I: Introductory Remarks
"How fortunate you are that you died while you were not
afflicted with illness." Thus said the Prophet addressing
the person whose funeral rites he was performing. Such an
assessment of death without illness coming from the founder
of Islam indicates the value attached to a healthy life in
Muslim culture. To be sure, good health is God's blessing
for which a Muslim, whenever asked: "How are you (lit. "How
is your health?")?", must respond: "All praise is due to
God!" However, this positive appraisal of good health might
seem to suggest that illness is an evil that must be
eliminated at any cost. No doubt illness is regarded as an
affliction that needs to be cured by every possible
legitimate means. In fact, the search for cure is founded
upon unusual confidence generated by the divine promise that
God has not created a disease without creating its cure.
Hence, the purpose of medicine is to search for cure and
provide the necessary care to those afflicted with diseases.
The primary obligation of a Muslim physician is to provide
care and alleviate suffering of a patient. Decisions about
ending the life of a terminally ill patient at her/his
request is beyond his moral or legal obligations. The Qur'an
reminds Muslims that "it is not given to any soul to die,
save by the leave of God, at an appointed time." (Q. 3:145)
Moreover, "God gives life, and He makes to die. (Q. 3:156)
And, hence, "A person dies when it is written." (Qadar, #
11)
Death, then, comes at the appointed time, by God's
permission. In the meantime, humans are faced with the
suffering caused by illness. How is suffering viewed in
Islam? Is it part of the divine plan to cause suffering?
With what end? These general questions about meaning and
value of suffering should lead us to appraise the suffering
caused by prolonged illness to an individual's personal and
family life. The need to take decision to end one's life
arises precisely at that critical point when the sick person
is undergoing severe discomfort and desperation, and when
all forms of advanced medical treatments have failed to
restore her/his hope in getting better.
Closely related to such a consideration on the part of the
sick person is whether the unbearable circumstances caused
by one's interminable illness makes existence worthwhile at
all. Does such an existence that is almost equivalent to
non-existence because of intense sense of helplessness in
managing one's life possess any value for its continuation?
Beneath these concerns lie a deeper question about the
quality of life that individuals and society regard as worth
preserving.
II: Question about the Quality of
Existence:
The importance attached to the quality of life question
has sometimes led Muslim scholars to evaluate suicide (in
Arabic expressed as qatl al-nafs = `homicide') in very
ambiguous ways. On the one hand, there is a unanimity in
declaring the act as an irrational behavior that human
beings should not commit; on the other, their interpretation
of the act being committed under situations a person is
unable to cope with, indicates a factual, even condoning
attitude toward suicide. The following case of an old man
who committed suicide under tragic circumstances highlights
the ethical and legal debate surrounding the right to end
one's life under compelling circumstances:
The Case of the Shaykh Who Committed
Suicide:
"Recently we saw what happened to a learned
Shaykh. This Shaykh had come to live in a very reduced
circumstances. Therefore, people began to avoid him more
and more, and his acquaintances no longer wanted to have
anything to do with him. This went on for a while until
one day he entered his home, tied a rope to the roof of
his room, and hanged himself, thus ending his life.
When we learned about the affair, we were shocked and
grieved. We discussed his story back and forth, and one
of those present said: What an excellent fellow! He acted
like a man! What a splendid thing he did of his own free
will! His action indicates magnanimity and a great
staunchness of mind. He freed himself from a long
drawn-out misery and from circumstances which were
unbearable, on account of which nobody wanted to have
anything to do with him, and which brought him great
privations and a steady reduction of means. Everybody to
whom he addressed himself turned away from him. Whenever
he knocked at a door, it was closed before him. Every
friend whom he asked for something excused himself.
While that person thus defended the action of the
suicide, someone else replied: If the Shaykh escaped from
the dreadful situation which you have just described,
without getting himself into another situation which
might be considerably more frightful and of a much longer
duration than that which he had been in, it would indeed
be correct to say that he did a splendid thing. What a
noble fellow, one might then say, he was, considering the
fact that he found strength and the means to commit such
a deed! One would have to admit that every intelligent
person should feel compelled to do the same thing, to
imitate him and to arrive at the same decision of his own
free will.
However, if he had learned from the sacred law
(sharayi`) - no matter whether the ancient or the new one
(al- shari`a) - that such and similar actions are
forbidden, it would be necessary to say that he did
something for which God has ordained quick punishment and
disgrace in the painful fire of Hell. My God! He could
surely have learned from any intelligent and judicious,
learned and educated person, from anybody who has some
intelligence and knows the elements of ethics - let alone
him who knows what to say and to do and to choose always
the best procedure of and occasion for doing things -
that such actions are forbidden and that even the
commission of much lesser deeds is prohibited. Why did he
not suspect himself and scrutinize his motives and
consult someone who might have given him good advice! And
all this happened on account of a situation which was
such that if he had extricated himself from it, he would
thereafter have encountered many things so much worse
that they would have made him forget his former
hardships.
