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Islamic Perspective In Medical Ethics

Shahid Athar, M.D.

Abstract


With the population of Muslims in the USA growing to about 8 million now, and Muslim physicians to about 18,000 American physicians win have to deal with medical ethics concerning their Muslim patients.

The introduction of new technology in medicine in areas of sustaining life support systems, organ transplantation, bio-technical parenting and acquired immune deficiency syndrome, have presented new questions, and affected our outlook in medical ethics. Muslim patients, their families and their physicians need to update their current knowledge and the Islamic perspective in these areas.

An attempt has been made to present the Islamic perspective as mentioned in Quran, the holy book of Islam.

- Key Words: Islamic Ethics In Medicine, Euthanasia, Abonion Surrogate Motherhood, AIDS. In the name of God, the beneficent, the Merciful "Blessed be He in whose hands is the Dominion, and he has Power over all things. He who created death and life that He may test which of you are best in deed and He is exalted in might, oft-forgiving". (Quran 67: 1-2)

The introduction of modern medical technology has posed perplexing new questions for Muslims, the answers to which they are still seeking. The Muslim masses are ignorant and naive, behaving like the bird which, fearful of its enemies, buries its head under the sand, thinking that it is safe. Muslims are split in two groups. One group is educated and modernized and accepts anything that serves science and humanity, irrespective of religious or moral laws that might be broken. The other group of so-called Islamic scholars have knowledge of Islam, but not of medical sciences. They are quick to give their opinion on everything. However, both groups should be reminded that Islam is not a religion of personal opinions.

"It is not fitting for believer, man or woman, when a matter has been decided by God and His Prophet, to have any option about the decision. If anyone disobeys God and His Apostle, he is indeed on a clearly wrong path." (Quran 33:36)

Muslims living in an advanced western society cannot stay aloof from the issues surrounding them. All factors affecting non-Muslims, sooner or later, directly or indirectly, will affect them too. The basic question in medical ethics is "Who is the giver of life and death". Should man control his life and death and that of other humans? Man now "thinks" he can create life or take it away, prolong life (or misery). Are physicians to serve the creations of God, or act as God themselves? Therefore, the Quran reminds man of his lowly origin:

"Does not man see that it is We who created him from sperm. Yet behold! He stands as an open adversary! And he makes comparisons for Us, and forgets his own creation. He says who can give life to (dry) bones and decomposed ones? Say "He will give them life who created them for the first time, for he is versed in every kind of creation." (Quran 36: 77-79)

The Current Medico-Legal And Moral Issues And Their Islamic Perspective

The Right To Live And to Die:


The care of the terminally ill is becoming very expensive. It is costing billions of dollars to keep patients alive in a vegetative state in intensive care units. The concept of euthanasia (mercy killing) is being revived. In 1987, 23,000 cases occurred in Holland. The question is who determines (the unconscious patient, the family, or the doctor) that the plug should be pulled and the life support system should be stopped. What is the definition of death? Is the living will justifiable? Is stopping the life support system an act of mercy, a medical decision, a murder, or just a financial decision?

The Islamic Perspective:


Islam does not believe in prolonging the life as everyone has been created for a life span. Scientists are to assist but not replace God in the creation of death of human beings. The Islamic morality starts in the womb and extends to the tomb. Islam places great emphasis on the sanctity of life and the reality of death.

"If anyone killed a person, unless it is for murder or spreading mischief on earth, it would be as if he killed all of mankind. And if anyone saved a life it would be as if he saved the lives of all mankind". (Quran 5: 35)

"Every soul shall have a taste of death." (Quran 2:35)

"No soul can die except by God's permission." (Quran 3:185)

Thus, while Islam gives importance to saving lives (medical treatment or otherwise) it makes it clear that dying is a part of the contract (with God) and the final decision (of term) is up to God. The quality of life is equally or more important than the duration of living.

My humble suggestion is that the physician and the family should realize their limitations and not attempt heroic measures for a terminally ill patient or to prolong artificially the life (or misery). The heroic measures taken at the beginning of life (i.e. saving a premature baby) may be more justified than at the end of a life span, though each case have to be individualized.

Islam is categorically opposed to euthanasia (mercy killing) and regards it as an act of murder. We do not see the difference between the gun used by a husband for his dying wife and the syringe used by the physician for his dying patient. Both are weapons of death, no matter what the intentions of the killer was.

2. The Organ Transplant
Nowadays many diseased organs are being replaced by healthy organs from living donors, cadavers and from animal source. Successful bone marrow, kidney, liver, comea, pancreas, heart and nerve cell transplantations have taken place. The incidence is limited only by cost and availability of the organs.

The ethical questions are what are the lights of the living donor, the dead body and the recipient. To prolong a life, does the recipient have a right to take away the organs from the dead? Is the sale of organs justified? Is the taking of animal organs justified? Is accepting organs from aborted fetuses justified? Is the cost of transplantation worth the benefit derived from it? The cost of a heart transplantation alone is $ 70,000 now, not including long term care. Will harvesting fetal tissues lead to more abortions?

