Woman Half-the-Man?

Islamic sacred law, the Shari`a, has been regarded by Muslims as a perfect, divinely ordained religious-ethical-legal system. The Shari`a relates Muslims to God's purposes by providing comprehensive directives in the two spheres of human activity: those actions that relate humanity to God, and those that relate humans to fellow humans. The former actions are categorized as `ibadat (literally, "acts of honoring God", technically, God-human relationships) and the latter are known as mu`amalat (literally, "transactions", technically, interhuman relationships). Whereas the God-human relations have remained more or less immutable in the Shari`a, the area of interhuman relationships has demanded rethinking and reinterpretation of the normative sources like the Qur'an and the Sunna (Tradition) to deduce new directives under changed social conditions. There are, however, epistemological problems connected with the way normative sources are retrieved and interpreted by Muslim jurists which have hampered the necessary progress towards one particular area in the interhuman relationships, namely, the personal status of Muslim women. The juridical deliberations in the exclusively male-oriented traditional centers of Islamic learning, the madrasa, have disregarded female voices in the emerging discourse connected with women's issues and human rights. The redefinition of the status of a Muslim woman in modern society is one of the major issues that confronts Muslim jurists' claims to be authority on legal-ethical sources of Islam. But such a redefinition, as I argue in the paper, is dependent upon Muslim women's participation in the legal- ethical deliberations concerning matters whose situational aspects can be determined only by women themselves. Without their participation in legal-ethical deliberations, women's rights will always depend on a "representational discourse" conducted by male jurists who, in spite of their good intentions, treats the subject as "absent" and hence, lacking the necessary qualification to determine her rights in a patriarchal society.

Male Jurists and Female Related Rulings

  It was in the late 1960s when I began my studies in Islamic jurisprudence at the madrasa (seminary) of the Ayatollah Milani in Mashhad, Iran. Studies in the madrasa were structured around texts, both initial expositions and commentaries on them. In general, classical Islamic juridical texts were organized to undertake "first things first." Hence, in the Shi`ite jurisprudence, with which I commenced my studies in Islamic law, immediately following theoretical discussion about the necessity of following one of the living mujtahids (theologian-cum-jurist), the teacher began with the rulings connected with ritual purification (kitab al-tahara = The Book of Purification).
I always sensed some uneasiness in the teacher as well as all male fellow students when the rulings on tahara reached intimate matters connected with female purification. At that point, as if sensing a need to justify the embarrassment, my teacher often told the story about the discomfort and inadequacy felt by the late Ayatollah Burujardi (d. 1961) when he had to lecture on the taharat al-niswan (women's ritual purification) to his largely male audience made up of senior members of the religious establishment of the Qumm madrasa. Such sessions were part of the advanced lectures given by Burujardi on juristic principles applied to deduce these rulings. Since the traditional centers of Islamic learning neither allowed female participation nor public discussion on matters concerning women's specific physical condition, the lectures on taharat al-niswan dealt only with closing judicial decisions, leaving the detailed explications of the method and reasoning behind them for individual perusal.
However, that does not seem to be the case in the early days of Islam. The Prophet himself was at various times asked questions regarding the rules of purification for women. Significantly, on many such occasions the women of the Prophet's household were the interlocutors and even the interpreters of the religious guidance that affected women's ritual purity. A'isha, according to the Muslim traditionist, al-Bukhari, was present when a woman in Medina came to ask the Prophet about the rules of cleanliness after finishing menses.

He replied: "Take a piece of cloth perfumed with musk and clean the private parts with it thrice." The Prophet felt shy and turned his face. So I (A'isha) pulled her to me and explained to her what the Prophet meant. In the same section another tradition reports that when the Prophet replied that she should purify herself with a piece of cloth scented with musk, the woman asked: "How shall I purify myself with it?" He said: "Glory be to God, purify yourself!" At that point A'isha came to the rescue of the Prophet and pulled her to herself and taught her the method of cleansing herself.

