 On behalf of the McLean Center for Clinical Medical Ethics, I'm delighted to welcome you to today's lecture in our year-long seminar series on ethical issues and end-of-life care. I want to call your attention to the speaker before I introduce today's speaker to next Wednesday's speaker, who will be Dr. Ranjana Shrestava. Ranjana is an oncologist, the author of four books, writes frequently in the New England Journal. She comes to us from Melbourne, Australia. And next Wednesday she'll speak on when good intentions aren't enough, barriers to optimal end-of-life care. So that will be here at regular time Wednesday at noon. Dr. Shrestava will also present another talk, a different talk, on Thursday afternoon at 5 o'clock also in this room. And we'll hand out some flyers so you can take a look at the program for Dr. Shrestava for next week. It's now my pleasure to introduce today's speaker, Dr. Asim Padela. Here at the University of Chicago, Dr. Padela is the director of the initiative on Islam and medicine, an assistant professor of medicine in the sections of emergency medicine and general internal medicine, and a faculty member at the McLean Center. Dr. Padela earned his MD from the Weill Cornell Medical College, completed residency at the University of Rochester in emergency medicine, and then was a Robert Wood Johnson clinical scholar at the University of Michigan, where he received an MS degree in health care research. Dr. Padela's research assesses how religion related factors affect health behaviors and outcomes among American Muslim patients, and also how such factors influence the practice of American Muslim physicians. Dr. Padela explores how scientific data can work in concert with traditional Islamic moral reasoning and theology to develop a comprehensive, theologically rooted Islamic bioethics. When he was a Robert Wood Johnson scholar back at Michigan, Dr. Padela led a study on American Muslim health behaviors and challenges. In 2010, Dr. Padela was a visiting fellow at the Center for Islamic Studies at Oxford University in England. Dr. Padela is a fellow also of the think tank called Social Policy and Understanding, and recently, Dr. Padela received a four-year grant from the American Cancer Society that was entitled, developing a tailored mammography screening intervention for American Muslims. Today, Dr. Padela will speak to us on the topic that you see above me, ethical obligations and goals of care at the end of life and Islamic theological framework. Please join me in giving a warm welcome to Dr. Sim Padela. Thank you, Mark, and the McLean staff for the gracious invite and the even more gracious introduction. I'm pleased to be here with my colleagues to talk a little bit about something that I sort of backed into. And because of that, I'm going to kind of give you the background of how I backed into this talk today and into this particular idea about creating a theological framework from an Islamic perspective for goals at end of life care. So Dr. Siegler mentioned that recently I completed, or I look at American Muslim physicians and how Islam influences their behaviors. And we recently completed a national study of American Muslim physicians. Within that, some of these data were very interesting to note. So for example, at the end of life care, 79% of these physicians found it more ethically problematic to withdraw than to withhold life support. And 70% of them found it more psychologically troubling. They were further challenged by end of life care where nearly half of the physicians we surveyed found or felt that brain death did not equate to death, legal death proper. Interestingly, a minority, a still a significant minority, 18% disagreed with the idea that it's mandatory to comply with a competent patient's request to withdraw life support. Yet, the overwhelming majority felt that physicians' recommendations at the end of life should incorporate quality of life considerations. So they were challenged by this idea, particularly the idea of withdrawing life support at the end of life. In terms of patient perspectives, I don't have a survey to share with you, but I did conduct some research of more qualitative nature at Michigan. And we conducted 13 focus groups in mosque communities across the ethnic divide amongst Muslims, Asian, South Asian, particularly African American and Arab. And end of life care challenges were a dominant narrative that they presented to us, particularly around ideas of shared decision-making, how that works out in families and communal contexts, and what Islam has to say about this. What are the Islamic perspectives on withdrawing with holding life support and goals of care? Indeed, this led us to write a paper around the idea of reconsidering respect for persons in a globalized world. I want to share with you that one of the stories that we wrote up in this paper was about a policy that a hospital in Michigan had of absolving patients or families of patients, particularly, of decision-making at the end of life. This was through a limited paternalism construct where they felt that families were at impasses, they're creating difficulties amongst family members, and the people that we thought of as surrogate decision-makers weren't necessarily those individuals that the family prioritized in decision-making. So this was something that was applied at a prominent hospital in Michigan that served Muslim patients. This was not just a phenomenon, and you can't see this, I guess it was cut, that according to Michigan, but one of our former faculty here, John Lantos, had me comment on a case he had with the Saudi family making decisions in the same manner. In that case, it was for a child. So we all, and the series here is about end-of-life care challenges, we all, whether it be from a Muslim perspective or from a secular perspective or any perspective, find that this area of medical care is challenging. And some of the challenges are similar for all peoples. So for example, the borders between life and death are being made fuzzy by our increasing technical scientific capability. We think about what we can do often, and for us in this room particularly, we're thinking about what should we do, right? Even though we can do it, should we do that? We think about if we