Priority Setting in Bioethics: Top 10 Bioethical Challenges
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Priority Setting in Islamic Bioethics: Top 10 Bioethical Challenges in Islamic Countries

Dr Alireza Bagheri | 01/03/2015
Priority Setting in Islamic Bioethics: Top 10 Bioethical Challenges in Islamic Countries

Introduction

The ethical dilemmas raised by new advances in science and technology have challenged all societies, religious as well as non-religious. In the last decades, secularisation of bioethics has become a dominant trend in bioethical discussions, as observed by Daniel Callahan two decades ago:

… the field of bioethics has moved from one dominated by religious and medical tradition to one now increasingly shaped by philosophical and legal concept

(Callahan 1990).

 

However, in many religious societies, for example in Muslim societies, religious tradition continues to be the dominant approach and the main source in responding to the ethical questions in biomedicine. Islamic Shari’a governs not only the private lives of individual Muslims, but it is also the basis for decision-making and setting of public policies. Hence, Muslim scholars have

tried to respond to the ethical questions in light of religious tradition. It should be noted that diversity exists among Muslims in different countries and positions taken by Muslim jurists on ethical issues are not unified.

Currently, the Muslim population consists of almost one-fourth of the world’s population, and in the era of globalisation, multiculturalism has become a distinctive characteristic of many societies worldwide. Therefore, not only is it important for bioethicists worldwide to understand their own traditions and values, but also that of different cultures and religious traditions within their communities. This may explain why recent Western academic research also stresses the importance of incorporating the Islamic discourse in bioethical debates (Brockopp 2008). Although Islamic countries are geographically diverse, they are nevertheless similar in terms of religious background. However, regarding bioethical issues, each Islamic country may have different priorities and challenges.

In order to identify the priorities of bioethical challenges in Islamic societies, an international questionnaire survey was conducted in 2010 and 2011. This article presents the results of the survey in its ranking of the top 10 bioethical priorities in Islamic countries.

 

Methods and Materials

In this study, a questionnaire survey was conducted to document the opinions of Muslim bioethicists—who have written on bioethical issues—about bioethics priorities in Islamic countries. In the first step, based on an extensive literature review on bioethical topics written by Muslim bioethicists, in English, Arabic and Persian, a list of topics in Islamic bioethics was identified. The list was sent to five Muslim bioethicists in different countries, asking them to mark topics that are more relevant and important in Islamic countries and in Islamic bioethics based on their opinions. Then, a questionnaire with 20 topics was developed and sent to Muslim bioethicists in 15 Islamic countries as well as several Muslim bioethicists who reside in Europe and North America. In this survey, participants were asked to rank the top 10 bioethical challenges from a list of 20 topics using numeric ranking (1 = most important to 10).

 

Results

Out of 65 questionnaires sent by email to Muslim bioethicists in 15 countries, 54 responses were returned, giving a response rate of 83 per cent. One response was not considered for data analysis because it was not completed correctly. As shown in the profiles of the respondents in Table 1, 62 per cent of them were healthcare professionals, 37 per cent were non-healthcare professionals, 30.2 per cent were females and 69.8 per cent were males. The following list includes the top 10 bioethical challenges in Islamic countries that participants have chosen among 20 topics listed in the questionnaire (Table 2).

It should be noted that there were 20 topics on the questionnaire. However, the following 10 bioethical topics in the questionnaire did not get priority to be included in the top 10 listings: public health ethics and pandemic planning; ethics in research; IVF, surrogacy and embryo donation; cloning and stem cell research; women’s health ethics; end-of-life ethics; environmental ethics; beginning-of-life ethics; genomic ethics; and nanoethics.

 

Table 1

 

 

 

 

Table 2

 

 

 

Discussion

In Islamic societies, the teachings of Islam have shaped Muslims’ personal social life as well as their practice and attitude towards health, illness, life and death. Therefore, for many Muslims, religious beliefs are a major determinant in decision-making, especially regarding healthcare.

Islamic legal and ethical traditions form the foundation when dealing with inquiry about new emerging issues in the field of biomedicine (Shomali 2008).

