Issues in Islamic Biomedical Ethics: A Primer for the Pediatrician
Islam presents a complete moral, ethical, and medical framework that, while it sometimes concurs, at times diverges or even conflicts with the US secular ethical framework. This article introduces the pediatrician to the Islamic principles of ethics within the field of pediatric care and child-rearing. It demonstrates how these principles may impact outpatient and inpatient care. Special attention is also given to adolescent and end-of-life issues.
Key words: Islam, Muslim, ethics, pediatrics, child, child-rearing, human rights, adolescence, contraception, organ transplantation, death.
Within the next 50 years, the majority of Americans will be of non-European descent,1 prompting the medical profession to broaden its understanding of cultural issues related to health care. Nowhere is this more crucial than in pediatrics. Pediatricians are often put in a position of advocating for the rights of patients. The majority of immigrants to the United States are 18 years old, and often their parents do not speak English sufficiently to communicate cultural and religious beliefs, potentially leading to misunderstanding or inappropriate intervention. The American Academy of Pediatrics has recently addressed this issue,2 but failed to address issues of religion and religious culture.
Many works regarding Muslim patients have focused on cultural aspects of care particular to a certain country or region, often not distinguishing between folk customs and Islamic customs. Articles examining ethical dilemmas based on a Muslim patient's beliefs often fail to distinguish between idiosyncratic beliefs, cultural norms, and religious principles.3-6 Common beliefs have been incorrectly noted.a,1,7,8
This article has 2 goals: to describe Islamic ethical and moral norms with regard to birth, child-rearing, reproduction, death, and patient care; and to delineate its practical implications in the clinical practice of the pediatrician. Throughout this article, the male pronoun is used for stylistic reasons, except when an issue applies only to women. Except where noted, all discussions using the male pronoun apply to men and women.
A Brief Overview of the Islamic Faith and Jurisprudence Islam has its roots in seventh century Arabia; however, it is not an "Arab" religion. In fact, out of the 1.5 billion Muslims in the world, of Muslims are Arab.9 The majority of Muslims worldwide are Asian or African. More than 50% of North American Muslims are indigenous, usually black, with an increasing number of white and Latino converts as well.10
Islam has a moral code as well as a civil law with a unifying ethical framework. A universal foundation of practices and beliefsb,2 creates a monotheistic culture, the aim of which is to create peace in one's self, family, and society by actively submitting to and implementing the will of God. This culture is further refined by various cultures based on their inclinations and sensitivities. Some differences among Muslims are attributable to differences of opinion by various schools of jurisprudence11 (of which there are 5 major ones: Ja'fari, Hanbali, Maleki, Hanefi, and Shafe'i). Others are not Islamic but ethnic, and may even violate Islamic norms.c
The 4 main concerns of Islamic ethics are similar to that of other ethical systems: autonomy, beneficence, nonmaleficence, and justice.12 In distinction to Western secular ethics, more emphasis is placed on beneficence over autonomy, particularly at times of death. Because the Quran is seen as an eternal and immutable truth, the framework and principles of the law are seen as immutable. As the circumstances of the day change, the application and interpretation of the law changes with each age. Islamic law (shari'a), then, is in spirit dynamic and flexible, exemplified by the idea that "necessity renders the prohibited permissible."13
The Status of Children in Islam
Children are valued and respected in Islam as individuals with inherent rights. The prophet Mohammad stated, "A child has three rights over his father: first, that he gives him a good name, second, that he teaches him reading and writing, and third, that he finds him a good spouse."14 In addition, a child has the right to be treated with respect and without violence (A. Aytatollahs Sistani and N. Makarem-Shirazi, personal communication, June 1999), to be treated when ill (A. Aytatollahs Sistani and N. Makarem-Shirazi, personal communication, June 1999), and not be forced into hard labor.15
The Status and Role of Parents in Islam
The role of parents is highly regarded in Islam. Parents in Islam are legal agents, caretakers to whom the onus of child-rearing falls. However, they are also surrogates of the Divine and are expected to treat their children gently, fairly, and well. Parents who abuse and neglect their children can lose custody of them. In return, they are accorded a respect one degree below that owed to God.