should, then how should we? What is the best way of performing certain such things? We are struggling with a population, particularly in minority contexts, that have low health literacy, and they might not understand what exactly the possibilities are for treatment and what goals of care might be. We have competing ideas in this room. I can attest to that by being in the case conferences, but we have competing ideas in this room and beyond around the ethical responsibility of those involved in the decision-making process. We have different ideas of what shared decision-making looks like between the patient and the physician. We have competing ideas around who surrogate decision-makers are and whether there should be a deference to medical authority in certain cases. And indeed, particularly in the minority contexts, there is a clear overlay of issues of trust between the patient's providers and the healthcare system. Within the Muslim population, I think there is a religious sort of influence upon decision-making. I can tell you from data, at least in this physician group, that 60% of these Muslim physicians felt that Islamic bioethics greatly or somewhat influenced their decision-making. I can tell you anecdotally and from qualitative data that the same holds true for Muslim patients. So this side might be familiar from my previous talks to the community here. So when you think about Islamic ethical legal perspectives on something, often the formulation of the question comes from a physician. And that's opposed to a religious scholar who then thinks about the scriptural source texts of Islam, the Quran and the Sunnah, which is the prophetic traditions, about the objectives of Islamic law and the legal maxims that we have within our tradition. And he thinks about whether such and such act is permitted from the spectrum of, it's permitted and obligatory to its forbidden and one shouldn't partake of that. And he issues the thoughts, well, this process can occur with many physicians involved and many collaborating jurists coming together to issue a decree as well. So I said I backed into this and so my interest having the data I just presented to you, particularly in Michigan, around the challenges that Muslim patients faced, I wanted to myself, what did the jurists have to say about a particular entity that was of interest to me at that time and that was brain death? So I wrote a couple of papers thinking about, well, how is medical science translated into the edifice of Islamic law? How do the jurists think about medical science? And then who is at the table when they make decisions? So what sorts of ideas and notions are brought forth? What notions are foregrounded and what are go to the background? When jurists and physicians come together to think about a complex entity such as brain death? And then I wanted to take it to the bedside and so I tried to think about the gaps that there might be within the discourse that make it challenging for Muslim patients and physicians to apply the verdicts at the bedside or to think about them. So that was my work and when I came to the University of Chicago, I was approached by a medical student who is the co-author on the paper that I'm presenting today and in the lead of this presentation, Afshan Mohiuddin, who received a Fentress Fellowship in her senior year here as a medical student and she was interested in this question. When does Islam permit withholding with throwing life support and particularly is there a distinction in the justifying conditions for withdrawal versus withholding life support? And taking a look at my work on brain death, we thought that perhaps we should forward into this area moving a little bit beyond brain death or preceding brain death. So I'm going to present to you some of what she found briefly before we get into the paper at hand. So she looked at Dritical Academies and what they had said about withholding with throwing life support and these data here I think are important for what I will discuss. So a prominent council in Europe sort of talked about withdrawing life support and they answered the question, is it permissible and when? Well, when the patient has lost perceptive capacity. In Saudi Arabia, they actually have a committee for Fazwa and research and they think about withholding life support. They have delineated that if three physicians testify that a patient is unfit for resuscitation, you can withhold life support, Islamically. And indeed in that case, in the legal country that's law and the country that's law. So they talk about three conditions here. The illness is unresponsive to treatment. The patient is in a state of mental activity or has suffered untreatable brain damage and then this sort of catch-all statement resuscitation would be ineffective. These three groups are in South Africa and they also address this question of withholding and withdrawing basically by saying that the patient has no chance of survival or can't stay alive without the respirator. It is permissible Islamically to withhold withdrawal life support. Moving to some other prominent councils, the Islamic Organization for Medical Sciences in Kuwait, this is an international body of jurists. They recommended, right, so they said this is recommended meaning it's ethically better to withhold life support if that life support is going to be the uses at the end, whatever that were to mean. Similar here, futile, useless was the same term. And then they said, okay, if the person's brain dead, you can withdraw life support and that's permissible Islamically. You'll see here that Imanah, this is a U.S. council, it's not a jurist council. I'm actually a member of this ethics committee. They look to what others have said and they come up with their own sort of guidelines and they have the same criterion for withholding and withdrawing. The patient's term may ill or is in a PBS state. Brain death is death in most states in the United States so they didn't really address that question that well. And sadly, we have these other two academies they talked about withholding, I'm sorry, withdrawing life support if death is impending and if the patient's brain dead. Okay, so this research has yet to be published but what did get published was what we talked about