Medical Assistance in Dying: Challenges for Muslim Healthcare Professionals

Abstract

There appears to be a great deal of discussion among non-Muslim healthcare professionals, especially nurses and physicians, about medical assistance in dying. However, the discussion of medical assistance in dying among Muslim health caregivers including physicians, social workers, spiritual caregivers, etc. remains insufficient. A thorough analysis of the content of available resources revealed that we need more literature to analyze the attitude of Muslim health caregivers towards medical assistance in dying. This article describes the general attitude towards medical assistance in dying among non-Muslim. This will allow us to observe the challenges and dilemmas faced by Muslim healthcare professionals around medical assistance in dying.

Keywords

Medical assistance in dying physician-assisted suicide legalized murder health caregiver’s attitude Islam religion theology

Introduction

Since the 1990s, medical assistance in dying (MAID) has remained a controversial issue among health caregivers because contemporary health practices and literature lag behind in providing a substantive definition of this medical practice. This issue remains controversial as Muslim health caregivers need to find a legal and ethical framework for a clear direction (Isgandarova, 2015). A review of the literature suggests that regardless of what we call it, MAID is a very controversial topic and the debate on this subject is much polarised as some name MAID as “absolutely unethical,” equivalent to “legalized murder,” and fundamentally “incompatible” with the Islamic idea that preaches life should be preserved.

Taking into consideration the dilemma around it, this paper first describes the general attitude towards MAID among health caregivers. This will allow us to observe the challenges and dilemmas faced by health caregivers. The second portion of this paper focuses on Muslim health caregivers’ responses to MAID and then I conclude with the factors that impact attitudes of Muslim health caregivers towards MAID that suggest they are mainly concerned with providing more appropriate care and access to various healthcare resources before implementing MAID.

Methodology

Locating and retrieving relevant literature on MAID is challenging. Therefore, I used a systematic review of the literature to obtain the appropriate information. I used only databases specific to systematic reviews such as ProQuest, JSTOR, OVID, and PubMed. I restricted the inclusion criteria to reviews of health caregivers’ response to MAID in the West, especially the countries that legalized MAID. However, I also reviewed non-English data such as those from Turkish in South African sources using Google Scholar.

In this paper, Muslim health caregivers refers to physicians, nurses, and allied health professionals who identify themselves as Muslim. In this regard, religion is the main distinction between Muslim and non-Muslim health caregivers. Nevertheless, Muslims do not belong to one monolithic ethnic or faith tradition. However, I did not use these distinctions to elaborate on the variety of responses among Muslim health caregivers with respect to their ethnic, cultural or sectarian preferences.

For the sake of the clarity, I included broad search terms because those used to describe this healthcare practice vary from country to country. For example, I used the terms such as “medical assistance in dying,” “physician assisted suicide,” “assisted dying,” “physician-assisted death,” and “suicidal euthanasia” for the literature search because these terms are of relevance to the research question and are broad enough in scope to capture all the relevant data in the literature. They are also narrow enough to avoid irrelevant articles such as end-of-life care and/or palliative care practices.

The variety of terms suggests that despite the common aspects of MAID, the preference for using certain terms to describe MAID in various countries highlights the specific culture. For example, the 2001 Dutch legislation defines “euthanasia” as an intentional termination of life by a doctor at the request of a patient. It is not common to use the word euthanasia when there is no request for it. For example, if the patient is in a coma, the common term is applied either “termination of life without request,” or the less popular “non-voluntary euthanasia.” Involuntary euthanasia against the will of the patient is also called mercy killing. In this regard, MAID can also be called active euthanasia. For example, in the US active euthanasia includes practices such as deliberately terminating the life of the patient with a lethal drug, which is different from passive euthanasia, which is withdrawing or withholding life-sustaining treatment when the patient is too sick to give consent for euthanasia (Boer, 2003). In the Carter versus Canada case, “euthanasia” was used to describe the “intentional termination of the life of a person, by another person, to relieve the first person’s suffering.” In this case, euthanasia means “voluntary euthanasia” or “euthanasia performed by the wishes of a competent person, expressed personally or by an advance directive” (Bill C-14, 2016).

In brief, the other forms of euthanasia include:

Passive euthanasia: a physician may choose not to treat an intercurrent disease or event in a patient with a terminal progressive disease.

Semipassive euthanasia: a physician may withhold nutrition and fluids from a patient in a coma as a result of terminal progressive disease.

Semiactive euthanasia: a physician may disconnect a ventilator from a patient with massive cerebral lesion for whom there is no hope of a return of consciousness.

