Comparative Study between Islamic and Western Bioethics : The Principle of Autonomy

by | Aug 1, 2022 | 0 comments


 

Abstract

Western ethics has developed into a philosophical science, drawing more upon human reason and experience as the arbiter between right and wrong action. This development is not paralleled in Islamic intellectual discourse. Islamic ethics incorporates various philosophical traditions but draws its resources mainly from religious texts. Islamic ethics is rooted in the Holy Qur’an, and the tradition of the Prophet Mohammed (PBUH). The four general principles of biomedical ethics are: (1) Respect for autonomy, (2) Beneficence, (3) Non-maleficence, and (4) Justice. Islam upholds the underlying virtue of these four principles, but diversity arises in their interpretation and practical applications. In the Western bioethics, patient’s autonomy and self -determination prevails in all sectors of social and personal life, a concept unacceptable in Islam.

Islam covers all aspects of life as an integrated system emphasizing the importance of the values and practices to achieve divine satisfaction. All medical decisions must be guided by the faith, which in practice implies adherence to the Shari’ah (Islamic law), participation in lawful matters, and the avoidance of forbidden points such as sexual promiscuity, alcoholism, illicit drug use, transgender, and assisted suicide.

Introduction

The world Muslim population is around1.8 billion followers worldwide, and increasingly growing at a rate of 1.8 per cent annually. The majority of which live in Islamic countries and an appreciable number live in non-Islamic states. Many Muslim physicians work in the Western countries. Citizens from Muslim-majority nations made up 4.5% of the US physician workforce in 2019.1Despite modernity and the forces of secularization, religion lies at the heart of most cultures. Padela et al. found that 55 per cent of doctors in US hospitals agree that their Islamic/religious beliefs influence their medical practice.2

Modern science was developed in the West within an atmosphere of hostility against the church. Advances in the area of science and technology were paralleled by repulsion against religion and faith. Technological progress in the field of medicine has created dramatic interactions with traditionally held values.3 Some Muslims are presently caught at a crossroad between the traditional and the modern values. The attraction of material wealth, individualism and sexual freedom has threatened a section of Muslim youth and educated elite to side away from the religion of Islam.4

The Holy Quran commands Muslims to not only do good but also to forbid evil actions. In Islam, individuals have an apparent picture of what is right and wrong as enshrined in the Quran and Sunnah (tradition of the Prophet).For Muslims, being rational does not mean only to justify things intellectually but also to examine every single aspect of moral conduct to determine whether such behaviour aligns with Islamic law or not.

While the medicine practiced by Muslims and for Muslims is generally the same medicine practiced in the West today, the medical ethics may be different. The universal applicability of the Western framework of professionalism in non-Western contexts has been recently questioned.5,6To date, few studies have investigated the perception and implementation of the physician charter in non-Western cultures.7 The use or non-use of a renowned medical treatment by Muslim doctors will sometimes be guided more by ethics derived from Islamic law than by purely medical considerations. The modern person rarely thinks of medicine as having any religious or ethnic boundaries.

A glance through medical libraries and catalogues of ethics reveals that there are Jewish medical ethics, Catholic medical ethics, etc. Islamic medical ethics is almost overlooked as a distinct branch of medical ethics but gained importance in the second half of the 20th century.8,9

Bioethical deliberation is inseparable from the religion itself, which emphasizes continuities between body and mind, the material and spiritual realms and between ethics and jurisprudence.

Islamic bioethics is an extension of Shari’ah (Islamic law) which is based on two foundations: The Qur’an and the Sunna. Development of Shari’ah over the ages has also required Ijmaa (consensus of all competent jurists after the death of the Prophet Muhammad Peace Be Upon Him (PBUH) and qiyas (analogy) using the human reason when no clear rule is found in the Quran or Sunna, resulting in 4 major schools of jurisprudence. Where appropriate, consideration is also given to maslaha (public interest) and urf (local customary precedent).

In absence of an organized “church” and ordained “clergy” in Islam, the resolution of bioethical issues is left to qualified scholars of religious law, who are called upon to provide rulings on whether a proposed action is forbidden, discouraged, neutral, recommended or obligatory.

