Dear Editor,
I read Dr. Panju’s article1 with great interest and thank her for this insightful work.

Although agreeing with the general sentiments expressed in the article I think this discussion should extend beyond patient behaviours and address an important ethical issue and that is whether doctors working in the NHS should fast whilst caring for patients? As a surgical middle grade and a practising Muslim I have found it extremely difficult to provide patients with optimum surgical care whilst fasting for up to twelve hours a day. This has been particularly challenging whilst operating where a high degree of focus and concentration is required. Fasting during the month of Ramadan is a core pillar of Islam and is thus an obligatory act for all healthy adult Muslims. Unfortunately, as highlighted by Dr. Panju’s article, patients all too often negate the latter part of this rule and continue to fast despite the risk to life. People who continue to fast in this manner are not only excused from doing so (known as ma’dhūr, (excused) in Arabic) but are actually committing a sin by fasting as mentioned in the Quran (the Holy book of Islam) ‘..and do not fall into destruction’2 and ‘do no harm yourselves’3. If however there is potential to harm others by fasting then surely this should be avoided also?

It is my opinion that doctors working in specialties that require a high degree of focus such as Surgery, Ophthalmology and Anaesthetics should avoid fasting. Considering this from the patient’s perspective, does a patient have the right to know whether their operating surgeon has been fasting for the last eight hours? This point can extend to other professions and vocations where people’s lives are potentially at risk from fasting. I know how I would be feeling on a flight if I knew the pilot had been fasting for the last twelve hours.

The Fiqh council of Birmingham (an Islamic committee made up of clerics that addresses modern religious issues) suggested to me that if a doctor feels that he/she is compromising patient care then they are excused from fasting on the day they are working and the fast should be made up later when they are not. However this should be assessed on an individual basis as some doctors may feel they can perform their duties optimally. A doctor may choose to take annual leave during Ramadan and avoid this issue completely.

There are of course other religions that perform ritual fasts, however Islamic fasting involves no food and drink during sunlight hours that can be particularly challenging during summer months and requires particular attention. I am aware that many Muslim doctors working in the NHS fast and claim not to be affected by doing so. There are numerous studies that have explored the effects of fasting on physiological and biochemical parameters in healthy adults, all with conclusions that fasting is safe4-5. Investigators from Denmark addressed this issue in a small cohort of surgeons and found that surgical skills were not negatively affected by fasting.6 However Dolu et al investigated the effects of Ramadan fasting on arousal and continuous attention using more objective parameters. They concluded that intermittent fasting did not affect arousal, but reaction times to an auditory stimulus increased and continuous attention also decreased in the fasting condition.7

Given the potential risks and harm to patient-care, I would suggest that the effects of fasting on doctor performance requires further study. Until strong evidence is available to support fasting doctors should avoid this whilst caring for patients.

References

1. Panju Z, Patients who fast in Ramadan need better advice. BMJ 2012; 345:e4754
2. The Holy Qur’an, Sūrah al-Baqarah, 2:195.
3. The Holy Qur’an, Sūrah, al-Nisā’, 4:29.
4. Azizi F. Islamic fasting and Health. Ann Nutr Metab. 2010;56(4):273-82.
5. Alkandari JR et al. The implications of Ramadan fasting for human health and well-being. J Sports Sci 2012 Suppl 1:s9-s19
6. Gӧgenur I, Jacobsen HL, Achiam M. The Effects of fasting on the surgical skills of surgeons. Ugeskr Laeger 2008. 170(51): 4236-7.
7. Dolu N et al. Arousal and continuous attention during Ramadan intermittent fasting. J Basic Clin Physiol Pharmacol 2007, 18(4): 315-22.

Competing interests: None declared