ETICHAL PERSPECTIVES 17, no. 4(2010): 626-651. 2010 by European Centre for Ethics, K.U.Leuven. All rights reserved.doi: 10.2143/EP.17.4.2059849Stef Van den Branden and Bert BroeckaertKatholieke Universiteit Leuven, BelgiumNecessary Interventions: Muslim Views on Pain and Symptom Control in English Sunni e-FatwasABSTRACT.WhilemanywesterncountriesnowhavelargeMuslimcommuni-ties,relativelylittlescholarlyattentionisgiventotheattitudesofMuslims regardingend-of-lifeissues.Meanwhile,wereceivestrongandsignificantsig-nalsfromphysiciansandpastoralcareteamsonthedifficultyofdiscussing pain treatment with Muslim patients. With this study of Islamic views on pain controlandpalliativesedationinEnglishSunnie-fatwaswewishtomakea contributionfromthefieldofreligiousstudiestoabetterunderstandingof how Muslim patients balance their personal needs for pain treatment with the Islamicnormativebackground.UsingBroeckaertsconceptualframeworkon treatment decisions in advanced disease, we conducted an in-depth analysis of EnglishSunnie-fatwasonpaincontrolandpalliativesedation.Thee-fatwas were selected using Bunts typology of Cyber Islamic Environments and Tyans definition of a fatwa. We found that references to the use of sedative medica-tiontoreducetheconsciousnessofthepatientforpaintreatmentwerevery scarce in the texts we analysed. Although the idea of patiently enduring pain is present in the e-fatwas, it does not dominate the discussion, since the allevia-tion of pain is equally encouraged. When the pain medication used is addictive, altersthepatientsstateofconsciousnessorcontainsalcoholmakingitprob-lematic from an Islamic normative point of view, the use of this type of med-icationcanbepermittedonthebasisofaprincipleinIslamicjurisprudence: necessitypermitsbreakingthelaw.Thepossibledangerofdeathafterthe administration of high doses of pain medicine is countered based on the inten-tion of the treating physician: he or she aims to alleviate the pain and not kill the patient. The study of English Sunni e-fatwas on pain and symptom control indicatestheabsenceofaninsurmountableethicalproblemconnectedtothe use of heavy pain medication. KEYWORDS. Pain control, palliative sedation, fatwa, Islam, bioethics93967_Ethical_Persp_10-4_07_VdBranden.indd 626 1/12/10 11:12627Ethical Perspectives 17 (2010) 4VANDENBRANDENANDBROECKAERT NECESSARYINTERVENTIONSI.INTRODUCTIONDealingwithphysicalorpsychologicalpainisoftenanexistentialexperi-encetouchingthelimitsoflifeitself.Fromavarietyofreligiousorideo-logicalbackgrounds,peopletrytomakesenseofthesufferingthatover-comes them. When looking at the role of religion or ideology in the process ofcoping,wecanmakeadistinctionbetweenthenormativereligious/ideological narrative on (dealing with) physical/psychological pain and the way in which people who are confronted with pain actually deal with it. In this article we focus on the normative discourses on pain control.Turning to Islam, on the normative level we often find two lines of thoughtconcerningattitudestowardsphysicalpain.Ontheonehand, weencountertheviewthatpatientlybearingpainhasapositiveinflu-ence on the souls prospects in the afterlife: since pain can be interpreted asaformofdivinepredestination,thepatientwhopatientlyenduresit willhavehisorhersinsforgiveninthehereafter(Al-Jeilani1987; Sachedina2005;Ebrahim2001).Authorswhoarticulatethistheologi-callybasedposition,however,arenotledtotheconclusionthatpain should not be treated. On the contrary, most of them specifically argue thatunlikethespiritualmeritsofpatientlyenduringpain,everypatient has the right to look for pain treatment. This brings us to the second line of thought concerning attitudes towards physical pain, one that offers a rationale in which the choice to treat the pain with medication is evalu-ated.TwoimportantelementswerefoundinIslamicdebatesonthe possibility of using high doses of pain medication. The first concerns the use of morphine, which is often