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The Issue of Human Euthanasia in Saudi
Arabia
XXXXXXXXX
Writing and Research, Section 202
Dr. Runna Alghazo
TABLE OF CONTENTS
Proposal…………………………………………………………...……..3
Introduction………………………………………………………..3
Research Questions………………………………………………..4
Research Thesis…………………………………………………...4
Research Importance………………………………………………5
Methodology………………………………………………………5
Important Definitions……………………………………………...6
Literature Review……………………………………………................8
Results…………………………………………………………………...13
Results for Research Question 1…………………………………..13
Results for Research Question 2…………………………………..13
Results for Research Question 3…………………………………..13
Results for Research Question 4…………………………………..14
Results for Research Question 5…………………………………..15
Discussion……………………………………………………...17
Discussion for Research Question 1……………………………….17
Discussion for Research Question 2……………………………….17
Discussion for Research Question 3……………………………….19
Discussion for Research Question 4……………………………….20
Discussion for Research Question 5……………………………….21
Conclusion…………………………………………………………22
References……………………………………………………...23
Appendix:
Survey Questions……………………………………………………...24
2
PROPOSAL
Introduction
The issue of voluntary euthanasia in human beings has been controversial for
many decades, but recent attempts at a ‘redefinition’ of death in light of the various
new possibilities of keeping a patient’s body alive have made it significantly more so.
Previously, physicians would declare a patient to be dead if the heart stopped beating,
as it followed logically that the brain would no longer function as well. Because it is
now possible to keep a patient’s heart and lung function intact through external life
support, the medical community has been forced to come up with a new criterion for
determining time of death – brain function.
Even so, there are differences in medical opinion about which type of brain
death constitutes a sign of death. Most physicians are in agreement that damage to the
brainstem is one such sign, because the patient is no longer able to breathe or survive
unless they are supported by machines. Whether damage to the cerebral cortex, the
thinking and feeling part of the brain, can be used to determine death is a more
morally gray area. Most patients with this condition are said to be in a ‘vegetative
state’, and are technically alive because they are able to breathe on their own. They do
not, however, possess any consciousness or awareness of the world around them. As
such, many patients in the vegetative state continue to live on for years with the help
of a feeding tube.
The question of when euthanasia becomes acceptable is thus of great priority
from a legal and ethical standpoint, because a lack of ruling requires medical
personnel and family members to make difficult and often impossible decisions
regarding life and death. The three states of the technically unconscious mind – brain
death, vegetative state, and coma – are thus primarily used as a basis for this decision.
3
In addition, the issue of human euthanasia in Saudi Arabia will inevitably be
influenced by the ruling of the Qur’an on the subject, as interpreted by the leading
scholars of Islam in the country. The ethics of such a practice from an Islamic
viewpoint is, therefore, equally and perhaps more important than any other
considerations that may arise when making the decision. This research paper will thus
examine religious and multiple other deliberations that need to be taken into account
before any decision to terminate can be made.
Research Questions
1. How is euthanasia in human beings classified, and what are the distinctions
between each type of euthanasia?
2. What are the various moral, ethical, emotional and financial considerations that
need to be taken into account before any legalization/criminalization decision can
be made?
3. How does Islam view the medical practice of euthanasia and under what contexts
is it considered acceptable?
4. What are the attitudes towards human euthanasia among physicians and medical
professionals, as well as the general public in Saudi Arabia?
5. How do views on human euthanasia differ in Saudi Arabia and in Europe and the
Americas, and what are the foundations for these differences?
Research Thesis
The terms ‘life’ and ‘death’ are no longer differentiated by the medical
community on the basis of heart and lung function, but on that of brain function.
Several important distinctions exist between the different forms of euthanasia, most of
4
which toe the line between what is ethically and religiously acceptable and what is
not. Because it is now possible to keep patients with irreversible brain damage alive
indefinitely with the help of external machines, most physicians declare a patient to be
‘dead’ when the brain stem is damaged beyond repair. Keeping a patient alive on life
support may pose an enormous burden on the economy, because the level of intensive
care required to keep the person alive can be extremely expensive. Moreover, the
family of the patient may never receive closure from the intellectual death of their
loved one; particularly, if the patient is being kept alive only with the help of
machines. In contrast to the situation involving brain death, he issue of euthanasia
among patients in a vegetative state is significantly more controversial. From the
point of view of Islam, euthanasia cannot be carried out voluntarily; however, in the
case of permanent and irreversible brain death, the decision to ‘pull the plug’ can be
made.