Accidental euthanasia: a physician may administer a narcotic to relieve severe pain in a patient with a terminal disease and the narcotic may suppress respiration thus causing death.

Suicidal euthanasia: a physician may provide drugs to a patient with a terminal disease and the patient causes his or her own death by taking an overdose of these drugs.

Active euthanasia: a physician may administer a large dose of a drug, which would be fatal in a patient in a terminal stage of a severe and hopeless disease. (Scheper & Duursma, 1994)

As outlined above, the language used in MAID is sensitive and subject to interpretation. Perhaps the Canadian experience of MAID is one of the best examples to describe the challenge surrounding MAID terminologies. For example, after heated debates the term “medical aid in dying” was adopted following Quebec’s Act Respecting End-of-Life Care. In this act, “medical aid in dying” is defined as “care consisting of the administration of a physician of medications or substances to an end-of-life patient, at the patient’s request, to relieve their suffering by hastening death.” Later on, the Special Joint Committee recommended the term “medical assistance in dying” for use in legislation: “The Committee prefers the term ‘medical assistance in dying’ to ‘physician-assisted dying,’ as it reflects the reality that healthcare teams, consisting of nurses, pharmacists, and other healthcare professionals, are also involved in the process of assisted dying” (Special Joint Committee on Physician-Assisted Dying, 2016, p. 10). Furthermore, it removes the stigma associated with doctors’ involvement in MAID practices, as they are the healthcare providers who directly administer or supply the means for the patient’s personal use that causes the termination of life.

Literature Review: Health Caregivers' Attitudes towards MAID

The review of health caregivers’ attitudes towards MAID suggests this discussion also provokes heated arguments among all health caregivers regardless of their cultural, ethnic and religious backgrounds. One of the explicit aspects of these arguments is around the attitudes of health caregivers towards MAID. These attitudes are not homogenous; even in the European countries (the Netherlands, Belgium, Luxembourg, Canada) and the US states (Oregon and Washington) where MAID was legalized a few decades ago, it is rarely practiced by health caregivers.

Various factors influence the attitude of health caregivers towards MAID. One study (Verbakel & Jaspers, 2010) indicates that religiosity is one the factors against MAID among health caregivers in Austria, Belarus, Belgium, Bulgaria, Croatia, Czech Republic, Denmark, Estonia, Finland, France, Germany, Hungary, Iceland, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, the Netherlands, Poland, Portugal, Romania, Russia, Slovakia, Slovenia, Spain, Sweden, Turkey, Ukraine, and the United Kingdom. The famous Biblical commandment thou shalt not kill is one of the biggest arguments used by these health caregivers. Also, people with a religious belief sometimes perceive suicide as a sin even in cases of unbearable suffering. In this respect, Catholics are less permissive of MAID than non-religious people. The section below describes the attitudes of non-Muslim physicians and nurses to MAID.

Physicians' Attitudes towards MAID

Physicians’ attitudes towards MAID can be grouped as those who:

perform MAID without hesitation;

only perform MAID as a last resort;

feel they are incapable of performing MAID;

refuse MAID on the principle that dying naturally is worth striving for; palliative care is the only option for them (Sercu et al., 2012; Berghs, Dierckx de Casterlé, & Gastmans, 2005; Dierckx de Casterlé, Verpoort, De Bal, & Gastmans, 2006).

In Flanders (Belgium), the willingness of general practitioners to perform MAID is determined by various factors such as the demanding nature of a patient’s request, physicians' views on what circumstances render MAID legitimate, and the ability of healthcare providers to inject a lethal dose. For example, 15 out of 52 general practitioners received at least one MAID request, but they had never performed it. In this case, the reasons for non-performance of MAID by physicians were:

The GP postponed his/her decision (2); the GP refused the request without a referral (1); the performance failed: euthanatics were unavailable at the pharmacy (2); the GP granted the request and asked another physician to administer the lethal injection (5). Patient-related reasons for non-performance in the remaining five cases were: the patient died before the euthanasia could be carried out (one patient); the patient decided finally not to use euthanasia (two patients); the injection was converted to palliative sedation on the family's demand, with the patient's consent (two patients) (Sercu at al., 2012).

Overall, general practitioners usually prefer increasing opioid dosages and palliative sedation instead of a lethal injection, which they consider falls outside the scope of euthanasia legislation.