It covers practical aspects of clinical and research-related decision-making. However, in the absence of a central authority for all schools of thought in Islam, determination of valid religious practice is left to the opinion of qualified scholars of Islamic Shari’a (faqih). Accordingly, in dealing with bioethical questions in Islamic jurisprudence, if there is no textual ordinance (nass) offering explicit guidance on the issue under consideration, decisions on the matters fall in the domain of juristic discretion (ijtihad). As observed by Farhat Moazam, in Islamic bioethics, discussions and rulings are not fashioned in a vacuum but shaped by interplay of perceived boundaries of authority within political and legal systems and existing societal norms (Moazam 2011). In practice, there is a constructive collaboration between Islamic jurists as the experts of the texts and scientists as the experts of the contexts to provide ethical guidelines for such complex dilemmas. In this study, based on the experts’ opinions, the relation between law, ethics and fatwa was ranked as the No. 1 priority among the 20 bioethical challenges in Islamic countries. In all ethical systems, religious or non-religious bioethics, the relationship between ethics and law is an important issue that needs to be discussed and defined. However, when it comes to Islam, another factor, namely Islamic juridical ruling or fatwa, plays a great role. It is generally acknowledged that bioethics in Islam is mainly a branch of Islamic law and ethics. A review of bioethics literature under the domain of “Islamic bioethics” shows that scholars usually make reference to the main sources of Islam: the Qur’an and the Sunna (words and practices of the Prophet of Islam). The main task of these scholars, however, is to give “an independent legal reasoning or interpretation,” known in the Islamic tradition as Ijtihad of what these sources would imply about different bioethical issues (Ghaly 2010). In practice, to deal with bioethical dilemmas, both biomedical scientists and religious scholars are involved in the discussions as well as decision-making process. With slightly different approaches, in order to arrive at a solution, the first step is to find the religious position regarding the issue at hand. For instance, on the issue of organ transplantation, the first question to be addressed is whether organ removal from a brain-dead patient is acceptable or not according to Islamic Shari’a, and only if the act

is permissible, a bill could then be submitted to the legislators for approval. However, it should be noted that in practice—in many cases—after all these steps, the related ethical dimensions of the case under consideration will be discussed.

In Islamic bioethics, the priority of the religious position is evident on the basis of the fact that in case of any question about the application of a new biotechnological manipulation (permission or prohibition of an act), scientists and physicians are very keen to explore the opinions of Islamic scholars (faqih) on the issue. The work of the Islamic Organization for Medical Sciences (IOMS)

shows how important it is to first elaborate on the opinion of Islamic Shari’a concerning the questions raised as a result of the advancement in the field of biotechnology (Al-Awadi 2000). Therefore, in Muslim societies, the ethicotheological discourse is overshadowed by juridical rulings. As Sachadina argues, “… although Islamic juridical methodology was firmly founded on some moral principles like rejection of harm and promotion of public good in deriving solutions that Muslims encountered in their everyday life, gradually, the judicial opinions were formulated without any reference to ethical dimensions of the cases under consideration”. He further observes: “… in general, ethical inquiry connected with moral epistemology or moral ontology is underdeveloped in the Muslim seminarian curriculum which is, in large measure, legal-oriented” (Sachadina 2009: 10, 19). It should be noted that on the one hand, the existence of positive fatwa legitimises the practice, even in the vacuum of legislation and ethical deliberation, while on the other hand if a practice is banned according to the opinion of Muslim jurists, then there is no room for legislation or ethical deliberation. For instance, embryo donation, surrogacy and sperm donation are not permissible in many Muslim countries (except Iran). Therefore, the topic is out of question and is not a priority for experts in the field to discuss. Choosing this topic as the No. 1 priority confirms how bioethical discussions depend on the relationship between ethics, law and fatwa, and how important it is to define these relationships.

Based on Islamic teachings, the principle of Justice represents a common concern in Islamic societies, and it is not surprising that in this survey, Muslim bioethicists have ranked “justice and health resource allocation” as the second top bioethical dilemma. Regardless of the controversy around the definition of the principle of justice and its application, justice is a universally shared principle. The ethical challenge of justly distributing limited resources is among the most persistent and thorny questions in health policy (Danis et al. 2011).

Justice is stated directly in the revealed divine texts. The Qur’anic verses define justice and equity in general terms; however, its definition and application to concrete situations have been left to the opinion of Muslim jurists. The Holy Qur’an makes reference to justice in a very strong and influential statement in which emphasis is placed on the importance of observing justice in all aspects of human life, public as well as private. It reads: “God commands justice and good deeds” (16:90); “Tell, I have been commended to be just between you” (42:15); and “when you judge between people, you judge with justice” (4:58).

As mentioned earlier, there is controversy on how to apply all these theoretical concepts and definitions in a concrete situation. In several efforts to develop a set of the principles of Islamic bioethics, justice has been considered an important principle (Larijani and Zahedi 2008). There is a scarcity of health resources in many Islamic countries and it is very crucial to develop a conceptual framework for just distribution of health resources based on the Islamic concept of justice.