Research Importance
With the incredible technological advances in medicine that make it possible
for a person to ‘live’ indefinitely even after extensive brain damage, the issue of when
to ‘pull the plug’ has come to the forefront. The need to establish a code of ethics and
sound legal ruling on the matter makes the examination of the different states of the
conscious/unconscious mind particularly crucial. This is necessary to ensure that
medical personnel and family members are not given undue power over the patient
and be forced to take difficult decisions regarding life and death into their own hands.
5
Methodology
This research paper relied primarily on previously published academic
journals and texts relating to the topic of euthanasia in human beings. The main
search engines used were EBSCO, the PMU ebrary and Google Scholar.
As part of the research, the paper also included a survey in the form of a
questionnaire posed to the students and faculty of PMU (representing the generalized
public of Saudi Arabia) as well as various medical personnel in hospitals in Dhahran
and Khobar (representing the experts or specialists in the field of medicine). These
was used for a comparative study of the differing views from country to country, as
well as an examination of the reasons behind these differences.
The survey involved specific instances and hypothetical situations to assess
the respondents’ opinions on the different forms of euthanasia, without actually
referring to the names of these forms (for the distinctions between each type, refer to
the discussion section in the second half of the paper). The survey also obtained
individual views on the definition of the term ‘death’, as well as their reasons for their
opinions on the issue. Questions were primarily of the yes-or-no type, and yielded
distinct results for each of the different forms of euthanasia.
Important Definitions:
Euthanasia - The act or practice of ending the life of an individual suffering from a
terminal illness or an incurable condition, as by lethal injection or the suspension of
extraordinary medical treatment.
Vegetative State - A coma-like state characterized by open eyes and the appearance
of wakefulness is defined as vegetative. This defines the behavior of a person in
6
whom brain damage has put out of action the cerebral cortex — the thinking, feeling
part of the brain — but without any lasting effect on the brain stem.
Brain death - Irreversible brain damage and loss of brain function, as evidenced by
cessation of breathing and other vital reflexes, unresponsiveness to stimuli, absence of
muscle activity, and a flat electroencephalogram for a specific length of time.
Coma - Coma, from the Greek word "koma," meaning deep sleep, is a state of
extreme unresponsiveness, in which an individual exhibits no voluntary movement or
behavior. Furthermore, in a deep coma, even painful stimuli (actions which, when
performed on a healthy individual, result in reactions) are unable to affect any
response, and normal reflexes may be lost.
Palliative care - any form of medical care or treatment that concentrates on reducing
the severity of disease symptoms, rather than striving to halt, delay, or reverse
progression of the disease itself or provide a cure. The goal is to prevent and relieve
suffering and to improve quality of life for people facing serious, complex illness.
Brain stem - Part of the brain situated between the cerebrum and spinal cord. It
contains the major autonomic regulatory centers that control the respiratory (lungs)
and cardiovascular systems (heart).
Cerebral Cortex - The extensive outer layer of gray matter of the cerebral
hemispheres, largely responsible for higher brain functions, including sensation,
voluntary muscle movement, thought, reasoning, and memory.
‘Pull the plug’ - Remove all life-supporting equipment. Example: The family debated
whether it was time to pull the plug on him.
Reference: www.answers.com
7
LITERATURE REVIEW
The medical practice of euthanasia has been a point of contention in the health
industry for many centuries. Support (or lack thereof) of the legalization of euthanasia is most
commonly based on ethical, religious, financial, legal and emotional grounds. There is no
major populace in any part of the world that stands unanimously and unequivocally in
support of euthanasia, though the general consensus varies from ‘mostly supportive’ to
‘vehemently opposed’ to its legalization in many countries.
This paper will focus almost exclusively on the attitudes towards euthanasia in Saudi
Arabia. While drawing comparisons between differing views in Saudi Arabia and the
Western world, the paper will also examine the motivations behind these differences. In other
words, by inspecting the various perspectives and considerations regarding end-of-life
matters, the paper will attempt to establish a position in this highly controversial debate.
Ethical and Moral Perspective
Most arguments that are based on concrete ethical principles and logical reasoning are
in general supportive of both active and passive euthanasia. Even so, there are some
arguments that present delicate and problematic situations as opposition to its enforcement
and legalization in practical life.
ARGUMENTS FOR
In his book, Harris (1995) connects the moral significance of euthanasia to the
way different people understand the value of life. The author defines euthanasia as
“the implementation of a decision that a particular individual’s life will come to an
end before it need do so – a decision that a life will end where it could be prolonged.”
