MAiD or AiD? Seeking ‘Medical assistance in dying’ or ‘Allah’s (assistance) in dying’?

by | Jan 10, 2022 | 0 comments

Abstract

Currently, the polemic discussion in the UK is MAiD or Medical Assistance in Dying. The stance appears to be evenly split between legalizing MAiD and keeping it illegal. The reality that on average, every eight days a Briton travels abroad to seek MAiD perhaps indicates a need to legalise it in the UK. The discussion, however, is not simply a matter of one’s right to die but that of another’s right to actively take part in ending the life of an individual upon request. In this article, I discuss from an Islamic perspective and in light of Abrahamic faiths, why life is valuable not only when ne enjoys physical health but perhaps even more valuable as long as the patient has the potential to experience spiritual joy. Lack of autonomy and what may seem like an undignified life may be overcome through an environment of accepting the fact that part of life is poor health and dependence. I also explore cases of wishing for death in the biblical account of Job and in the advice that Prophet Muhammad (peace be upon him) gave to his uncle Abbas when the latter wished for death. Additionally, I look at the importance of justice, preservation of life, and compassion in light of the maqasid al- Shariah, meaning the objectives of Islam. This article argues that MAiD, although a personal choice, is not supported by Muslim scholars in light of Islamic jurisprudence which positions only for death following a natural trajectory of physical decline. Moreover, MAiD involves physicians evaluating the quality of a patient’s life and whether it should end.

Background

The UK is seeing a shift in professional medical opinion to legalise Medical Assistance in Dying (MAiD) [1]. MAiD is also referred to in other studies by different terms including but not limited to: aid-in-dying, assisted suicide, euthanasia, medical assistance in dying, physician-assisted death, physician-assisted dying, and physician-assisted suicide. The RCP define MAiD as ‘The supply by a doctor of a lethal dose of drugs to a patient who is terminally ill, who meets certain criteria and who requests those drugs in order that they might be used by the person concerned to end his or her life’ [2].

The arguments in favour of MAiD have a common assumption that ‘the desire to end life in the presence of an eligible medical condition is a medical problem requiring a medical solution’ [3]. Accordingly, on average, every eight days, one British person travels to Dignitas (Zurich, Switzerland) to seek MAiD, where a lethal dose of barbiturates are prescribed by physicians with the explicit intention to empower a person to end their own life [4]. According to Statista,

“In   2019,   42   British   residents   went   to   Dignitas  in Switzerland for an  accompanied suicide. The number of Britons travelling to Switzerland for assisted dying has generally increased since 2002, with the highest number of assisted suicides from Britain occurring in 2016 with 47[5].”

According to the 2019 Oregon Health Authority annual report, the main reasons for patients receiving MAiD were, ‘loss of autonomy’ (90.4%), ‘decreasing ability to participate in activities that made life enjoyable’ (86.7%), ‘loss of dignity’ (72.3%), and ‘being a burden on family, friends/caregivers’ (59.0%)—whereas only a third reported ‘inadequate pain control—or concern about it’  [6]. These reasons are also supported by other studies on MAiD [7][8][9]. The main reason for patients wanting to go to Switzerland is because in the UK, according to Section 2 of the Suicide Act 1961, medically assisting another person to die is a criminal offence punishable by imprisonment for up to 14 years [10].

Not all Britons can afford to travel to Switzerland to seek MAiD due to the costs being prohibitively expensive [11]. Some of those who were granted approval, died whilst waiting for travel – which may have been perceived as an undignified death to their loved ones. The idea that these individuals could have died without having to endure suffering has evoked much compassion in recent years. In 2020, 61% of the general British population as well as 67% of British health care professionals expressed their belief that MAiD should be legalised [12]. The Royal College of Nursing adopted a neutral stance on the issue in 2009 [13], followed by the same stance from 49% of members of the British Medical Association [14]. A change in law may be acceptable to a large proportion of the UK population given the fact that MAiD is legal in Switzerland, Netherlands, Spain, Belgium, Luxembourg, Canada, Colombia, Australia and New Zealand, as well as in several states in the US.

The option to terminate one’s life or to seek help from a physician to end one’s life seems to be a possibility in the UK in the near future. Physicians will also have the choice to pursue this route and offer lethal methods to end the life of patients in what they would consider ‘compassion’. A patient’s attitude toward illness as ‘endless suffering’ is a matter of perspective; others may view it as part of ‘a spiritual journey’. The reasons for  not legalising MAiD, as well as counter-reasons to legalise, have been argued from vari us  perspectives. The key arguments against MAiD include preservation of life and the prohibition of killing that is ‘present in almost all civilised societies due to the immeasurable worth of every human life’ [15]; a form of ‘demedicalisation’ [3]; creating a wedge in the law that could lead to exploitation and increase in deaths by meant to be, irrespective of whether what happened was good or bad, just or unjust. To overcome the fear and anxiety due to feeling helpless in such circumstances, the Qur’an reminds its audience that ultimately, human beings are all in the care of an All-powerful being and no problem is actually ‘endless’. Rather, it is the physical and material life that ends but the spiritual life continues.

One such seemingly ‘suffering’ patient that can be found in the Bible and the Qur’an is the Prophet Job (Ayyub, in the Qur’an). The Bible provides a detailed account of Job’s mental turmoil after suffering from boils and sores
over his whole body due to what different authors have argued was leprosy, pox, scabies, eczema, erythema, or
elephantiasis [34] – a disease that appeared at the time to have been incurable. Throughout the biblical account is the metaphor of life as a journey[35]. Also central to the story is the meaningful spiritual relationship a human
being can experience despite suffering from poor health [36]. Interestingly, the theme of ‘return’ in the Qur’an is
echoed in the Book of Job, where Job says, ‘Naked I came from my mother’s womb, and naked shall I return’ [37].

