Abstract
A quarter of all deaths in the UK are estimated to be caused by heart disease. Currently, the most effective
solution to save patients with end-stage heart disease is a heart transplant. Due to the shortage of donors, many patients continue to remain on the waiting list, but not all are fortunate to receive a heart in time and are overcome by death. From an Islamic perspective, one reason that Muslims could be reluctant to sign up as heart donors appears to be based on an interpretation of the hadith that prohibits breaking any bone of the deceased. We argue, based on a contextualised examination of this hadith that the prohibition does not apply to heart transplants because of the way transplants are performed and regulated in the UK in our time. We also argue that during heart retrieval, ‘dividing’ the sternum is the more appropriate clinical verb to describe sternotomy rather than using the deleterious verb ‘breaking’ which has negative connotations. Our article aims to help British Muslims who are considering becoming heart donors – to potentially save lives – to make an informed decision from an Islamic perspective.
Introduction
Heart damage can occur in any individual for several reasons. Heart failure could be caused by underlying health conditions or in some cases by genetic factors. In the UK, as of Jan2022, the number of people living with heart or circulatory (cardiovascular) diseases was estimated at 7.6 million [1]. This number is twice as many as the number of people living with cancer and Alzheimer’s disease combined. Consequently, approximately more than 160,000 of all deaths each year in the UK are caused by cardiovascular diseases. This is approximately a quarter of all deaths each year [1].
The most common causes of heart failure include myocardial infarction (heart attack) and high blood pressure [2]. Another common cause is cardiomyopathy (a disease of the heart muscle), which might be inherited or caused by, for instance, a viral infection such as rubella. Heart failure can also result from abnormal heart valves, congenital heart disease, and infection (endocarditis). Despite current improvements in the treatment of cardiovascular diseases, according to the NHSBT annual report on cardiothoracic organ transplantation:
The number of patients waiting for a heart transplant has increased substantially over the past decade, from 130 in 2011 to a peak of 340 in 2020, representing a 162% increase over the 10 years [3].
The BHF also highlighted that at the end of January 2022, the number of people on the cardiac waiting list had grown to 293,500 people; nearly 2,700 more than the previous month [4].
To manage a failing heart, medicines and different forms of treatment can help. However, when the ability of the heart to function deteriorates severely, the only remaining option in a select number of patients is a heart transplant. Even in a heart transplant, there is a range of options to consider including a human heart, a porcine heart, and even an artificial heart. Xenotransplantation is when an organ is retrieved from one species and transplanted into another – as in the case of transplanting a porcine heart into the human body (xenograft) – there are, however, two major obstacles. Firstly, the human immune system is very likely to reject the animal tissue, Secondly, there is a potential risk of animal disease passing onto the recipient. As such, and as it stands, there appears to be more harm than benefit with regard to xenotransplantation. This opinion, however,could be reviewed based on future developments in this regard [5].
Whilst patients wait for a suitable donor heart, among the challenges that physicians face with regard to treating the heart is to prevent their patients’ hearts from further deterioration. In most cases, the deterioration leads to significant breathlessness and simple acts of daily living, such as washing, dressing, or leaving the house become exceedingly difficult. The practical and optimal treatment option for such patients would be a suitable donor heart. However, to help them survive until a suitable donor heart becomes available, artificial devices to support the heart can be used. These devices can be implanted or inserted to support the failing side of the heart. A left ventricular assist device (LVAD) or a right ventricular assist device (RVAD) are used, which could allow such patients more time [6]. LVADs are battery-powered artificial heart pumps that require recharging every 4-6 hours.
LVADs, however, are scarce, and every year, approximately only 80 patientsare given an LVAD [6]. Even though LVADs can be lifesaving, as of June 2022, no more than approximately 100 patients in the UK currently live with an LVAD. The BHF states that:
The longest that we’ve supported a patient for with an LVAD has been five and a half years. Nowadays, 80-85 per cent of patients are alive a year after having an LVAD fitted and 70–75 per cent after two years
Whilst LVADs could be improved in the future and might even replace heart transplants, currently, LVADs serve only to buy more time for patients until a suitable donor heart is found. Bearing this temporary solution in mind, Anthony Clarkson, Director of Organ Donation and Transplantation at NHS Blood and Transplant, states ‘We can save more lives if more organs are donated, and we urgently need more hearts to help the hundreds of people waiting for a transplant’ [7].