 To respond to new medical technology, Islamic jurists, informed by technical experts, have regular conferences at which emerging issues are explored and consensus is sought. Over the past few decades, these conferences have dealt with such issues as organ transplantation, brain death, assisted reproduction, and even genetic engineering and stem cell therapy. 9

Western secular model

The Western secular model of bioethics had its primordial origins in the West as a severe reaction against the authoritarianism of the Church. It was grounded in secular philosophical principles relying on human reasoning alone and without any religious contribution.4 Secular Western bioethics can be described as rights-based, with a strong emphasis on individual rights.

The principalism approach to biomedical ethics is broadly accepted and discussed among Muslim scholars. According to this approach, the four general principles of biomedical ethics are: (1) Respect for autonomy, (2) Beneficence, (3) Non-maleficence, and (4) Justice. One can easily find all these universal principles, not only in the Holy Qur’an and among the “sayings” of the Prophet(PBUH), but also in teachings of many other great Muslim scholars throughout the history.

There are a lot of similarities between western and Islamic values. Both values have the same intention of nurturing better mankind. Two western values, namely “Power” and “Hedonism” have no direct link with Islamic values. Muslims believe that only God the Exalted has the ultimate will and power over life and death. Islam encourages the attitude of promoting “maslahah” rather than focusing on worldly pleasures.10

In Islamic Ethics, the basic assumption is faith in God (with other pillars of Islam) and morality is the attempt of each individual as well as a society to approach him as far as possible. God alone defines the standard of right and wrong. God’s commands are purposeful and His will extends to all areas of life and every field of action.

In medicine, there are sometimes difficult decision-making options for the patient’s care.A physician may have to decide for his/her patient in light of available knowledge, his/her experience, his/her peers and consensus of the community. In addition, a Muslim physician derives his/her conclusion from rules of Islamic laws (Shari’ah) and Islamic medical ethics.

The first main principle of Islamic Medicine is emphasis on sanctity of human life which derives from the Qur’an: “If anyone saved a life, it would be as if he saved the life of all mankind”.11 The second main principle is the emphasis on seeking a cure. The Prophet Muhammad (PBUH) said: “Seek treatment, for God the Exalted did not create a disease for which He did not create a treatment, except senility”.12

The main feature of Western bioethics is the separation of religious and moral values and confining them to the private domain of individual conscience. The distinction of Islamic medical ethics vis-à-vis principilism-based medical ethics lies in it giving a religious basis to morality. The human being according to the Islamic dogma is created by God and he/she should obey the orders of God, as revealed by his Messengers. God himself gave human beings a degree of autonomy to choose between things and hence he/she will be held responsible for their actions.9,13

A Muslim physician should make a decision in the best interest of the patient, whether Muslim or non-Muslim, and without imposing his/her religious views on the patient.

 The Role of the Family

The Western attitude of individualism it is not accepted in many societies. In Asia, Africa, and the Middle East the family plays a major role in medical decisions. The patient whether he is elderly or a young person, has to listen to the opinion of his close family to the mode of treatment he/she is going to accept.9The role of the family and close friends should be respected in places where they have different philosophies and cultures that differ greatly from Western liberal, individualistic patterns. Even in the West, with different minorities, e.g., Chinese, Indians, Pakistanis, etc., the role of the family should be respected as the patients themselves agree to this role, and health providers have to understand that there are different cultures that do not give priority to autonomy, as it is understood in the West.13Beauchamp and Childress defended the right of patients to choose whatever they find appropriate. They can delegate decision-making to a member of the family, a proxy or even to the treating physician.14

In most countries of Asia, Africa, and the Middle East there is no health insurance for the public at large and the family usually bears the burden of any cost of medical intervention.

