In the name of Allāh, Most Gracious, Most Merciful

Seeking, Withholding and Withdrawing Treatment

بِسۡمِ اللهِ الرَّحۡمٰنِ الرَّحِيۡمِ

SEEKING, WITHHOLDING AND WITHDRAWING TREATMENT

This is very brief overview and summary of the Islāmic perspective on seeking, withholding and withdrawing treatment.

 

1. General beliefs and principles

1.1  A fundamental belief of a Muslim is pre-destination (al-Qadr). So the life of each individual on this Earth is predetermined and finite to the last breath. How, when and where each and every individual will die has already been decreed by the one and only Almighty God (to whom Muslims refer to as Allāh  ).

1.2  The objective of a Muslim is to live his/ her life on this Earth as ordained by the Almighty God. Living one’s life according to the Law of the Almighty attains reward from the Almighty and doing something outside the Law of the Almighty is sinful with potential punishment.

1.3  A Muslim believes that successful treatment and cure of any and all diseases ultimately lies in the hands of the Almighty God.

1.4  It is a duty of a Muslim to look after his body and health.

1.5  It is obligatory to try to preserve life.

1.6  The rights of an individual have to be balanced against the rights of a community/ State.

1.7  The local customary practices should be taken in to consideration. Physicians must practice medicine according to best practice according to their locality and within the Law of the land.

In reaching a ruling regarding seeking, withholding and withdrawing treatment Muslim jurists take in to account the objectives of Islāmic law, making use of legal maxims in Islam and the probability of benefit/ cure of a treatment.

 

The five categories of Islamic rulings are:

 

 

2. Seeking Treatment

Seeking/ providing treatment can be based on the above five categories of Islamic rulings depending on the probability of cure/ beneficial outcome of a particular treatment. Muslims jurists have traditionally divided these possible outcomes in to 3 categories (as below in blue). The possible outcomes can be summarized thus:

 

2.1  Duty: Life-saving treatment or treatment for an infectious disease, if one is in a position to undertake such treatment, then it is a duty (wājib) to do so, otherwise one is sinful. Fluids and nutrition are considered as treatment.

2.2  Permissible or commendable: Non-life saving treatment. However, one may decide to abstain from such a treatment putting one’s trust in the Almighty.

2.3  Reprehensible: Treatment in futile cases may be reprehensible.

2.4  Harām: Treatment is harmful without any benefit, any treatment which contains forbidden (ḥarām) ingredients such as pork, blood or alcohol, and any treatment involving sorcery, divination or talismans.

2.5  Treatment which contains forbidden (ḥarām) ingredients is permissible if there is a very high degree of certainty that it will be beneficial and there is no legally permissible (halāl) alternative.

 

Key questions to consider:

Q2.1. What is the intention of the person wanting to take the treatment?

Q2.2. Is the treatment in itself forbidden (ḥarām). If so, is there an alternative?

Q2.3. Is the treatment life-saving?

Q2.4. What is the probability that the treatment will be of benefit?

 

 

3. Withholding or Withdrawing treatment

Muslims believe that it is the soul (rūh) that gives the body life; death occurs when the soul (rūh) leaves the body, in a particular manner. Death in Islām is not the end of existence but merely a transition from one type of existence to another.

The treating doctors should take into account the patient’s religious beliefs and cultural background. A lack of understandings on such issues can often lead to avoidable confusion and conflict. 

3.1  Human life is sacred. A doctor should not actively participate in terminating the life of a patient under any circumstances (assisted suicide/ mercy killing).

3.2  Treatment of patients whose situation has been confirmed to be futile by the medical experts or medical committee should not be commenced. It is important to realise that withholding medical treatment is not physician-assisted suicide nor euthanasia. 

3.3  It is mandatory to administer vital food and fluids as long as the patient is alive unless a stage is reached whereby such measures would cause harm. 

3.4  If treatment as a rule leads to a cure and non-treatment leads to significant harm or certain death then treatment is mandatory and life-support cannot be withdrawn. 

3.5  If treatment is expected to lead to a cure or cure is probable then treatment should be attempted. If however, the physician and relatives of the patient, after mutual and informed decision-making, conclude that treatment is not in the best interest of the patient, then such treatment/ life support can be withdrawn. 

