The Cambridge textbook of bioethics

versus individual identity, a strong emphasis on purity, and a preference for sons.

The notion of karma and a belief in rebirth will be important for many Hindu and Sikh patients as they make ethical decisions surrounding birth and death. Unlike the linear view of life taken in Judaism, Christianity, and Islam, for Hindus and Sikhs, life, birth, and death are repeated, for each person, in a continuous cycle. The fundamental idea is that each person is repeatedly reborn so that his or her soul may be purified and ultimately join the divine cosmic consciousness (Radhakrishnan, 1968). What a person does in each life influences the circumstances and predispositions experienced in future lives. In essence, every action or thought, whether good or evil, leaves a trace in the unconscious that is carried forward into the next life. When a similar situation is encountered, that memory trace arises in the consciousness as an impulse to perform an action or think a thought similar to the earlier one. This impulse does not necessarily compel the person to repeat the act or thought. He or she can still exercise free will by either nurturing or uprooting what has been laid down in the unconscious. Karma theory rejects any absolute beginning and assumes that life has always been going on. Consequently, each person is thought to have a huge store of memory traces from previous lives that are transferred at birth and that, with the additions and deletions made through free choice in the current life, will influence rebirth in the next life (based on the Yoga Sutras of Patanjali, written around 2000 years ago; Woods, 1966). From this perspective, the moment of conception is the rebirth of a fully developed person who has lived many previous lives. Termination by abortion sends the soul back into the karmic cycle of rebirth.

Another major difference between Hindu and Sikh cultures and Western cultures concerns the question of identity. Who is the ethical agent in decision making: the patient or the family? In Western secular society, the individual person is viewed as having autonomy in ethical decision making. In Ayurveda (traditional south Asian

medicine) the person is viewed as a combination of mind, soul, and body in the context of family, culture, and nature (Kakar, 1982). Thus, the person is seen not as autonomous but rather as intimately integrated with his or her extended family, caste, and environment. This necessitates a holistic approach to ethical matters such as informed consent, one that includes the patient’s societal context as well as the religious or spiritual dimension of his or her experience.

Purity is an important value in Hindu and Sikh culture (Madan, 1985). In the classical Indian tradition, there are two terms for purity. Suddha (or shudh in Punjabi) evokes the image of the human body or elements of nature (e.g., the Ganges river) in their most pure, perfect, and desired state of being. Sauca (sucha in Punjabi) also means ‘‘pure’’ but relates more specifically to personal cleanliness. The most impure (asauca, or jutha in Punjabi) substances are the discharges of one’s body. Women, since they have more discharges than men, are seen as being more impure. Only before puberty or after menopause does a female approach the standard of purity of a male. The matter is even more complex because the purity–impurity axis in daily life is bisected by the auspicious–inauspicious axis (subha–asubha). For example, childbirth is auspicious if it occurs under the right circumstances. However, even if the circumstances are favorable, the act of childbirth itself, involving the discharge of bodily fluids, renders the mother impure. The baby is also impure, but this impurity becomes insignificant in view of the auspiciousness of birth, particularly the birth of a son, which is duly celebrated through ritual performance and social ceremonies during the following 11–13 days, culminating in the ritual of purification (Coward et al., 1989).

There is a general bias in favor of males over females in Hindu and Sikh culture. The roots of this bias are two-fold. In Hinduism, for example, the eldest son is required to light his father’s funeral pyre and to perform yearly rituals for the wellbeing of the father in the next life. The eldest son is also the head of the extended family and has

the responsibility to protect and provide for the women in the family; this includes a moral obligation to ensure that sexual mores are preserved. Sons at marriage receive a dowry with their wife, which adds to the family wealth. Daughters, in taking a dowry with them at marriage, do the reverse. The responsibility of eldest sons to provide for and protect the women in their extended families means that there is often a strong male dominance in matters of consent.

Why are Hindu and Sikh bioethics important?

