Muslim Views About End of Life Decisions
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.
Dr. Abdulaziz Sachedina University of Virginia