ISU-ISU KESIHATAN TERKINI DAN PENYELESAIANNYA MENURUT ISLAM PROF. DR. ABDUL LATIFF MOHAMED M.D.(Mal.), M.R.C.P.(U.K.), Ph.D.(Cardiology)(Leeds) Consultant Cardiologist Deputy Dean of Clinical Studies Cyberjaya University College of medical Sciences

Islamic Medicine “Evidence based” “Evidence based” Based on facts and researchBased on facts and research Elements of research and proof Elements of research and proof Treatments include Treatments include Do’aDo’a Effort : Physical, spiritual and socialEffort : Physical, spiritual and social Tawakkal : Belief in Allah as ultimate healerTawakkal : Belief in Allah as ultimate healer

Popular Issues 1. Organ Transplant 2. Brain Death and Life support system 3. Euthanasia 4. Post Mortem and Cadaver Dissection 5. “Haram elements” in Drugs 6. Use of Botox (botulinum toxin)

TRANSPLANT

History Mentioned in ancient Chinese mythology Mentioned in ancient Chinese mythology Pioneer : Alex Carrel – first heart lung transplant in dog. Pioneer : Alex Carrel – first heart lung transplant in dog. First carried out in human 1967 – Christian Barnard First carried out in human 1967 – Christian Barnard Only accepted as an established therapy in early 80’s Only accepted as an established therapy in early 80’s 1994 : performed in 257 centres 1994 : performed in 257 centres

Transplantable Organs Up to 50 lives can be saved or enhanced by a single donor. Solid organs alone can help up to eight individuals, and tissue can help many times that number. Solid organstissueSolid organstissue Solid Organs : HeartHeartHeart KidneysKidneysKidneys LiverLiverLiver LungsLungsLungs PancreasPancreasPancreas Kidney-pancreasKidney-pancreasKidney-pancreas IntestineIntestineIntestine Tissues: blood, bone marrow, connective tissue, corneas, heart valves, skin

Heart Transplant

Lung Transplant

Other “easier” transplants

Donors : Causes of death Cause of death No. Donors Head Trauma 68 Gunshot wound 21 Cerebrovasc. Accident 23 Asphyxiation5 Brain Tumour 1 Liver failure 1 Heart lung receipient 1

Procedure

Procedure

Graft Rejection : acute & chronic

Prevention Cyclosporine Cyclosporine Tacrolimus Tacrolimus Methylprednisolone Methylprednisolone Prednisolone Prednisolone Azathioprine Azathioprine

Transplant Team

Transplant Patient (Tee Hui Yee)

Cost Up to RM Hospital stay : around 23 – 24 daysHospital stay : around 23 – 24 days 2 -3 days in ICU2 -3 days in ICU DonorDonor ProcedureProcedure DrugsDrugs

Survival expectations Rehabilitation Rehabilitation 1 year survival more than 80 % 1 year survival more than 80 % Marginal decrease in suvival in pts. with Marginal decrease in suvival in pts. with Longer donor ischaemic timeLonger donor ischaemic time Older donor ageOlder donor age Non-O blood typeNon-O blood type 50 % mortality in 9-10 years 50 % mortality in 9-10 years

Survival curve

Problems DONOR !!! DONOR !!! Technology Technology “Learning curve” “Learning curve” Rejection – matching registry Rejection – matching registry Cost Cost

Alternatives

I. Opposing viewpoints Two prominent Muslim scholars who have written against organ transplantation are the late Mufti Muhammad Shafi` of Pakistan and Dr `Abd al- Salam al-Sukri of Egypt. Mufti Shafi` holds organ transplantation as not permissible on the basis of the following principles:

A. sacredness of human life/body The human body being an amanah (trust); and finally that such a procedure would be tantamount to subjecting the human body to material ends.

Do not kill (destroy) yourselves: For verily Allah has been to you Most Merciful (al-Nisa', 4:29). Do not kill (destroy) yourselves: For verily Allah has been to you Most Merciful (al-Nisa', 4:29). Make not your hands contribute to your own destruction (al-Baqarah, 2:195). Make not your hands contribute to your own destruction (al-Baqarah, 2:195).