The author elaborates on the liberal view of euthanasia, often used to argue for the
8
ethical validity of euthanasia. It is argued that if the harm of ending a life is linked
directly to the harm of depriving the individual of something they value and want,
then voluntary euthanasia is justified and acceptable. The author then continues to
examine how and why euthanasia is seen as both accommodating of and contrary to
the respect for the value of life.
Similarly, the author Rachels (1997) in the book Bioethics: An Introduction to
the History, Methods and Practice contends the notion that passive euthanasia is
morally acceptable while active euthanasia is not. This view is often based on the bare
idea that it is permissible to withhold treatment and allow a patient to die, but not to
take any direct action to kill a patient. The author argues that both killing and letting a
patient die has the same exact consequences and that either both are morally
reprehensible, or neither of them are.
It is stated that ‘letting someone die’ is not allowed as a defensible argum|ent
in most courts and rightly so, for the motivations behind those are the same as the
motivations required to actively kill a person. However, in a medical setting where a
doctor has nothing but the interests of the patients in mind, active and passive
euthanasia become highly similar, both in terms of motivations and consequences.
Accordingly, the author feels that decriminalization of one would automatically
require that of the other, and that it would hypocritical of the governments not to do
so.
P. Singer (2003) also provides support for both euthanasia and its legalization,
by examining the issue from a utilitarian perspective. The author provides reasoning
and statistical evidence as to why the slippery slope argument, frequently presented
by those who oppose euthanasia and which will be elaborated upon later in this paper.
9
He argues that while this argument was largely speculative a decade ago, evidence to
prove or disprove it can be drawn from two jurisdictions that have legalized
euthanized; namely, Oregon, U.S.A and the Netherlands. He states that there have
been no reports of the law being misused for involuntary euthanasia, and from all the
evidence that is available, it does not appear to be a situation in which the law is being
abused.
ARGUMENTS AGAINST
Contrary to the arguments above, Roy and Rapin (1994) of the European
Association of Palliative Care provide ethical arguments that oppose the legalization
of euthanasia and instead place emphasis on palliative care and treatment. They
present the slippery slope argument as part of the same, a utilitarian case that opposes
euthanasia on the grounds that vulnerable patients would be subtly pressured by
physicians to end their life for being a ‘burden’. By pointing out the inherent flaws in
human beings have been responsible for deep-seated discrimination and bias that
exists in every population, they argue that legalization of euthanasia by governments
could lead to rampant misuse and have potentially disastrous consequences.
In a similar fashion, Gillett (1988) compares the philosophical arguments
justifying euthanasia and the medical intuitions in health professionals that oppose it.
The author objects to the practice of euthanasia by stating that while rational and
reasoned arguments may support the use of euthanasia in certain situations, it goes
against every instinct of a humane doctor whose first impulse is to devote him/herself
to the protection and preservation of life. Thus, any health professional would
experience the ‘pause’ before carrying out euthanasia because they recognize the
10
sanctity of human life. It is this intuitive pause that plays an important role in our
moral reasoning even though it cannot be captured in concrete ethical principles.
Religious Perspective
As this paper will focus primarily upon Saudi Arabia, which is an Islamic country that
relies on religious ruling and jurisdiction, the acceptability of euthanasia is examined solely
in the case of Islam and no other religion. This is particularly important considering that all
legal issues are decided on the verdict of Islamic scholars and less on the basis of
philosophical arguments.
Bazzaz, Larijani and Zahedi (2007) examine the Islamic point-of-view on several
ethical issues that arise due to the accessibility of pain-relief and life-support treatments. With
evidence from the Qur’an and other Islamic sources, the authors state unequivocally that
human life cannot be terminated by any form of active euthanasia or physician-assisted
suicide. However, the ruling on withdrawal of essential life-support for end-stage patients is
more ambiguous. The paper states that this kind of decision-making must be made after a
balanced consideration of all medical, ethical, societal and cultural aspects.
Similarly, Sachedina (2005) examines the permissibility of active and passive
euthanasia as medical practices in Islam. After consulting several sources including the
Qur’an and Hadith, the author concludes that the killing of a terminally ill person (or active
euthanasia) is judged an act of disobedience against God. However, it is stated clearly that
pain relief treatment or withholding essential life-support treatment (in which a person whose
disease is causing untreatable suffering is allowed to die) is permitted, as long as explicit
consent is provided by the patient and/or his or her family.
11
Previous Research Data
There have been several surveys and case studies conducted in Europe and the
Americas concerning the debate about the legalization of euthanasia.
