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Presented by Prof Omar Hasan Kasule, Deputy Dean, Kulliyah of Medicine, International Islamic University, Kuantan Malaysia at the 2nd National Palliative Care Conference 24-27 March 1997 Penang, Malaysia.
Abstract
The paper presents guiding Islamic concepts on illness, death, cure, and the etiquette with the terminally ill. Illness is not all negative, it has positive human aspects. Death is not a terminal event; it is a transitional event from one state of existence to a better one. The cure of illness or death are in the hands of God; the healthcare givers' role is to make ensure that the remaining life-time has the highest quality possible. Health care workers must provide a total package to the terminally ill that addresses physical, psychological, spiritual, and legal needs. They should also be involved in the continuum of events before and after death including the burial and mourning processes. The physician bed-side visit has both social and professional aspects and should strengthen the patient psychologically. Spiritual preparation to face death involves repeating teachings of Islam on the nature of disease, death, and the hereafter. Caregivers should guide and participate with the relatives and friends through the processes of mourning which include preparation of the body for burial, the burial itself and the post-burial period. This all-round concern and participation of the caregivers with the patient and he relatives are a demonstration of total care. It comforts the living that when their turn comes somebody will care.
Key words: terminal illness, death
1.0 ILLNESS/DISEASE
Health is a condition in which all of the body functions are integrated and are being maintained within the limits of optimal design. Illness or disease is divergence from the normal. The Qur’an used the terms maradh [1], maridh [2] and saqiim [3] and treats illness as a physically disabling condition [4]. The Qur’an, primarily a book of moral guidance, spends more time on moral than on physical diseases. Humans are argued to undertake the necessary research to understand the physical diseases. The physician must realize that prognosis is a human empirical estimate of the future course of the disease based on extrapolation from available data and knowledge. True knowledge of prognosis is with God alone since it is in the realm of the unseen, ‘ilm al ghaib. Disease has positive aspects. Falling ill may be God’s way of forcing the person to take a desired rest or care for the body before it can deteriorate further. Disease can be an opportunity for personal redemption by expiation/atonement for previous sins [5], [6]. The trials that one goes through and the eventual patience can be rewarded by God’s forgiveness. Patience with chronic disease/disability is associated with high reward [7], [8].
2.0 DEATH
Death is inevitable; all humans will eventually die, hatmiyat al mawt, & shumuliyat al mawt [9]. There can be no exceptions now or at any time in the future. All death is by God's permission [10]. It is futile to attempt to avoid death, istihalat daf'u al mawt [11]. The human and death have inevitably to meet liqa al mawt [12]. The concept of finality of death implies that each human has only one death followed by eternal life in the hereafter [13]. Death is a transitional event, rite de passage, to the better life of the hereafter, al hayat ba'da al mawt [14]. To both the patient and the relatives, death is a test, a trial, ibtila’a [15], and a calamity, musibat [16]. The attitude to death varies according to the spiritual well-being of those involved. The good people welcome death as a rite de passage to a better existence in the hereafter. They look forward to death, al shawq ila al mawt as a happy event. The wish for death, tamanni al mawt, is discouraged as an escapist alternative to facing the psychological or physical distress of illness. Anxiety about death is a very human reaction to the unknown. Patients fear the process and circumstances but not the inevitable fact of death. The process of death is long. It starts with the humanly-understood causes like infection or trauma. The body progressively fails until a point of no-return is reached. There is a point during this process when the angels take away the ruh (qabdh al ruh), thus separating the essence from the body, qabdh al ruh [17].