3.6  If cure is not a realistic expectation then, although it is permissible to attempt treatment, it is better for the patient to place his trust in the Almighty God. 

3.7  A life-sustaining treatment such as mechanical ventilation is not a cure in itself. Such a treatment has an objective when it is started, when it becomes apparent that the objective cannot be reached then withdrawal of such a life sustaining treatment has to be considered.

3.8  Islāmic law permits withdrawal of futile and disproportionate treatment on the basis of the consent of the immediate family members who act on the professional advice of the physician in charge of the case.

3.9  The treatment of a patient can be terminated if a team of medical experts or a medical committee involved in the management of such patient are satisfied that the continuation of treatment would be futile or useless. (Article 62, Islāmic code of medical ethics).

3.10  The Presidency of the Administration of Islāmic Research and Ifta (Riyadh) issued fatawa no. 12086 on 28/03/1409 AH (1989 CE) stating, “if three knowledgeable and trustworthy physicians agreed that the patient’s condition is hopeless; the life-supporting machines can be withheld or withdrawn. The family members’ opinion is not included in decision making as they are not qualified to make such decisions.” 

3.11  Medication which is required to alleviate severe pain is permissible even if it is known that the medication may end the patient’s life.

 

Key questions to consider

Q3.1. What is/ was the intention or the underlying reason for withholding/ commencing/ withdrawing treatment?

Q3.2. What is the most likely outcome with the treatment according to the medical experts?

Q3.3. What is the most likely outcome without the treatment according to the medical experts?

Q3.4. What is the burden and harm to the patient caused by the treatment?

Q3.5. What is the burden on the relatives/ public?

Q3.6. What is the local customary practice in such cases?

Q3.7. What are the wishes of the patient and close relatives? 

 

The Islamic guidelines on withdrawal of treatment appear to be relatively straight foward based on a simple model of 3 levels of probability of successful treatment. However, in clinical practice things are rarely that striaght forward, in the vast majority of cases it is very complicated, with no clear cut answers. Under such circumstances one has to rely on the advice of the medical experts looking after the patient and in-line with local laws. It would prudent for individual Muslim jurists not to issue fatawa (legal opinion) in complex medico-legal cases without appropriate deliberation  with medical experts. It should be a multi-disciplinary approach in such cases.

 

 


 

 

 

It is important to realize that withdrawing or withholding medical treatment is not physician-assisted suicide or euthanasia. By withholding or withdrawing treatment the patients dies because of the underlying disease, not because of any intervention by the doctors. 

In end of life issues it is important for the treating doctors to take in to account the patient’s religious beliefs and cultural background. A lack of understandings on such issues can often lead to avoidable confusion and conflict. 

Muslims believe that life itself is a divine trust and its term is fixed, life can neither be prolonged nor shortened by any human intervention, it is predetermined.  

Regarding withholding and withdrawal of treatment the following principles are to be followed: 

  • It is mandatory to administer vital food and fluids as long as the patient is alive unless a stage is reached whereby such measures would cause harm. 
  • If treatment as a rule leads to a cure and non-treatment leads to significant harm or certain death then treatment is mandatory and life support cannot be withdrawn. 
  • If treatment is expected to lead to a cure or cure is probable then treatment should be attempted. If however, the physician and relatives of the patient after mutual and informed decision-making conclude that treatment is not in the best interest of the patient, then such treatment/ life support can be withdrawn. 
  • If cure is not a realistic expectation then although it is permissible to attempt treatment it is better for the patient to rely on the Will of the Almighty. 
  • If life-sustaining treatment is considered to be futile in the judgment of the medical experts then maintaing life support is unnecessary and a waste of resources. 
  • A decision to withhold or withdraw treatment should be made in consultation with the patient’s family and other members of the health care team.  

The Presidency of the Administration of Islāmic Research and Ifta (Riyadh) issued fatawa no. 12086 on 30/06/1409 AH (1988 CE) stating, “if three knowledgeable and trustworthy physicians agreed that the patient’s condition is hopeless; the life-supporting machines can be withheld or withdrawn. The family members’ opinion is not included in decision making as they are not qualified to make such decisions.”