|Year : 2007 | Volume
| Issue : 4 | Page : 629-637
|Seeking Remedy, Abstaining from Therapy and Resuscitation: An Islamic Perspective
Mohammed Ali Albar
Bioethics Center, International Medical Center, Jeddah, Saudi Arabia
Click here for correspondence address and email
| Abstract|| |
This paper discusses the Islamic viewpoint on seeking remedy. It is imperative to seek remedy in life threatening situations or in case of highly infectious diseases. In such circumstances, the Muslim government can impose quarantine and enforcement of treatment to protect the community. In case of minors, the guardian could be appointed by the Qhadi (magistrate), to give consent to the necessary management. Otherwise, an adult competent male or female should give his free consent in order to start any medical or surgical procedure. He can abstain from treatment at any time. When treatment benefit is doubted, seeking remedy becomes facultative and if it seems that the side effects and inconvenience of treatment is more than the expected benefits, it becomes Makrooh (disliked). If the treatment is futile, then there is no need to continue such treatment. If treatment involves amulets, divination, talismans or sorcery, then it should be prohibited. Usage of prohibited materials e.g. pork or alcohol is not allowed except in certain limited situations, where there is no alternative medicine and it should be prescribed by a competent Muslim physician where it is considered as a necessity (necessity knows no law). Fatwas from the permanent committee of Religious Sciences, Research and Ifta of the Kingdom of Saudi Arabia regarding "do not resuscitate" policy will be fully discussed.
|How to cite this article:|
Albar MA. Seeking Remedy, Abstaining from Therapy and Resuscitation: An Islamic Perspective. Saudi J Kidney Dis Transpl 2007;18:629-37
|How to cite this URL:|
Albar MA. Seeking Remedy, Abstaining from Therapy and Resuscitation: An Islamic Perspective. Saudi J Kidney Dis Transpl [serial online] 2007 [cited 2019 Oct 14];18:629-37. Available from: http://www.sjkdt.org/text.asp?2007/18/4/629/36527
| Introduction|| |
Aim of Islamic Teachings
The aim of Islamic teachings is the preservation of the five cardinal essentials, namely:
a) Dean: religion or creed. For its sake every thing else could be sacrificed.
b) Life: Preservation of the life of human being is sacrosanct. Allah said in the holy Quran: "Do not kill the soul which Allah prevented except in righteous situation."
"For that we have ordained to children of Israel; that whoever slains a person, without being soul (life) for soul (life) or corruption on earth, it is as if he slained the whole humanity; and that who saves a life, he is as he saved the whole humanity."
c) The Mind: preservation of sanity; and hence imbibing alcoholic beverages or taking drugs that affect the level of consciousness for the sake of leisure or fun is not allowed.
d) Property or wealth should not be squandered. The wealth of the person is in fact, the wealth of the community and hence should be spent in the appropriate way accepted by Islamic Sharia (law).
"To those weak of understanding (squandering their money), do not give them your property (actually their property) which God made you to supervise but feed them and clothe them and speak to them words of kindness and justice." 
e) Lineage or the progeny: any thing that is going to harm the progeny or lineage is prohibited. The structure of the family is the cornerstone of society and marriage is the only recognized institution for procreation. Procreation outside wedlock is not allowed. Fornication, adultery and sodomy are all prohibited and harshly punished if it became open. Anything that endangers any of the above should be avoided and hence considered Haram (illegal). Thus, three of the cardinal essentials of Islam are related to medicine, namely preservation of life, mind and progeny.
Even the preservation of Dean (religion) needs good health and hence, related to medicine. Similarly, acquiring property and wealth needs a healthy body and mind.
| Aim of Medicine|| |
Ibn Sina in his Poem Al Irgoza Fi Tib said: Medicine is preservation of health and restoring it when it get lost.  He defined medicine in his voluminous textbook of medicine, Al_Qanoon as "the science, which studied the body of man in health and disease, its aim being to preserve health, ward off disease and restore health when it is lost."
Abubaker Al Rhazi defined medicine as "the science, which keeps and promotes the health when it is there and restores it when it is lost."