The traditions clearly show that in the early days of Islam in issues dealing with women's ritual purification leading Muslim women provided with the necessary instruction. The Prophet could not and did not exclude women in dealing with their own particular situation in the performance of their religious duties. Moreover, as one can sense in some of these traditions, the Prophet himself sensed discomfort in going beyond expressing simply the rulings dealing with women's ritual purification. This feeling of inadequacy in dealing with peculiarly female concerns in Islamic rituals continues in the way later jurists treated juridical decisions affecting women. Certainly, the difference was that while the Prophet's wives and daughters were full participants in the legal deliberations affecting Muslim women, we have no record to suggest that the womenfolk of the jurist had similar opportunity to intervene in female ritual concerns.
Anecdotes about the male legal scholar dealing with intimate female issues and the problems he faces in conveying innermost contents of female ritual purification constitute legitimate entertainment among the "puritanical" members of the Muslim religious class. The subtle language of the Muslim "seminarians" speaking about the "unspeakable" deserves a separate study. But the contents of these anecdotes that lead modern researchers to the contextualization of the rulings about menses and sexual intercourse also point to the way in which powerfully gender- oriented Muslim culture treats matters connected with the "other gender:" excluding it in the interpretive process.
In the male-dominated religious discourse of the madrasa, information about women's experience is mediated through the "intertext" of the oral transmission of the anecdotes about women. The previous anecdote about the senior male legal scholar embarrassed by female ritual purification provides a symbolic link in contextualizing the experience of something absent - the elicitation of the condition of being a woman by a man in a legal investigation.
While intelligible reenactment of the subjective experience of the "other" through the formation of figurally represented relations is not entirely impossible, its cognitive content is not free of suspicion. For instance, in the context of a legal ruling pertaining to a woman's situation in a society, the legal language constitutes the meaning of utterance about the female "other" mediated through male representations of interpersonal relations, the mu`amalat. The legal utterance, in such circumstances, without taking full account of the concerns and conditions peculiar to female life, is promulgated and interpreted by a male jurist to apply to all women in a society. Hence, what we have in the text is figural rather than the actual representation of woman's situational and objective condition.
To overcome this cognitive impediment one needs to undertake the analysis of the symbolic network of Islamic legal discourse. In other words, contextualization of rulings about sexual segregation, for instance, that still stand unvitiated among the religious-minded Muslims today, cannot be provided by merely referring to the textual and cultural validation of the practice in Muslim societies. One needs to understand the intertextual network of symbols expressed by means of the narratives developed through interlocutory devices in which women are represented as actors, as questioners, even occasionally as disputants. To be sure, these narratives extend beyond the legal rulings about the male-female segregation. They in fact contribute to the formation of a symbolic configuration of Islamic cultural values.
Further elaboration on this particular issue of segregation is in place. In general, rulings about female segregation are based on the concept of `awra, meaning "indecent to expose." On the basis of this concept, jurists regard a woman's body, including her face, as `awra. However, there are controversial texts ascribed to the Prophet and some of his companions that regard even her voice as `awra and hence, "proper for veiling or covering" at all times. Through such an extension of the `awra to include the voice, Islamic law seems to advocate the position in which a woman is legally silenced, morally separated, and religiously veiled. Going beyond the text and the context of these rulings, as I want to demonstrate in this essay, could lead us to such an analysis of the intertextual dimension of the cases that form an entire genre in Islamic juridical texts. It could, furthermore, direct us to pose a fundamental question in the Muslim juridical studies: Can the male dominated religious epistemology provide an authentic voice in the interpretive process connected with the female "other"? How can male jurists undertake to map the subjective experience of the silent "other" of a Muslim society? At this juncture I need to point out my reservations about lending whole-hearted support to feminist jurisprudence that regards male dominated legal decisions as being conditioned by ideological interpretation of law, and the male bias being the source of violation of women's human rights. Even in the male dominated Islamic culture, at the level of figural representation, male jurists have been able to transmit female existence and experience, however imperfect, by eliciting that segment of their ideological utterances that consider both genders to be part of humanity. Without such an acknowledgement of essential humanness of men and women, it would have been impossible for them to transmit those values in the culture that saw woman and man in relational terms as parents, sister and brother, daughter and father, mother and son, and husband and wife. Islamic legal discourse has not always conceived of male-female relations in terms of gender power struggle.
The argument to be developed in this paper is that the major part of the present epistemological crisis in Muslim jurisprudence over women's issues is due to the blatant absence of female voice in Islamic legal discourse. It is remarkable that even when women transmitters of adth were admitted in the `ilm al-rijal ("science dealing with the scrutiny of the reporters") dealing with source criticism to authenticate adth-reports in the Sunna, and even when their narratives were recognized as valid documentation for deducing various rulings, they were not participants in the intellectual process that produced the prejudicial rulings encroaching upon the personal status of women. More importantly, the revelational text, regardless of its being extracted from the Qur'an or the Sunna, was casuistically extrapolated in order to disprove a woman's intellectual and emotional capacities to formulate independent decisions that would have been more sensitive and more accurate in estimating her radically different life experience. The demand today for new and expanded methodology of usul al-fiqh among the Muslim fundamentalist leaders, clearly shows the crisis that faces male-dominated epistemology in coming to terms with the demands about the recognition of the women's personal status and the substantive-cognitive role of their reason in reversing prejudicial decisions that deny her dignity as a full person.
In order to demosntrate the seriousness of this crisis in Muslim legal studies, let me begin by setting forth some preliminary observations about Muslim religious epistemology. There are four basic components that constitute legal studies:

