Friday, February 11, 2011

Jewish and Islamic Views on End of Life

   From the standpoint of the Hebrew Scriptures, the connection between Judaism and Islam goes back to birth of Ishmael to Hagar, Sarah’s Egyptian slave girl, in Genesis 16:1-16.  Abraham is the father of both Ishmael and Isaac, Sarah’s natural born son, and Islam traces its ancestry back to Ishmael. 
   The history of Islam as a religion begins in the seventh century AD.  Prior to the birth of Muhammad, Arab society believed in numerous gods. It was the birth of Prophet Mohammad in 570 A.D in the city of Mecca which brought a revolution to the entire fate of the nomadic Arabs. He became famous among the people of Mecca at a very early age because of his allegiance and reliability. He was widely known as Al-Ameen (honest, trustworthy) 
   At the age of 40, when Muhammad was meditating at Mt. Hera, he received a revelations from God. The angel Gabriel said to him, "Iqra" which means "to read". Mohammad replied "I cannot read". Gabriel embraced and released him. Then the first five verses of God was revealed to him which said, "Recite in the name of your Lord who created! He created man, out of a (mere) cloth of congealed blood. Recite; and thy Lord is most bountiful. He who had taught by the pen, taught man what he knew not." (96:1-5)
   Muhammad started proclaiming the message of believing in one God. The people who once called him "Trustworthy" and "Honest" boycotted and plotted to kill him. In 622 A.D., due to worsening living conditions and social isolation, Prophet Mohammad migrated to Medina along with his followers. This flight was known as Hijrah and marks the beginning of the Muslims calendar. Mohammad's message spread rapidly and the number of followers increased in Medina. During the next few years, a series of battles were fought between various tribes of Makkah and the Muslims of Medina. In 628 A.D, the Treaty of Hudaibiyah was signed between the two parties. Truce was declared for 10 years. The treaty was broken in 629 A.D by the non-Muslims of the Meccans. Mohammad moved towards Mecca with 10,000 men and the battle was won without a single bloodshed.  Muhammad died in 632 A.D , at the age of 63 in the city of Medina. Muhammad's death brought a huge catastrophe among Muslims. People could not believe that Mohammad had left them forever. Many of the followers were perplexed and distraught, and claimed him to be still living.  At that time Mohammad funeral, Abu Bakr, who was the most respected of all the followers affirmed that, "O people, those of you who worshipped Mohammad, Mohammad has died. And those of you who worshipped God, God is still living." 1
   When it comes to Jewish medical ethics, devotion to halakah (Jewish law) determines what a given rabbi will or will not recommend to a congregation member who is asking for advice.  A cardinal principle in Judaism is that human life is of infinite value. The preservation of human life takes precedence over all biblical commandments, with three exceptions: idolatry, murder and forbidden sexual relationships such as incest. Life’s value is absolute and supreme. Thus, an old man or woman, a mentally retarded person, a handicapped newborn, a dying cancer patient and their like, all have the same right to life as you or I. In order to preserve a human life, the Sabbath and even the Day of Atonement (Yom Kippur) may be desecrated or set aside and all other rules and laws, save the above three, are suspended for the overriding consideration of saving a human life. The corollary of the principle is that one is prohibited from doing anything that might shorten a life even for a very short time since every moment of human life is of infinite value.
   Islam considers access to health care as a fundamental right of the individual. In medicine, there are sometimes difficult decision-making options for the patient’s care. Thus, a physician at times has to decide for his /her patient in light of available knowledge, his/her experience, his/her peers and consensus
of the community. In addition, a Muslim physician derives his /her conclusion from rules of Islamic laws (Shari`ah) and Islamic medical ethics. The first main principle of Islamic Medicine is the emphasis on the sanctity of human life which derives from al-Qur’an:

                    Whosoever saves a human life saves the whole of mankind 2

   The second main principle is the emphasis on seeking a cure. This derives from a saying of Prophet Muhammad (PBUH):

    There is no disease that God has created, except that He also has created its treatment.3