Al_Iz ibn Abdulsalam, a renowned Islamic Jurist (7 th century of Hijra) in his book "Qawaeed Al Ahkam" (Basics of Rulings) said: "The aim of medicine is to preserve health; restore it when it is lost; remove ailment or reduce its effects. To reach that goal it may be essential to accept the lesser harm, in order to ward of a greater one; or loose a certain benefit to procure a greater one."
This is a very pragmatic attitude, which is widely accepted in Islamic jurisprudence and it is frequently applied in daily practice of modern medicine.
| Seeking Remedy|| |
Islam considers disease as a natural phenomenon and a type of tribulation that expiates sin. Not only the patient who suffers in dignity will be rewarded in the hereafter, but also his family who bear with him the ordeal. Even the visitors of such a person will get their reward from Allah.
Those stoics who forebear in patience will be rewarded by Allah in this world and the Day of Judgment. Allah says in the glorious Quran: "And give glad tidings to those who forebear in patience."
There are literally tens of Ayahs (verses) of the glorious Quran and hundreds of Hadiths (sayings) of the prophet Mohammed (PBUH) that encourage Muslims to forebear in case of calamity and disease. However man should seek remedy. For the prophet Mohammed (PBUH) himself sought remedy when he was stricken ill, ordered his family, companions and Muslims at large, to seek the appropriate remedy for their ailments and encouraged them to seek new modalities of treatment, when the old ones become ineffective. He said: "Never Allah sent a disease without sending its cure." (Narrated by Abu Huraira in Sahih AlBokhari.)
- Jabir ibn Abdul Allah Alansari said: the prophet Mohammed (PBUH) said:" For each ailment there is a cure and medicament. If the proper medicament is used, the disease will be cured by the will of Allah."
- Abdullah ibn Masood, another companion of the prophet Mohammed (PBUH) narrated that the prophet said: there is no disease that Allah sent without sending for it a cure. Some will know that cure, while others will not."
- Osama ibn Shareek said: the Bedouin Arabs came to the prophet (PBUH) and asked: should we seek remedy? He replied: O servants of Allah seek remedy for Allah in his Glory did not put a disease without putting for it its cure, except one ailment. They asked: which aliment? He said: Old age (senility).,
- Jabir ibn Abdullah Al_Ansari said: The prophet (PBUH) visited Saad ibn Abi Waqaas (his maternal cousin) and found him ill (after emancipation of Makkah). He put his hand on Saad's chest and said: Call for Al Harith ibn Keldah, the brother of Thaqif (a tribe living in Taif near Makkah), for he is a man who practices medicine."
- AlHarith ibn Keldah was a renowned Arab physician who learnt medicine in the well-known school of medicine at Jendisapure (Persia). He was not Muslim at that time.
The prophet Mohammed (PBUH), not only sought remedy for himself, his family and companions, but also he used and advised certain medicaments e.g. black cumin (black seed, Nigella sativa), Aloe Vera, Senna, Henna (Lawsonia inermis), Hijama (blood letting and cupping) and using honey for many ailments.
Imam Al Bokhari in his reference textbook (a compilation of the authentic hadiths i.e. sayings and acts of the prophet Mohammed) collected 118 hadiths in a chapter called "Book of Medicine." Imam Muslim wrote a similar number of hadiths regarding medicine and seeking remedy. In fact, every book of hadith compiled a fairly large number of hadiths regarding Medicine. Some authors wrote whole books on what they called "Tibbi Nabawi." The earliest one of them is Imam Ali Rizza (a descendent of prophet) who wrote a treatise in preventive medicine called Al Risalah Althahabia "The Golden Message" written in 200H/814 Gregorian.
The second was Abdulmalik ibn Habib Al Albiri Alandalusi (died in 238H/851G). The most well known is Tibbi Nabawi of Ibn AlQayem which has been widely circulated and in Modern era published in many editions with comments. It has been translated to many languages including English. The other well-known book is Tibbi Nabawi of Imam Althahabi (Al Zahabi), which was published in several editions. I found more than 20 books labeled Tibbi Nabawi; many of them are still in manuscripts of which I have many in my library (copies).
| Seeking remedy In Islamic Jurisprudence|| |
Seeking remedy in Islamic jurisprudence may be obligatory (mandatory) in certain life saving situations or may be preferred or encouraged (Mandoob) in other situations. It may be facultative or optional and may be Makrooh i.e. not preferred and in some situations and with certain type of treatment may be Haram i.e. not allowed.
