Addressing Islamic Bioethics

Addressing Islamic Bioethics IMRAN Rafi Ahmed PUNEKAR Professor Groch Theology of Life and Death December 7, 2004

PREFACE One inherent problem with many approaches to bioethics is that, while they may initially seem complete and thorough, they may be severely limited in applicability outside of the parameters within which they were constructed. In this way, ethical judgment systems are much like instances of game theory: misleading or meaningless when removed from the proper context and constraints. An alternative environment, whether due to the differing cultural values, historical setting, or present needs of a society, can radically transform the dynamics of ethical theory, in sometimes unwelcome ways. Perhaps one of the greatest challenges of any bioethical account is the incorporation and adequate handling of different religious and cultural backgrounds. That challenge becomes all the more daunting when a particular belief system or pattern of behavior holds views which seemingly contradict the majority, generally accepted, ideas upon which the ethical account is based. For instance, Beauchamp and Childress famous Principles of Biomedical Ethics which state that a healthcare provider must uphold the principles of: respect for patient autonomy, nonmaleficence, beneficence, and justice, leads one to a quandary when, say, dealing with patients of traditional Chinese origin, for whom family involvement and judgment far supersedes the value of autonomy and independence. 1 In the presence of such inherent and unavoidable shortcomings no ethical doctrine, after all, can be expected to have flawless universal application the responsibility lies upon the healthcare giver to determine when (and which) principles need be curtailed in the interest of the 1 Robert J. Levine, Informed Consent: Some Challenges to the Universal Validity of the Western Model, In In Contemporary Issuesin Bioethics, Ed 6, eds. Tom L. Beauchamp, LeRoy Walters, (USA: Thomson Wadsworth, 2003) 151-2

ultimate end of preserving the quality of health care provision. 2 In order to do so effectively, the health care giver must be well versed in cultural competence, the ability of the physician to transcend differences in culture, language, beliefs and values in the patient-physician relationship in order to ensure that the integrity and obligations of that relationship are maintained. 3 INTRODUCTION The aim of this paper is therefore to demonstrate the need for cultural competence in healthcare, using the care of Muslim patients as an illustrative example, and also to directly further the level of cultural competence by serving as a primer on Islamic positions on relevant bioethical concerns for healthcare providers for whom this information should be beneficial. To this end, some comparisons will be made between the bioethical teachings of Islam and those of the Catholic Church. Key issues which will be focused on include abortion, handicapped newborns, organ transplantation, and euthanasia. The understanding of Islam, as well as its application to the treatment of Muslim patients, is a growing concern across the world because of the rapidly growing nature of the Muslim population, and its increasing diversity. However, the approach to such an understanding is not a clear or simple one, especially in a country like America where, within the minority Muslim population, tens of different countries, regions, languages and cultures are represented. 4,5 This inherent complexity stresses the need for a 2 Robert M. Sade, Medical Care as a Right: A Refutation, In Cross Cultural Perspectives in Medical Ethics : Readings, ed. Robert M. Veatch ( Boston: Jones and Bartlett Publishers, 1989) 305. 3 Imran R. Punekar, The Necessity and Obligations of Cultural Competency in the Physician s Relationship with the Muslim Patient- effects on quality of health care, and Methods of Implementation, http://homepage.villanova.edu/imran.punekar/ethics.htm (accessed December 2, 2004) 4 Dr. Ahmed Mustafa, Director of Foundation for Islamic Education, Villanova, PA, interview by author, 23 March, 2004, Villanova, PA, Foundation for Islamic Education, Villanova, PA.

thorough and working understanding of the Islamic faith, its basic tenets, and its viewpoints on various common issues, which, though they may vary in regards to minor and/or social issues, remain fundamentally the same in all Muslim communities. 6 MORALITY AND ETHICS Devine, in the second chapter of his book Good Care, Painful Choices, outlines the difference between what he calls objective and subjective morality. The fundamental difference between the two is that subjective morality is defined by our perception and conscience; it depends on the person in order to be defined and given meaning, whereas objective morality exists outside of anyone s sphere and is a framework of morality that is universal and externally defined. 7 This concept relates to the contrast between the modern and classical world views. The classical world view holds that means are as important as the ends in any decision making process, and has as its core value the sanctity and equality of all human life. 8 This world view is similar in this sense to a Kantian attitude of life, and is supported by both the Christian and Islamic traditions. In much the same way that Kant argues that individual dignity must be held above all price, 9 Islam defends the value of life by asserting in the Holy Qur an, the book believed to have been revealed by God to the Prophet Muhammad (peace be upon him), that if 5 Barbara B. Ott, Suad Al-Junaibi, Jamal Al-Khaduri, "Preventing Ethical Dilemmas: Understanding Islamic Health Care Practices, Pediatric Nursing 29 (2003): 227. 6 Mustafa 7 Richard J. Devine, Good Care, Painful Choices: Medical Ethics for Ordinary People, 2 nd ed. (Mahwah, NJ: Paulist Press, 2000) 31-3. 8 Leonard Weber, Who shall live?, In Bioethics Definitions. 29 August, 2004, Prof. John Groch, Theology of Life and Death, Fall 2004, Villanova University, Villanova, PA. 9 Immanuel Kant. The Metaphysical Elements of Justice: Part I of the Metaphysics of Morals. Trans. John Ladd (New York: Bobbs-Merrill Co., 1965) ix

