IV. CONTEMPORARY ARAB WORLD

The Arab world comprises the twenty-one Arabic-speaking countries extending from the south of Iran westward to the coast of the Atlantic. Not all the people in these nations are descendants of the Semitic Arabs of the Arabian Peninsula, but the spread of Islam outward from Arabia in the seventh century led to widespread adoption of Arabic, the language of the Qur'an, Islam's scripture. Islam is the religion of 95 percent of the inhabitants of the Arab world. Of the world's nearly one billion Muslims, some 20 percent are Arab. Classical Arabic has been preserved through the constant standard in the Qur'an (the Islamic scripture that Muslims believe is God's very words received verbatim by Muhammad); colloquial dialects are used regionally but are easily understood by all.

Despite religion and language, the Arab world is not politically, socially, or economically homogeneous. Some countries are ruled by hereditary monarchies; others, by revolutionary military or quasi-military governments. Democracy is, on the whole, lacking, although it is the aspiration of the masses. Some countries are affluent (usually due to oil wealth), while others are poor; some are overpopulated and others sparsely populated. Currently the Arab world is categorized as belonging to the Third World. The average birth rate is 38.3 per 1,000, and the average infant mortality rate (first year of life) is about 68.2 per 1,000 (United Nations).

A characteristic of the region is the religious orientation of its people and the influence of religion on their lives. Islam recognizes both Judaism and Christianity as religions that come from God; all three religions hold generally the same prevailing moral values and thus have a unified ethical base. Society (of all religious backgrounds) tends to be conservative, sanctifying family integrity and family ties, upholding moralities prescribed by religion(s), averse to unchecked liberalism, and falling back on religion to categorize social trends and new lifestyles as acceptable or unacceptable.

Islam has a comprehensive framework of a legal system based on the Qur'an and tradition, covering all aspects of life, that serves as the source of legislation and the derivation of ethical rulings. And yet the great majority of the Arab world is not ruled by Islamic law, most of the governments being practically secular. One area has uniquely remained under the jurisdiction of Islamic law: that of family law. It is in this area that the bulk of medical ethics resides. Although many non-Muslims are physicians and patients in Arab countries, there is little dispute about medical ethics among them, since many common positions are shared by Islam, Christianity, and Judaism.

The medical profession is highly esteemed in the Arab world, and the physician is still called "the wise man," a centuries-old nomenclature. The physician is very highly regarded, and the doctor–patient relationship, based on trust and confidence, tends to be paternalistic.

Seeking medical help when one is sick is a religious duty. Muhammad said, "Your body has a right over you," and "Seek treatment, for God has created a cure for every illness; some already known and others yet to be known." The establishment of the medical profession is a religious duty of the community, which should designate some of its members to study medicine and should provide for the needs and requirements of medical education. A doctor should be appropriately qualified, for Muhammad said, "Whoever practices medicine without the appropriate knowledge is liable to pay compensation [if harm comes to the patient]."

It is not uncommon for medical practitioners who enjoy the confidence of their community to be consulted on nonmedical problems faced by families or individuals. People tend to accept that therapeutic ability is not absolute, and as long as the doctor has done his (or her) best, there is a willingness to accept and even forgive undesired outcomes. Insurance against professional liability is nonexistent, and the judicial system heeds this fact; unless it is a clear case of neglect or inexcusable ignorance, the physician is rarely held responsible for damages.

Medical education has deep historical roots in the major capitals (Baghdad, Cairo, and Damascus) since the era of Islamic civilization (eighth to sixteenth centuries). Modern schools have emerged since the nineteenth century, and many are as recent as the oil boom late in the twentieth century. With one or two exceptions, all Arab countries have one or more medical schools, Egypt, as many as thirteen.

English is the common language of education, with French or Arabic used in exceptional cases. Conversion to Arabic is under debate. Medical education and practice are open to both sexes and all religions without discrimination. Coeducation is the rule except in a few schools. There is no ban on examining the opposite sex. Dissection of the human body and postmortem examination are permitted; some schools, however, have to import cadavers from abroad to satisfy the need for teaching anatomy.