after. So after Afshan did this sort of review of literature, we spent some time talking about and thinking with Islamic scholars about what ties these juridical rulings together. What is the theology behind it or what might be a theological marker for quality of life and that's what I'm going to present to you today from this paper that just came out in the American Journal of Bioethics. So the paper addresses two questions. The first is what are goals of care and the end of life from an Islamic vantage point? And the second, what are the Muslim physicians' Islamic ethical legal obligations regarding care provision? And my goal for today is just to sort of describe to you some of the conceptual frames used in Islamic ethical legal reasoning so that we can have a dialogue about analogical reasoning tools that are used in other traditions. The first thing, the first concept I want to share with you is the idea of the moral status of actions and the sharia. I mentioned that Islamic scholars think about things along this continuum. Particularly the important point here is that they're worried about this, right? The consequence and the hereafter. Indeed, they look to scriptural source sex as to find evidence of the consequence and the hereafter and then they put things in this category from obligatory to prohibited. What it means when we say an Islamic obligation is that the person is morally liable because of that afterlife amplification. It could be an act of omission or of commission. Are you obliged to do something or you're obliged to not do something? In any case, this leads to the term of what is there a sin ascribed as activity, right? From the juridical source text. Thinking about the conversation about what happens then. People think about common here and other places think about duties and obligations. But the term in Islamic law is rukul. And that really translates to that which is owed to God or to man or humankind or both. So this approximates to duties but you notice it starts with the idea of an obligation. And so if we think about duties then there is a sense of the right circulative from there. So if a patient is obliged or obligated to seek medical treatment then the physician is obligated to provide that treatment. So this is the first concept of how we get at this thinking about end of life care. So what does the Islamic legal tradition have to say about the obligation upon patients to seek medical treatment? The prevailing positions in the classical tradition as canonized within the four Sunni schools of Islamic law. Sort of talk about this. So I'm gonna mention the dominant position. Realize that there might be minority positions within each school but these are the dominant positions meaning this is really important. That when an Islamic jurist issues a verdict he has to first offer the dominant opinion, right? The going opinion. And then there might be a contingency that will allow him to then think about a minority opinion but he can't just issue the minority opinion. He has to have a preponderance of reasons for going against the majority opinion. So first here you have the Hanifi school. They've thought about medical conditions always, medical treatment is always in the category of permissible. Meaning it's never obligated upon a patient to seek medical treatment. The same holds true for the Maliki school. This is the most dominant school in the world. The Shafi school of Islamic law, they have an opinion that it is obligatory and it is obligatory to seek medical treatment only when cure is certain and it's life-saving. And this was formulated by this prominent jurist, Al-Lazali, for those who know a little bit about Islamic studies. And the Hamili school of law, this is another prominent jurist, classical jurist in Taimiyah, he says the same thing as above. And it's interesting that these two individuals agreed because they didn't agree on a lot of things but in this they agreed. So what does this mean? The obligation to seek medical treatment, what was the reasoning behind it? Basically the rationale by these classical jurists was that there was a concern for the efficacy of medical treatment at that time. We didn't know if something was gonna be a benefit or not, so they did take, they categorized medical treatments by their efficacy and that's why there was a small class of treatments that were truly known to be efficacious. That was one concern. The second concern was a theological concern that everything meaning cure is from God, diseases from God, there might be a way for someone to get cured without resorting to an intermediary. So we cannot mandate people seeking something if we think that this can occur. We can't make it obligatory, meaning it can't be sinful if you don't. The other issue was that in the early community of the prophet and his time, there are record instances that the prophet himself and his early companions refused medical treatment. Just interesting and curious statement authenticated that he noted that amongst the categories of people who enter paradise really without judgment are those who do not seek treatment through ambulance and trust in God. So you might say the ambulance there was what was medical treatment at that time, but he mentioned this specifically. So there was this real counterbalancing of an idea of trusting in God, not knowing what medical treatment is gonna offer, and then can we actually make it an obligation upon patients to seek medical treatment? So contemporary jurists also dealt with this issue most recently in 1992 in this FIC Academy which is an international FIC Academy in Jeddah, one of the ones I mentioned previously. And so they say that it's obligatory for Muslims to seek medical treatment for these three conditions. When it's gonna save, stave off death, meaning that the treatment is life-saving. When that disease is going to cause a loss of an organ or disability. And now in the social context, social considerations, when that disease or illness is contagious it's gonna be a harm to others. So this is when they determined, so they recalibrated some of the older classical opinions that came up with something that looks pretty similar. So what was this idea of life-saving which is pertinent to end-of-life care to