For a heart transplant, physicians must consider several key factors in relation to the donor. These include ensuring that consent has been obtained to retrieve the donor’s heart, that the donor heart is healthy for transplantation, and that the donor has indeed died. Even after an individual consents to heart donation, the heart would only be retrieved only if it is suitable to transplant. As such, there could be medical reasons for why a heart donation would not proceed despite an individual having consented to be a donor.
In our discussion on this issue, we focus on the socio
theological reasons why a heart donationmightnot
proceed. One of the key arguments put forward against
organ donation by the former grand mufti of Pakistan
Mufti Shafi [8] revolves around human dignity. In this
context, we find that according to Muslim jurists, the
overarching goal of Islamic law is to preserve the honour
and dignity of the deceased. Muslim jurists agree on
several different actions that are considered
dishonourable. Fadlullah [9] lists some factors for
Muslims to consider in relation to cadaver donation
Below, we discuss four major factors related to honour
and dignity.
- Preservation of life: To take one’s own life is strictly
prohibited. However, fighting for one’s rights,
people, or resources also brings risk to one’s life.
Should one die for such a cause then such an act is
not viewed as suicidal by society but honourable
[10]. In the case of self-defence, the intention is to
ward off the antagonist and not die. Accordingly,
Shariah law permits and makes exceptions to general
rules when the outcome is to save a life. However a
life that is not a threat to the living cannot be taken to
save another life. - Human organs are not for sale: Selling human body
parts is viewed by Muslim jurists as dishonouring the
human body. As such, selling kidneys, for instance
is universally prohibited by Muslim jurists. - Consent: Operating on the body of another human
being without consent is not permitted [11].
According to Shariah law, a surgeon is not permitted
to cut deeply or even inject another human for
treatment without prior informed consent from the
patient. - Funerary rites: When a human dies, a proper and
timely funeral must be provided. If the deceased
identified themself as a Muslim, then the deceased
must be offered the Islamic funerary rites.
Accordingly, Muslims are instructed to carry out a
ritual wash and provide a shroud for all deceased
persons and bury them without any unnecessary
delay.
British Muftis are advised to consider heart donations
within the British context given the rules and regulations
enforced by the NHS and the Human Tissue Authority
(HTA). In the UK, the sale of a heart is prohibited and
would be highly unlikely because transplants are not
based on such financial agreements, rather the
transplantation process is regulated by the NHS and the
HTA. The transplantation process in the UK is
principally based on an algorithm designed to match a
suitable heart recipient [12]. The identity of the heart
donor is kept anonymous and the heart transplant process
does not include any mutual agreements between the
donor and recipient.
Consent
In the UK, a heart donation cannot proceed without
consent. Consent can be given either by opting to be a
donor or for those in England and Wales, by not opting
out of the law of deemed consent. Moreover, the law of
deemed consent in England and Wales is a soft opt-out
system. This process means that despite an individual not
having opted out from donating, the final decision rests
with the deceased’s family. Bearing the patient’s consent
in mind, Sachedina [13] highlights that ‘more pertinently,
desecration carried out in aggression is certainly different
to a clinical incision made with the deceased’s
permission left in the advance directive to retrieve an
organ’. As such, there appears to be no violation of
human dignity on the part of the donor or the transplant
team.
Funerary rites
Under ordinary circumstances, the corpse of a person
who identified as a Muslim is to be given a set of
funerary rites without any unnecessary delay. These rites
include a bath, a shroud (also known as a kafan), a funerary prayer, and a burial. These rites are considered
to be important as they are an expression of honouring
deceased Muslims. As a result of the heart retrieval
process, the burial is delayed, which is viewed by some
Muslims as a violation of human dignity [14].
However, it is common practice that organ retrieval is
carried out as soon as brain death is confirmed, thus the
burden of delaying the burial can be negligible and
arguable.