1. the usul: fundamental sources that provide paradigm cases and the general principles that are behind them;
2. the furu`: present instances for which legal decisions are being sought in the light of paradigm cases provided in the fundamental sources;
3. the mawdu`at: "objects" or "situations" that determine the status of present instances and the ordinances that could be based on them to decide whether it is an obligatory act, a recommended act, or an act permitted at discretion, and so on.
4. the ahkam: ordinances that specify the religious practice.

Whereas Muslim scholars are in agreement that acquisition of knowledge regarding the usul (fundamental sources) is incumbent individually on the community members who should undertake investigation of these sources themselves, in matters of ahkam (religious ordinances) they must follow the judicial rulings of a qualified jurisprudent, mujtahid. However, the practice of the community throughout the history has been to follow the juridical authority in acquiring knowledge regarding both fundamental sources and the rulings derived from them. This method of acquisition of religious knowledge on the authority of a learned member of the community is identified as taqlid (following the authority of a leading legist), which is theoretically permissible only in the matters related to religious practice. What is the status of mawdu`at (objects in a case)? Is taqlid permissible in acquiring knowledge about "objects" and "situations"?
Mawdu` (singular of mawdu`at) signifies the actual state of a thing before a ruling can be deduced. For instance, before a jurist issues a ruling regarding the shortening of the daily worship for those who travel between two neighboring cities, such as Berkeley and Palo Alto, he needs to define the legal extent of a large city. Such an explanation of the size of a city for legal purposes is known as mawdu`, that is, substantive information about factors that characterize a city. Or, in order to rule about ritual impurity of the blood that stains a shirt, a jurist needs to ascertain that it is definitely human and not insect blood, because the status of human blood is different in determining ritual impurity of the shirt.
Muslim scholars acknowledge that in investigating the mawdu`at one need not be an expert. In fact, an ordinary believer is in some instances even more proficient than a scholar in determining the factual state of an object or a situation. What matters is the practical knowledge about an issue under investigation. As such, one need not follow another person's knowledge in mawdu` if he or she is certain about its actual state. Moreover, juridical principle states that knowledge about mawdu` does not fall under the category of taqlid, that is, one need not follow the juridical authority in order to determine objects and situations of a case; rather, one should undertake its investigation individually. The presumption is that determination of the state or contextual situation of the case is a rational process open to all who possess sound reasoning. One should not let someone else determine the object on which a judicial decision would be based. However, there is a stipulation in Islamic law that in the case of a legally incompetent person or a minor, determining the mawdu` could be assumed by a legal guardian (wali), including a jurist.
To recapitulate, of the four fundamental components of Islamic legal system it is only ahkam -ordinances- that require following a jurist's research and conclusions based on the main sources of Islamic legal formulations. The other three parts are open to individual research and their ultimate acknowledgment or rejection. More importantly, it is in the area of mawdu`at, as they affect the religious practice, that there exists the space in which interpersonal negotiations between different groups and individuals are possible. The usul that should be based on firm rational inquiry have their place in the hearts and minds of the believers. Unlike the mawdu`at, the usul (the paradigm cases in the Qur'an and the Sunna) have only an indirect influence on the final outcome of a juridical ruling.
This male dominated religious epistemology has given rise to several fundamental questions related to the determination of the situational aspects of cases in connection with women. First of all, are women any different from men in understanding the process of identifying objects and their contexts as required prior to issuing the legal decision? How about their role in ascertaining the particular substantive state of woman's situation related to sexuality and reproduction, marriage and divorce? Is there any principle in the juridical theory that would suggest a form of thinking that distinguishes between the concerns of men and the concerns of women?