Attitudes towards MAID also depend on various interpretations of professional values. In one study in South Africa, some medical practitioners reported that they consider euthanasia against the Hippocratic Oath that states: “I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan.” These practitioners also believe that their acceptance of euthanasia would harm trust in physicians. Others strongly believe that part of a physician’s responsibility is to decrease or eliminate suffering and that euthanasia can, therefore, be justified (Brits, Human, Pieterse, Sonnekus, & Joubert, 2009). Similarly, Finnish physicians reported they are not positive about MAID. However, public opinion in Finland favours MAID. This leads to the question of “whether the views of the public have changed or whether only the openness and magnitude of the discussion has increased” (Louhiala & Hilden, 2006). The difference between public opinion and the physicians' opinions can be explained by the fact that physicians are active agents in practice, whereas lay people are the customers of their service.

Even in the Netherlands, which was the first country in the world to legalize MAID, physicians avoid MAID as a tool to bring comfort to patients who suffer and to end their suffering. Those who refuse and rarely practice MAID argue that it is against their personal and religious values and they find this practice emotionally challenging. Dutch physicians also believe their duty is to provide care and support, and promote a peaceful dying process or quality of end-of-life, rather than shortening a patient's life by “intentionally hastening a patient's death on his request” (Georges, The, Onwuteaka-Philipsen, & van der Wal, 2008). Therefore, they tend not to hasten death as they believe that “the death could happen soon without any need for external interference” (Georges, Onwuteaka-Philipsen, & van der Wal, 2008).

However, some physicians also feel comfortable and confident in interfering with the last stage of a patient's life by administering MAID. For example, in Australia, 53% of 532 physicians in Victoria reported they support the legalization of voluntary euthanasia. Among these physicians, 35% had received requests from patients to hasten death and administered drugs with the intention of hastening death (Neil, Coady, Thompson, & Kuhse, 2007). French physicians also feel confident in the legalization of MAID. Almost 59% of 1552 physicians, including general practitioners and neurologists, do not feel comfortable administering MAID. However, oncologists, who are more experienced in end-of-life care, and physicians, who are more trained in palliative care, are especially comfortable administering MAID (Peretti-Watel, Bendiane, Pegliasco, Lapiana, Favre, Galinier, & Moatti, 2003). Furthermore, the research also indicates that MAID is becoming more practiced by family physicians (63–71%) and nursing home physicians (21–36%) but not clinical specialists (37%) (Georges, Onwuteaka-Philipsen, & van der Wal, 2007). Furthermore, the physicians practice MAID more frequently with patients dying of cancer, or for patients dying at home among relatives and loved ones.

Nevertheless, a substantial disagreement among physicians concerning the definition of euthanasia causes their ambivalent attitudes towards MAID. In Australia, for example, physicians, who approved the legalization of voluntary euthanasia in the past, appear to be less supportive of MAID over the 17 years (End-of-Life Decisions in Medical Practice, 2007). Similarly, Dutch physicians reported less reluctance in practicing MAID. For example, in 2007, despite the increase in requests for euthanasia over the years (8,900 to 9,700) and an increase in euthanasia practices from 1.9 to 2.3 and 2.2%, they reported that “they would never perform euthanasia” (Buruma, 2007).

Nurses' Attitudes towards MAID

Nurses usually play an important role in MAID. Almost everyone agrees that nurses tend to have a unique relationship with patients and are an important part of the interdisciplinary team providing expert opinion for patients who request euthanasia from the early stages. This starts with “hearing the euthanasia request; participating in the decision-making process; participating in the execution of euthanasia, and supporting family members and colleagues, regardless of whether the death occurred naturally or by euthanasia” (Dierckx de Casterlé, Verpoort, De Bal, & Gastmans, 2006, 187–192). For example, in Flanders, 120 nurses reported being active caregivers in patients’ lives who received life-ending drugs without explicit request in cases when the physicians were absent, or the patient was over 80 years of age (Inghelbrecht, Bilsen, Mortier, & Deliens, 2010).

However, their attitude towards euthanasia is also very complex (Verpoort, Gastmans, & Dierckx de Casterlé, 2004). One of the important factors that affects nurses’ attitudes towards MAID is religion. For example, the nurses who adhere to the Catholic faith are more likely to be against euthanasia than members of other religious groups (particularly Protestants) (Cartwright, Steinberg, & Williams, 1997). In the case of Belgian palliative care nurses, religiosity is also the main factor for their attitude towards MAID (Dierckx de Casterlé, Verpoort, De Bal, & Gastmans, 2006). Belgian palliative care nurses who identify themselves as religious found MAID problematic. Nevertheless, this did not prevent them from providing care for patients who chose MAID.