Issues related to medical necessities
For a medical need, and in the case that a treatment
option falls within the realm of a defined prohibition, one
of the Islamic maxims that can be applied is that of the
permission of choosing the ‘the lesser of two evils’ [15].
Other maxims that can be applied include: ‘necessity
permits the prohibited’, ‘hardship facilitates ease’, and
‘needs (haja) share the same legal ruling of necessity’
[16]. However, the mere existence of a permissible
alternative is insufficient to disregard
whatwouldotherwise be a prohibited option. Rather, the
permissible alternative should be equally effective as the
one that is considered to be prohibited for the alternative
to gain preference.
Furthermore, an important ethical maxim states that ‘The
sanctity of a living person is greater than that of the
deceased’ [17]. This means that the interest of the living
takes precedence over the interest of the dead. Donation
from a deceased person would have no implications to
their life – which has ended – as opposed to the living
donating their organs. Also, donations from the deceased
would provide organs that cannot be obtained from living
human donors, such as the heart and the lungs. Moreover,
a single healthy cadaver can provide several organs that
could be transplanted to benefit different patients and
save their lives. As such, a heart donation would not only
help patients with a failing heart to survive but would
also help to alleviate their daily suffering.
In relation to medical necessity, a number of factors are
considered by Muslim jurists such as:
- What Islamic values would be violated?
- Why are these violations necessary?
- Is there an alternative?
- Who would be harmed if the concession is not made?
- Who benefits if the violation is tolerated?
Violations of Islamic values during heart retrieval
To retrieve the heart, a 24-30-inch vertical incision is
required along the abdomen and the chest followed by
sternotomy – which is the splitting of the sternum using a
highly designed medical saw with minimal force. The
sternum, which is to be split, has been viewed as a ‘bone
of contention’ among Muslim jurists because sternotomy
appears to conflict with Islamic values, which demand
that the deceased be treated with dignity. The objection
against sternotomy is based on a hadith, meaning a
saying of Muhammad, the Prophet of Islam (peace be
upon him, here forth referred to by his
honourificationRasulullah) that ‘to break the bone of the
deceased is equal to breaking the bone of the living’
Here forth, we will refer to this hadith as hadith
kasradhm al-mayyyit.
In terms of dignity, this hadith can be understood to mean
that a corpse should be left intact during the funerary
process, the burial, and arguably after the burial [19][20].
This dignity even extends to events that require the
exhumation or relocation of the buried corpse.
Consequently, splitting the sternum of a deceased donor,
raises ethical issues resulting in conflicting views.
Scholars including Shafi [8], Sunbhuli [21], Abu Zaid
[16], Qabbani [22], Bakru [23], and Ghumari [24] view
retrieving organs from a cadaver as strictly forbidden due
to the violation of human dignity. These scholars argue
that based on Ibn Hajar’s interpretation of the hadith, the
dignity of the deceased remains of equal importance as
when one is alive [25]. Bearing this in mind, Ebrahim
[26] highlights the sentiments of those reluctant to permit
cadaver donation by echoing the question, ‘How can one
be permitted to cut up a man’s body and remove an organ
from it?’
The necessity of the violation
By contrast, other Muslim jurists view cadaver heart
donation as being permitted due to dire necessity, lack of
alternatives, and based on the notion that donating upon
death is considered honourable [27][28]. This group of
Muslim jurists hold the view that the above mentioned
factors override the theological argument given by jurists
who oppose organ donation. As heart retrieval cannot be
done without sternotomy, the necessity to have the heart
retrieved can arguably be given greater importance.
Alternative treatment
A human heart is the most effective replacement for an
irreparably damaged human heart. Furthermore, as of
2022, there are no alternatives that equal heart donations
in effectiveness. In essence, by tolerating the splitting of a donor’s sternum, life could be saved. Alternatively, by
prohibiting heart donations – from consenting donors-
based on the notion that the sternum of a deceased donor
must not be split, the life expectancy of those who
require a heart transplant is adversely impacted.
Beneficiaries of heart donation
From a non-theological viewpoint, arguments are made
both in favour of and against cadaver organ donation. If
one’s existence ceases with death, then donating a heart
neither benefits nor harms the deceased. Even if the
recipient is grateful, the gratitude is received by the
family of the donor. On the other hand, from an Islamic
viewpoint, death is not the end. Rasulullah taught
Muslims that sadaqa (charitable actions) continue to
benefit a person even beyond death [29].
