| Abstract|| |
The objectives of this article is to evaluate whether the concept of brain-death can be examined by modern medicine alone as well as examine the impact of such an evaluation on Islamic views of this subject. Various clinical, philosophical, Islamic, and public-policy literature on the subject of death and brain-death have been examined. We present arguments to support the view that the subject of death (including brain-death) cannot be examined without a philosophical base. Any discussion on death should consist of definition of what it means to die, criteria for determining that death has occurred, and specific medical tests that show whether these criteria have been fulfilled. Medicine has no definition for death based on experimental sciences and death is defined by a philosophical concept. In order to accept the concept of brain-death in Western countries, they had to change first the philosophical definition of death. Also, there is still a debate in modern medicine whether death is an event or a process. Most recent Islamic literature has accepted the concept of brain-death as a medical fact, without discussing its philosophical base. This philosophical definition depends on many subjective factors. In Islam, death has a clear definition: it is the departure of the soul and hence, it is an event. However, the signs of this departure have not been specified and they were left to experts (physicians) to define them. In conclusion, medicine alone cannot formulate a concept regarding death. A philosophical definition of death must be used with it. The Islamic discussion on the concept of death should be focused mainly on its philosophical definition. The definition of death in the concept of "brain-death" does not contradict the concept of death in Islam.
Keywords: Brain-death, Islam, Medicine.
|How to cite this article:|
Boobes Y, Al Daker N. What it Means to Die in Islam and Modern Medicine. Saudi J Kidney Dis Transpl 1996;7:121-7
"And they ask you (O Muhammad,PBUH) concerning the "Ruh" (the Spirit);Say: "The Ruh" (the Spirit): its knowledge is with my Lord. And of knowledge, you (mankind) have been given only a little." (translated by Mohsin Khan)
| Introduction|| |
"So uncertain is men's judgment that they cannot determine even death itself". Pliny the Elder, Historia Naturalis.
The determination of death has been surprisingly difficult task that has occupied the thought of countless philosophers from different cultures over the millennia. Although the line that separates life from death is very thin, it is very important to be well defined, because it is the line that separates saving life from killing as well as doing well from committing a crime.
In the last three decades several developments have taken place, which have further pointed to the need to re-evaluate the concept of death. They include: the possibility of resuscitating patients who have suffered cardio-pulmonary arrest, who could then return to normal life; the development of techniques that can maintain ventilation, circulation, feeding, etc., by artificial means in patients whose brains are irreversibly damaged; and the recent achievements in transplantation surgery that have made it possible for the transplanted heart and lungs to stay functioning years after their original body had been buried in the ground.
These achievements in modern medical technology have raised questions about the traditional concept of death. In addition, newly developed organ transplantation programs in Western countries and the consequent need for viable organs have urged the medical society to re-evaluate the concept of death , .
Our objective in this paper is to examine whether the concept of death can be determined by modern medicine alone, and the impact of such determination on Islamic views on the subject.
| Data Sources|| |
Clinical, philosophical, Islamic, and public-policy literature on the subject of death and brain-death.
| What is Death in Modern Medicine?|| |
In Dorland's medical dictionary death is defined as the cessation of life  . What is life? Again, life has vague definitions in this dictionary, and one of them defines it as the obscure principle whereby organized beings are peculiarly endowed with certain powers and functions not associated with inorganic matter. Pallis has earlier pointed out that criteria of death cannot be discussed in a vacuum; they have to be related to some overall philosophical concept of death , .
In fact, a formulation of the concept of death consists of a definition of what it means to die, operational criteria for determining that death has occurred, and medical tests that show whether the criteria have been fulfilled  . Because they answer the question, "what does it mean to die"?, definitions of death are at the conceptual level, primarily abstract and philosophical , . Criteria provide objective standards for determining whether death, as defined conceptually, has occurred. Once criteria have been determined, specific medical tests can be devised to demonstrate their fulfillment.
Traditionally, death is diagnosed when the heart and the lung cease to function. This is based on a philosophical definition that death is the irreversible loss of vital fluid, blood and air-flow [Table - 1]. The rationale for this definition is that the loss of blood and air flows will definitely be followed by a chain of events at the end of which all features of life will disappear.
It is very important to emphasize the fact that modern medicine needs "a philosophical definition of death", and the discussion of ethics of any formulation of a concept of death should start from this point.
| The concept, brain-death, and the concept, higher-brain-death|| |
Brain-Death (or Whole-Brain-Death)
The concept of brain-death was first described in 1959 by two French physicians as "coma depasse"  . In 1968, the report of an Ad Hoc Committee of the Harvard Medical School  brought awareness of this concept to a much wider audience. Subsequently, more reports were published on the subject, and legal policies were adopted in many countries accepting it as death , . In 1981, the President of the United States of America ordered a committee to draw recommendations on this subject. This became known as the President's Commission , .
