the jawf.

5.4 Medical treatments

The general rule is that any substance that enters the body through any of its openings, manfadh, nullifies fasting. The openings are the two ends of the alimentary canal, the mouth and the anus.

Drugs of whatever form taken orally, per anus, nullify fasting. The medication schedule can be modified such that drugs are taken only during the night hours. Sub-lingual medication absorbed from the oral cavity with none entering the esophagus may not nullify puasa. All drugs that are applied externally on the skin do not nullify fating. Use of eye drops does not nullify fasting. Nose drops may nullify fasting because they could drop into the pharynx and be swallowed. Inhalants may nullify puasa if they have droplets of water that can enter the jawf.

Injections (sub-cutaneous, intra-muscular, and intra-venous) do not nullify puasa because they do not involve putting substances into the jawf. However nourishing and rehydrating injections nullify the purpose of puasa.

Hormonal preparations should not be used to delay menstruation in order to avoid interrupting puasa of Ramadhan.