In France, for example, 65% of the 602 nurses, especially women and older nurses, who participated in one research study favoured legalizing euthanasia. The proportion of nurses who discussed end-of-life issues with terminal patients was 70%; 81% also reported discussing the patients' prognosis; and many reported that they wanted to play an active role in helping incompetent patients make end-of-life decisions (Bendiane et al., 2007). The research also suggests the approval rate for MAID among French nurses is higher in comparison to French physicians. This sharp contrast might be explained by the fact that nurses usually “perform patient-requested euthanasia more frequently than physicians.” Furthermore, nurses more directly experience a patient's suffering and believe that no one should die in pain, but should have dignity. However, it is also a fact that nurses may also experience feelings of guilt, moral distress, and powerlessness, and may also feel reluctant to administer the lethal dose to the patient.

Various studies also suggest that, despite religious views that do not favour MAID, nurses are able to respect their patients' choices (Musgrave & Soudry, 2000). However, these conclusions may also not “portray the process of how they are involved in the formation of attitudes” (Berghs, Dierckx de Casterlé, & Gastmans, 441–446). For example, various factors such as medical training and experience, religiosity, the locus of control and patient characteristics (e.g. patient age, pain levels, number of euthanasia requests) should be taken into consideration to evaluate nurses’ attitudes towards MAID (Hains & Hulbert-Williams, 2013).

Other Health Caregivers' Attitudes towards MAID

Along with physicians and nurses, social workers, spiritual caregivers, pharmacists, and other health caregivers also play an important role in MAID in various capacities. These health caregivers do not directly administer MAID, but help in assessing eligibility or administering MAID. Therefore, the law and the respective professional organizations protect them from liability during their involvement in MAID. For example, social workers “assist potential clients in obtaining other services if members are unable or unwilling, for appropriate reasons, to provide the requested professional help” (The Code of Ethics and Standards of Practice Handbook, Second Edition, 2008).

Nevertheless, some of these professionals, including social workers, might see MAID as against their moral or religious values. Despite the emphasis in social work on the patient's autonomy and inherent dignity, many social workers also report feeling ambivalent towards MAID. For example, in Israel, social workers reported feeling incompetent with regard to euthanasia (Leichtentritt, 2002). This could also be explained by the fact that for Jewish patients and health caregivers, euthanasia can bring memories of cruel and uncivilized practices under Hitler. For example, in the 2000s it was difficult to observe the pain of the survivors and their families at the trial of an 84-year-old former neurologist and psychiatrist who was found guilty of murder in the deaths of children in medical “experiments” in which the children were intentionally infected with diseases and left untreated in a Vienna institution in 1944.

In Ontario, social workers emphasize the patient’s inherent dignity, will and decision making as an overriding principle. Further, the Ontario College of Social Workers and Social Service Workers (OCSWSSW) invites its members to consider Principle II: Competence and Integrity, Interpretation 2.1.1 in MAID. The Principle II dictates that “College members are responsible for being aware of the extent and parameters of their competence and their professional scope of practice and limit their practice accordingly” (OCSWSSW, The Code of Ethics and Standards of Practice Handbook, Second Edition, 2008). Nevertheless, OCSWSSW also considers that for moral or religious reasons, some members might not feel comfortable in assisting the client with MAID. Therefore, they stated that “complying with the potential client's request would violate the member's values, beliefs, and traditions to the extent that the member would not be able to provide appropriate professional service” (OCSWSSW, 2008).

OCSWSSW also acknowledges some legal implications scare social workers. However, OCSWSSW cites Bill C-14, which advises: “For greater certainty, no social worker, psychologist, psychiatrist, therapist, medical practitioner, nurse practitioner or other healthcare professional commits an offense if they provide information to a person on the lawful provision of medical assistance in dying.” Or “No person is a party to an offense under paragraph (1) (b) if they do anything to aid a medical practitioner or nurse practitioner in providing a person with medical assistance in dying in accordance with section 241.2.” Therefore, social workers can help patients who request MAID in respecting and facilitating their self-determination, arranging resources that might help them to make decisions, and provide accurate and complete information about the services available for them.

