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Q: I am caring for a patient who is Muslim. Part of her treatment plan includes heparin injections. I know that some Muslims do not eat pork. Am I required to tell the patient that the medication she is to receive is derived from pork?"

Response

Medications Derived from Animals and Culturally Diverse Patients

Why is it important to consider the origins of medications in health care?

The origins of medications may be an extremely emotional point for people in some ethno cultural and religious communities. Some medications are derived from various plants and animals that may not be culturally acceptable to different ethnic groups/religions. The difference in nutritional preferences of diverse cultures requires that information be provided on the origins of medications to ensure that each patient receives medication that is not in conflict with their personal, cultural and religious beliefs. Informing patients about the origins of their proposed medication is the first step in showing respect for their traditions and beliefs that will help them to make informed decisions.

Do different faiths have different requirements for medication?

Dietary requirements of different faiths need to be considered when prescribing and administering animal-derived medicines.

Some examples are:

Judaism and Islam strictly forbid consuming pork.
In Buddhism, Hinduism and Sikhism where vegetarianism is seen as a sign of spirituality, neither beef nor pork is allowed.
Christians in Afro-Caribbean communities, often choose not to eat pork, despite the fact that there is no explicit dietary restriction on pork consumption.
Other patients, particularly those who follow vegan or vegetarian diets, may object to the use of animals to meet the needs of humans.

Why do I need to talk to patients about medications derived from animals?

Extending choice is not just about responding to the needs and preferences of an increasingly diverse population. It is increasingly recognized that involving patients as full partners in decisions related to their treatment actually leads to better health outcomes.

According to the World Medical Association, the patient has a right to appropriate information in order to make decisions (WMA 1995, section 3), on such issues as:

Reasons why a particular drug has been prescribed;
Methods of administering it
Expected therapeutic actions
Potential side effects
Origins of the drug

A report of the Institute of Medicine, “Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare,” illustrates that cultural and psychosocial factors may affect a patient’s adherence to the drug regimen and influence drug. In addition, patient’s beliefs regarding the properties and effects of medications are of central importance in determining compliance. Therefore, informed choice in prescribing medications can provide a better overall utilization of health care resources and improve health outcomes.

How can you establish if a drug is of animal origin?

Contact the manufacturer and ask their medicines information department for specific detail of drug origin.
The names porcine or bovine are give aways! Porcine indicates pork was used in medication and bovine indicates beef was used in the medication.
Look for a summary of the product characteristics. This may indicate if the drug is of animal origin – however, this is not always explicit.
Read the patient information leaflet. This information may detail the medication components.
Check with a pharmacist.

What are some of the most commonly used animal derived medications?

Insulin is injectable hormone that lowers blood glucose levels and promotes transport and entry of glucose into muscle cells and other tissues. Examples are bovine and porcine insulin derived from cow and pigs respectively.

Heparin is an injectable hormone that is derived from pigs. Used commercially as a coagulant since the late 1930s, heparins are prepared by chemical extraction from the tissue of animals (i.e. pig intestine).

When is the best time to talk to patients about medication derived from animals?

There is no best time to raise the matter of animal-derived medication, but it is important to do so before the prescription is written and as far in advance as possible of the time at which it will be administered, so that the alternative pharmaceutical options can be made available to the patient.

If you are a prescriber, the most appropriate time to raise the matter is during your normal questioning and examination of the patient. Examples of some questions you may want to ask include:

“Are there any medicines that you prefer not to take or do not wish to take?”

“Are you aware that some of the medicines I might prescribe for you come from animals?”

If you are responsible for administering medication, the most appropriate time to raise the matter is during your initial assessment of the patient. Normal questioning about the patient’s daily life will include that person’s religion, current medication and preferences about food that can be extended. For example:

“As a Jew/Muslim, are you aware that some medicines come from pigs?”

“Do you have any preferences about whether or not your medicines come from animals?”

What can I do if the patient does not wish to receive medications derived from animals?