Medical Ethics

The Arab world has known medical ethics since the writings of Imhotep of Egypt (3000 b.c.e.) and the Code of Hammurabi of Babylon (about the same time). The Oath of Hippocrates (ca. 460–355 b.c.e.) later took over, and since the ninth century various Islamic adaptions of it, as well as treatises and books on medical ethics, have been contributed by Al-Rahawi, Ibn Rabban, Avicenna (Ibn Sīnā), and many others.

In modern times, medical ethics has been taught as part of the curriculum of various disciplines, but since the 1940s it has become a separate course in the majority of medical schools, whether as a part of forensic medicine, community medicine, history of medicine, or on its own.

Although Islam is the principal source of medical ethics, the increasing complexity of biomedical discoveries and technological achievements during the latter half of the twentieth century have made it difficult for religious scholars to comprehend the issues and formulate rules on ethical acceptability from an Islamic point of view. There has been need for a forum in which religious scholars join with biomedical scientists and specialists in relevant disciplines such as law and sociology, policymakers, economists, and civic leaders of both sexes, to discuss specific issues in order to develop an Islamic consensus. To continue this collaboration, institutions have come into being since the early 1980s: the Islamic Organization of Medical Sciences (IOMS, Kuwait), the Islamic Research Congress (Egypt), and the Fiqh Congress of Makka (Saudi Arabia). The rulings of these government-approved agencies have a high moral weight and almost fill the legal gap that results because legislation usually lags behind new developments. These agencies have significantly contributed to Islamic medical ethics, addressing a number of issues that will be surveyed briefly.

An important milestone was the formulation of the Islamic Code of Medical Ethics (IOMS, 1981), ratified by the First International Conference on Islamic Medicine (held in Kuwait, January 1981) and endorsed by many Arab and Islamic countries. This code comprises eleven chapters: Definition of Medical Profession; Characteristics of the Medical Practitioner; Relations Between Doctor and Doctor; Relations Between Doctor and Patient; Professional Confidentiality; Doctor's Duty in Wartime; Responsibility and Liability; Sanctity of Human Life; Doctor and Society; Doctor and Biotechnological Advances; and Medical Education. All topics were authenticated by sources in the Qur'an and Islamic law. The code also includes the latest version of the Islamic Medical Oath, which reads (roughly translated):

I swear by God: To regard God in practicing my profession; To respect human life in all stages, under all circumstances, and to do my best to rescue it from death, malady, pain and anxiety; To uphold people's dignity, cover their privacy, and keep their secrets; To be an instrument of God's mercy to near and far, virtuous and sinner, and friend and enemy; To pursue knowledge and to harness it for the benefit, not the harm, of human-kind; to revere my teachers, teach my juniors, and cherish the fraternity with my colleagues; and to live my faith in private and in public … and God is my witness to this oath.

Derivation of Islamic Medical Ethics

The totality of Islamic law, called the Shari'a, is drawn from the Qur'an, the verbal teachings of Muhammad, followed by analogy and consensus. The Shari'a is expressed in a code of moral behavior that states what is sinful and what is not, as well as a body of laws that states what is legal and what is not. These two systems need not coincide. (An example is a person who commits adultery in the privacy of a closed room. Such a person has committed a sin but not a legal crime, since Islamic law requires four witnesses in order to establish the legal charge of adultery. The fate of such a sinner is left entirely to God, who will punish or forgive upon the perpetrator's repentance and appeal for mercy.) When ruling on the admissibility (or inadmissibility) of an issue, jurists take into consideration a number of rules such as "Necessities overrule prohibitions," "Choose the lesser of two evils if both cannot be avoided," "Public interest outweighs individual interest," and, especially in matters not specified in the primary sources of Shari'a, "Wherever welfare goes, there goes the statute of God." Examples of applying some of these will follow later.

Sanctity of Human Life

Human life should never be violated except in situations explicitly specified in the penal code and observing the rigorous criteria it establishes. Commenting on the killing of Abel by his brother Cain (the two sons of Adam), the Qur'an states: "On that account We ordained for the Children of Israel that if anyone killed a soul, unless it be for murder or mischief in the land, it would be as if he killed the whole people. And if anyone saved a life, it would be as if he saved the life of the whole people" (5:32). This principle has been invoked when ruling on abortion and euthanasia.