Although both parents have a responsibility to raise morally and physically sound children, the mother's role is considered more important in early childhood. The prophet Mohammad has stated, "The keys to heaven are beneath the feet of mothers,"14 and, "A child's character begins to be formed while still a fetus."14 The father is responsible for education, marriage, and all financial costs related to child-rearing, whereas the mother may contribute financially if she is able and wishes to.
BIRTH TO ONE YEAR OF AGE
Felicitations: Is It a Boy or a Girl?
In Islam there is no preference for a boy over a girl, contrary to the customs of some Muslim countries. The sexes are seen as spiritually equal, and equally valuable. In the Quran we read, "Oh people, be careful of your duty to your Lord, who created you all from a single soul, and his mate of the same ..." (4:1). Whenever a child was born to him, the prophet Mohammad would not ask the sex of the child, but ask if it were healthy or not.16
Postnatal Ceremonies and Customs
There are many customs associated with the birth of a child, the majority of which are not mandated by the religion and, in some cases, may be discouraged or prohibited. For example, the Ladakhi of Kashmir hide the birth of the boy for the first few years, dressing him like a girl to avoid the evil eye and jealousy of neighbors.17 Muslims may have idiosyncratic or culturally influenced explanations for legitimate customs that are incorrect (cf below).
The following are Islamic customs, none of which are mandatory. Shortly after birth, the calls to prayer are whispered into the ears of the child. On the seventh day, in addition to circumcision (for boys), a sheep is slaughtered with the meat distributed to the needy (done for boys and girls).d Finally, the head is shaved with the weight of the hair given in silver or gold as alms to the poor (done for boys and girls).18
The circumcision of boys is an obligatory custom, similar to Jewish traditions.18,19 It is preferable for it to be performed on or after the seventh day of life, but it is not a problem if it is performed sooner.20 It is not necessary for the circumcisor to be Muslim.21 Analgesia and the safest methods available should be used. Whenever circumcision is contraindicated, such as known cases of bleeding disorders, it should not be performed at any time.22
Female circumcision is a controversial issue and is beyond the scope of this article. The majority of Muslim countries (except in parts of sub-Saharan Africa) do not practice it.23 It is considered to be a pre-Islamic custom and is not exclusive to Islam, but is indicative of certain regions. People indigenous to all parts of the world, of all beliefs and religions still practice it, including Jews, Christians, Buddhists, and Animists living in Asia, Africa, and even Mexico.24
Diet Islam is the only religion in which breastfeeding is addressed in the sacred scripture.25 "And the mothers should suckle their children for two whole years for him who desires to make complete the time of suckling ..."36 (2:233). Although not mandatory, breastfeeding is highly encouraged, for up to 30 months.27 A woman and her husband may mutually decide to not breastfeed at all, or to stop nursing before the recommended time. Often for Muslim women, breastfeeding is more than an act of feeding,
but a great religious deed, hence they may initially be resistant to advice of early weaning, even if medically indicated. If medically indicated, it should be stopped. The prophet Mohammad has stated, "Any woman who breastfeeds her child, for each time that she puts the infant to the breast, God will grant her the divine reward of freeing a slave. And when she has weaned him, [the Angel Gabriel] will alight down and with a hand on her shoulder say, "Live your life anew, for God has forgiven your past sins.'"14
There is no specific ruling on the introduction of solid foods, it is influenced by local customs. In general, Islam emphasizes eating healthy foods, in moderate amounts.
ONE TO SIX YEARS
Discipline, Play, Safety The guardianship of parents in Islam is provisional. Physical and sexual abuse, as well as acts of omission, are all grounds for temporary or permanent removal of parental guardianship in Islam, as in secular law (A. Aytatollahs Sistani and N. Makarem-Shirazi, personal communication, June 1999). To this end, the prophet Mohammad has said, "Parents are equally obliged to discharge their responsibilities toward their children and are accountable in case of failure."14
During the first 6 years of life, parenting should be more permissive, allowing children to explore and ask questions, children being considered more trainable than teachable. In this regard, the prophet Mohammad has said, "For the first seven years, leave them alone (ie, do not be too strict in manners, discipline, and formal education)", and, "Whoever asks questions in childhood will answer them as an adult."14 Furthermore,
he emphasized the importance of play when he said to his companions, "Let [the children] play, for this is how they grow (in intellect)."14 In Islamic jurisprudence, discipline should be brief, mild, and commensurate to the severity of the act committed. A light tap as a form of stern disapproval is permitted, nothing more.