There are several actions that you can take, but first always ensure that you have entered the responses to your questions in the patient’s record. This will inform other practitioners that the individual concerned does not wish to receive medication derived from animals. Additional practices such as the use of coloured stickers on the records, or at the patient’s bedside, may help to alert other staff to the patient’s wishes and reassure individuals that their preferences have been noted.

What alternatives exist for medication derived from animals?

The evolution from biological drug therapies to predominantly synthetic products used today provides clinical alternatives for those with religious or cultural issues with drugs of animal origin:

Today both fractioned and unfractioned low-molecular weight heparins remain a widely prescribed therapy. Where alternatives exist, the patient could be offered the choice of synthetic product or product not derived from cow and pigs, to meet their religious or other personal preference. More information on drugs of pork origin is available in the “Drugs of Porcine Origin booklet” at: http://www.medicines-partnership.org/our-publications/drugs-of-porcine-origin

The Canadian Diabetes Association has identified alternative insulins for use in Canada. For information on insulins identified by the Canadian Diabetes Association, please consult this link: http://www.diabetes.ca/Section_About/insulin.asp#things

What if there is no suitable synthetic alternative?

Your professional judgment may lead you to the view that the synthetic alternative is not suitable for the patient. In these circumstances it is important for you as a prescriber, to explain the situation as fully as possible to the patient and encourage that individual to ask questions. If the medication is absolutely necessary, then Islam, Judaism and other religions permit its use. For more information please refer to: http://www.diversityinhealth.com/issues/religion/islam.htm

What else can I do to prevent harm to the environment and human health?

A “principle of precautionary action”, developed in 1990s now guides human activities to support professional decision-making in an attempt to prevent harm to the environment and human health. For short it states: “When an activity raises threats of harm to human health or the environment, precautionary measures should be taken even if some cause and effect relationships are not fully established scientifically”.

Are there any studies on the influence of patients’ faith and use of animal derived medication?

In 2004 the Medicines partnership team of the UK published an article on a study on “Concordance in Muslim patients in primary care”.

This study of 50 Muslim patients and 18 general practitioners found that only 26% of patients would take a medicine if they were unsure as to whether it was forbidden (halal).

42% of patients stated that they would not take any medicines that they were not sure were halal, with 58% stating that they would stop taking a medicine if they found out it was forbidden (haraam) .

The severity of the illness is an important consideration in taking medicines that are forbidden.

In the study 8% of patients and 22% of general practitioners believed that it was acceptable for Muslims to take a forbidden medication for a minor illness or disease.

For treatment of major illness or disease, however, 36% of patients and 44% of general practitioners believed that it was acceptable to take a haraam medicine.

Only 50% of patients believed that their doctor was aware of their religious needs in respect of medicine taking.

More information on this study is found on the link below. http://wwwbmj.bmjjournals.com/cgi/content/full/331/7524/1034

In an emergency, how does a health care professional address informed choice?

In the province of Alberta, the Personal Directives Act gives room for a health care practitioner to provide emergency medical services, without consent, to a person but with some conditions, section 24(1) and (2). However, it is advisable to contact an expert for proper legal interpretations.

This Q&A is intended to provide healthcare professionals with an introduction to the religious and cultural issues associated with drugs of animal origin and the need for informed choice in a multicultural society. It is by no means exhaustive and the reader who needs to learn more may consult these topics below for detailed information.

Hindu Beliefs and Practices affecting Health Care http://www.healthsystem.virginia.edu/internet/chaplaincy/hindu.cfm

Jewish Beliefs and Practices Affecting Health Care
http://www.healthsystem.virginia.edu/internet/chaplaincy/jewish.cfm

Religion and healthcare – Islam
http://www.medhunters.com/articles/religionAndHealthcareIslam.html

Religion and healthcare – Sikh
http://www.medhunters.com/articles/religionAndHealthcareSikhism.html

The Personal Directives Act of the Government of Alberta
http://www.qp.gov.ab.ca/Documents/acts/P06.CFM