   Prophet Muhammad (PBUH), in another narration, is also reported to have said: Seek treatment, for God the Exalted did not create a disease for which He did not create atreatment, except senility.4
   This is further emphasized by the fact that three of the “Goals of the Islamic Shari`ah” are the protectionand preservation of life, intellect, and progeny. The other two are the protection of property and religion.
   Some of the rules of Islamic medical ethics are 1) Necessity overrides prohibition; that is, if there are certain items which are Islamically prohibited, under dire necessity they can become permissible. 2) Harm has to be removed at every cost if possible. 3) Accept the lesser of the two harms if both cannot be avoided. 4) Public interest overrides the individual interest. Islamic Medical Ethics also upholds the four basic principles of biomedical ethics. These are 1) Respect for the autonomy of the patient, 2) Beneficence, 3) Nonmaleficence, and 4) Distributive Justice.
   Thus, when a Muslim physician is making a decision about patient care, that decision should be in the best interest of the patient, whether Muslim or non-Muslim. Further, that decision should not only be based on his/her own knowledge and experience, but as a Muslim, he/she has to consider the Islamic teaching in regards to the situation, but without imposing his/her religious views on the patient.
    Life with suffering is regarded as being, in many cases, preferable to cessation of life and with it elimination of suffering.  The Talmud (Jewish oral tradition for interpreting the Torah), Sotah 22a, and Rabbi Moses Maimonides (1135-1204), Hilkhot 3:20, indicate that the adulterous woman who was made to drink “the bitter water” (Numbers 6:11-31) did not always die immediately.  If she possessed other merit, even though guilty of the offense with which she was charged, the waters, rather than causing her to perish immediately; produced a debilitating state which led to a protracted termination of life. The added longevity, although accompanied by pain and suffering, is viewed as a privilege bestowed in recognition of meritorious actions.  Life with pain is thus viewed as preferable to death.  It is this sentiment which is reflected in the words of the Psalmist: “The Lord has indeed punished me, but He has not left me to die” (Ps.118:88).5
    The cardinal principle of the preserving life is extended to include saving the life of an endangered person.  This is derived by the Talmud from the verse; “Neither shalt thou stand idly by the blood of thy fellow” (Lev. 19:16).  The Talmud and the various codes of Jewish law offer specific examples of situations in which a moral obligation exists with regard to rendering aid.  These include the rescue of a person drowning in a river, assistance to one being mauled by wild beasts, and aid to a person under attack by bandits.6
    While the cardinal principle certainly has merit, it is not without theological and philosophical difficulties.  Religion prescribes providential concern to God and thus views sickness as part of a divine scheme.  God does not allow His creatures, over whom He exercises providential guardianship, to become ill unless the affliction is divinely ordained as a means of punishment, for the purposes of expiation of sin or for some other beneficial purpose entirely comprehensible by God, if not man.
    Rabbinic teaching recognized that intervention for the purpose of thwarting the natural course of disease could be sanctioned only on the basis of specific divine dispensation.  Such license is found, on the basis of Talmudic exegesis, in the scriptural passage dealing with compensation for personal injury:

                   And if men quarrel with one another and one smiteth the
                   other with a stone or with the fist and he does not die, but
                   keeps to his bed…he must be pay for the loss entailed by
                   absence from work and cause him to be thoroughly healed.
                  (Ex. 21:18-19)