The ethical theories employed in healthcare today tend to apply a Western philosophical framework to issues such as abortion, euthanasia, and informed consent. Yet the diversity of cultural and religious assumptions with respect to human nature, health and illness, life and death, and the status of the individual demands that physicians be sensitive to and respectful of the varied perspectives patients bring to ethical decision making (Coward and Ratanakul, 1999). Hindus and Sikhs are important minority groups in North America. For instance, in Canada, recent census figures show that about 500 000 South Asians, of whom Hindus and Sikhs make up the majority, are living in Canada. There are more than 1 billion South Asians in the world population. Many Hindus and Sikhs, especially those who are second and third generation in western countries, have acculturated to the dominant rights-based approach of Western bioethics, but recent immigrants, particularly older people, may apply the duty-based approach of their own tradition when considering treatment options.

How should I approach Hindu and Sikh bioethics in practice?

To avoid miscommunication, physicians need to understand and respect the religious and cultural

Hindu and Sikh bioethics 405

traditions of their Hindu and Sikh patients. They also need to recognize the diversity of beliefs and practices within these populations. Individual patients’ reactions to a particular clinical situation will be influenced by a number of factors, including how recently they or their families arrived in Canada, their level of education, whether their roots are rural or urban, their socioeconomic status, and their religious stance (e.g., fundamentalist versus moderate). Table 50.1 summarizes essential points to keep in mind when providing care to Hindu and Sikh patients. Extended families are common and provide family members with social support and financial security. Tradition favors frequent visits to an ill person by friends and members of the extended family to offer support. Therefore, the physician may encounter more visitors at the patient’s bedside than he or she is accustomed to. Elderly members of the extended family provide advice, help with childcare, and are accorded respect. The family spokesperson, with whom issues of consent will usually have to be negotiated, is usually the most financially established senior person in the family; however, if there is a language barrier, a younger member of the family may fulfill the communication role for the family.

If the patient and physician do not speak the same language, every effort should be made to find a trained and impartial interpreter who is familiar with the patient’s traditions and culture. It is particularly important in issues of consent to ensure that information given to or received from the patient is not being censored or altered by the interpreter. Because of their deep sense of modesty and of purity, Hindu and Sikh women may not feel comfortable with male physicians or interpreters. Family members such as a teenaged daughter may function well as an interpreter for minor problems; however, an older, trained Hindu or Sikh woman who understands medical terminology and is not a family member will make the best interpreter, especially in urological and gynecological matters. In some circumstances a female relative or the patient’s husband may have to serve as an

interpreter, but, in view of the importance of preserving the confidentiality of the physician–patient relationship, using an interpreter who knows the patient personally is not the preferred approach.

The physician may need to alter his or her usual communication style in caring for Hindu and Sikh patients. By planning for a longer interview and adopting an indirect conversational approach, the physician is likely to learn more. It also helps to be alert to untranslatable Hindi or Punjabi words commonly used to express psychosomatic symptoms; for example, the phrase dil (heart) kirda (fragmenting) dubda (sinking), which an interpreter

or the patient may express in English as ‘‘a sinking heart,’’ implies tremendous anxiety that may result from a headache, nausea, stomach pain (especially epigastric), or generalized malaise. The physician should rule out organic disease before adopting a psychosomatic interpretation. He or she should also be alert for the term nazar (‘‘evil eye’’) accompanied by a black mark behind the ear or a black thread around the wrist to protect the patient against the malevolent wishes of another. In many Hindu and Sikh households, there is an attachment to traditional medicines (e.g., Ayurveda and Siddha), which may be used together with modern medicine

(Azariah et al., 1998). Cultural beliefs about health, disease and treatment often differ significantly from standard Western medical practice, and there are likely to be differing dietary practices as well, ranging from veganism (no meat, fish, eggs, or dairy products) to a rejection of beef but acceptance of chicken or fish.