substance? Today, a priori-ethnic case that the classical jurists talked about was the idea of a person who is bleeding to death. And for them, it's obligatory to seek treatment that would stop that hemorrhage because that would save their life. At that time, and today, there are treatments to stop someone or potentially stop someone or most dominantly stop someone from being to death. And they felt this was the priori-ethnic case that they talked about. Contemporary medicine complicates this binary notion. You and I know that, forget about stopping bleeding, we have the ability now to sustain quote-unquote physiological markers of life without also prolonging the cognitive affective functions of that body or person. So in the context of life-saving, in the context of end-of-life care what would life-saving look like? Now recall that I had mentioned in this review of the juridical opinions that most of the terms used when the scholars looked at medicine and when you can now withdraw with whole life support were vague, right? Care is useless, maybe that means not effective. The patient is terminal, what does that really mean? But they did talk about brain death and I'll tell you that even the scholars that considered it a dying state and not a dead state because there is a debate whether that, which it is, that they also said that treatment is not obligatory but moreover the physician can withdraw with whole life support. So these are sort of the foundations here. Useless treatment, patient is sort of near the end of life I guess or meaning in this case there's nothing to affect that end potentially and then brain death. So the conceptual premise I think the other tie between these things is that in one regard we don't have the capacity to change the outcome at all. So they're impending death. The other, which we'll talk about now in more detail is that whatever state you are able to potentially maintain for that individual with whatever medical technology you have at hand would potentially represent a life of diminished benefit. All right, okay. So we're now gonna go into some controversial waters here. So looking at the scriptural sources of Islam these are the things they talk about as the purpose of life. So the Quran, these are two verses from the Quran saying, declaring I have not created and managed except for worship. That's the reason for all of creation. And there's another verse here that says that you should worship your Lord until death comes to you. So that is the reason for creation. This notion underlying this, there are others as well is that a life of utility is that life that's related to notions of discharging religious obligations, right? The haqq, the haqq of the rites, the obligations owed to God first and foremost. Within the prophetic sort of narrations we have some teachings from him. And he said that none amongst you should make a request for death for when any one of you dies he ceases to do good deeds. So again, life is there, you should do good works and you shouldn't ask for death because that cuts you off from doing good works. Even more concretely, he said none of you should make a request for death because of the trouble that in which he's involved. But if there is no other help, then say, and he taught this prayer, oh God keep me alive as long as there's goodness in life for me and bring death to me, bring death to me when there is goodness and death for me. This actually, this, what's it called, what happened here? This supplication was adopted by companions and we know, for example, that in the medical context a person had to have caudary at that time for some sort of stomach ailment. He had this multiple times and a companion visited him and said, you know what? He's like, well if the prophet allowed us to ask for death I would have asked for death by now but I'm making this prayer. Okay, so the notion in these teachings was that the ability to affect good works is a part of life and that when that is compromised you can potentially, look at this out, you can potentially ask for death to come to you. So what is the theological rubric for this, right? This idea of a life of benefit or ultimate benefit? So the theological marker for quality of life, this is our argument, is this construct in Islamic law, moqallaf. And that signifies a morally liable individual. What that means is that a person, the requisite for that is that the person maintains sufficient cognitive capacity for assessing the benefit and harm to actions, worldly, otherworldly, whatever, but they can cognate through this complicated equation. And this is marked, what they call about it is the person has full intellect, aqal, and it exists on a continuum from tamiz, which is the idea of discernment to roshat-aprighteousness. It's not the precision of this faculty, but the idea that you have this faculty, you can discern benefit and harm. You can therefore act according to benefit and harm, to this life or the other life. In a Muslim context, this means that Muslims are frosy cannibal for religious duties. I just told you that if the verses talk about that you're created for worship and you recognize God, then Muslims should be discharging their responsibilities to worship God. So that's in a Muslim context. But in a non-Muslim context, the idea of a moqallaf potential exists. Children, non-Muslims, they all have this potential because they have, they might be in doubt with, the ability to discern good and harm. Benefit or non-beneficial actions can be distinguished. So this is a theological marker, what makes you morally accountable to society and to God. I'll say here that the moqallaf state also represents, in this case, the argument, a life of optimal quality because it allows for the potential to affect the afterlife, right? I mentioned to you that Islamic law is concerned with afterlife, so now this allows the potential for affecting the afterlife because you have the cognitive capacity to do so. And hence, then it is a quality of life metric. So we argue in the paper that Muslim physicians are obligated to work towards destroying this potential, this faculty, this capacity within the bounds of modern medieval science. That is the rubric on which that's the goal, the telos of end of life care for which a