any one slew a person - unless it be for murder or for spreading mischief in the land - it would be as if he slew the whole people: and if any one saved a life, it would be as if he saved the life of the whole people. 10 This verse illustrates both the condemnation of taking innocent life as well as the encouragement of saving life in Islam. Both aspects are obviously related to this discussion of bioethics, and will be touched upon in greater detail later in this paper. Other facets of the classical worldview include the assertions that: the world has an objective (in the case of Islam, God-given) meaning, in much the same way as morality is believed to be objective and God-defined in nature; the individual must discover the right thing to do; one s actions and intentions are more relevant than the consequences of those actions in determining the goodness of a decision; one must adhere to external (again, in Islam, God-given) obligations; and that life is a gift which must be treated appropriately. 11 The idea that life and this world are the gifts of God is seen in the verse describing creation in which it is related: Behold, thy Lord said to the angels: I will create a vicegerent on earth. 12 The word vicegerent is a particularly interesting one, as it reflects the concept, not simply of a steward, but of a deputy appointed to act on the authority of a ruler 13 meaning that man is to take care of the earth not just on behalf of God, but in the way in which God decrees. As is clearly already evident, Islamic theology follows this pattern of moral/ethical deliberation, and is, for the most part, a strictly classical ethical worldview. This is important to note within the context of medicine because of the fact that the classical ethical worldview, while it is still seen manifested in institutions like the Catholic 10 Holy Qur an, 5:32 11 Weber 12 Holy Qur an, 2:30 13 Encarta Dictionary, 2003.

Church, is not as widely held today as the modern ethical worldview, which is what many contemporary bioethical standards and protocols are based upon. Weber s modern worldview differs from the classical chiefly in the fact that, rather than the sanctity of life, it holds as its guiding principle the ideal of quality of life, and makes assertions contrary to the ones presented above. For instance, rather than arguing that meaning is objective, the modern world view states that meaning, and morality, depend on humans to become relevant and have any value. Similarly, under this outlook, the individual is deemed able to control his or her own destiny; the ends of an action may justify the means; and life is seen as a possession, its terms to be dictated as seen fit by the individual. This sort of outlook is reflected, especially in America, in our preoccupation with rights and liberties over duties and obligations, as well as the extremely high value we place on autonomy and self-determination. CULTURAL COMPETENCE A physician dealing with Muslim patients, or any diverse patients, should be cautious that he does not expect of those patients adherence to principles which may seem right only because they are familiar to himself. This is where the strict following of any bioethical standard can often lead one astray, and it becomes clear that a deeper, more extensive understanding of the background of the individual patient, in the form of cultural competence, is necessary. A brief understanding of the fundamentals of the Muslim faith are beneficial to the cultivation of cultural competence. Allah (pronounced Ul-laah, or ä l ) means God in Arabic, and is the term used for the Divine. Like Christianity and Judaism, Islam is also an Abrahamic faith which regards the same figures of Adam, Noah, Moses, Abraham and others as prophets of God. Islam accepts the books and messengers of the Judeo-christian tradition, and the Qur an instructs Muslims to treat

the People of the Book (Jews and Christians) with special respect because they share a belief in the same, monotheistic God and overlap in many religious ideals and goals. Reflecting the idea of Islam as a classical worldview, Muslims believe that the source of all guidance is God, who revealed several books to various prophets, of which, only the Qur an has remained unadulterated. Thus, the prime authority on any matter is the Qur an, which is followed by the Sunnah, the actions and words of the Prophet Muhammad (peace be upon him) which have been meticulously cataloged and preserved over the years. Aisha, the wife of the Prophet (p.b.u.h.) characterized her husband as a walking Qur an. 14 BIOETHICAL CONTROVERSIES and the ISLAMIC VIEWPOINT In light of the common conception of Islam as a foreign, incompatible religion, it may be surprising to find that much of modern technology and medicine is not only acceptable but even encouraged by Islam. For instance, personal health is considered a moral responsibility, and the pursuit of treatment an obligation. 15 Aside from everyday issues, however, there are several concerns which are constantly being debated today in bioethics that often have great emotional and moral values, in which it becomes especially important to be receptive to the particular background and outlook of a patient. Theses issues include abortion, handicapped newborns, organ transplantation, and euthanasia. Organ donation and transplantation is perhaps the simplest of these cases, as most people do not have an issue with the physical act of organ donation or reception as much as it is the potential abuse and exploitation related to procedure 14 Mansoor Alam, The Concept of One God and Its Importance In the Life of Human Beings--- Part II http://www.tolueislam.com/bazm/mansoor/ma_concept_of_god_ii.htm (accessed March 24, 2004) 15 Abdallah S. Daar, and A. Binsumeit Al Khitamy, Bioethics for clinicians: 21. Islamic bioethics. Journal of Ayub Medical College 164 (2001): 60

