ISLAMIC MEDICAL ETHICS: The IMANA Perspective

Transcription

1 Special Article JK-PRACTITIONER ISLAMIC MEDICAL ETHICS: The IMANA Perspective CONTENTS 1. Introduction of IMANA 2. Islamic Medical Ethics 3. Need for IMANA S Perspective on Islamic Medical Ethics IMANA Ethics Committee Shahid Athar, MD, Chair Hossam E. Fadel, MD, Vice-Chair Members Wahaj D. Ahmed, MD Abdul R.C. Amine, MD Malika Haque, MD Faroque A. Khan, MD Hussain F. Nagamia, MD Hasan Shanawani, MD Hassan Hathout, MD, PhD (advisor) Acknowledgment: 1. Iltifat Alavi, MD, Acting Executive Director 2. Mohammed I. Ahmed, MBBS, MS (Surgery) 4. IMANA s Perspective on Important Ethical Issues A. The Care of The Muslim Patient B. Definition of Life and Responsibility of Muslim Physicians Towards Human Life C. Definition of Death D. Mechanical Life Support in Terminally Ill Patients or those in Persistent Vegetative State and Euthanasia E. Islamic Living Will and Advance Directive F. Organ Donation and Transplantation G. Assisted Reproductive Technologies and Surrogacy H. Contraception and Sterilization I. Termination of Pregnancy (TOP) J. Genetic Engineering and Human Cloning K. Care of HIV Infected/AIDS Patients L. Examination of Patients of Opposite Sex M.Drug Research 5. References APPENDIX Websites on Islam, Islamic Medicine and Islamic Medical Ethics JK-Practitioner 2005;12(4): Reproduced without modification, with permission from Journal of the Islamic Medical Association Of North America (JIMA) :2005;37:33-42 Vol.12, No. 4, October-December

2 1.INTRODUCTION OF IMANA These are In 1963, Muslim students studying in American 1) Respect for the autonomy of the patient, colleges and universities organized themselves into an 2) Beneficence, association, the Muslim Students Association (MSA). 3) Nonmaleficence, and Four years later, in 1967, American Muslim physicians did 4) Distributive Justice the same and formed the Islamic Medical Association of Thus, when a Muslim physician is making a North America (IMANA). MSA transformed into the decision about patient care, that decision should be in the Islamic Society of North America (ISNA) and IMANA best interest of the patient, whether Muslim or nonbecame a constituent body of ISNA. Since its inception in Muslim. Further, that decision should not only be based on 1967, IMANA has dedicated itself to serving Muslim his/her own knowledge and experience, but as a Muslim, physicians, Muslim allied health care professionals, he/she has to consider the Islamic teaching in regards to Muslim patients and the community at large on issues the situation, but without imposing his/her religious views related to Islamic Medicine nationally and worldwide. on the patient. IMANA is also a member of the international Federation 3. NEED FOR IMANA S PERSPECTIVE ON of Islamic Medical Associations (FIMA). Islamic ISLAMIC MEDICAL ETHICS Medicine is defined as the art and science of practice of Muslim Physicians, Ethicists, Imams and medicine by Muslim physicians and other health care scholars are asked questions by Muslim and non-muslim providers in the service of humanity under Islamic patients, physicians and institutions as to what is Islam s guidelines as ordained by the divine book al-qur an and position or opinion on certain medical dilemmas affecting taught by Prophet Muhammad, peace be upon him the care and outcome of patients illness and life. Some of (PBUH). IMANA has headquarters in a Chicago suburb these issues, such as termination of pregnancy, are time and regional chapters in many cities of USA. It is governed honored situations while many such as transplantation, by a Board of Regents and an executive committee assisted reproduction and life support are products of according to established by-laws. It has several advances in medical technology. Since these are new operational committees including the medical ethics issues, Muslim physicians, have dire need for committee. For detailed information about IMANA, one recommendations from the guiding principles of the can visit Glorious Qur an, the tradition of Prophet Muhammad 2. ISLAMIC MEDICAL ETHICS (PBUH) and opinions of past and contemporary Muslim Islam considers access to health care as a scholars. The Qur an says:it is not fitting for a believer, fundamental right of the individual. In medicine, there are man or woman, when a matter has been decided by God, sometimes difficult decision-making options for the and His messenger, to have any option about their patient s care. Thus, a physician at times has to decide for decision. If any one disobeys God and His messenger, he is his /her patient in light of available knowledge, his/her 4 indeed on a clearly wrong path. Thus, IMANA decided to experience, his/her peers and consensus of the make a position paper, The IMANA Perspective, to community. In addition, a Muslim physician derives his provide to those who seek our opinion