He ought to have known that it is necessary to avoid
any connection with such an action, which is detested by
intuitive reason, considered sinful by tradition and
shunned with horror by nature; for the generally known
injunctions of the religious laws and the consensus of
all in each generation and region show that suicide is
forbidden and that nothing should be done which might
lead to it. The reason for prohibition of suicide is that
it might be committed under the influence of ideas and
hallucinations which would not have occurred to a person
in the full possession of his mental faculties. Later on,
in the other world, the person who committed suicide
under such circumstances would realize the baseness of
his action and great mistake he made; then, he cannot
repair, correct or retract what he did.
Even if compliance with the demands of the intuitive
reason, or information derived from reason and revelation
would have required him to commit such a deed, he should
not have handed himself over to destruction. He should
not have of his own free will done something which is
despised by persons who are discerning and perceptive,
religious and noble. He should not have broken
established customs, opposed entrenched opinions, and
arrogated the rights of nature. But all the more so
should he have refrained from his deed since the
intuitive reason and speculation have decided, without
leaving the slightest doubt, that man must not separate
those parts and limbs that have been joined together (to
form his body); for it is not he who has put them
together, and it is not he who is their real owner. He is
merely a tenant in this temple (i.e. the human body) for
Him Who made him to dwell therein and stipulated that in
lieu of the payment of rent for his dwelling he take care
of its upkeep and preservation, its cleaning, repair and
use, in a manner which would help him in his search for
happiness in both this world and the next world.
We ask God in Whose hands rests the power over
everything that He may guide us toward that way of life
which is preferable for this world and which will lead to
greater happiness in the world to come. For if we were
left without His kind care and customary benevolence, we
would be lost and forsaken."
(From Muqabasat of al-Tawhid)
III: Human Stewardship of Human Body and
Suffering
The case points to the cultural and religious attitudes
regarding human existence and the control over life and
death decisions when an individual is overcome by suffering.
Furthermore, it underscores the view that human being has
the stewardship not the ownership of his body to enable him
to assert his right to handle it the way he pleases. He is
merely the caretaker, the real owner being God, the Creator.
As a caretaker, it is his duty to take all the necessary
steps to preserve it in a manner that would assist him in
seeking the good of both this world and the next. In light
of such a stipulation about human duty toward his earthly
existence in Muslim theology, the problem of human suffering
through illness assumes immediate relevance. The Qur'an
provides essential philosophy behind human suffering by
pointing out that suffering is a form of a test or trial to
confirm a believer's spiritual station:
O all you who believe, seek your help in
patience and prayer; surely God is with the
patient.....Surely We will try you with something of fear
and hunger, and diminution of goods and lives and fruits;
yet give thou good tidings unto the patient who, when
they are visited by an affliction, say, `Surely we belong
to God, and to Him we return'; upon those rest blessings
and mercy from their Lord, and those - they are the truly
guided. (Q. 2:153-157)
Suffering in this situation is caused by the divinely
ordained trial. More pertinently, it functions as an
instrument in revealing God's purpose for humanity and in
reminding it that ultimately it is to God that it belongs
and to God it will return. Accordingly, suffering from this
perspective cannot be regarded as evil at all. In fact, the
Prophet is reported to have prayed: "O God, do not let Your
trial be the cause of misguidance for me!" In other words,
afflictions in the form of trial should not lead a person to
lose hope because despair stems from lack of trust in the
divine mercy.
In addition to this spiritual-moral dimension, suffering
serves an educational purpose. Here suffering is caused by
human misconduct. It serves as a form of punishment to
expiate for a sin. Disbelief in God's power to heal and
restore health is the major source of human desperation. It
is also regarded as the source of human arrogation of the
rights of God. Experiencing severe and untreatable suffering
caused by illness serves as a reminder of one's being
deprived of the divine blessing of good health through one's
disbelief in God. As such, suffering is a means to
self-purification from sinful behavior. It is in this state
that when afflicted with illness Muslims are advised to
beseech God to forgive their sins. Rather than contemplating
on ways to end one's life, either by refusal of life-support
treatment or by requesting to die with active assistance, a
Muslim is required to pray for an opportunity to have a
fresh start with restored health.
IV: Human Response to Suffering
This religious and spiritual valuation of suffering does
not answer the critical question when one is going through
illness: Should one take upon himself to alleviate suffering
where possible and endure otherwise?
In general, Muslims have tended to respond actively to
remove the cause of suffering. The notion behind this active
response is that since human being is the cause of her/his
suffering, she/he should undertake to do righteous acts to
rid the world of suffering. According to the Qur'an, "surely
the good deeds will drive away the acts of disobedience
(which cause suffering)." ( Q. 1:114) Contrary to this
activist posture, there was also an attitude of resignation
in some quarters among Muslims who believed that since God
is testing human faith and purifying it through affliction,
one must endure suffering. Nevertheless, even in this
passive response the Qur'anic promise that good works
alleviates divine punishment generated some endeavor to
overcome suffering.
These two attitudes had their justification in Muslim creed.
Muslims who believe justice to be the fundamental attribute
of God also regard human being as God's free agent, endowed
with volition and ethical cognition, and, hence, responsible
for her/his acts. Accordingly, she/he should exercise
her/his will in overcoming difficult and unbearable
situations. On the other hand, Muslims who maintain
omnipotence to be the essential attribute of God do not
believe that human being has the volition to act independent
of the divine predetermination. Hence, suffering must be
endured with patience and perseverance. Life is a testing
ground for humankind. Those who submit to the will of God
shall attain prosperity. God's plans will justify and
vindicate the righteous in the end.