Cuttini et. al (2004) conducted a survey of neonatal intensive care units staff across
Europe on the issue of legalization of euthanasia. A total of 142 neonatal intensive care units
were surveyed by census and the anonymous questionnaire was completed by 1391 doctors
and 3410 nurses. The results varied widely between countries, though the general consensus
amongst staff was that the law in their country should be changed to allow active euthanasia
“more than now”. In other words, a significant percentage of the surveyors were in favor of
legalization of voluntary, active euthanasia. Netherlands had the highest percentage of
doctors supporting active euthanasia (more than 53%), whereas France had less than a quarter
who did the same. Even so, there was no uniform support for the legalization of euthanasia in
any country, even in those where neonatal euthanasia is already practiced.
In addition, Chater et. al (2006) investigated personal attitudes of patients receiving
palliative care for advanced cancer towards euthanasia in a first-of-its-kind survey conducted
in Canada with seventy terminally ill cancer patients over a two-year period, from 1996 to
1998. The results indicated that the majority of participants (73%) believed that euthanasia
or physician-assisted suicide should be legalized, with their major reasons being pain and the
right of an individual to make their own choices concerning their bodies. 58% of the
participants indicated that, if legal, they might personally ask to be euthanized in the future,
especially if pain levels increase or become intolerable. The conclusions of the survey
indicated the fact that most patients in the survey with advanced cancer were in favor of
legalization of euthanasia.
12
Similarly, Breding et. al (2004) examined the case of an 8 month-old infant who was
abused severely by her father, resulting in her entering a persistent vegetative state. The
article described the ethical issues involved with appointing a guardian for the infant, and
makes a mention about the statistical probability of an infant recovering from a comatose
state, as well as the costs incurred from caring for patients in persistent vegetative states in
skilled nursing facilities (ranging from $126,000 to $180,000 per annum). The financial and
emotional impact on the family of the child is mentioned to be clearly significant as well.
Doing so, it provides support for the option of euthanasia in cases of severe child abuse with
poor prognosis for recovery, though only as a last option.
Most of the sources citing ethical/philosophical arguments and practical
considerations are slated in support of euthanasia, whereas those presenting religious
arguments are opposed to it. Even so, each argument holds significance and is backed up by
logical reasoning and sound evidence, and will prove to be useful to arrive at a stance on this
highly debatable issue.
13
RESULTS
Research Q 1: How is euthanasia in human beings classified, and what are the
distinctions between each type of euthanasia?
Euthanasia may be classified by means or by consent (Stanford Encyclopedia
of Philosophy [SEP], 1996). Euthanasia can be conducted with consent, also known
as voluntary euthanasia, or without consent. It may also be classified as active, non-
active, or passive, on the basis of the means used to carry out the procedure.
Research Q 2: What are the various moral, ethical, emotional and financial
considerations that need to be taken into account before any legalization decision can
be made?
Of the many influential factors into making this decision, moral and ethical
arguments often take precedence. Ethical arguments that argue for the legalization of
euthanasia generally cite the individual rights that a person should have over one’s
own body. In contrast, there exist several cases against euthanasia, the strongest of
which involves the slippery slope argument (Harris, 1995; Rapin & Roy, 1994; Singer
2003). Financial concerns associated with such a decision often come into the
forefront in the cases of patients being kept alive through intensive life-saving
machinery. Additionally, emotional considerations also arise whenever a decision to
terminate needs to be made, both in the cases of a person in intolerable pain, and a
patient that is being kept alive on life support with no hope for neurological recovery.
Research Q 3: How does Islam view the medical practice of euthanasia and under
what contexts is it considered acceptable?
With evidence from the Qur’an, it is clear that the active killing of a patient by
a physician, or voluntary active euthanasia, is unlawful and judged as an act of
14
disobedience against God. Physician-assisted euthanasia is also not permissible, as
suicide is forbidden in Islam (Bazzaz, Larijani & Zahedi, 2007; Sachedina, 2005).
However, in the case of patients suffering from complete and irreversible brain
death, including conditions such as an unresponsive coma and lack of an ability to
breathe on one’s own, withdrawal of life support is permissible in Islam (Sachedina,
2005).
Research Q 4: What are the attitudes towards human euthanasia among physicians
and medical professionals, as well as the general public in Saudi Arabia?
The majority of the individuals surveyed (64%) opposed active euthanasia,
whereas 35% stated that they believed a terminally ill, suffering patient should be
provided the option to end their own life. However, a mere 6% showed support for
physician-assisted suicide, with a significant majority opposed to both this kind of
suicide as well as active euthanasia.
