Abstract

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.

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 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 vicegerents 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 practicing 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 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 impulse¹⁰ 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 rights¹⁶ (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 judgment.

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 (Table 1).

Table 1: 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 practiced 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.^14,20-24

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 opinions²⁸ and rulings²⁹ 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.

References

1. Qur'an 2:30.

2. Al Khayat MH. Health and Islamic behavior. In: El Gindy AR, editor. Health policy, ethics and human values: Islamic perspective. Kuwait: Islamic Organization of Medical Sciences; 1995. p. 447-50.

3. Al Faruqi IR. Tawhid: its implications for thought and life. Kuala Lumpur: International Institute for Islamic Thought; 1982.

4. Bucaille M. Human reproduction. In: The Bible, the Qur'an and science. Indianapolis: North American Trust Publications; 1979. p. 198-210.

5. Al Bar MA. Human development as revealed in The Holy Qur'an and Hadith. (The creation of man between medicine and The Qur'an). Jeddah: Saudi Arabia Publishing & Distributing House; 1986.

6. Ebrahim AM. Abortion, birth control and surrogate parenting. An Islamic perspective. Indianapolis: American Trust Publications; 1989. p. 10.

7. The Islamic code of medical ethics. World Med J 1982;29(5):78-80.

8. Sachedina A. Islam. In: Reich WT, editor. Encyclopedia of bioethics. Rev ed. New York: Simon and Schuster/Prentice Hall International; 1995. p. 1289-97.

9. Qur'an 5:32.

10. Rahman F. Legacy and prospects. In: Islam. 2nd ed. Chicago: University of Chicago Press; 1979. p. 235-54.

11. Qur'an. 41:44.

12. Kamali MH. Urf (custom). In: Principles of Islamic jurisprudence. Cambridge: Islamic Texts Society; 1991. p. 283-96.

13. Daar AS. Xenotransplantation and the major monotheistic religions. Xeno 1994;2(4):61-4.

14. Daar AS: A survey of religious attitudes towards donation and transplantation. In: Collins GM, Dubernard JM, Land W, Persijn GG, editors. Procurement and preservation and allocation of vascularized organs. Dordecht: Kluwer Academic Publishers; 1997. p. 333-8.

15. Hathout H. Why an Islamic perspective? In: El-Gindy AR, editor. Health policy, ethics and human values: Islamic perspective. Kuwait: Islamic Organization of Medical Sciences; 1995. p. 81-5.

16. Shad AR. The rights of Allah and human rights. Lahore: Kazi Publications; 1981.

17. Hamdani DH. Canadian Muslims on the eve of the twenty-first century. J Muslim Minority Affairs 1999;19(2):197-209.

18. Qur'an. 52:21.

19. Qur'an. 4:85.

20. Daar AS, Shaheen FM, Al Bar M, Al Khader A. transplantation in developing countries: issues bearing upon ethics. Pakistan J Med Ethics 1997;2(4):4-7.

21. Habgood J, Spagnolo AG, Sgreccia E, Daar AS. Religious views on organ and tissue donation. In: Chapman JR, Deirhoi M, Wight C, editors. Organ and tissue donation for transplantation. London: Arnold; 1997. p. 23-33.

22. Yaseen MN. The rulings for the donation of human organs in the light of Shar'i rules and medical facts. In: El-Gindy AR, editor. Health policy, ethics and human values: Islamic perspective. Kuwait: Islamic Organization of Medical Sciences; 1995. p. 303-67.

23. Al Bar MA, editor. Organ transplantation: an Islamic perspective. In: Contemporary topics in Islamic medicine. Jeddah: Saudi Arabia Publishing & Distributing House; 1995. p. 3-11.

24. Moosa E. Languages of change in Islamic law: redefining death in modernity. Islamabad: Islamic Research Institute; 1999. Occasional paper no. 35.

25. Shaheen FA, Ramprasad KS. Current status of organ transplantation in Saudi Arabia. Transplant Proc 1996;28(3):1200-1.

26. Al Bar MA, editor. Contraception and abortion: an Islamic view. In: Contemporary topics in Islamic medicine. Jeddah: Saudi Arabia Publishing & Distributing House; 1995. p. 147-53.

27. Al Bar MA, editor. When is the soul inspired? In: Contemporary topics in Islamic medicine. Jeddah: Saudi Arabia Publishing & Distributing House; 1995. p. 131-6.

28. Ghanem I. [Abortion as a necessity] [Arabic]. Al Faisal Med J 1984;9:61-5.

29. Regarding termination of pregnancy for congenital abnormalities [no. 4]. 12th session of the Muslim World League Conference of Jurists; 1990 Feb 10-17; Mecca.

30. Serour GI, editor. Islamic views. In: Proceedings of the First International Conference on Bioethics in Human Reproduction Research in the Muslim World; 1991 Dec 10-13; Cairo. Cairo: International Islamic Center for Population Studies and Research, Al Azhar University; 1992. p. 234-42.

31. Ebrahim AM. Abortion, birth control and surrogate parenting. An Islamic perspective. Indianapolis: American Trust Publications; 1989.

Related Web sites

BBC World Service guide to Islam: www.bbc.co.uk/worldservice/people/features/world_religions/islam.shtml

Canadian Council of Muslim Women: www.ccmw.com

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 

Competing interests: None declared.

Contributors: Dr. Daar and Mr. Al Khitamy contributed equally to the research, analysis, writing and revisions.

Authors: 

Dr. Daar is Professor of Surgery, College of Medicine, Sultan Qaboos University, Oman. In 1998/99 he was a visiting professor at the University of Toronto in the Faculty of Law, Department of Surgery and the Joint Centre for Bioethics. He is a member of the Ethics Committee of the Human Genome Organization. 

Mr. Al Khitamy is a Muslim scholar who works in the Microbiology Department, Sultan Qaboos University Hospital, Oman.