Euthanasia and physician-assisted suicide: historical and religious perspective in the Middle East.

Euthanasia and physician-assisted suicide have provoked controversy. The ethical and legal issues have been debated but more emphasis on the cultural and religious aspects is needed.

Cultural differences could account for some inequalities related to physician-assisted suicide (PAS), especially as clinical decisions are necessarily influenced by the structure of society at large and the context in which they are made (Clark et al, 1991). Sociological influences on clinical decision-making include the social characteristics of patients and physicians, the patterns of social interaction and authority in clinical settings, and the structure of healthcare organisations. In the UK and other European countries, there are sizeable minorities who originate from the Middle East and similar cultures who come into contact with the health sector as patients or clinicians. Euthanasia and PAS are legally prohibited in all Middle Eastern countries and this review, though not exhaustive, explores these topical issues from historical and religious perspectives.

Historical perspective

A historical approach makes it possible to understand what meaning suicide and assisted suicide have for people from different cultural backgrounds and from different generations. The history of suicide from the perspective of Western society has been described by a number of writers, including Alvarez (1990) and Retterstol (1993).

In Athens, hemlock was supplied by the authorities to people who wanted to die by suicide after giving their reasons to the magistrates. They also had to plead their case before the senate in order to gain official permission (Alvarez, 1990), which has parallels with PAS laws in the Netherlands and Switzerland. It was believed that suicide was an act worthy of respect in the following conditions: when a service is done for others by the act of suicide; when suicide is to avoid being forced to perform unlawful or immoral acts; and when poverty, chronic disease or mental illness makes death more attractive than life (Alvarez, 1990; Retterstol, 1993).

In the Roman Empire soldiers were not allowed to perform acts of suicide because this would weaken the Empire, and citizens facing a trial faced a similar prohibition; their estates would be forfeited if they did so.

A contemporary Middle Eastern perspective

The strong legal, cultural and religious restrictions on euthanasia prevent the expression of opposing views. This is reflected in the paucity of research and data in this area (Askar et al, 2000). There is a dearth of literature on PAS in the Middle East, although a study in Kuwait examined the attitude of physicians working in government hospitals; it found that about 92% of all the respondents did not support the provision of the means for suicide to terminally ill patients, while 8% did (Askar et al, 2000). Studies on euthanasia are much more common and elaborate in high-income countries than elsewhere.

Another study of attitudes to PAS in Kuwait (Ahmed et al, 2010) found that 44% of university students felt that PAS was unacceptable at all times, whereas 23% felt that it was unacceptable unless the patient was old or requested it repeatedly.

Religious perspective

In the Middle East, the usual practice of allowing only limited disclosure of medical information to the terminally ill patient, and sometimes to the family, complicates matters and especially so with end-of-life decisions. Almost all ethical decisions in the Middle East are ultimately grounded upon, and inseparable from, some set of religious beliefs. The three main Middle Eastern religions, Judaism, Christianity and Islam, share a belief in the existence of God, an afterlife and the immortality of the soul; this is strongly reflected in opinions on euthanasia (Benjamin, 1981). The Judaeo-Christian Bible and the doctrine of ‘the divine ownership’ (1 Corinthians 10:26) stresses the dignity of the human being as a person. St Augustine, an early Church father, who opposed euthanasia, commented in 413 that the sixth commandment applies to suicide and euthanasia as well as to homicide (Bettenson, 1972). St Aquinas in 1271 adopted the view of the Jewish scholar Maimonides that killing an innocent person, whether healthy or about to die from natural causes, is absolutely prohibited. The Roman Catholic catechism teaches that euthanasia is a sin against the greatest commandment about loving God, oneself and one’s neighbour (Matthew 22:38–40) and against God’s specific plan for each person (Ephesians 2:10).

The Qur’an stresses that God is the ‘owner’ and the ‘giver’ of life (Qur’an 3:145; 16:61) and that God is the most merciful (Qur’an 4:29). Life is a ‘trust’ that we should keep and so the deliberate termination of one’s life or the life of another is not permitted unless it is in ‘the course of justice’ (Qur’an 6:151). Euthanasia is thus forbidden in Islam, particularly in the Prophet Mohammed’s teachings. Jundub narrated that the Prophet Mohammed said: ‘A man was inflicted with wounds and committed suicide; so Allah said: My slave has caused death on himself hurriedly, so I forbid paradise for him’ (Khan, 1995). Van den Branden & Broeckaert (2011) similarly concluded that euthanasia is forbidden in Islam when they studied 32 English sunni e-fatwas (Islamic religious rulings or scholarly opinions). Abu Hurairah narrated that the Prophet Mohammed said: ‘Whoever kills himself by a certain means, will keep on being tortured by such means in hell’ (Sabiq, 1983).

Another important issue, as discussed by Babji (2009), is that of end-of-life care and the differences between Islamic and more secular cultures regarding ownership of life and advance directives concerning personal wishes at the end of life, although there are similarities between these two systems, including the preservation of life, protection of individuals’ rights and a ban on assisted suicide (with some exceptions) (Babji, 2009).

Conclusions

The Middle East has a unique position in history. People from the region have collectively developed their cultures through years of interaction with different eras of history, cultures and religions. There are sizeable minorities in the USA, Australia, the UK and mainland Europe who emigrated from or have links with the Middle East. Also, there are millions of Muslims who currently live in Western countries. Therefore, it is essential for doctors practising in those countries to understand the historical, spiritual and cultural perspective of those who have their cultural roots in the Middle East. We also need to understand who the physician is, the relationship between professional and patient, and the impact of societal structures on that relationship. Only if professionals understand the cultural and religious needs of diverse groups of our patients can we offer them appropriate suggestions and advise on end-of-life decisions.