End-of-Life Care, Dying and Death in the Islamic Moral Tradition, edited by Mohammed Ghaly. Leiden: Brill, 2022.
For a long time, issues of modern bioethics were discussed and debated mainly in Western countries that have taken the lead in developing what has become “conventional” medicine, which today relies on cutting-edge treatments and technology, giving rise to many bioethical issues. Notable among these issues is end-of-life care (EoLC). This development has had many positive effects, for it has saved millions of lives in the last hundred years or so. Paradoxically, however, it has also led to many forms of hardship, making it possible, for one, for an arguably dead person to maintain many signs of life, perhaps against his and others’ “best interests.” It has literally made the once dreadful death a wish for people who remain incapacitated without any form of what can be described as quality or dignified life. It has become a nightmare for families that have not only to watch their loved ones suffer considerably and die slowly, but are also drained, socially, emotionally, and financially. A possible solution to this problem is, of course, euthanasia, “mercy killing” that is only legal in very few countries. For ethical, legal, cultural, or religious reasons, all other countries still criminalize “assisted suicide,” where the physician, whose goal is traditionally to keep his or her patient alive, assists this patient in dying “peacefully” and “in dignity.”
However, although Western countries are still leading state-of-the-art medical technology, in recent years, more and more countries now contribute to advancing medicine or can afford the same advanced medical facilities that are responsible/blamed for many of the currently debated bioethical issues. This applies to Muslim countries, particularly those affluent countries that make top medical technology available to their citizens, usually free of charge. As a result, a generation of scholars and medical professionals, Muslim and non-Muslim alike, is emerging and contributing to debates about the ethical issues associated with modern medicine from an Islamic perspective. These scholars do not seem satisfied with simply translating and presenting various views on these issues as they are debated in Western scholarship and practice, but are determined to play a role in shaping ideas, attitudes, approaches, and perhaps policies that are based on the long and rich tradition of Islam. I take this volume to be part of this welcomed and much-needed contribution to the field of bioethics.
The volume begins with a useful introduction by its editor, Mohammed Ghaly, where he introduces some of the ethical questions associated with EoLC during the now possibly long “dying process.” The volume, he points out, “is intended to be a reference work for researchers with interests in EoLC and in Islamic bioethics in general, while also opening up new avenues for future research” (2). Given that EoLC issues are varied and complex and require, therefore, a multi-disciplinary approach, the volume seeks to show that the Islamic tradition, with its diverse fields of knowledge, is capable of contributing ideas that address the multiplicity of medical, social, psychological, and eschatological aspects of EoLC. The aim is to develop a “thick discourse” on bioethical issues from an Islamic perspective. This effort, the editor insists, must be well-informed and systematic and explore holistically the potential of all aspects of the tradition, rather than remaining confined to Islamic jurisprudence (fiqh), as has been the case in recent decades.
In chapter 1, Ghaly aptly introduces the genres of Islamic sources that can be useful in developing theories on different aspects of EoLC. These include scriptural sources (i.e., the Qurʾān and the Prophet Muḥammad’s Sunna/Ḥadīth), works on eschatology, theology, philosophy, Sufism, and law (fiqh and its legal theory, uṣūl). Reiterating that any significant discourse on EoLC must attend to the totality of the patient as a human being whose humanhood and personhood are multi-faceted, he moves on to present some themes and questions relevant to EoLC, including eschatology, medical intervention, aspects that are not typically dealt with in clinical care (e.g., a patient’s spirituality), moral agency, and issues relating to communication among the various parties associated with EoLC (the patient, the family, and the healthcare providers, to whom we can add the state with its legislative, executive, and judicial arms). Everyone would probably agree that the complexity of the EoLC issue requires a holistic attitude, but it can also be argued that fiqh here is being unnecessarily narrowly defined. If fiqh – the human understanding, representation, and application of the Sharīʿa, the aim of which is the well-being of the believer in this world and the Hereafter – is broadly defined, it would be able to serve the need for a “thick” discourse on EoLC. Like any good jurist, a Muslim faqīh, after all, should have a holistic vision and approach that take into consideration all relevant personal and social aspects of questions and issues presented to him or her.