and enable them to /her conclusion from rules of Islamic laws (Shari ah) and pursue further reading on their own. The positions Islamic medical ethics. The first main principle of Islamic expressed in this perspective are only suggestions on Medicine is the emphasis on the sanctity of human life behalf of IMANA and are not to be considered Fatwa(s) which derives from al-qur an:whosoever saves a human (religious decrees) which are religiously binding. The 1 life, saves the life of the whole mankind. The second main members of ethics committee are not in a position to issue principle is the emphasis on seeking a cure. This derives a Fatwa on any of the issues which we are writing on from a saying of Prophet Muhammad (PBUH):There is no behalf of IMANA. However, from time to time, on a need disease that God has created, except that He also has basis, we do consult Muslim scholars to have their 2 created its treatment. Prophet Muhammad (PBUH), in opinion. These positions will be revised from time to time another narration, is also reported to have said:seek as new questions arise from advances in medical treatment, for God the Exalted did not create a disease for technology. The position paper is available to be read and 3 which He did not create a treatment, except senility. This downloaded from internet at at no cost. is further emphasized by the fact that three of the Goals of 4. IMANA S PERSPECTIVE ON IMPORTANT the Islamic Shari ah are the protection and preservation ETHICAL ISSUES of life, intellect, and progeny. The other two are the (A) Care of the Muslim Patient protection of property and religion.some of the rules of IMANA has published a brochure entitled Islamic medical ethics are Guidelines for Healthcare Providers in Caring for 5,6 1) Necessity overrides prohibition; that is, if there are Muslim Patients. Those who wish to obtain a copy can certain items which are Islamically prohibited, under call IMANA at (630) It is also available on line dire necessity they can become permissible. at in the Health and Ethics section.all 2) Harm has to be removed at every cost if possible. patients irrespective of their faith should be treated with 3) Accept the lesser of the two harms if both can not be human dignity and respect. Muslim physicians are advised avoided. to treat all patients with loving care as if they are members 4) Public interest overrides the individual of their own family. We suggest to all health care providers interest.islamic Medical Ethics also upholds the four that they familiarize themselves with the basic teachings basic principles of biomedical ethics. of Islam and Islamic moral values. It is easier for a 232 Vol.12, No. 4, October-December 2005

3 healthcare provider to deal with the patient if he/she sacred and must be protected. The respect for life in Islam understands the faith, values and culture of his/her patient. is common for all humans, irrespective of gender, age, These are some of the specific guidelines for healthcare race, color, faith, ethnic origin or financial status.imana providers especially of other faith traditions for caring for holds the position that biological life begins at conception their Muslim patients. while human life begins when ensoulment takes place. A 1. Muslim patients should be identified-if possible- verse from the Qur an reads:man We did create from a as Muslim (or with the religion Islam) in the quintessence (of clay); Then We placed him as (a drop of) registration information so as to prevent any mistakes sperm in a place of rest, firmly fixed; Then We made the happening unintentionally in terms of violating sperm into a clot of congealed blood; then of that clot We dietary rules or privacy. made a (fetus) lump; then we made out of that lump bones 2. Their care providers should respect their and clothed the bones with flesh; then we developed out of modesty and privacy. Muslim patients, particularly it another creature. So blessed be God, the best to women, may need a special gown to cover the whole 7 create! Ensoulment is believed to occur at 40 or 120 days body in order to avoid unnecessary exposure during after fertilization, according to different schools of 8 physical examination. Some examinations may be thought. (see Section I) The right of the human fetus in done over the gown. Islam is similar to the rights of a mature human being, 3. Provide Muslim patients Islamically slaughtered including the right to life, the right to inheritance, the right (Dhabiha) meat. Muslim patients should not be of compensation when injured by willful acts and the right served any pork, pork products or alcohol in their to penalize assailants.imana extends the principles of meals. A Muslim patient s family may be allowed to medical ethics to the patient in a vegetative state. Until the bring food from home, as long as it is meeting the death has been declared, the