thought to have an immediate addictive effect on the patient. Although Islamic law forbids the use of intoxicants suchasalcoholordrugs,necessitypermitsbreakingthelawwhenno alternativeisathand(Boubakeur;Al-ShahriandAl-Khenaizan2005). Thesecondelementconcernsthepotentiallylifeshorteningeffectof heavypainmedication.Althoughrecentstudieshaveshownthathigh doses of morphine do not affect patient survival when they are properly 93967_Ethical_Persp_10-4_07_VdBranden.indd 627 1/12/10 11:12628Ethical Perspectives 17 (2010) 4ETHICALPERSPECTIVES DECEMBER2010administeredandtitratedaccordingtothelevelofpain(Bercovitch, Waller and Adunsky 1999; Azoulay et al. 2008; Gielen 2010), the idea of life-shortening effects connected to the use of high doses of pain medi-cationremainsaliveininternationalethicaldebatesrelatedtotheques-tionofitsuse(VanderHeideetal.2003;Deliensetal.2000;Sprunget al.2008;Vincent1999;VanderHeideetal.2000).Inthewritingsof Islamicauthors,weseethattheyrecognisethepossiblelife-shortening effect of heavy pain medication, but often deal with the issue by stating that even if the death is hastened during the process of giving adequate analgesia,thisshouldnotbeaproblemifthephysicianhastheright intention: to alleviate suffering, not to kill the patient (Gatrad and Sheikh 2000; Sachedina 2005). The overview of Islamic opinions given above is the general view one gets from studying the literature. This, however, is still a static view in the sense that it does not contain actual advice of Muslim scholars to people inconcretesituations.Putdifferently,theopinionsoftheauthorswe have referred to thus far represent only one array of opinions in the broad fieldofIslamicbioethics.Anumberofotherchannelsthroughwhich Islamic opinions on these matters are spread also need to be studied.BackgroundThefieldofIslamicbioethicsemergedasaresponsetotheworld-wide exportationofWesternmedicalachievementsandtothegrowingnum-berofMuslimswho,livingasminoritiesinWesterncountries,have accesstofarreachingmedicaltreatments.Themany-voicednatureof debateinthefieldisalsocharacteristicforIslamicbioethics.Indeed,a recentstudyhasshownthatpeoplefromamultitudeofprofessional backgroundspronouncenormativestatementsonIslamicbioethics (Shanawani and Khalil 2008). Not only the professional backgrounds of the spokespersons vary greatly, also the channels through which Islamic normativepointsofviewconcerningbioethicalissuesarepresentedare very diverse: reference can be made, for example, to (online) publications 93967_Ethical_Persp_10-4_07_VdBranden.indd 628 1/12/10 11:12629Ethical Perspectives 17 (2010) 4VANDENBRANDENANDBROECKAERT NECESSARYINTERVENTIONSofMuslimscholars,publicationsofIslamicorganisationssuchasthe Islamic Organisation of Medical Sciences (IOMS) or the Islamic Medical Association of North-America (IMANA), to (online) fatwas and to pub-lications in international medical journals.OneofthechannelsthroughwhichIslamicnormativeend-of-life issues are discussed is fatwa issuing. Starting in the 1980s, this provision of Islamic normative guidance has been the subject of extensive research from a Western scholarly perspective (Anees 1984). The study of end-of-life ethics in these fatwas is a quite recent feature in the study of Islamic bioethics(Rispler-Chaim1993).Fatwasonthisthemethathavebeen studiedintheinternationalliteraturearemostlyArabicfatwaswithhis-toricalimportance.Contemporaryfatwasandfatwasinlanguagesother than Arabic receive distinctively less scholarly attention. Nevertheless, the importance of Sunni fatwas in English can hardly be underestimated. International literature indicates that during the past few decades, forces of globalisation and migration have had a very strong influenceonthereligiosityofMuslimminoritieslivinginnon-Islamic countries(Buskens2000;Caeiro2009;EickelmanandAnderson2003; Haddad 1998, 1999; Mandaville 1999, 2001; Rohe 2004; Roy 2000, 2002; VanBruinessen2001).Roy,MandavilleandBunt,forexample,discuss therepresentationoftheworld-wideIslamiccommunity(Arab.:umma) ontheInternet(virtualumma).Buntanalysestherepresentationofthe umma on the Internet using his typology of Cyber Islamic Environments (CIEs),inwhichhedistinguishesseveraltypes:blogs,fatwaservices, ritualperformances,Qurantranslations,etc.