A similar fraction of respondents (67%) opposed the legalization of active
euthanasia in Saudi Arabia. Amongst the medically-qualified respondents, 88%
indicated that they were strongly opposed to both active euthanasia and physician-
assisted suicide, and also believed that this form of human euthanasia should not be
decriminalized in Saudi Arabia.
When questioned on whether the legal definition of death should be made in
terms of heart and lung function or on that of brain functioning, 57% of the
respondents stated that they believed the latter to be as a determiner of death.
A comparable proportion (46%) however, indicated that they believed ‘death’
takes place at the natural end of the heart and lung function. 75% of the respondents
who possessed some degree of medical expertise chose brain death to be the sole
15
Physician-assisted suicide
Passive Euthanasia
Non-active Euthanasia (only in the case of complete brain death)
Active Euthanasia
0% 20% 40% 60% 80% 100%
6%
57%
73%
35%
93%
41%
27%
65%
NOYES
decider of death, however, and a small fraction equated death as the end of both body
and brain function.
Similarly, questions were posed in the form of hypothetical situations to assess
individual attitudes towards non-active and passive euthanasia. A distinction was
made in the case of non-active euthanasia, with one question relating to a Persistent
Vegetative State (PVS – a condition in which a person has no cognitive brain function
but is able to breathe on his/her own), and the other relating to complete and
irreversible brain death (a condition in which the person can no longer breathe
without the help of machines).
68% of the respondents stated that they disagreed with the option of
euthanasia in the case of PVS, but 73% supported its use in the case of complete and
irreversible brain death. The views of the medical experts surveyed roughly coincided
with these results, with 75% opposing euthanasia for a patient in PVS, and 88%
agreeing with its implementation in the case of complete brain death.
16
Are the forms of euthanasia above acceptable?
Lastly, the respondents were asked to choose one or more of the grounds upon
which their opinions were based. The overwhelming majority of these were religious
reasons (68%), ethical reasons (73%) and emotional reasons (57%). Other reasons
stated were legal (30%) and financial (10%). The proportions varied amongst the
physicians and medical students, with 88% choosing religious reasons as the basis of
their opinion, 75% ethical, 50% legal, 25% emotional and 25% citing financial
concerns.
Research Q5: How do views on human euthanasia differ in Saudi Arabia and in
Europe and the Americas, and what are the foundations for these differences?
Several surveys have been published on the issue of human euthanasia in
Europe and the Americas; there are less so in Saudi Arabia and/or the Middle East.
Cuttini et. al (2004) conducted a survey of neonatal intensive care units staff
across Europe on the issue of legalization of euthanasia. The results varied widely
between countries, though the general consensus amongst staff was that the law in
their country should be changed to allow active euthanasia “more than now”. In other
words, a significant percentage of the surveyors were in favor of legalization of
voluntary, active euthanasia. Netherlands had the highest percentage of doctors
supporting active euthanasia (more than 53%), whereas France had less than a quarter
who did the same.
In addition, Chater et. al (2006) investigated personal attitudes towards
euthanasia of patients receiving palliative care for advanced cancer, in a first-of-its-
kind survey conducted in Canada. The results indicated that the majority of
participants (73%) believed that euthanasia or physician-assisted suicide should be
legalized, with their major reasons being pain and the right of an individual to make
their own choices concerning their bodies. 58% of the participants indicated that, if
17
legal, they might personally ask to be euthanized in the future, especially if pain levels
increase or become intolerable. The conclusions of the survey indicated the fact that
most patients in the survey with advanced cancer were in favor of legalization of
euthanasia.
These surveys indicate that there are significant differences in the attitudes of
people in Europe and Canada, and the Middle East. Active euthanasia is found to be
widely supported and even legalized (such as in the Netherlands), whereas it is
considered immoral both constitutionally and ethically in Saudi Arabia.
18
DISCUSSION
1. How is euthanasia in human beings classified, and what are the distinctions between
each type of euthanasia?
Euthanasia may be classified by means or by consent (Stanford Encyclopedia
of Philosophy [SEP], 1996). Euthanasia can be conducted with consent, wherein the
patient provides explicit permission to the physician to carry out the procedure
(voluntary euthanasia), or without consent. The latter category has two very important
distinctions. Involuntary euthanasia involves the termination of a patient’s life against
his/her wishes, and is more or less equivalent to murder. Non-voluntary euthanasia, on
the other hand, includes instances in which the patient is unable to make a decision
about euthanasia, either because they are unconscious or not mentally competent, and
a proxy is requested to make medical decisions on his/her behalf.
