 To introduce Awesome Padilla to you, Awesome here at the University of Chicago is director of the initiative on Islam and medicine, an assistant professor in the sections of emergency medicine and general medicine, and a faculty member at the McLean Center. Dr. Padilla's scholarship focuses on the intersection of community health, religious traditions, and bioethics. Dr. Padilla was a Robert Wood Johnson Foundation clinical scholar at the University of Michigan from 2008 to 2011, a visiting scholar at the Center of Islamic Studies at Oxford University in 2010, and in 2013-14 is a Templeton Foundation faculty scholar conducting a national survey of Muslim physicians, bioethical attitudes, and experiences with religious discrimination. Dr. Padilla recently was awarded an American Cancer Society five-year career development award. Today, Dr. Padilla is going to speak to us about Muslim controversies regarding brain death. Join me please in welcoming us in Padilla. It's my pleasure to be here. Thank you, Mark, and the McLean support staff, leadership, and the endowment for allowing me to come here and share some thoughts with you. I know many of us, I think this is the last to come up one second. Thank you. Many of us have traveled here to attend the conference, so I think a better title for my talk would be this one, a Muslim travel guide to the value of brain death. So with that in mind, our itinerary today in a short talk will be to visit an Islamic Journal Council meeting room. The point will be for us to peer into the jurists' mind when they deliberate over brain death. On our way back, we're going to have a layover at the bedside of a patient who is near the time of death, and my goal there would be to take a snapshot of Muslim physician attitudes regarding brain death, which is part of the study that Mark just mentioned. The disclaimer I have is that my own commentary is my own commentary. It might be informed or biased, but you have to sit with me and think about it in that life. No one else am I presenting. I just got back from a UNESCO conference and they had this whole promotion about what they were doing. And at the end, actually, they said we bring together scholars of Judaism, Christianity, and Islam. And when they cut to Islam, they had me sitting there with my hand like this, which is what I like to do when I'm called to talk about Islam. So first, let me give you some Islamic biotics concepts that will explain what comes later. So good and evil, those terms, are not qualities that adhere in actions in the Islamic tradition. Rather, they're just divine description of qualities to things. Therefore, revelation is what is the source of normativity. And in Islam, the revelation is the Qur'an, which is sexual. And then there is the oral revelation, which is the sunnah, which represents the Prophet Muhammad's statements, actions, and tacit approvals. So with that idea, revelation is the source for norms. You have a methodology that comes out of that, of how to make things have normative value, how to extend things that weren't talked about in the text, how to extend that to those norms, to other things that come up. And that methodology is called the so-called fiqh. So traditionally, when you think about what are the Islamic ethical legal perspectives on something, a clinician usually asks a scholar the question. And that scholar thinks about the sources of Islamic law, the revelation, the objectives of Islamic law, and as well as the maxims and principles within that. He then thinks about whether that action that the physician is asking about falls within this categorization of moral status. Thinking about that, he judges something, which is a fatwa. You'll know that term, and either it's obligatory or it's forbidden but or somewhere in between. This process can have a lot of scholars coming together and deliberating around a table, and it can also involve a lot of different physicians giving testimony to things. This phenomenon is relatively new, where you have physicians and biomedical jurists coming together around a table. It was actually heralded in some sort of way by an event that happened in 1978, at that time exactly, which was the birth of this young female. So that's Louise Brown, and she was the first baby born by IVF. And there were most physicians sitting in the Middle East, thinking about what the Islamic response to this would be, that technology has gone so far that we were able to create babies in test tubes. So what would the Islamic tradition have to say about this, since the technology would be moving to the Middle East shortly? So right before then actually they had been jurists were thinking about the same thing. So in 1977 the Islamic Fig Academy was created in Mecca, which is sponsored by the Muslim World League. Shortly thereafter, these two physicians helped sponsor and found the International Islamic Fig Academy, which is based in Jeddah, Saudi Arabia, that was sponsored by the Organization for Islamic Conference. Later on, these physicians also were involved with other physicians who joined and come together for the Islamic Organization for Medical Sciences in Kuwait. These three institutions still function, and these are the premier organizations that have this methodology of bringing together physicians and jurists about the same ethical issue, coming together and issuing some sort of ruling. The procedure flows like this. You have Muslim physicians who decide on the questions to be addressed, what's pertinent right now. They then present the biomedical data related to that in paper form to jurists prior to meeting. They also, interestingly, translate