THE ETHICAL OBLIGATION TO MINIMIZE COVID-19 DEATHS AS AN END OF LIFE MANDATE FROM ISLAMIC PERSPECTIVE: QUALITY OF LIFE VS FORGOING TREATMENT
The current COVID-19 pandemic has introduced several challenges for the world’s religions including Islam and Judaism. Furthermore, religious leaders are faced with the challenge of dealing with religious congregations while also adhering to COVID-19 prevention strategies such as social distancing. To fully understand the extent to which the pandemic has affected the world and more specifically, Muslims and Jews, this paper has analyzed the nature of bioethics in Islam including quality of life in Islam. Additionally, the paper has presented major end of life issues such as euthanasia, physician-assisted suicide and forgoing treatment based on the Quran, Sunna and fatwas. The paper has also highlighted the lack of a definitive answer on what is brain death and whether it signifies actual death for Muslim patients. Moreover, the paper has compared and contrasted teachings from Islam and Judaism on death and end-of life care especially for patients suffering from COVID-19. Lastly, the paper has highlighted the transformation that both religions have made to accommodate the new way of conducting rituals including the rituals associated with caring for the dead.
The COVID-19 pandemic presents several challenges to public health and the global economy. Due to its rapid spread, increase in the number of infections and the number of deaths, COVID-19 has been declared a pandemic by the World Health Organization. Given the seriousness of the disease, countries across the world have intensified their control and preventive measures in addition to implementing strategies to manage the economic, health and social consequences of the pandemic. For some countries, implementing crisis management interventions acts as a turning point from enduring unstable economies. In addition to affecting economies, health and social factors, COVID-19 has had a significant impact on the world’s religions. Since the virus is transmitted through contact, mass gatherings like the Hajj for Muslims, are highly discouraged. Furthermore, religious leaders are required to expand their teachings to include COVID-19 prevention measures such as regular hand washing among others. However, in the unfortunate case where a Muslim has succumbed to COVID-19, Islamic burial laws exist to guide the process. According to Islamic traditions, the burial of a deceased individual is a collective obligation for the entire community. However, due to the unique situation that arises from a COVID-19 positive individual’s death, the rituals of ghusi (washing of the dead), kafan (shrouding the body with pieces of clothing) and al-janazah (final prayer) must be done with the highest level of care for the body handlers.
The COVID-19 pandemic has introduced several ethical challenges for religions in the world. To further provide clarity on this issue, this paper will highlight the nature of bioethics in research and the resulting end-of-life issues that arise during care. The paper will also highlight end-of-life contemporary issues in Islam such as euthanasia. Lastly, the paper with compare and contrast what Islam and Judaism say about forgoing end-of-life treatment especially during the COVID-19 pandemic.
The Nature of Bioethics in Islam
Islamic bioethics is the Islamic guidance on issues related to human life. In contemporary Islam, bioethics is believed to belong to a specific subfield of Islamic legal reasoning known as fiqh. The field of bioethics developed following the introduction of new technologies in medicine and end-of-life care. However, when the principles used to guide Islam’s ethical framework are applied to real-life clinical experiences, they are not sufficiently understood by healthcare providers. As a result, they act as a hindrance to the delivery of culturally sensitive healthcare. For the last couple of years, the concepts of bioethics have been developed in life sciences and health. However, as the field of bioethics continues to grow, so does the realization that while some interventions exist and can be given to patients, it does necessarily mean that that they should.
Islamic Sources and Bioethics
Muslim jurists, scholars and healthcare professionals, over the years, have been addressing issues associated with modern biotechnology. Among the key issues addressed include abortion and euthanasia. However, while a majority of debate has focused on the abovementioned issues, little attention has been directed towards new and disturbing ethical dilemmas caused by advanced technological innovations. Islam medical ethics obtains its teachings from the Qur’an (The Holy Text believed to be the direct word of God), the Sunnah (examples of Prophet Muhammad) and the Ijtihad (the law of deductive logic). Furthermore, since Islam does not admit clergies, the learned or the Ulema, are charged with the responsibility of interpreting religious texts for other Muslims. The views of the Ulema with regards to the ethical dilemmas in healthcare is that, in situations where specialist knowledge is required, the concept of a consensus edict can be used. On the other hand, for rulings associated with medicine, the consensus groups often include the Ulema and other specialist from other disciplines. The decision making process is also transparent with relevant individuals allowed to choose the best decision or judgment they are comfortable with. This process of deductive reasoning is what is referred to as Ijtihad.