Ibn Taimyiah said: "seeking remedy may be Haram (not allowed) or Makrooh (not preferred), may be facultative i.e. optional (Mubaah), it may be preferred (Mandoob) or may be obligatory when it is life saving." He also said: "seeking remedy is not obligatory in the opinion of majority of Ulama (religious law experts), they however differed which is better: to seek remedy or not, for those stoics who can forebear." During that time, almost all modes of therapy were of doubtful results and many involved certain dangers, especially when surgery was contemplated.
Seeking Remedy: Obligatory (Mandatory)
It is incumbent that everyone should seek remedy in life saving situations. In such cases, if the person is unconscious or he is a minor, there is no need to wait for obtaining consent from proxy or guardian. The physician (or nurse) should do his/her best to save the life, organ or limb without waiting for due consent. He/she would be liable otherwise. In case of infectious diseases that will endanger the health of the community, the government has the power to enforce treatment on a patient, irrespective of his will.  However, in cases like appendicitis, the doctor cannot enforce treatment if the patient refuses, except in case of a minor; then the court will appoint another guardian to give consent for treatment.
If the patient requires a caesarian section, the consent of the lady is sufficient and there is no need for consent of her husband, a practice common in many Arab countries where the consent of the husband is thought imperative.
In case where the life of the fetus is endangered, e.g. prolapsed cord, many jurists would advise caesarian section even without the consent of both parents. However, the jurists did not reach a consensus on this issue and it was deferred to another meeting.
The governments impose mandatory immunization schemes for children and in case of epidemics such as meningitis, vaccination is required for many Hajj seasons. Such actions have been supported and encouraged by many Fatwas (decision 67/5/7 of Islamic jurisprudence 7 th meeting).
Seeking Remedy: Encouraged and Preferred
a) In all cases where therapy is likely successful and harm from that mode of therapy is most unlikely.
b) In all cases were the ailment is going to hinder the activities and duties of a Muslim to himself, his family and his community.
c) The mode of therapy is "Halal." In case of "Haram" medication, it will be allowed if there is no alternative, if it is deemed necessary to cure the ailment and/or it is prescribed by Muslim physician.
The Prophet Mohammed (PBUH) said: "O servants of Allah seek remedy, for Allah has not put an ailment except that he puts its remedy except one ailment. They asked: what ailment? He said: old age.",
and in another Hadith he said: death.
Seeking Remedy: Facultative (optional)
a) Where benefit is not proved or even doubtful.
b) Where ill effects of that mode of therapy are uncertain.
c) The person should have autonomy and decide for himself, whether to accept or refuse that modality of treatment.
d) Informed consent is mandatory except in emergency situations.
Abstaining from Remedy is the Better Option
Seeking remedy may be Makroh in the following conditions:
a) When therapy is unlikely to bring benefit.
b) Where harm or even inconvenience from therapy may exceed its benefit.
Some jurists from the Hanbli School thought that abstaining from remedy is the better option in the following conditions:
a) Non-life threatening conditions.
b) No danger to the health of the individual.
c) Not encroaching on other's health.
d) In terminal cases.
There are two hadiths of prophet Mohammed (PBUH), which encourage abstaining from remedy. They are:
a) "There are 70,000 of my people who will enter paradise without being questioned; they are the ones who do not seek remedy by ruqia, the ones who don't consult talismans, the ones who don't allow themselves to be cauterized; and they leave the matters in the hands of their Lord and completely depend on
b) A black lady complained to the prophet that she got convulsions and got naked during these attacks and asked him to pray for her to get cured. He said: "if you persevere and be patient you will enter paradise". She said: "I will be patient but I don't want to get exposed (i.e. naked); he said: "I will pray for you that you might not get exposed"
She had attacks but never got exposed after that incident. (Narrated by AlBokhari.)
Many companions refused therapy in their last illness, as they felt it would be futile e.g. Abubaker Assidiq-the First Caliph, Muath ibn Jabal and Abu Darda'a.