that they find disturbing. Organ donation has been approved and encouraged by many Islamic scholars and organizations who cite the invaluable gift of life it is able to provide, and the Qur an s insistence on the value of life and the importance of its preservation. 16 The Islamic perspective is in line with the Catholic position which states that donation must be for ethical purposes, must occur only after death has been established, and can occur, in a case where the will of the patient is not clear, by consent by the family. 17 However, the issue at hand in this case is not so much the nature of the Islamic perspective, as the common ignorance of that perspective. Despite the presence of such encouragement, and due to the lack of a unified, defined leadership within the Muslim community (both locally and worldwide) such positions and rulings are often unheeded simply because they are not made known. What results, then, is a disjunction between what the religion and its scholars encourage and what Muslims actually practice. This is due, largely, to the diversity of the worldwide Muslim population, and, more often than not, Muslims that are unsure of the Islamic viewpoint must therefore make judgements in the context of their cultural upbringing. 18 This only further highlights the need for the physician in this case to be as well versed as is reasonable in order to be able, for instance, to effectively and respectfully approach grieving Muslim families about organ donation. Rashid notes that A medical approach, sensitive to both cultural and religious factors is vital to a complete and fulfilling interaction between the family and the physician. 19 Embryology is a very significant area within Islam and Islamic thought. This is due to the fact that the Qur an describes embryonic development in particularly vivid terms. For 16 Asrar Rashid, "Letter to the Editor, Archives of Disease in Childhood 85 (2001): 79. 17 Devine, 166. 18 Rashid, 79. 19 Rashid, 79.

instance, it talks in detail about the development of the embryo from a leech like structure to a mudghah something with what resemble chew marks (See Fig. 1). Figure 1 Drawings illustrating the similarities in appearance between a leech and a human embryo at the alaqah stage. (Leech drawing from Human Development as Described in the Quran and Sunnah, Moore and others, p. 37, modified from Integrated Principles of Zoology, Hickman and others. Embryo drawing from The Developing Human, Moore and Persaud, 5th ed., p. 73.) The Qur an states We created man from an extract of clay. Then We made him as a drop in a place of settlement, firmly fixed. Then We made the drop into an alaqah (leech, suspended thing, and blood clot), then We made the alaqah into a mudghah (chewed substance)... This has, understandably, led to the pursuit of embryonic Figure 2 When comparing the appearance of an embryo at the mudghah stage with a piece of gum that has been chewed, we find similarity between the two. A) Drawing of an embryo at the mudghah stage. We can see here the somites at the back of the embryo that look like teeth marks. (The Developing Human, Moore and Persaud, 5th ed., p. 79.) B) Photograph of a piece of gum that has been chewed. science in relation to the Islamic theology, as well as much development over the issue of abortion. The Islamic position on abortion, again, mirrors that of the Catholic faith. Abortions are generally not permitted except in cases where the mother s life is endangered. 20 The lack of a single religious authority, however, leaves some room for differences of opinion, with many 20 Islamicity, Q15 Abortion, http://www.islamicity.com/dialogue/q15.htm (accessed December 5, 2004).

scholars agreeing that abortion is not permitted post-conception except in the case of a serious health defect 21, and abortion being forbidden (except when the mother s health is endangered) after the point at which the soul is said to enter the body, which according to some scholars who base their opinion on one hadith, or saying of the Prophet (p.b.u.h.) occurs 45 days postconception, and according to others (who rely on a different hadith) occurs 120 days after fertilization. 22 Exceptions are made, however, in the very early stages of pregnancy (ie. before the infusion of the soul) in cases of rape or incest. 23 The reasoning behind this general approach to abortion follows the logic of the classical world view in that life is seen as a gift from God which cannot be neglected and whose value cannot be negated by human sentiment. Islam holds an analogous position towards handicapped newborns as well as euthanasia. In the case of handicapped newborns, it is believed that only God can determine when someone dies. The Qur an states: "Wherever ye are, death will find you out, even if ye are in towers built up strong and high!" 24 Death occurs at the appropriate time, no matter what. This belief stems from the concept of God as Omnipotent and possessing Divine Decree. 25 A Muslim mother in Sweden, after being approached about a DNR for her handicapped newborn said No, I don t want to participate in a conversation about it [withdrawing]. I think that it is God who makes the decision, I am being very distressed, it is too difficult to talk about it. 26 Muslims believe that it 21 Mustafa 22 Islamicity 23 Mustafa 24 Holy Qur an, 4:78 25 Shareef, Shakeel, Faith and Aqeedah, series of lectures at the Islamic Association of North East Pennsylvania, Wilkes-Barre, PA, January March, 2002. 26 Anita Lundqvist, Neonatal End-of-Life Care in Sweden, Journal of Perinatal and Neonatal Nursing 17(2003) 81.