In Islamic societies across the world, the teachings of Islam play a crucial role in shaping Muslim’s attitudes towards health and life in general. Islamic legal and ethical traditions are the main guiding factors when dealing with emerging issues in bioethics. Furthermore, both Islamic legal and ethical traditions cover major aspects both research and clinical related decision-making. However, due to lack of a central authority guiding all schools of thought in Islam, a majority of the decision-making is left to the faqih (qualified scholars of Islamic laws). Moreover, when bioethical questions arise in Islamic jurisprudence and there is no textual source or base that is offering complete guidance, decisions are left to the ijtihad. This further shows that in Islamic bioethics, decisions are always shaped by several factors within the political and legal systems in society. Besides, in practice, Islamic jurists and scientists always come together to provide guidance in the case of any dilemma. The fatwa or the Islamic judicial ruling, also plays a crucial role in the decision-making process when it comes to matters bioethics.
A common concept in Islamic bioethics is the Maqasid-al-Shariah which, as the name suggests, uses major concepts of the Shariah to analyze and assess bioethical issues. According to this concept, major bioethical issues are examined from three aspects: intention of the issue, method and final goal. Afterwards, an evaluation is done on the issue from; the hierarchy of human interest, inclusivity and the degree of certainty. This new approach to bioethics can be used effectively to overcome complex and complicated bioethical issues in society.Maqasid Al-Shariah refers to the higher objectives of Islamic law. Additionally, the concept reflects the true purpose of the Lawgiver which is to command, prohibit or propose an action. It also represents an understanding of human interests and the intent of lawgivers to protect it. In this sense, the Maqasid acts as an axiology of the interests of humans which are legitimized by the Divine Lawgiver. Maqasid al-Shariah-based Islamic bioethics can be understood to be an Islamic morality system that is based on two key knowledge disciplines; biological science and knowledge related to human value systems. Furthermore, Maqasid acts as a standard providing guidance in the case of a bioethics discourse and when there is a need to decide the hierarchy of value and other human kind needs that are consistent with the Islamic perspective. Overall, Maqasid al-Shariah protects mankind’s interests based on the Islamic framework and not on human desires and wishes.
Sunni Muslims and the Role of Muslim Jurists in Bioethics
The great majority of the world’s Muslims are Sunnis. Statistics shows that approximately between 85% and 90% of Muslims in the Middle East are Sunnis. Furthermore, similar statistics indicate that in Egypt, Jordan and Saudi Arabia, Sunnis make up over 90% of the population. The name “Sunni” owes its origin from the phrase “Ahl al-Sunnah” which means “the people of the tradition” or people who live their lives based in the teachings and actions of Prophet Muhammad. Sunnah guides all Muslims. However, Sunnis use it as the primary guiding force. When addressing matters concerning bioethics, Sunni Muslims prefer incorporating ijmaa (consensus) and qiyas (analogy) in addition to the Quran, the Sunnah and reason or alaql. Furthermore, due to the connectedness of Islamic law and ethics, Islamic bioethics must incorporate Islamic law or Sharia in addition to other moral considerations. As a result, all decisions must be double checked against both the legal and moral standards.However, there are individuals who still take absolutist positions-but according to scholarly orthodox traditions, Islamic scholars should incorporate social contingencies into their opinions on whether to adopt modern practices. This is usually based on “maslaha”-a legal tool that acts as a calculus weighing benefits against risks.
One scholar who practices this is the current Grand Mufti of Egypt, Shaykh Ali Gumaa, who is actively engaging in education initiatives to teach Muslims about the dangers of absolutism since the context of any situation is extremely important. In line with this, there are several medical and reproductive technologies that are permitted under Sharia law. They include: in vitro fertilization is permitted but only for married heterosexual couples; surrogacy and any sort of donation is not permitted, freezing of sperm; embryo or testicular tissues is permitted provided the samples are stored in great conditions; sex selection can also be done but only in the case of medical necessity; embryo reduction is still under debate and a clear fatwa (an authoritative religious proclamation) has not yet been provided; micromanipulation is only permitted in cases where the main goal is to overcome infertility but never to mix DNA; gene therapy is also permitted but only if its advantages outweigh its losses; lastly, reproductive cloning is not permitted but therapeutic cloning is allowed only is the cloned cells are obtained legally.
Currently, there are no Muslim jurists who only specialize is tackling bioethical issues. Many Muslim jurists are graduates of Sharia Faculties and have received training that addresses a wide range of issues in the social, political, financial and bioethical fields. One of the main shortcomings of having Muslim jurists who have not specialized on bioethics is that there is lack of interpretive techniques that are only unique to Islamic bioethics.Islamic jurists, in other occasions, have failed to interpret the language of the Quran and the Sunna in a way that would result in the same legal result. In these occasions, legal reasoning or ijtihad, is applied. Ijtihad was developed to fill in the gaps left behind in the Quran and the Sunna. Muslim Jurists have also developed a corpus of several linguistic rules that attempt to fill the abovementioned gap. The main reason for exercising personal reasoning is so that the jurist can establish a unique legal norm for every case they confront. In addition to the ijtihad, Muslim jurists can also rely on ijmaa or consensus. Ijmaa also refers to the agreement of jurists, who after being subjected to different legal opinions and are living in a particular age, come to an agreement. This consensus is founded on the Quran or the Sunna. Furthermore, under the same realm of legal reasoning as ijtihad and ijmaa, in qiyas, or analogy. Qiyas is not viewed as a legal source, rather, jurists can use it as a legal source that can provide content to help them make a legal decision. Overall, Muslim jurists are tasked with the role of applying the two primary sources of Islamic law; the Quran and the Sunna either by applying the definitive legal rulings or by using their own legal reasoning depending on the situation at hand.