Muslim patient is obligated to work towards. Now let's take you through some of the cases we discussed in this paper. So one, particularly with all the A and B. So here we have the patient and the surrogates express wishes regarding clinical care, desires to maintain or initiate clinical therapy or desires to non-initiate or cease, right? Stop withdrawal life support. The first case you have, you know, this idea of the physician is thinking about, well, can I, with the medical technology hand, work towards restoring this cognitive capacity that the patient had previously? This is an important, right? Because I'll tell you about the exception to this rubric. But the patients say, for the example might be, that a young gentleman, all right, undergoes a car accident, suffers some sort of cerebral injury, right? So now what are we doing? What is the physician's obligation, the Muslim physician's obligation? Well, if I cannot help restore the status, right? Underlying the status is what? The idea of the cognitive capacity then to distinguishing it harmful and beneficial actions that are not obliged, I'm not obligated to provide medical treatment. The patient or his family wants so. So what do we do then? I'll talk about that in a second. On the other hand, the other controversial end would be, if, right, we think we can restore this potential, but the expressed wishes are not to do so. So in the first case, right? So there's no obligation, I mean, the idea of not an obligation, right, doesn't mean that it's impermissible after distinguishing between that, right? So because you're not morally, Islamically, obligated to do something doesn't mean you can't do it. It's not the opposite, right? That you're morally liable for doing it. So we have to distinguish between this. But there is a concern within Islamic law and theology for trampling over what we consider the idea is called Karama. And I think from my conversations with others in this room that this maps on well into the idea of intrinsic dignity. All right, so if a patient is on life support for a purpose other than their own life or their own benefit, what are we doing here? Are we trampling upon that idea of Karama, that the human is a dignified being? And the second idea here is well, the other aspect that we have to be concerned about is are we subjecting this body to an official treatment? So say you think the person's brain dead and they're just a body, say you accept that. And some Islamic streams are thinking you accept that. Then the body even without, right, if they think it's dead, there's no personhood here, still has Karama, extends to beyond life. So you're potentially trampling upon the inviolability of the body by subjecting them to things, invading them, right, invading that body, piercing it with IVs, whatever you're doing. Now, case B is if you recall here for a second is the physician, right, feels that they can work towards recovering this potential, but the express wishes are not to do so. So then this is a conflict, right, between, and it could be resolved as we do here in sort of many cases, we talk about referring and the duty to refer if you can't do something, right, and controversial moral decision making at the bedside. Maybe it's theoretical and not sometimes practical, but that exists. The other within Islamic law is this idea of you have to follow the law of the land in particularly minority contexts, even in a Muslim context. So if you have a Muslim ruler who is following an opinion within the bounds of Islamic law, that is one that you don't agree with or your scholars don't agree with, you will sin if you don't follow that, because it's within the bounds of law. It's not an impermissible action at all costs. If it's not a categorical prohibition, meaning that there is an ability to reason why this might be okay, you're obliged, you're obligated to follow the law of the land. So here we know in the US courts have given precedence to patient autonomy express wishes over objections of the charity. This is in law. So scholars have said that you must follow the law of the land. You can't say I have a conscientious objection, and therefore I'm going to not do anything. You have to find some other ways or you have to go into the law of the land. All right, the other concepts I wanna mention before we get into our Q and A is the idea of certitude. So I mentioned that the physician is obligated to work towards restoring this potential by the standards of medical science known to him, what's available to him. In Islamic law, we have the concept of dominant probability that an obligation exists, right, that you can have to think about things that occur. And if they occur more than 50 years at a time, this is now a criterion upon which to make actions happen. So if it's something that might happen in one in a million times, right, it might try this therapy or whatever else and something might happen, that's not the measure by which a physician should act. We have to act within the bounds of what is known to occur for most probability with some treatment. So that's the criterion. The other thing, a little bit about palliation, right, because you might be treating a patient for the idea of palliation and removing pain and suffering. This is part of custom and medical practice, right? And actually someone would say, this is a part of being a physician, right? This is your duty. The only thing I wanna mention here, and we can get into this more, is that in Islamic theology, pain is not evil. All the time, okay? So this leads into conversations around terminal sedation and other things as well, but this is not, this is the case here. Therefore, hardship is not necessarily to remove at all costs, okay, for the patient. Now, this whole thing I've laid out for you, we, is a first sketch at trying to understand a quality of life rubric, right? Looking at the reasoning that, well actually just the statements of the scholars, they don't have much theological reasoning behind it, but they give this permissibility and they might have this in their minds, but don't explain it very well. So we're trying to tie those together, but it only applies to patients who have held this Makalif potential prior to illness injury and that that injury compromises