Implementation of Informed Consent in Complementary & Alternative Medicine (Cam) in Homeopathy Services by Ahmadiyya Congregation Practices in Yogyakarta and Jakarta

Overview of Research

The Ahmadiyya Muslim Congregation is an Islamic revival movement, international in scale, dynamic and rapidly growing. Founded in 1889, today the Ahmadiyya has spread to 210 countries with followers in the tens of millions. The Ahmadiyya Muslim Community is the only Islamic organization that believes that the long-awaited Messiah has arrived in the form of Mirza Ghulam Ahmad as (1835-1908). This research was conducted in two provinces where the Ahmadiyya Congregation is located in Yogyakarta, precisely in Pucanganom Village, Rongkop, and Asih Sasama Clinic, Saptosari, Gunung Kidul Regency, while in Jakarta, namely the National Homeopathy Department, precisely on Jalan Balikpapan I/10 Central Jakarta. The study participants were 20 people consisting of 10 Yogyakarta’s participants (1 doctor, 1 midwife and 2 preachers from the Ahmadiyya; 3 patients from the Ahmadiyya and 3 patients from non- Ahmadiyya); and 10 participants in Jakarta with descriptions of homeopathic practitioners who have medical and non- medical backgrounds; director and secretary of the National Department of Homeopathy. Researchers conducted in- depth interviews for 45-90 minutes face to face interview for the DIY area and online interviews for the DKI Jakarta area which were recorded as primary data (Table 1).

In homeopathic medicine, the patient has a history of disease that is categorized from acute to chronic disease chronic. Chronic disease is a disease with permanent characteristics, causing disability in the sufferer, and to cure it the patient needs to take care for a long period of time. Generally, homeopathy treat mild diseases (common illness), mild moderate and acute. Some patients who are familiar with homeopathy become the primary treatment for patients of the Ahmadiyya congregation and have never complained about the side effects of homeopathy.

“Alhamdulillah, yes, I rarely get sick, maybe it’s just the flu, I cough, then I happened to sprain my leg, I asked for homeopathic medicine. Immediately tried homeopathic remedies and it immediately felt less pain.” (P15, female, 45 years old, Ahmadiyya patient, self- employed). Meanwhile, non-Ahmadiyya patients generally already suffer from chronic diseases. Patients know homeopathic remedies from local residents. According to them, homeopathy is more effective in treating the disease than conventional medical drugs. The patient also does not feel any side effects from homeopathic remedies. The patient’s decision in choosing homeopathic treatment is because they are not satisfied with conventional medical treatment, the distance is long and the cost is expensive.

“There is a narrowing of the kidney channel and swelling of the kidney stone, and the muscles are all sore. “Because I’ve been to smart people like shamans like that, it’s not reduced, but the complaints are still the same muscle pain. Then there are neighbors who say, have been there to Mr. Mubalig’s place, he said there is treatment like therapy like that. Yes, I took the initiative to go there, it turns out that there are changes too, but little by little, just keep going.” (P18, male, 38 years old, non-Ahmadiyya patient, and self- employed).

Perspective of Informed Consent according to Practitioners, Patients and management of the Department National Homeopathy (DHN)

In this study, it was found that there were still many who did not understand the term “informed consent”. Medical personnel define informed consent as the delivery of information about medical care or services accompanied by written or oral consent. Doctors in the Ahmadiyya can become homeopathic practitioners because apart from socialization and homeopathy counseling from the caliph, doctors are also interested in learning homeopathy as first aid for minor ailments to treat their families. The implementation of informed consent in homeopathic services according to the doctors must be in accordance with the procedure even though it is given to the closest person.