The Four Principles of Biomedical Ethics and Islam
The relationship that Islam has to medicine is extremely intimate. Islam, as a religion, has over the years encouraged the use of medicine and science to solve human suffering. Furthermore, Islamic medical ethics believes and practices the four main principles of biomedical ethics of autonomy, beneficence, non-maleficence and justice.
Respect for autonomy involves clarifying the distinction between an individual’s capacity to rule themselves and another individual’s reaction to the capacity. According to the Quran, religion does not have compulsion. Therefore, everyone has the will to accept Islam or reject it. The Quran is also full of scripture that encourage freedom of faith. In Islamic teaching, the man is entrusted with his body. As such, he is only permitted to act in a manner that is in line with God’s wished. Based on this, the health provider should encourage patients to avoid a risky life-style that could harm their health. This Islamic autonomy also extends to decisions about life and death with the preservation of life among the top five purposes of a sacred life. Furthermore, one is forbidden from committing suicide. A physician has therefore, no authority to terminate any life under their care. While there might be pain and suffering at the end of any illness, Muslims are encouraged to persevere since they will be rewarded by God. However, of importance to note is that administering pain killers is permissible if the pain is to the extreme.
Beneficence is referred to as the aspect of human nature that compels everyone to act in the best interest of others. The Quran and the Hadiths of Prophet Muhammad contain scripture of the prophet doings god and avoiding engaging in harmful activities Prophet Muhammad further encourages Muslims to be beneficial to others and to engage in charitable works. The principles of beneficence and non-maleficence are usually grouped together. The main concepts of the principle of non-maleficence include; avoiding inflicting harm or doing evil, preventing harm or evil, removing harm or evil and lastly, promoting good. This is in line with Prophet Muhammad’s teachings that order Muslims to promote good, remove harm and preventing evil or harm by doing good. Furthermore, Al Izz idn Abdul Salam, a renowned Islamic jurist, in his writings said that the main aim of medicine is to conserve health, restore it by removing ailments or by reducing its effects. On the other hand, Islamic jurisprudence axioms claim that avoiding harm should take precedence over doing good. This means that if a certain action is to end in both good and harm, thwarting off harm is the most preferred course of action. Based on clear Islamic teachings, physicians should never recommend or give their patients harmful materials.
The principle of justice is often viewed as being synonymous with fairness and can be summarized as the moral obligation to fairly when adjudicating between competing claims. Justice can be divided into three key categories; distributive justice, right-based justice and legal justice. The Holy Quran also talks extensively about justice. According to the Quran, God raised his prophets to establish justice and to also be part of the mission and endeavors to enforce it especially in all spheres of life. Justice is also a command from God. Moreover, justice is a comprehensive terminology that includes everything that is virtuous in philosophy. The Quran calls out to all believers to stand firmly for God and to avoid being swayed by the hatred of others and depart from justice. Overall, it is evident that the four principles of Bioethics are also present in Islamic teachings.
Value of Life in Islam
In Islam, life is considered sacred and among the greatest gifts from God. Thus, every moment of life has value and must be appreciated and protected. The Quran further emphasizes on the value of life by stipulating that saving life is an obligation and the unwarranted act of taking a life a crime. All forms of life are also extremely precious however, human life is placed above all others. To God, human life is extremely important to the extent that he develops it step-by-step as highlighted in the Quran. Life must also be appreciated and respect. Committing murder is not only considered a criminal act but is also considered to be an insult to human life in general. According to Islam, God is the only source of life and it is a gift, for which mankind is held responsible. Knowing the source of life is particularly important when answering one of the basic questions in bioethics, ‘who gives life and death?”
