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| In the name of Allah, Most Kind, Most Merciful "Our Position" The position of Islamic Medical Association of North America On issues of Medical Ethics By IMANA Ethics Committee Shahid Athar, MD, Chair List of Content: ================ Introduction of IMANA IMANA's position on: A Euthanasia, Mechanical life support, Living Will, case manager and Advance Directive. Appendix: Recommended Resources Islamic Medical Association of North America (IMANA) ==================================================== In 1963, Muslim students studying in American colleges and universities organized themselves into an association (Muslim Students' Association). Four years later, in 1967, American Muslim physicians did the same and formed IMANA. MSA transformed into the Islamic Society of North America (ISNA) and IMANA became a constituent body of ISNA. Since its inception in 1967, IMANA has dedicated itself to serving Muslim physicians, Muslim patients and the community at large on issues related to Islamic Medicine nationally and worldwide. IMANA is also a member of the international Federation of Islamic Medical Associations (FIMA). Islamic Medicine is defined as the art and science of practice of medicine by Muslim physicians and other health care providers in the service of humanity under Islamic guidelines as ordained by the divine book Quran and taught by Prophet Mohammad (peace be upon him). IMANA has headquarters in a Chicago suburb and regional chapters in many cities of USA. It is governed by a Board of Regents and an executive committee according to established By-Laws. It has several operational committees including the medical ethics committee. For detailed information about IMANA, one can visit www.IMANA.org. Need for Position Papers on Islamic Medical Ethics ================================================== Muslim Physicians, Ethicists, Imams and scholars are asked questions by Muslim and non-Muslim patients, physicians and institutions as to what is Islam's position or opinion on certain medical dilemmas affecting the care and outcome of patients' illness and life . Some of these issues, such as termination of pregnancy, are time honored situations while many such as transplantation, assisted reproduction and euthanasia are products of advances in medical technology. Since these are new issues, Muslim physicians, have dire need for recommendations from the guiding principles of Quran, the tradition of Prophet Mohammad (p) (ref: Quran 33:36) and opinions of past and contemporary Muslim scholars. Thus, IMANA decided to make position papers which will be available to those who seek our position in order to pursue further reading on their own. The position papers are only suggestions on behalf of IMANA and not to be considered Fatwa(s) (religious decree) which has a legal binding. The members of ethics committee are not in a position to issue a Fatwa on any of the issues which we are writing on behalf of IMANA. However, from time to time, on need basis, we do consult Muslim scholars for their opinion. The Position Papers will be revised from time to time as new questions arise from advances in medical technology. The Position Papers are available to be read and downloaded from internet at www.imana.org at no cost. Islamic Medical Ethics ====================== Islam considers access to health care a fundamental right of the individual. In medicine, there are sometimes difficult decision making situations for choosing better options for the patient's care. Thus, a physician at times has 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 (Shariah) and Islamic medical ethics. The two main principles of Islamic Medicine are: 1) emphasis on the sanctity of human life which derives from Quran 5:32 "whosoever saves a human life, saves the life of the whole mankind", 2) emphasis on seeking a cure which derives from a saying of Prophet Mohammad (p), "seek cure as God has created no disease without creating a cure for it except for old age". This is further emphasized by the fact that three of the "Goals of the Islamic Shariah" are the protection & preservation of life, intellect,& progeny .The other two being the protection of private ownership & the freedom of religion. Some of the rules of Islamic medical ethics are Islamic Medical Ethics also upholds the four basic principles of biomedical ethics. These are 1) Respect for the autonomy of the patient, Thus, a Muslim physician has to make a decision not only based on his/her own knowledge and experience, but as a Muslim in light of his /her Islamic teachings, in the best interest of his /her patient, whether Muslim or non Muslim . 