I begin my discussion today with a few real life scenarios.
1. A 30 year old male from a neighbouring country approached me a few years back asking me how he could “donate his kidney” to his employers friend who wanted to “buy” it. This was during my sojourns in a friendly country. I took him aside and strongly counselled him against the act, but still asked him how much money he was offered. As I walked off he called out again and asked me “How about if I sell one kidney and buy another cheaper one in Cal !!!!!!!!.
2. My present nephrology colleague tells me of his experience with a patient transplanted ten years back who came to him with a normal creatinine and some urologic complaints. During the course of investigations, a renal scan revealed normally functioning native kidneys and a poorly functioning transplanted kidney - a case of transplantation in retrospect, for acute renal failure!
3. A PHD student of Islamic Studies developed renal failure a few years back, met me in consultation and as per my advice got transplanted from his sister which unfortunately failed for technical reasons. He got retransplanted from another sister in a European country which got ‘mismanaged’ and in desperation wanted to go to a famous city in Pakistan to buy a kidney. Fortunately he consulted a well known scholar who told him to avoid this if he could because this was not acceptable on religious grounds and now another family member has come forward to donate.
4. A 15 year old patient of mine developed renal failure 4 years back . Both parents wanted to donate “pre-emptively”. A solitary brother also developed renal failure 6 months later. Now I recently received an email from the parents stating that since both parents have “donated” to their two sons their family is unique in that all four of them have one functional kidney!
We have all been approached in our practices all over the world by patients who have been transplanted “elsewhere”, related or unrelated. we have often obliged in terms of some form of follow up. however what is the ethical course related to this, from a physician / surgeon’s point of view? should we attempt to learn and understand? should we push the issue under the rug?
TO UNDERSTAND THIS, WE NEED TO DEFINE “ETHICS”
The Oxford English Dictionary defines Ethics as “the science of morals; the department of study concerned with the principles of human duty ”Oxford University” Press 1993.
DEFINITION RELATING TO MORALS
Ethics systematically examines what is right , good or just in human conduct. Morality is the social, religious or professional tradition of values about what is right, good or just in human conduct. Miller, RB. in Caring for the renal patient, ED Levinedz, WB saunders 1997, pp203-242
CURRENT ETHICAL QUESTIONS IN NEPHROLOGY INCLUDE:
GENERAL NEPHROLOGY: Allocation of resources; individual versus population.
ACUTE RENAL FAILURE: when is it futile to continue?
DIALYSIS: ESRD treatment in an unequal world, Who should receive dialysis? When can one with hold dialysis? Advance directives?
SIMILARLY ETHICAL QUESTIONS IN TRANSPLANTATION RELATE TO :
Source of Donor organs e.g. an encephalic babies, lack of consensus on Cadaveric transplant in Pakistan, Living donors, including paid, unpaid, under coercion or in minors. Executed prisoners. Patients in a persistent vegetative state as donors. Animals (Xenotransplantation)? Equitable distribution of organs. Modified from Stewart Cameron and R. Hoffenberg Kidney International Vol 55(1999) pp724-732
ISLAMIC ETHICS OF ORGAN TRANSPLANTATION
This question is no longer an issue in the West and several Muslim countries. Well documented consensus opinions from Islamic Fiqh Academy, Muslim World League, Makkah,1985, Eighth Working session ’state” it is permissible within the SHARIAH(Islamic Law) to remove the organ from one persons’ body and transplant it into another persons’ body in order to save the life of that person or to assist in stabilizing the normal functioning of the basic organs of that person’.
CONDITIONS TO BE MET; (ISLAMIC FIQH ACADEMY) FOR PERMISSIBILITY OF ORGAN TRANSPLANT FROM AN ISLAMIC POINT OF VIEW:
- 1. Donor’s Life is not harmed in any way.
- 2. Donor voluntarily donates without any form of coercion.
- 3. The procedure is the only medical means available to alleviate the plight of the patient.
- 4.The success rate of the procedure for removing and transplanting the organ is relatively high.
Currently accepted International Criteria include: unresponsiveness to painful stimuli, pupils’ non-reaction to light, pupils fixed and dilated, inability to swallow, yawn or vocalize, inability to breathe spontaneously within a three minute period after switching off the ventilator, Flat line
NOW, LET US REVIEW THE QURANIC CONCEPT OF DEATH
“Allah takes the soul at the time of death (al-Zumar39;42)”.They ask you (O, Muhammad PBUH) concerning the Ruh(spirit or soul). Say: The spirit (or soul)is of the authority of my Lord, of knowledge it is only little that is
communicated to you.(Bani:Israel,17:85). Hence the lack of consensus among Muslim scholars still as to the defining moment of death.