(Bunt2009).Ofparticular interesttoourstudyaretheonlinefatwaservices:clearlytheyprovide applied Islamic normative guidance for Muslims that is very easily avail-able to anyone having access to the Internet (e-fatwa). Roys analysis of theseonlinefatwaservicesdemonstratesthatthemessagesspreadin these services are often uniform and fundamentalist i.e. only focusing onQuranandSunna,andleavingoutanyreferencetojurisprudential reasoningasitdevelopedinlatermedievaltexts(Roy2002).Because oftheratherlimitednumberofIslamicsources(i.e.Quranictextsand 93967_Ethical_Persp_10-4_07_VdBranden.indd 629 1/12/10 11:12630Ethical Perspectives 17 (2010) 4ETHICALPERSPECTIVES DECEMBER2010prophetic traditions) on the one hand, and because of the repeated post-ings on the other, the same messages often the same texts are com-municatedandtakenover,resultinginauniformisationofthemessage (Roy2002;Azzi1999).TheuseoftheEnglishlanguageresultsinthe developmentofanalternativecircuitofauthoritativeIslamicdiscourse andastretchingofthetraditionalconceptofIslamicauthority(Ander-son1997,2000).WhereasthetraditionalmuftiwoulddeliverIslamic guidance restricted to a specific geographical area, contemporary author-itiessuchasYusufal-Qaraawispeakoutfortheworld-wideIslamic communityandpresentthemselvesasglobalmuftis(al-Khateeb2009). Thesubjectsthataredealtwithintheseonlinefatwaservicesareas diverse as life itself. End-of-life ethics, however, is a growing subject. In spiteofthis,thebioethicalguidelinespresentedintheformofEnglish SunnifatwaspublishedonIslamicwebsiteshave,untilnow,attracted little scholarly attention.TobetterunderstandtheviewpointsthatMuslimpatientsand/or their family members in clinical settings might bring forward when con-frontedwiththeneedforpainmedicationorsedativemedication,we need to study the type of Islamic normative guidance that is available to them through online English Sunni fatwas. With this study we intend to provideinsightintothesearchofMuslimsforIslamicnormativeguid-ance that appeals to them in sometimes upsetting medical situations and in the specific nature of English Sunni fatwas on pain treatment and pal-liative sedation within the whole of Islamic viewpoints on the subject.1 II.METHODIslamic WebsitesMany fatwa-resembling texts are available on the Internet. To distinguish fatwasfromotherfatwa-resemblingtextsprovidingIslamicnormative guidance through the Internet, we employ a twofold point of departure: 93967_Ethical_Persp_10-4_07_VdBranden.indd 630 1/12/10 11:12631Ethical Perspectives 17 (2010) 4VANDENBRANDENANDBROECKAERT NECESSARYINTERVENTIONSTyansdefinitionofafatwaandGaryBuntstypologyofCyberIslamic Environments.AccordingtoTyansdefinitionintheEncyclopaediaof Islam,afatwaisanon-bindingclarificationofanambiguousjudicial point or an opinion by a jurist trained in Islamic law (mufti), in response to a query posed by a private inquirer (mustafti) (1965), a definition that is also atthebasisofMozaffarisstudyonfatwas(1998).Bydemarcatingthe fieldusingthisdefinitionofafatwa,viewsonthetopicpublishedby IslamicorganisationssuchastheIslamicOrganisationforMedicalSci-ences(IOMS)ortheIslamicMedicalAssociationofNorthAmerica (IMANA)arenotanalyzedinthisarticle.Althoughtheydealwiththe issue, they were not created as an answer to a specific question asked by a single person, dealing with a specific situation. We started our search for English Sunni e-fatwas on pain and symp-tom control in Roys 2002 study in which he describes the concept vir-tualummaandreferstoIslamicwebsitesthatcanbetakentoberepre-sentative. Despite the overwhelming number of Islamic websites websites that focus mainly