Life and Death in Islam
Death is considered to be an inevitable and irreversible experience. An individual’s set of beliefs and values significantly influences their attitude towards life and death. Muslims believe that health is God’s gift to them and sickness comes in only through God’s will. Dying is usually a time to reflect and repent. It is also a time for one to get closer to God by immersing themselves in prayer and in reciting the Quran. Dying is also a time where the faithful seek forgiveness from others for past transgressions. At this stage, Muslims are encouraged to be steadfast when dealing with pain and suffering since perseverance will result in the expiation of sins and access to the afterlife. When illnesses occur, there are several expectations that are placed upon others to take care of the sick. Relatives and friends are encouraged to visit the sick individual to honor them, pray for their welfare, seek forgiveness and offer support in whatever capacity they can. The Quran talks about God being the ultimate owner of everything. Therefore, based on this explanation, humans do not own their lives. Furthermore, the human body is considered to be a trust from God. Therefore, when one falls sick, they are obligated to seek appropriate care. However, this concept is not fully compatible with the concept of informed autonomy, where a terminally ill individual may refuse treatment, preferring to let death take its course. The Quran also states that God created death and life a way to test humans on how they live their earthly lives. Furthermore, the Quran states that God predestines the moment that everyone will dies even before they are conceived in their mothers’ wombs. Lastly, the Quran makes it clear that death is inevitable for everyone.
Islam also teaches that life exists even after death. This is known as Akhirah. Furthermore, individuals believe that when they die, they will remain in their graves until Yawm al–din, or the Day of Judgment. On that day Muslims believe that they will be raised from their grave and brought before Allah to be judged on how they lived their lives. This is referred to as the resurrection of the body. A Muslim’s life is made up of trials and tests through which, their final destiny is determined. As such, Muslims believe that death is the act of the soul returning to its creator, God. With the inevitability of death etched in their consciousness, Muslims ensure that they keep their life in line with God’s teachings as they also live in preparedness for the inevitable. The Holy Quran equates death to sleeping claiming that is complete with dreams and the period between death and resurrection is equated to a single night of sleep.at the moment of one’s death, they are able to know their destiny. Life, as the Holy Quran teaches, does not end with death.
Islam views disease as a natural phenomenon that is used to expiate sin. The patient who suffers in dignity stands to be rewarded in the hereafter. Furthermore, the family members who gave the patient support when they were sick will also be rewarded in the hereafter. In addition to the Holy Qurans, there are hundreds of Hadiths or sayings of the Prophet Mohammed that encourage believers to forebear when they face calamity or diseases. However, they are encouraged to seek remedy for their ailments. Furthermore, Muslims are encouraged to seek new and modern forms of treatment when the old ones become ineffective. Whenever Prophet Mohammed fell sick, he would seek treatment for himself, and when his family and companions fell sick, he also encouraged and advised them on the appropriate remedy to use. Furthermore, Mohammed would state that Allah would never send a disease without sending a cure also.
Seeking remedy in certain situations may be considered mandatory or may be highly encouraged or preferred. In other situations, seeking remedy may be optional and might not be preferred or even may be considered to be Haram (not allowed). As discussed earlier, it is expected that everyone should seek treatment to save their own life. However, if an individual is unconscious or if they are a minor, then there is no need to obtain consent before administering a remedy. On the other hand, treatment is encouraged only in cases where the remedy is likely to be successful and when the ailment is expected to hinder the duties of a Muslim to his family or even to the community. Seeking treatment is considered optional only when the benefit is proven and when the remedy is expected to cause harm. Muslims are also encouraged to abstain from seeking remedy when it is highly unlikely that the remedy will bring any benefits. And lastly, seeking remedy is prohibited if it is based on other sources other than the Quran, uses blood, pork or any form of intoxicant.
Islam strongly encourages believers to treat illness with both prayer and medicine. Religious scholars always insist that individuals use scientifically established medical procedures in combination with praying and asking God for assistance. By doing so, Muslims avoid exclusively relying on prayer alone and refraining from taking vital medication. Furthermore, verses from the Quran can be used as a form of emotional healing. Muslims can also use verses from the Quran and prayers which are used to treat the sick to complement modern medicine. This practice is referred to as ruqya. While scientific medication should be taken first, ruqya is a form of treatment that could be used to reduce emotional stress. Lastly, while all might fail, individuals are always encouraged to draw from the healing powers of the Quran and seek God’s assistance. They should not rely on frauds who claim that they have the ability to heal.
End of Life Care
The Purpose of life, from an Islamic point of view is to worship God alone. Death is looked at as a cessation of the life of the current world and a transition to the afterlife. Life in the grave is viewed as a transition stage until judgment day arrives, on which everyone will be recompensed for their worldly actions. Illness, is viewed as an opportunity to get closer to God and a divine reward for those who endure hardship. While there is proof that Muslims are required to seek general medical treatment, rulings regarding life-sustaining interventions in patient care are not so clear in Islam. As such, it is crucial to understand measures such as artificial hydration and nutrition. While artificial nutrition and hydration has been documented to have clear benefits for certain groups of individuals, the benefits of the treatment for patients at the final stages of a disease is not clear. Individuals who are terminally do not experience hunger or thirst and might not benefit from artificial nutrition and hydration. In addition, for patient’s whose condition worsens, artificial interventions such as artificial nutrition, may be withdrawn to allow for the patient’s vital organs to cease functioning on their own. Palliative care interventions are essential especially for Muslim patients who are in their final stages of illness since euthanasia in prohibited in Islam. The physician must therefore ensure that the patient is fully informed of their condition for them or their surrogate, to make informed decision in accordance with Islamic beliefs and teachings.