3.0 CURE
It is God’s pre-destination that a person falls sick. Treatment/prevention of disease not against pre-destination, qadar. Medical treatment is subsumed under the principle that qadar can reverse another pre-destination, radd al qadar bi al qadar. In the end all cure is from God, Allah huwa al shafi [18]. God's cure is through the agency of humans. Humans should not be arrogant by attributing cure to themselves and not God. In the same way humans can not refuse to take measures to cure disease claiming that God will take care of it. God did not reveal any disease, bau, without also revealing its cure, dawau, [19]; Humans are encouraged to search for these cures for all diseases [20]. The secularization of medicine has led to marginalization of spiritual treatment modalities such as supplication, dua [21], and prayer, salat [22], and reciting the Qur'an [23]. The spiritual cures are mediated through the physical processes of psychosomatic modulation or priming of the immune, and metabolic functions of the body. Choice of what treatment modality to use should involve a careful weighing of benefits and possible harm or injury. It is a principal of Islamic law, sharia, to give priority to preventing harm, dar'u al mafsadat, over accruing a benefit, jalb al maslahat. The equilibrium between benefit and harm of treatment modalities should be looked at using three Islamic principles: tauhid, wasatiyyat, & shumuliyyat. The concept of tauhid motivates looking at the patient, the disease, and the environment as one system that is in equilibrium; thus all factors that are involved with the three elements are considered while making decisions. The concept of wastiyyat motivates the need for moderation and not doing anything in excess. The concept of shumiliyyat extends the tauhidi principle by requiring an overall comprehensive bird’s view of the disease and treatment situation.
4.0 BED-SIDE ETIQUETTE
Visiting a patient is an obligation, wujuub iyadat al mariidh: The physician rounds fulfil the social obligations of visiting the sick [24] in addition to the professional care given. Visiting the sick is considered one of the excelent acts, fadhl iyadat al mariidh, [25]. The prophet regularly visited his companions who fell sick [26]. The physician should interact with the patient as a fellow human and should keep in mind the fact that the human relation has priority over the patient-physician relation. Some bed-side visits should therefore be purely social with no medical procedures or medical discussions. The following are recommended visiting etiquette, adab ‘iyadat al mariidh: dua for the patient [27], reading Qur'an for the patient [28], and asking the patient for dua, asking about the patient’s feelings, su'al anhu, being careful about what is said in the presence of the patient, doing good/pleasing things for the patient, ihsaan, making the patient happy, tatyiib nafs al maridh, encouraging the patient to be patient, tashjiu al mariidh [29], and discouraging wishing for death wishing death, tamanni al mawt [30].
5.0 PROFESSIONAL CARE
Medical care must be professionally competent and considerate. The caregiver should listen to and solve outstanding medical and non-medical problems of the patient. The sunnah has given us guidance about forced feeding and forced treatment [31]. The patient retains freedom to accept treatment or to reject it. The patient can not be forced to take any medication or to be treated by any physician. Treatment with new/experimental drugs or procedures require informed consent. If the patient has lost legal capacity, ahliyat, by being unconscious or by losing mental capacity, the legal guardian, waliy, will take binding decisions on behalf of the patient. The patient must be made as comfortable as is possible. Narcotics are given for severe pain. Drugs are used to allay anxiety and fears. The caregivers should maintain as much communication as possible with the dying. They should attend to needs and complaints and not give up in the supposition that the end was near. Attention should be paid to the patient's hygiene such as cutting nails, shaving hair, and dressing in clean clothes. As much as possible the dying patient should be in a state of ritual purity, wudhu, all the time. Necessary measures should be taken to control spread of infectious disease. The Prophet forbade mixing of the healthy and the sick in such situations [32].
6.0 SPIRITUAL PREPARATION
The terminal patient should as far as is possible be helped to fulfil acts of worship especially the 5 canonical prayers. Physical movements should be restricted to what the patient's health condition will allow. The terminal patient should be reminded of the following important spiritual concepts. Death of the believer is an easy process that should not be faced with fear or apprehension. The soul of the believer is removed gently [33]. Believers will look at death pleasantly as an opportunity to go to God in the knowledge that God looks forward to meeting those who want to meet Him. Dying under God's pleasure [34] is the best of death and is a culmination of a life-time of good work. Thinking well of God is part of faith [35] and is very necessary in the last moments when the pain and anxiety of the terminal illness may distract the patient's thoughts away from God. Having hope in God at the moment of death [36] makes the process of dying more acceptable.
