April 22 by Dr. Mohamed Moussa
Praise be to Allah, and prayer and peace be upon the Messenger of Allah, His family, companions, and followers.
As to what follows...
Recently, many have repeatedly asked this question: When should life-support machines be removed from the patient? And could they not be used from the beginning if there was no chance of recovery?
To answer this question, we must first define death and life in general, and then define the legitimate death in particular, and its signs.
“Life” is the opposite of “death,” since life is about movement and growth, while death is about stagnancy and fading. In this sense, life and death are in our surrounding universe. The earth on which we walk would be dead, and then Allah sends down upon it rain, then it quivers and becomes alive, as Allah says:
“… and you see the earth barren, but when we send down upon it rain, it quivers and swells and grows [something] of every beautiful kind.” (Surah El-Hajj: 5)
And He also says: “As provision for the servants, and we have given life thereby to a dead land. Thus is the resurrection.” (Surah Qaf: 11)
The plants do grow, drink, breathe, pollinate, fade, and die. And the case is the same even for a virus that invades our bodies and the animals’ bodies: if it was outside the body it does not affect much, but as soon as it enters the body, it becomes living cells that attack the body and may even kill the person.
Sperm has a life as well. Semen contains millions of sperms, all of which die except the one that fertilizes the ovule, then the cells start splitting, and so it becomes a cloth, then a lump, then bones, and then the bones are covered with flesh. And during this whole process, there is movement and growth which are symbols of life, yet even with all this, it (the fetus) is not considered human until it has a soul, and only then it is considered another creation, human, as Allah says:
“Then we placed him as a sperm-drop in a firm lodging. (13) Then we made the sperm-drop into a clinging clot, and we made the clot into a lump [of flesh], and we made [from] the lump, bones, and we covered the bones with flesh; then we developed him into another creation. So blessed is allah, the best of creators.” (Surah Al-Mu'minun: 12 - 14)
On the narration of Muslim and Al-Bukhari in their Sahih books that on the authority of Abdellah Ibn Masoud, may Allah be pleased with him, that:
“Allah's Messenger (ﷺ), the True and Truly Inspired said, '(The matter of the Creation of) a human being is put together in the womb of the mother in forty days, and then he becomes a clot of thick blood for a similar period, and then a piece of flesh for a similar period. Then Allah sends an angel who is ordered to write four things. He is ordered to write down his (i.e. the new creature's) deeds, his livelihood, his (date of) death, and whether he will be blessed or wretched (in religion). Then the soul is breathed into him.’”
And in the same case, Ibn Qayyim, Allah rests his soul, in his book Explanation of the Sections of the Quran, explained:
“If they asked if the fetus was in movement, could feel, before the soul was breathed into him? The answer is that it had growth movement and nutrition just like plants. This movement and nutrition were not its will, then when the soul was breathed into him, its will and sense joined its growth movement and nutrition.”
In addition, Abu Hamid al-Ghazali, Allah rests his soul, says in the Signs and Adversity of Death from his Revival of Religious Sciences: “Every part which does not have a soul does not feel pain. When it has a soul, then the soul is conscious of the pain. Thus when a body part is injured or burned, the pain goes to the soul, and the body feels pain as it propagates through the soul.
The agony is the pain that goes to the bottom of the soul and affects all its parts, so that all the parts of the soul -that are spread across the body- feel the pain. If the body is hit by a thorn, then the pain the body feels in fact runs in the portion of the soul equivalent to the location that the thorn struck.
The agony pain attacks the soul and affects all the parts: all the veins, nerves, and joints, and every part of the hair, the skin, and the whole body; its anguish and pain are unbearable.”
Imam al-Ghazali also says in Revival of Religious Sciences: “The soul is the good-natured, aware, and knowing [part] of the human. And it is a godly matter whose nature the most brilliant minds cannot understand.”
And so the life that we talk about is the human life and so is death. And this cannot happen without a soul.
And now, let us define legitimate death.