As discussed earlier, Muslims are encouraged to seek treatment for any form of illness. Pain relief, including taking of opioids is acceptable. In some instances, Muslim patients may wish to remain conscious in order to worship God as long as possible. Among the five duties of Islam, is wudu, or ceremonial cleansing. However, if a Muslim is too ill to perform wudu, there are several alternatives for this including; using a dry ablution kit. A DNR or “do-not-resuscitate” order is an issue introduced by modern medicine. As such, it not mentioned in the Quran, the Sunnah or Hadith. To provide guidance on this, Islamic scholars, through a fatwa, claim that if three trustworthy physicians agree that a patient’s condition will not improve, life-supporting machinery can be withdrawn, and thus, implementing a DNR. When caring for a patient who is near death; friends, relatives and family members are called upon to gather around the dying individual, spiritual blessed water is place in the mouth of the dying person to bless them, the patient is also allowed offer prayer is they are able to, certain religious texts are read to comfort the dying person. Lastly, withdrawal of life-sustaining treatment is only acceptable in specific situations such as when death is inevitable.
End of Life Issues
Due to recent advancements in biotechnology, genetic screening and life-support technologies, several bioethical issues have been raised. Currently, end of life issues are one of the main healthcare ethics challenges facing the public. Some of these issues include; euthanasia, physician-assisted suicide, withdrawal of treatment, DNR orders and consent. Decision-making especially in terminal care can be both demanding and stressful for all individuals involved. Issues such as euthanasia, while regulated widely, is still being performed across the world. Furthermore, for individuals nearing their death, continuing to feel pain may appear to be worse than death. The suffering can be so great that the patient may wish to end their life either through euthanasia or physician-assisted suicide. In light of religious beliefs, mankind does not have a right to determine their own lives but has autonomy to do what they want to, with their health.
Most Contemporary Issues
A majority of Muslims across the world, oppose the use of euthanasia. For them, human life is sacred and is a gift from Allah. Only Allah determines how long an individual will live. On the other hand, devout Muslims also believe that do-not-resuscitate or (DNR) orders are a softer version of euthanasia. As such, they reject it based on the fact that Muslims cannot kill or be complicit in the killing of another except when justice is to be served. However, doctors can stop trying to prolong life in certain where there is little to no hope for a cure. This is further emphasized by the Islamic Medical Association of America (IMANA), which emphasizes that when death is inevitable, the patient should be allowed to die without additional and unnecessary procedures.
In Islam, death is believed to be a stage of divine evolution. Additionally, the external existence of Muslims after death is highly dependent on how an individual lived their life while still alive. Physician-assisted suicide (PAS) and euthanasia from both the ethical and legal perspective. According to the Islamic code of law, taking one’s life is highly forbidden. Life is a gift from God and should therefore be preserved. Furthermore, Muslims have no right to end their own life. Besides, all Islamic doctrines view PAS and euthanasia as being forbidden. However, if the patient is fatally ill, withholding or withdrawing futile medical treatments is permissible. From a legal standpoint, Islamic countries have not legalized PAS and euthanasia. As such, when they are conducted in these countries, they are considered to be suicides even when patients consent to them and homicides when physicians take part in them.
Brain Death in Islam
Islamic scholars and medical experts have used concepts borrowed from Islamic law to formulate ethico-legal opinions regarding brain death. For some juridical councils like the Organization if Islamic Conferences’ Islamic Fiqh Academy, brain death is similar to cardiopulmonary death. However, for other organizations such as the Islamic Organization of Medical Sciences (IOMS), brain death is the intermediate state between life and death. Other councils also have different notions entirely while the ethico-legal assessments are also not uniform especially in matters regarding the conceptualization of brain death. The determinations of these aforementioned councils have sway upon Muslim clinicians and patients who face the challenges of brain death. According to the Islamic Fiqh academy, brain death can be considered legal death only if all the vital functions of the brain stop working irreversibly and the brain starts to degenerate. Some proponents argue that brain death is death simply because it indicates departure of the soul from the body and it is the soul that animates the body. Others, on the other hand, believe that brain death cannot be considered to be death because the brain is separate from the soul. There needs to be renewed interdisciplinary investigations to explore Islamic beliefs regarding brain death.