A Muslim patient lives in social coherence, in which influences of the relatives play their role. Healthcare practitioners should not always allow patients’ families to control what can or cannot be disclosed to competent patients. This is particularly important when patients are approaching death so that they may address their material and spiritual wishes—among other needs—as they prepare for death.15

 Autonomy

Autonomy is a Greek word, autos: self, nomos: govern, rule, i.e., self-rule or self-government. In order to have autonomy two conditions are essential: Free will and capacity of intentional action by an adult competent individual. Personal autonomy means self-rule free from being controlled by others and from inadequate understanding that prevent meaningful choice.9

The concept of autonomy in Western culture emphasizes individualism, personal gratification, and self-actualization. 16Within such a paradigm, sexual acts between any consenting adults, abortion, and one’s right to euthanasia or suicide are seen as acceptable variations of the norm and secular bioethics does not offer any limits.The right to self-determination, while highly regarded, is not absolute in Islam, as humans actions and hence freedoms are curtailed by law, public and individual conscience. Islam seeks a balance between these three concentric circles.4

Strict adherence to the Western medical ethics and autonomy is insufficient to solve ethical dilemmas in modern medicine, as it denies the role of faith in human being.3Islamic jurisprudence acknowledges autonomy as stipulated by the assertion that no one is entitled to dispose the right of a human being without his/her permission.17

The Holy Qur’an declares “there is no compulsion in religion” and each person has the full will to accept Islam or refuse it “Then whosoever wills, let him believe, and whosoever wills, let him disbelieve”.18The Qur’an said to the Prophet Muhammad: “So, will you (O Muhammad) then compel mankind, until they become believers.”19

Religious morality is not incompatible with human freedom and responsibility. The Qur’an is replete with verses that orders freedom of faith and human personal responsibility. The Qur’an puts its trust in the rational power of human beings to distinguish between truth and falsehood.20

The practice of contemporary medicine has been tremendously influenced by Western ideas and it is assumed by many that autonomy is a universal value of human existence.21

Limits of Autonomy

In the West, freedom is equal to autonomy and is regarded as a distinct value category22 .  Islam does not permit man to act as he wishes but limits him with certain rules. These rules are basically from the scripture and the life of the prophet (PBUH).Although the underlying essence of an individual’s autonomy is something which can be said to be intrinsic to the Islamic faith, the practical outward manifestations with relation to public interest, and the ultimate view of the human being’s subservience to God contrast significantly with the Western philosophical model.Islam, on the other hand, does not permit man to simply behave, or indeed misbehave, as he wishes, but rather gives a holistic set of guidelines for all facets of life and an example in the life of the Prophet23. This is followed by the free will to either accept or reject the divine command: ‘Let there be no compulsion in religion: the Truth stands out clear from Error’24

Patients have the right to choose, as well as the right to accept or to decline information. Health provider should explain all facts and possibilities of management, salient side effects and leave decision to the competent adult patient or his guardian (innon-competent). If the patient himself asks the health provider for his advice, he should give it.

The freedom of one person cannot, in anyway, interfere with other people’s freedom; otherwise it will be a hegemony or dictatorship. The limit of the freedom is respect of others freedom, faith and conduct as long as it is not going to disturb the community or sects in that community.

The rights of any one are reciprocated by duties. Those who speak of woman’s rights to abortion, as the fetus is part of her body, and she, according to their point of view, can remove that part if she wishes. There is a fallacy here; the baby in her womb is another life (formed from both parents), and it is an independent new life though still needing the mother’s placenta and womb for its growth. Killing that fetus (baby) is killing another life or at least (in its early stages) a prospect of another life9.

In Islam, freedom means to relieve oneself from body slavery and to select consciously the correct way. It has a more extensive concept than freedom in the West and conveys acting based on conscience rather than deliberately. In Islam, freedom directs human to the right/divine way.

Muslims feel very strong that it is God who does the actual healing, the doctor being only the agent for the will of God. For a Muslim patient, absolute autonomy is very rare, there will be a feeling of responsibility towards God13.

In Islamic context, the priority appears reserved for the principle of public benefit and the collective interest takes precedence over that of the individual autonomy25.

Furthermore, the family often remains the important subject for the patient’s decisions in difficult situations.

The human being in Islamic teaching is entrusted with his body, his faculties, his youth, and his fortune.  He cannot mutilate himself, or do harm to himself by smoking, taking drugs or imbibing alcohol. Health provider should, in Islamic teachings, encourage the patient to avoid risky behavior and life-style which would encroach on his health.9It is obligatory for Muslim physicians to dissuade or even prevent hazardous lifestyle and behaviors that undermine individual and collective well-being, such as sexual promiscuity, alcoholism, environmental pollution, illicit drug use, and smoking26.