Job is seen to have lost the ability to perform enjoyable and meaningful activities. He also reaches a stage when
he wishes that he was never born, ‘May the day of my birth perish’ [38] and saying, ‘I would prefer strangling
and death over my life in this body’ [39]. At one point he shares a reasonable concern, ‘Even if I speak, my pain is not relieved, and if I hold back, how will it go away?’ Eventually, Job realises that there will be no change to
his condition except by death, ‘My days have passed; my plans are broken off – even the desires of my heart’
The most emotional moment is perhaps when Job says, ‘Where then is my hope? Who can see any hope for me? [42]. In all of these moments, Job’s innermost thoughts and emotions could have led him to contemplate suicide or seek assistance in dying given that he was clearly in a very distressing situation. However, what appears to be the source of strength in Job is spirituality and faith, ‘I will maintain my integrity until I die. I will cling to my righteousness and never let go. As long as I live, my conscience will not accuse me’[43]. The righteousness that Job spoke of could be understood from his words. ‘Agree with God, and be at peace, thereby good will come to you. Receive instruction from his mouth and lay  up his words in your heart’ [44]

The point to note from the above passages is not that it is simply a religious text. The narrative provides a detailed biographical account of someone who had reason to lose hope and wish for death. However, Job does not see the value of life solely on the merit of bodily integrity but spiritual health. Shariah law, likewise, encourages patients to value spirituality over physical health and acknowledges the fact that if both are lost then one is likely to lose all hope and seek death. Bearing in mind that each individual has their own pain threshold, this biblical account may inspire and empower one to increase their pain tolerance. Promoting the spiritual aspect of life may then be equally, if not more important than restoring physical health in patients. The notion of holistic care is longstanding in the Christian tradition; in the Middle Ages, Church institutions would continue to care for patients’ spiritual health when nothing else could be offered for improving physical or mental wellbeing [45].

Loss of autonomy
Among the main reasons for patients seeking MAiD is loss of autonomy [46]. Al-Bar and Chamsi-Pasha define ‘personal autonomy’ as ‘self-rule free from being controlled by others and from inadequate understanding that prevent meaningful choice’ [47]. The secular liberal notion of autonomy, however, differs from the Islamic paradigm. whereas Western ethics is epistemologically based on philosophical science, reason, and experience, autonomy according to Islamic ethics is rooted in religious texts [48]. In this vein, Van Bommel says:

“For a Muslim patient, absolute autonomy is very rare, there will be a feeling of responsibility toward God, and
he or she lives in social coherence, in which influences of the relatives play their roles”. Consequently, personal choices are only accepted if they are the “right” ones[49].

In relation to MaiD, autonomy is discussed in conjunction with quality of life. The use of language to describe life plays an important role in how life is valued. To implicitly position ‘life’ and ‘suffering’ as opposites, as is often posited by advocates of MAiD, may lead to viewing suffering as a separate experiential entity that is not part of the whole that is life. Does hospitalisation or being bed-ridden transition a person into a stage between life and death or is it still a part of life? Likewise, the moment one loses autonomy or dignity, does that mean that the value of life has ended? There is scope within Shariah law to withdraw life-support from a patient who is, for instance, brain dead; not doing so would still allow the body to remain active and functioning although is no life. However, in MAiD, the mind is still functioning and there is life, but the individual has lost autonomy over the body.

Returning to Job’s thoughts, ‘Naked I came from my mother’s womb, and naked shall I return’ there is an interesting parallel here with the Qur’an, which reads, ‘A person surely does transgr ess when he believes he is independent’[50]; meaning that an individual who believes themself to be independent in decision-making without fully understanding how their decisions could affect one’s self or others might make disastrous choices that would transgress the boun daries of the Shariah.Job’s thoughts show that lack of autonomy is not necessarily something negative. At birth, the baby arrives in a state of complete vulnerability; naked and needing assistance to be dressed, to move, and to be fed. A stage in life is then reached wherein seemingly there is independence, and yet we still rely on relationships with others and access to resources. Towards the end of one’s life, once again, a person relies on these meaningful relationships to help them fulfil their needs and to be dressed, moved, and to be fed. Jesus prepared his disciple Peter for old age with the following advi e, ‘When you were younger you dressed yourself and went where you wanted; but when you are old you will stretch out your hands, and someone else will dress you and lead you to where you do not want to go’ [51]

The Qur’an reminds humanity not to get complacent during this middle stage by highlighting the difficult truth– that no one is ever really truly autonomous or independent. Van der Geest and Satalkar, in their research on autonomous decision-making in the face of death, concluded that ‘people lose much of their autonomy when they grow old and fragile, and will be increasingly inclined or fo rced to leave decisions to others’ [52]. Given the fact that human beings are born dependant and are likely to die in a state of dependence, the middle stage is more a luxury than a standard by which to determine the val ue of life and yet, as Denys points out; ‘Being in contr ol has become the ultimate moral virtue of Western citizens. We desire full control not only of our life but of our death as well’ [32]. The baby-boomer generation wh ich experienced life through the lens of individualism may expect greater freedom of choice over death [53] which creates a challenging tension with the observation that a utonomy, as conceptualised and upheld in the case of MAiD, appears largely an illusion [54].

Another interesting parallel is that the beginnings of the Qur’an refer to human bein gs as originating from alaq which refers to the earliest embryonic form when it clings to the uterine wall. The final chapter of the Qur’an is believed to be Nasr which focuses on receiving ‘help’. Thus, the beginning and end of the Qur’an parallel the dependency of human beings. Moreover, Prophet Muhammad (peace be upon him) also advised Muslims to recite Surah Ya-sin daily; this cha pter includes the reminder, ‘And to whomever We grant a long life, we reverse them in development’ [55]. Likewise, another passage from the Qur’an that focu ses on lack of autonomy in old age reads, ‘Allah is the One who has created you in a state of weakness; then He granted you strength and then, later on, He gives you infirmity and grey hairs in place of strength’ [56].