It is not permissible to hit a child in the face, neck, abdomen, or back even lightly (A. Aytatollahs Sistani and N. Makarem-Shirazi, personal communication, June 1999). The pediatrician cannot condone child abuse as a religiously acceptable practice. Although it is the pediatrician's legal obligation to report cases of child abuse, it is preferred to arrange for religious social agencies to help place the child in foster care when available and appropriate (A. Aytatollahs Sistani and N. Makarem-Shirazi, personal communication, June 1999). There have been numerous cases where Muslim children have been placed in the care of non-Muslim families, some of whom have attempted to change the child's religion.28-31
Day Care, Working Mothers, and Divorce
Women are free to work outside the house and hold any profession in Islam as long as the sanctity of the family remains intact and a woman's honor is not compromised.32 The decision to place children in day care is a personal matter. Muslims who come from more traditional cultures tend to prefer care at home by the mother or by a relative, if possible.
Divorce is permissible in Islam, although traditionally, there has been a low rate of divorce (10. Among US-born or married Muslims, there has been a trend toward higher divorce rates, averaging vs 49% for the US population), according to an ongoing US Department of Education study.33 The pediatrician will encounter Muslim children with divorced parents. Anticipatory guidance should be given with regard to emotional and school disturbances that may arise during and after a divorce.
SEVEN TO FOURTEEN YEARS
This is the most sensitive period of child-rearing, where etiquette, discipline, education, and religious teachings are begun and solidified. The prophet Mohammad has said, "For the next seven years (ie, 7-14 years of age) teach them." It is encouraged to have children perform chores and have responsibilities commensurate to their abilities and level of maturity, education, however, takes precedence, and hard labor is not permitted.
FIFTEEN YEARS AND BEYOND
Rites of Passage
There are no formal rites of passage in Islam. There may be local customs based on the country of origin. When a Muslim reaches the age of maturity, the rituals, obligations and duties of Islam become incumbent on him, such as daily prayer and fasting.
Maturity and Modesty
Maturity, is defined in 2 ways: the onset of spiritual awakening (bulugh) and the attainment of intellectual maturity (`aql). The first is generally an arbitrary age, 9 for girls, and, 15 for boys, and heralds the aforementioned noted religious responsibilities. The second is determined by a person's ability to live and function independently, which has no specific age.
Once a person is considered intellectually mature (`aaqil), then they are considered to be adults, with regard to medical and legal decisions. Practically speaking, in Muslim countries, this is usually decided on an ad hoc basis. However, there is a move in some Islamic countries to base maturity on a somewhat arbitrary and uniform age of 15 (for boys and girls), for legal considerations such as voting, marriage, and property ownership.34,35
This dichotomy of minor and adult status is an area of potential conflict with secular law in that a Muslim patient may be 18, thus "free" (by secular law) to decide his own course of action in treatment, but meet objection from his parents if not considered intellectually mature. Islamic law requires Muslims to respect and obey the laws of the host country unless they violate Islamic law. The pediatrician in such circumstances should try to clarify what the basis of objection of both the parents and their child are and try to resolve them while maintaining family harmony. It may be helpful to consult with an Islamic scholar (ie, Imam, Sheikh, etc.) of a local mosque to determine if the patient is considered "aaqil.
Modest dress is incumbent on all Muslims on reaching the onset of maturity (bulugh). Both boys and girls are expected to wear clothing that does not reveal the curves of the bosom, hips, or behind. Girls, in addition, begin to wear a head covering (hejab) that only reveals their face. It may be taken off for an examination by a male examiner if absolutely necessary (cf below). The form of dress for girls is determined by cultural preferences and is not specified in Islam.