Next, Aasim Padel, a practicing physician who has already established himself as a solid scholar of Islamic bioethics, discusses how issues typically debated in different branches of philosophy and cultural and sociological studies are relevant to bioethics, and how the issue of brain death – the subject of his chapter – is multi-dimensional and must be treated as such. In debates over “brain death,” a misnomer as Padela points out (51n1), regarding death as a social construct – nay, a plurality of various possible constructs – rather than a mere physical phenomenon, puts us in a better position to make moral assessments and recommendations. Presenting the many uncertainties now associated with death and which have an obvious impact on how dying patients are treated, he argues that “in any given context, a specific purpose for death is identified, which then leads to the selection of criteria to verify [that] death has occurred, and subsequently death behaviors are enacted by various stakeholders” (57, emphasis added). This seemingly scary sentence is explained fully by Padela, who points out that religious scholars who defer to physicians on medical issues are unaware of the complexity of these controversial issues within biomedicine itself (and others who do not defer do not tend to understand the issues accurately, 66). The failure to connect death purposes, criteria, and behaviors and to appreciate the multi-dimensional and multi-disciplinary nature of brain death, Padel argues, has prevented Muslim scholars from developing an informed discourse on this and other end-of-life (EoL) issues. This chapter – which builds on many of Padela’s earlier writings – is a must-read for anyone seeking a better understanding of the different aspects of the issue of brain death, sociological, biological, biomedical, ethical, political, legal, religious, and even metaphysical.
Chapter 3, written in Arabic, discusses the issue of thanatophobia (death anxiety) in the Islamic tradition. It begins with presenting Greek theories of thanatophobia, followed by a discussion of the views of three pre-modern Muslim scholars, Muḥammad ibn Zakariyyā al-Rāzī (d. 313/925), Abu ʿAlī Miskawayh (d. 421/1030), and Ṣadr al-Dīn al-Shīrāzī (d. 1050/1640). It shows how the views of each of these scholars were similar to and influenced by specific Greek approaches. (Later, references are made to some modern Western thinkers, such as Spinoza (d. 1677) and Heidegger (d. 1976).) Unfortunately, although the two authors of this chapter occasionally mention that Muslim thinkers dealt critically with the Greek tradition, the overall impression that we get from their discussion is that the views of these scholars were largely unoriginal, to the point that we can question whether or not we can present their views as “Islamic” in any sense. The chapter is notably devoid of any Islamic scriptural references that these Muslim thinkers may have used to “authenticate” the Greek views they copied. Yet, when these views are critiqued in the conclusion, they are critiqued as Islamic rather than Greek theories.
Chapter 4, also in Arabic, deals with pain and how the celebrated seventh/thirteenth-century Sufi Jalāl al-Dīn al-Rūmī (d. 672/1273) philosophized it. The two authors argue that Sufi literature is more useful than other genres in addressing the subject of different forms of pain and suffering (used synonymously in this chapter). They give a quick overview of Sufi literature and of al-Rūmī’s interesting life and contributions. Speaking of pain, they point out that it is one of the hardest terms to define, especially since some of their forms are desired and enjoyed (e.g., pain associated with love), as al-Rūmī – who does not define pain but only illustrates it – explains. Yet al-Rūmī also distinguishes between genuine pain associated with the disunion from the beloved and contemporary pain that people usually mean when they use the term (117–118). Furthermore, pain, in al-Rūmī’s view, can in fact be a sign of God’s passion towards a person. It is not clear here to which kind of pain al-Rūmī refers, for the authors mention the pain associated with illness, but give an example of spiritual pain (118–119). This is one of the moments where the distinction between the authors’ and al-Rūmī’s views is not clear. And similar to chapter 3, the authors argue that al-Rūmī’s approach to pain is “rooted in the neo-Platonian paradigm,” where the soul is enslaved in the body and separate from it (116). Some of al-Rūmī’s ideas are also compared to those of the German philosopher Gottfried Wilhelm Leibnitz (d. 1716). It is not clear why this comparison is relevant here if the chapter is not meant to be comparative. One could only wish to see in chapters 3 and 4 discussions that are less metaphysical and more relevant to current ethical, legal, and practical aspects of their topics and of EoL.
