51 Islamic bioethics
An 18-year-old Muslim man sustains severe head injures in a traffic accident while riding his motorcycle. He is declared brain dead. The transplant coordinator approaches the grieving mother to obtain consent for organ donation. At first, the patient’s mother is shocked at this approach. She then politely says that she would like to wait for her family to arrive before making a decision.
A 38-year-old Muslim woman is found to have a rapidly growing carcinoma of the breast. She requires surgery and postoperative chemotherapy. She is five weeks into her first pregnancy and is advised to terminate the pregnancy before the chemotherapy.
What is Islamic bioethics?
In Islam, human beings are the crown of creation and are God’s vicegerents on earth. (Qur’an, 2:30) They are endowed with reason, choice, and responsibilities, including stewardship of other creatures, the environment, and their own health. Muslims are expected to be moderate and balanced in all matters (al Khayat, 1995) including health. Illness may be seen as a trial or even as a cleansing ordeal, but it is not viewed as a curse or punishment or an expression of Allah’s (God’s) wrath. Hence, the patient is obliged to seek treatment and to avoid being fatalistic.
Islamic bioethics is intimately linked to the broad ethical teachings of the Qur’an and the tradition of the Prophet Muhammad, and thus to the interpretation of Islamic law. Bioethical deliberation is inseparable from the religion itself, which emphasizes continuities between body and mind, the material and spiritual realms, and between ethics and jurisprudence (al Faruqi, 1982) The Qur’an and the traditions of the Prophet have laid down detailed and specific ethical guidelines regarding various medical issues. The Qur’an itself has a surprising amount of accurate detail regarding human embryological development, which informs discourse on the ethical and legal status of the embryo and fetus before birth (Bucaille, 1979; Albar, 1996).
Islamic bioethics emphasizes the importance of preventing illness, but when prevention fails, it provides guidance not only to the practicing physician but also to the patient (Ebrahim, 1989). It teaches that the patient must be treated with respect and compassion and that the physical, mental, and spiritual dimensions of the illness experience be taken into account. The Muslim physician understands the duty to strive to heal, acknowledging God as the ultimate healer.
The main principles of the Hippocratic oath are reflected in Islamic bioethics, although the invocation of multiple gods in the original version, and the exclusion of any god in later versions, have led Muslims to adopt the Oath of the Muslim Doctor, which invokes the name of Allah. It appears in the 2003 Islamic Code of Medical Ethics, which deals with issues such as organ transplantation and assisted reproduction. In Islam, life is sacred: every moment of life has great value, even if it is of poor quality. The saving of life is a duty, and the unwarranted taking of life a grave sin. The Qur’an affirms the reverence for human life in reference to a similar commandment given to other monotheistic peoples: “On that account We decreed for the Children of Israel that whosoever killeth a human being … it shall be as if he had killed all humankind, and whosoever saveth the life of one, it shall be as if he saved the life of all humankind” (Qur’an, 5:32). This passage legitimizes medical advances in saving human lives (Sachedina, 1995) and justifies the prohibition against both suicide and euthanasia.
The Oath of the Muslim Doctor includes an undertaking “to protect human life in all stages and under all circumstances, doing [one’s] utmost to rescue it from death, malady, pain and anxiety. To be, all the way, an instrument of God’s mercy, extending … medical care to near and far, virtuous and sinner and friend and enemy.”
Islamic bioethics is an extension of Shariah (Islamic law), which is itself based on two foundations: the Qur’an (the holy book of all Muslims, whose basic impulse is to release the greatest amount possible of the creative moral impulse [Rahman, 1979] and is itself “a healing and a mercy to those who believe” [Qur’an, 41:44]); and the Sunna (the aspects of Islamic law based on the Prophet Muhammad’s words or acts). Development of Shariah in the Sunni branch of Islam over the ages has also required ijmaa (consensus) and qiyas (analogy), resulting in four major Sunni schools of jurisprudence. Where appropriate, consideration is also given to maslaha (public interest) and urf (local customary precedent) (Kamali, 1991). The Shia branch of Islam has in some cases developed its own interpretations, methodology, and authority systems, but on the whole its bioethical rulings do not differ fundamentally from the Sunni positions. In the absence of an organized “church” and ordained “clergy” in Islam, the determination of valid religious practice, and hence the resolution of bioethical issues, is left to qualified scholars of religious law, who are called upon to provide rulings on whether a proposed action is forbidden, discouraged, neutral, recommended, or obligatory.