The concept of brain death poses several challenges to clinicians who are required to bridge the gap that exists between religion, law and medicine. The First World Meeting on Transplantation of Organs had representatives from the Muslim faith and representatives from other religious denominations. During the meeting, ethicoreligious issues that focused on the definition of death were intricately discussed. The consensus was that cerebral death was a reasonable enough concept for physicians to focus on. In line with this, a definition of brain death was agreed upon. A person was to be considered dead, if there was an irreversible cessation of brain functions including brain stem. However, currently, the criteria used to determine the presence of brain death varies significantly by definition and compliance. In Islam for example, the idea of brain death is still subject to great debate
Foregoing Treatment in Islam
Medicine of the Prophet is made up of several divinely inspired therapeutic words by Prophet Muhammad (pbuh). The prophet made statements on 37 ailments and approximately 61 medical plants and shrubs while making prescriptions for the sick. Although the prophet did not arrive as a physician, he was inspired by Allah to make over 1000 statements on healing since man should remain well and should be free from any form of sickness to be able to fulfill their mission on earth. Over the years, the traditions of the Prophet (pbuh) on healing have been proven through research to be true especially for Nigella sativa or black seed, which was a favorite of the Prophet.
While Islam encourages all to seek medical help when they fall sick, plastic surgery and its health benefits is still under contention especially in Islam. Islamic law closely regulates the lives of believers. As such, Islam stipulates that believers should be satisfied with how they were created by Allah. That being said, Islam welcomes the practice of plastic surgery as long as it benefits the patient. Even if this is considered to be changing Allah’s creation, Islamic law is not clear when it comes to matters regarding cosmetic or plastic surgery. Its reservations towards cosmetic surgery is not absolute. Rather, it is an objection to exaggerations and extremism. Perhaps the most significant of the prophet’s (pbuh) statements is that God always gives a cure for every illness. While Muslims are encouraged to believe in God, they are also encouraged to seek medical attention.
However, there are several situations where Muslims can withdraw or even withhold life support treatments. For many Muslim patients, their families and clinicians, understanding when it is ethically justifiable to withhold medical treatment is a challenge. Furthermore, there is lack of ethico-legal guidance on this matter. To answer this question, several fatwas have been proposed by Muslim judiciaries. A majority of the fatwas permit the foregoing of treatment provided several conditions are met. For example, care can be discontinued especially in situations where the patient’s death is inevitable. Other fatwas distinguish between two main categories of end-of-life treatments, they include; life support and ancillary interventions. Life support primarily refers to treatments like assisted mechanical ventilation while ancillary interventions refer to nutrition, hydration and even pain control. For fatwas that clearly make this distinction, they rule that while life support treatment can be stopped, ancillary treatment should always be continued. In general, while futility considerations allow for the withdrawal of life-sustaining treatment, available fatwas shy away from providing specific examples where treatment would be considered futile.
Covid-19 Deaths in Islam and Judaism
According to statistics by UK’s office for National Statistics, Muslim males in England and Wales have the highest death rates from Covid-19 of all the religious groups. Furthermore, the figures show that during the first months of the outbreak, Muslim male mortality was about 198.9% for every 100,000 people while for females the rate was 98.2% deaths for every 100,000. On the centrally, individuals who viewed themselves as having no religion had the lowest death rate with approximately 80.7% deaths for every 100,000 males and 47.9% deaths for every 100,000 females. On the other hand, the impact of coronavirus on the Jewish community involves significant contrasts. In many Jewish communities across the world, the coronavirus is continuing to cause mayhem. However, it is not possible to say exactly how many Jews have died of the pandemic since countries do not count the deaths of their Jewish citizens separately. However, what is clear is that the Jewish rate of COVID-related deaths is significantly higher in the diaspora compared to the death rate in Israel.
Epidemics in Islam and Judaism
Since the first case of coronavirus was confirmed, the novel virus has spread to every corner of the world and religions across the world have played a significant role in this spread. Churches and other religious congregations that defy health directives to combat the virus significantly endanger the lives of their members and their loved ones. Since collective worship has been identified as an effective mechanism for accelerating the spread of the virus, religion can then be viewed as being complicit in one of the most deadly global health crisis of the current generation. For many individual, the expression of faith is done through close contact such as hand-holding, sharing of communion such as in Christian churches, standing next to each other during prayer in Mosques and touching and kissing religious objects at synagogues.
The discussion on how to observe public distancing strategies (PDS) during the COVID-19 pandemic is not unanimous among Muslims. For example, the international Islamic Fiqh Academy which is affiliated to the Islamic Cooperation (OIC) recommends adhering to PDS including closure of mosques and suspending Tarawih and Eid prayers. Additionally, to further implement the recommendations of the OIC, educational institutions have been closed and pilgrimage cancelled. Able-bodied adult Muslims are also encouraged to fast during Ramadan in line with the recommendations of the Quran. However, when one is ill, they are discouraged from fasting. Moreover, all fatawa agree that illness is a valid reason why an individual should be exempted from fasting. When it comes to fasting during the COVID-19 pandemic, health practitioners who are weak or who are caring for their patients, may break their fast. However, they are encouraged to still adhere to the rules of atonement.