The cases

Contrary to the physician’s expectation, Mr. and Mrs. E do not wait for the counseling appointment but travel to the USA to have the pregnancy terminated. For Hindus and Sikhs, the single most important ethical consideration surrounding the start of life is their belief in karma: that the fetus is not developing into a person but, rather, is already a person from the moment of conception. Abortion at any stage of fetal development is thus judged to be murder. However, abortion is accepted by Hindus and Sikhs if essential to preserve the life of the mother (Coward 1993). Furthermore, the religious prohibition of abortion is sometimes at odds with the cultural preference for sons. For Mr. and Mrs. E, the desire for a son outweighs the stance of their religion against abortion.

Mr. F affirms his religious belief in the sanctity of life and insists on maximum medical intervention. Baby F’s edema resolves by 50% over the next 24 hours and resolves completely by 72 hours. She requires minimal medical intervention and leaves the hospital at 10 days. Karyotyping results are normal. In this example, it might have been easy to allow the cultural bias against female babies

Hindu and Sikh bioethics 407

to prevail. However, unlike in the first case, the parents’ religious beliefs overruled their cultural biases – and the clinical and ethical judgement of the physician involved.

REFERENCES

Azariah, J., Azariah, H., and Macer, D. R. J. (eds.) (1998).

Bioethics in India. Proceedings of the International Bioethics Workshop in Madras: Biomanagement of Biogeo-resources, Jan 1997, University of Madras. Christchurch, NZ: Eubios Ethics Institute.

Coward, H. G. (1993). World religions and reproductive technologies. In Social Values and Attitudes Surrounding New Reproductive Technologies, Vol. 2. Ottawa: Royal Commission of New Reproductive Technologies, Research Studies, pp. 454–63.

Coward, H. G., Lipner, J. J., and Young, K. K. (1989). Hindu Ethics: Purity, Abortion and Euthanasia. Albany, NY: State University of New York Press.

Coward, H. and Ratanakul, P. (eds.) (1999). Introduction. In A Cross-cultural Dialogue on Health Care Ethics, ed. H. Coward and P. Ratanakul. Waterloo, ON: Wilfrid Laurier University Press, pp. 1–11.

Kakar, S. (1982). Indian medicine and psychiatry: cultural and theoretical perspectives on ayurveda. In Shamans, Mystics and Scholar, Ch. 8. Boston, MA: Beacon Press.

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Madan, T. N. (1985). Concerning the categories of subha and suddha in Hindu culture. In Purity and Auspi-

12–14 and IV:7–9, Vol. 17. Varanasi: Motilal Banarsidass, Harvard Oriental Series.

An 18-year-old Muslim man sustains severe head injures in a traffic accident while riding his motorcycle. He is declared brain dead. The transplant coordinator approaches the grieving mother to obtain consent for organ donation. At first, the patient’s mother is shocked at this approach. She then politely says that she would like to wait for her family to arrive before making a decision.

A 38-year-old Muslim woman is found to have a rapidly growing carcinoma of the breast. She requires surgery and postoperative chemotherapy. She is five weeks into her first pregnancy and is advised to terminate the pregnancy before the chemotherapy.

What is Islamic bioethics?

In Islam, human beings are the crown of creation and are God’s vicegerents on earth. (Qur’an, 2:30) They are endowed with reason, choice, and responsibilities, including stewardship of other creatures, the environment, and their own health. Muslims are expected to be moderate and balanced in all matters (al Khayat, 1995) including health. Illness may be seen as a trial or even as a cleansing ordeal, but it is not viewed as a curse or punishment or an expression of Allah’s (God’s) wrath. Hence, the patient is obliged to seek treatment and to avoid being fatalistic.

Islamic bioethics is intimately linked to the broad ethical teachings of the Qur’an and the

tradition of the Prophet Muhammad, and thus to the interpretation of Islamic law. Bioethical deliberation is inseparable from the religion itself, which emphasizes continuities between body and mind, the material and spiritual realms, and between ethics and jurisprudence (al Faruqi, 1982) The Qur’an and the traditions of the Prophet have laid down detailed and specific ethical guidelines regarding various medical issues. The Qur’an itself has a surprising amount of accurate detail regarding human embryological development, which informs discourse on the ethical and legal status of the embryo and fetus before birth (Bucaille, 1979; Albar, 1996).