4a: IMANA's Position on the Care of Muslim Patients (2) ====================================================== IMANA has published a brochure entitled "Guidelines for Healthcare Providers in Caring for Muslim Patients". (2). Those who wish to obtain a copy can call IMANA at (6.... It is also available on line at www.imana.org . All patients irrespective of their faith should be treated with human dignity and respect. Muslim physicians are advised to treat all patients with loving care as if they are members of their own family. We suggest to all health care providers that they familiarize themselves with the basic teachings of Islam and Islamic moral values. It is easier for a healthcare provider to deal with the patient if he /she understands the faith, values and culture of his/her patient. These are some of the specific guidelines for healthcare providers especially of other faith traditions for caring for their Muslim patients. 1. Muslim patients should be identified if possible as Muslim (or with the religion Islam) in the registration information so as to prevent any mistakes happening unintentionally in terms of violating dietary rules or privacy. 2. Their care providers should respect their modesty and privacy. Muslim patients, particularly women may need a special gown to cover the whole body in order to avoid unnecessary exposure during physical examination. Some examinations may be done over the gown. 3. Provide Muslim patient Islamically slaughtered (Dhabiha) meat. Muslim patients should not be served any pork, pork products or alcohol in their meals. A Muslim patient's family may be allowed to bring food from home, as long as it is meeting the patient's dietary restrictions. 4.Make it easy for Muslim patients to perform Islamic prayers if they can... 5. Inform them of their rights as a patient and encourage an Islamic living will. (a sample of a living will is enclosed). 6. Take time to explain test procedures and treatment. Some of the more recently immigrated Muslims may have a language problem. Muslim women, can give consent for any treatment or procedure. 7. Allow their Imam (religious teacher) to visit them and pray for them. Priests of other faith traditions can pray for or with Muslim patients with their permission, using non denomination words like God. 8. Autopsy is permitted if medically indicated or required by law. 9. Organ donation is permitted with some guidelines and is encouraged. 10. Always examine a female patient in the presence of another female (chaperon) or a female relative (except in medical emergencies). Especially for labor and delivery ,if the patient's obstetrician is unavailable & upon her request ,provide the same sex healthcare provider, if feasible. Her husband is encouraged to be present during the delivery. After death of a Muslim patient in a health care facility, allow the family and Imam to arrange for preparing the dead body for burial under Islamic guidelines. A corpse should be given the same respect and privacy as he/she was receiving while alive. Muslim relatives and friends of the dead are encouraged to stay in the room where the dead body is kept to recite Quran. Muslim corpses are not embalmed. 4b: Definition of Life and the Responsibility of Muslim Physicians towards Human Life {34) ========================================================================================= Muslims believe that God is the Creator of life and life is a gift from Him (Quran: 36:77-78). Muslims believe that all life is sacred and must be protected. The respect for life in Islam is common for all humans, irrespective of gender, age, race, color, faith, ethnic origin, financial status or productive stage of life. IMANA holds the position that biological life begins at conception while human life begins when ensoulment takes place (Quran 23:12-14). Ensoulment is believed to occur at 40 or 120 days after fertilization, according to different schools of thought. [ Also see section 4g]. The right of the fetus in Islam is similar to the rights of a mature human being, including the right to life, the right to inheritance, the right of compensation when injured by willful acts and the right to penalize assailants. The position paper extends the principles of medical ethics to the patient in a vegetative state. Until the death has been declared, the patient in a vegetative state is considered a living person and has all the rights of a living person. 