   Even though this Exodus passage deals specifically with the financial compensation of one who has been injured by another, there is reference made to liability for medical expenses.  Therefore it follows that liability for such expenses implies a Biblical license to incur those expenses in the course of seeking the assistance of a practitioner of the healing arts. Thus the Talmud, Bava Kamma 85a, comments, “From here [it is derived] that the physician is granted permission to heal.”7
   Since death is a natural part of the life cycle, what does Judaism teach with regard to dealing with those who are dying?           
   A goseis (a dying person) is to be considered alive in all respects and according to Jewish law. Nothing can be done to a dying person which would cause the nefesh (soul) to leave the body before the proper time.  Placing cooling vessels or metal on his navel, tying the jaw shut, moving the patient, and removing his bedding are all forbid. Reflecting upon the Shulhan Aruch (a legal code composed by Rabbi Joseph Caro in the mid-1500s), Moses Isserles (1520-1572), a renowned scholar known as “the Maimonides of Polish Jewry”, wrote his Mapah (“Tablecloth”) to serve as a supplement to Caro’s writings.  Isserles distinguishes between accelerating the death of a goses and simply removing obstacles impeding death, which he considers proper.  If something or someone is present which is preventing the nefesh from leaving, for example, a person chopping wood nearby it is permissible to remove the woodchopper.  The same is true if there is salt on the person’s tongue. These distinctions where seen by many later Jewish authorities as sanctioning certain forms of passive euthanasia.    The practice of euthanasia--whether active or passive--is contrary to the teachings of Judaism. Any positive act designed to hasten the death of the patient is equated with murder in Jewish law, even if the death is hastened only by a matter of moments. No matter how laudable the intentions of the person performing an act of mercy-killing may be, his deed constitutes an act of homicide.
    In discharging his responsibility with regard to prolongation of life, the physician must make use of any medical resources which are available. However, he is not obligated to employ procedures which are themselves hazardous in nature and may potentially foreshorten the life of the patient. Neither is either the physician or the patient obligated to employ a therapy which is experimental in nature.
    The attempt to sustain life, by whatever means, is the expression of the highest regard for the precious nature of the gift of life and of the dignity in which it is held. Only the Creator, who bestows the gift of life, may relieve man of that life, even when it has become a burden rather than a blessing.
     In his commentary on Leviticus 26:11, Moses Nahmanides (1194-1270) argues that a patient may justifiably reject medical treatment and, when he is prompted to do so because he has placed his trust in God, renunciation of further therapy is even meritorious.  Moses Maimonides argues that such line of reasoning is faulty; stating that if one follows this reasoning to its logical conclusion that even partaking of nourishment would undermine one’s faith in God.   Were a person to become hungry and seek bread he would undoubtedly be cured of the severe malady of hunger and would no longer rely upon God.  In actuality, Maimonides declares, just as one gives thanks to God upon eating for having created food with which one might assuage hunger, one gives thanks to God for having created the cure for one’s illness.8
     Another criterion to be considered is that of a tereifah (a terminally ill person).  While a goseis is someone in the last stages of life, a tereifah is one whose death may not be imminent, but will not recover from his or her illness.  Taking these two criterions into consideration we will examine such issues as withholding artificial nutrition and hydration (ANH) and pain management.
      When dealing with a goseis, Jewish law prohibits withholding or withdrawing medication and ANH as long as the treatment is believed to be beneficial.  Treatment should be continued as long as it is effective and the patient’s request is to continue. Jewish law maintains that the patient’s decision regarding treatment is to be accepted as the final word. 
      Withdrawing/withholding medication is allowed when dealing with a tereifah.  Every person must be afforded normal food and liquids; however, ANH could be viewed as closer to medication than food and water depending upon the patient’s condition and their ability to take nourishment.
     Pain management (hospice) should not cross the line where the effect of the treatment could hasten the death of a goseis or a tereifah.  The reduction of suffering should be the main concern when offering pain management to someone who is dying.  The withholding or withdrawal of life support systems is permissible provided that doing so is simply allowing nature to take its course.
     Jewish law does not allow one to commit suicide nor assist in the suicide of another.  The withholding or withdrawing of life support systems does not qualify as either active or passive euthanasia according to Jewish law.  
     There are some Reform rabbis who have advocated for assisted suicide when the patient is experiencing severe suffering and there is little to no hope of recovery; however, based upon my research these rabbis appear to be in the minority regarding rabbinical teachings.
    In the Winter 1976 issue of Jewish Life magazine, J. David Bleich wrote an article entitled “The Quinlan Case: A Jewish Perspective” which looked at this case from the stand point of Jewish law.  While Karen Ann was not Jewish, it is important to be able to reflect upon this landmark decision from the stand point of Jewish law.