on reporting news from Arabic speaking countries, on providingtranslationsoftheQuranandonIslamicidentityissues(e.g. Islamic feasts and the wearing of a headscarf) the majority of the web-sitesselectedbyRoynolongerexistordonotprovidefatwasonpain and symptom control. This prompted us to explore further using snow-ball sampling techniques on the links sections of Islamic websites and the hitsprovidedbythemostwidelyusedonlinesearchrobots(Google, Yahoo,Lycos)untilsaturationwasreached.Wefound9EnglishSunni e-fatwasdealingwithpainandsymptomcontrolonislamonline.net, islamweb.net and islamicity.com. AlthoughthesethreewebsitescanbeconsideredthemajorIslamic websites(newssitesandmuchmore)ontheInternet,oneshouldbe aware of the differences between them in terms of background. Islamon-line.net(AlexaTrafficRank7,668)wascreatedbySheikhYusuf al-Qaraawi,theQatarbasedal-Azhareducatedandverypopularjurist ofthemiddleway(Arab.:madhabal-waat;Grf2009).Theindication 93967_Ethical_Persp_10-4_07_VdBranden.indd 631 1/12/10 11:12632Ethical Perspectives 17 (2010) 4ETHICALPERSPECTIVES DECEMBER2010jurist of the middle way refers to the fact that al-Qaraawis jurispruden-tial reasoning is not bound by one specific Sunni school of law (anbali, Maliki, anafi or Shafii). His goal instead is to look for common ground between the different schools of law. His wesbite islamonline.net aims at informingandhelpingMuslimminoritiesbasedinWesterncountriesto maintain an Islamic identity by applying a form of Islamic jurisprudence (Arab:fiqh)dealingspecificallywiththeissuesrelevantforminorities (Arab.: fiqh al-aqalliyat). No fewer than 180 Muslim scholars and organisa-tionsofMuslimscholarscontributetoissuingfatwasasananswerto questionsposedbyaquestioner(mustafti)onthewebsite.2Additional backgroundconcerningtheindividualscholarsandgroupsisgenerally availableonthewebsite,althoughsomelinkse.g.islamonlinefatwa editing desk, a body of scholars connected to the website do not pro-videsuchinformation.Giventhefurtheranonymityofthemembersof the islamonline fatwa editing desk, we will refer to the group as a whole.Islamweb.net(AlexaTrafficRank2,945)isacomparablewebsite, althoughitisnotasmuchfocusedonbringingworldnewsasitison providing information on Islam. The website is available in Arabic, Eng-lish, French, German and Spanish. Fatwas published on the website are issuedandcontrolledbyagroupoflicentiategraduatesfromtheAl-ImaamMuhammadBinSaoudIslamicUniversityinSaudiArabiaand otherIslamiceducationalinstitutesinYemenandMauritania,headed byDr.Abdullaahal-Faqeeh(sic).3Abdullahal-Faqihisprofessorof political sciences at Sanaa University in Yemen. He holds a PhD (2003) fromNortheasternUniversity(Boston,MA)andpublishesinternation-allyondemocratization,Middle-Easternpoliticsandpeaceprocesses. Giventhisscholarlybackground,Dr.al-Faqihoftenprovidesdifferent andmorenuancedresponsestoethicalissueswhencomparedtothe normative viewpoints published on islamonline.net.Islamicity.com (Alexa Traffi Rank 45,703) is a major news site estab-lishedin1995offeringseveralsections:discoverIslam(mosqueloca-tor,prayertimes,Quransearch,Q&AasktheImam,),amultimedia 93967_Ethical_Persp_10-4_07_VdBranden.indd 632 1/12/10 11:12633Ethical Perspectives 17 (2010) 4VANDENBRANDENANDBROECKAERT NECESSARYINTERVENTIONSsection (IslamiTV, prayer channel, Aljazeera TV, ) and miscellaneous services (bazaar & shopping, hijri date converter, e-cards, cooking reci-pes, ). The website is operated by Human Assistance & Development International(HADI).HADIpresentsitselfasanIslamicnon-profit organisation established in 1991 in Culver City (CA) and supporting sev-eral(inter)nationalprogrammesdealingwitheducation(e.g.Centerfor Languages,Arts&SocietiesofSilkRoad),information(e.g.islamicity.com),outreach(e.g.ICmarriagecenter),relief(e.g.WestAfricaFood Fund) and discovery (e.g. guided tours). It has proved to be impossible toretrievefurtherinformationonthoseinvolvedortoretrievemore