4c: Definition of Death (24, 26, 33) =================================== IMANA has published a position paper on death in the Journal of Islamic Medical Association. (J.Islam.Med.Assn 1997;29:99) Permanent cessation of cardiopulmonary function, when diagnosed by a physician, is considered death. The concept of brain death is necessitated when artificial means to maintain cardiopulmonary function are employed. In those situations, cortical and brain stem death, as established by a specialist using appropriate investigations can be used. It should be the physician who should be responsible for making the diagnosis of death. Thus a person is considered dead when the conditions given below are met. 1. The physician has determined that after a standard examination, a person's cardiopulmonary function has come to a permanent stop 1) 40:68 "It is He who gives life and death and when He decides upon an affair, He says to it: Be and it is". When death becomes inevitable, as determined by a team of physicians including critical care physicians, the patient should be allowed to die without unnecessary procedures. While all ongoing medical treatments can be continued, no further or new attempts should be made to sustain artificial life support. If the patient is on mechanical support, this can be withdrawn. The patient should be treated with full respect, comfort measures and pain control. No attempt should be made to withhold nutrition and hydration. In such cases, if and when the feeding tube has been withdrawn it may not be reinserted. The patient should be allowed to die peacefully and comfortably. However, no attempt should be made to enhance the dying process in patients on life support. IMANA is absolutely opposed to Euthanasia and assisted suicide in terminally ill patients by healthcare providers or by patient's relatives. Suicide and Euthanasia are prohibited in Islam (Quran17:33). IMANA recommends that all Muslims have a "living will", "advance directive" and a case manger for their care, to help physicians to know their wishes, when he or she is unable to give directions (i.e. in a coma). A sample of such proposed living will is provided here which can be modified by the patient after consulting with family and attorney. (Ref: J.Islam.Med.Assn.1997; 29:99). Islamic Living Will and Advance Directive (a sample) Declaration made this ________day of ______, 20__. I , a Muslim of sound mind , willfully and voluntarily make known my desires that my dying shall not be artificially prolonged under the circumstances set forth below and I declare: If at any time I have an incurable injury, disease or illness certified in writing to be a terminal condition by my attending physician(s), and my attending physician has determined that the use of life-prolonging procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the provision of appropriate nutrition and hydration and the administration of essential medications and the performances of any medical procedures necessary( as determined by my physician) to provide me with comfort or to alleviate pain. In the absence of my ability to give direction regarding the use of life-prolonging procedures, it is my intention that this declaration be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and I accept the consequences of the refusal. ____________ is my case manager to enforce my living will, if I am not physically able to give direction. I do not permit autopsy of my body unless my death occurred in a suspicious manner and it is important to know the cause of death or if it is required by the court of law. It is my desire that Muslims attending my dying process ensure that Islamic Shariah is practiced during preparation of my body for burial. My body be treated with grace and privacy and buried with Islamic guidelines under the directions of my Muslim family, Imam or other qualified Muslims as soon as it is feasible. Signed--------------------------------------- Date---------------Place------------- ---============================================================- The declaring person has been personally known to me and I believe (him/her) to be of sound mind. I did not sign the declaring person's signature above for or at the direction of the declaring person. I am not a parent, spouse, or child of the declaring person . I am not entitled to any part of the declaring person's estate or directly financially responsible for his/her medical care. I am competent and at least eighteen (18) years of age. Witness (to the document) _________________________ Date________________ Witness (second) _______________________________ Date________________ 4e: IMANA's Position on Organ Donation and Transplantation (1) We, at IMANA, understand that certain organs may fail in the human body while the rest of the body may still be functional. The current state of medical knowledge holds the view with scientific proof that if the diseased organs are replaced by healthy organs and if accepted, the body machine can continue to function rather than die because of one diseased organ. Islam instructs all Muslims to save life (Quran 5:32). Thus, on this basis, transplantation in general, both giving and receiving organs, is allowed for the purpose of saving life. This has to be done under the following guidelines: " The medical need has to be defined. 