Islamic Bioethics
Islamic
bioethics derives from a combination of principles, duties and rights,
and, to a certain extent, a call to virtue. In Islam, bioethical
decision-making is carried out within a framework of values derived from
revelation and tradition. It 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. In this way, Islam has the
flexibility to respond to new biomedical technologies. Islamic bioethics
emphasizes prevention and 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. Because
Islam shares many foundational values with Judaism and Christianity, the
informed Canadian physician will find Islamic bioethics quite familiar.
Canadian Muslims come from varied backgrounds and have varying degrees
of religious observance. Physicians need to recognize this diversity and
avoid a stereotypical approach to Muslim patients.
Case 1: 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.
Case 2: 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 5 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
viceregents on earth.[1] 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, [2] 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 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.[3] 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.[4]
[5]
Islamic bioethics emphasizes the importance of preventing illness, but
when prevention fails, it provides guidance not only to the practising
physician but also to the patient.[6] The physician understands the duty
to strive to heal, acknowledging God as the ultimate healer. Islamic
bioethics 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 main principles of the Hippocratic oath are acknowledged 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 1981 Islamic Code of Medical Ethics, [7]
which deals with many modern biomedical 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:[8] “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.”[9] This passage legitimizes medical advances in saving
human lives[8] 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 2 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[10] and is itself “a healing and a mercy to those
who believe”[11] ) 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 4 major Sunni schools of
jurisprudence. Where appropriate, consideration is also given to maslaha
(public interest) and urf (local customary precedent).[12] 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,[8]
who are called upon to provide rulings on whether a proposed action is
forbidden, discouraged, neutral, recommended or obligatory.
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. Thus, 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
Islamic Organization for Medical Sciences, (www.islamset.com), based in
Kuwait, 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. In Canada, some
Muslim communities from central and eastern Europe and east Africa may
be more liberal than more conservative communities, say, from Pakistan
or some of the Middle Eastern countries.
There is little that is strange or foreign in Islamic bioethics for
Canadian physicians, who are often surprised at the similarities of
approach to major bioethical issues in the 3 monotheistic religions,
particularly between Islam and Judaism.[13] [14]
The 3 monotheistic religions, Judaism, Christianity and Islam, believe
in the same God, the God of Abraham (hence the common designation as the
“Abrahamic” religions) and of the entire universe.[15] Of all the
prophets of Islam, Noah, Abraham, Moses, Jesus and Muhammad are
considered to be the most important. Although Islam has some doctrinal
differences from Judaism and Christianity, it shares essentially the
same code of morality.[15]
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[16] (of God, the community and the individual) do
feature in bioethics, as does a call to virtue (Ihsan).
Why is Islamic bioethics important?
In 1999 there were about 550 000 Muslims in Canada (out of about 1
billion worldwide), and their numbers are projected to increase.[17] It
is still primarily a young, immigrant population, and it is ethnically
and linguistically diverse. Although settled throughout the country, two
thirds of all Muslims live in Toronto, Montreal and Ottawa. Ontario and
British Columbia are the provinces with the fastest growing Muslim
populations. Those of Indo-Pakistani and Arab origin are the most
numerous, although the Muslim community represents all continents and at
least 60 countries. In recent years, the former Yugoslavia was the
single largest source of Muslim immigrants, outpacing such traditional
source countries as Pakistan, Lebanon, Egypt and India (Daood H. Hamdani:
personal communication, 2000).
Many Muslims incorporate their religion in almost every aspect of their
lives. They invoke the name of God in daily conversation and live a
closely examined life in relation to the Qur'an and the traditions of
the Prophet, believing that their actions are very much accountable[18]
[19] 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 this significant
segment of the Canadian population.
How should I approach Islamic bioethics in practice?
Information about Islamic bioethics can be obtained most easily on the
Internet (see related Web sites at end of the article). Another source
is Muslim patients themselves. However, many Muslim patients may not be
aware of contemporary rulings 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.
Canadian Muslims come from different cultural backgrounds, although many
have become acculturated to the general Canadian way of life. 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, Canadian 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.
Practical measures for Muslim patients Diet: Muslims have fairly strict
dietary rules. Pork is forbidden, as is alcohol (although it can be used
externally). Meat must be processed in special ways (halal), but if
halal meat is unavailable, kosher meat (and kosher food in general) may
be acceptable.