There is an agreement between Islamic jurisprudence scholars and medicine scholars of the fact that death is “the parting of the soul from the body.”
And so, what are the signs that help to know that a person is dead?
There are the known signs like loss of sight, sluggishness, stiffness, coldness of the body, loss of breathing, and heart arrest. There are also some signs that are only recognized by specialists and doctors: brainstem death; and the brainstem is, as was agreed upon by specialists, “the center of breathing, and heart and blood circulation control. It also controls movement, memory, and behavior.”
This means that [when a person is dead] the brain becomes damaged and stops functioning completely, even if some of the body parts, like the heart and the lungs, are still functioning under life-support machines: it is like the life of the plants, as we demonstrated before.
Based on this, if the brain was damaged and stopped functioning completely, and met all the signs mentioned by the major scientific centers such as Harvard (e.g. the patient in coma does not show any response to the most intense stimuli, he shows no movement under observation for a one hour period, there is breathing interruption as the result of removing the machines and observing for 3 minutes, there is no neural reflex, especially brainstem reflexes, and running an electroencephalography as it has a major role in confirming the diagnosis).
The same previous tests need to be repeated, and if there is no change [in the symptoms], then machines are removed. After removing the machines, there has to be a sufficient wait time to confirm the death. After that, the patient is determined dead and the known rules of funeral apply.
And now we move to the second part of the question: Should the patient be under those machines if his condition was severe and the percentage of recovery was very weak? And in the similar case of the person undertaking painful chemical therapy, should we stop this kind of treatment and save him from suffering? Or should we keep following the treatment?
One of the thorough Fatwas about this topic is the one given by the scholar Sheikh Yousef Al-Qaradawi in response to some questions that he received by the Islamic Medical Organization in South Africa about Islamic medicine, its rulings, and ethics. Among these questions was the one we are dealing with.
I will state it with some modifications that suit the topic: “it is known for Islamic law scholars that the treatment and medication are not considered obligations by the major scholars and the Imams of the Islamic schools of jurisprudence. They are even permissible [but not forbidden or obligatory] according to them, and have been considered as an obligation by a few of them, as is the case of the companions of Shafii and Ahmad, mentioned by Ibn Taimia (The major Fatwa of Ibn Taimia 260/4; Kurdistan Scientific Publishing House in Cairo).
Some others considered them (treatment and medication) preferred.
Scholars even argued on which is better: “medication or patience.” Some of them consider patience to be better, on the basis of the narration of Ibn `Abbas in the two Sahihs that `Ata’ Ibn Abu Rabih said: "Ibn `Abbas said to me:
'May I show you a woman of Paradise?'
I said: 'Yes.'
He said: 'Here is this dark-complexioned woman. She came to Allah's Apostle (ﷺ) and said: <I am suffering from falling sickness and I become naked; supplicate Allah for me,> whereupon He (the Holy Prophet) said: <Show endurance as you can do and there would be Paradise for you and, if you desire, I supplicate Allah that He may cure you.> She said: <I am prepared to show endurance (but the unbearable trouble is) that I become naked, so supplicate Allah that He should not let me become naked, so he supplicated for her.>’” (Al-Bukhari and Muslim).
Many of the companions and followers did not get medication, and some of them even chose illness, like Abi Kaab, and Abi Dhar, may Allah be pleased with them, and they still were not criticized for the abandonment of medication (The major Fatwa of Ibn Taimiia 260/4; Kurdistan Scientific Publishing House in Cairo)
Imam Abu Hamid al-Ghazali made a section in The Book of Trust in Allah from the Revival to respond to the people who said that that leaving medication is better in any case (Check: Revival of Religious Sciences 290/4 and what follows).