Chapter 5 deals with the subject of plague as discussed by the tenth/sixteenth-century Egyptian scholar Zakariyyā al-Anṣārī (d. 926/1520), who, at the age of 90, and after experiencing a major epidemic, wrote an entire treatise on ṭāʿūn and some other things relating to unordinary deaths. The author, Hans Daiber, presents the subject of each of the fourteen chapters making up al-Anṣārī’s treatise, where sayings and views of many earlier scholars and medical practitioners – such as Ibn Sīnā (d. 427/1037) – are quoted. Next, he presents, in one paragraph, al-Anṣārī’s treatise as an EoLC work – the book deals with persons dying of the plague, illness, and fighting for the cause of God (145). Daiber moves on to discuss various ideas in the treatise that were meant to serve as a guide for believers, which is developed again in a section on al-Anṣārī’s theological-mystical worldview. Daiber argues that al-Anṣārī’s treatise betrays Ḥanbalī-Sufi influence. In addition to the fact that “Ḥanbalī-Sufi” in itself requires some explanation, it is not clear why Daiber considers the many ideas that he mentions to demonstrate al-Anṣārī’s affiliation with the Ḥanbalī madhhab – and which were meant to guide believers, such as taslīm, qaḍāʾ, īmān, ʿamal, niyya, and even the use of ḥadīth – particularly Ḥanbalī rather than Islamic. The reader would hope to see a more thorough discussion of how al-Anṣārī’s ideas relate to the many issues associated with EoLC.
In chapter 6, Pieter Coppens discusses narratives about the death of some prominent figures from Islamic history, an attempt to contribute to the field of “history of emotions” that is virtually absent in the study of Islamic tradition. The assumption here is that ars moriendi (the art of dying) is constructed: people learn how to die. Comparing scholars from early Islamic history with figures from the late nineteenth and early twentieth centuries, Coppens argues that, paradoxically, whereas Sufis in early Islamic history, who shared a lot among themselves, had diverse attitudes and emotions towards death, early “modern” figures (religious scholars, political activists, etc.) had an astonishing degree of homogeneity in their approaches to death despite their many differences. Realizing the limitations of his otherwise interesting research in this chapter, Coppens does not have a firm explanation for this discrepancy between the traditional and the modern. But on how this relates to EoL issues, the subject of this volume, he points out that these narratives on death invite us to reflect on whether the traditional attitudes and emotions still have value and relevance or perhaps even surpass their rigid modern counterparts.
In chapter 7, Ghaly tackles the issue of palliative care (PC) – that is, care given to persons with serious illnesses and usually approaching the end of their lives – and life-sustaining treatment (LST). Despite their being widespread phenomena in today’s world, Islamic discussions of these kinds of medical interventions are still rather poor, a situation that this chapter obviously seeks to improve. Ghaly relies here on juristic discussions in the first place, but to remain faithful to his call for a “thick” treatment of bioethical issues, he promises the reader to write later about the relevance of other Islamic genres to the issues being discussed. Next, he presents some of the key Islamic codes and fatwā organizations that have contributed to these issues. Many of these fatwās and views employ a variety of principles, such as harm (ḍarar), certainty (yaqīn) vs. doubt (ẓann), necessity (ḍarūra), the objectives of Islamic law (maqāṣid al-sharīʿa), etc, all of which are used against the backdrop of a core question: under Islamic law, is medical treatment permissible, recommended, or obligatory (not to mention “not recommended (makrūh),” a view that was once prominent but has largely fallen out of favor now). He also presents many of the questions and dilemmas that medical practitioners and others face when dealing with people requiring PC and LST. One question, for example, is whether the same religious ruling (ḥukm) should apply to the permissibility or otherwise of withholding or withdrawing cardiopulmonary resuscitation (CPR) and of artificial nutrition and hydration (ANH), two standard means of LST. Another issue is whether administering analgesics in doses that the physician and/or the patient know are lethal can ever be permissible, especially in cases of unbearable pain and certainty of death. Next, Ghaly discusses an issue that is integral to the human aspect of the medical profession, that is: how should a physician communicate bad news to their patients and their families? Anecdotes from Islamic history are used here to establish an Islamic etiquette for dealing with such questions.