Western biological views about such and such technology or such and such matter in paper form to scholars, so potentially mark your writings might have been translated and given to these scholars there to think about. Then, on the basis of that, they develop their own Islamic arguments in paper form and then come to the meeting. Meanwhile, the jurists have gone all this material and they're developing their own Islamic ethical legal opinion. Together, these people come and they have a consensus-based deliberation. So with that background, let's talk about brain death. You all know this, so just to highlight the fact that in our cultural construction, brain death became an entity around 1968 with the ADOC Committee in Harvard that defined, in their paper they say this, we define the reversible coma as a new criterion for death. We all know that it signifies a complete loss of the critical functions of the brain, but it's a prognostic and not a diagnostic entity. So we think that someone will not gain any functioning or consciousness really after that point, but we're not diagnosing all that. It's not brain failure. You and I know this as well with recent cases in brain death where women have been able to have labor, or undergo labor, who are classified as brain dead. And then there's a case recently of someone who may have been brain dead and may not be brain dead, so we don't know. Death in Islamic tradition is pretty significant because it's the occasion by which we have various legal obligations and communities that come in our eyes. For example, the waiting period for the widow begins at death. The inheritance must be distributed in a certain time period, and really the community is obliged to perform proper bolero and funeral in a short time period. And if they don't do that in a short time period, they're all sinning. It also prompts critical metaphysical questions, such as what are the indicators of a soul to body losing animative capacity? And then death might be an instance, but we all know about this idea of a process. The same thing is reflected in the Islamic tradition where we think about the idea of unstable life or a dying process, which has very fuzzy borders. There are concepts related to the body itself. These are, in some way, analogous to other concepts that we have in modern secular or even other religious traditions. The idea of dignity and sacredness. And these arise from Islamic textual sources. So the prophetic statements around the body talk about the prohibition to mediate the body. There's a specific statement that says that breaking bones of a dead person is akin to breaking bones of a living person. And we also have the tradition of the body being a reflection of God in a certain way. There's some variations about that. But the body, even if it's not living, is a bearer of rights. So it's not just an empty shell, right? So there is a sacredness and dignity that extends to that after death. So now to the zeridical meeting rooms. So I'm going to look at the Islamic Figure Academy and the Islamic Organization of Medical Sciences. There are many topics of discussion, but these are the ones that I distilled down from my own reading and that of my mentors. The first issue was the indicator of death. So whether this was death was something that should be known to just specialists or laity. Should we be able to recognize death by someone on the street, find something, a person there, they're dead? Should that should be the case or should it be that there would be a specialist odd that can say this is also a form of death? And this had to do, obviously, with a certainty of traditional indicators in the Islamic law. Those would be breath and heart versus special syndicators, which would be the neurological criteria. Relate to this, obviously, is the idea of the epistemic value of medical testimony. So should physicians have to be assured, certainly 100%, that this person has no brain functioning and will never regain consciousness or any similitude of that? Or do they need to have a proponent of probability, dominant probability to do that? That was another aspect of discussion and there was always question around the soul-brain linkage. So let me give you a snapshot of two people's sort of writings from the scholar's standpoint. So Shafiq asking from Jordan in 1983, he sort of talked about the idea, his argument was that brain death is death in Islamic tradition. He said that there's no, that end of life, when that occurs, specifically has no clear scriptural braces. There are no Quranic ayaats, there's no prefecturation that says this is when a person dies. Therefore it's left open. And because it's left open, specialists, right? Specialists and specialist knowledge can serve as an indicator. Because of that, he said that medical testimony only requires dominant probability because it's just worldly knowledge. There's no clear textual guidance. We're not basing this on a hermenecal theory from the Quran. Therefore any sort of probability, as long as preponderance of opinion or dominant is sufficient enough for them to decide a person's death. Hence brain death is death. And he says in his testimony that it indicates the departure of the soul. So he did tie this idea of brain and soul. I'm not quite sure, but he did mention this idea that the brain dead person has no volitional activity and sensation. So was that critically needed for the soul? I'm not quite sure, but he mentioned that as well. On the other hand, there was another prominent jurist also from Jordan, I believe, his name is Sheikh Tawfiq Al-Wa'it. And he said brain death is not death in Islam. And he said, his