Prof. Musa Mohd Nordin
Consultant Pediatrician, Malaysia
Chairman, Advisory Board of the Federation of Islamic Medical Associations (FIMA)
The cardinal purposes of the Muslim’s individual, community and global life experiences have been comprehensively defined by the maqasid al- shari`ah, the highest objectives of Islamic jurisprudence. The wellbeing and welfare of the community is protected by the preservation of the five essentials (daruriyyat) in human life, namely faith and morality (din), life (nafs), intellect (‘aql), progeny (nasl) and wealth (mal) .
In the hierarchy of the maqasid al-shari`ah, the sanctity of human life is prioritised, second only to the preservation of din. Life is a divine gift and trust from Allah (ﷻ) and its protection and continuation is of utmost urgency and importance. “And if anyone saved one life, it would be as if he had saved mankind entirely”.
Allah, the Life Giver (al-Muhyi) is also the Life Taker (al-Mumit).
“He gives life and causes death (yuhyi wa yumit), and to Him you will be returned” .
The following prayer taught by the Prophet (ﷺ) reiterates the fact that only Allah (ﷻ) decides and determines the timing of life and death: “O Lord! Please let me live if that is for my good and please let me die if that is better for me”.
Death marks the departure from the continuum of temporal life here on earth and a journeying towards eternal life in the hereafter. We are exhorted to invest our life righteously so as to enjoy the fruits in the life hereafter. We are regularly reminded to prepare for the afterlife and central to this exhortation is the constant preparedness for death
Life and death issues become even more pronounced and complicated with end of life care and the myriad of clinical choices available. Advances in medicine and surgery have revolutionized the care of patients with cancer, cardiac disease and others with major organ failures. There have been improvements in the morbidity and mortality rates of the critical and terminal patients, however with variable and questionable betterment of their quality of life. The power of the science of healing has somewhat overwhelmed the art of healing and has unwittingly unleashed new sets of clinical, ethical, legal, cultural and religious issues which now challenge our objectives and ethics of end of life care.
Physicians, patients and their families are faced with extremely perplexing and painful dilemmas which include among others:
- How much more should we allow our loved ones to suffer?
- Should we explore all treatment options even though the prognosis is poor?
- Should we allow the respirator, and other life support modalities, to be disconnected upon the advice of the attending clinicians?
- Should we consent to Do Not Resuscitate orders (DNR)?
- How much longer can we afford the care of our loved ones in the ICU?
The Federation of Islamic Medical Associations (FIMA) first formally addressed these difficult yet important end of life care issues in our 2002 and 2005-06 Year Books [5,6]. With the plethora of life-saving interventions, sophistications of therapeutics and intensive care modalities, we felt that it was pertinent to re-examine a wider range of these end of life issues, from the perspectives of maqasid al-shari`ah, as the third part of the Encyclopedia of Islamic Medical Ethics .
We have comprehensively addressed and updated the scientific and medical developments of end of life care, as well as analysed the psychosocial, ethical, legal and Islamic perspectives.
I have summarized the practical and key messages from these excellent reviews of major issues related to end of life care which are relevant to the daily practice of physicians who care for the critically ill or terminal patient :
- Global life expectancy in 2015 was 71.4 years, ranging from 60.0 years in the WHO African Region to 76.8 years in the WHO European Region. Global average life expectancy increased by 5 years between 2000 and 2015. A thorough and contemporary understanding of the effects of aging on the various systems in the human body is a basic essential towards framing a holistic program for end of life care and its unique challenges. Apart from addressing their physical, cognitive and psychological needs, we must not neglect their continuing roles in society and benefit from their talents, experience and wisdom.
- Like all other specialties of medicine and surgery, a Muslim physician’s approach to the specific issues related to end of life management must be understood within the context of disease and its treatment in the Islamic paradigm.
- “There is no disease that Allah has created, except that He also has created its remedy” . This narration and several other Prophetic traditions emphasize the Islamic tradition for research into cures for ailments, thus urging believers to be at the forefront of medical research and the treatment and elimination of diseases.
- If the medical intervention is shown to be effective and safe and strongly correlated with a cure or recovery, Muslim scholars have opined that it is mandatory (wajib) to undertake the treatment.
- Otherwise, the default rule for all forms of treatment is optional (ikhtiyari) and not mandatory (wajib) according to the four schools of thought in Islam (madhhab). A few scholars hold the opinion that seeking treatment is supererogatory (sunnah). Very few scholars opine that it is obligatory (wajib) [9,10]
- If the specialist physician counsels his patient and/or family that the chances of a cure or recovery is virtually nil, then there is clearly no religious rationale for ruling that it is wajib or sunnah to offer or to continue with the said treatment modality.
- Therefore, not beginning or discontinuing the treatment modality (e.g. intubation, ventilation etc) is nothing more than choosing not to operationalise the ikhtiyari ruling. Thus, the physician cannot be penalised according to the laws (ahkam), nor should he/she feel any guilt when choosing not to execute an action which is ikhtiyari.
- Since the preservation of life is a priority of the maqasid al-shari`ah, we should always endeavor our very best to preserve and maintain life.
- When we recognize that a cure or recovery is not a realistic expectation, or the treatment options are an exercise in futility, or the treatment entails extreme measures, we may opt to withdraw or withhold such treatment modalities and should counsel the patient or family accordingly.
- We should ensure our patients continue to enjoy appropriate medical and nursing care, maintaining their fluid and nutritional requirements and provide optimal pain relief.
- We should encourage hospice care of the terminally ill as it is consistent with the teachings of Islam. The palliative care advocates a holistic approach, caring for the physical, psychological, social and spiritual wellbeing.
- We should check with the patient or the immediate relatives about any advanced medical directives that stipulate the patient’s choice of medical care or interventions, should clinical circumstances (e.g. coma or dementia) render him incapable of decision making when the need arises.
- Apart from healing the physical aspects, we should manifest our empathy by comforting our patients and encouraging them to beseech healing, patience, perseverance, and mercy from Allah (ﷻ).
- The definition and diagnosis of death, has significant importance and many implications from the medical, legal, ethical and Islamic perspectives.
- Euthanasia is categorically prohibited (haram) in Islam, even though it is increasingly advocated and legal in a few western countries.
- Encourage the practise of Talqin to ensure that our patients’ critical and end of life moments are righteous with the remembrance of Allah (ﷻ)
- Al-Shatibi (790/1388), al-Muwafaqat fial-Shari`ah, 1975; 2: 8–11, p 10.
- The Glorious Qur’an, Chapter 5, verse32
- The Glorious Qur’an, Chapter 10, Verse56
- An-Nasa’i 3/54, 55, Ahmad 4/364. See also Al-Albani, Sahih An- Nasa’i 1/281.
- Contemporary bio-medical issues in the light of Islam. FIMA Year Book 2002. Second Edition 2003, 97-114
- Geriatrics and end of life issues. Biomedical, ethical and Islamic horizons. FIMA Year Book 2005-06. Dec 2006, 1-127
- Medical care at end of life. Encyclopaedia of Islamic medical ethics (III). FIMA Year Book 2016.
- Sahih al- Bukhari 7/582
- Dr Yusuf al-Qaradawi, Fatwa al-Muathirah, Malay Edition, Dec 1995, Volume7 & 8, p 361.
- Dr Yusuf al-Qaradawi, Fatwa al-Muathirah, Malay Edition, Dec1995, Volume7 & 8, p 363.