“Indeed, people in the village are afraid to sign. But I said that the signature doesn’t mean this is weird, I explain this as a doctor; I provide therapy to be clear, and where, how, and for what. Don’t just give. I also have basic of his, and then I show my certificate college and everything, eventually the patient understands. So the signature of the mother (patient) is my responsibility, if later the mother (patient) is asked outside, someone asks, what medicine is it, from whom, as if I forced the mother, I never did.” (P13, male, 34 years old, doctor) Meanwhile, non-medical personnel (non-doctors) and patients interpret informed consent as a blank sheet that must be signed. However, the implementation of informed consent in homeopathic services in the Ahmadiyya congregation has been carried out properly, properly and completely informed. For preachers who have taken special education for preachers, there is homeopathic material for one semester which is intended to prepare for community service. Then, practitioners also take part in a 100-hour training provided by the National Homeopathy Department and/or self-study in Singapore or the UK to earn an academic degree in homeopathy.

“If you study it, you could say it’s like education or the term is homeopathic classes that I actively participated in when I was educated at the final level of Jami’ah, where the preachers were equipped with knowledge of this homeopathic system of medicine that was around 2007, I was there for 6 months studying homeopathy officially. As long as I haven’t received the education, I still help the preacher, analyze patients, give prescriptions, help prepare medicine, that’s the first time I’ve studied homeopathy, officially starting in 2007.” (P11, male, 39 years old, preacher) Perspective of the patient the Ahmadiyya chose homeopathy as their primary treatment because since childhood they have known and been familiar with the socialization of homeopathy.

“Usually this is the medicine, for this, but I don’t know, the language is difficult. So I don’t know, when it’s explained, yes it is.” (P15, female, 45 years old, Ahmadiyah patient, self- employed). Meanwhile, non-Ahmadiyya patients choose homeopathic treatment because they have the hope of healing, without side effects and free of charge. The implementation of informed consent homeopathic in the Ahmadiyya congregation generally uses informed consent oral.

“Yes, Mr. Mubalig is here, visit here. I can’t walk, Mr. Mubalig who visited here, then asked Mrs. how did it change? It’s fine, sir, but I asked for (homeopathic medicine) before drinking, I was told to fast first, one hour, after drinking I also fast for one hour”. (P19, female, 55 years old, non-Ahmadiyya patient, farmer).

Homeopathic Services in General by Practitioners of the Ahmadiyya

Homeopathic services are health services that are jointly organized within the organization of the Ahmadiyya congregation with the main objective of serving humanity (humanity first) and aid for common illnesses. In homeopathy there are no special procedures such as conventional medical treatment such as patient registration and medical procedures or interventions, especially invasive procedures. The flow in homeopathic medicine is that the patient comes to the dispensary (medicine house) homeopathy, either at the branch or at the center. The patient comes with his will and consciousness to ask for homeopathic remedies.

Firstly, practitioners ask the symptoms and complaints patient’s holistically so that usually the anamnesis takes the longest time. Furthermore, practitioners with medical backgrounds will provide a diagnosis or patient’s illness, while non-medical practitioners will usually only ask about the patient’s symptoms and complaints without diagnosing the disease then the practitioner will make and mix homeopathic medicines according to the symptoms or complaints.

Practitioners present alternative courses of action if homeopathic remedies cannot help treat the patient. Generally, medical practitioners will refer to doctor specialist, while non- medical practitioners will advise patients to go to the hospital. In conveying the patient’s prognosis, the practitioner usually knows that the patient’s prognosis will be good or not, and this homeopathic remedy can help the patient, but if the disease is chronic, the patient will be advised to conventional medical treatment. Financing in homeopathic medicine is generally free. However, practitioners who have independent homeopathic clinics have set certain rates for drugs and consultations.

Implementation of the method and content of informed consent in homeopathic services: Practitioner’s Perspective

This study found that the application of the method and content of informed consent for medical and non-medical personnel is the same as Indonesia Minister of Health Regulation No. 290/2008 regarding how a practitioner, especially medical personnel, applies the method and content of informed consent. Homeopathic treatment services in the Ahmadiyya are basically health activities whose purpose is to provide first aid, assist healing and improve the quality of life of members of the Ahmadiyya so that informed consent is used orally, while for non-Ahmadiyya, informed consent written is required provided by the National Homeopathy Department. “...I was wondering if there were any complaints, how long has it been, because I’m basically a doctor, so I asked what the symptoms were, then it seems like it can be done with homeopathy or not, if not I say it’s homeopathy just to help, but I think you have to go to the doctor, go to the hospital, because the consultation is so tough.” (P03, female, 46 years old, doctor).

