An Introduction to Islamic Ruaim Muaygil, MD, PhD(c) Albert Gnaegi Center for Health Care , Saint Louis University King Saud University & King Saud University Medical City, Riyadh, Saudi Arabia What this talk is NOT

• An exhaustive examination of Islam, Islamic law, or Islamic bioethics. • It does not speak for all - in the clinic or outside. • Does not intend to essentialize all Muslims to their religious identity. Islam: An Overview

• The last of the 3 Abrahamic religions. • Monotheistic faith. • 2nd largest religion in the world (1.8 billion followers). • Fastest growing. • 3.3 Million Muslims in the US. Origins

• 7th century Arabian peninsula- revealed to Prophet Muhammed. • Islam recognizes other prophets including Abraham, Moses, and Jesus and understands them to be messengers of God. • Muslims see their faith as the universal and complete version of previous Abrahamic religions. The Five Pillars

1. Shahada: Faith “No God but God and Muhammed is the messenger of God.” 2. Salat: Prayer, 5 times a day. 3. Zakat: Almsgiving (small % every year, only those who can). 4. Siyam: Fasting . During Ramadan (if able to do so). 5. Hajj. Pilgrimage to Mecca. (once in lifetime, for those who can). Sources of Islamic Law

Sharia (Righteous path) Fiqh (Deep Comprehension)

• Primary source. • Secondary source. • Quran: Divine, unaltered, unchanging, word of of • Deliberative, interpretive tradition that guides the God. Final revelation. formulation of laws from the sources of . • : Sayings and actions of Prophet • Method of inquiry. Muhammed. • Product of human understanding and reasoning. • Basis of ethical inquiry. • Subject to human error. • Product of divine intervention. • Islam does not admit clergy, idols, icons, rather promotes direct connection with God. Islam and Medicine

• Golden age of Islamic civilization: (9th and 13th century ) • Massive translation movements helped preserve Greek knowledge. • Innovation in a multitude of areas including science, math, astrology, medicine, and philosophy. • Medicine and religion were intertwined. Many of the era’s most influential physicians were also theologians and philosophers. Abu Baker Al-Razi 9th century

• Heavily influenced by Galen. • Also critiqued and improved upon his work. • Important texts on differential diagnosis (small pox vs. measles), first to utilize case/control group research models. • Pioneer of teaching hospitals where his students took meticulous case notes. • Believed that good ethics, including attention to the spiritual, was good medicine. • Akhlaq Al-Tabib, “”, which became one of the earliest Islamic medical ethics textbooks. Ibn Sina (Avicenna) 10th century

• Al Qanun fi al Tibb, the “Cannon of Medicine”, condensed both Greek and novel medical theory, and continued to be studied well into the 18th century. • Kitab al shifa, or “book of healing” was a philosophical text. • Writes about curing the ignorance of the soul through a meditation on the nature of God, and advocates for a contemplation of various sciences and philosophical theories in order to understand God’s existence. Ibn Rushd (Averroes) 12th century • philosopher, physician, and jurist • Kitab al-kulyat fi al-Tibb, “Generalities in Medicine”, he wrote on anatomy, physiology, pathology, and pharmacology among others. • Believed that performing anatomical dissections allowed us to contemplate the remarkable work of God, therefore, strengthening our faith. • When searching for “truth” in medical diagnosis we must first understand and contemplate our realities, ultimately bringing us closer to God. Islamic Bioethics in the 21st Century

• Practical applications: • How to better meet the needs of Muslim patients? • What is the Islamic position on X? • Conceptual Issues: • What is the practice mostly concerned with? • How can it grow and better serve Muslim patients and clinicians? General Characteristics

• Virtue ethics: The good virtues that a good Muslim physician should have. • Divine command theory: • Action is permissible or prohibited according to Islamic law. • Medicine as an instrument of God, the ultimate healer • But: no overarching regulating authority in Islam. • Multiple positions on same issue. • I will present some majority opinions. Principles of Fiqh – Adapted to Bioethics

1. Principle of Intention (Qasd): E.g. Pain relief that may hasten death. 2. Principle of Certainty (Yaqin): Medical expertise has significant weight. 3. Principle of Injury (Darar): Removal and avoidance of illness is obligatory, outweighs benefits. E.g. Public good > Individual interests. 4. Principle of Necessity (Darura): Necessity allows the prohibited. 5. Principle of Custom (): Professional standards of practice. Issues at the Beginning of Life

“Each of you will have had his created existence brought together in his mother’s womb as a drop for forty days, then a leech like clot for the same period, then a piece of flesh for the same period, after which God sends an angel to blow the spirit into him”

- Life begins with ensoulment: 120 days

• : • Existing life (mom) takes precedent over a developing one (fetus) • Before 120 days: permitted • After: permitted to preserve mother’s life or wellbeing. • Prenatal Testing: • Permitted, needs ethical examination. • Gender selection: • Discouraged but not prohibited. • Assisted Reproduction: • IVF Encouraged. • But: genetic material must come from the married couple. • Principle: preservation of lineage. • Surrogacy: disputed. • Stem cell research: • Permitted with donors’ consent. Issues at end of life