Islamic bioethics emphasizes the importance of preventing illness, but when prevention fails, it provides guidance not only to the practicing physician but also to the patient (Ebrahim, 1989). It teaches that the patient must be treated with respect and compassion and that the physical, mental, and spiritual dimensions of the illness experience be taken into account. The Muslim physician understands the duty to strive to heal, acknowledging God as the ultimate healer.

The main principles of the Hippocratic oath are reflected in Islamic bioethics, although the invocation of multiple gods in the original version, and the exclusion of any god in later versions, have led Muslims to adopt the Oath of the Muslim Doctor, which invokes the name of Allah. It appears in the

2003 Islamic Code of Medical Ethics, which deals with issues such as organ transplantation and assisted reproduction. In Islam, life is sacred: every moment of life has great value, even if it is of poor quality. The saving of life is a duty, and the unwarranted taking of life a grave sin. The Qur’an affirms the reverence for human life in reference to a similar commandment given to other monotheistic peoples: ‘‘On that account We decreed for the Children of Israel that whosoever killeth a human being . . . it shall be as if he had killed all humankind, and whosoever saveth the life of one, it shall be as if he saved the life of all humankind’’ (Qur’an, 5:32). This passage legitimizes medical advances in saving human lives (Sachedina, 1995) and justifies the prohibition against both suicide and euthanasia.

The Oath of the Muslim Doctor includes an undertaking ‘‘to protect human life in all stages and under all circumstances, doing [one’s] utmost to rescue it from death, malady, pain and anxiety. To be, all the way, an instrument of God’s mercy, extending . . . medical care to near and far, virtuous and sinner and friend and enemy.’’

Islamic bioethics is an extension of Shariah (Islamic law), which is itself based on two foundations: the Qur’an (the holy book of all Muslims, whose basic impulse is to release the greatest amount possible of the creative moral impulse [Rahman, 1979] and is itself ‘‘a healing and a mercy to those who believe’’ [Qur’an, 41:44]); and the Sunna (the aspects of Islamic law based on the Prophet Muhammad’s words or acts). Development of Shariah in the Sunni branch of Islam over the ages has also required ijmaa (consensus) and qiyas (analogy), resulting in four major Sunni schools of jurisprudence. Where appropriate, consideration is also given to maslaha (public interest) and urf (local customary precedent) (Kamali, 1991). The Shia branch of Islam has in some cases developed its own interpretations, methodology, and authority systems, but on the whole its bioethical rulings do not differ fundamentally from the Sunni positions. In the absence of an organized ‘‘church’’ and ordained ‘‘clergy’’ in Islam, the

determination of valid religious practice, and hence the resolution of bioethical issues, is left to qualified scholars of religious law, who are called upon to provide rulings on whether a proposed action is forbidden, discouraged, neutral, recommended, or obligatory.

Islamic scholars have been writing about bioethical issues for a very long time. For example, the four bioethics principles of beneficience, nonmalevolence, autonomy, and justice popularized by Beauchamp and Childress (2001) were discussed by Muslim scholars as early as the thirteenth century (Aksoy and Tenik, 2002; Aksoy and Elmai, 2002; Ajlouni, 2003).

To respond to new medical technology, Islamic jurists, informed by technical experts, have regular conferences at which emerging issues are explored and consensus is sought. Over the past few years, these conferences have dealt with such issues as organ transplantation, brain death, assisted conception, technology in the intensive care unit, and even futuristic issues such as testicular and ovarian grafts. The broader Islamic bioethics discourse has included work on human embryonic stem cell research (Serour and Dickens, 2001; Walters, 2004; Aksoy, 2005), organ transplantation (Daar, 2000; Goolam, 2002; Khalil, 2002; Shaheen et al., 2004; Todorova and Kolev, 2004; Golmakani et al., 2005), triage (Elcioglu and Unluoglu, 2004), informed consent (Moazam, 2001; Rashad et al., 2004), end of life decision making (Hedayat and Pirzadeh, 2001; Clarfield et al., 2003; Lundqvist et al., 2003; Rodrı´guez Del Pozo and Fins, 2005), abortion (Daar and al Khitamy, 2001; Moosa, 2002; Al-Kassimi, 2003; Mohammed, 2003; Asman, 2004; Wong et al., 2004; Schenker, 2005), assisted reproduction and genetic testing (El Dawla, 2000; Schenker, 2000, 2002, 2005; Fadel, 2001, 2002; Serour and Dickens, 2001; Albar, 2002; Arbach, 2002; Tsianakas and Liamputtong, 2002; Ahmed, 2003; Raz and Atar, 2003; Raz, et al., 2003; Sher et al., 2004), nursing (Rassool, 2000; Lundqvist et al., 2003; Ott et al., 2003; Rashad et al., 2004), and pharmacy (Chipman, 2002). Many medical schools in countries with Muslim majorities have bioethics curricula. There