7.0 ETHICAL AND LEGAL ISSUES
During the long period of hospitalization, the health care givers develop a close rapport with the patient which becomes a relationship of mutual trust and sharing. It is therefore not surprising that the patient turns to the care givers in confidential matters like drawing a will. The health care givers as witnesses to the will must have some elementary knowledge of the law of wills and the conditions of a valid will, shuruut al wasiyyat. One of these conditions is that the patient is mentally competent. The law accepts clear signs by nodding or using any other sign language as valid expressions of the patient's wishes. The law allows bequeathing a maximum of one third of the total estate to charitable trusts, waqf, or gifts. More than one third of the estate can be bequeathed only with consent of the inheritors. Debts must be paid before death or before the division of the estate. The issue of euthanasia can arise in terminal illness. A paper presented by the author at a seminar on Ethics in Medicine held at Hospital Kuala Lumpur on 28th November 1998 [37], analyzed euthanasia in its various forms employing the 5 Purposes of the Law, maqasisd al sharia, and the 5 Principles of the Law, al qawaid al fiqhiyyat al kulliyat. It concluded that active and passive euthanasia are both illegal because the intention behind them is the same, taking life. A physician is legally liable for any euthanasia actions performed even if instructed by the patient. The only allowable actions are patient refusal of normal food, hydration, or heroic medical procedures. Physicians have not right to interfere with ajal which was fixed by God. Disease will take its natural course until death. This course is not known by physicians for each individual patient. It is therefore necessary that they concentrates on the quality of the remaining life and not reversal of death. Life support measures should be taken with the intention of quality in mind. Instead of discussing euthanasia, we should undertake research to find out how to make the remaining life of as high a quality as is possible. The most that can be done is not to undertake any heroic measures for a terminally-ill patient. However ordinary medical care and nutrition can not be stopped.
8.0 DEATH, BURIAL, AND MORNING
The last moments are very important. The patient should be instructed such that the last words pronounced are the kalimat, the testament of the faith. Once death has occurred the body is placed in such a way that it is facing the qiblat. Eyes are closed and the body is covered. Qur'an and dua are then recited. The health care giver should take the initiative to inform the relatives and friends. The relatives should be advised about the shariah rules on mourning. Soft weeping and tears are allowed. The following are not allowed: tearing garments, shaving the head, slapping the cheek, wailing, and crying aloud. On receiving the news of death it suffices to say ' we are for God and to Him we will return'. Relatives are comforted by telling them hadiths of the prophet about death. These hadiths extol the virtues and reward for the person who loses his beloved ones and remains patient. The health care team should practice total care by being involved and concerned about the processes of mourning, preparation for burial and the actual burial. They should participate along with relatives as much as is possible. The body must be washed and shrouded before burial. The washing should start with the right. The organs normally washed in wudhu are washed first then the rest of the body is washed. Perfume can be used. Women's hair has to be undone. After washing the body is shrouded, kafn, in 2 pieces of cloth preferably white in color. Representatives if the health care givers along with others attend the funeral prayer, salat al janazat. The more people attend and pray for the deceased the better. It is recommended that as many people as possible accompany the funeral procession, tash'yii an janazat: [38] and should stay until interment is completed [39]. Burial should not be delayed, ta'ajil bi al janzat [40]. After burial, the health care givers and the general public should participate in consoling the bereaved and making food for them. The Islamic etiquette of mourning, hidaad, and condolence, ta’ziyah, should be observed. Only the good of the deceased should be mentioned about the deceased, thanau al naas ala al mayt [41]. Confidentiality, medical and other, must be maintained by the health care giver as a trust.
REFERENCES:
Holy Qur'an 2:10, 5:52, 8:49, 22;53, 24:50, 33:12, 33:60, 47:20, 74:31.
Holy Qur'an 5:6, 24:61, 73:20, 2:196, 4:43, 9:91, 48:17, 2:184-185.
Holy Qur'an 37:145.
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Kasule, Omar Hasan: Euthanasia: Ethico-Legal Issues. Paper presented at the Seminar on Ethics in Medicine held Hospital Kuala Lumpur on 28th November 1998
Sahih al Bukhari Kitaab al Janaiz {Book of Funerals}
Sahih al Bukhari Kitaab al Janaiz {Book of Funerals}
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