detailed background information on the HADI organisation. A Conceptual FrameworkIn response to the prevailing linguistic confusion in international debates onend-of-lifeethics,BertBroeckaerthascompiledaconceptualframe-workontreatmentdecisionsinadvanceddisease(2006;2008;2009). Centraltotheconceptualframeworkisthedistinctionbetweenthree possible groups of treatment decisions: (i) choices with regard to curative or life-sustaining treatment; (ii) choices with regard to palliative treatment and symptom control; (iii) choices with regard to euthanasia and assisted suicide, where lethal medication is intentionally administered. In the present article we focus on the elements in the second groups ofBroeckaertsconceptualframework:paincontrolandpalliativeseda-tion.Broeckaertdefinespaincontrolastheintentionaladministration ofanalgesicsand/orotherdrugsindosagesandcombinationsrequired to adequately relieve pain, and frames palliative sedation as an advanced typeofpainandsymptomcontrol,definingthesaidtreatmentdecision as the intentional administration of sedative drugs in dosages and com-binationsrequiredtoreducetheconsciousnessofaterminalpatientas muchasnecessarytoadequatelyrelieveoneormorerefractorysymp-toms (2008, 2009).93967_Ethical_Persp_10-4_07_VdBranden.indd 633 1/12/10 11:12634Ethical Perspectives 17 (2010) 4ETHICALPERSPECTIVES DECEMBER2010Text AnalysisAlthoughend-of-lifeissuesarediscussedinmanyfatwas,wecollected only9EnglishSunnie-fatwasonthespecificsubjectofpainandsymp-tom control. Each of these fatwas was subjected to an in-depth text ana-lysis in order to reveal the key elements in the Islamic ethical framework regarding pain and symptom control. On the level of content, data abstrac-tionwasaimedatidentifyingtheelementsofBroeckaertsconceptual frameworkoftreatmentdecisionsinadvanceddisease(paincontrol,pal-liative sedation) on the one hand and at tracking the procedure in jurispru-dential reasoning (Arab.: uul al-fiqh) used by the mufti on the other. In the processofanalysis,wealsopaidattentiontothestructureofthefatwa, looking for the order in which theological and non-theological arguments are used. The analysis of the data resulted in a database identifying each of theaforementionedelements(author,date,mustafti,subject,standpoint andelementsofuulal-fiqh),facilitatingcomparisononboththelevelof content and the structure of the fatwas. Referring to the fatwas, we have to reckon with several characteristics of online publications: not all of the e-fatwashaveaclearindicationoftheauthor;somee-fatwashaddisap-peared from the site since the last consultation resulting in the absence of a working URL; other e-fatwas do not mention the date of online publish-ing.Anonymousfatwasarereferredtothereforebystatingthewebsite, followedbyAnonymous.Thefatwaswithoutindicationofthepublica-tion date are referred to as s.d. (sine dato). The English translation of the QuranicversesmentionedinthisstudyistakenfromAbdullahYusuf Alis translation and can be found in box 1.III.RESULTSPalliative SedationWhenlookingattheissueofsedation,aninitialfindingisthatrefer-encestotheuseofsedativemedicationtoreducethepatientsstateof 93967_Ethical_Persp_10-4_07_VdBranden.indd 634 1/12/10 11:12635Ethical Perspectives 17 (2010) 4VANDENBRANDENANDBROECKAERT NECESSARYINTERVENTIONSconsciousness did not occur in the fatwas published on islamonline.net orislamicity.com.Evenwhenthetermsedationisused,thefatwas found on these websites only deal with pain treatment without mention-ing cases in which the consciousness of the patient is reduced. We did, however, find three fatwas in which the reduction of consciousness for alleviatingpainismentioned,eachofthempublishedonislamweb.net. Allthreeofthesaidfatwascontainreferencestoacommonlycited principleinIslamicjurisprudence:necessitypermitsbreakingthelaw (Arab.:arura).Wecanillustratethisonthebasisofaselectionof quotes from the fatwas themselves. In the 2001 fatwa entitled Use of