In summary, the attitudes of health caregivers towards MAID are changing due to an emphasis on patient autonomy and beneficence. In Austria, for example, a large survey of medical students from 2001 to 2009 reveals that they do not necessarily see MAID as controversial. This correlates with the increasing acceptance of MAID in many European countries (Stronegger, Schmölzer, Rásky, & Freidl, 2011). A study among 151 undergraduate students (early-stage nursing training, late-stage nursing training, and non-nursing controls) shows that 82% of the general public are in support of law change; however, 68.8% of medical professionals do not consider it necessary. Religiosity again is the main factor influencing the attitude of health caregivers. However, contrary to their negative attitude towards MAID, many support the practice of euthanasia. This changing attitude shows that unlike in the past, the general public and health caregivers have a genuine positive approval of euthanasia. The change in attitudes could be explained by media and legal focus on euthanasia over the past few years. Also, “the more internal an individual's locus of control, the more negative their attitudes are likely to be” (Hains & Hulbert-Williams, 2013, 713–716).

Results: MAID and Muslim Health Caregivers

The practice of MAID among Muslims is rare. However, Muslim scholars have extensively discussed all forms of euthanasia in the context of Islamic ethics and biomedical ethics (Sachedina, 2011). Almost all these discussions involve a heated argument among Muslim theologians, jurists, and health caregivers who try to address the challenges of modern medical ethics, including any medical dilemma in the context of brain death, feeding tubes, sex selection, spiritual counseling, and organ transplantation, etc. The discussion ends with recognizing the importance of the Islamic tradition in legitimizing ethical responses to these advances.

In contemporary Islamic literature, many Muslim health caregivers and religious or spiritual leaders endorse some forms of euthanasia, such as passive and involuntary (i.e. withholding or withdrawing life-saving treatment). For example, the Senior Religious Scholars Commission and Ali Muhammad al-Bar (1995), a Muslim physician trained in Islamic jurisprudence, approved the permissibility of turning off life-support mechanisms in the case of the diagnosis of brain death. However, currently we do not have enough data on these attitudes and practices. Therefore, it is difficult to provide an in-depth reflection on the current practice, i.e. how Muslim doctors and nurses handle the question of medically assisted suicide in particular. The limited data that are available only highlight certain aspects, specifically the moral and ethical aspects of the issue (Sachedina, 2006).

Nevertheless, a more general discussion shows that Muslims usually do not welcome MAID, particularly if they live in predominantly Muslim countries. One study among university students in Kuwait showed that the attitude towards MAID depends on a combination of four factors: the patient's age (35, 60 or 85 years); the level of incurability of the illness (completely incurable versus extremely difficult to cure); the type of suffering (extreme physical pain or complete dependence); and the extent to which the patient requests a life-ending procedure, euthanasia or MAID (no request, some form of request, repeated requests) (Ramadan, Sorum, & Mullet, 2010). The authors indicated that (1) 44% of respondents do not accept MAID, regardless of the reason or circumstances; (2) 23% did not approve, however, they had more tolerance towards MAID when the patient was older or requested MAID repeatedly; (3) 16% of respondents did not approve it in cases when the patient was young: however, they accepted it if the patient was elderly; (4) 5% of respondents did not accept MAID even if the patient suffered in the extreme, but they were tolerant towards MAID if the patient was completely dependent; and finally, (5) 11% of respondents approved MAID if it was requested by the patient. The findings suggest that “the majority of the Kuwaiti university students opposed Physician-Assisted Suicide (PAS) either categorically or with a slight variation according to circumstances. Nonetheless, a minority approved of PAS in some cases, particularly when the patient was elderly” (Ramadan, Sorum, & Mullet, 2010).

One study in South Africa also shows that less than one-third of the Muslim participants support euthanasia in the case of terminally ill patients with cancer (Hosking, Whiting, Brathwate, et al., 2000). The findings of another study with Muslim professionals in Kuwait suggest that Muslim professionals, including physicians, nurses, spiritual caregivers etc., do not have a permissive attitude towards MAID (Ramadan, Sorum, & Mullet, 2010).

The literature also highlights that although passive euthanasia is practiced in some Muslim countries, for example in Turkey, active euthanasia is a controversial practice for physicians in many Muslim countries. Even in Turkey, which endorses liberal religious rulings on these issues, physicians are not comfortable prescribing lethal injections. For example, according to the Turkish Medical Physician's Union, the physician's primary duty is to heal the patient; physicians have no right to apply euthanasia to the patient for any reason. Only a few Muslim physicians acknowledge that although MAID should be granted for patients who do not respond to treatment and are suffering, it is not possible in Turkey at present. However, they realize that at some point in Europe and in other parts of the world this practice will be applied in cases when terminally ill patients request MAID.