patient in a vegetative state is 5 patient s dietary restrictions.. Make it easy for considered a living person and has all the rights of a living Muslim patients to perform Islamic prayers if they person. can. (C) Definition of Death 5. Inform them of their rights as a patient and The definition of the end of human life from the 9,10 encourage an Islamic living will. A sample of a living Islamic point of view has been previously discussed. will is included. (see Section E) IMANA has previously published a position paper on Take time to explain test procedures and death. Permanent cessation of cardiopulmonary treatment. Some of the more recently immigrated function, when diagnosed by a physician or a team of Muslims may have a language problem. Muslim physicians, is considered death. The concept of brain women can give consent for any treatment or death is necessitated when artificial means to maintain procedure. cardiopulmonary function are employed. In those 7. Allow their Imam (religious teacher) to visit situations, cortical and brain stem death, as established by them and pray for them. Clerics of other faith specialist(s) using appropriate investigations can be used. traditions can pray for or with Muslim patients with It is the attending physician who should be responsible for their permission, using non denominational words making the diagnosis of death. Thus a person is considered like God. dead when the conditions given below are met. 8. Autopsy is permitted if medically indicated or 1. The physician has determined that after a required by law. standard examination, a person s 9. Organ donation is permitted with some cardiopulmonary function has come to a guidelines and is encouraged. permanent stop. 10. Always examine a female patient in the presence 2. A specialist physician (or physicians) has of another female (chaperon) or a female relative determined that after standard examination, the (except in medical emergencies). Especially for labor function of the brain, including the brain stem, and delivery, if the patient s obstetrician is has come to a permanent stop, even if some other unavailable and upon her request, provide a female organs may continue to show spontaneous healthcare provider, if feasible. Her husband is activity. encouraged to be present during the delivery. (D) Mechanical Life Support in Terminally Ill Patients 11. After the death of a Muslim patient in a health or Those in Persistent Vegetative Stateand Euthanasia care facility, allow the family and Imam to arrange for The following verses in the Glorious Qur an are preparing the dead body for burial under Islamic some of the verses which address issues of life and death. guidelines. A corpse should be given the same respect It is He who gives life and death and when He decides 12 and privacy as he/she was receiving while alive. upon an affair, He says to it: Be and it is. No soul can die Muslim relatives and friends of the dead are except by God s permission, the term being fixed by encouraged to stay in the room where the dead body is 13 writing Every soul will have a taste of death. In the end, to kept to recite Qur an. Muslim corpses are not 14 us, shall you be brought back. It is He who gives life and embalmed. Who takes it away and to Him shall you be brought (B) Definition of Life and the Responsibility of Muslim 15 back. Nor take life which God has made sacred-except for Physicians towards Human Life 16 a just cause IMANA does not believe in prolonging the Muslims believe that God is the Creator of life misery of dying patients who are terminally ill or in a and life is a gift from Him. Muslims believe that all life is persistent vegetative state (PVS). PVS is defined as a sub- Vol.12, No. 4, October-December

4 acute or chronic condition which usually follows severe treated with grace and privacy and buried with Islamic brain injury and is characterized by normal sleep/wake guidelines under the directions of my Muslim family, pattern and total lack of cognitive function with preserved Imam or other qualified Muslims as soon as it is feasible. blood pressure, respiratory control, that persists for more S i g n e d _ D a t e _ than two months.when death becomes inevitable, as Place determined by a team of physicians, including critical care The declaring person has been personally known physicians, the patient should be allowed to die without to me and I believe (him/her) to be of sound mind. I did not unnecessary procedures. While all ongoing medical sign the declaring person s signature above for or at the treatments can be continued, no further or new attempts direction of the declaring person. I am not a parent, spouse, should be made to sustain artificial life support. If the or child of the declaring person. I am not entitled to any 17- patient is on mechanical support, this can be withdrawn. part of the declaring person s