This was the opinion of the Ummah scholars regarding giving treatment and medication to the patient. Most of them consider it permissible, few considered it as recommended, while others consider it to be an obligation. And I am with the opinion of making it an obligation in the case of an illness with an unbearable pain that can be successfully treated and cured, on the basics of what Allah and the Prophet say; the Prophet seeked treatment and recommended it to His companions, as it was mentioned by Imam Ibn Qayyim in Provisions of the Hereafter (Check: part three, edition of The Message in Beirut). The least this proves is that treatment and medication are a Prophetic tradition (Sunnah) or that they are recommended.
From the above, medication and treatment are considered as an obligation or a recommendation if there is a chance of recovery. But if there is no chance of recovery according to Allah’s way in means and reasons that are known by its experts, doctors and specialists, then nobody would recommend treatment and medication, let alone mandate them.
And if giving the treatment, in whatever way (e.g. drinking, injection, glucose nutrition, medical ventilator, etc…) will result in pain and prolong the period of illness, it is not considered as an obligation or recommendation. In fact, the opposite may be the one considered an obligation and recommendation. Therefore, stopping the treatment and removing the life-support machines are allowed and legitimate and even needed, and the doctor has the right to do it for the sake of the comfort of the patient and his family. And he has no discomfort if Allah wills.
Many of the jurisprudence and Fatwa Councils have agreed to this opinion: like the European Council For Fatwa and Research, the Kuwaiti Endowments Ministry, International Islamic Fiqh Academy, and the Permanent Committee for Islamic Research and Issuing Fatwas in Saudi Arabia.
Here are two models. The first one is of the International Islamic Fiqh Academy, and the second is that of the Permanent Committee for Islamic Research and Fatwas in Saudi Arabia:
International Islamic Fiqh Academy Decision
Decision no. (5), D 7/1986/3 on “Life support machines.”
The International Islamic Fiqh Academy held its 3rd conference session in Amman, the capital of Jordan, from the 8th to the 13th of Safar 1407, corresponding to the 11th to the 16th of October 1986.
After the discussion of all the aspects about the topic of “life-support machines” and listening to the detailed explanation of specialized doctors, the following has have been decided:
It is considered a legitimate death and the rulings of death apply if the following signs are shown:
The heart and breath completely stopped, and the doctors declared that the arrest is irreversible.
The brain functions completely broke down, the specialized doctors declared the breakdown to be irreversible, and the brain started disintegrating.
In this case, the removal of the life-support machines is justified, even if some parts of the body are still functioning due to the machines. (Published in Amman, Jordan, October 1996)
Decision of the Permanent Committee for Islamic Research and Fatwas in Saudi Arabia:
Fatwa # 12086 (Hijri date: 06/30/1409)
After the study made by the committee, this is the answer:
First: If the patient arrived to the hospital and was already dead, there is no need for using life-support machines.
Second: if the patient’s condition cannot be recovered, with the approval of three trustworthy specialized doctors, there is no need for using life support machines.
Third: If the patient’s illness was severe and untreatable, and there is a certainty of death approved by three trustworthy specialized doctors, there is no need for using life support machines.
Fourth: If the patient had disability or was mentally incapable and had a chronic disease, cancer, or heart and lung diseases with multiple cardiac and lung arrests, and with the condition that three trustworthy specialized doctors have confirmed so, then there is no need for using life-support machines.
Fifth: If there was evidence in a report by three trustworthy specialized doctors of an untreatable brain damage, then there is no need for using life support machines, since they have no benefits.
Sixth: If according to three trustworthy specialized doctors the treatment of heart and lung is unsuccessful and inapplicable for a certain case, there is no need of using the life-support machines, and no consideration is given to the opinion of the patient’s family, since they are not specialized in this field.
From the above, it is clear that there is an agreement between the councils’ opinions and the individual scholars’ opinions on removing the life-support machines in the case of brain damage, even if the heart is still pulsing, and if the doctors confirm so. They also agree on not using the machines if the patient’s case is untreatable: this opinion is for the sake of mercy for the patient and his family whose [regular] life stops because of the patient’s illness, this is a discomfort for them. And Allah knows best.
Allah knows best the intention behind one's deeds, and He guides the way.