Before the onset of bulugh, it is not problematic for boys or girls to be seen by a male or female physician. After bulugh, except for emergencies or necessity, the preference, in descending order, is as follows: same sex Muslim physician, same sex non-Muslim physician, opposite sex Muslim physician, opposite sex non-Muslim physician.36
Independence and Responsibility
The teen years in Islam are seen as a period of apprenticeship and companionship for parent and child. This is the period where parents are expected to advise their adolescents. They should encourage their teens to think independently and rationally. In this respect, the prophet Mohammad has said, "[From 14-21 years of age] the child is your advisor and companion."37 Like a king with his advisor, the parent maintains authority and guardianship while showing respect and considering opinions that the adolescent has about various subjects and issues.
The prophet Mohammad gave many important responsibilities to the youth and encouraged them to be active in social and charitable causes such as teaching, feeding the poor, and helping orphans. He appreciated the sensitive nature of adolescence when he said, "I counsel you to be good to the youth, for they have the softest hearts."38 Anticipatory guidance should be given in a manner to foster a sense of autonomous decision-making, rather than using scare tactics. Modern research on behavior modification in adolescents bears this out.39
Individuation and the Family Structure
Eastern cultures are patriarchic and authoritarian, with great emphasis based on deference to elders and suppression of personal interests for the good of the family. Immigrant Muslims often hold these views because of societal norms, common with Hindus, Christians, and Buddhists from the same areas.40 The Islamic family is patrilineal, but not patriarchal. It is based on consultation, with the father as the guide. The process of autonomy and separation is not to as great a degree as it is in Western secular societies, placing greater value on connectedness than in Anglo-American society.41 When conflicts arise, an attempt should be made to preserve family harmony and respect the feelings of elders.
Privacy and Confidentiality
Despite the strong emphasis on the family in Islam, the right to patient confidentiality is considered higher and more compelling. The principle to maintain patient confidentiality is considered the highest virtue of a Muslim physician.42 In Islam, when a patient reaches the age of maturity, the physician is not obligated to reveal any matters that his patient has confided in him to his parents or anyone else.43,44 This includes admissions of premarital sex (cf below). Muslim parents may not be aware that Islam grants this type of confidentiality to dependents and may expect to be informed of private conversations between their adolescent and the physician.
Contraception, and Abortion
Premarital sex is forbidden and abstinence is expected of both boys and girls until the time of marriage. Because dating is not permitted, Muslims tend to marry earlier than in Western societies. Adolescent marriages are permissible, but less and less common because of the emphasis on higher education for girls. The average age of marriage for girls in most Islamic countries is between 19 and 22.44,45 Although arranged marriages are permissible and still occur in some parts of the world, forced marriages are not permissible.
The bride must consent to the marriage, regardless of her age. Practices such as "honor killings," where a female member of the family is killed to avenge a perceived violation of sexually appropriate behavior and restore "honor" to the family, are not permissible in Islam, and are considered a form of murder.
Birth control is permissible in Islam for married couples because sex is considered to be a wholesome pleasure in and of itself46,47 unlike in Orthodox Judaism and Catholicism where the concept of "seed-wasting" necessitates that each act of intercourse be a potential act of reproduction.48 The two criteria for contraception use are that it doesn't cause permanent damage to the (male or female) reproductive organs,49 and that it prevents fertilization.49 Condoms, diaphragms, spermicidal creams, intrauterine devices, oral contraceptive devices, Norplant (Population Council,
New York, NY), tubal ligations, and vasectomies are all permissible.50 There is no problem in prescribing oral contraceptive devices to single girls when medically indicated, such as for menorrhagia or metrorrhagia.
The vast majority of scholars consider life to begin at the time of conception.51 Abortion, defined as the willful evacuation of an embryo or fetus, is considered equivalent to murder and is not ordinarily permitted,52 except when the mothers life is at stake, and the fetus is 4 months old.53 It is not permissible if the pregnancy was attributable to adultery or premarital sex, or because of minor or significant deformities.53
Drug Awareness, Counseling, and Suicide
Recreational use of all intoxicating or mind-altering substances is forbidden in Islam. This includes alcohol, stimulants, and hallucinogens; mild stimulants such as caffeine are permitted. There is still some debate about cigarettes, with most scholars saying that it is forbidden based on the concept of not using what is harmful to the body. Suicide is not permissible in Islam.