Dividing the sternum
Antagonists of sternotomy and heart transplants present
Hadith kasradhm al-mayyyit as conclusive evidence to
prohibit cadaver donation. The argument follows that
sternotomy is forbidden and, as such, heart retrieval is
also forbidden. However, Sheikh Abdul Majeed Saleem
(The Grand Mufti of Azhar 1950-52) argued that the
hadith defines a ruling that is bound to the context in
which it was created [30]. A closer reading of the hadith
suggests that the deceased should be treated in a manner
similar to the living. In essence, it is not the act of
‘breaking’ that is forbidden, but it is the premise that the
human body deserves the same honour and dignity in life
and in death. There is clear implication in the hadith that
breaking the bones of the deceased is ‘forbidden’ in the
same way it is ‘forbidden’ to break the bones of a living
person.
In the foregoing discussion, the verb ‘splitting’ and
‘breaking’ have been used to describe sternotomy. These
verbs negatively connotate excessive force and damage.
However, from a surgical perspective, the term ‘division’
is more appropriate. A heart retrieval follows standard
surgical procedure and as such, the sternotomy is
performed by a trained surgeon using highly efficient
medical equipment. A precise cut to the bone is possible
with minimal risk of damage to other tissues. The
sternum is, therefore, arguably ‘cleanly divided’ in a
straight line in the middle and not ‘broken’. The heart is
transplanted through a similar precise sternotomy. This
division is then wired back together once the heart is
retrieved. The procedure is identical to other forms of
open-heart surgeries in a living patient. Bearing this in
mind, if the sternum of a living person could be divided for life-saving purposes then on that basis, why would
dividing the bones of the dead be prohibited for the same
reason?
Legitimately arguable then is the idea that if the bones of
a living personcanbe surgically operated on for medical
reasons, the bones of the deceasedcouldalso be surgically
operated on for acceptable medical reasons. When a
patient consents to have particular bones divided for a
medical need, Islamic law permits such procedures. In
most cases, this would be by explicit verbal or written
consent. Examples include orthopaedic procedures,
craniotomy, amputations, separation of conjoined twins,
bone marrow transplants etc. However, therecanbe
situations when explicit consentmightnot be possible, but
rather consent is assumed or granted – such as in a case
whena patient is rendered unconscious due to a serious
head injury, or in the case of cardiopulmonary
resuscitation (CPR) where potentially a rib could be
fractured. As such, the act of ‘fracturing’ the bone of the
deceased itself is not the primary issue but rather
determining the ‘necessity’ of the possible fracturing.
Just as it is permitted to divide particular bones of a
living patient for a medical necessity, the hadith could
arguably be understood to endorse the same for the bones
of a dead person.
Is donating a heart honourable?
Sternotomy is performed only after consent is obtained
by or on behalf of the donor. According to Al-Qaradaghi
[31], the consent of the donor eliminates the violation
argument and makes the surgical procedure permissible.
A possible tentative argument as to why organ harvesting
from the deceased is not tolerated in Islamic law is the
potential delay in performing the funerary rites. This
delay can be argued as ‘dishonouring’ the rights of the
deceased. With this notion in mind, all efforts need to be
made to ensure that funerary rites including a timely
burial are offered. In terms of honouring the deceased, a
heart donation does not prevent or significantly delay the
donor from any of their Islamically afforded funerary
rites.
Furthermore, a counter-argument for permitting
sternotomy for a heart donation is that just as funerary
rites bring honour to the deceased, so does saving the life
of another human being. The Qur’an states that ‘whoever
saves a life, it is equal to saving all of humanity’ [32].
Sheikh Ibrahim Al-Ya’qubi [33] described organ
donation as being honourable for the deceased in the
sense that the organs continue to remain beneficial for the living. Egyptian scholar MuhammadAbuShadi described
organ donation as a noble act in the same way that
sacrificing one’s life for a just war is considered noble
[34]. In relation to corneal transplants, Badawi [35]
remarked that ‘the success of recovering vision for a
human is a wonderful gift and is demanded by the
Sharia’. Mufti Kawthari (2004) adds that:
Current procedure of organ transplantation is not
considered dishonouring a human body. The surgery is
performed in the most respectable way and it is not
considered to be disrespectful. This is the reason why
many highly respected people of the community regard
donating of organs as a mark of merit, and they are not
looked down upon [36].