Privacy: Women tend to be reluctant to uncover their bodies. If
possible, physicians should ask female patients to uncover one area of
their body at a time; they should be particularly careful and gentle
when examining breasts or genitalia, and explain in advance what they
are about to do. A chaperone should be present, particularly if the
physician is male. Although not absolutely necessary, many Muslim
families will prefer to have a female physician for the female family
members, especially for gynecological examinations, and a male physician
for the male members, if circumstances permit.
Communication: Many Muslims will have arrived in Canada in the recent
past and may have language barriers. It is advisable, therefore, to have
an interpreter present who is preferably, but not necessarily, of the
same sex as the patient.
Religious observance: In general, health concerns override all religious
observances. However, the more devout Muslims and those who are
physically able, along with their companions, may wish to continue some
religious observances in hospital. They would need running water for
ablutions and a small quiet area to place a prayer mat facing Mecca
(qibla). Staff should avoid disturbing them during the 10 minutes or so
that it takes to pray, usually up to 5 times a day. Some patients will
also frequently recite silently from the Qur'an or appear to be in
meditation. During the month of Ramadhan Muslim patients may ask about
fasting, even though they are not required to fast when ill. Muslims
regard both fasting and praying as being therapeutic.[8]
Consent: Essentially, the principles and components of consent that are
generally acceptable in Western countries are also applicable to
Muslims, although Muslims (depending on their level of education,
background and culture) will often want to consult with family members
before consenting to major procedures. Particular care should be
exercised when the consent involves abortion, end-of-life issues or
sexual and gynecological issues.
Hygiene: Muslims are on the whole very conscious of matters pertaining
to bodily functions and hygiene. Bodily discharges such as urine and
feces are considered ritually unclean and must therefore be cleaned in
certain ways. Ablutions are especially important before prayers, and so
it is crucial to provide running water close to the patient, with
sandals to wear in the toilet. Muslim patients will resist having a
colostomy because it makes ritual cleanliness for prayers difficult to
achieve. The surgeon therefore needs to spend more time than usual
explaining the medical need and the steps that can be taken to minimize
soiling.
The cases
Case 1
Organ transplantation is practised in almost all Muslim countries.[14]
This generally involves kidney donations from living relatives, but
cadaveric donation is increasing.[16] The Qur'anic affirmation of bodily
resurrection has determined many religious and moral decisions regarding
cadavers. [8] Mutilation, and thus cremation, is strictly prohibited in
Islam. However, carrying out autopsies, although uncommon in Muslim
countries, is permitted under certain circumstances, for example when
there is suspicion of foul play.[8] Similarly, many Muslim scholars have
permitted cadaveric organ donation.[14] [20] [21] [22] [23] [24]
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 Amman, Jordan, in October 1986.[23]
[24] Most, but not all, Muslim countries 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.[25]
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 lecturer
in Islamic studies at a local college, 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.
Case 2
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, most Muslim
scholars agree that ensoulment occurs at about 120 days (4 lunar months
plus 10 days) after conception;[5] [26] other scholars, perhaps in the
minority, hold that it occurs at about 40 days after conception.[27]
Scholars of jurisprudence 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
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, but not both, 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[28] and
rulings[29] 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 say that they would dearly love to have a child in
the future and inform the physician that Islam permits in-vitro
fertilization.[30] 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, in Shariah, the birth mother, not the ovum
donor, would be the legal mother. [31] Surrogacy is therefore excluded.
Related Web sites
• BBC World Service guide to Islam:
www.bbc.co.uk/worldservice/people/features/world_religions/islam.shtml
• Calgary Islamic Homepage:
http://members.home.net/islam/index_i.html
• Canadian Council of Muslim Women:
www.ccmw.com
• Islam (Encyclopaedia Britannica):
www.britannica.com/bcom/eb/article/8/0,5716,108138+1+105852,00.html?query=islam
• Islamic Organization for Medical Sciences:
www.islamset.com
• Islamic studies:
www.arches.uga.edu/~godlas
• Islam Top Sites:
www.islamtopsites.com
• Masjid addresses in Canada:
www.msa-natl.org/resources/IS_Can.html
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