End-of-Life Care and Islamic Concept of Accountability
Islamic Theology’s Contribution to Medical Decision Making in End-of-Life Care John J. Paris, Boston College Andrew Hawkins, Boston College Medicine was an easier profession in the time of Hippocrates. There was little that could be done and little that was done. The decision on what to do was almost exclusively the prerogative of the physician. As one reads in the “Decorum” in the Hippocratic Corpus, Hippocrates (1977) instructed physicians to tell the patient nothing of his present or future condition. The doctor alone determined what was best for the patient. And in the treatise entitled The Art, Hippocrates exhorts his fellow physicians not to apply medical treatments to the patient who is “overmastered” by disease—not because such treatments would not work, but because when the intervention failed, people would lose confidence in the physician’s judgment. Even in that golden age, physician self-interest was a basic concern. Insights into the role of the patient and the physician with regard to treatment decisions come from both the clinical traditions of medicine and cultural contexts, one of which is religion. The influence of the Christian tradition on health care has been well documented (Marty 1984; McCormick 1984; Vaux 1984), as has that of the Jewish faith (Dorff 1990). Padela and Mohiuddin’s target article (2015) explains the guidance Islamic theology provides to Muslim patients and physicians concerning treatment decisions particularly with regard to end-of-life care. In addressing those issues, the authors are doing for the Muslim world what Richard McCormick did with regard to the import of the Catholic moral traditions on medical ethics in his classic 1974 Journal of the American Medical Association essay entitled “To Save or Let Die.” In that widely cited and highly influential article, McCormick spelled out how from the 16th century onward Catholic moral theologians applied the principles of their theology to medical practice. The particular emphasis of McCormick’s article was the role of theology in end-of-life care. His essay, particularly the emphasis on a patient’s “capacity for relationships,” brought clarity and reasoned analysis—as well as Catholic theological understanding—on the purpose of creation and the salvific goal of human existence. It also provided guidance on the troubling question of “Granted we can save this life, what kind of a life are we saving?”
Prior to the late 20th century developments in medical technology and pharmacology, there was very little even the most sophisticated physician could do to ward off death. In those days the Ars Moriendi, that is, “The art of dying well,” was the dominant theme of end-of-life care. In a beautifully written New Yorker essay, Atul Gawande (2010) describes the goal of the Ars Moriendi as “Reaffirming one’s faith, repenting one’s sins, and letting go of one’s worldly possessions and desires” to prepare to meet one’s Creator and Judge. In counterdistinction, Daniel Callahan (1993) describes the contemporary American belief that there is a technological fix for every medical problem. Death, in that worldview, as Callahan describes it, is seen as “an option.” The older perspective of the inevitability of death has yielded to the secular belief that we can not only defeat disease, but destroy death itself. Gone is the Christian concept of death as an integral part of life—the final step of a journey from and back to God. That perspective is best captured in Gustav Mahler’s Symphony No. 2, the so-called “Resurrection Symphony,” where we hear the soaring voice of the mezzo soprano proclaim, “I am from God, and to God I shall return.” As St. Paul puts it in his first epistle to the Corinthians, “Oh Death, where is thy victory? Oh Death, where is thy sting?” (1 Corinthians 15: 51–56). The answer Paul provides is that death, far from being final, is but the end of mortal existence. Death is rather the entrance into eternal life. That stand is captured in Handel’s Messiah where, following a blazing trumphet blast, we hear the bass baritone intone, “The trumphet shall sound and the dead shall be raised incorruptible.” Padela and Mohiuddin (2015) provide a similar theological understanding of life and death in their analysis of the influence of Islamic theology on medical practice. The authors begin by explaining the fundamental doctrines of their religion. For the Muslim, “accountability before God (taklif)” is the foundation of all human behavior. To be accountable, the individual must be mature, conscious, and responsible before God for his or her actions.