Islamic scholars have been writing about bioethical issues for a very long time. For example, the four bioethics principles of beneficience, non-malevolence, autonomy, and justice popularized by Beauchamp and Childress (2001) were discussed by Muslim scholars as early as the thirteenth century (Aksoy and Tenik, 2002; Aksoy and Elmai, 2002; Ajlouni, 2003).
To respond to new medical technology, Islamic jurists, informed by technical experts, have regular conferences at which emerging issues are explored and consensus is sought. Over the past few years, these conferences have dealt with such issues as organ transplantation, brain death, assisted conception, technology in the intensive care unit, and even futuristic issues such as testicular and ovarian grafts. The broader Islamic bioethics discourse has included work on human embryonic stem cell research (Serour and Dickens, 2001; Walters, 2004; Aksoy, 2005), organ transplantation (Daar, 2000; Goolam, 2002; Khalil, 2002; Shaheen et al., 2004; Todorova and Kolev, 2004; Golmakani et al., 2005), triage (Elcioglu and Unluoglu, 2004), informed consent (Moazam, 2001; Rashad et al., 2004), end of life decision making (Hedayat and Pirzadeh, 2001; Clarfield et al., 2003; Lundqvist et al., 2003; Rodríguez Del Pozo and Fins, 2005), abortion (Daar and al Khitamy, 2001; Moosa, 2002; Al-Kassimi, 2003; Mohammed, 2003; Asman, 2004; Wong et al., 2004; Schenker, 2005), assisted reproduction and genetic testing (El Dawla, 2000; Schenker, 2000, 2002, 2005; Fadel, 2001, 2002; Serour and Dickens, 2001; Albar, 2002; Arbach, 2002; Tsianakas and Liamputtong, 2002; Ahmed, 2003; Raz and Atar, 2003; Raz, et al., 2003; Sher et al., 2004), nursing (Rassool, 2000; Lundqvist et al., 2003; Ott et al., 2003; Rashad et al., 2004), and pharmacy (Chipman, 2002). Many medical schools in countries with Muslim majorities have bioethics curricula. There are established mechanisms for addressing emerging biomedical and bioethics issues, and curricula are updated accordingly.
The Islamic Organization for Medical Sciences, (www.islamset.com) also holds conferences and publishes the Bulletin of Islamic Medicine. Most Islamic communities, however, would defer to the opinion of their own recognized religious scholars.
Islam is not monolithic, and a diversity of views in bioethical matters does exist. This diversity derives from the various schools of jurisprudence, the different sects within Islam, differences in cultural background, and different levels of religious observance.
There is little that is strange or foreign in Islamic bioethics for Western physicians, who are often surprised at the similarities of approach to major bioethical issues in the three monotheistic religions, particularly between Islam and Judaism (Daar, 1994, 1997).
If secular Western bioethics can be described as rights based, with a strong emphasis on individual rights, Islamic bioethics is based on duties and obligations (e.g., to preserve life, seek treatment), although rights (Shad, 1981) (of God, the community, and the individual) do feature in bioethics, as does a call to virtue (Ihsan).
Why is Islamic bioethics important?
The number of Muslims worldwide is estimated to be over 1.2 billion and their numbers are projected to increase. Even in Western countries, the number of Muslims is increasing; for example in Canada the number of Muslims had reached 550 000 by 1999 (Hamdani, 1999).
Many Muslims incorporate their religion into almost every aspect of their lives. They invoke the name of God in daily conversation and live a closely examined life in relation to what is right or wrong behavior, drawing often from the Qur’an, the traditions of the Prophet, and subsequent determinations by Muslim jurists and scholars, believing that their actions are very much accountable (Qur’an, 52:21, 4:85) and subject to ultimate judgement.
Although individuals are given certain concessions on assuming the status of a patient, some try to live their lives in a Muslim way as patients, even when admitted to hospital. Greater understanding of Islamic bioethics would enhance the medical care of Muslims living in Western societies.
How should I approach Islamic bioethics in practice?
In the West, information about Islamic bioethics can be obtained most easily on the Internet (see related websites below). Another source is Muslim patients themselves. However, many Muslim patients may not be aware of contemporary discourse on bioethical issues. If the community has religious leaders or its own social workers, these can be useful sources. Hospitals should keep their contact numbers close at hand, especially in emergency departments.
There are varying degrees of observance of traditional Muslim beliefs and practices. Physicians need to be sensitive to this diversity and avoid a stereotyped approach to all Muslim patients.
At the practical level, physicians who are aware of Islamic bioethics will understand that the provision of simple measures can make big differences for their Muslim patients. In addition to understanding the religion and culture, there are a few practical considerations that may apply, particularly for the more devout Muslim (Table 5.1).