The flow of homeopathic treatment services by medical and non-medical practitioners is almost the same; there are only differences in the diagnosis and patient prognosis. For practitioners of medical personnel and non-medical personnel, both will ask each patient’s symptoms and complaints and then for medical personnel practitioners will explain and disclose the patient’s disease or diagnosis. Furthermore, the practitioner explained that if later there was aggravation, which is a reaction that occurs due to consuming homeopathy with certain potency (dose), the patient can return to the consultation again.

Homeopathic medicines are presented in the form of globules (lactose sugar) which are dripped with solution mother tincture (extraction from plants, animals or minerals) and types of external ointments, and there is no invasive action. In conveying the patient’s prognosis, the medical practitioner will usually know whether the patient’s illness is acute or not. If the disease is acute, then the prognosis will be good after using homeopathy but if the disease is chronic, then the practitioner will suggest seeking conventional medical treatment. However, for non-medical practitioners, if they find a patient with a chronic illness, they will advise the patient for treatment at the hospital.

“...if the disease is acute and the prognosis is good, we will just tell you. Homeopathic medicine can help, but if within a certain period of time it doesn’t, then you have to find another way or it gets worse than homeopathy can’t help anymore.” (P03, female, 46 years old, doctor).

Funding for homeopathic remedies is generally free, but for Ahmadiyya congregation patients there is a sacrificial fee called ‘candah’, which is a membership fee ranging from 1/16 to 1/10.

“Well, this is it. This may be a bit different from my other colleagues. Because in me, this is a practice, yes, and there is a permit, there is legality... Now for financing, there is indeed some kind of service from the service, we have to determine the minimum and maximum. For treatment at my clinic, the minimum medicine is IDR 25,000, the maximum is around IDR 30,000 to IDR 50,000 for the public, yes, but there is also for members, but it doesn’t matter as long as it doesn’t cost anything.” (P05, male, 43 years old, Independent Homeopathic Clinic) Practitioners who have independent homeopathic clinic usually have set a certain standard of fees for medicines and homeopathic treatment consultations. Homeopathic independent clinics also adjust to patients who come, practitioners will first see the patient’s needs and patient background such as age and occupation so that it is not evenly distributed all patients have to pay, especially consulting services. The practitioner will not provide a consultation fee so the patient only pays for the homeopathic medicine. In other words, the practitioner will see a patient feel comfortable, happy not add to the patient’s burden.

Implementation of the Method and Content of Informed Consent in Homeopathic Services: Patient Perception

The results of this study found that patients of the Ahmadiyya have known homeopathy since childhood, while non-Ahmadiyya patients generally know homeopathic treatment by word of mouth. The important elements in this study were found that patients or guardians who came to homeopathic services must be competent, willing, providing information, making decisions on plans, and authorizing.

The first element is competent, for example, Ahmadiyya patients who have known homeopathy since childhood and ask for medicine. to practitioners or preachers.

“Once, when you weren’t feeling well and couldn’t leave the house, you just asked my mother to contact the preacher. I said the characteristics are the same as the mother and the preacher who came to my house.” (P17, male, 18 years old, Ahmadiyya patient, student) In another study, a non-Ahmadiyya patient experienced narrowing of the kidney tract and swelling of kidney stones accompanied by pain in all muscles. The patient has had multiple surgeries and outpatient treatment at the hospital, but his illness has not yet recovered. The patient finds it difficult to walk with a weak physical condition and is accompanied by his wife so that the one who can give consent is his wife by still asking the patient.

“Yes, Mr. Mubalig explained everything. The medicine is this, for this it is explained. For example, if you have a history of illness, you will be asked what it is, and then you will be given medication”. (P18, male, 38 years old, non-Ahmadiyya patient, and self- employed).

The second element is willingness, as a prerequisite for the approval of medical treatment to be valid. It is found in the study that if homeopathic remedies cannot help treat the patient, the practitioner will refer him to the hospital but if the patient still decides to choose homeopathic treatment, the practitioner can still treat the patient’s symptoms and complaints by giving informed consent written.