Address correspondence to John J. Paris, Boston College, 140 Commonwealth Ave., Chestnut Hill, MA 02467, USA. E-mail: john. [email protected]
January, Volume 15, Number 1, 2015
ajob 17
The American Journal of Bioethics
Everyone—patients, physicians, and society—has responsibilities to God for their behavior. Multiple surveys, many cited in the authors’ essay, confirm David Todres and colleagues’ (1977) finding that a physician’s religious beliefs have a decided impact on practice patterns, particularly with regard to withholding or withdrawing life-sustaining medical interventions. One problem observed by the authors, which is also noted by McCormick, is that the guidance from the theologians is often highly abstract. Theologians, not surprisingly, provide sparse practical application of their belief system to specific medical cases. As we have learned from the seemingly endless debate in the American scene over “futility,” abstract terms frequently prove too amorphous to be helpful in resolving disputes over appropriate medical treatment (Heft, Siegler, and Lantos 2000). The Islamic authors do a great service for the non-Muslim reader in providing a guide to the theological beliefs of Islam. Fundamental to that religion is “accountability before God (taklif).” An individual who has taklif is a mukallaf—one who can perform willful acts while aware of their potential afterlife ramifications. From this, it follows that whatever treatments are undertaken by the patient, they are ultimately the object of God’s judgment. Islamic theologians distinguish the obligation to use medical measures based on the expectation of potential benefit. If the presumed benefit is “highly” likely, there is a substantial obligation to utilize it. If, on the other hand, there is “little likelihood” of success, the intervention may be foregone. The issue here, as with the 16th-century Catholic use of “ordinary/extraordinary,” is moral obligation, not technique or hardware. Failure to utilize that which would certainly restore one to healthy functioning would be sinful. As such, it would result in divine punishment in the afterlife. While in an earlier era these issues were fairly straightforward, modern medicine with its technology that can stave off death—but frequently cannot restore a cognitive functioning status—blurs the issue. It is here that medicine turns to moral or religious beliefs for guidance on whether or not to employ the so-called “half-way” technology that can sustain the semblance of life, without restoration of the individual to a fully functioning, integrated cognitive existence, that is, to the status of mukallaf. Some of the modern medical issues such as brain death and the use of artificial nutrition and fluids remain
18 ajob
unresolved in Islamic as well as other religious traditions. Despite such limitations, the authors have provided nonMuslim physicians with a readily accessible understanding of the foundational expectations a devout Muslim patient or family brings to the clinical setting. That awareness will prove helpful to Muslim and non-Muslim physicians in determining the appropriate medical response in end-oflife care. & REFERENCES Callahan, D. 1993. The troubled view of life: In search of a peaceful life. New York, NY: Simon & Schuster. Dorff, E. N. 1990. A Jewish approach to end-stage medical use, 65–126. New York: The Committee on Jewish Law and Standards of the Rabbinical Assembly. Available at: http://www.rabbinicalassembly. org/sites/default/files/public/halakhah/teshuvot/19861990/ dorff_care.pdf Gawande, A. 2010. Letting go: What should medicine do when it can’t save your life? New Yorker. Available at: www.newyorker.com/ magazine/2010/08/02/letting-go-2at4 (accessed September 29, 2014). Heft, P. R., M. Siegler, and J. Lantos. 2000. The rise and fall of the futility movement. New England Journal of Medicine 343(4): 293–296. Hippocrates. 1977. The 1923 translation by W. H. S. Jones, The Loeb Classical Library (Cambridge, MA: Harvard University Press), reproduced in S. J. Reiser A. J., Dyck, and W. J. Curran, Ethics in Medicine, 8. Cambridge, MA: MIT Press. Marty, M. 1984. Health and medicine in the Lutheran tradition. New York, NY: Crossroads Publishing. McCormick, R. A. 1974. To save or let die: The dilemma of modern medicine. Journal of the American Medical Association 229 (2): 172–176. McCormick, R. A. 1984. Health and medicine in the Catholic tradition. New York, NY: Crossroads Publishing 1984. Padela, A., and A. Mohiuddin. 2015. Ethical obligations and clinical goals in end-of-life care: Deriving a quality-of-life construct based on the Islamic concept of accountability before God (taklıf). American Journal of Bioethics 15(1): 3–13. Todres, I. D., D. Krane, M. C. Howell, and D. Shannon. 1977. Pediatricians’ attitudes affecting decision making in defective newborns. Pediatrics 60(12): 197–201. Vaux, K. L. 1984. Health and medicine in the reformed tradition. New York, NY: Crossroads Publishing.