Euthanasia may also be classified as active, non-active, or passive. Active
euthanasia is the practice of deliberately ending the life of an individual (with
consent) suffering from a terminal illness, as by lethal injection. Non-active
euthanasia includes the withdrawing of life support to end the life of an individual
(with consent from the medical proxy) who has suffered extensive and irreversible
brain damage. Passive euthanasia entails the withholding of common treatments upon
request (such as antibiotics, chemotherapy in cancer, or surgery) or the distribution of
a medication (such as morphine) to relieve pain, knowing that it may also result in
death. Physician-assisted suicide is also distinct from active euthanasia, as it entails
physicians providing the means for the patient to end his/her life rather than actively
administering death themselves. (Rachels, 1997; Rapin & Roy, 1997; SEP, 1996).
19
2. What are the various moral, ethical, emotional and financial considerations that need
to be taken into account before any legalization/criminalization decision can be
made?
There are several divergent opinions relating to euthanasia in the field of
medical ethics. Most arguments that are derived from concrete ethical and
philosophical principles are generally supportive of both active and passive
euthanasia, although a significant amount of moral opposition to these exist as well.
Ethical arguments that argue for the legalization of euthanasia generally cite
the individual rights that a person should have over one’s own body, particularly in
the case wherein the patient undergoes the agonizing pain associated with several
terminal illnesses. It is argued that if the harm of ending a life is linked directly to the
harm of depriving the individual of something they value and want, then voluntary
euthanasia is justified and acceptable (Harris, 1995). Similarly, Rachels (1997)
contends the legalization of passive and non-active euthanasia over its active
counterpart, stating that they are hardly any different when one considers the
motivations behind each, and their consequences.
Conversely, there are several cases against the medical practice of euthanasia.
Arguably the strongest ethical opposition to euthanasia involves the slippery slope
argument, a utilitarian case that opposes euthanasia on the grounds that vulnerable
patients would be subtly pressured by physicians to end their life for being a ‘burden’
(Rapin & Roy, 1994; Singer, 2003). In addition, it can also be argued that euthanasia
goes against every instinct of a humane doctor whose first impulse is to devote
him/herself to the protection and preservation of life. Thus, any health professional
would experience the ‘pause’ before carrying out euthanasia because they recognize
the sanctity of human life, and it is this intuitive pause that plays an important role in
20
one’s moral reasoning even though it cannot be captured in concrete ethical
principles. (Gillett, 2004)
Additionally, there are several financial concerns associated with euthanasia.
They are particularly more significant in the cases of patients who have suffered
extensive brain damage and are being kept alive through life support. Intensive care is
very expensive; it has been estimated that the costs incurred from caring for patients
in persistent vegetative states in skilled nursing facilities range from $126,000 to
$180,000 per annum (Breding et. al, 2004). Patients who experience brain death
require additional expenses, because they require a heart and lung machine as well as
an assortment of other costly life-saving equipment to stay alive. The long-term
expenses from these treatments can therefore pose a great burden on both the
surviving family and the economy, especially in developing countries.
Several emotional considerations also need to be taken into account when the
issue of whether to terminate arises. The pain and distress terminal diseases can cause,
even after the use of pain relievers, can be incomprehensible to a person who has not
gone through it. Even without considering the physical pain, it is often difficult for
patients to overcome the emotional pain of losing their independence (SEP, 1996). In
the case of patients being kept alive on life support with no hope for neurological
recovery and/or ever regaining consciousness, his/her family and friends may not find
closure for the intellectual death for their loved one. In other words, while the body of
the patient may be alive and functioning, there would be nothing left of the person
that his/her family knew and loved, and this would most likely add to their grief and
distress.
21
3. How does Islam view the medical practice of euthanasia and under what contexts is it
considered acceptable?
