JOURNAL OF THE ROYAL SOCIETY OF MEDICINE Volume 91 March 1 998 Death and dying-a Muslim perspective Aziz Sheikh MRCP MRCGP J R Soc Med 1998;91:138-140 The care of dying patients and their relatives is one of the most difficult aspects of a doctor's job. Enabling an individual to die with dignity can also be deeply rewarding. Britain today is a cosmopolitan society made up of people from numerous religious and cultural traditions. The care of patients with backgrounds different from one's own requires knowledge and skills. There are approximately 2 million Muslims in the UK1. Although most originate from he Indian subcontinent2 substantial numbers have arrived recently from Africa and to a lesser extent Central Europe. Islamic Law (Shariah) is based on the Qur'an and Hadith (the practices and sayings of the Prophet Muhammad)3. The Shariah defines certain expected behaviours at the time of death and these are generally adhered to by Muslims in Britain. In this paper I offer some guidance on caring for Muslim patients in their final illness. MUSLIM BELIEF REGARDING DEATH, ABORTION AND EUTHANASIA For a Muslim, death marks the transition from one state of existence to the next.
Islam teaches that life on earth is an examination-the life to come is the eternal abode where one will reap the fruit of one's endeavours on earth. Death is therefore not to be resisted or fought against, but rather something to be accepted as part of the overall divine plan4. Further, death is not a taboo subject in Muslim society and is a matter upon which one is encouraged to reflect frequently. In counselling of Muslims regarding a terminal illness, or relatives after a bereavement, these points should be borne in mind. Islam views life as sacred and a trust from God (Allah).
Termination of pregnancy is therefore generally not permissible within the Islamic frameworks. If the subject needs to be broached this should be done with extreme sensitivity. To step outside the Islamic framework and have an abortion may engender much guilt. Similarly, deliberate euthanasia is prohibited6. Note, however, that undue suffering has no place in Islam and if death is hastened in the process of giving adequate analgesia then this is allowed. What is important is that the primary intent is not to hasten death. THE FINAL ILLNESS Certain death customs are almost universally practised by
Muslims. Ideally Muslims would wish to die at home7. Making death clinical and remote in a hospital setting is not in keeping with the Islamic tradition. The dying person will expect to be visited by friends and relatives, who are encouraged to pray for his or her welfare in the life to come. This is a time when Muslims seek each others' forgiveness for excesses that may have been inadvertently committed. Fifty people visiting in the space of a few days would not be exceptional; so strict adherence to '2 visitors per bed' will cause difficulty for all concerned.
Members of the immediate family will often stay by the bedside reciting from the Qur'an. Having a copy of the Qur'an on the ward, for those who have not remembered to bring their own, is a kindness. The daily prayers play a pivotal role in the day-to-day life of a Muslim, and prayer assumes an even greater role in times of suffering and distress. Family members will encourage the dying to continue with their prayers as long as they are able to do so. Before the prayer, ablution is performed; bed-bound patients will need help in this respect. Muslims pray towards Mecca, which is to the outh-east of Britain. Again for the bed-bound, positioning the bed in the direction of Mecca will simplify matters. Having a compass and prayer timetable available would be very useful; a prayer timetable is easily available from most local mosques. Many of the visitors and relatives will also need to perform their prayers and, unfortunately, hospitals seldom cater for this need8. DEATH, WASHING AND BURIAL When a Muslim dies, the eyes and mouth should be closed and the limbs should be straightened. The body should ideally face in the direction of Mecca. It is a religious equirement that the dead be buried as soon as possible and considerable family distress can be avoided by speedy production of the death certificate. The body will be washed and shrouded in simple unsewn pieces of white cloth. A funeral prayer is held in the local mosque, and family and community members follow the funeral procession to the graveyard where a final prayer is said as 138 the deceased is laid to rest. Events occur in rapid succession Department of Primary Health Care and General Practice, Imperial College School of Medicine, Norfolk Place, London W2 1 PG, UK
JOURNAL OF THE ROYAL SOCIETY OF MEDICINE Volume 91 March 1998 and often the dead will be buried within 24 hours. The Muslim is always buried rather than cremated9. POST-MORTEM EXAMINATIONS AND ORGAN TRANSPLANTS When 'new' issues arise that are not explicitly dealt with in the Shariah, Muslim jurists are required to study the issue in question and using the principles enshrined within the Qur'an and Hadith give a legal opinion (fatwa). A fatwa is an opinion and therefore not binding; thus one can expect a broad range of views on a given question, and this is true of post-mortem examinations and organ transplantation.
The majority opinion is that post-mortem examinations are not allowed. One reason is that the examination will inevitably delay the burial. Secondly, Islamic belief holds that it may be possible for the deceased to perceive pain. This is based on the statement of the Prophet Muhammad that 'to break the bone of a dead person is like breaking the bone of a living person'10. A small but growing minority hold that post-mortem examinations are permissible11. Where the law of the land demands post-mortem examinations-i. e. at the coroner's request-Muslims have no choice but to comply.