Like Muslim physicians, Muslim nurses do not favour MAID. In one study of 89 nurses in adult intensive care units and Ministry of Health hospitals in a province of Turkey, it was evident that various concerns about euthanasia affected the opinions of the nurses. Firstly, many intensive care nurses defined euthanasia “as willing for one's own death by intensive care nurses” (57.3%) (Çelik, Kalkan, Gundogdu, & Topal, 2012). Secondly, more than half of the nurses (59.5%) responded that the practice of euthanasia is against nature, the universe and God. Third, the responses suggest that nurses usually (85.4%) do not receive requests for euthanasia from the patient or their families. Also, a majority of nurses (80.9%) prefer to care for the terminally ill patients in intensive care units rather than perform active or passive euthanasia. Therefore, more than half of the nurses (58.4%) do not support legalizing euthanasia in Turkey (Çelik, Kalkan, Gundogdu, & Topal, 2012).

Nevertheless, many nurses in Turkey do not have adequate knowledge about euthanasia and view it as an activity that ends the life of the patient based on the caregiver's or the relative's preference. If euthanasia is requested by a patient, nurses tend to view it as an attempt at suicide or suicidal ideation, which, according to the majority of Muslim scholars, is against the Islamic faith. Muslim nurses strongly believe that only God bestows life and only God should take life. Nevertheless, many nurses in Turkey, for example, support passive euthanasia rather than active euthanasia (Tepehan, Ozkara, & Yavuz, 2009). In addition, they prefer serving and providing appropriate care to terminally ill patients whose natural death is imminent, rather than performing MAID. These nurses consider serving these patients is their sacred duty. In addition, in Turkey, the discussions around MAID are more centred around the general law, particularly the right of a person to live based on Articles 17, 81, 83, 84, and 85 of the Constitution. In summary, the attitudes of Muslim health caregivers towards MAID are not that different from other non-Muslim professionals as they are also ambiguous about practicing MAID.

Discussion: What Affects the Attitude of Health Caregivers towards MAID?

In this subsection, I address two important issues that cause intense debates among Muslim religious scholars, ethicists, doctors, and legislators. First, I briefly discuss the position of Islamic jurisprudence concerning MAID and second, I address the professional dilemma.

Islamic Jurisprudence and MAID

Religion and moral values affect the attitudes of health caregivers toward MAID. However, although Islam and secular ethical systems share some values, their inferences are different. Firstly, to a great extent, religious teachings influence the attitude of health caregivers toward MAID. For example, Muslims believe in divine predestination and therefore assume that any suffering has a purpose. As Sachedina (2011) outlined, either they believe their suffering atones for their past sins or it will bring reward after the divine test. However, it is also evident that they struggle to enlighten themselves as to how Islam allows adaptation to particular situations. In addition, many Muslims also refer to the life of the Prophet Muhammad who compared suffering and pain of the believer to a tree in the fall where God absolves a sin with every leaf that falls off the tree. However, in Islamic literature, there is a lack of appropriate terminology to refer to the practice of MAID. Abdulaziz Sachedina’s book Islamic Biomedical Ethics: Principles and Application (2011) provides the most important contribution to this discussion in Islamic literature. In this book, Sachedina used Arabic words to understand and analyze active euthanasia that might help us understand MAID. Currently, there are two phrases in Arabic, both referring to passive and active euthanasia: the first literally means ‘death out of mercy', and the second ‘dying with mercy' or mercy ‘killing’ (al-qatl al-rahim). The general discussion usually involves suicide in Islam (Rozenthal, 1946).

Islamic literature recognizes the difference between murder and voluntary euthanasia, and questions as to whether there are alternatives to pain management and treatment, relief of suffering, etc., are missing. Various discussions in these fields usually focus on the moral concerns around this practice. For example, a famous fatwa (religious ruling) by the European Council for Fatwa and Research (2008) states:

The patient whatever his illness and however sick he (or she) is shall not be killed because of desperation and loss of hope in recovery or to prevent the transfer of the patient’s disease to others, and whoever commits the act of killing will be a deliberate killer. The Qur’anic text confirms without a shadow of a doubt that homicide is forbidden absolutely, as Allah Almighty says: “And take not life, which Allah has made sacred, except by way of justice and law” (VI: 151).

And as Allah Almighty also says: “Because of that We ordained for the Children of Israel that if anyone killed a a person not in retaliation of murder or for spreading mischief in the land, it would be as if he killed all mankind” (V:32).