It is stated explicitly in the Qur’an that “it is not given to any soul to die, save
by the leave of God, at an appointed time.” (3:145). Moreover, the statements “God
gives life, and He makes to die.” (Qur’an 3:156), and “A person dies when it is
written.” (Qur’an, 3:185; 29:57; 39:42) both indicate that destiny is determined by
God for every person, and that no man has the right to decide the death of another
person. Therefore, it is clear that the active killing of a patient by a physician, or
voluntary active euthanasia, is unlawful and judged as an act of disobedience against
God. As suicide is also forbidden in Islam, it follows logically that any active step the
patient may take to end his/her life is not considered permissible. (Bazzaz, Larijani &
Zahedi, 2007; Sachedina, 2005)
On the other hand, the Qur’an also provides a reminder that there are times
when human beings need to recognize their limits and let nature take its course
(39:42). As such, the repeated and continued use of intensive life-saving treatment to
keep a patient alive, when there is no possibility of reversal of the effects of the
disease and discontinuation of this treatment would result in immediate death, would
then be futile and against the will of God. At several meetings of the Islamic Juridical
Council held in Makkah, Jeddah and Amman, Muslim jurists of different schools of
thought ruled that “once invasive treatment has been intensified to save the life of the
patient, life-saving equipment cannot be turned off unless the physicians are certain
about the inevitability of death.” However, in the instance of brain death, when the
patient undergoes irreversible damage to the brain stem and cannot breathe on his/her
own, the jurists ruled that “if three attending physicians attest to a totally damaged
brain that results in unresponsive coma, apnea, and absent cephalic reflexes, and if a
22
patient can be kept alive only by a respirator, then the person is biologically dead,”
and that withdrawal of life support was, in this case, permissible in Islam. (Sachedina,
2005)
4. What are the attitudes towards human euthanasia among physicians and medical
professionals, as well as the general public in Saudi Arabia?
The survey indicated that there were differing results relating to each
individual form of euthanasia (c.f. the Results section). The overwhelming majority of
both the general public and medically-qualified personnel were opposed to active
euthanasia and its legalization in Saudi Arabia. As roughly 70% of both cited
religious and ethical reasons behind this opinion, it is safe to assume that the outcome
is so because the majority of the population is Muslim, and the Qur’an clearly states
that God is the sole determiner of the death of a person, and not man. Moreover,
Saudi Arabia is a strictly conservative country, and the greater part of its population is
similar in terms of moral/ethical conventions. Likewise, a very large percentage of
respondents were opposed to physician-assisted suicide, another result that was most
likely due to the fact that suicide in Islam is forbidden (Sachedina, 2005).
When questioned on whether cessation of heart and lung function or brain
death should be used to determine time of death, the results were roughly equal, with
the latter option exceeding the former by a tiny percentage (9%). The former option is
more or less the traditional view of death, which is probably the reason behind this
choice. A small proportion (8%) also chose both for a person to be declared dead. It is
likely that this is largely due to ignorance or unawareness of the fact that it is possible
for a person to be kept alive on a heart-and-lung machine, whilst they are entirely
brain dead. In such circumstances, it becomes important to choose one of the several
options in order to make a decision of whether to terminate. Amongst the medical
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experts, however, brain death was chosen by 75% of the respondents as the primary
determiner of death. Since they have more expertise on the matter as well as more
awareness about emerging medical technology, their view roughly corresponds to the
legal definition of death in most countries, including Saudi Arabia.
In the questions relating to non-active euthanasia, specifically in the issue of
withdrawal of life-support, the results were conflicted between two forms of
consciousness – Persistent Vegetative State and Brain Death. 68% of the respondents
indicated that they were opposed to euthanasia in patients who had suffered extensive
brain damage but retained the capability to breathe on their own, while only 27%
were opposed to the same in patients who had suffered complete brain death. This is
most likely due to the belief that patients in PVS are still alive and breathing, and
euthanasia in this case would thus be equivalent to murder. In the case of patients
being kept alive solely on life-saving equipment, he/she is already dead biologically
and hence, it would be best to let nature take its course and allow the person to die
peacefully and painlessly.
On the issue of passive euthanasia, the results were once again nearly equally
dispersed between whether a person should be allowed to turn down life-saving
treatments or not, particularly with the knowledge that refusal of such treatments will
result in death. The question is tricky, because some view the refusal of life-saving
treatments to be more or less equivalent to suicide, which is prohibited in Islam.
However, 63% of the medically-qualified respondents indicated that they believed
patients should be given the option to refuse treatment, most likely due to the legal
ramifications and disputes that could arise in the case of forced treatment.
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5. How do views on human euthanasia differ in Saudi Arabia and in Europe and the
Americas, and what are the foundations for these differences?
In comparison with the survey conducted in Saudi Arabia, it was found that
there are significant differences in the attitudes of people in the two regions towards
hum Specifically, active euthanasia and physician-assisted suicide were found to be
widely supported in the Canada and many countries of Europe, whereas it was quite
strongly opposed to in Saudi Arabia (Chater et. al, 2006; Cuttini et. al, 2004). This
most likely due to the fact that these are secular democracies, whereas Saudi Arabia is
a religious monarchy. They have a substantial faction of people that are atheistic,
agnostic, or not Muslim, and the environment in these countries is noticeably more
liberal. Religious differences are therefore the most likely grounds for the disparity,
closely followed by ethical and moral differences.