Abortion

In general terms abortion is legally prohibited and punishable. However, some physicians perform abortions illicitly, mainly in the private sector. In some countries, if abortion is done to avoid tarnishing the family name (pregnancy of the unmarried is a great shame in the Arab world), this circumstance is considered a mitigating factor if the case ever goes to court. Tunisia has gone a step further and legalized abortion after the third child, thus allowing it to be considered a form of family planning.

Among the religious community, various views on abortion have been held over the centuries. The writings of early scholars differed according to their perception of the beginning of life, and their views continued to be followed by generations of their adherents. On the belief that life started when the mother felt the movements of the fetus inside her (quickening, usually at the end of four months), some thought that abortion before then entailed no aggression on life. Others maintained that the fetus attained its human form at the end of the seventh week, and aborting it at or beyond this date would be unlawful. The majority, however, espoused the views of the great jurist Al-Ghazālī (eleventh century c.e.), who believed that life started with the fusion of the male and female seeds, and that it proceeded through an occult phase to the palpable phase felt by the mother. This view of the beginning of life therefore outlaws abortion and makes it reprehensible at any stage of pregnancy.

Modern juridical opinion has put an end to the historical diversity of opinion and settled for Al-Ghazālī's, following a number of conferences in the 1970s and 1980s (see, e.g., Gindi, 1989b) at which religious scholars met with medical scholars and a full account of the process of conception and early development was illustrated by ultrasound and cinematographic recordings of the fetus in utero. Five criteria were collectively acknowledged as signifying the beginning of life: (1) it is a fairly clearly defined event; (2) it exhibits the phenomenon of growth; (3) such growth, unless interrupted, leads to the known subsequent stages of life; (4) it contains the genetic package characteristic both of humanity and of a unique individual; and (5) it is not preceded by any stage combining the first four criteria (Gindi, 1989a).

Abortion is permitted if the continuation of pregnancy poses a serious threat to the life of a sick mother (the choice of the lesser of the two evils if both cannot be avoided). In Shari'a the mother is the root and the fetus the offshoot, and it is lawful to sacrifice the latter if it is the only way to save the former.

Selective abortion for the sake of sex selection is doubly unlawful, being an aggression on life as well as discrimination against the female (almost invariably the unwanted sex). The Qur'an severely rebuked pre-Islamic Arabs (up to seventh century c.e.) for practicing female infanticide (16:59). Sex selection by means not entailing embryocide, to suit the wishes of individual families, has been debated. There is consensus that its admissibility would eventually lead to an upset of the sex ratio in favor of male preponderance, which could lead to grave social consequences.

Euthanasia, Suffering, and Care of the Elderly

Euthanasia and suicide are completely unacceptable in Islam. There are no euthanasia proponents, and therefore there is no debate. Suicide and complicity thereto are legal crimes, but the problem is of minute dimensions. The Prophet Muhammad told about a man who took his own life due to an illness that taxed his endurance, upon which God said, "My subject has himself forestalled Me; I have forbidden him Paradise" (narrated by Al-Bukhari). Resort to medical or surgical means for alleviation of pain is lawful, but the taking of life is a matter of God's sovereignty.

Patience in the face of unavoidable pain or adversity is an important value, and the Prophet teaches that through such patience a person's sins are washed away by God, like a tree shedding its leaves. The right to die is therefore not recognized because humans do not own life; they are only entrusted with it. The same applies to the "duty to die," recently proposed for human beings who, through age or infirmity, become consumers but not producers. Caring for a growing group of old and disabled can be very costly, as modern budget figures show, but under Islamic law society has to meet this need by rearranging expenditure priorities rather than allowing euthanasia. Care of the old is a principal value in Islam, especially with regard to one's parents: "Your Lord has decreed that you worship none but Him and that you be kind to your parents.… Whether one or both of them attain old age in your life, say not to them a word of contempt nor repel them, and lower to them the wing of humility out of compassion, and say: 'My Lord, bestow on them your mercy even as they cherished me in childhood'" (Qur'an 17:23, 24).