If anyone slays a human being unless it be in legal punishment for murder or for spreading corruption on earth it shall be as if he had slain the whole of mankind; whereas if anyone saves a life, it shall be as if he had saved the life of all mankind (al-Ma'idah, 5:32). In the Hadith literature it is recorded that the Prophet Muhammad (PBUH) made the following declaration in his Farewell Sermon (Khutbat al Wada`ah) Your life and your property and your honour are sacred until you meet your Lord."2

Hadith: Breaking the bone of a dead person is equal in sinfulness and aggression to breaking it while a person is alive.4

B.The human body as an Amanah The Holy Qur'an (17:70; 21:20) tells us that Allah (SWT) has honoured man, made serviceable to him whatever is in the heavens and on earth as a blessing and mercy.

C.Subjecting the human body to material ends The impermissibility of subjecting the human body to material ends may be deduced from these two examples: Fatawa `Alamgiriyyah : if a person, owing to hunger, finds himself on the verge of death, and is unable to find even the meat of a dead animal in order to save himself, and at that instant is offered human flesh, it would not be permissible for him to partake of it. Fatawa `Alamgiriyyah : if a person, owing to hunger, finds himself on the verge of death, and is unable to find even the meat of a dead animal in order to save himself, and at that instant is offered human flesh, it would not be permissible for him to partake of it. Hadith Literature : the Prophet Muhammad (PBUH) said that Allah (SWT) has denounced or cursed the one who joins the hair of a woman to that of another so as to make her hair appear long - and He (SWT) has also cursed the woman with whose hair such hair is joined Hadith Literature : the Prophet Muhammad (PBUH) said that Allah (SWT) has denounced or cursed the one who joins the hair of a woman to that of another so as to make her hair appear long - and He (SWT) has also cursed the woman with whose hair such hair is joined

D. Prohibition of making use of forbidden things as medicines Hadith of the Prophet (PBUH): "Allah created the disease and also the cure. For every disease He has provided a cure. So treat yourselves with medicines, but do not treat yourselves with prohibited things".

E. Safeguarding the honour of human life Abd al Rahman ibn `Uthman (RA) reports that a doctor came to the Prophet (PBUH) and asked him about the permissibility of making use of frogs in medicines. The Prophet (PBUH) forbade him from doing that. Abd al Rahman ibn `Uthman (RA) reports that a doctor came to the Prophet (PBUH) and asked him about the permissibility of making use of frogs in medicines. The Prophet (PBUH) forbade him from doing that.

F. Avoiding the doubtful In a hadith, the Prophet (PBUH) said: Both legal and illegal things are obvious, and in between them are doubtful matters. So whoever forsakes those doubtful things lest he may commit a sin will definitely avoid what is clearly illegal; and whoever indulges in these doubtful things boldly, is likely to commit what is clearly illegal. Sins are Allah's hima (i.e. private pasture) and whoever pastures (his sheep) near it is likely to trespass in it at any moment. Both legal and illegal things are obvious, and in between them are doubtful matters. So whoever forsakes those doubtful things lest he may commit a sin will definitely avoid what is clearly illegal; and whoever indulges in these doubtful things boldly, is likely to commit what is clearly illegal. Sins are Allah's hima (i.e. private pasture) and whoever pastures (his sheep) near it is likely to trespass in it at any moment.

II. Favorable viewpoints Muslim scholars who advocate the permissibility of organ trans- plantation are of the opinion that it should be recognized as a form of altruistic service to fellow Muslims.

A. Al-maslahah (public welfare) (i)Necessity makes the unlawful permissible. (ii)When two interests conflict let the one which will bring greater benefit take precedence. (iii)If forced to choose, choose the lesser of the two evils.