In this case informing the coroner's officer that the deceased is a Muslim may speed up the process since many coroners are aware of Muslim sensitivities. If for any other reason a post-mortem examination is considered desirable, family members must be told they have a free choice in the matter and their views must be respected. With regard to organ transplants opinion is more divided. For the reasons cited above many oppose the donating of organs. Further, it is argued that since life is a trust one has no right to 'donate' any part of one's body to someone else.
An increasing number of Muslims, however, are of the view that, in cases where it may save life, organ donation is permissible on the basis of the Islamic doctrine that 'necessity allows the prohibited'12. CASE HISTORIES I close by offering two examples of poor practice and one of good. Case I A married genetics student attended the antenatal bookingin clinic in her first pregnancy. A routine dating ultrasound scan revealed that the fetus had increased nuchal thickness. Suspecting a diagnosis of Down's syndrome her consultant referred her to a tertiary centre for further investigations.
Here she was followed up with serial ultrasound scans which revealed various congenital malformations that were considered incompatible with life. She was repeatedly a less than 1% chance of survival. This she consistently declined, stating that abortion was against her faith. Ultrasound monitoring continued until 34 weeks when she spontaneously went into labour. The baby, stillborn, was named and buried and is frequently visited by family members. Case 2 The parents of Zahra (not her real name), a 12-year-old girl with a progressive neurodegenerative disease, were invited o attend for a consultation to discuss their daughter's prognosis. The consultant responsible for Zahra's care informed them that she had deteriorated considerably over the past few months and that she was likely to deteriorate further in the near future. Throughout the discussion it was emphasized that Zahra had led a fruitful life, and that maximum effort would be made to ensure that she was kept pain-free. The session was predominantly doctor-led, with the family being given little opportunity to discuss their hopes and fears. It ended with the clear message that
Zahra's end was imminent. She died shortly afterwards. Despite the best intentions of the clinician concerned, his lack of awareness of Muslim perspectives on the subject of death and dying led to a dysfunctional consultation. Though the issues raised by the consultant are frequently of great concern to those of a secular belief framework, they are of lesser concern to Muslims. Death is not seen as the end but rather as a passage into the eternal life. With regard to the impending or actual death of a child, it is customary to comfort the family by reminding them that children are ure and innocent, and hence have Paradise assured to them in the life to come. For a Muslim, there is no greater achievement. Case 3 A woman in her late 70s was admitted to hospital with pneumonia. It had been her third admission with the same condition in as many months. Tired and weak she had lost the will to continue and had stopped eating and drinking. After a few days of intensive treatment with little sign of improvement the consultant communed with family members regarding further management. A joint decision was made to suspend active treatment and to let nature take its course.
She was kept comfortable with analgesia and regular mouthwashes. The family were given open visiting access and there remained someone with her at all times. When she died a few days later the necessary paperwork was completed immediately and she was buried within 12 hours. KEY MESSAGES *Muslims have beliefs and rituals surrounding death that advised to have a termination on the basis that the baby had are poorly understood by the medical profession. Greater 139 IJOURNAL OF THE ROYAL SOCIETY OF MEDICINE Volume 91 March 1998 understanding and sensitivity in this respect would help ase suffering and distress both to patient and family. *Visiting the sick and dying is a religious duty. Muslims dying in hospital may therefore have many visitors. Relaxation of hospital visiting regulations would facilitate this. * Prompt issue of the death certificate will allow the burial to take place rapidly, in keeping with Islamic Law. * Post-mortem examinations are generally prohibited. In the event of a post-mortem being desirable or necessary, this should be discussed fully with the family, who should be informed of their rights. * On organ transplantation, mixed views are expressed by he Muslim community in Britain. REFERENCES 1 Qureshi B. Transcultural Medicine Dealing with Patients from Different Cultures. London: Kluwer, 1989:161 2 Badawi Z. Islam in Britain. London: Ta Ha Publishers, 1981:10 3 Doi AR. Shariah: The Islamic Law. London: Ta Ha Publishers, 1984:21- 58 4 Neuberger J. Caring for Dying Patients of DjJerent Faiths, 2nd edn. London: Mosby, 1994:36 5 Ebrahim AF. Abortion, Birth Control and Surrogate Parenting-An Islamic Perspective. Indianapolis: American Trust Publication, 1989:67-77 6 Darsh SM. Islamic Health Rules. London: Ta Ha Publishers, 1986:11-12 7 Gartrad AR.
Muslim customs surrounding death, bereavement, postmortem examinations, and organ transplants. BMJ 1994;309:521-3 8 Sheikh A. Quiet room is needed in hospitals for prayer and reflection. BMJ 1997;315:1625 9 Black J. Broaden your mind about death and bereavement in certain ethnic groups in Britain. BMJ 1987;295:538 10 Al-Asqalani AIH. Bulugh Al-Maram. Riyadh: Dar-us-Salam Publications, 1996:199-200 11 Risper-Chaim V. The ethics of postmortem examinations in contemporary Islam. J Med Ethics 1993;19: 164-8 12 Anon. The Muslim Law (Shariah) Council and organ transplants. Accident Emerg Nursing 1996;4:73-5 140