The Islamic Perspective:


The basic question is who owns our organs, we, our relatives, or our creator?
A. Animal to Human: lf we can kill them for our food and let their meat become our flesh, why can't we use their comea to give us eyesight?
B. Living to Living: This is like giving a gift at no cost. The sale is prohibited.
C. Dead To Living:This is not permitted since it involves the desecration of the dead body.

3. The Issues in Abortion:


Currently about 2 million fetuses per year or 4000 per day are aborted in the U.S. The medico-ethical questions are many. Is abortion equal to murder? When is a fetus a living being? What are the rights of the fetus? Who guards those rights? Do both parents (even unwed) have the same rights over the life of the fetus? If life is a gift of God, who are we to take it away? Is killing an infant and the aged and terminally ill the same thing? What should be done with the pregnancy that is the outcome to rape? What is the role of Muslim obstetrician? Is the sale of aborted fetus for transplantation of tissues and organs, or of their delicate skin to make expensive cosmetics justified?

The Islamic Perspective:


Islam considers abortion of a viable fetus an infanticide except when to save the life of the mother. Even in this situation every attempt should be made to save both lives. The fetus is alive as a cell from the very beginning, with shaping starting at 4 weeks and movements at 4 months. According to Hadith at 120 days the angel visits the fetus and blows the spirit into it. This coincides with starting of the baby's first movement. The viability of the fetus medically has improved with the development of neonatalology. The smallest infant, weighing 4 oz at 3 1/2months, was saved.

The Quran refers to abortion in many places:
"Kill not your children for fear of want. We shall provide sustenance for them as well as for you. Verily the killing of them is a great sin." (17:31)

"Kill not your children on a plea of want. We will provide sustenance for you and for them. Come not near shameful deeds whether open or secret. Take not life which God has made sacred except by way of justice and law. Thus He commands you that you may learn wisdom." (6:151)

"The pledge of the believing women that they shall not kill their children." (60:02)

"And when the female infant who was buried alive is asked for what crime she was killed?" (81:2)

The pagans of today, the liberated woman, are not killing their infants for fear of want, or for the shame of the birth of a girl, but rather to enjoy the life of sexual freedom. To them God reminds:

"Such as took their way of life to be mere amusement and play and were deceived by the life of this world. That day we shall forget them as they forgot the meeting of this day of theirs and as they were bent upon rejecting our signs." (7:51)

4. Issues In Bio-Technical Reproduction


Infertility and the desire of a couple to have a child of their own is not a new problem. However new techniques to solve this have added a new twist. Now we have successful technology to fertilize an egg outside the uterus (test tube babies) and inject sperm into the uterus from the husband or a surrogate male donor, take the ovum of a woman and fertilize it with the sperm of her husband and inject it into the uterus of another woman for incubation.

The questions are:

A. Is marriage a legal contract between a man and a woman or is it a sacred covenant between the two, and God is the witness of such?

B. Was the child born of an intact legal marriage or outside the marriage?

C. In the case of the surrogate father, who is !he real father and does the child have the right to know who he is?

D. In case of the surrogate mother, who is the real mother, the one whose ovum is being used, or the one who lets her uterus be used.

E. Is renting a uterus for this purpose allowed or justified?

F. A woman married or single can technically have one child per month if she lets her ovum be fertilized by different sperm incubated each month in a hired uterus. This will save her the pains of pregnancy, labor and lactation. Is this right?

The Islamic Perspective:


In Islam the marriage of a man and a woman is not just a financial and physical arrangements of living together but a sacred contract, a gift of God, to enjoy each other physically and continue the lineage.

"And God has created for you consorts from amongst yourselves, and out of your consorts He created children and grandchildren for you, and provided you out of His bounty. Will they then believe in vain things and be ungrateful to God's favor?" (16:72)

"Among His signs is that He created consorts for you amongst yourselves, so that you may find tranquility with them, and He set love and compassion between you. Verily in this are signs for people who reflect." (30:12)

The Prophet (SAW) has emphasized marriage by saying: "Marriage is my tradition. He who rejects my tradition is not of me." In fact he described marriage as half of religion, the other half being God fearing.

Therefore violation of this sacred contract of marriage by a biomedical technique is violation of Islamic law:

Some prophets were childless and asked God to give them children (ref Quran 19:2-7 and 21:89-90 for the prayers of Zakariya and 51:28-39 for the story of Abraham and Sarah). Therefore it is justified to seek parenthood in a legitimate way and still recognize who controls it.

"To Allah belongs the dominion of the heavens and earth. He creates what He wills, He bestows female upon whom He wills, and He bestows males upon whom He wills. For He is all knowledgeable, all powerful." (42:49-50)

This bio technical parenting is only allowed if it is the product of an intact marriage i.e. during the life span of marriage. Artificial insemination using the husbands sperm, fertilized in the uterus of the wife or the test tube is allowed.

Surrogate motherhood is not acceptable because of two questions:

A. Who is the mother?

B. There is a question of lineage.

"None can be their mother except those who gave birth." (58:2)

Recently a mother kept an embryo fertilized by her daughter and her son-in-law and gave birth to her son/or grandson.