that potential, right? Like the case I just told you, someone had a car accident, they have now an interest ribo hemorrhage. What's gonna happen? Not for someone who doesn't have that capacity prior, right, they're out of that rubric. And the reason for this actually isn't in Islamic law itself. That Islamic law treats patients with diminished cognitive capabilities, right? As a very varied category. And jurists have overwhelmingly inclined towards protection. They don't make cutting-fast rules for them. They just sort of let things, catastrophes in operative here, but also if there is anything they say, they say we have to do the best for them, the most for them that we can do within our bounds. So this is why we would not put this in this category. The other thing, we can talk about this again in the Q and A. This is a theological debate about moral culpability for people who have diminished capacity or who are having intermittent capacity or cognitive capability. So there is a theological debate, hence we don't tie it to the Macaulay status. So as I said, this is an initial sketch, right? So we looked at a little bit about Islamic law, trying to understand how theology plays into that to come up with some sort of idea of a quality of life metric. And then we have to think about how that would be played out, right? With surrogate decisions, thinking of other things in the medical practice, but all these other things also need to be thought about. So this is my initial sketch. I thank a lot of people who have helped us think about this and particularly my co-author Afshan Mohiddin. And now I think we can have some engaged debate. Dr. Padila's talk is open for questions or comments. Yes, please, in the back. Oh, no, I'm sorry, the microphone's here. We'll come right up to you. Thanks, Asim. Very illuminating. One question I have relates to the quote you had from the citation from the prophet, saying that you should trust in God, not amulets. And it seems to me that historically, a lot of people don't realize that was originally the position of ancient Israel. You couldn't see doctors initially because for a good period of history, they were using amulets that would be associated with idol worship and you had to go see the priest instead to be healed. And it was only with the introduction of Greek medicine which brought a sort of science at the time that there was a synthesis, if you will, in which the physician was thought to be sort of as the instrument of God. God sort of creates, gives the doctor the knowledge, God creates the world with healing herbs and therefore there actually then becomes a sort of obligation, if you will, to see the doctor. And what's striking to me that persists in Judaism, but today it was picked up by Christianity. And while at the time of the prophet, doctors were at least in his culture using amulets, there was later, certainly in the medieval period of Islam, the sort of height of Greek introduction of Greek medicine. And I just wonder how people worked that out at the time, why there wasn't a sort of similar kind of, or maybe there is, and it's just been bypassed by the jurists, so enlighten me about that. But what kind of theological reflection went on once there was scientific medicine and not amulets as the means for treatment? So the term that was used in the hadith is ruqya, so it's not the term used for sorcery-based amulets. These were ruqya was people would have, at that time of the prophet later, would use verses of the Quran for healing, for example, or they would, later on this comes like numerical things, right, these sort of people sort of adopted ideas around magic numbers and so to speak. So for example, there's a relation of someone presiding in one particular set of verses for healing. So the term that's used here is ruqya, which is within, at that time is now absorbed in Islam as a form of healing using Quranic verses, okay? So there's a stream of scholars, he actually mentioned this, he didn't mention amulets that were used for sorcery, but he mentioned this, this is even, you can think about it, using Quranic verses, this is actually a direct link to God, right? But he even mentioned this. And so just trust in God, not necessarily the verses. Now, this could be, have many different things, but the point here was that the scholars can't say, this is just a historical example, let's discard this, this is an authentic narration. Within your juridical mindset, you have to incorporate these authentic traditions and say, well, now we have to allow permissibility, right, for this action, because it can't be a normative example, if he said something and we can interpret it in a way that would make, that would allow for something else. So the multiplicity of interpretation has to be incorporated within the law, which allows actually, paradoxically people don't understand this, Islamic law is actually very vast. Everything's almost pure laurel. There are very few things that are impermissible because of this, they have to incorporate this authentic tradition. If it was a weak tradition, they could kind of discard it, but they couldn't. Hi, my name's Susan Cochran and I work with Gift of Hope, Organ and Tissue Donor Network, and my question is about organ donation. We find that many of the authorities in Islam have supported organ donation because the Quranic verse, to save one life is as if you've saved the world, but then when we approach Muslim families, they struggle with wanting to donate. I just wondered what your comments were about that. Incidentally, I think two years ago, at the McLean Fellows Conference, I think I gave a talk on this exact issue around organ donation, and I want to refer you to that talk that's on Mark's website. I think that we have to tease out a little bit of, the first of all is not, there are opinions from scholars that it's not permissible, okay? So we, and we should be clear when we talk about this, that there is this spectrum polarity. Secondly, the way that people interpret things is right, there's a theory this is permissible, but in practice, there are many things that might be objectionable within the practice of organ donation. And those might have overlays of why people might don't want to be involved in the practice. I'll