January, Volume 15, Number 1, 2015
Copyright of American Journal of Bioethics is the property of Routledge and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Islamic Theology’s Contribution to Medical Decision Making in End-of-Life Care John J. Paris, Boston College Andrew Hawkins, Boston College Medicine was an easier profession in the time of Hippocrates. There was little that could be done and little that was done. The decision on what to do was almost exclusively the prerogative of the physician. As one reads in the “Decorum” in the Hippocratic Corpus, Hippocrates (1977) instructed physicians to tell the patient nothing of his present or future condition. The doctor alone determined what was best for the patient. And in the treatise entitled The Art, Hippocrates exhorts his fellow physicians not to apply medical treatments to the patient who is “overmastered” by disease—not because such treatments would not work, but because when the intervention failed, people would lose confidence in the physician’s judgment. Even in that golden age, physician self-interest was a basic concern. Insights into the role of the patient and the physician with regard to treatment decisions come from both the clinical traditions of medicine and cultural contexts, one of which is religion. The influence of the Christian tradition on health care has been well documented (Marty 1984; McCormick 1984; Vaux 1984), as has that of the Jewish faith (Dorff 1990). Padela and Mohiuddin’s target article (2015) explains the guidance Islamic theology provides to Muslim patients and physicians concerning treatment decisions particularly with regard to end-of-life care. In addressing those issues, the authors are doing for the Muslim world what Richard McCormick did with regard to the import of the Catholic moral traditions on medical ethics in his classic 1974 Journal of the American Medical Association essay entitled “To Save or Let Die.” In that widely cited and highly influential article, McCormick spelled out how from the 16th century onward Catholic moral theologians applied the principles of their theology to medical practice. The particular emphasis of McCormick’s article was the role of theology in end-of-life care. His essay, particularly the emphasis on a patient’s “capacity for relationships,” brought clarity and reasoned analysis—as well as Catholic theological understanding—on the purpose of creation and the salvific goal of human existence. It also provided guidance on the troubling question of “Granted we can save this life, what kind of a life are we saving?”
Prior to the late 20th century developments in medical technology and pharmacology, there was very little even the most sophisticated physician could do to ward off death. In those days the Ars Moriendi, that is, “The art of dying well,” was the dominant theme of end-of-life care. In a beautifully written New Yorker essay, Atul Gawande (2010) describes the goal of the Ars Moriendi as “Reaffirming one’s faith, repenting one’s sins, and letting go of one’s worldly possessions and desires” to prepare to meet one’s Creator and Judge. In counterdistinction, Daniel Callahan (1993) describes the contemporary American belief that there is a technological fix for every medical problem. Death, in that worldview, as Callahan describes it, is seen as “an option.” The older perspective of the inevitability of death has yielded to the secular belief that we can not only defeat disease, but destroy death itself. Gone is the Christian concept of death as an integral part of life—the final step of a journey from and back to God. That perspective is best captured in Gustav Mahler’s Symphony No. 2, the so-called “Resurrection Symphony,” where we hear the soaring voice of the mezzo soprano proclaim, “I am from God, and to God I shall return.” As St. Paul puts it in his first epistle to the Corinthians, “Oh Death, where is thy victory? Oh Death, where is thy sting?” (1 Corinthians 15: 51–56). The answer Paul provides is that death, far from being final, is but the end of mortal existence. Death is rather the entrance into eternal life. That stand is captured in Handel’s Messiah where, following a blazing trumphet blast, we hear the bass baritone intone, “The trumphet shall sound and the dead shall be raised incorruptible.” Padela and Mohiuddin (2015) provide a similar theological understanding of life and death in their analysis of the influence of Islamic theology on medical practice. The authors begin by explaining the fundamental doctrines of their religion. For the Muslim, “accountability before God (taklif)” is the foundation of all human behavior. To be accountable, the individual must be mature, conscious, and responsible before God for his or her actions.