The question that is so central to this conference, namely,
the patient's "right to die" cannot be negotiated because,
in the first place, life is a divine trust and cannot be
terminated by any form of human intervention; and, in the
second, its term has been fixed by the unalterable divine
decree.
V: End of Life Decisions in Islam
The belief in God's immutable decree is also revealed in the
Muslim law where not only the right to die is not
recognized; the right to be assisted in dying, whether
through "passive" or "active" means is also ruled out. It is
important to clarify here that since the end of life
decision is through divine decree, the law refuses to
recognize individual right in that matter. However, it
recognizes the possibility of arriving at a collective
decision by those involved in providing the health care,
including the attending physician and the family. The
juridical principle of nonmaleficence that states `No harm
shall be inflicted or reciprocated in Islam' (la darar wa la
dirar fi'l-islam) provides the justificatory force of the
ruling to that effect. Moreover, there is no immunity for
the physician who unilaterally and actively decides to
assist a patient to die.
VI: Pain Relief Treatment and Withdrawal of
Life-sustaining Treatments
There are, however, two situations in the treatment that
could be interpreted as "passive" assistance in allowing a
terminally ill patient to die. Pain relief treatment, which
could shorten life, but which is administered to relieve
physical pain and psychological distress and not to kill, is
permitted in Islamic law simply because the motive is
regarded as a sufficient justification, protecting the
physician against criminal or other liability in such
circumstances. As long as the situations do not involve an
intention to cause death a medical intervention to provide
necessary treatment for the relief of pain or other symptoms
of serious physical distress is not regarded as
criminal.
Similarly, in relation to withdrawing treatment, whether
pursuant to a refusal of a death-delaying treatment or
through a mutual and informed decision-making by patient,
physician and other parties involved in providing care for
the patient, although there is an intention to allow the
person to die when it is certain that death will result from
its omission, Islamic law regards it a non-culpable act. The
reason is that delaying the inevitable death of the patient
through life-sustaining treatment is regarded as being
against the benefit of the patient. Moreover, the principle
of `juristic preference' (istihsan=`to deem something
preferable') protects the physician by authorizing departure
from the already established ruling about the prohibition of
allowing death to occur in order to avoid any rigidity and
unfairness in recognizing the incurable preexisting
conditions of the patient. Furthermore, by authorizing the
removal of life-sustaining treatment in cases where it
results merely in death-delaying procedure, the `juristic
preference' serves the ideals of justice and public interest
in a better way. In other words, enforcing the existing
prohibition against allowing the patient to die could prove
to be detrimental in certain situations, and a departure
from it may be the only way of attaining a fair solution to
a particular problem. Withdrawal of life-sustaining
treatments in such cases is regarded as allowing inevitable
death to take its natural course. Notwithstanding a fine
line between having and not having an intention to cause the
death in such omissions, Islamic law does not forbid
withdrawal of the futile and disproportional treatment on
the basis of the consent of the immediate family members who
act upon the professional advice of the physician in charge
of the case. Some Muslim jurists have recognized the
validity of a competent patient's informed refusal of
treatment or "advance directives" which allow the person to
die under circumstances when there is no medical reason to
continue treatment. However, even in such rare recognition
of the patient's autonomy in Muslim culture, the law
actually takes into consideration the patient's long term
treatment relationship with a physician whose opinion, in
the final analysis, serves as the grounds for turning off
the respirator, for example. In this case, the death is
regarded to have been caused by the person's underlying
disease rather than the intentional act of turning off the
respirator.
The underlying principle in this ruling is that intention
alone does not make an act culpable. The person's death is
actually caused by the preexisting disease when the
withdrawal of the treatment is justified through the expert
opinion. In other words, the law does not regard withdrawal
of the treatment as the cause of the person's death. This
can be compared with giving a person a lethal injection. The
injection is the sole cause of the person's death and is
clearly regarded as the cause of this in fact and in law by
Muslim jurists.
To recapitulate Islamic ethical-legal perspective on the
"right to die" of a terminally ill patient without any hope
of getting better, it is important to restate that the
justificatory force of the rulings on "allowing to die" by
withdrawal of life-sustaining treatments is contingent upon
a well informed consultation with the physician and other
parties involved in the patient's treatment. More
importantly, since Islamic legal deliberations contain and
ground morality as part of its spiritual response to God in
interhuman relationships, patient's own determination and
physician assisting him to terminate life, are both regarded
as acts of disobedience against God. Pain relief treatment
or withholding or withdrawing of life-support treatment, in
which there is an intention of allowing the person to die
when it is certain that the disease is causing untreatable
suffering, are permissible as long as the structures of
consultation between all the parties concerned about the
well being of the patient are in place. In final analysis,
besides the exceptions noted in the two situations, there
are no grounds for the justifiable killing of a terminally
ill person, whether through voluntary active-euthanasia or
physician assisted suicide in Islam.
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