However, it is generally agreed that in his or her defense of life, the doctor is well advised to realize the limitation of medical efforts. It is the process of life that the doctor aims to maintain, not the process of dying. When treatment holds no promise, it ceases to be mandatory and withholding or discontinuing the artificial means is justified. No active intervention, however, shall be made to terminate life.

Death

Under ordinary circumstances the time-honored recognition of death based on cessation of heartbeat and respiration is workable, followed by a waiting period of two hours before the death certificate is issued. Nevertheless, advances in transplant surgery and the occasional need for a fresh heart for transplantation have called for a more sophisticated definition of death. Such a heart can usually be procured from a trauma victim whose brain—including brain stem—is dead and who therefore has been pronounced dead although artificial means are employed to maintain the functions of respiration and circulation.

The issue was discussed in a number of conferences bringing together high-ranking religious scholars and medical scientists (see, e.g., Gindi, 1989a). An old juridical rule, "The movement of the slain," was reviewed. Centuries ago it was ruled that if an aggressor stabbed a victim in the abdomen and the bowel extruded, this was considered a fatal injury; although the victim could still move, his or her prospects for life were practically nil. "The movement of the slain" was the descriptive term given to the death throes. If a second aggressor finished the victim off, the first aggressor would still be charged with murder for having dealt the fatal injury; and the second aggressor would be punished, but not for murder. Realizing that abdominal trauma with extrusion of the bowel is no longer considered a fatal injury by contemporary surgical standards, the scholars removed it from the category of "the movement of the slain." In its stead, the condition of brain death including the brain stem fulfills the description, since the victim has practically departed from life without the prospect of return and, in spite of the signs of life (circulation, respiration, etc.), is subject to the rulings governing the dead, including taking the heart for transplantation into a needy recipient, without the death of the patient being legally or morally attributed to the surgery. The disconnection of artificial life-support apparatus from such patients would be permissible.

Transplant Surgery

Transplant surgery is practiced in many Arab countries, and some have excellent units. The Qur'anic saying "And whoever saves a life, it is as though he has saved all the people" (5:32) is the basis of considering organ donation as an act of charity. It is a religious duty of the community to provide necessary donors, in analogy with the decree of Umar (the second caliph) that if a person dies due to lack of sustenance, the society should pay legal reparations as if they killed him. The human body is honored whether living or dead, but its surgical violation to procure a needed organ is ruled permissible by invoking the juridical rule of "choosing the lesser of the two evils," for the alternative would be the death of the prospective recipient. Bodily organs should not be offered for sale, but if purchase is the only source, then buying is permissible under the rule "Necessities overrule prohibitions." In reality, however, apart from close relatives, most donors receive a price under the pressure of poverty. The need is felt for a governing authority to regulate the process, lest an exploitative market be created and patients with limited means be excluded. Donation should be purely and truly voluntary through consent of the living donor, bequeathed in a will or with the consent of the next of kin.

Transplantation of fetal suprarenal medulla to the brain to ameliorate certain diseases is lawful, although abortion performed specifically to obtain that tissue remains unlawful. The anencephalic fetus may be used as a donor, and its maintenance by artificial means for that purpose is acceptable, but removal of organs is permitted only after its natural death, without artificially terminating its life. Transplantation of sex glands to provide sex cells (ova or sperm) is unlawful because the prospective fetus would have been formed by elements not bound by a marriage contract. Sterile sex glands providing only hormones are devoid of that objection, but obviously their use is not medically feasible (Gindi, 1989c).

Hygiene and Preventive Healthcare

"Cleanliness is part of the faith," Muhammad said. Ritual ablutions are necessary before prayers several times daily, including a full bath (tuhr) after sexual intercourse, menstruation, and the puerperium. Muhammad forbade overindulgence in food and drink, and enjoined physical fitness. Circumcision of male children is required by Islam. Female circumcision, not an Islamic commandment, has been practiced in Sudan and Egypt since pre-Islamic times, and is now waning.