These activities are confined within the sphere of personal autonomy in the West and are thus regarded as an individual’s choice. In Islam, an individual’s freedom of choice is constrained by the harm it causes to others. Here again, the individual’s autonomy is denied by the Islamic injunction on nonmalficence3.

Although autonomy remains a central doctrine of bioethics, it should not be the absolute privilege of the patient but rather a shared responsibility between the patient, family, and the physician. Promoting patient autonomy does not mean that the physician’s expertise should be ignored or disregarded.3

The physician is not only a by-stander providing data alone, but a caring person for his patient or client. A patient who has had bypass surgery may want to continue to smoke or a patient with bacterial meningitis may refuse antibiotics. Other examples concern a patient’s right to demand treatment that the patient wants but that the physician thinks is unnecessary, inappropriate or even harmful.9This attitude is different from the Western type of autonomy which keeps a distance between the health provider and the patient.

Islamic bioethics is straight-forward in prohibiting reproductive cloning on its own features and also guess social chaos and anarchy. Western secular bioethics has both arguments and counter arguments both for and against this scientific innovation.

Transgender

One of the hot topics that have been considered in the public sphere nowadays is the issue of the transgender or Transsexual phenomenon. Transgender is related to the problem of gender identity. It refers to the condition in which the perpetrators identify their identity and gender differently from their sex biologically. Current discussions on gender and sexuality are largely influenced by Western socio-cultural practices. Some current views and practices on gender and sexuality are not consistent with traditional Western Christian and Islamic values.27

 Transsexuals are people who experience a gender identity that is inconsistent with their assigned sex and desire to permanently transition to the sex or gender with which they identify, usually seeking medical assistance (including sex reassignment therapies, such as hormone replacement therapy and sex reassignment surgery) to help them align their body with their identified sex or gender. In other words, these are persons who are healthy and have fully developed parts of the body, but they change their sex only to satisfy their sexual or inner pleasure. The process of switching to other sex is based on surgery which is done by changing the male organs to female or vice versa. A surgeon removes the penis and testicles of males and makes a hole in the vagina and gives hormones in order to grow up breast and female voice. If a female wants to change her sex, then a surgeon removes her female sex organs and plants an artificial penis, and gives hormones in order to grow up beard on face, etc. But these changes are just apparently and do not have any actual function. 27Artificial female or male is not able to perform sexual reproduction or have any sperms or mensuration etc.

There is a steady rise in the number of sex change surgeries being performed annually, with a total 8304 in 2017 to a total of 9576 in 2018, with 2885 of male to female surgeries and 6691 of female to male surgeries. The reported complications based on the limited available literature are variable, with certain procedures like double flap phalloplastyin transgender men as high as 53%.28

 Poor mental health and psychological distress are disparately high among transgender people. In the USA, where transgender adults represent an estimated 1·4 million individuals, according to the National Centre for Transgender Equality, 40% report attempted suicide and depression, 33% anxiety, and 26% alcohol or drugmisuse.29 

Transgender is totally prohibited in Islam and considered to be impermissible in accordance with the Holy Quran and the Prophet’s sayings. It is not possible for anyone, no matter who he is, to change the creation of Allah, may He be exalted, from male to female or vice versa. The Quran mentionsthe saying of the Satan:”I will mislead them, and I will create in them false desires; I will order them to slit the ears of cattle, and to deface the (fair) nature created by Allah.”30  The Hadith in Sahih Bukhari states that “Narrated Ibn’ Abbas: Prophet Muhammad cursed effeminate men who assume the manners of women and those women who assume the manners of men.” According to the Hadith in Sunan Abu Dawud “Narrated Abu Hurayrah: The Apostle of Allah cursed the man who dressed like a woman and the woman who dressed like a man.”

In Islam, the person with somatic sex ambiguity due to a disorder of sex development (DSD), such as 46,XX congenital adrenal hyperplasia or 46,XY androgen insensitivity, is recognized as “khunthah”31 (literally translated as hermaphroditism).