However, there is a lack of services that provide practical tips to patients, their families, and caregivers. An adequate insight into the meanings and explanations of attitudes of patients who want to end their life due to unbearable suffering is also missing. Therefore, many Muslim healthcare givers do not know how to address their concerns, or provide hope and help that make sense in their context. One of the concerns is related to a strict dogmatic approach to the issue without reflection of the lived experience of suffering. This alone suggests that many Muslim health caregivers, including physicians, social workers, psychologists, spiritual caregivers, etc. need to develop an awareness of their attitudes and moral, ethical, theological, and professional awareness towards the different forms of euthanasia to assist their clients and families. We also need to mention that considerable differences exist among Islamic schools of theology and jurisprudence regarding MAID. These differences affect the attitudes of Muslim health caregivers, depending on their affiliation with these schools. Although we need more evidence-based research, we hypothesise that substantial differences in the rates of liberalization, particularly in comparison to conservative Muslims, affect the more favourable approach to MAID. However, based on a famous hadith, Muslim jurists agree that actions are judged by their intention that should encourage Muslim health caregivers to make an informed decision based on their theological affilaition. For example, alleviating the suffering of the client is the conscious inner motive that distinguishes the purpose behind the healthcare decisions.

Professional Dilemma

Many Muslim health caregivers argue that instead of funding, the focus should be on life-saving practices. Some are also concerned that this might be practiced to save healthcare costs. For example, in his explanation of the Qur’anic concept of justice (Q. 4:135; 8:29, 181; 5:8, etc.), which is one of the major principles that shape a Muslim response to ethical decisions with respect to physician assisted suicide, Sachedina (2011) explains that “any error of judgment in this regard could lead to a morally and legally questionable decision to end an individual’s life by either actively acquiescing in the patient’s death or actively causing it” (p. 145). I agree with this position when we take into consideration that this kind of decision may easily be used as an excuse against marginalized and vulnerable patients, especially those with a disability, the elderly, the poor, and other racial minority groups because of their disadvantaged position compared with the rich and powerful. In addition, the patient’s decision to end their life affects not only them but also their immediate and extended family.

Therefore, Muslim health caregivers are concerned that MAID might be abused and applied to people from vulnerable groups who do not have access to more resources in healthcare system. One of the objections was that focusing too much on MAID takes attention away from providing more funding for palliative care. Nevertheless, as outlined in the statement of Justice Smith for the Supreme Court of British Columbia (pp. 731–736), there is no relationship between legalizing assisted suicide and the quality and availability of palliative care:

My review of the evidence regarding Oregon, the Netherlands, and Belgium suggests that in those jurisdictions, legalization of assisted death has not undermined palliative care; on the contrary, palliative care provision has improved since legalization by some measures. Few conclusions, however, can be reached about the possible impact on palliative care from a change in Canadian law regarding physician-assisted death.

First, as Canada points out, palliative care is a developing field; it may be assumed that it is improving not only in permissive jurisdictions but also in jurisdictions that continue to prohibit physician-assisted death.

Second, there are differences in the history, culture, and modes of medical practice among the jurisdictions.

Third, further improvements in palliative care in Canada would require a commitment of public resources, since healthcare in Canada is largely delivered through a public system. Some of the debate in the United States has raised the question whether health insurers would refuse to fund palliative care when assisted death was available; no evidence was provided to show that that fear has become reality in Oregon or Washington. It is difficult to imagine that Canadian politicians, public officials or healthcare providers if physician-assisted death were legal, would reduce resources for palliative care services for that reason.

In summary, having reviewed the evidence and the submissions on this point, I conclude that while a change in the law to permit physician-assisted death could affect the palliative care system, predictions as to how would be speculative. I find that the evidence establishes that the effects would not necessarily be negative (Attorney General, 2012).

Furthermore, Justice Smith also reflected on this aspect of MAID by stating, “there are risks inherent in permitting physician-assisted death and that the utmost care would be needed in designing and managing a system that would allow it” (Carter c Carter 2012, para 854). However, she also stated that “the risks inherent in permitting physician-assisted death can be identified and very substantially minimized through a carefully designed system imposing stringent limits that are scrupulously monitored and enforced.”