Examples Islamic Law would permit the cutting of the belly of the dead pregnant woman in order to remove the foetus should any movement be detected. Thus, the right of the living supercedes consideration over the dead. Islamic Law would permit the cutting of the belly of the dead pregnant woman in order to remove the foetus should any movement be detected. Thus, the right of the living supercedes consideration over the dead. Likewise, Islamic Law would allow the cutting of the belly of the deceased who had swallowed a valuable diamond or a piece of gold in order that it may be returned to its rightful owner. Likewise, Islamic Law would allow the cutting of the belly of the deceased who had swallowed a valuable diamond or a piece of gold in order that it may be returned to its rightful owner.

organ transplantation should be hedged with certain restrictions 1. That the transplantation is the only form (means) of treatment. 1. That the transplantation is the only form (means) of treatment. 2.The expected degree of success of this procedure is relatively high. 2.The expected degree of success of this procedure is relatively high. 3.The consent of the owner of the organ or of his heirs have been obtained. 4.Death must have been fully established by Muslim doctors of upright character before such a venture is undertaken. 4.Death must have been fully established by Muslim doctors of upright character before such a venture is undertaken. 5.The recipient has been informed of the operation and its implications.

B. Al-Ithar (Altruism) Help you one another in righteousness and piety (al-Ma'idah, 5:2) and from the Sunnah the following hadith may be cited: The believers, in their love and sympathy for one another, are like a whole body; when one part of it is affected with pain the whole of it responds in terms of wakefulness and fever

Living donor : restrictions 1.The consent of the donor must be obtained. 2.That the transplantation is the only form of treatment possible. 3.That there is no obvious danger to the life of the donor. 4.The respective transplantation has been proven successful in the past. 4.The respective transplantation has been proven successful in the past.

Third session : Amman, Jordan, on October 16, 1986 the Council of Islamic Jurisprudence (majma` al-fiqh al-islami) The person is considered legally dead, and all the guidelines provided by the Shari`a to determine death are applicable when following signs are confirmed: When complete cessation of the heart or respiration occurs, and the expert physicians ascertain that the cessation is irreversible.When complete cessation of the heart or respiration occurs, and the expert physicians ascertain that the cessation is irreversible. When complete cessation of all functions of the brain occurs, and the expert physicians ascertain that the cessation is irreversible and the brain is in the state of degeneration. In this condition it is permissible to discontinue the life supportive system from the patient even when some of the patient's organs like the heart are kept functional by artificial means. God knows the best!When complete cessation of all functions of the brain occurs, and the expert physicians ascertain that the cessation is irreversible and the brain is in the state of degeneration. In this condition it is permissible to discontinue the life supportive system from the patient even when some of the patient's organs like the heart are kept functional by artificial means. God knows the best! The document then proceeds to list the procedure that must be followed as part of the Brain Death Documentation: Brain death is the irreversible cessation of all spontaneous brain activity including the brain stem. Before any supportive means is discontinued, the family members must be counseled. This should be documented in the patient's chart.Brain death is the irreversible cessation of all spontaneous brain activity including the brain stem. Before any supportive means is discontinued, the family members must be counseled. This should be documented in the patient's chart.

C. Sale of organs HARAM (i)A person cannot trade in something of which he is not the owner. (ii) A hadith which states that: `Amongst those who would be held accountable on the Last Day is one who sold a freeman and ate up the proceeds.

D. Non-Mulsim organs The permissibility for Muslims to receive the organs of non-Muslims is based on the following two conditions: 1.No organs are available from Muslims. 2.A Muslim's life would be in danger should the transplantation not be carried out.

Fardhu Kifayah In order to circumvent the problem of Muslims becoming recipients of non- Muslim organs, some of the contemporary Muslim jurists are of the opinion that a Muslim's gesture in donating any of his organs is to be categorized as fard kifayah

The Inclusion of Organ Donation into one's Will O you who believe! When death approaches any of you, (take) witnesses among yourselves when making bequests, two just men of your own (kindred) or others from outside (your kindred) if you are journeying.....(al-Ma'idah, 5:106) Likewise, the Prophet Muhammad (PBUH) also emphasized the need to write down one's will. He said: "It is not right for any Muslim person, who has anything to bequeath, that he may pass even two nights without having his last will and testament written and kept ready with him"

(a) al-Ithar (altruism i.e. generosity towards humankind) A. Al-ithar (altruism) A living person's gesture in willing to donate his/her cornea, for example, after death has taken place should be viewed as an act of altruism. After all, through corneal transplant the donor would have made a noble contribution in restoring the sight of another fellow human being suffering from corneal blindness.