Transgender is different from “sex reassignment” or “sex correction”. The process of “sex correction” is done for people who have a defect in the sex glands. This results in the presence of a “suspicious” person between male and female which is known to jurists as “hermaphrodite” and his sexual organs are ambiguous between masculinity and femininity. He can usually have surgery to establish his true and correct gender. The operations of “sex correction” are correction from the wrong position to the correct position, and it is permissible in Islam. This treatment is not altering but correcting physical abnormalities.

In many European countries today, freedom to choose sex is encouraged in the early school stages, and there are organized campaigns in this aspect to influence public opinion, and to instil that concept and encourage people to it. Some Western legislations consider sex conversion as a human right that may not be restricted by any restrictions, to the extent that these legislations, as is the case in Denmark and Norway, have created legal sex conversion. Some homosexual patients who are fully aware of their sexual preferences assume the pose of having gender dysphoria in order to justify their sexual proclivity to continue with their relationships with other males or seek male attention. Homosexuality is prohibited under Islamic law.32

End of life

Based on the Prophetic tradition, patients are not prohibited from seeking treatment to cure their illnesses. At the same time, they can also choose to be patient with the illness and abandon seeking treatment. According to al- Ghazzālῑ in his notable work Iḥyā’ ‘Ulūmuddῑn, refusing treatment is made due to certain conditions33, which include the following: i) A person who is suffering from a chronic disease and the recovery is unlikely. ii) A person who is terminally ill and death is imminent.iii) A person who chooses to stay patient with the hope that the illness that he/she is currently suffering from will elevate his/her status in the sight of God. iv) A person who was sinful throughout his/herlife chooses to stay patient with the illness so that his/her patience will be the source of forgiveness from God.33

According to the juridical opinions from many scholars, abandoning treatment is permissible and not considered sinful when there is lack of established efficacy with regards to the treatment. Consequently, if there is no treatment with a probable clinical efficacy to cure the illness, especially in the case of the first two conditions that were mentioned by al-Ghazzālῑ, seeking treatment is deemed not to be needed.34,35

In end-of-life cases, the doubtful efficacy of life support is often raised. End-of-life patients are included among those who are permitted to refuse treatments. Medical practitioners are also not obliged to perform treatments that bring doubtful benefits to the patients36, particularly life sustaining treatment in end-of-life care.

In Islamic ethics, an individual’s welfare is intimately linked with his or her family and community. Hence, neither autonomy nor paternalism is the determining factor in deciding a course of action in matters relating to end-of-life decisions, but rather, a joint decision made by all parties associated with the patient, which may require the involvement of religious authorities, if needed.37,38

Advance Medical Directive

Advance Medical Directive (AMD) is not a Western innovation. It was practiced by the Prophet Muhammad (PBUH) fourteen centuries ago. Advanced directive is a document in which a healthy person explains in writing which medical treatment he/she would accept or refuse at that critical juncture when he/she may not be in a position to express his/her wishes in case of emergencies, terminal illnesses, and situations where they may be incapable of making decisions. In other words, this document assists the attending physician to withhold or withdraw certain medical procedures and allow the patient to die naturally.

The following may be incorporated into the living will:

  1. a) Request to discontinue treatment: A terminally ill Muslim patient can request that treatment be discontinued if the treatment would not in any way improve his/her condition or quality of life based on the Islamic juridical principle of la dararwa la dirar(no harm and no harassment). The intention here is not to hasten death, but the refusal of “overzealous” treatment. However, “palliative” care in the sense of maintaining personal hygiene and basic nutrition should not be discontinued.

 

  1. b) Instruction to switch off the life-support equipment:

A healthy Muslim may instruct that should he/she, as a result of a terminal illness or massive head injury, be diagnosed as brain dead, then the life-support equipment should be switched off.