estate or directly financially 20 The patient should be treated with full respect, comfort responsible for his/her medical care. I am competent and measures and pain control. No attempt should be made to at least eighteen (18) years of age. withhold nutrition and hydration. In such cases, if and Witness (to the document) Date when the feeding tube has been withdrawn, it may not be Witness (second) reinserted. The patient should be allowed to die peacefully Date and comfortably. However, no attempt should be made to (F) Organ Donation and Transplantation enhance the dying process in patients on life support. We, at IMANA, understand that certain organs IMANA is absolutely opposed to euthanasia and assisted may fail in the human body while the rest of the body may suicide in terminally ill patients by healthcare providers or still be functional. The current state of medical knowledge by patient s relatives. Suicide and euthanasia are holds the view with scientific proof that, if the diseased prohibited in Islam. 18,21 organs are replaced by healthy organs and if accepted, the (E) Islamic Living Will and Advance Directive body machine can continue to function rather than die IMANA recommends that all Muslims have a because of one diseased organ. Islam instructs all Muslims 1 Living Will, Advance Directive and a case manger for to save life. Thus, on this basis, transplantation in general, their care, to help physicians to know their wishes, when both giving and receiving organs, is allowed for the he or she is unable to give directions (i.e. in a coma). A purpose of saving life. This has to be done under the sample of such proposed living will is provided here following guidelines: which can be modified by the patient after consulting with 1. The medical need has to be defined. family and /or an attorney. 2. The possible benefit to the patient has to be (Sample) defined. Declaration made this day of, 3. Consent from the donor as well as the recipient 20,, a Muslim of sound mind, willfully must be obtained. and voluntarily make known my desires that my dying 4. There should be no sale of organs by any party. shall not be artificially prolonged under the circumstances 5. No financial incentive to the donor or his set forth below and I declare: If at any time I have an relatives for giving his organs, but a voluntary incurable injury, disease or illness certified in writing to be gift may be permitted. On the other hand, there a terminal condition by my attending physician(s), and my should be no cost to the family of the donor for attending physician has determined that the use of life- removing the organ. prolonging procedures would serve only to artificially 6. Any permanent harm to the donor must be prolong the dying process, I direct that such procedures be avoided. withheld or withdrawn, and that I be permitted to die 7. Transplantion of sex organs (testicles or ovaries) naturally with only the provision of appropriate nutrition which would violate the sanctity of marriage is and hydration and the administration of essential forbidden. medications and the performances of any medical 8. Cadaver donation is permitted but only if procedures necessary (as determined by my physician) to specifically mentioned in that person s will or in provide me with comfort or to alleviate pain.in the driving license.blood Transfusion is absence of my ability to give direction regarding the use of permissible. Giving blood to or receiving blood life-prolonging procedures, it is my intention that this from people of other faiths is permissible. declaration be honored by my family and physician as the (G)Assisted Reproductive Technologies and final expression of my legal right to refuse medical or Surrogacy surgical treatment and I accept the consequences of the We believe infertility is a disease and desire for a refusal. is my case manager to enforce my cure by an infertile couple is natural. However, in Islam, living will, if I am not physically able to give direction. I for an action to be permissible all means of achieving that do not permit autopsy of my body unless my death action are also to be pure.we believe in the sanctity of occurred in a suspicious manner and it is important to marriage and the importance of preserving lineage.the know the cause of death or if it is required by the court of Qur an says:and God has made for you mates (and law. It is my desire that Muslims attending my dying companions) of your own nature, and made for you, out of process ensure that Islamic Shari ah is practiced during them, sons and daughters and grandchildren, and provided preparation of my body for burial and that my body be for you sustenance of the best: will they then believe in 26 vain things, and be ungrateful for God s favours? The 234 Vol.12, No. 4, October-December 2005