Seeking Remedy is Prohibited
a) If it involves amulets, (other than Quran), sorcery, divination or talisman. It encroaches on creed. ,
b) Any medication made of liquor or any intoxicating drink.,
c) Use of Pork or Porcine material.
d) Killing animals e.g. frogs etc. and using them as medicine.
e) Using blood.
Only in conditions or situations, when it becomes life saving that these substances will be allowed. It will also be allowed to use these substances if there is no alternative medication. A competent Muslim physician should prescribe it.
| Resuscitative Measures|| |
The first recorded use of a ventilator to resuscitate a patient was performed in Baghdad in second Hijra century (8 th century AD). Ibn Abi Usaibia (600-668 H/1204-1267 AD) mentioned in his book Tabakat Al Atiba that court physician, Salih Ibn Bahla resuscitated the life of the cousin of Haroon Ar Rashid (149-193 H / 766 - 809 AD) by using bellows and a sniff called El Kundus through the patient's nose.
| Islamic View of Treating Terminal Illness (withholding and withdrawing)|| |
- It is not imperative on a Muslim to seek remedy, except in life saving situations and where the illness is infectious and is going to affect the community e.g. tuberculosis or other infectious remediable diseases. The health authorities can impose certain measures like enforcing treatment or quarantine certain highly infectious diseases, for the safety of the community.
- The principle of autonomy should not be over ruled except where the danger extends to the community, but it is of paramount importance to understand that Islamic teachings hold high the principle of autonomy.
- The ailing person should have control over the type of remedy he is required to undergo and his informed consent is mandatory. Unfortunately, the freedom of choice is not always available and in many third world countries may never exist.
- The rule of autonomy entails a competent major person who can decide for himself what is best for him. In pediatric patients, the parents or the custodian of the child usually takes the decision in the best interest of the child. The Qhadi (the magistrate) can replace a new custodian to act in the best interest of the child. The court in Kuwait enforced renal dialysis for a child suffering from renal failure against the parent's wishes.
- There are many Fatwas (legal Islamic Decisions) allowing withdrawal of all resuscitative measures when brain-death is diagnosed. The respirator could be switched off and any drugs being administered, discontinued. The decision of diagnosing brain-death is always a medical one and the ensuing ending of resuscitative measures should not be left to the family. It has to remain a medical decision.
- Similarly, if the treating physicians find a certain modality of treatment useless or going to increase the suffering of the patient, that modality of treatment should not be enforced from the start. Simply put, that means withholding certain useless or harmful modes of treatment. The Prophet Mohammed (PBUH) says "above all do non harm" and this rule of non-maleficence is the corner stone of all medical ethics.
- Stopping a useless type of medication/ treatment or certain measures that support life will come under the same rule, but the lifting of life support should be decided by a committee involving the treating physicians, ethicist and a community member. It should also be discussed with the family.
The first Fatwa to stop the life support machine in cases of brain-death was that of Riyadh 1983: The Permanent Committee for Research and Fatwa, Fatwa No 6619 on 15/2/1404 (1983) Riyadh.
Q. If a person is on life support measures, but it was proved that his brain has stopped functioning irreversibly, is it permissible to remove the life supporting machines?
A. In such a case, it is permissible to stop the life support machines, as he is considered dead. The movement of the heart and respiration are only through the machines working on a person with no life. But it is imperative to ascertain his death after lifting the life support machines and before declaring death i.e. when circulation and respiration stops irreversibly.
The second Fatwa is that of The Council of The Islamic Fiqh Academy (OOIC) 3rd Session (11-16 Oct. 1986) Amman-Jordan Resolution No. 5.
According to Shariah, a person is considered dead and all the Shariah rules regarding death become effective if he/she shows one of the following two signs:
- Complete cardiorespiratory arrest and confirmation by physicians that such arrest is irreversible.
- Cessation of the brain activity and confirmation by physicians that such cessation is irreversible and that the brain has entered the state of decomposition.
Under these circumstances, the intensive care equipment supporting him can be stopped, even though some organs of his body, like his heart, continues to function with the help of the support equipment.
This Fatwa is a landmark since it equated brain-death with complete irreversible cardio pulmonary arrest. It was passed with majority of votes and allowed the start of cadaver organ transplantation in Saudi Arabia and other gulf countries.