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Diversity and Alberta Health Services Home Diversity Competency Resources Publications Demographics Programs & Services Health Info. for Diverse Populations Community Partners Contact Us	Diversity and Alberta Health Services Diversity Education and Resources Diversity FAQ'S On-line Diversity Competency Self-Assessments \| Diversity FAQ's \| Diversity Library \| Diversity Definitions \| Health and Diverse Populations \| Research & Publications Q: I am caring for a patient who is Muslim. Part of her treatment plan includes heparin injections. I know that some Muslims do not eat pork. Am I required to tell the patient that the medication she is to receive is derived from pork?" Response Medications Derived from Animals and Culturally Diverse Patients Why is it important to consider the origins of medications in health care? The origins of medications may be an extremely emotional point for people in some ethno cultural and religious communities. Some medications are derived from various plants and animals that may not be culturally acceptable to different ethnic groups/religions. The difference in nutritional preferences of diverse cultures requires that information be provided on the origins of medications to ensure that each patient receives medication that is not in conflict with their personal, cultural and religious beliefs. Informing patients about the origins of their proposed medication is the first step in showing respect for their traditions and beliefs that will help them to make informed decisions. Do different faiths have different requirements for medication? Dietary requirements of different faiths need to be considered when prescribing and administering animal-derived medicines. Some examples are: Judaism and Islam strictly forbid consuming pork. In Buddhism, Hinduism and Sikhism where vegetarianism is seen as a sign of spirituality, neither beef nor pork is allowed. Christians in Afro-Caribbean communities, often choose not to eat pork, despite the fact that there is no explicit dietary restriction on pork consumption. Other patients, particularly those who follow vegan or vegetarian diets, may object to the use of animals to meet the needs of humans. Why do I need to talk to patients about medications derived from animals? Extending choice is not just about responding to the needs and preferences of an increasingly diverse population. It is increasingly recognized that involving patients as full partners in decisions related to their treatment actually leads to better health outcomes. According to the World Medical Association, the patient has a right to appropriate information in order to make decisions (WMA 1995, section 3), on such issues as: Reasons why a particular drug has been prescribed; Methods of administering it Expected therapeutic actions Potential side effects Origins of the drug A report of the Institute of Medicine, “Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare,” illustrates that cultural and psychosocial factors may affect a patient’s adherence to the drug regimen and influence drug. In addition, patient’s beliefs regarding the properties and effects of medications are of central importance in determining compliance. Therefore, informed choice in prescribing medications can provide a better overall utilization of health care resources and improve health outcomes. How can you establish if a drug is of animal origin? Contact the manufacturer and ask their medicines information department for specific detail of drug origin. The names porcine or bovine are give aways! Porcine indicates pork was used in medication and bovine indicates beef was used in the medication. Look for a summary of the product characteristics. This may indicate if the drug is of animal origin – however, this is not always explicit. Read the patient information leaflet. This information may detail the medication components. Check with a pharmacist. What are some of the most commonly used animal derived medications? Insulin is injectable hormone that lowers blood glucose levels and promotes transport and entry of glucose into muscle cells and other tissues. Examples are bovine and porcine insulin derived from cow and pigs respectively. Heparin is an injectable hormone that is derived from pigs. Used commercially as a coagulant since the late 1930s, heparins are prepared by chemical extraction from the tissue of animals (i.e. pig intestine). When is the best time to talk to patients about medication derived from animals? There is no best time to raise the matter of animal-derived medication, but it is important to do so before the prescription is written and as far in advance as possible of the time at which it will be administered, so that the alternative pharmaceutical options can be made available to the patient. If you are a prescriber, the most appropriate time to raise the matter is during your normal questioning and examination of the patient. Examples of some questions you may want to ask include: “Are there any medicines that you prefer not to take or do not wish to take?” “Are you aware that some of the medicines I might prescribe for you come from animals?” If you are responsible for administering medication, the most appropriate time to raise the matter is during your initial assessment of the patient. Normal questioning about the patient’s daily life