If one follows the prerequisite individual rational inquiry in the mawdu`at it would be correct to conclude that the Islamic belief system dictates that women need to represent their own concerns in all matters of family and maternity care. Implicit in this proposition is the recognition of women's right to assess their particular social situations and determine the legal applications in accordance with their sense of priorities. Furthermore, since the Islamic belief system does not speak about justice in terms of equality of sexes and treats the underlying difference of sex as natural, not the creation of society, defining a particular mawdu` has to be undertaken by the party concerned. From the juridical literature examined in its historical context, it is evident that, relatively speaking, Muslim jurists succeeded in pursuing the Qur'anic impulse towards family relationships and asserting individual rights on the basis of God- centered equality. And, although man retained wide authority over the wife, laws were enacted to give woman unprecedented respect and protection in the patriarchal context.
In family law, the rights of women, children, and other dependents were protected against the male head of the family, who, on the average, was stronger than a woman and more independent, since he is free of pregnancy and immediate care of children. Islamic marital rules encouraged individual responsibility by strengthening the nuclear family. Islamic law protected male prerogative on the grounds that men were required to support the household; whereas women were protected primarily by their families. All legal schools gave a husband one-sided divorce privileges because for divorce initiated by a woman would mean unsettle her husband's economic investment. Under these rules a husband could divorce a wife almost at will; but a wife who wished to leave her husband had to show good reason. The main legal check upon the man in divorce was essentially financial and a matter of contract between equal parties that included a provision about bridal gift. Part of the gift (sidaq or mahr), which might be substantial, was paid at the time of marriage; if he divorced her without special reason, he had to pay her the rest.
The equality of women in the law carried with it an important financial independence. Muslim women could own property which could not be touched by any male relative, including her husband who was required to support her from his own funds. Moreover, women had a personal status which might allow them to begin their own business. However, this potential female independence was curbed primarily by cultural means, keeping marriages within the extended family, so that family property would not leave the family through women marrying out.
Hence, although wives and daughters were given a stronger position than they had in the pre-Islamic Arab culture, in one area the Qur'an left the status of women to become the mawdu` for laws that permitted, though mitigated, unequal status between men and women, reducing a woman to "half-the-man." Her distinctive contribution in determining her own social context was thoroughly excluded by eliminating her as the interpreter of her own objects and situations. Patriarchal structures of Arab culture, in the form of loosely camouflaged traditions ascribed to the Prophet, left her intellectually crippled, while the male jurists prepared the text of the laws for her insidious domination by male members of the society.
It is relevant that it is mainly in the sphere of interpersonal relationships, the mu`amalat section of the jurisprudence, that woman's input in clarification of her mawdu` - her substantive social context - was kept in check. In the sphere of God-human relationship, the `ibadat section of law, her equality with man before God was never questioned. Nevertheless, the manner in which her input in the mu`amalat was circumscribed had implications for her performance of the `ibadat, the requirements of God-human relationship. Thus, for instance, the prohibition of independent female travel, requiring the presence of a male relative, has directly affected her religious freedom to undertake the performance of the obligatory hajj (annual pilgrimage) in Mekka. This prohibition, it must be pointed out, was based on the juristic principle that "averting causes of corruption has precedence over bringing about that which has benefit" (dar'u al- mafasid muqaddam `ala jalb al-masalih). Other similar juristic principles have also been regularly invoked to curb not only women's rights but also the rights of minorities to function as full citizens in some Muslim societies.