OPINIONS OF SCHOLARS:
Muslim Jurist Qadi Mujahid Al Islam Qasimi states that once the brain stem dies the soul leaves the body. Qasimi, Dimaghi Mawt, p 14. Opposing views also exist including from Sh. Mukhtar Salami, Mufti of Tunisia who states that “it would not be right to consider a brain dead person to be ‘dead’ as long as the essential systems of such a person are alive”. Salami: When does life end? IOMS p 422-423
The Majlis-e- Shura (consultative assembly) Al Islami, Gatesville, Cape Town, South Africa, May5 1994,states that “when those qualified to make judgments on brain death declare such a person brain-dead, then the Shariah (Islamic law) concurs with this judgment and also regards this patient dead”.
COUNCIL OF ISLAMIC FIQH ACADEMY OF OIC , 4TH SESSION JEDDAH 1988
Resolved that “it is permissible to transplant the organ from the dead to the living on the condition that it has been authorized by the deceased or by his heirs after his death”. “Death may take two forms: 1. when all functions of the brain come to a complete stop, and no medical cure can reverse the situation. 2. when the heart and respiration come to a stop and no medical cure can reverse the situation”. Resolution no (1) of OIC (Organization of Islamic Countries) Islamic Fiqh Academy, resolutions and recommendations 1985-89 p52
LET US IDENTIFY SOME OTHER ETHICAL QUESTIONS TO PONDER UPON: VIZ
Sacredness of Human body and life? Are we violating its sanctity? Concept of human body as an “Amana” or Trust? i.e. Do we even own it to make any decisions about it? Subjecting human body to material ends? Role of public welfare or “Masliha”? Role of Altruism or “Ithaar”? Does this override the previous constraints? Sale of Organs? Inclusion of organ donation in one’s will? Diagnosis of brain death? Who shall decide?
Switching off life support in case of brain-stem death? Retrieving organs from brain-stem death patients? Is the sanctity of the body not violated? Clearly Islamic ethicists continue to debate on these issues.
How to define the moment of death? Islamic Medical ethics in the twentieth century, Vardit Rispler-Chaim 1993,p28-43
Who are the preferred donors and what conditions should they fulfill? Does an organ of the deceased defile the recipient? Animal to human transplant? May money be accepted for an organ donation? The council of Islamic ideology in Pakistan clearly finds this “repugnant to Islamic” principles, yet this practice goes unabated in certain leading cities of Pakistan. What is the role of the doctor? Are organ banks permissible?
These are some of the other contentious issues that need further research. Pending this, I believe that answers may well be encompassed in the four principles advocated by Beauchamp and Childress.
- 1. Respect for peoples’ autonomy, in effect deliberated self-rule or self-determination, making thought out choices for oneself
- 2. Non-maleficence or the obligation not to harm
- 3. Beneficence or the obligation to benefit
- 4. Justice i.e. the obligation to treat conflicting claims fairly or justly, especially for health care ethics, in the context of scarce resources, of respect for people’s rights and of respect for morally acceptable laws.
Transplantation and Ethics Raanon Gillon in Birth to death; Science and bioethics, Ed Thomasma and Kushner1996,p106-118
When two consenting adults buy and sell their organs respectively, this falls under the definition of a victimless crime, but my question is, analogous to prostitution, if the “seller” belongs to the lowest and thus exploitable strata of society, is it still a victimless crime? This I hope will convince our transplant colleagues who advocate “organ sale” Modified from Issues in Criminology, Scarman Center, Univ. of Leicester,1997, p 139-179
Islamic principles clearly allow what is not forbidden and Prophet Muhammad (PBUH) recommended to stay away from the doubtful. This in my view should guide Muslim Nephrologists and transplant surgeons and the rest of the scientific community can be cognizant of this guiding principle when dealing with Muslim patients.
I hope I have conveyed the major issues upon which Islamic Ethics has evolved consensus regarding organ transplantation and some of the more contentious issues over which debate continues amongst Muslim physicians. My own bias in accepting these “PRO-Transplant” views needs to be placed in perspective too and certainly some Muslim scholars still consider organ donation “not permissible”. Thank you.
Mr Qaiser Shahzad, Dept of Islamic Medical ethics, Shifa College of Medicine and Professor M. Amin, Dean Shifa college of Medicine who taught me how to ask an ethical question.
Dr. Khawaja Sayeed Ahmed, Dr. Nayer Mahmud, my Nephrology colleagues and Dr. Saeed Akhtar, our transplant Urologist, who
had the courage to take on the “organ traders” and speak out against this evil.
DEDICATED TO: (Late) Prof. SAMEER BIN HURAIB, King Fahad National Guard Hospital Riyadh. He and I were both invited as a pair to contribute to this conference but Alas! He has joined his Maker and may his soul rest in peace and tranquility. Ameen.