In the case of patients with irreversible and complete brain death, however, the
difference was not as profound. This may be due to the fact that scientific technology
today provides physicians the capability to gauge the extent of brain damage, and to
determine, quite accurately, the degree to which the person may be brain dead. In
such cases, the decision to prolong life through intensive care becomes futile, and it is
agreed in both regions that withdrawal of life support may thus remain the only
option.
Conclusion
The current legal ruling on human euthanasia in Saudi Arabia is decided by the
leading theological scholars of Islam, and is similar to the Islamic ruling on euthanasia; that
all forms of euthanasia are actively disallowed except in the cases of complete and
irreversible brain death (Sachedina, 2005). This statute is consistent with the view of both
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the general public and medical experts on the subject of euthanasia, with most citing
religious, ethical and emotional reasons as the bases of the views.
The projected scenario for any change in policy is thus unlikely, not only due to the
fact that Saudi Arabia is first and foremost a religious country but also because there is very
little opposition from most of its population towards the rule.
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REFERENCES
1. Bazzaz, J. T., Larijani, B., & Zahedi, F. (2007). End of life ethical issues and Islamic views. Iran J Allergy Asthma Immunol, 6, 5-15.
2. Breding, J., Friedlander, S. F., Gladsjo, J. A., Kalemkiarian, S., Oak, J., Sine, D., et al. (2004). Termination of life support after severe child abuse… Pediatrics: Official Journal of the American Academy of Pediatrics, 113, 141-145.
3. Chater, S., Curran, D., Faye, B. J., Graham, I. D., Kozak, J. F., Viola, R. A., et al. (2000). Attitudes of Terminally Ill Patients Toward Euthanasia and Physician-Assisted Suicide. Archives of Internal Medicine, 160, 2454-2460.
4. Cuttini, M., Casotto, V., Kaminski, M., Beaufort, I. D., Berbik, I., Hansen, G., et al. (2004). Should euthanasia be legal? An international survey… Arch Dis Child Fetal Neonatal Ed, 89, F19-F24.
5. Gillett, G. (1988). Euthanasia, letting die and the pause. Journal of Medical Ethics, 14, 61-68.
6. Harris, J. (1995). Euthanasia and the value of life. In J. Keown (Ed.), Euthanasia examined: Ethical, clinical and legal...
7. Rachels, J. (1997). Active and passive euthanasia. In N. S. Jecker, A. R. Jonsen, & R. A. Pearlman (Eds.), Bioethics: An Introduction to the History, Methods, and Practice (pp. 77-83).
8. Rapin, C.H., & Roy, D. J. (1994). Ethics regarding euthanasia. European Journal of Palliative Care, 1, 57-59.
9. Sachedina, A. (2005). End-of-life: the Islamic view. The Lancet, 366, 774-79.
10. Singer, P. (2003). Voluntary euthanasia: A utilitarian perspective. Bioethics, 17, 5-6.
11. Stanford Encyclopedia of Philosophy. (1996). Voluntary Euthanasia. Retrieved June 3, 2009 from, http://plato.stanford.edu/entries/euthanasia-voluntary
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APPENDIX
Survey Questions
1. State your level of medical expertise:
o Medical professional/health practitioner
o Medical student
o Other
2. Do you think the term ‘death’ should be defined by:
o End of heart and lung
function
o Brain death
o Other. Specify:
___________
o No opinion.
3. If a patient is suffering from an extremely painful, terminal illness, do you
believe they should be given the option to end their own life?
o Yes o No
a. If yes, should the physician-in-charge be given the option to assist in this
form of “mercy-killing”?
o Yes o No o N/A
b. Do you think this form of euthanasia should be legalized in Saudi Arabia?
o Yes o No
4. A patient has survived a car crash, but the resulting trauma has caused the patient to
experience some form of brain damage. The patient now has no cognitive brain
function, or the awareness of the world around him/her.
a. If the patient is in a persistent vegetative state (able to breathe on his/her
own), do you think the family should be given the option to terminate his/her
life?
o Yes o No
b. If the patient has undergone brain death and can no longer breathe
without
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the help of machines, do you think the family should be given the option
to terminate his/her life?
o Yes
o No
5. Do you believe that patients who refuse life-saving treatment (such as antibiotics,
chemotherapy for cancer, or surgery) should be given an option to do so, with
the knowledge that withholding these treatments can result in death?
o Yes o No
6. Your basis for your opinions include: (Tick all that apply)
o Religious reasons
o Ethical reasons
o Legal reasons
o Emotional reasons
o Financial reasons
o Other
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