(b) Al-darurah (the rule of necessity). Dr. Tanzil-ur-Rahman, former Chief Justice of Pakistan, is of the opinion that the inclusion of corneal donation, for example, in one's will may be held permissible on the basis of the rule of necessity. He explains that the rule of necessity is based upon the juridical principle of al-Istihsan (juristic prefrence), that the needs of the living are given preference over those of the dead. Thus the inclusion of organ donation in one's will could be a positive step in resolving organ donation shortages worldwide.

PURPOSES OF THE LAW (MAQASID SHARIAH) AD DHARURIYYAT THE PRESERVATION OF : 1. Religion 1. Religion 2. Life 2. Life 3. Mind 3. Mind 4. Progeny 4. Progeny 5. Property 5. Property

Keputusan Lujnah Fatwa Kebangsaan): 1)Pemindahan/pendermaan organ adalah hukumnya harus dalam keadaan darurat. 2)Orang yang mati otak adalah dihukumkan mati. Walaubagaimanapun sebelum dibenarkan untuk melakukan pemindahan/pendermaan atau melakukan keatas orang yang mati otak, ada beberapa syarat yang perlu dipatuhi untuk memelihara kesucian Islam:

1. Transplan organ ada 2 keadaan a)Keadaan penderma masih hidup - Menjalankan perubatan dengan cara terperinci dan profesional tentang kebaikan dan keburukan pemindahan ini, kejayaan dan kegagalan pemindahan - Dengan redha penderma tanpa paksaan - Sudah dipastikan pemindahan itu berjaya pada kebiasaannya - Keadaan darurat yang mendesak bagi menyelamatkan nyawa orang yang didermakan kepadanya, terutama yang ada hubungan nasab dan keluarga - Organ yang dipindahkan bukan dijadikan dagangan dan jualbeli, dagangan dan jual beli hanya akan mengundang perbuatan khianat yang memberi mudarat kepada penerima, memberi keuntungan kepada orang tengah dan juga kesempatan kepada doktor-doktor yang tidak bertanggungjawab mengaut keuntungan. - Kebenaran bertulis daripada penderma dan penderma dibolehkan menarik balik pada bila-bila masa. - Organ yang diperlukan lebih dari satu

b)Keadaan penderma yang telah mati - Menjalankan pemeriksaan perubatan dengan cara terperinci dan profesional tentang kebaikan dan keburukan pemindahan ini, kejayaan dan kegagalan pemindahan, ia memerlukan pemeriksaan rapi. - Dengan redha penderma melalui wasiat ataupun waris- waris dan perakuan daripada kerajaan - Sudah dipastikan pemindahan itu berjaya pada kebiasaannya atau dalam ertiakta lain pemindahan itu dijamin berjaya. - Dilakukan pemindahan itu dengan penuh disiplin ilmu, iman dan taqwa, penghormatan yang sewajarnya kepada si mati mengikut hukum syarak serta tiada unsur-unsur penghinaan. - Keadaan darurat yang mendesak bagi menyelamatkan nyawa orang yang didermakan kepadanya, terutama yang ada hubungan nasab dan keluarga. - Organ yang dipindahkan bukan dijadikan dagangan dan jualbeli, dagangan dan jualbeli hanya akan mengundang perbuatan jenayah yang memberi mudarat kepada penerima, memberi keuntungan kepada orang tenh dan juga kesempatan kepada doktor-doktor yang tidak bertanggungjawab mengaut keuntungan.

ii) mati otak - menjalankan pemeriksaan perubatan dengan cara professional tentang berlakunya mati otak. - Digalakkan mendapat persetujuan dari keluarga terdekat dari suami, anak, ibu, bapa. - Perakuan tentang berlakunya mati otak hendaklah dilakukan oleh sekurang- kurangnya 3 orang doktor professional (doktor islam diutamakan) - Sekiranya dengan kecanggihan rawatan perubatan (sains dan teknologi) boleh mengubat maka suasana ini gugur. ii) mati otak - menjalankan pemeriksaan perubatan dengan cara professional tentang berlakunya mati otak. - Digalakkan mendapat persetujuan dari keluarga terdekat dari suami, anak, ibu, bapa. - Perakuan tentang berlakunya mati otak hendaklah dilakukan oleh sekurang- kurangnya 3 orang doktor professional (doktor islam diutamakan) - Sekiranya dengan kecanggihan rawatan perubatan (sains dan teknologi) boleh mengubat maka suasana ini gugur.