Paradigm Cases in Rulings about Woman's Status  

The paradigm cases dealing with the status of women are derived directly from an investigation of the sources of law. The sources are treated hierarchally, reflecting the religious evaluation of the epistemes contained in the Qur'an and the Sunna. Thus in formulating judicial decisions (fatawa) a jurist goes first to the Qur'an, then to the exegetical works in conjunction with the Sunna, and finally, to the juridical corpus, in that order, to follow the process of extrapolating fresh decisions from paradigmatic cases. I follow this approach with the methodological concern that any study of this kind requires a normative interpretation of the religious underpinnings presented in the Qur'an. It is foundational to my study to raise the question: Should "Islam," as a belief system, be defined and judged by its practitioners or should its practitioners be defined and judged by a normative standard provided by the revelational sources on which the religious belief system is constructed? I believe I need an interpretive standpoint from which I can judge that some affirmations regarding women are peripheral or incidental to the tradition and that others are central and essential, that some are privileged and can serve as a guide for the interpretation of others. With this in mind, I begin to respond to my question: "Woman, half-the-man?" by looking at the Qur'an and its exegesis as the source of religious affirmations that altered, in decisive ways, the objects and situations within which legal-moral judgements were made regarding women in Muslim society. The estimation of a woman's position in the jurisprudence, is contextualized in the following pertinent reference, where the Qur'an speaks about contracting a debt:

O believers, when you contract a debt one upon another for a stated term, write it down, and let a scribe write it down between you justly, and let not any scribe refuse to write it down, as God has taught him; so let him write, and let the debtor dictate, and let him fear God his Lord and not diminish anything of it.....And call in to witness two witnesses, men; or if the two be not men, then one man and two women, such witnesses as you approve of, that if one of the two errs the other will remind her; and let the witnesses not refuse, whenever they are summoned.....And fear God; God teaches you, and God has knowledge of everything. (emphasis added) (Q. 2:282)  