is the duty of the physician to do one s best to preserve life because nobody can determine the future except God, and life is better than no life. However, scholars do acknowledge that brain death does constitute death and do not permit the artificial prolonging of life. 27 Unlike in the modern ethical worldview, quality of life considerations are not considered valid, because only God is able to make such a determination, and, having created life, has already shown that it possesses value. This argument extends to the case of euthanasia. God s gift of life is not an unconditional giving, but one imbued with responsibility and dignity, hence the use of the word vicegerent explained earlier. Furthermore, because God created our lives, created this world and everything which we see around us and everything we have that has been provided to and for us: man has an eternal obligation to be grateful and maintain the dignity of that creation. The reasoning for this is simple; we do not really own our lives in the normal sense of the term, and in the sense that it is used in the modern ethical world view. We did not create our lives, but our lives came from God and will return to God. Thus, whatever is done to life, and of course this argument extends to all forms of creation (not only human life), must be done in accordance to the wishes of and responsibility to God. Since we did not create human life, nor do we give it meaning, we have no right to take it except for the sake of God (as in the case of capital punishment, according to religious standards). Personally I find all these arguments very persuasive, and feel that there is much similarity between the monotheistic faiths. This understanding, I feel, can greatly aid the provision of health care, and the understanding of minority and Muslim patients. An analogy that I feel represents the above argument is as follows: If a student of Villanova finds a fire extinguisher attached to a wall and empties it out of a window as a prank, this clearly is morally 27 Mustafa

wrong. Yes, the extinguisher was given to the student, as a member of the institution, but only for proper use. Although it was given and, in a way, becomes the student s extinguisher, that student does not own the extinguisher, he did not create it nor bring it here, nor is he responsible for its end result. The student has every right to utilize it in the case of a fire because in that instance it is being used in accordance with the intent with which it was placed there. However, for the student to waste it is analogous to a person taking another person s life, it is a premature ending of the life of the extinguisher which ought to have been utilized properly and removed at the discretion of the owner, which is not the student at all. Related to this argument is the religious belief in Qadr, or the Supreme Decree of God, which is one of the pillars of faith in Islam. 28 This says, basically, that one must believe in the Supreme Decree of God and believe that nothing occurs without his Consent. This, in conjunction with the idea that piety is submission to God and His Will, makes clear that, at least in Islam, one cannot will against God without committing a moral wrong. This is why killing, whether in the form of abortion, a DNR against a handicapped newborn or euthanasia is seen as unjustifiable except where circumstances indicate that there is no viable alternative. CONCLUSION These arguments represent my personal views on each of the issues, and I feel that I have molded myself and shaped my specific stances based on the knowledge I have gained through talking to teachers and scholars of Islam. All of the above is a reflection of my personality, as I chose to include only those issues which I felt strongly about and had sufficient knowledge in to be able to present the argument intelligently and effectively. I find it comforting that there is a high correlation between the Catholic and Muslim stances, and believe that it represents an 28 Shakeel Shareef, Faith and Aqeedah, series of lectures at the Islamic Association of North East Pennsylvania, Wilkes-Barre, PA, January March, 2002.

opportunity for increased understanding and the pursuit of shared goals. As a pre-med student I feel that this is something I can effectively engage myself in, and see myself being a force of change and a new outlook on cultural competence in medicine. As a result of this interest, I have even applied for a Fulbright scholarship to the United Arab Emirates in order to study the relationship of Islam and Medical Ethics in greater detail, observe that relationship in action, and generate programs and ways by which that knowledge can be consolidated and expanded upon. My goal in this is not only to educate American physicians about the challenges of treating Muslim patients, but also educate Muslims about their own religion, and attempt to organize some sort of centralized, diverse and respected institution which can serve to work with hospitals, doctors and patients in order to provide necessary services such as interpretation, Muslim chaplain services, a reference database for Islamic positions, as well as Continuing Medical Education (CME) courses emphasizing the need of, and ways in which cultural competence can be established, furthered, and utilized in order to provide the best possible level of health care to everyone.