Also, the physicians' concerns regarding end-of-life decision making are related to the fact that MAID should be approached with sensitivity and with careful attention paid to the individual patient and context. In this regard, physicians who are for and against MAID are concerned with multiple factors. First: the question at stake is how to reconcile MAID with the Hippocratic Oath with the need to end the suffering of patients, protect the patient's life at all times, and act according to the patient's will. Second, MAID is a complex process and should take into consideration not only the physical aspect of illness but other important psychosocial and legal aspects as well. For example, they need to evaluate the case carefully and identify what the inappropriate motives for euthanasia might look like: does the patient's preference to MAID arise from financial or resource pressures within hospitals and nursing homes? Does the request for euthanasia come from relatives or directly from the patient? Does the patient who wants MAID receive best-practice palliative care? What is the quality of decision making in seriously ill patients? How does a right to euthanasia affect the physician-patient relationship? What are the end-of-life moral dilemmas arising from MAID? Finally, physicians might also feel confused with the language of the legislation in their jurisdictions. The legislation might confuse or hinder a good medical decision concerning helping terminally ill patients.

Muslim health caregivers have two main concerns: one, they expressed a fear that there is a threat of being subject to MAID without the person’s consent; and second, MAID might end life before death occurs naturally. In some debates of cases such as that of the Canadian Tracy Latimer, who suffered from cerebral palsy, the argument was that in our society some might assume that “killing” an individual with a disability is an act of “mercy” or “compassionate homicide.” In Tracy’s case, she was poisoned with carbon monoxide by her father, Robert Latimer, although it was evident that with the right intervention her pain might have been kept under control. In the case of R. versus Genereux, there were people who defended Dr. Genereux, who aided two men who were HIV positive to die by prescribing lethal quantities of a barbiturate.

It was also evident that some people found it troubling that MAID in Canada can potentially “reduce annual healthcare spending by between CAD$34.7 million and CAD$138.8 million, exceeding the CAD$1.5 million to CAD$14.8 million in direct costs associated with its implementation” (Trachtenberg & Manns, 2017). In this context, they agree with some of those who also discuss the benefits of MAID in the context of government savings. Nevertheless, they also agree that their patients have a right to make the decision for themselves, which includes their right to assistance in ending their lives with dignity, and even that legalized voluntary euthanasia. Such an approach conforms with the Health Care Consent Act, 1996, Canada that suggests that no treatment should be provided without consent:

10. (1) A health practitioner who proposes a treatment for a person shall not administer the treatment, and shall take reasonable steps to ensure that it is not administered, unless, (a) he or she is of the opinion that the person is capable with respect to the treatment, and the person has given consent, or (b) he or she is of the opinion that the person is incapable with respect to the treatment, and the person’s substitute decision-maker has given consent on the person’s behalf in accordance with this Act. 1996, c. 2, Sched. A, s. 10 (1).

Conclusion

At first sight, it was evident that there appears to be a great deal of discussion of MAID among non-Muslim health caregivers, but less among Muslim health caregivers. However, the literature is rich with information about the attitudes of physicians and nurses towards MAID but among other health caregivers including social workers, spiritual caregivers, etc. remains insufficient. Similarly, at first sight, there might seem to be a great deal of discussion of MAID among Muslims from a theological perspective but less on practice perspective. Nevertheless, the content of available resources reveals that we need more literature to analyze the attitude of Muslim health caregivers towards MAID both from theological and professional perspectives.

One of the important discussions of MAID among Muslims should also include the definition of MAID not in the context of extremely broad definitions of euthanasia. For example, a future research question might strictly focus on the reasons for the unwillingness of Muslim physicians to perform MAID; whether they believe it falls outside the scope of euthanasia legislation or whether they consider it a last resort.

Thus, the Islamic faith is the main factor that predicts the approval of MAID in respect to greater physical suffering in Muslim countries. Due to the Islamic faith in Muslim countries, within the general population suicide is relatively uncommon, which could suggest that a Muslim population might not approve of MAID. In summary, health caregivers' attitudes towards MAID reflects the above discussion on countries’ attitudes towards MAID.

Footnotes

Nazila Isgandarova has a Ph.D. from the University of Toronto, Doctor of Ministry degree in pastoral counselling, marriage and family studies from Wilfred Laurier University, and Master of Social Work from the University of Windsor. She is a Registered Psychotherapist at the College for Registered Psychotherapists of Ontario and Registered Social Worker at the Ontario Social Workers and Social Service Workers. She is also certified American Board of Forensic Professionals for the CMCC AMA Guides to Impairment Rating. She is the recipient of the prestigious Forum for Theological Exploration research award for her study on domestic violence against Muslim women, Canadian Association for Spiritual Care Senior Research Award and Society for Pastoral Counselling Research Award. She is also an instructor at Emmanuel College of Victoria University in the University of Toronto. Her book, titled Muslim Women, Domestic Violence, and Psychotherapy: Theological and Clinical Issues, was published by Routledge in 2018.

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