will include that person’s religion, current medication and preferences about food that can be extended. For example: “As a Jew/Muslim, are you aware that some medicines come from pigs?” “Do you have any preferences about whether or not your medicines come from animals?” What can I do if the patient does not wish to receive medications derived from animals? There are several actions that you can take, but first always ensure that you have entered the responses to your questions in the patient’s record. This will inform other practitioners that the individual concerned does not wish to receive medication derived from animals. Additional practices such as the use of coloured stickers on the records, or at the patient’s bedside, may help to alert other staff to the patient’s wishes and reassure individuals that their preferences have been noted. What alternatives exist for medication derived from animals? The evolution from biological drug therapies to predominantly synthetic products used today provides clinical alternatives for those with religious or cultural issues with drugs of animal origin: Today both fractioned and unfractioned low-molecular weight heparins remain a widely prescribed therapy. Where alternatives exist, the patient could be offered the choice of synthetic product or product not derived from cow and pigs, to meet their religious or other personal preference. More information on drugs of pork origin is available in the “Drugs of Porcine Origin booklet” at: http://www.medicines-partnership.org/our-publications/drugs-of-porcine-origin The Canadian Diabetes Association has identified alternative insulins for use in Canada. For information on insulins identified by the Canadian Diabetes Association, please consult this link: http://www.diabetes.ca/Section_About/insulin.asp#things What if there is no suitable synthetic alternative? Your professional judgment may lead you to the view that the synthetic alternative is not suitable for the patient. In these circumstances it is important for you as a prescriber, to explain the situation as fully as possible to the patient and encourage that individual to ask questions. If the medication is absolutely necessary, then Islam, Judaism and other religions permit its use. For more information please refer to: http://www.diversityinhealth.com/issues/religion/islam.htm What else can I do to prevent harm to the environment and human health? A “principle of precautionary action”, developed in 1990s now guides human activities to support professional decision-making in an attempt to prevent harm to the environment and human health. For short it states: “When an activity raises threats of harm to human health or the environment, precautionary measures should be taken even if some cause and effect relationships are not fully established scientifically”. Are there any studies on the influence of patients’ faith and use of animal derived medication? In 2004 the Medicines partnership team of the UK published an article on a study on “Concordance in Muslim patients in primary care”. This study of 50 Muslim patients and 18 general practitioners found that only 26% of patients would take a medicine if they were unsure as to whether it was forbidden (halal). 42% of patients stated that they would not take any medicines that they were not sure were halal, with 58% stating that they would stop taking a medicine if they found out it was forbidden (haraam) . The severity of the illness is an important consideration in taking medicines that are forbidden. In the study 8% of patients and 22% of general practitioners believed that it was acceptable for Muslims to take a forbidden medication for a minor illness or disease. For treatment of major illness or disease, however, 36% of patients and 44% of general practitioners believed that it was acceptable to take a haraam medicine. Only 50% of patients believed that their doctor was aware of their religious needs in respect of medicine taking. More information on this study is found on the link below. http://wwwbmj.bmjjournals.com/cgi/content/full/331/7524/1034 In an emergency, how does a health care professional address informed choice? In the province of Alberta, the Personal Directives Act gives room for a health care practitioner to provide emergency medical services, without consent, to a person but with some conditions, section 24(1) and (2). However, it is advisable to contact an expert for proper legal interpretations. This Q&A is intended to provide healthcare professionals with an introduction to the religious and cultural issues associated with drugs of animal origin and the need for informed choice in a multicultural society. It is by no means exhaustive and the reader who needs to learn more may consult these topics below for detailed information. Hindu Beliefs and Practices affecting Health Care http://www.healthsystem.virginia.edu/internet/chaplaincy/hindu.cfm Jewish Beliefs and Practices Affecting Health Care http://www.healthsystem.virginia.edu/internet/chaplaincy/jewish.cfm Religion and healthcare – Islam http://www.medhunters.com/articles/religionAndHealthcareIslam.html Religion and healthcare – Sikh http://www.medhunters.com/articles/religionAndHealthcareSikhism.html The Personal Directives Act of the Government of Alberta http://www.qp.gov.ab.ca/Documents/acts/P06.CFM
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