are established mechanisms for addressing emerging biomedical and bioethics issues, and curricula are updated accordingly.

The Islamic Organization for Medical Sciences, (www.islamset.com) also holds conferences and publishes the Bulletin of Islamic Medicine. Most Islamic communities, however, would defer to the opinion of their own recognized religious scholars.

Islam is not monolithic, and a diversity of views in bioethical matters does exist. This diversity derives from the various schools of jurisprudence, the different sects within Islam, differences in cultural background, and different levels of religious observance.

There is little that is strange or foreign in Islamic bioethics for Western physicians, who are often surprised at the similarities of approach to major bioethical issues in the three monotheistic religions, particularly between Islam and Judaism (Daar, 1994, 1997).

If secular Western bioethics can be described as rights based, with a strong emphasis on individual rights, Islamic bioethics is based on duties and obligations (e.g., to preserve life, seek treatment), although rights (Shad, 1981) (of God, the community, and the individual) do feature in bioethics, as does a call to virtue (Ihsan).

Why is Islamic bioethics important?

The number of Muslims worldwide is estimated to be over 1.2 billion and their numbers are projected to increase. Even in Western countries, the number of Muslims is increasing; for example in Canada the number of Muslims had reached 550 000 by 1999 (Hamdani, 1999).

Many Muslims incorporate their religion into almost every aspect of their lives. They invoke the name of God in daily conversation and live a closely examined life in relation to what is right or wrong behavior, drawing often from the Qur’an, the traditions of the Prophet, and subsequent determinations by Muslim jurists and scholars, believing that

their actions are very much accountable (Qur’an, 52:21, 4:85) and subject to ultimate judgement.

Although individuals are given certain concessions on assuming the status of a patient, some try to live their lives in a Muslim way as patients, even when admitted to hospital. Greater understanding of Islamic bioethics would enhance the medical care of Muslims living in Western societies.

How should I approach Islamic bioethics in practice?

In the West, information about Islamic bioethics can be obtained most easily on the Internet (see related websites below). Another source is Muslim patients themselves. However, many Muslim patients may not be aware of contemporary discourse on bioethical issues. If the community has religious leaders or its own social workers, these can be useful sources. Hospitals should keep their contact numbers close at hand, especially in emergency departments.

There are varying degrees of observance of traditional Muslim beliefs and practices. Physicians need to be sensitive to this diversity and avoid a stereotyped approach to all Muslim patients.

At the practical level, physicians who are aware of Islamic bioethics will understand that the provision of simple measures can make big differences for their Muslim patients. In addition to understanding the religion and culture, there are a few practical considerations that may apply, particularly for the more devout Muslim (Table 5.1).

The cases

The first case raises the issue of organ transplantation. Organ transplantation is practiced in most countries with Muslim majorities. This generally involves kidney donations from living relatives, but cadaveric donation is increasing (Daar, 1997, 2000; Goolam, 2002; Khalil, 2002; Shaheen et al., 2004; Todorova and Kolev, 2004; Golmakani et al., 2005).