“ Do not kill yourselves, God is most merciful to you” Quran 4:29 “Whoever kills a soul- unless for a soul or for corrupting the world– it is as if he had slain mankind entirely. And whoever saves one – it is as if he had saved mankind entirely.” Quran 5:32 Death: Whole brain criteria, irreversible loss of brain function, including brainstem. • Life-supporting Treatment: • Not obligatory. Especially when treatment is burdensome and no improvement likely. • Principle of certainty, custom, injury. • Terminal Sedation: • Permitted to relieve pain, even if hastens death • Principle of intention. • DNR: • Permitted when not likely to be beneficial. • Physician Aid in Dying and : • Clear prohibition. • Withholding/Withdrawing Life Sustaining Treatment: • Depends on intention: prohibited to hasten death, permitted if treatment unlikely to be effective, or is overly burdensome, relies on medical judgement. • Organ Donation: • Encouraged. • Saving a life, eternal good deeds. Other Topics

• Fasting and Performing Prayer: • Permitted not to in some circumstances: (pregnancy, diabetes, bedridden) • From movements to saying words. • Be cognizant of times and rituals. • Milk Kinship: • Through breast feeding (5-6 times), develops a familial kinship legally (marriage, inheritance). • Milk banks raise issues. • Permitted if donor is known, or milk is pooled from several sources. • Pig products: • Vaccines or in valves. • Avoided unless necessary. • Principle of necessity. Islam and Women Is Islam Inherently Oppressive to Women?

• Prophet Mohammad put forth an ethical articulation of the Islamic doctrine that proclaimed spiritual, moral, and biological equality of men and women. • In subsequent centuries, the understanding of Islamic texts changed in line with the core cultural values and knowledge of the time, some of which represented patriarchal positions. • Muslim countries today interpret Islamic texts differently resulting in widely differing laws, policies, and regulations, and reflecting a unique, cultural, contextual understanding of Islam. • Oppression of some Muslim women is rooted in particular, context-specific, and historically informed interpretations of Islam, and is a reflection of political and cultural goods. Muslim Women and Bioethics

• Informed Consent, Truth telling, and Decision-Making: • No Islamic obligation for women to defer to male relatives. • Culture and tradition vs Islamic dictate. • Modesty: • E.g.: only treated by a clinician of the same gender, covers face or body. • Preferred, but not obligatory when seeking care. • Principle of necessity. • Hymenoplasty: • Prohibited (coerced). Principle of injury. • Permitted if prevent other “dangers.” • Domestic Violence: • No Islamic basis that supports spousal abuse. Conceptual Issues

• There is a considerable dearth of Islamic bioethics scholarship. • Does not sufficiently address moral dilemmas in health care: 1. Seemingly apologetic. 2. Overly legalistic. Bioethics = Jurisprudence. 3. Absent critical moral analysis or intellectual reflection. • Islamic bioethics is then unable to achieve what it set outs to do: empower and support Muslims when they encounter health care dilemmas.

Ghaly, M. Islamic Perspectives on the Principles of Biomedical Ethics. World Scientific Publishing, London, United Kingdom, 2016 The Future Task of Islamic bioethics

• What we need is a new theoretical framework. One which blends legal, philosophical, and moral considerations, and results in a balanced and effective practice. • Influenced and informed by the works of scholars like Al-Razi, Ibn Sina, and Ibn Rushd. • Simply knowing whether something is permissible is not enough. • Does not answer the question of whether we should! • Examine the meaning of important concepts: personhood, dignity, necessity, harm. • My intention is not to call for the suspension of religious judicial rulings: • Investigation of Islamic rulings, an examination of their moral underpinnings, and a displacement of the social and historical context from which they developed. • Must not be taken as final, and must be open to reinterpretations and challenges. Islamic Feminism As a Model

• Aimed at re-interpreting religious texts and sacred rulings through a feminist lens. Began in the early 1990s, but arguably has existed for centuries. • Changing the dominant, patriarchal understandings of Islam. • Reclaims Islam for women: 1. A nuanced distinction between divine prescriptions and human elucidations. (Fiqh vs. Sharia) 2. Revisionist and transformative readings: Shift from essentialist understandings of the Quran to more contextual examinations that take the texts’ overall moral vision into account.

Mir-Hosseini, Z. “Muslim Legal Tradition and the Challenge of Gender Equaliy” in Men in Charge? Rethinking Authority in Muslim Legal Tradition, eds. Mir- Hosseini, Z. Al-Sharmani, M. Rumminger, J. Oneworld Publications: London, England, 2015t Guiding Principles of Sharia

Maqsid Al-Sharia as the objects of medical Practice in this in this new intellectual, re-interpretive process 1. Preservation of Life. 2. Preservation of Religion. 3. Preservation of intellect. 4. Preservation of lineage. 5. Preservation of wealth. • These constitute the internal aims of the Sharia teachings. Texts should be interpreted and laws formulated in conjunction with these principles. • A great starting point for the development for a more robust and rigorous Islamic bioethics project. Key Points

• No regulating, overarching authority: • Wide diversity! No one position. • People may make own decisions. • Must consider ethical and moral permissibility along with religious rulings. • Try to differentiate between religious dictates and cultural traditions. • Muslims come from multiple different cultures • Religion holds more weight, harder to negotiate. • Humility: Let patients be our guides. Questions? [email protected]