Implementation of the Method and Content of Informed Consent in Homeopathic Services: Management Perspective National Homeopathy Department (DHN)

The National Homeopathy Department was established in 1997, but since 1996 members of the Ahmadiyya have started to help, sorting out homeopathic medicines where every year the Ahmadiyya held an annual meeting and the caliph of the Ahmadiyya congregation who was in Indonesia provided homeopathic kits to be managed by the Ahmadiyya in Indonesia. The goal is that all members of the Indonesian Ahmadiyya congregation can feel the benefits of homeopathy as first aid and be given if they have complaints or symptoms before consulting a doctor or health facility. Furthermore, National Homeopathy Department (DHN) established a dispensary homeopathic (house of medicine) in branches throughout Indonesia which was held by PJH (the person in charge of homeopathy) and DHN’s duties were to distribute homeopathic medicines to all these branches, to provide education to preachers and members of the Ahmadiyya who could perform homeopathic services. In this study, DHN also explained the effectiveness of homeopathic remedies that actually homeopathy treats symptoms of common illnesses.

“...so far there have been no problems, yes, all patients who seek treatment, all people who need homeopathic medicines, if at the beginning the symptoms of complaints are given with drugs that match their complaints, they usually subside by themselves.” (P08, female, 48 years old, secretary of DHN) The symptoms that the patient complains about are those treated by homeopathy, but when the symptoms spread, DHN asks the practitioner to consult the DHN team first. DHN’s task is not only to distribute drugs to the branches of the Ahmadiyya congregation throughout Indonesia but also to have records on patient status consisting of name, age, gender, patient address, patient complaints, what homeopathic medicines were given and medical records. DHN also stated that the application of informed consent homeopathic in the field mostly uses verbal consent.

“If there are some who already understand homeopathy, there is no need to explain, but once there are those who do not understand, we will explain. Because for our safety we also go out (non-Ahmadiyya), but if we go inside (internal Ahmadiyya) it remains as our data record that if needed we already have informed consent.” (P08, female, 48 years old, secretary of DHN) In homeopathic medicine itself, there are no medical procedures such as surgery, invasive procedures, but only the administration of homeopathic medicines such as oral medicines and ointments. However, DHN requested that practitioners continue to explain homeopathy to patients, especially non-Ahmadiyya with several considerations such as benefits and side effects. If the patient and/or guardian have agreed, then they are then asked to sign that the patient receives this homeopathic remedy openly and will not be present in advance which can harm both parties.

The Importance of Informed consent and the Elements of Informed Consent in Homeopathic Services by Practitioners of the Ahmadiyya

First, the purpose of having informed consent in homeopathic treatment by the Ahmadiyya is to respect human dignity. Therefore, the Ahmadiyya makes homeopathic medicine a humanitarian mission, without compensation and to respect the dignity of human beings who are free and autonomous to have the right to choose what type of treatment services will be used or not used by patients. Second, informed consent aims to avoid fraud and coercion of the Ahmadiyya congregation in Indonesia which until now is still underestimated by some Indonesian people, therefore homeopathic treatment is needed, so an informed consent form is needed, especially for non-Ahmadiyya patients. Third, legalizing homeopathic treatment services even though there is an independent Indonesian Homeopathic Association whose members are both doctors and non-doctors and not on behalf of the Ahmadiyya. Therefore, the need for informed consent is not only given enough information so that patients understand, but can work together with doctors or homeopathic practitioners better for the patient’s healing process.

The results of the study found that the homeopathic practitioner of the Ahmadiyya had elements such as good qualities in revealing the disease or diagnosis of the patient, then after explaining the diagnosis of the disease. Then explain the purpose of the action by disclosing the correct and complete content of homeopathic information such as the procedure for taking the drug and the possible reactions it may cause. Non-medical practitioners also offer appropriate medical intervention or treatment plans and solutions if homeopathic remedies cannot help treat the patient’s illness. Therefore, the information provided must be good, correct and complete.