In chapter 7 on suicide, Khalid Elzamzamy presents the modern psychological position that focuses on mental health to explain suicide, in contrast to the Islamic perspective that focuses on spirituality and religious teachings. The aim is to show that what the author presents as two “dichotomies” (which they do not have to be given that they deal with different aspects of the phenomenon) can complement each other; Muslim jurists need to be aware of the mental health and other aspects of suicidal thoughts, whereas psychiatrists and other medical professionals can benefit from the role that religion can play in both preventing suicide and helping its survivors (that is, the families of a person who has committed suicide) cope with and overcome the intense emotions associated with the event. “Islamic psychology” is a new discipline seeking to achieve this and other goals. The author gives some general information on suicide, both from the World Health Organization and Islamic sources, which can be useful for anyone without much knowledge of the subject. Some of the points needed proper citation of evidence, such as Elzamzamy’s statement that suicide has low rates in Muslim communities (206–207), despite the limited data on the phenomenon for different reasons (217). Some pieces of evidence need reconsideration, such as the reference to a fatwā that categorically prohibits suicide and condemns anybody committing it to illustrate that some fatwās may “facilitate suicide” (210). Throughout, the author speaks of suicide “victims” and calls for more compassionate stances towards them. There seems to be an assumption here that all suicide results from mental and other health issues. Be this as it may, this view would obviously raise all sorts of problems for Muslim jurists (and even theologians; e.g., is God unaware of these causes of suicide?), knowing that the same logic can be used to justify committing other acts that Islamic law prohibits. In fact, it could be argued that it is this “victimization” of suicide that could “facilitate” it.
In the long chapter 8, Ayman Shabana takes on a subject that is considered anathema in Islamic writings, euthanasia. Shabana begins his article by pointing to a known dilemma in Islamic theology: every Muslim is free and responsible for his acts, but must nonetheless submit to God’s will. Furthermore, whereas individual Muslims have agency and rights, their communities also have expectations and rights, leading to a trilogy of rights: individual, communal, and divine. How these relate to euthanasia is the subject of this chapter. Specifically, it asks if any form of “induced death” can be Islamically legitimized. In contrast with their categorical rejection of “active” euthanasia, however, some Muslim scholars are tolerant of “passive” euthanasia (the withholding or withdrawal of treatment), which can be understood in the context of current debates on brain death and LST. Some fatwās by Muslim jurists and institutions are usefully presented and discussed here. The chapter also discusses some important concepts relevant to euthanasia, such as autonomy (a Kantian term that has been both defined and judged variously), competence, principalism (and its constituent ideas of nonmaleficence, beneficence, and justice), and identity (a concept that is close in this context to “self-determination”). In the Islamic context specifically, these include “rights of God,” with which a believer cannot interfere, and “rights of man/people (God’s servants),” which every believer can assert or drop, the “objectives of the Sharīʿa” and their proper ordering, and Islam’s overall worldview and normative tradition.