argument was that there must have caution around equating people who seem to be unconscious as dead. And he said there's a scriptural basis for this. We have a story in the Islamic tradition around people in the cave who were sleeping for 300 years. And people who would look at them would think they would be dead. So we have a basis for not, right? For not calling someone who's unconscious dead. And he was responding to that brain death paper, that activity that said irreversible coma is going to be a form of death. So that was his response. Well, we know people who are unconscious weren't dead. So we should be cautious when saying that. He also mentioned that the brain is not especially tied to the soul, nor it's privileged over any other organ. His idea was that the divine miracle moves the body. It's not the brain necessarily. And loss of motion does not indicate the soul's departure. We should not link those two. And he also mentioned the idea that the body has sanctity even without the soul. So we can't just, even if we were to accept this person's dying or dead, we must be careful of the things that we do because there is sanctity to that shell, so to speak. There were other frames within this conversation of the predominant frame that used by the proponents of brain death was the idea of public benefit, maslaha. And they said, this was because of organ transplantation that someone can benefit from the organs in this brain individual. And they cited the legal maxim that living take precedence over to dead. So the opposition sort of said, well, hold on. We have another idea in Islamic law around is tishab, which means you presume a state of certainty before a state of uncertainty. So if I know I own something and I have a contract showing that, then someone has to prove that there is a contract that's showing that I don't own this. Otherwise, you leave it as it is. The status remains the same. So in this case, you presume someone's living unless you have a certain knowledge that death has occurred. Certainty is not eroded by doubt and we can't use special knowledge in that case. In the end, these are the rulings from these two academies. The OIC, IFA said brain death is death. And specifically, they say all vital functions of the brain cease irreversibly and the brain has started to generate. That was their vision of what brain death is. The IOMS said no, right? It's unstable life, meaning there's a dying state, not death. And they ruled that if a person has reached brain stem death, so they clarified what type of brain death, some of the rulings of unstable life apply. Specifically, they answered the question whether you could withdraw life support and they felt that was permissible. Now taking the idea from the jurist to the bedside, you'll notice I've highlighted some words here because there's still some conceptual ambiguity. So what are the vital functions of the brain that was not answered by the OIC, IFA? What do they mean by irreversibility? We have this debate, we've heard one recently about what does irreversible mean when you're talking about death, right? Cessation or they were not answered again. The idea of the brain degenerating is something that I don't know that is required in the brain death neurological death criteria. We actually don't take a sample of the brain and look at it under the microscope. So I'm not sure how that made that neither. On the other hand, the IOMS said some of the rulings of unstable life apply. So they didn't specify what rulings accept for this withdrawal life support. So the question that we would ask based on things that happened recently around can we keep a body on support for the baby to mature to some sort of gestation age was not answered by this question, by this ruling. In summary, Islamic law is plural. All of these opinions are opinions and they're both actionable. So they're both valid. And both opinions have some conceptual ambiguity and they both leave some practical questions unanswered. And this occurred almost 30, almost 40 years ago now. So we need to update these rulings. So I'll take you from, right? I said the jurists to now the bedside. So I just finished this national survey of American Muslim physicians. There are some numbers up there about how many people we surveyed. I wanted to tell you that we found 70% of this physician pool was psychologically troubled by withdrawing life support. Maybe part of that was because 44% reported that brain death is not death. They did not feel these reconditioned states. You might say, given my interest in theology and empiricism, that maybe the reason for this is because the jurists themselves, these jurical bodies were ambivalent. There was a plurality of opinions. Therefore this might be reflected in American Muslim physician attitudes. But you should know that both councils all the physicians who testified at both these councils, they were unanimously agreed that brain death is death. There was no detraction from that viewpoint at the council chamber, okay? So the idea of ambivalence came from elsewhere, not from the physician testimony. My survey does address this question of whether these transnational sort of verdicts did play a role. You'll note that more than half of the physicians never read any Islamic pathos books. 64% never or rarely talked to any jurists. 