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Nephrol Dial Transplant (1996) 11: 964-965 Nephrology Dialysis Transplantation Minisymposium Definition of death, organ donation and interruption of treatment in Islam Abdel Moneim Hassaballah Internal Medicine, Cairo University and The Arab Contractors Medical Center, Nasr City, Cairo, Egypt Introduction Islam as a religion is unique in providing a complete code of life. In Islamic countries religious rules and values form the main source of personal and professional concepts and ethics. Therefore, it is impossible to separate religion from the discussion of current or new laws covering different aspects of life. Accordingly, it is very important to take this into consideration when we discuss the subject of organ donation and the interruption of treatment in Islamic countries. Islamic principles on the person's relationship to his body • Human life is very valuable, killing a soul is like killing the whole of humanity and saving a soul is like saving the whole of humanity. • Human lives are equal. That is why Islam uses a single criterion for the reparation of physical damage sustained by a human being regardless of his social status, wealth or degree or knowledge. • The donor of life is God and the determinant of death is God. No man or authority has the right to decide the fate or end of a human life (aside of applying criminal laws). • Man is honoured in himself, his thinking power, his dignity and his physical wholeness.' We have honored Adam's offspring1 {Holy Koran 17:70). Life manifests itself in the existence of one human being or in thousands, millions or billions. The principle of donating organs from dead persons Initially there was some resistance to accept organ transplantation in the Islamic world. Objections were mainly based on cultural rather than religious reasons. Thus Muslim Jurists have permitted transplantation of Correspondence and offprint requests to: Prof. Dr A. Moneim Hassaballah, M.D., The Arab Contractors Medical Center, Nasr City, PO Box 9033, 11765 Cairo, Egypt. teeth and bones—practiced by muslim surgeons for over a thousand years. Even porcine bone grafts were advocated by some Muslim surgeons in spite of the fact that the pig is considered the most 'unclean' animal in Muslim life. These grafts 'take' much better than other xenografts, and heal more quickly. In support of transplantation the following sayings of the Prophet PBUH (The Hadith) can be quoted: 'The faithful in their mutual love and compassion are like the body...if one organ complains of an ailment, all other organs will rally in response' 'The faithful to one another are like the blocks in a whole building...they fortify one another'. From the holy Koran we learn its respect for human life, and its encouragement of Muslim Jurists in modern days, through a most important piece of documentation, to legitimize medical advance to save human lives: 'Whosoever killeth a human being for other than manslaughter or corruption on earth, it shall be as if he has killed all mankind. And whosoever saveth the life of one, it shall be as if he saved the life of all mankind' {Holy Koran 5:32). Over and above such documentation and as a means of interpretation and implementation, the following are the integral rules and general principles in Islam: • Need and necessity are equivalent. • Necessity allows 'prohibited' matters. • Injurious 'harm' should be removed. • Prevention of evil has priority over obtaining benefit. • The greater benefit prevails over the lesser benefit. Thus the greater 'harm' can be removed by a lesser 'harm' i.e. it is permitted to remove a greater harm by a smaller harm (quote intervention). Accordingly, we find that there is a general acceptance of the principle of organ donation from living and/or dead persons in all Islamic countries. Thus, the Head of the Azhar Islamic Institute, the Grand Mufti in Egypt, the Saudi Grand Ulama Council, the Grand Mufti in Kuwait 1996 European Dialysis and Transplant Association-European Renal Association Definition of death, organ donation and interruption of treatment in Islam and in Iraq, Algiers Supreme Islamic Council as well as the Council of Islamic Ideology in Pakistan have all approved organ donation from dead persons. In some countries specific laws to legislate cadaveric organ donation have been approved such as in Saudi Arabia, Iraq, Kuwait, and Jordan. In Egypt a law regulating corneal donation has existed since 1959, but donation of other organs has not been formally approved as yet. Brain death and organ donation The subject of brain death was discussed at the 3rd international conference of Islamic Jurists held in Amman, Jordan, in 1986. A historical resolution was taken equating brain death with cardiac and respiratory death. Fatwa no. V (religious proclamation) of the conference in Amman 1986 declared the following: 'A person (is) considered legally dead and all the shariah's principles (Islamic Law) can be applied when one of the following signs is established: (i) Complete stoppage of the heart and breathing which are decided to be irreversible by doctors. (ii) Complete stoppage of all vital functions of the brain which are decided to be irreversible by doctors and the brain has started to degenerate. 965 approval of the necessary law which has been under study and discussion for the past 5 years. Financial 'reward' and organ donation Paid organ donation has been strongly condemned by several Fatwas all over the Islamic world. Confirming this attitude a fatwa has been passed at the 4th international conference of Islamic Jurists held in Jeddah in 1988 and by the Grand Mufti in Egypt (1988). This was also condemned by Jordanian law no. 23 (1977) and no. 17 (1980), and the Iraqi law no. 85 (1986) and by Saudi Center for Organ Transplantation in 1993. Accordingly, it is generally accepted that selling of body organs is absolutely prohibited by Islam as the body of the human being and its organs are not for sale. Discontinuation of treatment by will Although life is the gift of God, body is the divine trust given to mankind to enable it to serve God as completely and fully as the wonderful creation of God has made that serving possible. God has set limits on what human beings may do with their own bodies and only the transgressors of the divine boundaries would indulge in torturing themselves in any form. Consequently, suicide and homicide are both prohibited. Moreover, man is not the owner of his self 'Do not Under these circumstances it is justified to disconnect life supporting systems even though some organs continue to function automatically (e.g. the heart) under the effect of the supporting devices.' kill thy self God is merciful to thee. He who does so, we shall put him in hell. God shall do so' {Holy Koran Since then successful campaigns for organ donation from brain dead cadavers were launched in Saudi Arabia, Kuwait, and Jordan and now donation from heart beating cadavers is acceptable and is actually performed in these countries. They now practice kidney, liver, and heart transplantation in a reasonable number. In Egypt some delay has been encountered as some members of the medical profession have as yet not accepted the concept of brain death. Consequently some Jurists are still opposing acceptance. Hence the 'Peoples Council' (Parliament) has delayed the 4:30). God honoured man when he gave him his humanity. Therefore, it is against Islamic rules to stop treatment of a living person whether by his will if he is competent or by the will of his near relatives if he is demented or non-competent. The role of the medical profession is to try to cure his ailment and to relieve his pains, but not to help him to end his life. Again in the percepts of Islam, the sick patient who shows fortitude and acceptance of his suffering, gains great credit with his Creator: killing him or ending his life will prevent such credit and is abhorrent to islamic beliefs.