The Muslim Council of Britain also concurs with the recommendations of the OIC. They note that healthcare workers who are wearing personal protective equipment and are subjected to long shifts are at an elevated risk of being dehydrated which could result in them making medical errors. For these healthcare workers, fasting is exempted. In addition to exempting fasting for healthcare workers, The Muslim Council of Britain recommends organizing prayers at home during the holy month of Ramadan. Muslims are also required to live stream Tarawih in their homes and arrange virtual iftars with their loved ones. In North America on the other hand, the National Muslim Coalition Statement on Coronavirus Pandemic has encouraged all Muslims to practice self-quarantine and to social distance as advised by their public health authorities and local governments. The coalition has also advised Muslims to conduct Friday prayers in the homes.
Besides affecting the weekly Sabbath, several Jewish holidays have been affected. These holidays include; the Purim, Passover, Shavout, Rosh Hoshanah, Yom Kuppur, Sukkot and Shemini Atzeret. However, decisions on how the Jewish community observes COVID-19 regulations is complex because decisions between different denominations differs. However, in this time of coronavirus, most denominations are leaning towards using technology on such holidays such as the Shabbat. The Committee on Jewish Laws and Standards together with the Rabbinical Assembly office have encouraged the ill to stay at home and self-quarantine. This is mainly based on the principle of Pikuach nefesh which translates to saving lives instead of observing the Sabbath. For those who wish to be part of the weekly minyan and to recite prayers including the mourner’s kiddish, may do so virtually either through audio or through video with a minyan. This can be with members of their own congregation meeting preferably within their time zones. They can recite Kaddish, barkhu or the kedushah while hearing Torah readings. However, congregational leaders are required to provide guidance for how home davening and Torah studies can be conducted. Furthermore, congregational leadership should advice on how individuals can attend Shabbat or Yom Tov services. Coronavirus infection rates among Israel’s ultra-orthodox Jews is disproportionately high compared to other Israelis. Estimates show that approximately 40%of residents in ultra-orthodox neighborhoods are infected. Synagogues in such neighborhoods are cited as being sources of the increased spread of infections. Furthermore, the spread of COVID-19 can be reduced significantly if religious leaders adopt a more pragmatic approach. The clergy should also be co-opted in the suspension of congregations. Countries should also prepare Standard Operation Procedures (SOPs) especially during times of infectious disease epidemics.
End of Life and Foregoing Treatment in both Islam and Judaism
Spiritual care plays a crucial role in holistic patient care. Awareness of patient beliefs for healthcare providers, should facilitate discussions about spirituality. Besides, all healthcare providers are more likely to handle Muslim patients, yet many of them lack basic skills and knowledge of the Muslim faith and how to apply the teachings in palliative care. Furthermore, some of the positive concepts in Jewish approaches regarding palliative care are also not well known. One of the most important foundations of palliative care is the understanding of how serious illnesses are treated. In Judaism, the Biblical commandment that requires individuals to return lost objects to their rightful owners acts as a source for doctors to heal their patients. Is a doctor has the ability to return to a patient their lost health, then they must ensure that they do so. Furthermore, based on this scripture, doctors must return to a patient their lost quality of life and ultimately to a life that they enjoyed and one that was not full of suffering. In Islam on the other hand, suffering plays a crucial role in the life of a believer. Furthermore, sickness and suffering are considered to be part of life and a spiritual test from God. When one suffers from emotional and physical pain brought about by illness, they view it as a test of their faith. In sickness, Muslims are encouraged to be more thankful to Allah and take care of themselves and their health.
In Islam however, treatment to reduce pain during sickness is obligatory. Islamic teachings encourage Muslims to seek treatment whenever they fall sick. Furthermore, pain relief using morphine or other analgesics, is allowed and even recommended even if it hastens death. Death is also inevitable in Islam and only occurs when God commands. Death should be accepted and should not be fought against. The promise of an afterlife consoled the dying and encourages them to take as they enter a new world of the divine. Since death can happen at any time, Muslims are required to always be prepared for this inevitability. When their time comes, they should not delay death. In Judaism on the other hand, there are contradictory views especially when it comes to death. According to the Jewish faith, death is evil and life is a wonderful gift and an opportunity to serve the Creator. As such all Jews are required to do their best to preserve life. The Torah is the collective body of teachings from God. The Torah teaches that man is able to fulfill God’s commands better than the angels. Furthermore, in Judaism, death provides all with an attitude of gratitude for their lives and the fact that time on earth is limited should motivate all to live their lives well.
