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Written for a student workshop on ethics held at the Kulliyah of Medicine UIA Kuantan on 6th January 2008 by Professor Omar Hasan Kasule Sr.
CASE #1: A 23 year old girl from the war torn country of Chechnya was admitted due to an episode of attempted suicide from drinking a small amount of weed killer (paraquat). She had been raped by a few soldiers and is now pregnant from the incident. She recovered well from the poisoning but continued to suffer from major depression. She has requested a “therapeutic†abortion and mentioned that she will be happy if the abortion was successfully completed as soon as possible. One of the soldiers who raped her later came and repented and promised to marry her and be the legal father of the baby if she continues with the pregnancy. She refused the offer and the incident worsened her depression.
ANS #1: There are 2 issues here: attempted suicide and abortion. Both violate the second objective of the shari’at which is protection of life, hifdh al nafs, and are therefore both repugnant to the Law. What is needed is psychotherapy for the depression of rape, unwanted pregnancy, and unwanted birth. When the baby is born the mother could keep it or give it to a foster parent. The issue of marriage is theoretical because under Islamic law the rapist has to be killed as soon as he admits the crime.
CASE #2. A young lady who was a victim of an earthquake suffered multiple injuries to her body, neck and face. She was pretty before the injuries and was planning a marriage with her fiancée. Her fiancée has now refused to marry her unless she takes some measures to improve her beauty. She fears that no one will marry her and she will not have a chance to reproduce and have a family. She has requested a plastic surgery and multiple botulinum toxin (BoTox) injections which has a very high chance to improve her beauty and secure a happy marriage and a bright future.
ANS #2: The injuries are considered an injury and a disease. It is obligatory to treat disease under the hadith of the prophet that for every disease is a cure. Under the principle of injury an injury has to be removed, al dharar yuzaal. Therefore plastic surgery and botox treatment in this case are allowed because they will help achieve the noble purpose of marriage which fulfils the third objective of the Law that is protection of progeny, hifdh al nasl. These operations are not in any way change of Allah’s creation, tabdiiil khalq al llah
CASE #3. A young man suffered multiple abdominal injuries to the abdomen during the earthquake in Pakistan. He underwent multiple colonic surgery which needed revision due to lack of aseptic/sterile OT facilities. Eventually he required a colostomy at the level of the descending colon which drained into a colostomy bag. He also suffered from urinary incontinence due to injuries on his lumbar vertebrae and was required to be on CBD-continuous bladder drainage via urinary catheter. He has stopped praying since then because he felt that he was unable to complete his ablution.
ANS#3: A draining colostomy or urinary catheter does not affect wudhu or salat. The patient makes wudhu for each salat and prays immediately after wudhu. He has to make wudhu again for the next salat.
CASE #4. A young man was treated for an open fracture of his right tibia and fibula which was a result of being crushed by a tree during the Tsunami. He was recovering well until day 7 of the operation when he developed sudden shortness of breath and severe hypoxia. Spiral CT confirmed the diagnosis of Pulmonary Embolism and he was proposed to be started on low molecular weight heparin (LMWH). He was told that the LMWH was porcine in origin (derived from pig). He was also told that a new technology was available to graft his tibia and the graft was from the bones which originated from pig. He immediately refused all treatment. He was given conventional iv heparin and his APTT monitored. His condition deteriorated and later died from a propagation of the embolus in his right main pulmonary artery.
ANS #4: Under the principle of necessity, dharuurat, the prohibited is allowed for the sake of life and good health, al dharuraat tubiihu al mahdhuuraat, if no halal alternative exists. The patient therefore is not only allowed to use the porcine anti-coagulant, he has a legal obligation, fardh / waajib, to use it under the purposeof the shari’at of protecting life and health, hifdh al nafs. He will be committing a sin to refuse the treatment and thus suffers a deterioration of his health or even death.
CASE #5. A pregnant lady was recovered at day 4 after Tsunami. She was found to be dehydrated and very anxious. Examination revealed a 37 week gravid uterus (estimate) with a 40 second contraction every 20 minutes. There was evidence of leaking liquor and what appeared to be a shower. Feotal heart sound was heard and did not show significant deceleration with the contractions. She has refused to pray as she claims that she has already reached 1st stage of labour and is not required to pray.
ANS #5. The issue here is when does nifas and its rules start and there are many opinions. My personal view is that any bleeding or liquor with established labor signifies the start of nifas. We have also to consider the tensions and anxiety of labor as not being conducive to the calmness needed in salat. If in doubt about established labor salat can be delayed, jam’u taakhiir, to be offered with the next salat if labor does not progress further. If it progresses then the obligation of salat does not exist because of nifaas.
CASE #6. As a result of an earthquake, a 35 year old lady lost her husband. They were already planning to have a child through in-vitro fertilization before the earthquake and harvesting of the egg and sperm has been successfully completed. They have been married for 15 years without any children. The IVF centre was successful in producing 5 embryos and at the request of the lady, implanted all 5 into her uterus after the earthquake. She had a successful pregnancy and delivered a quadruplet. Her 15 years wait for having children ended with 4 healthy babies.
ANS #6: In the best interests of the 4 babies, the Law assigns paternity to the dead father and they can have all the attached rights. However if this matter had been raised before implanting the embryos the ruling would have been a denial because the Law does not recognize parenthood without a valid akad nikah and in this case the akad nikah was abrogated at the moment the husband died.