Along with the development of bioethics, there is an increasing emphasis on the concept of human rights by making a direct link between bioethics and human rights. Several international bioethical documents have been developed in reference to the Declaration of Human Rights. For instance, the aim of the UNESCO Declaration of Bioethics and Human Rights was to provide a universal framework in the field of bioethics to promote respect for human dignity and human rights (Universal Declaration 2005). However, when it comes to religious perspective on human rights, there are some concerns and reservations in Islamic countries. Since 1948, when the Universal Declaration of Human Rights was adopted and signed by many Islamic countries (but not all), the controversy began on whether the Declaration is consistent with the Islamic Shari’a. In an attempt to define human rights according to Islamic Shari’a, the Cairo Declaration of Human Rights in Islam adopted 45 member states of the Organization of the Islamic Conference (OIC, now Organization of Islamic Cooperation) on 5 August 1990. This Declaration is by far one of the most important documents on human rights in the Muslim world (Cairo Declaration 1990). Article 24 of the Cairo Declaration states: “All the rights and freedoms stipulated in this

Declaration are subject to the Islamic Shari’a” and Article 25 asserts that: “The Islamic Shari’a is the only source of reference for the explanation or clarification of any of the articles of this Declaration”. However, as the Universal Declaration of Human Rights has been criticised by Islamic countries for not being sensitive to cultural contexts, the Cairo Declaration has also been subject to criticism—that it failed to specify what exactly constitutes Shari’a, and therefore, the restriction of the rights, mentioned in that Declaration, is ambiguous (Kayaoglu 2013). As the respondents to this questionnaire were bioethics experts who are quite familiar with the concept of human rights as well as Islamic traditions, one can conclude that it shows the importance of the concept of human rights and also the need to resolve the conflict between the international

norm of human rights and the religiously acceptable notion of human rights in Islamic societies.

The number four challenge chosen by participants was “bioethics capacity-building”. Given the fact that bioethics in the modern sense has been developed in Western countries, it was not until the last two decades that Islamic countries started to build capacity in bioethics. Although efforts and the level of importance differ among these countries, bioethics institutes, research centres and academic courses have been established in many Islamic countries. In this regard, bioethics initiatives in Iran, Pakistan, Egypt, Turkey and Malaysia are noticeable. However, choosing this topic as a bioethical challenge shows that capacity-building in bioethics is critically needed in Islamic countries.

The issue of the patient’s rights is ranked number five in the listings. There has been a growing attention to the concept of patient rights in Islamic societies, and some countries have developed their national charter of patients’ rights (Parsapoor et al. 2012). However, there are several factors which make it difficult—if not impossible—to establish a healthcare delivery system based on patient-centred care. In Islamic countries, there exists first a predominant paternalism in the healthcare system in which physicians reserve the ultimate power in the decision-making process. Second, the family plays a big role in making decisions concerning healthcare. Therefore, the notion of patient rights and patient-centered care as perceived in the West would be a challenge for bioethics in Islamic countries, as shown in this survey.

Since more than half a century ago, brain death and organ transplantation have sparked long-lasting discussions among Islamic jurists and physicians. Interestingly, the issue remains a tough topic in Islamic countries; it is ranked as a number six challenge. It should be noted that because most of the articles in Islamic bioethics have combined these two topics together, in this questionnaire survey, these two topics were presented as one option. In fact, there is no textual ruling in the Qur’an and the Islamic tradition about brain death. Therefore, it is a matter open to juristic discretion (ijtihad) and this explains the existing controversy among Islamic jurists. However, referring to the importance of saving life in Islam, Islamic countries, which have the capability to perform organ transplantation, have adopted necessary legislations allowing organ removal from brain-dead patients for the purpose of transplantation (Bagheri 2005).

The issue of individual autonomy and informed consent form the seventh priority in this survey. A close examination of Islamic bioethics confirms the importance of informed consent in biomedical research as it does in Western bioethics. However, in terms of individual autonomy, especially in clinical settings, unlike in the West where individual autonomy is the cornerstone of

bioethics, it can be claimed that such notions of individual autonomy is not recognised in Muslim societies. In fact, regarding individual rights and autonomy, two principles in Islamic bioethics—public good (maslahah) and the principle of “no harm and no harassment”—form the basis of decision-making in health-care and public policy.

A review of the decisions taken by some Islamic juridical authorities, such as Majma’ al-fiqhi al-islami (the Islamic Juridical Council) based in Saudi Arabia, shows that in their decisions, they have tried to balance the likely benefits and harms to society as a whole. These decisions indicate the search for proportionality between individual and community interests and the need, in certain cases, to allow collective interests to override individual interests and rights (Sachedina 2009: 48).

In bioethical discussions, the so-called principlism, i.e. four principles of bioethics—respect for autonomy; nonmaleficence; beneficence; and justice—has gained popularity as a useful tool to deal with bioethical dilemmas (Beauchamp and Childress 2012). Many commentators have emphasised that for resolving moral quandaries that Muslim societies face, this approach might not be appropriate (Westra et al. 2009), and to provide culture-specific guidance in Muslim societies, the specific principles derived from Islamic legal ethics need to serve as sources in the context of Islamic bioethics (Mohaghegh Damad 2011). Currently, there is an increasing interest to define principles of biomedical ethics based on Islamic ethics. However, some of these attempts have been criticised as such: “a try to show the compatibility between the principles of biomedical ethics used in the West and the ethical precepts of Islam without exploring the nature of moral theological discourse that informed the development of the Islamic legal-ethical system, the Shari’a”. In general, the principle of public good (Maslahah), the principle of “do no harm” (La Darar wa la Dirar), the principle of justice, the principle of necessity (Darurah), and the principle of protection against distress and constriction (al-‘usr wa al-h.araj), are most frequently cited in Islamic bioethics literature (Sachedina 2012; Larijani and Zahedi 2008).