The Qur’an focuses on the reality of old age and need, and it also emphasises the importance of taking care of those who reach this stage. According to the Qur’an, in the same way that a parent is accountable to take care of their child, accordingly, the Qur’an inst ructs that parents should be honoured by the child(ren) when the former eventually rely on the latter. The Qur’a n captures caring for parents in the following words, ‘Whether one or both of them reach old age while they are wit h you, say not to them ‘uff,’ and do not repel them but speak to them respectfully’ [57]. The verse points out two important aspects, a) ‘while they are with you’ p romotes a norm that one is expected to keep their parents close to them, this can include both emotional and ph ysical closeness, and b) when the parents become dependent as they begin to lose autonomy, their day-to-day w ishes are to be fulfilled by the children, just as the parents took care of theirs in childhood. The verse also encourages the children to avoid exclamations of anno yance such as uff in Arabic, the equivalent in English being exclamations such as ‘what now?’, ‘oh not again’, or tutting. Likewise, non-verbal utterances like eye-rolling that express annoyance are discouraged.

If the children do not support the parents, then the wider family is called upon to honour the one in need. If the family also is unable to support the ind ividual, then the community is called to put measures in place to provide care for the needy. This stage req uires managing community funds and revenues to be bu dgeted to provide quality care for the ill and needy dependants. As Hartling argues, ‘A patient overwhelmed by suffering may bemore in need of compassion, care, and love than of a kind offer to help end his or her life’ [58]. Investing in developing sophisticated assistive technology like Intel’s speech-generating device for Stephen Hawking could be life-changing and enable patients to m aximize potential for communicating with and being care d by their loved ones and maintain an ongoing role with in wider society[58].

If a person, however, is incapable of providing consent due to illness, is that person able to enjoy a spiritual connection? If not, should a Muslim have an advanced directive to seek medical-assisted death before losing all ability to consent? From a Shariah viewpoint, there are two points to note a) a person who is incapable of making rational decisions is recogni sed as being marfu’ al-qalam meaning one for whom the pen is lifted i.e., unaccountable by Shariah law. Secondly, in terms of honour and dignity, Proph et Muhammad taught that a person continues to gain the same reward in sickness of the good they did during sound health [59]. This aspect is strongly advised to be prese nted to Muslim patients when discussing advanced directives – would they wish to forfeit such rewards according to the teachings of their faith?

Refusing life-sustaining interventions vs undertaking life-ending interventions

One may argue that because Shariah law does not oblige a patient to take medication and allow death to take its course, does this mean it permits a form of suicide? One significant difference betwe en refusing medication and MAiD is that there is no third-party assisting in dying. Shariah law allows the matter to be resolved between the patient and the Divine wi thout a third party getting involved to actively end life . A process, which although appears to be compassionate, is not the third party’s responsibility, nor would the third party be held accountable, according to Shariah law, for not providing such lethal drugs.

Secondly, if a patient refuses burdensome medical treatment, this is not the same as causing the death of a patient. Burdensome medical interventions could include medication that would cause unpleasant side effects that are disproportionate to the possible benefits. Another example of burdensome includes experimental treatment. Additional questions that need to be explored could be – what percentage of patients who refuse medical treatment knowing it could lead to death, also avoid MAiD? What are the reasons or motivations for patients who do value their lives to allow death to occur naturally? Also, although patients may express their thoughts on wanting to die, is this the same as actually undertaking a life-ending action?

Is there a potential danger that family members interpreting such thoughts as serious considerations, might then incentivise the patient to pursue the notion further? Importantly, legislators of MAiD may need to query that despite the strict regulations that are in place before MAiD can be considered, how possible is it for family members to sow the seeds of M AiD in the minds of patients which ultimately leads to the patients seemingly seek MAiD of their own choice? This leads to the notion that a patient’s decision for MAiD is a consequence of ‘internalised external pressure’ [7]; a ‘supreme paradox’ as Hirsch calls it, that ‘someone is cast out of the land of the living and th en thinks that he, personally, wants to die’ [60]. In this regard, Ghazal highlights that ‘The reality is that true autonomy and ‘choice’ devoid of external influences and pressures is fragile a philosophical concept at best, and open to harmful manipulation at worst’ [30]. Gibs on argued that if an elderly person truly had autonomy, they would request others to help them fulfil their daily activities [61]. However, when such help is not available, the individual begins to lack autonomy and therefore, the choice to end one’s life becomes a result of a lack of autonomy. These factors question the reality of autonom y and whether or not the individual decision can be detached from the influence of others around the patients [62].

For a detailed account of how complex the decision-making process can be and how easily decisions can be influenced, read van der Geest and Satalkar’s case study of Gertrude’s mother [63]. Another case study by Borneman et al. explores the benefits and drawbacks of discussing end-of-life matters with patients in light of religion and ethics [64]. Another case that made media headlines was the case of Valentina Ma ureira, a 14-year-old Chilean girl with cystic fibros is, begging her government via YouTube videos to all ow physicians to assist in her death. She admitted being influenced by the case of Brittany Maynard, a 29-year-ol d American with terminal brain cancer who died by MAi D a year earlier. However, Valentina decided to persevere with life after being inspired by Maribel Oviedo, aged 22, from Argentina, whose life was saved after receiving a lung transplant [65].

Wishing for death

The scriptures are clear when it comes to saving a life, feeding the hungry, providing water to the thirsty, and clothing the naked i.e., there is a moral responsibility or obligation to undertake action to ach ieve these aims. However, there is no such instruction as to provide a ‘compassionate’ or ‘dignified’ death. Assisted death is also not a new issue exclusive to the modern era. The issue of seeking assistance in death is explored in the Bible, where one account describes Kin g Saul asking his attendant to assist him to die, but the latter refused. Later another man was said to have ended Saul’s life acting per Saul’s wish. The Prophet David, however, condemned this person guilty of murder [66].