The cases
The first case raises the issue of organ transplantation. Organ transplantation is practiced in most countries with Muslim majorities. This generally involves kidney donations from living relatives, but cadaveric donation is increasing (Daar, 1997, 2000; Goolam, 2002; Khalil, 2002; Shaheen et al., 2004; Todorova and Kolev, 2004; Golmakani et al., 2005). Many Muslim scholars have permitted cadaveric organ donation (Albar, 1995a; Yaseen, 1995; Daar, 1997, 2000; Daar et al., 1997; Habgood et al., 1997; Goolam, 2002; Khalil, 2002; Shaheen et al., 2004; Todorova and Kolev, 2004; Golmakani et al., 2005). The Qur’anic affirmation of bodily resurrection has determined many religious and moral decisions regarding cadavers (Sachedina, 1995). Mutilation, and thus cremation, is strictly prohibited in Islam. However, carrying out autopsies, although currently uncommon in Muslim countries, is permitted under certain circumstances, for example when there is suspicion of foul play (Sachedina, 1995).
Death is considered to have occurred when the soul has left the body, but this exact moment cannot be known with certainty. Death is, therefore, diagnosed by its physical signs. The concept of brain death was accepted by a majority of scholars and jurists at the Third International Conference of Islamic Jurists in 1986 (Albar, 1995a; Moosa, 1999). Most, but not all, countries with Muslim majorities now accept brain death criteria. In Saudi Arabia, for example, about half of all kidneys for transplantation are derived from cadavers, with application of brain death criteria (Shaheen and Ramprasad, 1996).
The mother of the recently deceased boy in the intensive care unit was initially shocked because she did not expect an approach so soon after her son’s death. The coordinator, however, has been specifically trained and is very experienced and culturally sensitive. She allows the mother time to reflect and wait for her family to arrive. The mother’s faith has taught her that God decides when a life is to end, and although she is grieving she knows that nothing could have saved her son when the moment of death arrived. A friend of the family, a professor of Islamic studies at a local university, arrives and confirms that it is acceptable in Islam to donate organs under such circumstances. The family jointly agrees to the donation. The surgical team is made aware of the Muslim requirement to bury the body on the same day and arranges for the organs to be removed that afternoon.
The second case raises issues of the commencement of life. The general Islamic view is that, although there is some form of life after conception, full human life, with its attendant rights, begins only after the ensoulment of the fetus. On the basis of interpretations of passages in the Qur’an and of sayings of the Prophet, some Muslim scholars agree that ensoulment occurs at about 120 days after conception (Albar, 1995b, 1996), while other scholars hold that it occurs at about 40 days after conception (Albar, 1995b).
Islamic law scholars do have some differing opinions about abortion. Abortion has been allowed after implantation and before ensoulment in cases in which there were adequate juridical or medical reasons. Accepted reasons have included rape. However, many Shias and some Sunnis have generally not permitted abortion at any stage after implantation, even before ensoulment, unless the mother’s life is in danger. Abortion after ensoulment is strictly forbidden by all Islamic authorities, but the vast majority do make an exception to preserve the mother’s life. If a choice has to be made to save either the fetus or the mother, then the mother’s life would take precedence. She is seen as the root, the fetus as an offshoot.
In the case presented here, the chemotherapy is necessary for the mother’s health, although it might cause a miscarriage or severe developmental abnormalities in the fetus. The pregnancy itself may worsen her prognosis. These are medical indications for termination. Although not generally accepted, some modern Islamic opinions (Ghanem, 1984) and rulings (Muslim World League Conference of Jurists, 1990) have also accepted prenatal diagnosis and accept severe congenital anomalies and malformations per se as a reason for termination before ensoulment.
Two physicians certify that the chemotherapy and abortion are necessary, and the pregnancy is terminated with the consent of the patient and her husband. The couple says that they would dearly love to have a child in the future and inform the physician that Islam permits in vitro fertilization (Serour, 1992; Albar, 1995c; Fadel, 2001, 2002; Serour and Dickens, 2001; Al-Qasem, 2003). They ask if it is possible before chemotherapy to retrieve and freeze her ova, to be fertilized later. This would be permissible provided the sperm, with certainty, came from her husband, and that at the time of fertilization they are still married and the husband is alive. The option of surrogacy is broached by the physicians as an alternative. On checking with their local religious scholar, the couple is informed that, under Islamic law, the birth mother, not the ovum donor, would be the legal mother (Ebrahim, 1989; Al-Qasem, 2003). The couple decides not to pursue surrogacy.
REFERENCES
Related websites
An earlier version of this chapter has appeared: Daar, A. S. and Khitamy, A. (2001). Islamic bioethics. CMAJ 164: 60–3.