Ibn Abd Al-Barr (d.1071) argued that the hadith
kasradhm al-mayyyit applies to a specific context. He
further argued that by consensus of all Muslim Jurists,
legal financial compensation applies only when someone
breaks the bone of the living [37]. The application of
such ruling implies that the similarity between breaking
the bones of the deceased and that of the living is in
terms of honour and dignity. Saleem [30] comments that
the hadith could not have in any way taken into account
organ transplantation due to the simple fact that it did not
exist at the time. On this note, Yaseen [38] asks that since
current transplantation practice was not considered at all
in early Islam, what were their concepts of benefits, if
any, from the transfer of a kidney, an eye, spinal marrow,
a bone, the skin or any other human part? Certainly, not
in the way we view reasons for extracting organs in the
21st century.
In light of the fact that organ transplantation was not
possible, Al-Mawwaq (d. 1491) [39] from the Maliki
school of law commented that the hadith prohibits
abusing a dead body. Accordingly, Moroccan scholar,
Mustapha Ben Hamza argued that the hadith prohibits
exhuming graves in order to plunder them and such
practises cannot be equated with transplantation, which is
life-saving [40]. Sheikh Al-Qaradhawi also reiterates that
the hadith refers to the mutilation practised in battles
such as those committed at the battle of Uhud, when the
Meccans mutilated the deceased soldiers of the Muslims
[41].
In relation to retrieving the cornea from a deceased
donor, Al-Haridi [42] stated that the wider meaning of
the hadith is to honour the deceased and not tamper with
dead bodies unnecessarily (see also Bakru [43]). Saqar
[44] also argued that there is a greater good in
transplantation and is the lesser of two evils.
Conclusion
Having analysed hadithkasradhm al-mayyit and the
manner in which Muslim jurists interpreted the hadith in
a number of scenarios, a few points can be concluded
Firstly, manipulating the bones of the living for medical
reasons, after gaining consent by the patient, is permitted.
The central argument in all cases is principally necessity,
avoiding harm, and lack of alternatives. The underlying
principle for hadith kasradhm al-mayyit appears to be
prohibition of breaking bones unnecessarily, whether that
be of the living or the deceased.
Although no precedent in classical Islamic jurisprudence
resembles heart donation, the discussions around human
dignity, consent, tolerance, and charitable deeds allow a
framework within which to situate heart donations.
According to the Qur’an, saving the life of another
human being is among the most honourable actions and
saving one life is considered to be equal to saving all of
humanity. As of 2022, the best alternative for a critically
failing human heart is a human heart.
Heart donation is a novel case compared to the cases
discussed in classical Islamic jurisprudence. In practice,
for a heart donation, the donor gives consent prior to
death; with the intention to save the life of another
human being – as well as to hope to benefit in the afterlife
through this act of sadaqa. Muslim jurists and health
professionalscould promote heart donations better by
highlighting the fact that the heart transplant procedure
differs in context to that of hadith kasradhm al-
mayyit,which seems to have played an unnecessarily
significant role in discouraging heart donation.
Furthermore, the anxieties of British Muslimscanbe
addressed by highlighting that consent is mandatory.
Furthermore, organs are strictly monitored by the Human
Tissue Authority (HTA) to ensure that organs and tissues
are not subject to any commercial transactions.
Moreover, a heart donor can be honoured not only by the
customary funerary rites but also by the exclusive honour
of being a life-saving donor.
This article focused on the issue of sternotomy to retrieve
the heart. However, there exist other concerns in relation
to heart donation such as ensuring the donor has died of
brain death. In this regard, concerns related to brainstem
death are not discussed in this paper. Further
ethnographic research could be conducted at the
grassroots level in the UK by social scientists in
collaboration with British Muslim jurists with regard to
the perception of heart donors by the British Muslim
community.
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