CASE #7. A 29 year old man suffered a closed mid-fracture of the ulna and radius bones and was recovered 5 days after the tsunami. There were no X ray facilities and the fracture was reduced without X-ray guidance and POP (plaster of Paris) was placed to immobilize the fracture. He also had a large open wound on the dorsum of his right foot. He did not want to miss his prayers, so instead of taking ablution in the usual way, he performed Tayyamum in all the prayer times. There were occasions that because he felt it was convenient, he performed tayyamum for his Maghrib prayer and then feeling that is was alright to still be clear from hadath, he continued with Isya prayers without repeating his tayyamum. He was told by a learned friend to repeat / Qadha all his prayers after the removal of his POP as it was not performed in perfection.
ANS #7: Dry ablution, tayammum, has the same consideration as wudhu. Salat performed under tayammum is valid and need not be repeated. Also one tayammum can be used for more than 1 salat if there is no hadath in the meanwhile.
CASE # 8. Some time in the future, stem cell technology and cloning is then successful to produce cell lines differentiating to form autologous organs. A young lady suffers from severe 80 percent burns on her chest and abdomen after a fire incident and has requested that her stem cells be used to create new skin to graft her 3rd degree burn. She later developed renal failure and the family requests that a kidney be produced to replace/transplant her kidneys.
ANS #8: The jurists are unanimous that cloning tissues and organs is permitted by the Law. The only controversial issue is cloning a human being. This issue cannot be resolved by the Law because it has not happened yet and the Law does not provide rulings for hypothetical events.
CASE #9: A man was brought in to the ICU after a massive road accident. He suffered severe head injury and had no spontaneous breathing. He was ventilated and after resuscitation was stabilized in ICU. He had a heart rate of 102 / min supported by dobutamine and adrenaline infusion and continued to have no spontaneous breathing. CT scan showed cerebral oedema with multiple bleeding and infarct in the area of the midbrain and cerebellum. His GCS (Glasgow Coma Scale) assessment revealed a scale of 4 and he had loss of gag reflex and “dolls eye†reflexes. There were no response to deep pain. He was found to have O negative blood group and HLA typing revealed compatibility to 3 recipients for his heart, cornea and kidneys. With the permission of all family members, all 3 organs were harvested and he was pronounced dead after the procedure.
ANS #9: There are 2 issues here: definition of death and the autonomous decision to donate the organs. At the moment the consensus of the jurists is that brain stem death is a legal definition of death. It is not clear to me from the case that brain stem death has been established. If it is established then members of the family have the right of guardianship, wilaya, to decide on behalf of the incompetent patient.
CASE #10. A young lady in reproductive age suffered from multiple injuries on her private areas. She insisted that only a female doctor should treat her. It was the 2nd day of the Tsunami and there were no female doctors available. Her condition became worse and later developed septicaemia and her bleeding had caused her Hb to drop to 5 g/dL. She refused blood transfusion as the blood donor was not known to her. She insisted that she can only receive blood from Muslims. She later deteriorated and succumbed to all her injuries and complications.
ANS #10: Under conditions of necessity, dharurat, with no alternative available the usual restrictions of the Law are set aside. It is therefore permitted for a physician of the opposite gender to treat a patient if a physician of the same gender is not available. There is no ruling restricting blood donation to or from non-Muslims.
CASE #11. A couple in Acheh lost all 6 of their children in the Tsunami. They now almost 40 years of age and are worried that they will not be able to have anymore children. They have requested for an IVF technique to harvest 6 - 8 embryos. The couple also are carriers of Thallasemia and are worried that there may be a chance that the future children may suffer from Thallasemia major. They have requested for a pre-implantation diagnosis of both Thallasemia and Down syndrome. Two affected alive embryos were discarded and the remaining implanted in the uterus of the legally wed couple. She had healthy quadruplets after 7 months.
ANS #11: Allah judges actions by the intentions behind then according to the principle of intention, qa’idat al qasd. In this case the intention behind pre-implantation diagnosis was to discard affected embryos which is destroying life and is illegal. The diagnosis would have been legal if the intention was to identify the healthier embryos for priority implantation while the others would be kept and not destroyed.
CASE #12. After the Tsunami, all echocardiography and ultrasound machines in the General Hospital of Banda Acheh was destroyed. A young lady was admitted to the O & G ward with shortness of breath and cyanosis. She was G1 P0 at 20 weeks POA (period of amenorrhea). Examination revealed central cyanosis which occurred on exertion, a loud P2 with fixed wide splitting of the second heart sound, left parasternal heave and raised JVP was detected. ASD with pulmonary hypertension was diagnosed and an abortion and suction curettage was performed. The feotus died but the mother survived.
ANS #12: The action of aborting the fetus when the mother’s life was at risk is accepted by the Law but the reasoning in Islamic Law is different from that of secular law. In Islamic Law the life of the mother is considered of equal importance to that of the fetus so we cannot choose one over the other. We however carry out the abortion because we will lose one person. If the abortion were not carried out we would lose two persons because the fetus will not survive independent of the mother. So the choice is clear between losing 2 and 1. Secular law does not recognize the fetus as a person independent of the mother and therefore considers maternal interests superior to fetal interests.