Sedatives and Anesthetics in Islam (sic), theanonymousauthoranswersthequestionposedbyadoctoronthe permissibilityofusingsedativesinIslam.FromanIslamicnormative pointofview,theuseofalcoholorotherbodyandmindintoxicating substancesisstrictlyforbidden.Whiletheauthorclearlystatesthatthe use of sedatives is normally forbidden in Islam, he refers nevertheless to theviewsofImamal-NawawiandImamAlaadinal-Hambali,whosay thatnecessitymakeslawfultheforbiddenthings,andstatesthatseda-tivesmaybeusedinordertocureapatientontheconditionthatthe dosage is restricted to the minimum, that it is adequate and proportional to be able to perform a medical operation. Negative side effects such asalethaloutcomeareleftuptotheexpertiseofthetreatingphysi-cian.Thismeansthatiftheexpertiseofthephysicianleadshimorher tothinkthattheuseofsedativemedicationwillhavealethaloutcome, the use of that type of medication is prohibited in that situation (Islam-web Anonymous 2001). The fact that the author of the fatwa combines the principle of necessity with the argument of the intention of the treat-ing physician demonstrates how the said fatwa, on the level of content, blendsinperfectlywiththegeneraloverviewofIslamicargumentson using pain medication as found in Islamic literature. What is remarkable in the fatwa is that the mustafti frames his medical question immediately withintheIslamicnormativeframework,sinceheaskswhethertheuse of sedatives does not run counter the Islamic prohibitions on the use of 93967_Ethical_Persp_10-4_07_VdBranden.indd 635 1/12/10 11:12636Ethical Perspectives 17 (2010) 4ETHICALPERSPECTIVES DECEMBER2010intoxicating substances. From a non-Islamic perspective, this is remark-ableinthesensethatthemustaftidoesnotseemtostartfromtheidea ofthewellbeingofthepatient,butfromtheideaofcorrectIslamic behaviour.FromaMuslimperspective,thetwoareverymuchentan-gled.Ontheonehand,aholisticviewofthewellbeingofthepious Muslim patient encompassing both the spiritual and the physical has to take the Islamic normative position on the use of sedative medication intoaccount:clearlynopiousMuslimpatientwoulddeemtheusefor-bidden substances to be beneficent to his or her wellbeing. On the other hand,Islamiclawisaimedatpromotingthewellbeingoftheperson (Auda 2008). A brief examination of the intricate status of the principle of necessity in Islamic jurisprudence at this juncture should help clarify the way in which Islamic law promotes the wellbeing of the person. In the classical methodology of Islamic jurisprudence (Arab.: uul al-fiqh), a situationisanalysedstartingfromtheQuranandthepropheticaltradi-tion(Arab.:sunna).Whennoimmediateanswercanbefoundinthese twocanonicalsources,scholarsturntotheopinionsofotherscholars (Arab.: ijma) or to the use of what is called analogical reasoning (Arab.: qiyas). Quran, sunna, scholarly consensus and analogical reasoning con-stitutethefourmainsourcesintheclassicalmethodologyofIslamic jurisprudence.If,however,theapplicationofthesefoursourcesof Islamicjurisprudenceshouldresultinanextremesituationthatputsa person under serious threat, the rule of necessity can be called upon to allowtheunlawful(LinantdeBellefonds1965;Hallaq2009).Wefind clearexamplesofthisinthefatwasanalysedhere:ifthesurvivalofa patient depends on his or her using alcohol based medication, the pro-hibitiononusingalcoholbasednourishmentcanbeoverruledbythe necessity of the act. The element of analogical thinking in the classical theoryofIslamicjurisprudenceisbutoneremnantofseveralother forms of rational reasoning. Many of the other forms have been excluded fromal-Shafiisclassicaltheoryasstandardprinciples,amongthem interest, juridical preference, presumption of continuity and custom 93967_Ethical_Persp_10-4_07_VdBranden.indd 636 1/12/10 11:12637Ethical Perspectives 17 (2010) 4VANDENBRANDENANDBROECKAERT NECESSARYINTERVENTIONS(Auda2008).Historicallyspeaking,theprincipleofpreferencewas coinedbytheanafischoolandwasrejectedbytheShafiischoolof