Even in the time of Prophet Muhammad (peace be upon him), there are examples o f individuals wishing to die. Several of Muhammad’s military comrades were severely injured in battles, being crippled or blinded, resulting in them becoming dependent on others. Muhammad, however, vehemently condemned suicide and under no circumstance promoted a hastened death. However, in line with his exemplar character of compassion, he acknowledged the pain and suffering being experienced and tau ght that one may ask Allah directly for death if He deemed it better than life.

Muhammad’s uncle Abbas [67], reached a stage towards the end of his life where he wanted his suffering – as a result of old age – to end and simply die. Muhammad, however, successfully persu aded his uncle to focus on the still-valuable spiritual dimension of life. Abbas was advised against dying by Muhammad for two reasons a) living allows one to continue to manifest goodness, and b) life still allows one to make amends. Abbas was convinced to see his life th rough until the natural end, and even outlived Muh ammad. Abbas’ willpower continues to live until today as an inspiration to Muslims facing end-of-life challenges, as well as for those who may have contemplated suicide as an escape from sadness and grief.To some degree, we see a similarity in the case of Abbas, who felt that he had lived a ‘completed life’ and that he wished to live no more. Suc h narratives can also be found in interview studies conducted wherein patients who sought MAiD felt they too had lived enough [68]. From a Shariah viewpoint, there is no measure by which such claims can be made. According to the Qur’an, even the least act of goodness will b e rewarded [69] and that too multiplied at the least, tenf old [70]. By this standard and for the one who has certainty in this belief, every good act is worth the invest ment. Prophet Muhammad explained that simple acts of kindness could even be a smile or a kind gesture or uttering a kind word; in the 21st century, the assistance of technology provides new avenues to undertake actions of kindness and benefit to others.

The faith aspect in the for egoing discussion is crucial. The Assisted Dying bill proposes that terminally ill patients with full mental capacity who are not expected to live more than six months may be eligible to apply for MAiD. Given the transformational power of spiritual experiences, a question that needs to be asked is, ‘Could spiritual experiences not be anticipated and deemed valuable for another six months?’ M oreover, the bill mentions physical and mental capacity. However, there is no mention of spirituality. Dhar et al. define spiritual health as,

A state of being where an individual is able to deal with day‑to‑day life issues in a manner t hat leads to the realization of one’s full potential, mean ing and purpose of life and fulfilment from within. Such a state of being is attainable through self‑evolution, self‑a ctualisation and transcendence [71][72].

The support for MAiD has also been ar gued based on a passage from the Sirach 30:17 which reads, ‘Death is better than a miserable life, and eternal rest than chronic sickness’ [73]. However, reading this pa ssage in context clarifies that the text appears to encour age perseverance and faith. Verse 15 reads, ‘Health of the soul in holiness of justice, is better than all gold and silver: and a sound body, than immense revenues’. Verse 1 6 then adds that ‘There is no riches above the riches of the health of the body: and there is no pleasure above the joy of the heart’. The point to note here is that if only the physical body is given value, then upon its deterioration, life remains without riches – not that life has no value. But the passage highlights that alongside the bod y is the health of the soul and the joy of the heart, which is the spiritual aspect of life that truly adds to the valu e of life. To seek death based solely on physical or me ntal deterioration implicitly denies the full potential of the human experience. Without faith adding value to life and joy of the heart, life becomes reduced to physical pain at which point it appears that Sirach concludes that in such a case, ‘Better is death than a bitter life’. In the words of Jesus too, life has two dimensions, the bi ological and the spiritual life and whereas ‘Flesh gives birth to flesh’, ‘the Spirit gives birth to spirit’ [74].

At what point then can one say a deterioration or non-existence of faith accommodate the wis h to seek death? This question again is difficult to answer. According to the teachings of Prophet Muhammad, h e instructed that one may proceed to seek death by reciting the words, ‘O Allah, keep me alive as long as my life is of value, and grant me death, when death is better for me’ [75]. The prayer does not encourage an individua l to devalue their own life nor invite society to do the same based on physical health. Instead, life and death are left in the care of the Divine and not a third party to intervene or expedite death.

So according to Shariah law, what value does one’s life hold when the body is in per petual deterioration and end-stage illness? Muhammad is reported to have said that ‘Allah does not judge a person by their physical appearance or financial status, but by the condition of their spiritual state and actions’ [76]. Although society may view a person’s value or indeed an individual may themself view their own wo rth relative to how much they can contribute to society, fro m a Shariah stance, this may be viewed as a self-degrading approach. If one judges the value of their life based on physical ability and autonomy, then according to Shariah law, they may be judging themselves harsh er than the compassionate approach Muhammad described – that Allah values the spiritual condition. The had ith also mentions, however, that Allah looks at ‘actions’, which may lead one to feel they are less valuable because of their immobility or weakness.

However, as the Qur’an states – the blind, the lame, and the sick are not to be blamed, shamed, or be held accountable or responsible for matters that they are unable to carry out physically. In a teaching by Jesus, and echoed by Prophet Muhammad, an individual is thanked by the King, ‘I needed clothes and you clothed me, I was sick, and you looked after me, I was in prison and you came to visit me’. The person surprisingly asks how he could ever have possibly served in such a way, the King replies, ‘Whatever you did for one of the least of these brothers of mine, you did fo r me’ [77][78]. From a Shariah standpoint then, the ones who are severely challenged physically are encouraged to continue focusing on spirituality, whereas those w ho are healthy and able, are instructed to provide adequate care for the former.

Rationale for Muslim jurists to discourage ‘caring’ physicians from assisted in dying?