     For the benefit of those who are unfamiliar with the case of Karen Ann Quinlan, I will offer a brief summary.  In 1975, Karen, age 21, attended a party at a friend’s home and suffered cardiopulmonary arrest after ingesting a combination of alcohol and drugs.  After being transferred from Newton Community Hospital in Newton, NJ to St. Clare’s Hospital in Denville, NJ, she subsequently went into a persistent vegetative state (PVS).  The hospital neurologist described her as no longer having cognitive brain function but retaining the capacity to maintain the vegetative parts of neurological function.  She was able to make facial expressions, utter sounds, and maintain a normal blood pressure; however, she was unaware of anyone of anything around her.  The doctors stated that she did have some brain stem function, but that, in her case, it could not support her breathing.  She had been on a respirator since her admission to the hospital.
    Joseph and Julia Quinlan, Karen’s parents, requested that she be taken off the respirator and allowed to die.  However, the hospital refused because she did not meet the Harvard Criteria for brain death (no brain stem function).  Based upon the medical standards of the time, a doctor could not terminate a patient’s life support if that patient did not meet the legal definition of brain death. According to the Harvard Criteria, she could not be declared legally dead, and the physicians believed she would die if the respirator were removed.
    Joseph Quinlan went to court to be declared Karen’s guardian (since she was over 21) and to gain power to authorize “the discontinuance of all extraordinary procedures for sustaining Karen’s vital processes.”  The court denied the petition to have Quinlan’s respirator removed and also refused to allow him to be appointed her guardian.
    He then, subsequently, appealed to the New Jersey Supreme Court to have Karen’s life support removed based upon the First Amendment of the United States Constitution.  The court rejected the opinion and also declared that this case was not covered under the Eighth Amendment—protection against cruel and unusual punishment—was not applicable either since that amendment dealt with criminal punishment. It declared Karen’s circumstances to be “an accident of fate or nature”. 
     The case subsequently made it all the way to the United States Supreme Court based upon the issue of right to privacy.  Balanced against her right to privacy was the state’s interest in preserving life.  Judge Hughes of the New Jersey State Supreme Court argued that based upon the level of “bodily invasion” suffered by Karen, consisting of 24 hour a day nursing, antibiotics, respirator, catheter, and feeding tube, the state’s interest in preserving life was secondary to Karen’s right to privacy.9
    In March 1976 the New Jersey Supreme Court ruled that, if the hospital ethics committee agreed that Karen would not recover from irreversible coma, her respirator could be removed.  Furthermore, all parties involved would be legally immune from criminal and civil prosecution.  However, after Karen’s respirator was removed, she continued to breathe on her own and remained in a PVS until she died of multiple infections in 1985 at Morris View Nursing Home in Morris Township, NJ.
     According to Jewish law, Karen would qualify as tereifah.  Even though she had brain stem function, Karen was terminally ill.  The medication which Karen received during her treatment at St. Clare’s Hospital was not needed to alleviate any pain since there was no indication that she was suffering from pain.  Instead, it was seen as burdensome on the part of Karen’s parents and eventually the New Jersey Supreme Court concurred.   There was no reasonable hope of Karen’s recovery.  She was given nutrition and hydration both at St. Clare’s Hospital and Morris View Nursing Home and would definitely have qualified as “alive” following the removal of her respirator, even though she remained in a PVS, given the fact that she was able to breathe on her own and was receiving nourishment.
      One issue which Rabbi Bleich addressed in this article and is still being discussed and debated today is the exact mental capabilities of someone in a PVS. 
      No scientist has ever determined the absolute (as distinct from recordable) threshold of psychic activity.  No clinical experiment has ever been conducted to determine at what level of consciousness a comatose patient becomes incapable of remorse or repentance.  However, even if possible, such an undertaking would be irrelevant.  Human life, regardless of its quality, and indeed, of its potential for even the most minimal fulfillment of mitzvot (offering blessing to God), is endowed with sanctity.
   There is a definite conflict between ethical teachings of Judaism and the prevalent moral climate.  Unfortunately, Jews are prone to celebrate Jewish thought when it coincides with what chances to be in vogue and to ignore it when it runs counter to ideas or practices heralded by the dominant culture.  Judaism has something to say—and to teach—about moral issues.  Jewishness is more than a matter of ethnic identity and Judaism more than perfunctory performance of ritual.  Jews who take their Jewishness seriously must necessarily search for the uniquely Jewish answers to the dilemmas of life and death which emerge from the Jewish tradition.  Judaism teaches that man is denied the right to make judgments regarding the quality of life. He is never called upon to determine whether life is worth living—that is a question over which God remains sole arbiter.10
   Muslims believe that God is the Creator of life and life is a gift from Him. Muslims believe that all life is sacred and must be protected. The respect for life in Islam is common for all humans, irrespective of gender, age, race, color, faith, ethnic origin or financial status. The Islamic Medical Association of North America (IMANA) holds the position that biological life begins at conception while human life begins when ensoulment takes place. A verse from the Qur’an reads:

Man We did create from a quintessence (of clay); Then We placed him as (a drop of) sperm in
a place of rest, firmly fixed; Then We made the sperm into a clot of congealed blood; then of
that clot We made a (fetus) lump; then we made out of that lump bones and clothed the bones
with flesh; then we developed out of it another creature. So blessed be God, the best to create!11

  Ensoulment is believed to occur at 40 or 120 days after fertilization, according to different schools of thought.12The right of the human fetus in Islam is similar to the rights of a mature human being, including the right to life, the right to inheritance, the right of compensation when injured by willful acts and the right to penalize assailants. IMANA extends the principles of medical ethics to the patient in a vegetative state. Until the death has been declared, the patient in a vegetative state is considered a living person and has all the rights of a living person.
   The definition of the end of human life from the Islamic point of view has been previously discussed.13,14 IMANA has previously published a position paper on death.15 Permanent cessation of cardiopulmonary function, when diagnosed by a physician or a team of physicians, is considered death. The concept of brain death is necessitated when artificial means to maintain cardiopulmonary
function are employed. In those situations, cortical and brain stem death, as established by specialist(s) using appropriate investigations can be used. It is the attending physician who should be responsible for making the diagnosis of death. Thus a person is considered dead when the conditions given below are met.
1. The physician has determined that after a standard examination, a person’s cardiopulmonary function has come to a permanent stop. 2. A specialist physician (or physicians) has determined that after standard examination, the function of the brain, including the brain stem, has come to a permanent stop, even if some other organs may continue to show spontaneous activity.
   The following verses in the Qur’an are some of the verses which address issues of life and death:

It is He who gives life and death and when He decides upon an affair, He says to it: Be and it
No soul can die except by God’s permission, the term being fixed by writing…17
Every soul will have a taste of death. In the end, to us, shall you be brought back. 18
It is He who gives life and Who takes it away and to Him shall you be brought back.19
Nor take life which God has made sacred-except for a just cause…20

   IMANA does not believe in prolonging the misery of dying patients who are terminally ill or in a persistent vegetative state (PVS). PVS is defined as a sub-acute or chronic condition which usually follows severe brain injury and is characterized by normal sleep/wake pattern and total lack of cognitive function with preserved blood pressure, respiratory control, which persists for more than two months.
   When death becomes inevitable, as determined by a team of physicians, including critical care physicians, the patient should be allowed to die without unnecessary procedures. While all ongoing medical treatments can be continued, no further or new attempts should be made to sustain artificial life support. If the patient is on mechanical support, this can be withdrawn.21-24
   The patient should be treated with full respect, comfort measures and pain control. No attempt should be made to withhold nutrition and hydration. In such cases, if and when the feeding tube has been withdrawn, it may not be reinserted. The patient should be allowed to die peacefully and comfortably.
  However, no attempt should be made to enhance the dying process in patients on life support. IMANA is absolutely opposed to euthanasia and assisted suicide in terminally ill patients by healthcare providers or by patient’s relatives. Suicide and euthanasia are prohibited in Islam.22, 24
   The Islamic view on the sanctity of human life, quoted above, is identical to the following passage from The Talmud:

  For this reason was man created alone, to teach Thee that whosoever destroys a single soul…Scripture imputes guilt upon him as though he had destroyed a complete world; and whosoever preserves a single soul…, Scripture ascribes merit to him as though he had preserved a complete world.”  25

   Jewish and Islamic views on medical ethics are rather similar.  This should come as no surprise to those familiar with Islam considering the fact that the Prophet Muhammad borrowed quite heavily from the Hebrew Scriptures while composing The Qur’an.  While it is true that there are numerous political differences between Jews and Muslims, dating back thousands of years, it is important to realize the common ground that these two religions have in the area of medical ethics.
    It is also essential for those interested in the study and practice of medical ethics to understand what these two religions teach so that they can best serve the needs of those patients they will encounter who live either lives as practicing Jews or Muslims.
                                                                     End Notes