One of the main concepts of palliative care is that it avoids treatments that increase suffering and add onto the amount of suffering without any hope of a cure. So what do Islam and Judaism say about palliative care? The perspective of Jewish healthcare providers varies significantly based on the degree of conservatism. For example, highly religious Jewish healthcare providers are less likely to withdraw life-sustaining treatment during terminal illness. According to Orthodox Jewish law, the deceased must be rapidly buried and physicians expected to contact family members as fast as possible. Burial also occurs within 24 hours unless the following day is a Sabbath. The Jewish Burial Committee should also be contacted immediately. Islam on the other hand, tries as much as possible to avoid conducting postmortem examinations that could result in distortions or deformities. When it comes to matters of artificial nutrition and hydration, Muslim physicians are more likely to oppose withholding such treatments. In Judaism, the degree of religiosity is inversely related to the likelihood that the physician will approve end-of-life pain medications if they were believed to hasten death. On matters euthanasia and physician-assisted suicide. Voluntary euthanasia refers to the practice of intentionally ending one’s life by a physician through the administration of drugs. Muslim physicians have negative attitudes towards euthanasia. Furthermore, patients with strong religious affiliations had a higher likelihood of opposing euthanasia compared to individuals who are not affiliated to any religion. Highly religious Jewish healthcare providers are less likely to withdraw life-sustaining treatment in the case of terminal illness. However, end-of-life care is high in all individuals irrespective of their degree of religiosity.
COVID in Both Religions and Ethical Obligations
The practice of religious rites has had to change with the introduction of the COVID-19 pandemic. Gravesite gatherings, close up prayer sessions, consoling the bereaved and other timeworn rituals have been cancelled or transformed for fear of the pandemic. However, with the creation of this vacuum so has tradition been transformed. This transformation has been more evident in Judaism and Islam since both religions rely on touch and intimacy when taking care of the deceased. In some situations, funeral home owners have had to cross religious lines to help perform sacred rituals and rites of passage. The Centers for Disease Control (CDC) recommends that precautions are taken with regards to rituals that involve touching the dead. The CDC also urges funeral homes to adorn proper personal protective equipment when handling dead bodies, especially of individuals who have died due to COVID-related complications. However, of importance to note is that the CDC has not yet determined whether dead bodies can still spread the disease.
According to the Fiqh council of North America, a group of scholars who offer their opinions with regards to Islamic law, there are several alternative ways of handling bodies of COVID-19 victims without actually touching them. When push comes to shove, the council encourages Muslim leaders to adopt alternative methods of cleansing such as the use of sand instead of water and avoiding opening body bags. Muslim funeral homes and mosques have also tried to accommodate mourners by ensuring that prayer sessions are held outdoors and in other open spaces to prevent the spread of the disease. The risks are also extremely high for the Jewish burial societies to conduct ritual purifications in person. The living individuals in the room, and not the dead, pose an even greater danger of spreading the virus. Leaders in the Jewish community are recommending virtual services of spiritual taharas, to minimize the spread of the disease. For those who insist on conducting the service in person, they are encouraged to wear full personal protective equipment. When a body is properly prepared following the recommendations of the CDC and other healthcare organizations, the likelihood of the disease spreading is greatly reduced.
To prevent the transmission of the disease, a whole society approach should be adopted. During this time of uncertainty, religious leaders must turn to their religious texts and theology to find comfort for their communities and to encourage adoption of safe practices. Furthermore, to slowdown the spread of the virus, religious leaders from Islam and Judaism have taken to media to conduct their daily prayer and worship sessions and to mobilize individual volunteers to take care of the less abled in society. Additionally, religious leaders have ensured that they engage in discussions that focus on personal well-being and the importance of adhering to safety guidelines as promoted by health organizations such as the WHO and governments. For the Jews, religious texts such as the Talmud, encourage them to preserve human life above all else. Muslims, on the other hand, are encouraged to save lives since by doing so, they are saving the life of humanity. Muslim clerics are also supporting governments by creating fatwas that call for the cessation of religious gatherings and encourage adherence to already set preventive measures. All these teachings emphasize on the significance of taking action and following government-implemented measures and interventions such as social distancing to protect oneself and also to protect the community.
Currently, the world is facing one of the greatest disruptions in recent history. The novel COVID-19 pandemic has transformed how people live, interact and even worship. Muslims throughout the world are also struggling with the repercussions of the pandemic with social gatherings such as prayer gatherings in mosques forbidden. The Jews are also struggling with the new normal in a quest to prevent the spread of the disease. However, Muslims are encouraged by the Quran and the Sunna to preserve life by taking medication and seeking treatment. While suffering is welcomed in Islam, Muslims are encouraged to seek medical care including pain control and end-of-life care. Comforted by the promise of being rewarded for their good deeds on earth, Muslims are taught to welcome death and prepare for it when they fall sick. Family members and friends are also encouraged to be supportive of the sick by visiting them, praying for them and even forgiving them for all their wrongdoings. With this in mind, Muslims, Jews and the rest of the world will be able to overcome the challenges of COVID-19, regardless of the devastation that the virus has left behind
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