In order to accept this concept of death, the medical community in the West had to revise the philosophical definition of death. Bernat, et al proposed the following definition: death is the permanent cessation of functioning of the organism as a whole  . In 1981, the President's Commission offered the same definition in a different formula: death is the irreversible absence of the body capacity to organize and regulate itself , .
The rationale for this definition is that the organism, the living being, is a superior entity and as such, it is essentially different from the mere sum of the individual parts of the body and their functions. If a body has lost its capacity to organize and regulate itself (lost its integrating capacity), it becomes a mere collection of organs that can still be viable and working only by extensive external support, but once this support is stopped all features of life will soon disappear ,,,,, . It is the brain that controls the individual parts of the body and the way in which they work together (integration). Furthermore, supporters of this concept consider that brain-death has always been the fundamental criterion for establishing death. It is simply that, before the advent of ventilators and other artificial support systems, brain-death was assumed when the heart stopped  .
This definition emphasizes the loss of vegetative functions of the brain (such as control over respiration, circulation, hormonal secretion, etc.), and neglects consciousness and cognitive functions. It was considered that consciousness and cognition are properties possessed by persons and, as such, are irrelevant to the concept of death. "……The concept 'person' is not biological but rather a concept defined in terms of certain kinds of abilities and qualities of awareness.... death is a biological concept. Thus, in a literal sense, death can be applied directly only to biological organisms and not to persons.."  , and the definition should include only those characteristics that are common to all living things , .
"Humans are only one kind of living things; what is essential to being human is some-thing that differentiates us from other living things, something that we do not share with dogs or trees or mosquitoes. Being alive, on the other hand, is something we do share with other living things ……"  .
The corresponding criterion for this definition is the irreversible cessation of whole-brain function, and the specific tests to determine the fulfillment of this criterion could be the Harvard criteria, or others [Table - 1].
Many Western scholars argue strongly against the concept of brain-death ,,, . They advocate an alternative understanding of death that is grounded in the loss of "person-hood" and "consciousness and cognition". Their contention is that the definition of death in the "brain-death" concept neglects these functions of the higher brain, and emphasizes only the loss of vegetative functions. However, medicine is rapidly approaching the time when all these vegetative or homeostatic functions will be replaceable by artificial technology. A mechanical substitute for a person's consciousness is conceptually absurd. Death should be the loss of the functions that are irreplaceable, i.e., personhood and consciousness , .
On the other hand, one of the objections raised by these scholars is that there is a lack of correspondence between the definition of death and its criterion. The definition emphasizes vegetative functions only, while the criterion includes all brain functions. The following hypothetical case can illustrate this point. After anesthetizing a 20-year old man, an unethical physician selectively destroys all the brain stem and cerebral areas responsible for integration and regulation of the body's sub-systems. In a surgical tour de force not possible in today's technology, the blood supply and neural connections to the rest of the areas are left intact. Although he has lost the ability to spontaneously regulate respiration, blood pressure, temperature, etc., these functions are carefully maintained by artificial means. The patient is awake and alert, and gives meaningful responses to questions by moving and blinking his eyes. The patient is dead according the whole-brain definition, because he has lost the ability to integrate his body sub-systems; according to the whole-brain criterion, he is alive, because his entire brain is not destroyed  .
The corresponding criterion for this definition is the irreversible cessation of higher-brain functioning (persistent vegetative status), and the specific tests to determine the fulfillment of this criterion are not developed yet, but they could be based on the absence of responsiveness or voluntary movements [Table - 1].
| What Is Death In Islam?|| |
In Islamic societies a discussion of ethics cannot be separated from religion  . In the case of the concept of death, the Islamic discussion should be focused mainly on the philosophical definition. The other two elements of the concept are purely medical, so they will be dealt with by medicine. In this way, the discussion will be easier and more objective.
At the conceptual level, the death in Islam is the gateway between the two lives, the life of this world and Hereafter. It is the complete departure of the soul "Al Rouh" from the body, "It is Allah that takes the souls (of men) at death" (The Holy Qur'an, Surat Al Zumar, 42) ,,, . Although this departure is a progressive and it could take days to be completed, however, a person cannot be considered dead until the complete departure of his soul has occurred, before that he is considered alive, and any aggression on him is forbidden. In his book Al Mouhalla, Bin Hazm said: "It is a consensus that a person can be either alive or dead, and there is no third possibility"  . Al Gazzali said: "Death is defying the all organs (to the soul), all organs are machines, and it is the soul that uses them"  . This implies that death itself is an event that occurs at a specific moment.