Debilitating illnesses may le ave patients extremely weak and suffering from issues such as urinary or fecal incontinence- or cognitively incapable of making complex decisions. Late-st age terminal illnesses could result in patients being bedbound and dependent on others for the most basic everyday tasks like eating, washing, and going to the bathroom. Some may view such a condition as undignif ied and may argue that if an animal was in the same condition, it would be put down out of compassion. From a S hariah stance, human life has greater value than other life forms. So whilst there is an argument for putting down animals out of compassion, the same argument is more complex to be applied to human life. The issue from a Shariah viewpoint is not only about ‘does one have the right to die?’ but also ‘does another have the right to gra nt death to an individual upon their request?’

The argument based on notions of compassion appears to be emotionally valid. However, basing laws on emotions and wishes runs a significant risk of failure. An individual may wish for many things – does this mean someone who is caring should feel respo nsible to provide assistance and help fulfil all such wish es? According to Shariah law, the provision of care cannot be in contradiction to justice. The Qur’an promotes kindness and care towards each other; however, what is care and what is not is left to Muslims to decide – who may also hope that such acts of kindness are in accordance with Allah’s will and worthy of reward.

However, according to the scriptures, the Divine will is not vague when it comes to taking li fe. There are no instructions that allow taking the life of an innocent human being out of ‘compassion’. According to theMaqasid al-Shariah, meaning the obje ctives of Shariah law, preservation of life is a key objective [79]. In the case of capital punishment, the evidentiary requirements are so stringent that one may even argue that they are impossible to meet [80].

The fact that the Qur’an [81] regards saving a life as great as saving all of humanity- and taking life unjustly as tragic as eradicating all of humanity – is a clear statement that the Divine will, according to scriptu re, is to preserve life [82] rather than to ‘end it unjustly’ or ‘upon request’. Likewise, in Judaism, ‘human life is so important, that the saving of human life takes prece dence over most other commandments’ [64]. This being t he case, to argue that ending life out of mercy or compassion – which may be based on plausible arguments – is in direct conflict with the clear prohibition given in the verse: ‘Do not kill yourselves, for verily Allah has bee n to you most merciful’ [83]. Accordingly, Chamsi-Pasha and Albar argue that:

Killing a person to ease his suffering even though it is at the request of the person will be inconsis tent with Islamic law, regardless of the different names given to the procedure, such as, active voluntary euthanasia, assisted suicide, or mercy killing[18].

Advocates of MAiD argue that the arg uments against it are based on hypothetical fears [84]. Th ey further argue that the suffering of the patients is a fact whereas the arguments against MAiD are mere opinions of others. Seeking medical assistance in dying would end the physical suffering of an individual, however, studies have shown MAiD to cause deeply damaging unintended consequences inter alia, post-traumatic stress disorder (PTSD) and depression of s uffering for those involved in MAiD [85]. Effects of MAiD on surviving family members, wider society, and on the physician who assists patients in dying, therefore, also needs to be considered [86].

Impact on family members

The negative impact on fa mily members could include having resolved feelings about the rate at which the  decisions were made to end life and finding having to have chosen the time of death ‘unnatural’ [87]. Possibly due to cultural factors, some family members may feel the difficult burden of keeping the process and the cause of death a secret [88].

Impact on physicians

Studies of physicians who offered MAiD have consistently shown detrimental effects [89] including conflict between respect for patient autonomy and wishes, and the call to pre serve and value life [90], and feelings of mixed emotions and inner conflict with their role [91]. Moreover, even the physicians who stay clear of MAiD could also be stigmatized [92] and be seen to appear to be opposed to ‘compassion’. There is also a growing concern that ‘neutrality’ is being interpreted as ‘tacit support for change, precipitating legalisation’, to which Finlay counter-argues ‘If you’re neutral about something, it may be that you don’t know about it, or haven’t thought it through, or because it doesn’t apply to you’. Finlay further adds, ‘A majority who look after dying patients are clear that they don’t want to be involved in assisting suicide and carry that responsibility for ending life. The BMA should respect their professionalism’ [93].

Wider society

In a study related to MAiD by Winnington and MacLeod, they found three key themes emerge: 1) that MAiD will become ‘expectation for others to pursue when unwell and potentially facing a lif e-threatening illness’, 2) that MAiD brings with it a ‘stigma’, and 3) ‘the potential for such legislation to produce a contagion effect’ [92]. MAiD could also result in a chang e in palliative care possibly leading to expedited dischar ges due to financial pressures from an already overburdened health care system – as was the case when hospices were threatened in Quebec and British Colombia [94].

Conclusion

Medically-assisted death is a personal choice that requires legal support. Where MAiD is legal, those who wish to end their lives exercise their right to practise their freedom of choice. From a Shariah persppective, however, patients are encouraged to value their life from a spiritual aspect. The fact that a patient who ha s lost autonomy may feel undignified, such attitudes could be addressed not only from a medical perspectiv e but especially through spiritual and social ones. Physicians may feel that providing MAiD is compassi onate, however, according to Shariah law, such a provisi on is not justified as it conflicts with its objectives. According to Shariah, one is permitted to supplicate for a divinely-assisted death to help alleviate distress, however, Muslim jurists discourage actively ending one’s own life or for another to offer the means to actively end it upon a patient’s request.

Part of the process for helping end-of-life patients reach a better-informed decision is to include spiritual care. Muslim patients as well as members o f other faiths are strongly advised to consider the spiritual teachings of their faiths before considering MAiD. Faith leaders need to prepare accessible literature in this regard. To claim that society can allow an individual to make a fully informed decision about death is highly questionable given that no one knows what happen s once life ends, apart from the fact that life as we kno w it, ends. In a society where autonomy is highly prom oted, a balance is required to withstand the challenges of sickness and poor health. Better health education that hel ps to prepare for the realities of ageing and sickness may result in patients developing greater resilience and self-w orth when faced with difficult life choices.