  1. c) Inclusion of organ donation.9,39

In Islam, respecting the wishes of patients is in line with the tradition of Prophet Muḥammad which was narrated by his wife, ‘Ā’ishah saying: “We poured medicine in one side of the Prophet’s mouth during his illness and he started pointing to us, meaning to say, “Don’t pour medicine in my mouth.” We said, “(He says so) because a patient dislikes medicines.” When he improved and felt a little better, he said, “Didn’t I forbid you to pour medicine in my mouth?” We said, ” (We thought it was because of) the dislike, patients have for medicines. He said, “Let everyone present in the house be given medicine by pouring it in his mouth while I am looking at him, except `Abbas as he has not witnessed you (doing the same to me).’40

The consent of a patient to accept or refuse medical treatment corresponds to the above tradition, which was exemplified by Prophet Muḥammad (PBUH). His refusal of treatment in the above tradition is similar to what is intended by AMD, which is to empower patients to decide and determine their choice of future healthcare. Therefore, it can be inferred from the Prophetic tradition that Islam does not prohibit the implementation of AMD in decision-making. Patients must be able to understand and accept the consequences should life-sustaining therapy be withheld or withdrawn. The attending medical practitioners must be able to identify the capacity of a patient to make decisions. Medical practitioners in charge must honour the wish of the patients to refuse intervention. However, there are clear limits that must be adhered to in Islam, such as the prohibition of the following:

  1. i) euthanasia and assisted suicide; ii) refusal of curative and life-saving treatment and iii) refusal of basic care, which includes provision of artificial nutrition and hydration if the intention is to hasten death.39

Assisted dying

Life is given by God and cannot be taken away except by Him or with His permission. Preservation of life is one of the five basic purposes of sacred law. The Qur’an says “… if anyone killed a person, not in retaliation of murder, or (and) to spread mischief in the land – It would be as if he killed all mankind, and if anyone saved a life, it would be as if he saved the life of all mankind…”.41One cannot take one’s own life: “And do not kill yourselves (nor kill one another). Surely, God is Most Merciful to you”.42

The physician has no right to terminate any human life under his care. There is pain and suffering at the terminal end of an illness, but Muslims believe there is immeasurable reward from God for those who patiently persevere in suffering. “Only those who are patient shall receive their rewards in full, without reckoning.”43

Giving pain-killers including morphine derivatives is acceptable in Islam if the pain is severe.

Assisted dying is increasingly advocated in public discourse as a humane response to a terminal prognosis and distress on the part of selected patients, and their care providers.44

There appears to be momentum internationally to permit some form of assisted dying within legal processes, with the Governments in areas of Australia, Germany, Ireland, Portugal, Spain, and New Zealand being the latest to produce legislation in support of these practices45.

In Western Europe, an increasing and strong public support for euthanasia and physician-assisted suicide has been reported; in Central and Eastern Europe, support is decreasing. In the United States, less than 20% of physicians report having received requests for euthanasia or physician-assisted suicide, and 5% or less have complied.46 Bauer argues that Euthanasia cannot be restricted to exceptional cases, based on the idea that the patient’s autonomy is to be valued more highly than their actual illness. If autonomy is of absolute value, it could not be limited to the most serious cases of illness.47

Islamic law clearly prohibits euthanasia in all circumstances. However, the wishes of the patient not to have his dying prolonged artificially in the presence of hopeless prognosis need to be respected and abided by. Such wishes may be declared in the accepted “standing Do Not Resuscitate (DNR) orders” in certain hopeless medical conditions.48 Assisted dying or euthanasia is not allowed even if the patient insistently request it and his family agree to it. No one is authorized to deliberately end life, whether one’s own or that of another human being.49

Conclusion

The concept of autonomy in Western culture emphasizes individualism, personal gratification, and self-actualization. Autonomy is an important ethical principle that is basic to human dignity, however the obligation to respect autonomy is not absolute as there are challenges to its universal validity.

Islamic bioethics affirm health preservation and disease prevention. Islam does not permit man to act as he wishes but limits him with certain rules. Muslim patients can make their own choices and decisions about medical care and treatment within the defined limitations of the Islamic law (Sharī’ah).Medical decisions are guided by the faith, which in practice implies adherence to the Islamic law, participation in lawful matters, and avoidance of forbidden actions. For example, transgender, cloning, and assisted suicide are prohibited in Islam.

Islam is not just a religion, but rather a way of life. As a comprehensive religion, Islam covers all aspects of life in an integrated system asserting the importance of the values to achieve divine satisfaction. 

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