However, since the departure of the soul cannot be identified, it cannot be used to elaborate an operational criterion. On the other hand, the signs of the departure of the soul have not been clearly mentioned in Al Qur'an or Al Hadith; it was left to the expert "physicians" to define. The main signs of death mentioned by old Islamic scholars were: relaxation of feet, no spontaneous movement including respiration, fixed eyes, coldness of the extremities, etc. , . None of their statements had considered that the absence of heart beat is a prerequisite for a diagnosis of death , . Only the contemporary Islamic scholars have made a linkage between death and heart-beat  .
Islam and Brain-Death
A full discussion of this subject lies beyond the scope of this paper. However, we will review it briefly.
Recently, many Islamic authors have discussed the concept of "brain-death". Some of them rejected it ,, , the others endorsed it ,,,,,, . However, both sides have treated it as a pure medical issue, including its philosophical definition. Only in the paper by Al Bar  , there was an indirect discussion of the philosophical definition.
As mentioned earlier, it is very important in discussing the Islamic view on any new medical issue to dissect the part related to real medicine (i.e. based on experimental science), from that related to philosophical issues which usually depends on many subjective factors. Our discussion will be focused mainly on the different definitions of death
Islam differentiates clearly between the presence of some features of life in the body, and "being alive". In the Qur'an, Allah said. Then We made the sperm into a clot of congealed blood; Then of the clot We made A (fetus) lump; then We made out of the lump bones and clothed the bones With flesh; Then We developed out of it another creature: (The Holy Qur'an, Surat Al Muminoum, 14). This was explained further by our prophet Mohammed (Peace be upon him) who mentioned, in Al Hadith, that the soul joins the body at the end the fourth month of embryonic life  . From this verse and Hadith we can conclude that: firstly, life starts at a specific moment during the formation of the fetus: secondly, and more interestingly, the presence of certain features of life at the level of cells or organs, that are present before this moment, does not necessarily mean the presence of the soul in the body "being alive".
On the other hand, Islam differentiates also between the life of animals and that of plants. Although plants are living things, they do not have soul, while animals do. This stresses that life is not equal to soul, and also in our discussion of the definition of death we cannot equate the life of plants with that of animals or human. Consequently, we can say that in general, the definition of death in the concept of "braindeath" does not contradict the concept of death in Islam.
However, on closer scrutiny, the definition, as explained by the loss of the brain vegetative functions only, cannot be accepted. With such explanation, one can imagine the hypothetical example of the 20-year old man, given by those who are advocating higher-brain-death. In fact, person-hood and consciousness, the awareness of self and environment, are functions that need a very high level of integration. They represent a continuous interaction between the information received by our five perception organs (eyes, ears, nose, tongue, and skin) and the data-base of old information stored in the memory: the result of this interaction could imply an action. Person-hood will express itself in the way these interactions occur, and it depends mainly on two components, the first one is inherited, and the other one is the experience (database) of that person. There are continuous interactions between these two components. This means that consciousness and person-hood have the regular integration loop, afferent branch, central part, and finally efferent branch. With this interpretation, the integrating capacity will include both the vegetative functions and consciousness as well as cognition functions. Loosing part of these functions will not be enough to consider it death.
On the other hand, consciousness and cognition are some of the highest biological functions. The biological basis of thinking, feeling and social behavior is being explored, and some of the anatomical areas involved in these functions have already been identified  . Thus, death as a biological concept, should be applied to the two parts, vegetative functions and cognitive functions. Also, consciousness and cognitive functions are not properties possessed by persons only, they are shared with other living things (animals). However, each species has different types of these properties.
Many other criticisms concerning the lack of correlation between the operational criteria and the tests, need to be addressed; however, this is beyond the objective of this paper.
Islam and Higher-Brain-Death
In general, Islam does not consider the loss of consciousness alone as an indicator of death. Unconsciousness is not equal to the departure of the soul  . Thus, the concept of higher-brain-death can be rejected easily as its definition contradicts the concept of death in Islam. Whether the integrative functions can be replaced by artificial machines or not is not of importance in Islam. Real life is not the one that comes from artificial machines which replace the integrative functions. Unless it is innate and spontaneous, the mere functioning of our sub-systems, or even their integration, is not considered as a sign of life  . It follows that the persistent vegetative status is life and not death.
| Conclusion|| |
Medicine alone cannot formulate a concept of death. A philosophical definition of death leads to be used. The Islamic discussion of brain-death, or any other concept of death, should be focused mainly on its philosophical definition, then we may examine whether the operating criteria can fulfill it. The definition of death in the concept of "brain-death" does lot contradict the concept of death in Islam, while that of the "higher-brain-death" does.
(The Holy Qur'an. The translation of the neaning of verses is based on A. Yusuf Ali, the Holy Qur'an, Text Translation and commentary, Dar Al Qur'an Al Kareem, Beirut.)
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