tell you a personal example. Recently, you know, my wife, okay, so this is very, very personal. My wife has signed up on a license. I haven't, okay? And she, so she read some story about something in the popular press around DCD, I think, actually, right? So two minutes, five minutes, go to the OR, then done, whatever. And then the Harvey started. She read some comment, she said, oh no, oh my God, I can't be signed up for organ donation. What's, how do I get out of this? And I said, well, we can talk about it, how do you get out of it? But they're gonna go over with me, whatever you wrote in your, right? Because this is, so people read and get knowledge from many different phases. Islam might be a component, but it's not the only component. And we have to be very cautious about how we talk about things. And really, if in all transparency, it should be having these discussions in open forums with people, with those authorities as well as the lay. Along the lines of your last answer, when you took the first poll, did you get a feeling of how much of the American Muslim practice was actually based in faith-based practice or simply cultural practice? I'm not sure what you mean by that. So the initial poll that you showed was about American Muslim physicians and how they practiced medicine in America. And my question was, their practices, are they truly based in the faith, the principles of faith that you presented today? Are those more cultural practices that come from their points of origin, their countries of origin, their areas of origin? I see. And may or may not be substantiated by their faith? So I can address that in three ways. So one thing we did ask about their usage of other modalities of healing, okay? Which is, you can say it's folk practices and the very minority ever did any of that. So we asked about, do they prescribe the Quran for the Muslim patients to heal? Do they use other treatments based on sort of herbs or whatever else is a minority? You could expect that because they were trained in allopathic medicine. We asked them, there was a, I think one third of them had actually been born and trained here, okay? So distinguishing between that group and the people who were of immigrant origin in terms of their ethical standpoints on things, there was an initial analysis, these aren't written papers yet, but there was different models of decision-making, right? So for example, we had a question about quality, should judgements about quality of, not this one, but should judgements about quality of life have decision-making, should you take that into account when you're resuscitating babies? And there was a difference between the immigrant group and the non-immigrant group. When you're given the different statistics around, you know, if someone talked about, this was actually a question adopted from Father's work about there might be a possible miracle at the end of life. Do we continue treatment because of that hope for miracle, difference between the immigrant group and the non-immigrant group? We haven't teased it out, but in terms of authenticating what is an Islamic really ideal that they're practicing in some culture, I don't have a metric to do that, but I did notice some differences and at least where they matriculated from medical school in these ideas. Is there a concept of brain death also? I mean, I would understand, like regarding to organ transplantation that, you know, being kept physically alive for a heart or liver donation is not permissible because it's not for your own good, but how would it be with a post-mortem kidney donation then? Yeah, so I think there's a lot of complicated ideas that we have to talk about when we talk about brain death and organ donation. And as I respond to the organ donation thing, last year at the McLean Conference I gave a talk on brain death and you should know that that's on the website. And aside from that, there is two opinions or two dominant opinions, some considered dying state and the other scholars considered death and both allow for withdrawal life support. Organ donation within that context, one group did, one group didn't, largely because they're overlaid while we think this is permissible, not permissible. So it's a complicated construct there. I think what you're trying to get at is the idea of public benefit or communal benefit, right? Can we keep someone more, right? And so there is a maximum Islamic law around that, the communities' needs are part of individual needs, but that hasn't interestingly been used to talk about organ donation much in my reading. Up in the back. So, Asim, I was struck by how, for many of your slides, if we delete at the Arabic words, may the concepts seem very familiar or similar to may the largely Judeo-Christian Western ideas that have been presented in many of the prior sessions. Would you say that's a fair statement or are there key distinctions which you wanna highlight in terms of the presentation? Yes, so I think that you hit it on the head, Marsha. I think there's a lot of conceptual analogs and what I caution against is the surface reading of those. Meaning that if you buy the argument, these are historical constructions of formulations that were responding to a certain reality, a Muslim reality, right? And then they were then formulated in response to that, that there are ways where these won't be exactly mapping onto concepts that we have here. So yeah, I mentioned one clear thing I'll tell you about duties and obligations. I said, okay, there are conceptual analogs for that, but Islam wouldn't say that rights in here within men, right, they're confirmed from the deity. And if so, then you have to find a direct link to a statement in the Quran or the Prophetic Tradition that will confer that right upon an individual. So there might be a place where this breaks down. And if you just say, well, look, we have a concept of rights in Islam, it's called the Arabic word haquq, you might gloss over this distinction. So I think there are a lot of conceptual analogs which we want to have these sort of conversations and get at the heart of the matter. But we should caution the simplifications of that. But they come from the similar sources, people are people, we think about things in similar ways. Obviously