THE ISLAMIC PARADIGM “No one can challenge or oppose God’s will. Hence, if the matter is achieved then it is certainly under the will of God. Nothing can be created without God’s will creating it. As long as humans continue to do so, it is the will of God. We do not search for the question whether it is in accord with the will of God. Our search is whether the matter is licit or not” (Qardawi)

HUMAN GENETIC & REPRODUCTIVE TECHNOLOGY

INFOTECHNOLOGY - 20 th BIOTECHNOLOGY - 21st

Biotechnology Issues 1. In Vitro Fertilisation (ART) 2. Human Cloning 3. Therapeutic Tissue Cloning (Stem Cells) 4. Preimplantation Diagnosis 5. Sex Selection 6. Designer babies

Dr. E & Dr. S pioneered the fertility technique called IVF IVF – fertilisation outside the body in a test-tube 1978 – birth of the first test tube baby, L.B.

ART – ISLAMIC PARADIGM I LAWFUL if it only involves a married couple while the marriage contract is valid UNLAWFUL if it involves an alien party, whether in the form of semen, an ovum, an embryo or a womb. If the marriage contract has ended due to divorce or death, the egg/sperm/embryo becomes alien to either party. Surrogate motherhood is not allowed

ART – ISLAMIC PARADIGM II ART centres accredited by health authorities. Ensure confidentiality, guard against mixing of lineages and commercialism. Credentialing of staff to ensure highest standards of professionalism, trustworthiness, integrity and responsibility Acts of legislation to govern ART practice

2. Cloning

REPRODUCTIVE HUMAN CLONING Cloning technology aimed at producing human clones is not permissible Cloning technology aimed at producing human clones is not permissible Majority considered it Haram in all its details Majority considered it Haram in all its details Few – Haram in order to prevent a cause of harm(la darar wa la dirar – the necessity to refrain from causing harm to oneself and others) Few – Haram in order to prevent a cause of harm(la darar wa la dirar – the necessity to refrain from causing harm to oneself and others) The use of SCNT technology even between husband & wife was not approved The use of SCNT technology even between husband & wife was not approved

3. THERAPEUTIC CLONING Production of human clonal embryos for the harvesting of stem cells Production of human clonal embryos for the harvesting of stem cells Used for research or possible therapeutic purposes Used for research or possible therapeutic purposes The end-point would not be a human being The end-point would not be a human being Confusion / disgust at the concept of creating cloned babies transferred to TC Confusion / disgust at the concept of creating cloned babies transferred to TC “Burning down the stable to catch a flea” “Burning down the stable to catch a flea”

POTENTIAL APPLICATIONS Basic research into human development & disorders Discovery of novel proteins for tissue regeneration & repair Development of human cell model for drug discovery and toxicology Development of tissue for transplantation

SOURCE OF STEM CELLS Adult stem cells Adult stem cells Embryonic stem cells (ESC) Embryonic stem cells (ESC) Surplus embryos from IVF procedures Surplus embryos from IVF procedures Embryos created for research purposes Embryos created for research purposes Embryos from SCNT Embryos from SCNT

SOURCE OF CONTROVERSY Is an ovum and sperm a person ? Is an ovum and sperm a person ? When do the products of conception become a person ? When do the products of conception become a person ? Does a zygote have a full set of human rights ? Does a zygote have a full set of human rights ? Does the foetus have a soul ? Does the foetus have a soul ? The concept of personhood is neither logical nor empirical The concept of personhood is neither logical nor empirical Based on one’s assumptions about the nature of the world Based on one’s assumptions about the nature of the world A religious or quasi-religious concept A religious or quasi-religious concept