The passage is regarded as the scriptural basis for the law of evidence (shahadat) in jurisprudence. Moreover, it has also been evoked to communicate the inferiority of a woman's evidence as compared to a man's. Exegetical literature discusses variations in the reading of the phrase: "....if one of the two errs ('an tadilla ihdahuma)," and consider whether the clause is conditional and if it connotes the superiority of male memory power. In fact, abars cites a specified opinion which he rejects and which maintained that the Qur'an made this provision of "reminding" in women's evidence because "forgetfulness overcomes women [inherently] more than it does men."
None of the commentaries in the classical age go beyond lexical and grammatical exposition of the statement to establish that women are in need of being reminded in order to render their evidence equal to that of a man who enjoys impeccable memory. To be sure, Baydawi maintains that the Shafi`ite jurists implemented the terms of this verse only in the case of business and financial transactions (amwal), whereas the anafites extended the requirement to criminology and law of retribution.
Yet, the grammatical conclusion that the Qur'anic statement "if one of the two errs...." is a conditional clause had enormous implications in explicating the nature of divine commandment in jurisprudence. This grammatical specification had been acknowledged despite the fact that only one transmitter among the early transmitters of the Qur'anic text had insisted in reading the clause as conditional with 'in. For the jurists looking at the denotation of the statement the question is: Is the conditional commandment given for the specific situation in the Medina society to be interpreted as an unconditional commandment, evincing the probable conclusion that regardless whether a woman errs or not, her evidence is to be reduced to half of a man's evidence?
In fact, some later exegetes, like the Shi`ite Mulla Fath Allah Kashani, maintained that the statement is unconditional because woman is inherently weaker in her rational judgment than man who is intellectually stronger, and forgetfulness is far from his nature. Furthermore, he asserts that, according to Sufyan b. `Uyayna, the verse's requirement of two women brings together the evidence of two women and raises it to be equivalent to that of one man. However, both the explicit denotation and the implied context of the verse in the exegetical literature strictly allowed a conditional commandment to be surmised. It denied the unconditional purport with its implications for the inherent inferiority of a woman that was asserted in the legal decisions, including those maintained by the Shafi`ites in the limited area of financial transactions.
In the legal texts, the object and the social situation of a Muslim woman, as extracted from the conditional commandment of the Qur'an, was defined in terms of her position in the regional culture. The cultural evaluation of a woman was transmitted in some of adth-reports that were used to overcome the conditional denotation of the Qur'anic law of evidence. These were used as evidentiary documentation to extrapolate unqualified stipulations that a woman's evidence equals half of that of a man's, regardless of the situational factors.
When we examine the hadith literature to determine how far Q. 2:282 had reinforced the cultural estimation of a woman's intelligence in providing evidence, we discover that al-Bukhari has preserved an interesting rubric in one of the odd places towards the end of his compilation dealing with the evidentiary nature of a "single" narrative (khabar al-wahid). Al-Bukhari's rubrics actually serve as his judicial decisions (fatawa) for which he produces hadith-reports that follow as documentation. Thus, under the rubric of Khabar al-mar'at al-wahida (narrative reported by a "single" woman), he cites the following tradition:

[`Abd Allah] ibn `Umar said: Some companions of the Prophet, including Sa`d, were going to eat meat. But one of the wives of the Prophet called them, saying: "It is the meat of a certain reptile (dabb)!" The people then stopped eating it. On that the Prophet said: "Carry on eating, for it is lawful." Or, he said: "There is no harm in eating it, but it is not from my meals."