Furthermore, research is required to gat her the views of ethnic minority communities on MAiD, and also how the law could have an impact on the quality of health care that patients from ethnic minority grou ps may receive. What effects could MAiD have on the level of trust in the doctor-patient relationship especially o n patients from marginalised communities? By doctors offering MAiD, are they validating the idea that a patient’s life has no worth? Would medical mistrust affect h ealth intervention uptake and outcomes in marginalised communities as was seen during the COVID-19 pandemic and vaccine hesitancy? Another question that needs to be given consideration is – to what extent would legalizing MAiD inadvertently affect patients to consider ending their lives – when they would have otherwise found value to their lives?

References

  1. BMJ. Assisted dyin g [internet]. 2021 (cited 2021, Sep 25). Available from: https://www.bmj.co m/assisted-dying
  2. RCP. Assisted dying survey 2014: Consultation document [pdf]. 2014 (cited 2021, Sep 3). Available from: https://www.rcplondon.ac.uk/file/7184/download
  3. Thomas, L. H. Demedicalisation: radically reframing the assisted dying debate—an essay. BMJ, 2020, 371
  4. Ziegler, S.J. and Bosshard, G. Role of non-governmental organisations in physician assisted suicide. BMJ. 2007, 8, 334(7588), 295-8.
  5. Michas, F. Annual number of accompanied suicides to Dignita s in Switzerland from Great Britain from 2002 to 2019 [internet]. 2020, Feb 18 (cited 2021, Oct 25). Available from: https://www.statista.com/statistics/1095576/digni tas-accompanied-suicides-from-gb/
  6. Oregon Health Authority. Death with Dignity Act annual reports [internet]. 2021 (cited 2021, Sep 5). Available from https://www.oregon.gov/oha/PH/PROVIDERPA RTNERRESOURC ES/EVALUATIONRESEAR CH/DEATHWITHD IGNITYACT/Pages/ar-index.aspx
  7. Hendry, M., Pasterfield, D., Lewis, R., Carter, B., Hodgson, D. and Wilkinson, C. Why do we want the right to die ? A systematic review of the international literatu re on the views of patients, carers and the publi c on assisted dying. Palliative medicine. 2013 Jan;27(1):13-26
  8. Rodríguez-Prat, A., Balaguer, A., Booth, A. and Monforte-Royo, C. Understanding patients’ experiences of the wish to hasten death: an updated and expanded systematic review and meta-ethnography. BMJ open. 2017 Sep 1;7(9):e016659.
  9. Ohnsorge, K. Gudat, H. and Rehmann-Sutter, C. What a wish to die can mean: r easons, meanings and functions of wishes to die, reported from 30 qualitative case studies of term inally ill cancer patients in palliative care. BMC Palliative Care. 2014 Dec;13(1):1-4.
  10. Legislation GOV UK. Suicide Act 1961[internet]. 1961, Aug 3 (cit ed 2021, Oct 25). Available from: https://www.legislation.gov.uk/u kpga/Eliz2/9-10/60/contents
  11. Dying in Dignity. The trus cost: How the UK outsources death to Dignitas [internet]. 2017 (cited 2021, Sep 25). A vailable from: https://features.dignityindying.or g.uk/true-cost-dignitas/
  12. Statista. (2020). Attitudes towards assisted suicide in cases of terminal illn ess and extreme pain in Great Britain in 2019, a mong the general population and healthcare professionals [internet]. 2020, Jan 23 (cited 2021, Sep 30). Available from: https://www.statista.com/statisti cs/1089684/gb-support-for-assisted-suicide/
  13. Dignity in Dying. Royal College of Physicians will drop its longstanding opposition to assisted dying [internet]. 2019 March 21 (cited 2021, Oct 25). Available from: https://www.dignityindying.org.uk/news/royal-college-physicians-drop-longsta nding-opposition-assisted-dying-neutral/
  14. Hallows, N. BMA moves to n eutral stance on assisted dying [internet]. 2021 Sep 14 (cited 2021, Sep 25). Av ailable from: https://www.bma.org.uk/news-a nd-opinion/bma-moves-to-neutral-stance-on-assi sted-dying
  15. Christie, B. Will Scotland become the first part of the UK to legalise assisted d ying? BMJ, 2021 Sep 1, 374:n2206.
  16. Mildred, J. The slippery slope of assisted dying is real [internet]. 2018, Aug 29 (cited 2021, Oct25). Available from: https://www.economist.com/open-future/2018/08/29/the-slippery-slope-of-assisted-dying-is-real
  17. United Nations Hum an Rights Office of the High Commissioner. End of Mission Statement by the United Nations Special Rapporteur on the rights of persons with disabilities, Ms. Catalina Devandas-Aguilar, on her visit to Canada [internet]. 12 Apr 2019 (cited 2021, Oct 25). Available from: https://www.ohchr.org/en/NewsEvents/Pages/Dis playNews.aspx?New sID=24481&LangID=E
  18. Chamsi-Pasha, H. and Albar, M.A. Assisted dying: Islamic Perspective. JBIMA, 2021, 9(3).
  19. Dabbagh, S. and Aramesh, K. The compatibility between Shiite and Kantian approach to passive voluntary euthanasia. J Med Ethics Hist Med, 2009, 2: 21.
  20. Sachedina, A. End -of-life: the Islamic view. Lancet, 2005, 366, 774–779.