5 Qur an says:it is He who has created man from water: then 4. When it is done for family planning, i.e., the has He established relationships of lineage and marriage: husband and wife are satisfied with the number 27 for thy Lord has power (over all things). Based on these of children they have, some scholars will permit Qur anic guidelines, IMANA holds the following 22 it but it is makrouh (hated). positions: (I) Termination of Pregnancy (TOP)Abortion is 1. All forms of assisted reproductive technologies the willful termination of pregnancy by artificial (ART) are permissible between husband and means: drugs, chemicals, mechanical or surgical wife during the span of their marriage using the procedures before the age of viability (23 husband s sperm and the wife s ovaries and menstrual weeks, i.e. calculated from the first uterus. No third party involvement is day of the last menstrual period) for any reason. 22,28,29 allowed. Chemical or mechanical means to prevent the We believe in the sanctity of marriage and that formation of zygote (fertilized ovum, which the death of the husband terminates the marriage marks the beginning of human life) is not contract on earth, thus frozen sperm from a considered abortion. We believe that life begins deceased husband can not be used to impregnate at conception and unless interrupted by disease his widow. or artificial means, the fertilized ovum will 2. Sperm, ova and embryo donation are not continue to grow and become a viable mature permitted. human being. However, some scholars 3. Additional embryos produced by IVF between differentiate between biological life, which starts husband and wife can be discarded or given for at conception, and human life, which starts after genetic research, if not to be used by the same ensoulment.7,8 The two Shaykhs (al-bukhari couple for a future attempt. 22 and Muslim) relate on the authority of Abdullah 4. Surrogacy involving a third person is not ibn Mas ud that God s Messenger (PBUH), has permissible, as we believe that it exceeds the said:the creation of each one of you is brought in boundaries of the marriage contract and the belly of his mother for forty days, then for a lineage similar period he is a germ cell, then for another 5. Use of fertility drugs is permissible. forty days he is an embryonic lump, then an angel An infertile couple, if they can not find is sent to him and ordered to write down four a permissible cure, can care for an orphan or words. He is told: write down his career, his someone else s child as their own within the livelihood, his life duration and whether he is to Islamic guidelines of adoption, not the legal be miserable or happy, and the angel breathes 33,34 adoption as practiced in the United States spirit into him Further, the time of ensoulment (H) Contraception and Sterilization according to this hadith is considered to be at 40 Islam prohibits sex out of wedlock days after fertilization by some scholars, while (i) Contraception:For married couples, others consider it to be at 120 days after contraception for several reasons, including 8 fertilization. IMANA s position on health of the mother, social or economic reasons 22,25,32,35,36 abortion can be classified as follows: etc, is permitted, provided that it is practiced by 1. Elective abortion of a viable fetus in a healthy mutual agreement of the husband and wife and mother is prohibited. that the method used is reversible and not 2. Abortion is permitted if continuation of harmful. Withdrawal, prophylactics, birth pregnancy may cause the pregnant woman to die control pills and other hormonal methods are or cause serious deterioration of her health, both allowed. Contraceptive methods which can lead medical and mental, if done before 120 days after 22,31 to abortion are not allowed. fertilization, i.e. 19 menstrual weeks. (ii) Sterilization: Sterilization, whether by 3. Fetal congenital malformations in which vasectomy or tubal ligation, as a national policy abortion can be sought and is permitted are lethal for family planning or population control, is malformations not compatible with extra uterine 22 unlawful and should not be allowed. On an life such as bilateral renal aplasia, Trisomy 13, individual level it is permissible provided that 18, etc. But even in these situations it is both husband and wife want it and: preferable to do it before the 120th day after 1. When there is a significant medical fertilization or 19 weeks of gestation, calculated contraindication to the pregnancy, for example, from the first day of the last menstrual period if there is a significant risk to the wife s health if 4. In non-lethal malformations such as severe she conceives hydrocephaly, cervical meningomyelocele, 2. When other methods of birth control have failed Down s syndrome and unbalanced or are causing significant side effects translocations, abortion may be permissible 3. When a genetic disease of the husband or wife or before the 120th day of conception after both poses a high risk of being transmitted to the consulting Islamic scholars and medical experts fetus e.g. autosomal dominant or autosaul in the field. recessive conditions when both husband and 5. Pregnancy occurring because of rape, war crimes wife are carriers. and incest may be a cause to seek abortion.in all Vol.12, No. 4, October-December