4f: IMANA's Position on Assisted Reproductive Technologies (22, 23, 30) We believe infertility is a disease and desire for a cure by an infertile couple is natural. However, in Islam, for an action to be permissible all means of achieving that action are also to be pure. IMANA holds the position that all forms of assisted reproductive technologies (ART) are permissible between husband and wife during the span of their marriage using the husband's sperm and the wife's ovaries and uterus. No third party involvement is allowed. We believe in the sanctity of marriage (Quran: 16:72) and that the death of one of the spouses terminates the marriage contract on earth, thus frozen sperm from husband can not be used. Sperm, ova and embryo donation are not permitted. Additional embryos produced by IVF between husband and wife can be discarded or given for genetic research, if not to be used by the same couple for a future attempt. Surrogacy involving a third person is not permissible, as we believe that it exceeds the boundaries of the marriage contract and lineage (Quran 58:2, 25:54). Use of fertility drugs is permissible. An infertile couple, if they can not find a permissible cure, can care for another child or someone else's child as their own within the Islamic guidelines of adoption, not the legal adoption as practiced in the United States. 4g: IMANA's Position on Contraception and Abortion (Termination of Pregnancy) (7) I. Contraception Islam prohibits sex and conception out of wedlock. For married couples, contraception for several reasons, including health of the mother, social or economic reasons etc, is permitted, provided that it is practiced by mutual agreement of the husband and wife. Contraceptive methods which can lead to abortion are not allowed. II. Termination of Pregnancy Abortion is the willful termination of pregnancy by artificial means: drugs, chemicals, mechanical or surgical procedures before the age of viability (23 weeks) for any reason. Chemical or mechanical means to prevent the formation of zygote (fertilized ovum, which marks the beginning of human life) is not considered abortion. We believe that life begins at conception and unless interrupted by disease or artificial means, the fertilized ovum will continue to grow and become a viable mature human being. However, some scholars differentiate between biological life which starts at conception from human life which starts after ensoulment (Hadith Ibn Mas`uud). Further, the time of ensoulment according to this hadith is considered to be at 40 days after fertilization by some while others consider to it to be at 120 days after fertilization. IMANA's position on abortion can be classified as follows: " Elective abortion of a viable fetus in a healthy mother is prohibited. In all cases in which abortion is sought, the recommendation should be made by a team of Islamic scholars and medical experts in the field. Prohibition of infanticide is mentioned in following verses in Quran 17:31, 6:151 and 60:12. 4h: IMANA's Position on Genetic Engineering and Human Cloning (16, 18, 29, 31)) ================================================================================= Genetic research and engineering to alter or delete diseased genes is allowed and genetic research using stem cells from products of miscarriages or surplus ova after IVF procedures is permissible. However, to conceive in order to abort the fetus and harvest and use its stem cells is not permissible. We believe that each individual is born with unique qualities and genetic makeup . Islamically, a child should be born out of marriage between husband and wife and the lineage of the child should be maintained. (Quran 25:54). Therefore, human reproductive cloning is not permitted in Islam... Therapeutic cloning may be permissible within strict guidelines. 4i: IMANA's Position on the Care of HIV Patients (20) ==================================== HIV infection, in addition to being associated with Homosexuality is also known to be acquired through heterosexual acts, as well as I.V. drug use, blood transfusion and child birth. While Islam is opposed to homosexual life style, promiscuity, and drug abuse, IMANA is not opposed to the care of HIV patients. In fact, it instructs Muslim physicians to care for HIV patients with the same degree of compassion as they would for other patients. We do not discriminate against any patient on the basis of their lifestyle. We do advise healthcare providers to take precautions for themselves while taking care of HIV patients. 4j: Miscellaneous Issues ======================== a. Birth control methods between husband and wife: IMANA approves of all methods of contraception between husband and wife which are not harmful, are reversible and are not abortificient. Prophylactics, withdrawal methods or oral contraceptives are allowed. However permanent measures such as tubal ligation , vasectomy, morning after pill and certain forms of IUD are not permissible. b. .Examination of opposite sex: This is allowed in the presence of a third person of the same sex as the patient. In case of a minor, one of the parent's presence is desirable. Only necessary examination needs to be done. Pelvic examination must be done using gloves. IMANA encourages but does not mandate same sex health care provider. Medical or nursing students may be allowed during examination of a female patient, but only with her prior consent and in the presence of a female nurse or relative. Drug Research: Biomedical research involving double blind trials, controls and the use of placebos in drug research is allowed, but the patient must be informed and consent must be taken. Worsening of the disease while in drug research, either due to placebo or an ineffective dosage of the drug must be carefully monitored and the trial should be ended for the safety of the patient. 