  21. Aramesh, K. and Shadi, H. An Islamic perspective on eutha nasia. Am J Bioeth, 2007, 7, W4–6.
  22. Rady, M.Y. and Verheijde, J.L. Islam and physician-assisted death. Crit Care Med, 2009, 37, 2493-2494.
  23. Dayeh, A.J. Euthanasia. In: Hossam E.F., Muhammad, A.A.K . and Aly, A.M. (eds.). FIMA Year Book 2005–2006: Geriatrics and end of life issues: Biomedical, ethical and Islamic horizons. Amman, Jordan: J ordan Society for Islamic Medical Sciences; 2007, pp. 95-104.
  24. Misha’l, A.A. Com mentary. End of life medical interventions. In: In: Hossam E.F., Muhammad, A.A.K. and Aly, A.M. (eds.). FIMA Year Book 2005–2006: Geriatrics and end of life issues: Biomedical, ethical and Islamic horizons. Op cit. pp. 85-88.
  25. IMANA Ethics Committee. Islamic medical ethics: the IMANA perspective. Journal of the Islamic Medical Association of North America, 2005, 37(1), 33-42
  26. Albar, M.A. Ahkaamat’tadaawiwa’lhaalaat al-ma’yoosminhawaqadhiyyamautar’rahma. Jeddah, KSA; Dar A l Manara; 1995.
  27. BIMA. (2021). BIMA Position Statement on the Legislation of Assisted Suicide [Facebook post]. 2021, Oct 23 (cited 2021, Oct 23). Available from: https://www.facebook.com/BritishIMA/photos/p cb.4362421847211772/4362421717211785
  28. Padela, A. Muslim Doctors and Islamic Bioethics: Insights from a Na tional Survey of Muslim Physicians in the United States. In:Aasim P. (ed.). Medicine a nd Shariah: A Dialogue in Islamic Bioethic s. Notre Dame, University of Notre Dame Pres s; 2021. pp. 193-226
  29. Curlin, F.A., Sellergren, S.A., Lantos, J.D. and Chin, M.H. Physicians’ ob servations and interpretations of the influence of religion and spirituality on health. Archives of internal medicine, 2007, Apr 9, 167(7), 6 49-654.
  30. Al-Ghazal, S. K. Rapid respons e to: It’s time for all doctors to engage on assisted dying [internet]. 2021, Sep 9 (cited 2021, Sep 9) . Available from: https://www.bmj.com/content/37 4/bmj.n2206/rr-4
  31. van den Branden, S. and Broeckaert, B. Living in the hands of God. English Su nni e-fatwas on (non-) voluntary euthanasia and assisted suicide. Medicine, Health Care and P hilosophy, 2011, Feb;14(1), 29-41.
  32. Denys, D. Is euthanasia psychiatric treatment? The struggle with death on request in the Netherlands. American journal of psychiatry. 2018, Sep 1;175(9), 822-3.
  33. The Holy Qur’an: chapter 2, verse 156.
  34. Kwon, J.S.J. Psychosomatic Approach to Job’s Body and Mind: Based on Somatic Symptom Disorder. Journal of religion and health. 2020, Aug 59(4), 2032-44
  35. Greenstein, E.L. Metaphors of illness and wellness in job. In: S.C. Jones and C.R. Yoder (eds.).“When the Morning Stars Sang”: Essays in Honor of Choon Leong Seow onn the Occasion of His Sixty-Fifth Birthday. Berlin, Boston: De Gruyter; 2017, pp. 39-50.
  36. Dell, J. The Book of Job. Berlin, Germany: de Gruyter; 1991.
  37. The book of Job: Chapter 1, verse 21.
  38. Ibid: Chapter 3, verse 1.
  39. Ibid: Chapter 7, verse 15.
  40. Ibid: Chapter 16, verse 6.
  41. Ibid: Chapter 17, verse 11
  42. Ibid: Chapter 17, verse 15.
  43. Ibid: Chapter 27, ve rses 5-6.
  44. Ibid: Chapter 22, ve rses 21-22.
  45. Maravia, U. and A l-Ghazal, S.K. Bimaristans: Services and their educational role in Islamic medical history and their influence on modern medicine and hospitals. JBIMA, 8(3), 1-15.
  46. Wiebe, E., Shaw, J., Green, S., Trouton, K. and Kelly, M. Reason s for requesting medical assistance in dying. Canadian Family Physician. 2018, Sep 1:64(9), 674-9.
  47. Al-Bar, M.A. and C hamsi-Pasha, H. Autonomy. In: Mohammed Ali B. and Hassan C-P. (eds.). Contemporary Bioethics. Springer, Cham; 2015, pp. 107-118
  48. Padela, A. Islamic medical ethics: a primer. 2007, Bioethics, 21(3), 169-78.
  49. Chamsi-Pasha, H. and Albar, M.A.Western and Islamic bioethics: H ow close is the gap? 2013, Avicenna J Med, 3( 1),8-14.
  50. The Holy Qur’an: chapter 96, verses 6-7.
  51. The Gospel of John: Chapter 21, verse 18.
  52. van der Geest, S. and Satalkar, P. Autonomy and dying: Notes about decision-making and “completed life” euthanasia in the Netherlands. Death studies. 2019 Oct 22:1-0.
  53. Schuklenk, U. Is Assisted Dying the Baby Boomers’ Last Fron tier? Bioethics. 2016, 30(7) ,470.
  54. Hartling, O. Euthanasia and the Ethics of a Doctor’s Decisions: An Ar gument Against Assisted Dying. London, UK: Bloomsbury Academic.
  55. The Holy Qur’an: chapter 36, verse 38.
  56. The Holy Qur’an: chapter 30, verse 54
  57. The Holy Qur’an: chapter 17, verse 23
  58. Hartling, O. Euthanasia and assisted dying: the illusion of autonomy – an essay by Ole Hartling. BMJ, 2021 Sep 9; 374:n2135.
  59. Al-Tabarsi, R.D. Makarim; al-fa sl 1: fi adaab al-maridh wa’la’id wa ilajih; fi thawab al-mareedh. Beirut, Lebanon:Mu’assasat al’Arabi; 2004