we should share some values. I want to go back to Baader's question, just say it in a slightly different way. There are Catholic physicians who practice in Jewish physicians and Protestant physicians come out of a certain religious tradition, but in their practice, they're not practicing based upon the theological statements or requirements of that tradition. They're practicing a kind of secular medical practice in the US. I gather that was sort of behind your question, what percent of Muslim physicians practice out of the religious tradition and which out of a cultural or secular tradition? Right, so the quote, a statistical quote to you was that 60% of Muslim physicians in this group had said that Islamic bioethics or notions of Islamic bioethics influenced their practice, right? So greatly or somewhat. So there's something about Islam or some notions or whatever the reading they've done doesn't influence the way they think about things, particularly on things like this. So I'm leaving in February for a, I've invited to do a workshop on a life care. I did one in Dallas, the last year. I mean, people, when you have these challenges and you're facing something that you think might have religious implications, you often at that time, you at least try to figure out what the religion has to say about that. Particularly because most of the patients expect most physicians and the community to know that. Yet, medicine is globalized, the way we think about, I mean, these things are, the way that we think about things are similar across time and space now in modernity. So my other response to that is that I think that in certain contexts, just like Jewish physicians and Christian physicians might find around reproductive health, we have to think about things differently. Muslims might find that in the end of life care. But in other areas, things are similar and there's no cultural issue or religious issue. My question sort of expands on what you've been talking about because in this country, we do have religious intersections with treatment and certain groups have very strong prescriptions such as Catholic positions on some things and Jehovah's Witness and Christian science and some others. And given that there's a strong attitude as far as I understand among Muslims about inshallah, I'm wondering if there are some corresponding kinds of constraints for Muslim believers. So let me read from what you just said. So you're asking about inshallah, the term for those who don't know that term in parlance, it means God willing. So you're talking about the idea of reliance of God, having other implications in other areas of medicine? That they defer treatment because of some kind of a religious prescription or just because the very general attitude of God willing or whatever happens depends on God's will. So yeah. So I've been doing some work on fatalism and certain behaviors amongst Muslims. The data I can quote to you is from my work on cancer screening where I found that fatalistic notions did not impede cancer screening amongst American Muslim women from across these three ethnicities in Chicago with regards to cervical cancer and breast cancer screening. That's data. Now anecdotally, I will say that even my father says, if I wanna get it, I wanna get it, don't worry about it. I don't wanna go get screening, right? Or I have friends, parents who are diabetic, if I'm gonna, let me eat that sweet, whatever, it's okay. If I wanna die because I ate that sweet, I'm gonna die because I ate that sweet. So I don't know if the data doesn't matter just because of reality, but I think that this idea of quote unquote mapping on fatalistic beliefs because you have a deistic structure to your life, it's something that occurs across communities and it happens in different ways. People might not say I wanna die because God, I just might die if I walk across the street, so why not do this? Kind of follow up to that, like there's certain, I think I'm curious about it, there's certain positions that won't perform, for example, abortions because of their religious beliefs that they're not allowed to do that. So I think maybe the previous person was asking more about that, are there any procedures or religious constraints that may be placed on Muslim physicians based on religious beliefs? That's an excellent research question, one that will be addressed by this national survey as it is analyzed. I think, I just wanna make a comment for a second. Often when we talk about religion and medicine, we have this idea of clash and a lot of the questions even here have this notion of clash and we're trying to protect against areas for the benefit of the patient or others that physicians would not do something. I don't think that that is, I think that's overplayed. And I think that when you talk to Muslim physicians and I've done some quality of work, they might have some reservations around certain things and they might ask religious authorities and they saw the idea of a law of the land and often times they find a justification for doing whatever the norm of customary practice is. Based on the law of the land or custom within that society. So I think there are outs for them but I think end of life care is a clear problem which is why I talked about today, right? They have, even if they act the same way, they're psychologically troubled, they're looking for guidance, they don't believe brain death is death, half of them, there are challenges here and we have to think about how we would negotiate them as a professional identity but also whether there's something here to think about how we think about plurality in the medical community. So I just wanna, if that's a cop out to your question, that's a cop out but I think we should think about things in a more nuanced way. I don't know what the data shows today but if you did a general survey of the American physician population, had you done one 20 years ago, I wouldn't be surprised that 43% didn't believe in brain death either. You wonder if some of this is not just temporal phenomena and attitudes change and evolve. Other questions? I found this a fascinating talk and I really wanna thank you for coming. Well, my pleasure, thank you so much. Thank you. Thank you. Thank you. Thank you. Thank you.