5: Frequently asked Medical Ethics Questions (Answers provided by Hassan Hathout, MD, PhD) ========================================================================================== Q1. Can Muslim patients take medicines which may contain alcohol or pig by- products? A. No, Muslims should not take these medicines unless they are life saving drugs and no substitute is available. (One school believes that when pork has changed chemically, it is not haram or najs- illegal and impure). Q2. I am 3 months pregnant and doing fine. Can I fast during Ramadan? A. It is preferable that you utilize God's granted exemption and do not fast. Your baby is dependent on you for his or her nutrition and hydration. Why do you want him or her to fast with you? Q3. Is use of placebos in clinical trial endorsed by Muslim Ethicists? A. Yes, but make sure that the protocol is fully explained to the patient and by delaying the treatment, no worsening of his medical condition takes place nor his life is endangered. Q4. While fasting can a Muslim patient have a blood test (venous draw) or check his glucose with a finger stick? A. Yes, if it is a medical necessity. Q5. While fasting can a Muslim patient take tablets, injections, inhalers or patches? A. The general rules are: Q5. on Separation of conjoined twins, one dependent on the other, which one to save? A. It is a difficult situation. The emphasis should be to save both lives and one cannot be sacrificed over the other. However, if one has to do so, the twin who cannot function on its own and acts as a vestigial organ of the other, may have to be sacrificed during the process of separation. Q6. Should a female patient only seek a female Gynecologist? A. If available, same sex health care providers are encouraged but, if not available and in life saving situations, "necessity overrides the prohibition" - a rule of Islamic Sariah. Q7. Can a female Physician do genital/rectal examination of male patients? A. Yes, but in the presence of a male nurse or male relative of the patient. The answer to the previous question also applies here. Q8. Should Muslim Physicians care for AIDS patients? Is this endorsing homosexuality? A. We do not discriminate other patients because of their lifestyle (smokers, alcoholics, over eaters etc) nor should we do so for AIDS patients. We should care for them as we care for any patient, taking all the necessary precautions to protect ourselves. By the way, not all AIDS cases are due to homosexuality. Q9. Should Muslim OB/GYN Physicians perform abortion, vasectomy or tubal ligation? A. Such procedures are prohibited in Islam except to save the life of the mother. Muslim Physicians also may not perform them (even on patients of other faith) unless medical necessity. Q10. We are getting married and can not afford to have children, as both of us are still students. What contraception measures are allowed? A. All contraception measures between married couples for a valid reason and with consent of both are permitted if they are not irreversible (sterilization/tubal ligation), abortifacient (RU 486, IUD) or may be harmful (oral contraceptives). That leaves only abstinence, condoms and the withdrawal method. Q11. My wife can not conceive. Can she use her ovum and my sperm to be fertilized in her sister's uterus? A. No. Surrogacy is not permitted in Islam. (some jurist disagree with this opinion) Q11. We got married 3 months ago. My husband is in a coma after an auto accident and is expected to die soon. I love him very much. Can I save his sperm to have his baby after his death? A. No. After his death, his sperm can not be used. All methods of assisted reproduction are allowed between husband and wife only during the intact span of marriage. Q12. I am pregnant and expecting delivery soon. Should I request my husband be present but no other male attendant during labor? A. Yes. You can make such a request. Q13. My friend is in the hospital. He is to have a major operation and will require blood. Is blood transfusion allowed and should we select the donor? A. Yes. Blood transfusion is allowed. Blood is routinely screened for HIV and other diseases. It would be nice if you could find a relative of your friend to match and donate his or her blood. Q14. At what stage of pregnancy does the termination become abortion, after 120 days or