77% never or rarely sought any guidance from a local imam who might have come in contact with these verdicts. When you ask them about the verdicts, almost 80% never really looked at these verdicts. So the tension of 54% saying that brain death is not equal death did not come from a reflection of Islamic theology or jurical rulings into their own mindset. There was something else going on that made Muslim physicians feel that there was something wrong in this practice. So moving back, Islamic biotics discourse does have some conceptual ambiguity and sometimes doesn't meet the mark that we need at the bedside. And so my hope in this program that I lead here is actually to kind of think about who the Islamic biotics experts are, right? Are they just medical scientists, the physicians and their professional organizations who know the practice of medicine? Is there religious leaders and Islamic authorities? Those who counsel the populace or they have trained in how to look at Islamic law or professors of Islamic studies who have looked at the corpus of juridical rulings and come together to some idea of what the common ideas are. Are there biotheists at the bedside who make these decisions? Are those of the Islamic biotics experts? I'm not quite sure, but I do know that all of us need to sit together and to come together and think about what are the parameters of the Islamic biotics as a discipline field and what is the methodology that we employ? I have written a little bit about this and I'm just trying to clarify my own ideas in conversation with others in this room. Thank you for your time. Thank you so much. My first question is, do you have any data on what percent of non-Muslim US physicians consider brain death to be equivalent to cardiac death? I don't know actually, maybe people here know. I have not yet written this paper up so I haven't looked at the other data. Okay, thank you. Thank you, that was very interesting. I see, I have one question. Given how little of their own study, what percent of these physicians were American born and American trained and what percentage were foreign born? So there's about a two-thirds, one-third split. So two-thirds were foreign grads, right? And then a one-third were people who were born here and therefore went to medical school here largely. Maybe you didn't ask this, but let me answer this question. That might be in some people's minds. All these physicians were highly religious. So like almost 80% said that they went to the mosque once a week. They all rated on a scale of one to 10. This was all a very skewed sample. They said that their religiosity was from eight to 10, like 90%, everybody else fell there. So this was a very highly religious group. I want to approach this in a slightly different way. When you look at the information on autopsies in the Muslim community, especially Perinatal, and I was looking from the woman from Toronto because it's the Toronto Sick Children's Hospital that has some good guidelines on how to engage the Muslim community. So if I understood your presentation on how they arrived at brain death, I want to tack it in the different direction. How do they understand, you know, looking at the body and dissecting the brain to understand not one area of the body, maybe in terms of the whole. Just if you could flesh out their understanding of how we learn from the body. So I'm not quite sure what your, the question is, but I can give, maybe some of this will answer that. So traditionally, as I mentioned, the idea of having dignity extends beyond death. So the body should not be violated at all, except for a legal cause. And the legal causes that have been mentioned by Islamic jurists are, for example, you know, murder, culpability, homicide, those sorts of things. Or even in some cases, if you have to retrieve the valuable of someone who's lost in the other person's body, right? So like if someone was gonna die, he says, I have a diamond, I'm stealing, I'm gonna swallow it and you shoot him. Well, you should retrieve that diamond. The idea of autopsy for medical learning was something that was not necessarily approved by the classical jurists. So in the Muslim tradition, there were a lot of biopsies, I'm sorry, autopsies of animals and not humans because of this reason of the dignity of the human body. Nowadays, a lot of things happen where their autopsies are done of non-Muslims who have donated their bodies, right, to science. So that we again, try to maintain the sanctity of the Muslim body because we don't wanna do that without any sort of consent. I don't know if that answers your question, but if that's what you're getting at, that's it. Close enough, close enough. John. John Lantos, Kansas City, thanks for saying that, it was great. Talk a little bit about how in this casuistic tradition where you get two different bodies of experts coming in with slightly different rulings, how a local Imam or leader might guide a physician who comes to them with, I'm assuming, and correct me if I'm wrong, that for an individual physician, they would turn to their local Imam who would look to the authorities for guidance, but the authorities seem to disagree. So what happened? Right, so it seems from my own data that the Muslim physicians in the ISC don't talk to anybody, right, from the juridic side, which is good or bad or indifferent, but I do know from patient data that they often do advise patients. So the tradition is plural. So the idea is that you can pick any, and I'll mention in the Muslim world what happens that these juridical councils issue their ruling. They have health policies stakeholders from different countries who decide on their legal corpus, what they're going to make policy or not policy based on these recommendations. So these are the elite of the elite, right, scholars sitting at these councils. So that's how it happens in the Muslim world. Here you have some hodgepodge of what's occurring. Thank you so much, guys. Thank you.