"It is He who created man from water, then has He established the relationship of lineage and marriage, for your Lord has power over all things." (25:54)

Islam recognizes the sacredness of the womb (uterus).

"O mankind! Revere your Lord who created you from a single person and created, of like nature, his mate, and from them twain scattered (like seeds) countless men and women. Revere God through whom you demand your mutual rights and (revere) the womb (that bore you), for God ever watches you.(4:1)

5. The Ethical Questions About AIDS Patients.


AIDS is spreading like the plague. About 52,000 cases have been reported in the USA alone, half of whom have already died. One case is being reported every 14 minutes. 700,000 Americans carry the virus and CDC officially estimates that 1.5 million are infected. It is projected that 365,000 active cases will never be reported in the USA by 1992. According to Dr. James Curran of The Centre for Disease Control in Atlanta the figure may be as high as 440,000. You don't have to be homosexual to get AIDS, through sexual transmission and sharing the needle in IV drug users is the main mode of transmission. 18,000 hemophiliacs,. have AIDS now due to blood transfusions. 15% of all AIDS victims are women and about 540 children are reported to have the infection. The spread of AIDS is changing the sex life style of single women, and men. AIDS has been reported in 112 countries. Next to the USA, the highest numbers in the western countries are France, West Germany and Britain.

The economics of AIDS are startling. in the USA, the medical care cost of AIDS will rise from $ 1.8 billion in 1986 to $ 8.5 billion in 1991, the research, education and screen from $ 542 million to $ 2.3 billion and a total cost from $ 7 billion to $ 55.6 billion.

The Ethical Questions Related To The Care of AIDS Patients Are:


1. Who will pay for the cost of AIDS cases since insurance companies will not insure them?

2. Should AIDS patients be quarantined and forced to change their lifestyle?

3. Should IV drug users be given free clean needles, syringes and drugs?

4. Should HIV positive carriers carry an ID card?

5. Should someone be tested for HIV without his knowledge and what should be done with positive results?

6. Does paying for AIDS cases by the public or the government mean that they endorse the lifestyle of the patients?

The Islamic perspective, though not clearly defined, would be in the prevention of the disease and after its occurrence treating it like any other disease, i.e. tuberculosis, syphilis, or small-pox. We never question the lifestyle of patients with other common diseases i.e. diabetes, hypertension, coronary heart disease in terms of discriminating them or restricting their care. AIDS may be "a wrath of God" because of certain lifestyle which should be discouraged but many "innocent" people are being affected without being their fault. Therefore, they should not be penalized. In each community every attempt should be made to prevent the spread of the disease but once it has affected an individual full attention and care be given to lessen his/her suffering and maintain the dignity and quality of life.

Conclusion:


I have tried to present the situation of ethics as it is being practiced with questions for those involved. I have not attempted to give detail account of each biomedical techniques. I am sure most of the readers, medical or non- medical have some knowledge in this area. With 8 million Muslims in the USA and 18,000 Muslim physicians populated here, it will be wise that non- Muslim physicians, clergy and law makers become acquainted with Islamic perspective in medical ethics. I strongly recommend that in each institutions dealing with question of life and death, a local Muslim physician be on the medical ethics committee.

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Acknowledgement: The author wishes to thank K.C. Khemka, Phd and Robert D. Robinsons, M.D. for reviewing this manuscript.

Selected References

1. The Holy Quran: Translated by A. Yusuf Ali, Published by Amana
     Corp, Washington, DC.
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2.  William, Robert H., "To Live and To Die- When, Why And How,
     Published by Spiinger-Verlag, New York.
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3.  "The Physician And The Hopelessly 111 Patient" Legal,Medical And
      Ethical Guidelines-Published by Society For The Right To Die-New
      York.
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4. "Right To Live And Right To Die" -Interfaith Symposium Of Islamic
     Medical Association,Houston, Texas, Nov. 87.
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5. Hathout, Hassam "Islamic Perspective In Obstetrics & Gynecology
     Published by Islamic Organization For Medical Sciences.
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6. "Bio-Technical Parenting "- Interfaith Symposium Of Islamic Medical
     Association, Anaheim, CA. July 88.
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7. "Moral and Ethical Issues In Medicine" 6th Annual Symposium, St.
     Vincent Hospital, Indianapolis, Indiana, Dec. 1987.
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8. Gaveebo, Hassan "An Islamic Code Of Medical Ethics"- Journal of
     Islamic Medical Association, Vol. 20, 1988,Page 21-24.
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9. "Islamic Medical Ethics" Special issue of Journal of Islamic Medical
     Association - January 1988.
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10. Athar, Shahid "AIDS: The 20th Century Plague And What Muslims
     Should Know About It, Crescent International, Toronto, Nov. 1987.
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11. Scitovsky, Anne A. and Dorothy P. Rice "Estiinates Of The Direct And
     Indirect Costs of AIDS In USA In 1985, 1986, 1991- Public Health
     Report 1987, Vol. 102 No. I Page 5-17.