LST is taken up again in more detail in chapter 10, where Rafaqat Rashid, a religious and bioethical scholar and medical general practitioner, begins by critiquing the uninformed and vague fatwās dealing with EoL situations that nonetheless influence the decisions of millions of Muslims worldwide. These fatwās do not usually distinguish between the withholding and withdrawal of LST and distinguish at times between CPR and ANH. This last distinction, the reason for which is unclear to Rashid, is probably based on the belief that whereas a patient’s heart may miraculously start working again, a patient cannot miraculously survive starvation, for which reason ANH must be maintained. (Rashid is definitely aware of this, as his later discussion shows, 290–291, 318.) To avoid the uncertainty betrayed by most fatwās, Rashid proposes conceptualizing the subject in the frame of religious duties and obligations, a quantitative and qualitative balancing of benefits and harms of medical treatment, and prognosis and the probability of success of treatment, rather than of vague concepts such as the futility and the “suitability” or otherwise of treatment. To illustrate his points, he refers to real medical scenarios, which the reader will appreciate. Similar to Padela, Rashid asserts that issues of futility, for instance, can be and are indeed debatable among medical professionals, for which reason religious scholars and others cannot simply defer to physicians every time they face a certain dilemma. We always need, he asserts, both scientific/medical and value judgments when dealing with many EoL issues. This is another long and dense chapter, but it will be useful for anyone interested in engaging in serious, but difficult, EoL discussions.
Next, Hadil Lababidi discusses the advantages and disadvantages of ANH in dementia patients, who are typically old (75+). Dementia, to be sure, is much more than the loss of memory; in its advanced stages, it involves severe physical, cognitive, and behavioral aspects that eventually kill the patient. A dilemma with which this chapter deals becomes evident when we learn that dehydration and reduced food consumption are a natural part of the dying process – in fact, they reduce the pain and stress associated with it (333–334). This means that ANH can have an unnecessary negative impact on the duration and quality of death for a patient whose dying process has already kicked off. Palliative care, therefore, should always be decided on a case-by-case basis to take all factors associated with the illness and the patient into consideration. The use of analgesics, such as opioids, and the controversy around it are also discussed here. Debates about the characterization of ANH itself are also presented; whereas it is treated by some as a form of medical treatment, others do not perceive it as such, a disagreement that has serious repercussions on its status in religious and even secular discourses. Here, the issue of the obligatoriness or otherwise of medical treatment in Islamic law and the physician’s liability in secular contexts stand out. Lababidi also refers to some important legal maxims that have been used in fatwās and discussions on illness, EoL, and death, such as “no harm, no harassment” (Lababidi’s translation of lā ḍarar wa-lā ḍirār), and “hardship necessitates relief” (al-mashaqqa tajlib al-taysīr).
Finally, chapter 12 deals with, not EoL, but failed beginnings of life, i.e., miscarriage, abortion, and stillbirth, which Beate Anam discusses under the interesting sub-title, “A Balancing Exercise between Islamic Legal Thinking and Life’s Challenges.” This is the only chapter in the volume that interestingly begins with a real case of a Muslim German couple facing a dilemma associated with a miscarriage of their two-months fetus and a refusal by an imām to allow them to bury it (or s/he) on the grounds that it did not develop into a human being yet, a position that Anam finds analogous to the “atheistic materialistic way of thinking on this issue” (366). Similar to many other co-authors, Anam points to the lack of serious discussions of failed pregnancies and the parochial approach of many Muslim scholars and fatwās. Her proposed approach is interdisciplinary, bottom-up, and case-by-case analyses, all with the realization of the temporal, geographical, social, and even legal contexts of each situation. She goes on to present different views on issues associated with uncompleted pregnancies, such as the issue of funeral (at what age can/should it be performed for the aborted fetus), the burial site (if the fetus is not considered as a human being, it can be buried anywhere or not at all), “joint burial” (which is not the norm), especially when the fetuses belong to families following different religions, and bereavement (an issue that applies to men as much as to women, Anam asserts).
At the end, whereas a few chapters in this volume have a rather narrow focus and perhaps lost sight of the purpose of the volume, most chapters take a holistic approach and point to the need to understand, study, and appreciate the various aspects pertaining to EoL and criticize simplistic and reductionistic accounts and treatments of the issues and dilemmas associated with it. The volume will provide any person interested in these issues, especially if the interest is in the “Islamic perspective,” with a powerful momentum on which to build through further readings. The reader will become familiar with the main topics, concepts, questions, attitudes, approaches, and solutions associated with EoL. This, again, is a much-welcomed and appreciated effort indeed.