Illness has three possible meanings in Islam: a natural occurrence, expiation of sin,e or a test of the believer's patience and gratitude.54 Regardless of the cause, it is obligatory for the parent to seek treatment for an ill child (A. Aytatollahs Sistani and N. Makarem-Shirazi, personal communication, June 1999), based on the prophet Mohammad's saying, "For every illness, there is a cure, except death."55 Immigrant Muslims may delay seeking treatment because of the cultural norms of health care utilization in their native country, and not because of their religious beliefs per se.
When there are 2 equivalent treatments, and an intellectually mature teenager chooses one and his father chooses the other one and they cannot be reconciled, the physician may respect the decision of his patient (A. Aytatollahs Sistani and N. Makarem-Shirazi, personal communication, June 1999). Parents may continue to object feeling (incorrectly) that their rights as parents have been violated. The physician should try to both understand these feelings and explain the dictates of secular law. The counsel of a religious leader may be helpful in explaining the Islamic ruling.
Giving Bad News
The primary role of the physician in Islam is to heal and to prescribe effective medications and regimens, not to "cure" them, per se. Health is seen in a holistic sense, incorporating the well-being of the body, mind, and soul,56 similar to the definition used by the World Health Organization.f The prophet Mohammad has said, "He of you who finds himself enjoying good health, secure in his community, and has his daily sustenance, it is as if he had the whole world at his fingertip."56
When a cure is not in sight, or the disease is considered terminal, the physician is expected to give a positive message to the patient without necessarily lying.57 The head of the immigrant Muslim family may have an expectation that the physician will give him "the bad news" in private while sparing the patient and/or other family members grief. Indigenous Muslims are more likely to value openness and frankness as is more characteristic of North American society. This issue becomes more a matter of style and is left to the discretion of the physician. The following, however, is good advice in general when dealing with a patient of any belief system or religion:
"Showing compassion and giving hope to a patient [of the] possibility of recovery by the permission of God helps their state of well-being. First, even if there is no hope of cure, remember that the hidden hand of God is always at work, so you (as a physician) should not despair (either).
Second, how much the better that if a patient is to go from this world, that he goes content with your services. Don't be one of those who say, `You will not recover.' It is this type of pessimism that hastens a patient's death and prolongs his illness, and causes him to depart from this world with a sullen heart. Thus, if you give him hope, you have shown kindness and done a great deed. You have done a great favor to these patients, the majority of which are depressed to begin with (from their illness). And even if they do depart, it will be with sweetness and a happy soul. For you (oh physician), that is invaluable."58
Death and Dying
Traditionally, death was defined by the cessation of respiration and cardiac activity.59 With the advent of cardiac transplants and respirators most Muslim scholars have redefine death as either the cessation of cardiac and respiratory activity or brain death.60 Brain death is defined as follows: "When the brain is damaged, and its activities completely cease, brain death is present, even if it is possible for the patient to be kept alive in a vegetative state with artificial respiration and medications ... even if the heart and liver are functioning. Brain death is indisputably established and is considered irreversible if, when artificial respirations are ceased, spontaneous respiratory effort ceases within five minutes."60
Thus Muslim children who meet the above criteria of brain death may be removed from artificial means of sustaining life.61 However, this issue is by no means universally agreed on. Consultation with the family and their spiritual counselor, with clear explanation of the patient's overall state as well as that of his brain and heart, along with consideration of local laws should be all be weighed before a final decision is made.
Euthanasia, defined as intentionally hastening a patient's death, is considered murder, and is not permissible in Islam. This includes using a substance that causes premature death (active euthanasia), withholding treatment (passive euthanasia), or "assisted" suicide.61,62 Patients in pain from terminal illnesses may receive analgesic medicine until the time of death (A. Aytatollahs Sistani and N. Makarem-Shirazi, personal communication, June 1999).
63 A patient or their guardian may refuse treatments that do not in any way improve their condition or quality of life.63 Withholding or withdrawing treatment in a brain-dead patient would not be considered a form of euthanasia, and thus is permissible.