6 cases in which abortion is sought, the homosexual lifestyle, promiscuity, and drug abuse, recommendation should be made by a team of IMANA is not opposed to the care of HIV patients. In fact, Islamic scholars and medical experts in the it instructs Muslim physicians to care for HIV patients field.prohibition of infanticide is mentioned in with the same degree of compassion as they would for several Qur anic verses. One of these verses 45 other patients. We do not discriminate against any patient is:kill not your children for fear of want: We on the basis of their lifestyle. We do advise healthcare shall provide sustenance for them as well as for providers to take precautions for themselves while taking 37 you. Verily the killing of them is a great sin. care of HIV patients. (J) Genetic Engineering and Human Cloning (L) Examination of Patients of the Opposite Sex Genetic research and engineering to alter or IMANA encourages but does not mandate same delete diseased genes is allowed and genetic research sex health care provider. Examination of a patient of the using stem cells from products of miscarriages or surplus opposite sex is allowed in the presence of a third person of ova after IVF procedures is permissible. However, to the same sex as that of the patient. In case of a minor, one conceive in order to abort the fetus and harvest and use its of the parents presences is desirable. Only necessary stem cells is not permissible. We believe that each examination needs to be done. Pelvic examination must be individual is born with unique qualities and genetic done using gloves. Medical or nursing students may be makeup. Islamically, a child should be born out of allowed during examination of a female patient, but only marriage between husband and wife and the lineage of the with her prior consent and in the presence of a female child should be maintained.27 Therefore, human 46 nurse or relative. 43,44 reproductive cloning is not permitted in Islam. (M) Drug Research Biomedical research involving Therapeutic cloning may be permissible within strict double blind trials, controls and the use of placebos in drug 43 guidelines. (K) Care of the HIV Infected/AIDS Patient research is allowed, but the patient must be informed and HIV infection, in addition to being associated consent must be taken. Worsening of the disease while in with homosexuality, is also known to be acquired through drug research, either due to placebo or an ineffective heterosexual acts, as well as intravenous drug use, blood dosage of the drug, must be carefully monitored and the transfusion and child birth. While Islam is opposed to 47 trial should be ended for the safety of the patient. Appendix : Websites on Islam,Islamic Medicine and Islamic Medical Ethics 1. www. Islamicmedicine.org REFERENCES: 1. The Glorious Qur an, Chapter 5, Scholars. J Islam Med Assn America. Care at the End of Life and Verse ;22: Euthanasia. J Islam Med Assn 1997; 2. Sahih Al-Bukhari, Book 79, Kitaab 9. Yaseen MN. The End of Human Life 29: al-tibb, Chap ter 1, Hadith in Light of The Opinion of Muslim 19. Athar S. Ethical Decision Making in [on-line] Available from: Scholars and Medical Science. J Patient Care. In Health Concerns for / Islam Med Assn 1991;23: Believers: Contemporary Issues. 3. Sunan Abi Dawuud. Vol. 2, Book 27, 10. Ahmed WD. An Islamic View of Chicago: Kazi Publications; January Kitaab al-tibb, Chapter 1, Hadith Death and Dying. J Islam Med Assn 1996, pp [on-line] Available from: 1996;28: Khan FA. Religious Teachings and Medical Ethics Committee, Islamic Reflections in Advance Directive- 4.The Glorious Qur an, Chapter 33, Verse Medical Association of North Religious Values and Legal 36. America. Death. J Islam Med. Assn Dilemmas in Bioethics: An Islamic 5. Medical Ethics Committee, Islamic 1997;29:99. Perspective. Fordham Urban Law Medical Association of North 12. The Glorious Qur an Chapter 40, Journal. 2002;30(1): America. The Guidelines for Health Verse H a t h o u t H. I s l a m a n d Care Providers When Dealing with 13. The Glorious Qur an Chapter 3, Euthanasia.(Guest Editorial) J Islam Muslim Patients. J Islam Med Assn Verse 145. Med Assn 1994;26: ;30: The Glorious Qur an Chapter 29, 22. Al-Abd OM. Islamic Organization 6. P e n n a c h i o D L. C u l t u r a l Verse 57. for Medical Sciences. Islamic Law Competence: Caring for your 15. The Glorious Qur an Chapter 10, Ruling on Certain Medical Muslim Patients. Medical Verse 56. 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