The fact that the “principles of Islamic bioethics” have been chosen as the eighth priority by survey respondents confirms the need to initiate a multidisciplinary project with the participation of Islamic jurisprudence, ethics, philosophy, medicine and law to develop Islamic principles of biomedical ethics which are acceptable for the key stakeholders in the field. However, in developing the principles of Islamic bioethics, the methodological approach is a critical challenge.

Abortion is a controversial and challenging issue in all societies of the world and all religions have their own perspectives on abortion. In Islamic jurisprudence, regarding abortion, the main ruling is that it is not permitted, except if the mother’s life is in danger and the foetus is in the pre-ensoulment stage. In ruling fatwas on abortion, the issue of the mother’s life is an important

factor in all Islamic jurisdictions. However, a study shows a diversity of opinions about abortion among Islamic traditions (Bagheri et al. 2011). In practice, most schools in Islam turn to the onset of ensoulment for rulings on abortion, and hence, with disagreements about the onset of ensoulment in Islamic jurisdictions, it results in different fatwas on abortion. It should be noted that abortion after ensoulment is not permitted in major Islamic traditions. In comparison to other bioethical topics, an issue such as abortion would potentially affect a large population and this may explain why in the survey participants’ opinions, the abortion debate deserves the ninth place in the top 10 bioethical challenges.

“Bioethics committees” ranked number 10 on the list of challenges. Since the last decade, following the guidelines of international organisations such as WHO and UNESCO, national ethics committees have been established in many countries, including Islamic countries. It should be noted that “ethics in research” was among the 20 topics in the questionnaire, but the participants did not cite ethics in research (including the research ethics committee) as among the

top 10 bioethical challenges. This may suggest that in choosing the “ethics committee” and not “ethics in research” as a priority, participants were more concerned about hospital ethics committees involved in clinical consultation as well as organisational ethics. However, the numbers of Islamic countries participating in multinational research projects are increasing and it is crucial that along with other more general issues in ethics review, ethics committees should be capable of reviewing externally-sponsored research to protect research participants in those research collaborations (Larijani et al. 2006).

Finally, as mentioned earlier, there were more topics in the questionnaire, which did not make it into the top 10 listings. It is worthy of consideration to elaborate why they are not considered a priority in Muslim countries. For instance, topics such as embryo donation and surrogacy are practised only in Iran (Afshar and Bagheri 2013), and these techniques are prohibited in other

Islamic countries; therefore, it is not an important issue for discussion, and is obviously not a priority for most of the Islamic countries. Moreover, the topic of nanoethics, which requires very sophisticated advance technology and resources, is not yet at a stage to be considered as a priority among other bioethical challenges in Islamic countries. As Table 2 shows, the issue of “bioethics committees” has been considered as Priority No. 10 on the list; this may explain why “ethics in research” did not get into the top 10 list. However, the reasons why other bioethical issues like environmental ethics and women’s health were not considered as a priority in bioethical discussion need further examination.

 

Conclusion

Ranking the top bioethical challenges in Islamic countries is an effective and valuable way of bringing those issues to the attention of researchers, as well as health policymakers. While attention to different bioethical dilemmas in Islamic countries varies significantly, with some topics receiving a great deal of attention from the governments and media, and others going largely unnoticed, it is useful to determine which bioethical challenge should be given more priority to guide the efforts in addressing those ethical challenges. Therefore, having a list of ethical challenges in Islamic countries is instrumental in the efforts to determine the concept of “Islamic bioethics”. Given the expansion of multiculturalism in many societies, the result of this survey would benefit bioethicists and policymakers in all multicultural societies.

 

Study Limitation

There are different methodologies to rank priorities in a given field. In this study, an international questionnaire survey method was used to prioritise bioethical challenges in Islamic countries. Although this method allowed for priorities to be set by a large participation of experts on a global scale, the results lack an in-depth discussion among its participants. A combination of a quantitative and qualitative research would provide more accurate results.

 

Acknowledgements

I would like to thank all participants of this survey and also I am grateful to Abul Fadl Mohsin Ebrahim and Aamir Jafarey for their valuable comments on the earlier draft of this article. For data analysis, the author is thankful to Farshid Alaeddini.

 

References

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  • This article was first published in the Asian Bioethics Review, Vol 6, No 4 (2014).

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