1)    “Religion of Islam”
2)    The Qur’an 5:32
3)    Sahih Al-Bukhari, Book 79, Kitaab al-Tibb, Chapter 1, Hadith 5354. [on-line] Available from:
4)    Sunan Abi Dawuud. Vol. 2, Book 27, Kitaab al-Tibb, Chapter 1, Hadith 3855. [on-line] Available from:
5)    “The Obligation to Heal in Judaic Tradition: A Comparative Analysis” by J. David Bleich in Jewish Bioethics (ed. by Fred Rosner and J. David Bleich) NJ: KTAV Publishing House, 2000, p. 20
6)    Judaic Tradition, p. 22
7)    Judaic Tradition, p. 23
8)    Judaic Tradition, p. 29
9)    “Court and End of Life—The Right to Privacy: Karen Ann Quinlan”
10) “The Quinlan Case: A Jewish Perspective” by J. David Bleich in Jewish Bioethics, p. 293
11) The Qur’an 23:12-14
12) Yaseen MN “The Inception of Human Life in the Light of Statements of The Holy Qur’an and Sunnah and the Opinions of Muslim Scholars” J Islam Med Assn 1990:22:159-67
13)Yaseen MN “The End of Human Life in Light of The Opinion of Muslim                                      Scholars and Medical Science” J Islam Med Assn 1991:23:74-81
14) Ahmed WD “An Islamic View of Death and Dying” J Islam Med Assn 1996;28:175-7
15) Medical Ethics Committee, Islamic Medical Association of North America               “Death” J Islam Med.Assn 1997:29:99
16) The Qur’an 40:68
17) The Qur’an 3:145
18) The Qur’an 29:57
19) The Qur’an 10:56
20) The Qur’an 17:33
21) Ebrahim AM. “ICU Ethical Dilemmas” The Islamic Medical Association of    
      South Africa (2004)
     22) Medical Ethics Committee, Islamic Medical Association of North America.         
           “Care at the End of Life and Euthanasia” J Islam Med Assn 1997:29:100-
23) Athar S “Ethical Decision Making in Patient Care” in Health Concerns for               Believers: Contemporary Issues  (Chicago: Kazi Publications; January 1996) pp. 79-84
     24) Khan FA “Religious Teachings and Reflections in Advance Directive-Religious Values and Legal Dilemmas in Bioethics: An Islamic Perspective” Fordham Urban Law Journal. 2002:30(1):267-75
     25) The Talmud, Sanhedrin 37


WD Ahmed “An Islamic View of Death and Dying” J Islam Med Assn 1996:28

Shahid Athar “Ethical Decision Making in Patient Care” in Health Concerns for               Believers: Contemporary Issues  (Chicago: Kazi Publications; January 1996)

AM Ebrahim “ICU Ethical Dilemmas” The Islamic Medical Association of South Africa (2004)

FA Khan “Religious Teachings and Reflections in Advance Directive-Religious Values and Legal Dilemmas in Bioethics: An Islamic Perspective” Fordham Urban Law Journal. 2002:30(1)

Medical Ethics Committee, Islamic Medical Association of North America.         
“Care at the End of Life and Euthanasia” J Islam Med Assn 1997:29

Medical Ethics Committee, Islamic Medical Association of North America                “Death” J Islam Med.Assn 1997:29

Fred Rosner and J. David Bleich (ed.) Jewish Bioethics (NJ: KTAV Publishing House, 2000)

Sahih Al-Bukhari, Book 79, Kitaab al-Tibb, Chapter 1, Hadith 5354

Sunan Abi Dawuud. Vol. 2, Book 27, Kitaab al-Tibb, Chapter 1, Hadith 3855

The Qur’an

The Talmud, Sanhedrin 37

MN Yaseen “The Inception of Human Life in the Light of Statements of The Holy Qur’an and Sunnah and the Opinions of Muslim Scholars” J Islam Med Assn 1990:22

Yaseen MN “The End of Human Life in Light of The Opinion of Muslim                                      Scholars and Medical Science” J Islam Med Assn 1991:23

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