In 2003, the following organs were transplanted in Saudi Arabia from brain-dead individuals: 71 kidneys, 15 livers, 5 full heart transplants, 22 hearts for valves and one lung transplant. The number of reported brain-death cases in the Kingdom of Saudi Arabia, increased from 24 in 1987 to 427 in 1999, after which, the reported cases decreased to an average of 350 per annum. The harvested cases represented 20 to 22% of reported cases. There is a lot of resistance to the acceptance of brain-death as death, both by the Ulema (clergy) and a section of the public including some physicians.
The third Fatwa is that of Islamic Jurisprudence Council of Makkah Al Mukkaramah, 10th Session (Oct. 17-21, 1987), Resolution No. 2. The life supporting equipment could be lifted from the patient whose brain functions have completely and irreversibly stopped and has been decided by three specialist physicians, even though the heart and respiration are still functioning (with the help of machines).
- However, such a person will not be considered legally dead until his respiration and circulation stops irreversibly after lifting the life support machines.
This Fatwa, although looks similar to the Fatwa of Amman in allowing the removal of supporting equipment from brain-dead persons, does not allow procuring organs from heart beating cadavers. It indicated that the heart and circulation should stop ireversibly before allowing harvesting of vital organs.
However, in Saudi Arabia, the government supported the Fatwa of Amman and hence allowed cadaver organ transplantation.
The following Fatwa is a landmark in regulating resuscitative measures, stopping of machines in cases thought to be not suitable for resuscitative measures. The decision should be based on medical criteria and decided by at least three competent physicians. The family should be approached and the facts discussed fully with them.
The Permanent Committee for Research and Fatwa, Fatwa No. 12086 on 28/3/1409 (1989). Question from Military Hospital (N.W. region) on using resuscitative measure on the following cases:
Q. 1. If a person who arrives to the hospital is already dead?
A. 1. There is no need to use any resuscitative measures in such a case.
Q. 2. If the medical file of the patient is already stamped: Do not resuscitate, according to the patient's or his proxy's will and the patient is unsuitable for resuscitation.
A. 2. If three competent specialized physicians agree that he is unsuitable for resuscitation, then there is no need to do so.
Q. 3. If three physicians have decided that it is inappropriate to resuscitate a patient who is suffering from a serious irremediable disease and that his death is almost certain.
A. 3. If the disease is irremediable and his death is almost certain, as witnessed by three competent physicians, there is no need to use resuscitative measures.
Q. 4. If the patient is mentally or physically incapacitated and is also suffering from stroke or late stage cancer or having severe cardiopulmonary disease or already had several cardiac arrests.
A. 4. If the condition of the patient is as described and the decision not to resuscitate has been reached by three competent specialist physicians, then it is permissible not to resuscitate.
Q. 5. If the patient had irremediable brain damage after a cardiac arrest?
A. 5. If the condition is authenticated by three competent specialist physicians, then there is no need for the resuscitative measures as they they will be useless
Q. 6. If the treating physicians decided that resuscitation will be useless in a certain patient, is it permissible not to resuscitate even though the patient or his relatives asked for resuscitative measures to be carried on.
A. 6. If resuscitative measures are deemed useless and inappropriate for a certain patient in the opinion of three competent specialist physicians, then there is no need for resuscitative measures to be carried out. The opinion of the patient or his relatives should not be considered, as it is a medical decision and it is not in their capacity to reach such a decision.
Finally it is important to understand that:
Intensive Care and Resuscitative Measures are:
a. Life saving for many.
b. Immediate mortality high.
c. Poor quality of life of some survivors.
d. Expensive and limited.
Avoid Inappropriate Use To: ,
a. Reduce human suffering of the patient (poor quality of life).
b. Avoid prolonging death process.
d. Reduce suffering of relatives.
a. Do not admit hopeless cases.
b. Limit aggressive therapy when prognosis becomes dismal.
c. DNR (do not resuscitate) or limiting therapy decided by the medical team. It is a medical decision taken in consultation with the family after full explanation of the situation.
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|2.||The Glorious Quran: Sura AlAnam 6/ verse (aya) 151. |
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Mohammed Ali Albar
Bioethics Center, International Medical Center, P.O. Box 11639, Jeddah 21463
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