WHEN DOES LIFE BECOME HUMAN LIFE ? “methods that fail to respect the dignity and value of the person must always be avoided. I am thinking in particular of attempts at human cloning with a view to obtaining organs for transplants: these techniques, in so far as they involve the manipulation and destruction of human embryos, are not morally acceptable, even when their proposed goal is good in itself” Pope John Paul II; 29 Aug 2000 “methods that fail to respect the dignity and value of the person must always be avoided. I am thinking in particular of attempts at human cloning with a view to obtaining organs for transplants: these techniques, in so far as they involve the manipulation and destruction of human embryos, are not morally acceptable, even when their proposed goal is good in itself” Pope John Paul II; 29 Aug 2000 The soul enters the body at conception and the fertilised ovum is a human person with full human rights The soul enters the body at conception and the fertilised ovum is a human person with full human rights

THE “SCIENTFIC” POSITION The pre-embryonic stage is defined as the period from fertilisation up to the determinant of the primitive streak at the age of 14 days The pre-embryonic stage is defined as the period from fertilisation up to the determinant of the primitive streak at the age of 14 days The pre-embryo is unable to feel pain or pleasure and has no moral status The pre-embryo is unable to feel pain or pleasure and has no moral status The pre-embryos may be cryopreserved, discarded or used for research The pre-embryos may be cryopreserved, discarded or used for research

THE SCIENTIFIC PARADIGM …to cut off this research (without clear understanding of the science of TC and its potential to contribute to mankind) would be “an act of intellectual vandalism comparable to papal censorship of Galileo and Copernicus” (Lord May) …to cut off this research (without clear understanding of the science of TC and its potential to contribute to mankind) would be “an act of intellectual vandalism comparable to papal censorship of Galileo and Copernicus” (Lord May)

EMBRYOLOGY & ENSOULMENT “Read! In the name of your Lord, who has created. Has created man from alaqa” 96:1-2 “Read! In the name of your Lord, who has created. Has created man from alaqa” 96:1-2 “And indeed We created man from a quintessence of clay. Then we placed him as a small quantity of liquid (nutfa) in a safe lodging firmly established. Then we have fashioned the nutfa into something which clings (alaqa). Then We made alaqa into a chewed lump of flesh (mudgha). And We made the mudgha into bones, and clothed the bones with flesh. And then We brought it forth as another creation. So blessed be God, the best to create” 23:12-14 “And indeed We created man from a quintessence of clay. Then we placed him as a small quantity of liquid (nutfa) in a safe lodging firmly established. Then we have fashioned the nutfa into something which clings (alaqa). Then We made alaqa into a chewed lump of flesh (mudgha). And We made the mudgha into bones, and clothed the bones with flesh. And then We brought it forth as another creation. So blessed be God, the best to create” 23:12-14 “and breathe into him of His spirit” 32-9 “and breathe into him of His spirit” 32-9

JURISPRUDENCE OF MEDICINE The Islamic mind dismisses the pair of contraries : religious-secular; sacred-profane; church-state The Islamic mind dismisses the pair of contraries : religious-secular; sacred-profane; church-state “The Shariah (Islamic Law) is the epitome of the Islamic spirit, the most typical manifestation of the Islamic way of life …” “The Shariah (Islamic Law) is the epitome of the Islamic spirit, the most typical manifestation of the Islamic way of life …” Bioethics is inseparable from religion. Is built entirely upon the Shariah and flourishes within her jurisdiction Bioethics is inseparable from religion. Is built entirely upon the Shariah and flourishes within her jurisdiction

DESIGNER BABIES The ultimate shopping experience The “slippery slope” 29/08/2000 Adam Nash HFEA – Dec (14%) ban IGM

Other Issues 1.Abortion 2.Contraception 1.Euthanasia 2.Brain Death

CONCLUSIONS Unique opportunity to fathom the treasures and secrets of God’s creation Along with it grave and unprecedented risks Nevertheless, since we do not will unless God wills, can these breakthroughs be regarded as part of the divine will to afford humanity yet another opportunity for moral training and maturity (TARBIYAH) in our quest for excellence (IHSAN). “Thus we have appointed you a middle nation, that you may be witness against mankind, and that the messenger may be witness against you …” 2:143