Many Muslim scholars have permitted cadaveric organ donation (Albar, 1995a; Yaseen, 1995; Daar, 1997, 2000; Daar et al., 1997; Habgood et al., 1997; Goolam, 2002; Khalil, 2002; Shaheen et al., 2004; Todorova and Kolev, 2004; Golmakani et al., 2005). The Qur’anic affirmation of bodily resurrection has determined many religious and moral decisions regarding cadavers (Sachedina, 1995). Mutilation,

and thus cremation, is strictly prohibited in Islam. However, carrying out autopsies, although currently uncommon in Muslim countries, is permitted under certain circumstances, for example when there is suspicion of foul play (Sachedina, 1995).

Death is considered to have occurred when the soul has left the body, but this exact moment cannot be known with certainty. Death is, therefore,

diagnosed by its physical signs. The concept of brain death was accepted by a majority of scholars and jurists at the Third International Conference of Islamic Jurists in 1986 (Albar, 1995a; Moosa, 1999). Most, but not all, countries with Muslim majorities now accept brain death criteria. In Saudi Arabia, for example, about half of all kidneys for transplantation are derived from cadavers, with application of brain death criteria (Shaheen and Ramprasad, 1996).

The mother of the recently deceased boy in the intensive care unit was initially shocked because she did not expect an approach so soon after her son’s death. The coordinator, however, has been specifically trained and is very experienced and culturally sensitive. She allows the mother time to reflect and wait for her family to arrive. The mother’s faith has taught her that God decides when a life is to end, and although she is grieving she knows that nothing could have saved her son when the moment of death arrived. A friend of the family, a professor of Islamic studies at a local university, arrives and confirms that it is acceptable in Islam to donate organs under such circumstances. The family jointly agrees to the donation. The surgical team is made aware of the Muslim requirement to bury the body on the same day and arranges for the organs to be removed that afternoon.

The second case raises issues of the commencement of life. The general Islamic view is that, although there is some form of life after conception, full human life, with its attendant rights, begins only after the ensoulment of the fetus. On the basis of interpretations of passages in the Qur’an and of sayings of the Prophet, some Muslim scholars agree that ensoulment occurs at about 120 days after conception (Albar, 1995b, 1996), while other scholars hold that it occurs at about 40 days after conception (Albar, 1995b).

Islamic law scholars do have some differing opinions about abortion. Abortion has been allowed after implantation and before ensoulment in cases in which there were adequate juridical or

medical reasons. Accepted reasons have included rape. However, many Shias and some Sunnis have generally not permitted abortion at any stage after implantation, even before ensoulment, unless the mother’s life is in danger. Abortion after ensoulment is strictly forbidden by all Islamic authorities, but the vast majority do make an exception to preserve the mother’s life. If a choice has to be made to save either the fetus or the mother, then the mother’s life would take precedence. She is seen as the root, the fetus as an offshoot.

In the case presented here, the chemotherapy is necessary for the mother’s health, although it might cause a miscarriage or severe developmental abnormalities in the fetus. The pregnancy itself may worsen her prognosis. These are medical indications for termination. Although not generally accepted, some modern Islamic opinions (Ghanem, 1984) and rulings (Muslim World League Conference of Jurists, 1990) have also accepted prenatal diagnosis and accept severe congenital anomalies and malformations per se as a reason for termination before ensoulment.

Two physicians certify that the chemotherapy and abortion are necessary, and the pregnancy is terminated with the consent of the patient and her husband. The couple says that they would dearly love to have a child in the future and inform the physician that Islam permits in vitro fertilization (Serour, 1992; Albar, 1995c; Fadel, 2001, 2002; Serour and Dickens, 2001; Al-Qasem, 2003). They ask if it is possible before chemotherapy to retrieve and freeze her ova, to be fertilized later. This would be permissible provided the sperm, with certainty, came from her husband, and that at the time of fertilization they are still married and the husband is alive. The option of surrogacy is broached by the physicians as an alternative. On checking with their local religious scholar, the couple is informed that, under Islamic law, the birth mother, not the ovum donor, would be the legal mother (Ebrahim, 1989; Al-Qasem, 2003). The couple decides not to pursue surrogacy.

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