before? A. According to Imam Ghazali School of thought, life begins at conception, but other Islamic Jurists may have different opinions and allow termination of pregnancy before 120 days for a valid reason. Q15. Is post-mortem (autopsy) of a dead body allowed? A. Yes, but only as a medico- legal necessity to ascertain the cause of death. Q16. What should be done to the products of miscarriage? Should they be destroyed or buried? A. Preferably they should be handled with the same respect as another death and be buried if possible. (there is no need for funeral prayer). Q17. After a massive brain hemorrhage, my mother is in a coma and is on artificial life support. Her physician says there is no hope of her surviving and wants to pull the plug. We love her very much. What should we do? A. Islam does not encourage prolonging misery in a vegetative state and patients should be allowed to die naturally when nothing more can be done. You should agree with the medical decision, maybe seek second opinion, but insist that hydration and nutrition be maintained until death. Q18. Question from a medical student: "As a Physician, when I find out that my patient has a terminal illness and will die very soon, should I tell the truth to my patient and his family as soon as I know it myself? A. You should always tell the truth but do not be dogmatic about it. You can explain the diagnosis and natural history of the disease process but do not give a time limit as you do not know for sure when the patient will die.
Q19. My grandfather never took care of his diabetes. Now he has developed gangrene in his foot. Doctors recommend amputation to save the rest of his leg. He refuses. What should we do? A. You should talk to him again and again that God entrusted him with care of his body and if he does not do what doctors recommend, his condition may worsen and he will be questioned about it on the Day of Judgment in addition to having additional suffering in this life. Q20. My sister, who is pregnant, found out the baby has the congenital defect, Down's syndrome. Should she abort the fetus or carry it to term and spend her life caring for a disabled child?
A. Carry to term. There is extra reward in going through this test from God in caring for such a child. Q21. For a patient who has cancer with bone metastasis and is in constant pain, is it better that he takes strong pain killers all the time or be in pain and remember God? A. He should take pain killers as God does not want him to suffer. In severe pain he may not have the strength to remember God. Q22. I am on a heart transplant waiting list. Should I accept a heart from a criminal or an atheist? A. Yes, and pray that God changes your new heart to adopt it to your pious body. Q23. Should the pregnancy resulting from rape be continued to term or aborted? A. Carried to term unless the life of the mother is in danger. Why commit another crime? Q24. Is patient's autonomy (i.e. right to not seek treatment) equal to planned suicide? If so, should it be allowed? A. Patient's autonomy involves a sound mind while suicide decision is made in severe depression. One can refuse treatment because of side effects, but to kill yourself is against the will of God. Q25. I am a Muslim female medical student who does hijab (head cover). How can I scrub before surgery without removing my head cover and pulling up sleeves? A. You should do Masah (wadu) over the head cover, or remove in the presence of a female co-worker only. Q26. Is gene therapy and genetic manipulation to cure diseases allowed? Can we use embryonic stem cells for this? A. To seek cure for a disease is mandatory. Thus, gene therapy is allowed and stem cells from spontaneously miscarried embryos can be used. However, it is wrong to conceive or create an embryo just to harvest cells and then destroy it. Q27: If God is the Healer, then why should I take medication? A: It is not the Will of God that you suffer. You should take the medicine then pray to the Healer that it works and He heals you through that medicine. When Prophet Muhammad got ill, he took medicine and has advised us the same. References from The Holy Quran (A. Yusuf Ali Translation; Amana Corp) " 5:32 "On that account, We ordained for the children of Israel that if anyone, slew a person - unless it be for murder or for spreading mischief in the land, it would be as if he slew the whole people; and if any one saved a life, it would be as if he saved the life of the whole people. Then although there came to them our messengers with Clear signs, yet, even after that, many of them continued to commit excesses in the land." Recommended Resources ======================= " FIMA Year Book 2002- Published by Federation of Islamic Medical Associations Some web sites on Islam, Islamic Medicine and Medical Ethics " www.Islamicmedicine.org Reprint Requests: http://islam-usa.com/index.html |
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