When death is imminent, the patient, male or female, child or adult, should be turned toward the direction of prayer (qibla),64 which is northeasterly in North America. Autopsy is not permitted unless deemed necessary for forensic purposes.65 The body of the deceased is washed by a Muslim, wrapped in a white shroud and buried, usually within 48 to 72 hours. A special prayer is said for the deceased before burial.
Muslims believe in an afterlife, and see life as a journey back to the beloved, God. Hence, death and dying are seen as a natural and inevitable phenomenon. However, the death of a child often causes feelings of profound grief. Children who die before the age of physical maturity are believed to go heaven.66 This fact may be used in comforting bereaved parents. Islam does not encourage acts of self-flagellation during periods of grief such as chest- and head-beating, although this traditionally does occur in some cultures that have Muslim populations.67
The saving of a life is considered one of the highest merits and imperatives in Islam. In the Quran it is said: " ... and who so ever gives life to a soul, it shall be as if he had given life to mankind altogether"26 (5:32). The majority of Muslim scholars consider organ transplantation permissible from Muslim and non-Muslim donors68,69 based on the principle that the needs of the living supersede those of the dead.70 Xenografts, including porcine organs, are also permissible.
71 With regard to cadaveric donation, the permission of the closest living relative suffices and it is not necessary for the patient to have specified their preference in a living will or otherwise before death.92 This practice is becoming more and more accepted in Muslim countries.73-75 It is encouraged for the physician to discuss these issues when appropriate, and to emphasis that organ donation is compatible with Islamic teachings. Ultimately, local laws need to be followed with regard to organ harvesting and transplantation.
Drawing and transfusing blood and blood products are permissible, both from and to Muslims and non-Muslims.76 Vaccinations are permissible and are recommended based on the principles of prevention of harm and illness, and, protecting the public good (isteslah).
The necessity of saving a life supercedes all dictates of modesty and care. During resuscitations or other emergent procedures, any available health care providers may examine and perform procedures on the Muslim patient.
Daily observances consist of prayers said at intervals throughout the day and night. Muslims fast during the entire lunar month of Ramadan, which varies in relation to the months of the Gregorian calendar. The fast lasts each day from dawn to dusk, during which time Muslims abstain from food, drink, smoking, and conjugal relations. The infirmed and children are not required to fast.
Pregnant and lactating women should not fast if they fear that it may harm their child.77 The decision to fast during a time of illness is left to the discretion of the patient. However, patients should not fast if a physician feels that it is harmful to their condition.78 Non-nutritive medications are permissible by all routes except oral when fasting.79 Any nutritive injection or solution, such as dextrose or total parenteral nutrition solutions, invalidate the fast and any Muslim requiring such treatments should not fast.
Kosher Versus Halal and Medical Ingredients
Kosher food is not interchangeable with halal. Halal meat includes fish with scales, shrimp, and all herbivorous animals which must be ritually slaughtered except pigs. All types of grains, legumes, fruits, and dairy products are permissible. There is no restriction on combining meats and dairy (unlike with kosher preparations). Medications containing alcohol (ie, suspensions) are not permissible. Glycerin suspensions are preferred.
Muslims are a growing minority in the West representing various Eastern and Western ethnic groups. Half of all US Muslims are indigenous, mainly black, with a growing number of white and Latino converts. The Islamic faith binds them together in common values and beliefs, with variations in practice arising from culturally dictated mores and adherence to 1 of the 5 schools of jurisprudence.
Islamic practices and beliefs were reviewed for various age groups for the outpatient and inpatient settings. There are many similarities between Islamic concepts of health, treatment, and children's rights and secular ones. Notable exceptions include a greater emphasis in Islam on the sanctity of life from conception onward, the concept of maturity, and adolescent issues surrounding premarital sex and contraceptive distribution.
This discussion is a theoretical one based on Islamic theological and jurisprudence concepts of health, illness, and child-rearing. Muslims vary in their degree of education, faith, and application of religion. Various cultural influences may be given preference over Islamic rulings, even when it contradicts Islamic teaching.
We thank to Dr Ernest F. Krug III, Director, Center of Human Development, Dire rulingsctor, Clinical Ethical Consultation Service, William Beaumont Hospital, and the staff of the Center of Study and Research in Medical Ethics, Ministry of Health, Islamic Republic of Iran, for their invaluable comments.