An important dietary matter is the object of the narrative, on the basis of which a legal ruling permitting a particular kind of meat is being deduced. However, this permission is stated on the authority of the Prophet, who reportedly reverses an opinion prohibiting its consumption expressed by one of his wives. The implications of this hadith for the admissibility of a woman's evidence in specifying the object of a ruling cannot be sufficiently emphasized. The hadith indicates that a narrative related by a "single" woman, even if she happens to be one of the Prophet's wives, cannot be permitted as evidence for a prohibitive legal ruling. On the contrary, as reported in another tradition in the same section, a hadith reported by a "single" truthful male transmitter is admissible as documentation for all kinds of ordinances.
The purpose of al-Bukhari's compilation is not to provide additional documentation by citing the above verse as proof for his implied conclusion that regarding a "single" female narrator's credibility is vitiated by the absence of another female. However, the law of evidence in Q. 2:282 is the unmistakable context of this tradition. This and other similar traditions raise serious questions not only about the authenticity of these narratives that ignored the intertextuality of the daily details of the lives of women entrapped in male jurist's subjectivity and his skewed vision of her social role; it also puts in doubt the claim by the pious for the validity and applicability of these legal rulings in all age and at all times. Moreover, in the absence of reevaluation of the relevant authoritative texts within their historical and cultural contexts, Islamic jurisprudence has been impaired by irrelevant hairsplitting exercises, reflecting an acute formalistic rather than substantive approach to religious knowledge. Hence, instead of squarely confronting the question of mawdu`at dealing with women's situation in Muslim society under variable historical circumstances, the jurists have vacillated between the prestige of the written tradition and non-essential conceptual and terminological devices developed in the Islamic legal theory to interpret it. Both the methods of inquiry and the forms of argument indicate the juridical tradition's inadequacies in furnishing solutions to the concrete problems faced by Muslim women. The nature of religious discourse employed in the madrasa setting makes it epistemically impossible to speak about specific objects and situations peculiar to Muslim woman's personal status, without referring to the revelational knowledge preserved in the prestigious texts. It is ultimately the written tradition - and not human reason that can negotiate the intertextuality of the judicial decisions made by a male jurist. Application of human reasoning, in any of its forms, has been permanently crippled by the madrasa attitude, articulated in various works of Islamic thought, that human reason on its own is not capable of extracting practical knowledge regarding an ideal Islamic order.
The legal rulings regarding the inferiority of woman's evidence were extrapolated mainly on the basis of the Qur'an 2:282, fortified by traditions that accepted the inherent inferiority of women in matters of religion and intelligence. These rulings reveal even more serious problems in defining the object and situational context (mawdu`at) particular to women's social and personal condition. Undoubtedly, it was in the area of evidence that it was inferred that al-Bukhari implied that a single woman's testimony is half that of a man's. Yet the conditional commandment of the verse 2:282 could not be interpreted so explicitly in view of the contextual restriction imposed by the kind of transaction. To resolve this apparent contradiction between the restrictive and conditional terms of the verse, and the unqualified terms related in some traditions, jurists had to define the objects and situations in which female evidence and attending conditions could become operative.
Investigation in the specific text and the context of the Qur'an and the hadith led jurists to recognize substantially different situations in Muslim interpersonal relations where women functioned as witnesses, providing objective testimony for ultimate judicial rulings. The Qur'anic law of evidence treated only one instance of the social situation in which her evidence in the matter of contract involving financial obligation was, for practical reasons, devalued. Muslim jurists were cognizant of other situations in which this conditional and situational enactment of the Qur'anic law could not be generalized. Consequently, they promulgated three situations in the process of validating a woman's testimony on any interpersonal situation, including contractual agreements:

1. A non-permissible situation in which women's testimony is not admissible at all;
2. A permissible situation in which women testified with men; and, therefore, their testimony is admissible;
3. A permissible situation in which women's testimony is admissible, even if there were no men testifying with them.  

It is worth noting that in none of these cases is a woman admitted as the only witness. In all instances she is mentioned in plural, not necessarily in the formula of two women equal to one man, as implied in the Q. 2:282. In most of the examples cited for each situation it is not difficult to find the underlying concern of the Muslim culture in which a woman's role was defined by the powerful male functioning as her manager. More pertinently, while her testimony was admitted in instances of marriage and debts or in areas of her expertise such as determining cases of rape and pregnancy, her evidence was excluded from cases of divorce and murder. When it came to cases of adultery, Islamic law admitted two women's testimony if accompanied by that of three men. However, if there was only one male witness and six or more female witnesses, their collective testimony could not be regarded as valid. On the other hand, a single woman's claim that she is virgin when accused of adultery by four male witnesses, stands unvitiated provided a midwife establishes the validity of her claim.

Issues in Islamic Biomedical Ethics: A Primer for the Pediatrician

The United States is becoming increasingly pluralistic. Pediatricians must become familiar with the factors that affect the emotional, physical, and spiritual health of their patients that are outside the ken of the traditionally dominant value system. Although many articles have addressed the cultural and ethnic factors, very few have considered the impact of religion. Islam, as the largest and fastest-growing religion in the world, has adherents throughout the world, including the United States, with 50% of US Muslims being indigenous converts.

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.

RELIGIOUS BACKGROUND

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

Circumcision

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

Responsibility

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.

MISCELLANEA

Seeking Treatment

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

Procedures

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).

Emergency Care

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.

Religious Observations

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.

SUMMARY

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.

ACKNOWLEDGMENT

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.