Address correspondence to John J. Paris, Boston College, 140 Commonwealth Ave., Chestnut Hill, MA 02467, USA. E-mail: john. [email protected]
January, Volume 15, Number 1, 2015
ajob 17
The American Journal of Bioethics
Everyone—patients, physicians, and society—has responsibilities to God for their behavior. Multiple surveys, many cited in the authors’ essay, confirm David Todres and colleagues’ (1977) finding that a physician’s religious beliefs have a decided impact on practice patterns, particularly with regard to withholding or withdrawing life-sustaining medical interventions. One problem observed by the authors, which is also noted by McCormick, is that the guidance from the theologians is often highly abstract. Theologians, not surprisingly, provide sparse practical application of their belief system to specific medical cases. As we have learned from the seemingly endless debate in the American scene over “futility,” abstract terms frequently prove too amorphous to be helpful in resolving disputes over appropriate medical treatment (Heft, Siegler, and Lantos 2000). The Islamic authors do a great service for the non-Muslim reader in providing a guide to the theological beliefs of Islam. Fundamental to that religion is “accountability before God (taklif).” An individual who has taklif is a mukallaf—one who can perform willful acts while aware of their potential afterlife ramifications. From this, it follows that whatever treatments are undertaken by the patient, they are ultimately the object of God’s judgment. Islamic theologians distinguish the obligation to use medical measures based on the expectation of potential benefit. If the presumed benefit is “highly” likely, there is a substantial obligation to utilize it. If, on the other hand, there is “little likelihood” of success, the intervention may be foregone. The issue here, as with the 16th-century Catholic use of “ordinary/extraordinary,” is moral obligation, not technique or hardware. Failure to utilize that which would certainly restore one to healthy functioning would be sinful. As such, it would result in divine punishment in the afterlife. While in an earlier era these issues were fairly straightforward, modern medicine with its technology that can stave off death—but frequently cannot restore a cognitive functioning status—blurs the issue. It is here that medicine turns to moral or religious beliefs for guidance on whether or not to employ the so-called “half-way” technology that can sustain the semblance of life, without restoration of the individual to a fully functioning, integrated cognitive existence, that is, to the status of mukallaf. Some of the modern medical issues such as brain death and the use of artificial nutrition and fluids remain
18 ajob
unresolved in Islamic as well as other religious traditions. Despite such limitations, the authors have provided nonMuslim physicians with a readily accessible understanding of the foundational expectations a devout Muslim patient or family brings to the clinical setting. That awareness will prove helpful to Muslim and non-Muslim physicians in determining the appropriate medical response in end-oflife care. & REFERENCES Callahan, D. 1993. The troubled view of life: In search of a peaceful life. New York, NY: Simon & Schuster. Dorff, E. N. 1990. A Jewish approach to end-stage medical use, 65–126. New York: The Committee on Jewish Law and Standards of the Rabbinical Assembly. Available at: http://www.rabbinicalassembly. org/sites/default/files/public/halakhah/teshuvot/19861990/ dorff_care.pdf Gawande, A. 2010. Letting go: What should medicine do when it can’t save your life? New Yorker. Available at: www.newyorker.com/ magazine/2010/08/02/letting-go-2at4 (accessed September 29, 2014). Heft, P. R., M. Siegler, and J. Lantos. 2000. The rise and fall of the futility movement. New England Journal of Medicine 343(4): 293–296. Hippocrates. 1977. The 1923 translation by W. H. S. Jones, The Loeb Classical Library (Cambridge, MA: Harvard University Press), reproduced in S. J. Reiser A. J., Dyck, and W. J. Curran, Ethics in Medicine, 8. Cambridge, MA: MIT Press. Marty, M. 1984. Health and medicine in the Lutheran tradition. New York, NY: Crossroads Publishing. McCormick, R. A. 1974. To save or let die: The dilemma of modern medicine. Journal of the American Medical Association 229 (2): 172–176. McCormick, R. A. 1984. Health and medicine in the Catholic tradition. New York, NY: Crossroads Publishing 1984. Padela, A., and A. Mohiuddin. 2015. Ethical obligations and clinical goals in end-of-life care: Deriving a quality-of-life construct based on the Islamic concept of accountability before God (taklıf). American Journal of Bioethics 15(1): 3–13. Todres, I. D., D. Krane, M. C. Howell, and D. Shannon. 1977. Pediatricians’ attitudes affecting decision making in defective newborns. Pediatrics 60(12): 197–201. Vaux, K. L. 1984. Health and medicine in the reformed tradition. New York, NY: Crossroads Publishing.
January, Volume 15, Number 1, 2015
Copyright of American Journal of Bioethics is the property of Routledge and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
