This guide is for both Muslim and non Muslim physicians to enable them to deal with the patients who are fasting.

During the holy month of Ramadan billions of Muslim across the globe fast from dawn to dusk for a full lunar month. They day begins at the later third of the night when they wake up to prepare for meal (Sahoor) and eat till the early hours of dawn. Fasting hours start before the call for morning prayers. During the hours of fasting they abstain from eating, drinking and smoking, a real ‘Nil by Mouth’. Fast is completed at dusk as soon as the sun sets. This meal is called “Iftaar”. Most Muslims would open the fast with dates and water, than culture tales over and various dishes are prepared to satisfy the eyes and the stomach. This usually follows by long night of prayers and some sleep. The whole cycle goes on for 29 to 30 days.

Physicians all over the world usually face a challenge when dealing with Muslim patients while they are fasting as they are often not trained into dealing with such cases. To make the matters worse, often the patients who are fasting are themselves not fully aware of the religious rulings around fasting and sickness. The guide below is an effort to address some of those dilemma’s. These guidelines are based on the guidance issued by Saudi Ministry of Health.

Before we look in to the rulings related to each treatment modality, it is important to know the Quranic verses that talk about fasting. Allah says in Quran;

“O those who believe, fasting is prescribed upon you, as it was prescribed to those before you, that you may become righteous” 2/183

“(fasting) a certain number of days, so whoever among you is sick or on a journey then an equal number of other days (should be made up). And for those who can afford it there is a ransom, the feeding of a needy person. Then whoever does good of his own accord, so it is better for him. And that you fast, it is better for you only if you knew.” 2/184

“ The month of Ramadan is that in which the Quran was revealed, a guidance for mankind, and clear proofs of guidance, and the criterion. So whoever of you witness this month, then he must fast in it. And whoever is sick or on a journey, then an equal number of other days (should be made up). Allah intends for you ease, and he does not intend hardship for you, and (He wants) that you should complete the count, and you glorify Allah for having guided you, and that you may be grateful (to Him).” 2/185

Hence it is clear from this verse and the verse before that the people who are sick are excused from fasting. If the sickness is temporary than they can make up the numbers once they are better or if it is long term than they have to give charity and feed particular number of poor. However the issue happens when the believer is not that sick not to fast but has to take certain medications for treatment. If the medicine cannot be given a twice daily dosage i.e to be taken at dawn & dusk than the following rules will apply.

Asthma Inhalers: ALLOWED (Inhalers are inhaled to the lungs, intention is not for the stomach, hence the fast is not broken. However smoking breaks the fast as it is an addiction and it also goes to the stomach)
Oxygen: ALLOWED (Goes in to the lungs and we normally breathe air which has oxygen)
Sublingual tablet: ALLOWED/NOT ALLOWED (They dissolve in to the blood stream rather than going to the stomach. However if swallowed, it breaks the fast)
Eye drops: ALLOWED (Eye drops are small dosages which often get absorbed in the eye and do not reach to the stomach. The are also not nutritious)
Nasal Drops NOT ALLOWED (Nose has a direct passage to the stomach and their is a Hadith (sniffing water up deeply except when you are fasting).
Ear drops & irrigation: ALLOWED (If the ear drum is not perforated. Ear irrigation should not be done when ear drum is perforated but in case it is done than the fast may break as middle ear is connected to the throat)
Insulin Injection (Diabetes): ALLOWED (They are not nutrients and cannot be considered as food or drink)
Blood sample for analysis: ALLOWED (It is small amount and does not weaken the body)
Blood donation: NOT ALLOWED (Weakens the body. Its analogy is with cupping which is not allowed)
Renal Dialysis (both types): NOT ALLOWED (It includes nutrients from which body can benefit, hence considered as food and drink. Its is permissible for such patients not to fast)
Anal Suppositories: ALLOWED/NOT ALLOWED (Allowed if it does not have nutrients/ Not allowed if it has nutrients like salt, sugar or other electrolytes that can help body)
Insertions in Urogenital system: ALLOWED (No anatomical relation between these ares and digestive system. They are also not considered as food or drink)
Oesophageal speculum/endoscopy: ALLOWED/NOT ALLOWED (A speculum which is not covered by oily material or solutions is allowed. However speculum which is covered or any instrument which uses water to wash the lens is not allowed. Endoscopy is Not allowed as it uses water, which goes in to the digestive tract)
Local Anaesthesia: ALLOWED (It is not a nutrient, does not go into the digestive tract and does not cause loss of consciousness)
General anaesthesia ALLOWED/NOT ALLOWED (If a person is unconscious for the whole day than majority of the scholars are of the opinion that it breaks the fast. However it doesn't break the fast if person regains the consciousness for the part of the day as intention of fasting was secured with part of day time. One should also consider the risk of ingesting liquids during the anaesthesia, which would break the fast. Better for such patients not to fast)
Injections: ALLOWED/NOT ALLOWED (Fast is not broken with Diagnostic injections like contrast and therapeutic injections which are not nutritious like antibiotics. These can be given iv or IM. However if the injections have nutrients like glucose or electrolytes than fast is broken whether given IM or IV)

Physicians, whether Muslims or non Muslims, have the right to inform patients not to fast or break their fast if it is causing harm to their body or an obstruction to an essential treatment.

I hope the above guidelines would give the reader some direction when you face the dilemma of treat or not to treat a fasting patient.

References;

The provisions of the medical breaking the fast, MOH & King Fahad hospital Saudi Arabia (Adel Al-Naheit)
International Islamic Fiqh Academy, affiliated to the Islamic Conference.
Contemporary actions that nullify fasting by Sheikh Dr Khaled Bin Ali Al-Moshaiqeh
Fatwa in fasting patients, department of religious enlightenment at MOH.
translation of verses from Tafheem Ul Quran.