  60. Sulmasy, D. Ethics and the psychiatric dimensions of physician-assisted suicide. In: Jones, D.A., Gastmans, C. an d MacKellar, C. (eds.). Euthanasia and assisted suicide: lessons from Belgium. Cambridge, UK: Cambridge University Press; 2017, pp. 49-64.
  61. Gibson, G. Money and indepen dence in old age. In: Arber S. and Maria E. (Eds.). Ageing, independence and the life course. London: Jessica Kingsley Publishers; 1993, pp. 46-64
  62. Seale, C., Raus, K., Bruinsma, S., Van der Heide, A., Sterckx, S., Mortier, F., Pa yne, S., Mathers, N. and Rietjens, J. UNBIASED consortium. The language of sedation in end-o f-life care: The ethical reasoning of care pro viders in three countries. Health, 2015, Jul 19(4), 339-54.
  63. van der Geest, S. and Satalkar, P. Autonomy and dying: Notes about decision-making and “completed life” euthanasia in the Netherlands. Death studies, 2019, Oct 22, 613 -622.
  64. Borneman, T. Bluman, O.F., Kl ein, L., Thomas, J., Ferrell, B. Spiritual care forr Jewish patients facing a life-threatening illness. Journal of palliative care, 2013, Mar 29(1), 58-62.
  65. Brennan, C. (2015). How Chilean cystic fibrosis sufferer, 14, who begged her government for the right to die has changed her mind thanks to inspirational Argentinian survivor, 22 [internet]. 2015, March 23 (cited 2021, Se p 25). Available from: https://www.dailymail.co.uk/news/article-3007179/Chilean-gi rl-14-begged-government-let-die-struggles-cystic-fibrosis-changes-mind.html
  66. 2 Samuel 1: Chapter 6, verse 16.
  67. Hanbal, A. Musnad Ahmad bin Hanbal (vol 6); Musnadan’nisa; Hadith Umm al-fadhal imra’at Abbas. Beirut, Lebanon: Aalam al-Kutub; 1998.
  68. Drion, H. (1992). S uicide in the elderly. Crisis, 132, 2, 52
  69. The Holy Qur’an: chapter 99, verse 7
  70. The Holy Qur’an: ch apter 6, verse 160
  71. Dhar, N, Chaturv edi, S.K. and Nandan, D. Spiritual health, the fourth dimension: a public health perspective . WHO South-East Asia Journal of Public He alth. 2013, Jan 1, 2(1), 3-5.
  72. Dhar, N., Chaturvedi, S.K. and Nandan, D. Spiritual health scale 2011: Defining and measuring 4th di mension of health. Indian journal of com munity medicine: official publication of India n Association of Preventive & Social Medicine, 2011 Oct,36(4), 275-282.
  73. Romain, J. and Carey, G. There is nothing holy about agony: religious people and leaders support assisted dying too. BMJ, 2021, Sep 9, 374.
  74. The Gospel of John: Chapter 3, verses 1-8
  75. Al-Bukhari, M. I. Shahih al-Bukhari; Kitab al-mardhaa; Bab nahytamann al-mareedh al-maut. Beirut, Lebanon: Dar Tauq al-Naja; 2001.
  76. Naisapuri, M. H. Sahih Muslim; Kitab al-birwas’silawa’laadaab; Bab tahreemdhulm al-muslimwakhadhlihi w’ihtiqarihwairdhiwamalih.Beirut, Lebanon: D ar Ihya al-Turath al-Arabi; N.D.
  77. The Gospel of Matth ew: Chapter 25, verse 36.
  78. Naisapuri, M. H. Sahih Muslim;Kitab al-birwas’silawa’laadaab; Bab fadhleyadat al-mareedh. Beirut, Lebanon: Dar Ihya al-Turath al-Arabi; N.D.
  79. Ebrahim, A.F.M. and Padela, A.The Islamic juridical principle of dire nec essity (al-darura) and its application to the field of biomedical interventions. In: Aasim P. (ed.). Medicine and Shariah: A Dialogue in Islamic Bioethics. Notre Dame, Indiana: University of Notre Dame Press; 2021. p. 57-70.
  80. Asif, N. An introduction to sharia law and the death penalty [internet]. 2021, Jan 26 (cited 2021, Sep 25). Av ailable from: https://www.law.ox.ac.uk/research-and-subject-groups/death-penalty-research-unit/blog/2021/01/introduction-sharia-law-and
  81. The Holy Qur’an: chapter 5, verse 32.
  82. Mahdi, N. Hukum Eutanasia Mercy Killing [internet]. 2012, Dec 27 (cited 2021, Sep 25). Available from: www.muftiselangor.gov.my/2016-06-27-08-57-00/fatwa/fatwa-terkini/217-hukum-eutanasia-mercy-killing
  83. The Holy Qur’an: chapter 4, verse 29.
  84. Davis, J. It’s more vital than e ver that we have data to support the debate on assisted dying. BMJ, 2021; 374:n2173.
  85. Wagner, B., Muller, J. and Maercker, A. Death by request in Switzerland: Pos ttraumatic stress disorder and complicated grief after witnessing assisted suicide. European Psychiatry. 2012, 27(7), 542-6.
  86. Gamondi, C., Pott, M., Forbes, K. and Payne, S. Exploring the experiences of bereaved families involved in assisted suicide in Southern Switzerland: A qualitative study. BMJ Supportive & Palliative Care. 2015, 5(2), 146-52.
  87. Dees, M.K., Vernooij-Dassen, M.J., Dekkers, W.J., Elwyn, G., Vissers, K.C. and van Weel, C.Perspectives of decision-making in requests for euthanasia: a qualitative research among patients, relatives and treating physicians in the Netherlands. Palliative Medicine, 2013, 27(1), 27-37.
  88. Rapid Response Service (2017). Impact of medical assistance in dying on family and friends. Toronto, Canada: Ontario HIV Treatment Network [internet]. 2017, June (cited 2021, Sep 25). Available from: https://www.ohtn.on .ca/rapid-response-impact-of-medical-assistance-in-dying-on-family-and-friends