Preventive healthcare is well heeded. One of Muhammad's pertinent teachings is "If there is pestilence in a locality, do not enter it, and if you are already in it, do not go out." Alcohol is categorically forbidden by Islam (as are stupefying drugs, in order to protect mind and health). Nevertheless, the law in many Arab countries allows the sale and consumption of alcoholic beverages. Currently, there is widespread objection to the practice, and steps have even been taken to avoid alcohol in medicinal preparations. Extramarital sex is forbidden in Islam, although it certainly takes place in a clandestine manner. The virginity rate of girls at the time of marriage approaches 100 percent. The sexual revolution and its sequelae in the West since 1960 have not erupted in the Arab world, although the powerful influence of communications markets the Western model and at the same time evokes a strong reaction expressed in a revival of religious values.

Care of the environment is emphasized in Muhammad's teachings, but unfortunately poverty, overcrowding, and unbridled movement from rural to urban regions with limited and failing infrastructure have led to a gap between the real and the ideal in many Arab cities. Muhammad taught, "Faith has many branches, including the removal of dirt from the street," and "Beware of the triple curse of polluting water resources, shady spots, and trodden roads." On water conservation he instructed those expending much water while making the ritual ablution: "Economize, even if you are at a flowing river." Encouraging agriculture, he said, "Whoever farms land will be rewarded by God every time a person eats from its crop, even if a thief steals and eats from it." Another of his recommendations is "If the end of the world comes and you have a little shoot in your hand to plant, then plant it if you can."

Kindness to animals is a religious dictate. They should not be overburdened or worked to exhaustion or tortured, and they should not be killed except for food. Muhammad spoke of God's pleasure with a man who, encountering a thirsty dog unable to reach water in a well, filled his shoe with water and offered it to the dog, and—conversely—God's anger with a woman who imprisoned a cat. These concepts were borne in mind when discussing the ethics of animal experimentation. Although it is approved when necessary for medical research, due care and humaneness should be shown in keeping and handling the animals.

Contraception

Contraception is lawful provided both husband and wife agree. Contraceptive measures are easily available and in some countries are subsidized by the state to curb overpopulation. Family planning should not be directly or indirectly imposed; the method should not be harmful; it should not entail abortion. Governmental and voluntary agencies use propaganda and education to promote family limitation in overpopulated countries, whereas incentives for a larger family are given in the underpopulated, affluent countries. However, family limitation policies are often attacked by some religious elements for a variety of reasons (Hathout, 1989), including the accusation that they are "imperialistic" designs against poor countries (see Information Project for Africa). The use of the intrauterine contraceptive device has been controversial for fear that it acts by inducing abortion, but its use is widespread. The 1987 World Health Organization (WHO) announcement that its mechanism of action was contraceptive and not abortifacient was welcomed by religious authorities.

Breast-feeding is highly recommended in the Islamic tradition; the Qur'an says: "The mothers shall give suck to their offspring for two whole years, for those who desire to complete the term of lactation" (2:233). This would have been a potent measure for wider spacing of pregnancies at the level of the society at large, being associated with a high rate of ovulation suppression (of course it would not be a reliable prescription for contraception for the individual family). Unfortunately, the growing number of women joining the labor force does not work in its favor. Surgical sterilization (both male and female) is frowned upon except for pressing medical indications or at an advanced age (nearing menopause) for the highly parous woman.

Reproductive Interventions

The quest for fertility is legitimate, and treatment of infertility by medical or surgical means is lawful and available within the Shari'a. Artificial insemination is permitted only if the husband's semen is used; donor semen is forbidden (by religion and by law) because it is outside the marriage contract. Since legitimate marriage is the only approved venue for reproduction, in vitro fertilization technology is permitted only if it involves a married couple and is carried out during the span of their marriage. No alien "element" should be involved, be it donated sperm, donated ovum, donated embryo, or surrogate uterus. When the wife is widowed or divorced, she is no longer the wife of her husband, and she can no longer be impregnated by his semen that had been preserved in a semen bank, for the marriage contract has come to a conclusion. Surrogacy is outlawed, and contracts for surrogate pregnancy are null and void.

Alternative family structures, not based on legitimate marriage, have no place in Arab societies.

hassan hathout (1995)

BIBLIOGRAPHY

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