law(Hallaq2005c).Thefactthattheprincipleofnecessitydoesnot figureinal-ShafiisclassicaltheoryofIslamicjurisprudencedoesnot prevent other schools of law from accepting it as a valuable element in jurisprudentialreasoning:theanafiandanbalischoolsforinstance accepttheprincipleofnecessity(Arab.:arura)asaformofjuristic preference (Arab.: istisan) that can be used when a rigorous application oftheelementofanalogicalreasoningfallsshortinprotectingthe wellbeing of the person in extreme situations (Auda 2008; Hallaq 1997). InthebodyofthefatwawefindreferencestotwoMuslimscholars. Thefirst,YahyaibnSharafan-Nawawi(1234-1278CE),wasaShafii scholarwhoisbestknownforhiscollectionoffortyadithofthe ProphetMuhammad,acollectionofhighlyauthoritativesayingsofthe prophet on a variety of topics (Heffening 1993). We could not retrieve backgroundinformationonimamAlaadinalHambali,thesecond scholarmentioned.Inthisfatwa,weclearlyseethattheanonymous author refers to a principle in Islamic jurisdiction and to historical schol-ars in that field: he thereby clearly follows the classical methodology of uul al-fiqh and accepts the principle of necessity as a means to safeguard the wellbeing of the person. He also refers the mustafti to a Muslim doc-tor Mohammed Bin Mohammed Al Moctar Al Shingity (on whom we could find no further online reference) for a deeper understanding of the topic. Wefindthesamecharacteristicsintermsofuulal-fiqhinthe2002 fatwaentitledPainMedicationforOperation.Inthefatwainquestion,an anonymous mustafti inquires about the restrictions applicable to types of painmedicationwhenundergoingsurgery.Theanonymousscholar statesthattheuseofmedicinecontainingalcoholcanonlybeallowed whennoalternativeexistsandonlyifthepatientusesnomorethan requiredfortheoperation.Theauthorthenreferstoal-Nawawiand toIbnRajabal-anbali,anotherclassicalhistoricalauthor.Arguingon 93967_Ethical_Persp_10-4_07_VdBranden.indd 637 1/12/10 11:12638Ethical Perspectives 17 (2010) 4ETHICALPERSPECTIVES DECEMBER2010thebasisoftheprincipleofnecessity,al-Nawawistatesthattheuseof medicationcausingunconsciousnessislawfulinthecaseofamedical operation.ThestatementbyIbnRajabal-anbaliusedbytheanony-mous author goes in much the same direction as it uses pleasure as the criterion for deciding upon the lawfulness of intoxicants: when one uses intoxicantsthatdonotgivepleasure,itispermissibleintheviewof al-anbali.Again,wenotethecentralityoftheprincipleofnecessity (Arab.:arura)inthereasoningdevelopedinthefatwa.IbnRajabal-anbali is a anbali scholar who lived during the fourteenth century CE andiswellknownforhiscommentaryonal-Nawawiscollectionof40 adith (Makdisi 1971). The anonymous author of this fatwa does not give a personal opinion, but bases himself fully on the viewpoints of the clas-sicalscholars.Inthissense,heisconductingwhatiscalledtaqlid,the ArabictechnicalterminIslamicjurisprudenceforimitation:insteadof giving an answer based on a personal reading of the normative sources, the scholar takes over the classical interpretation of established scholars (Calder2002).Onemightwonderwhethertheuseofthisprocedurein modern times maintains the dynamics of the system of Islamic jurispru-denceneededforadequatelydealingwithcontemporaryissues(Hallaq 2005b, 2005a). Theanonymousauthorofthe2004fatwaentitledInjectingaPatient withMorphinegivesaresponsetotheanonymousmustaftisquestionon the permissibility of using morphine as a medicine to relax a patient prior tooxygentreatment.Toanswerthequestion,theanonymousrespond-ingscholarsaysthathedidsomepreparatoryresearchonthemedical aspectsofadministeringmorphine.Basedontheprincipleofnecessity, he argues that it can be lawful to use morphine. In this fatwa we find the viewthattheuseofsedativemedicationshouldbeavoidedbecauseof the danger of potential addiction, but that necessity permits breaking the law: if a trustworthy caregiver considers the use of morphine to be nec-essary, it may be allowed in the situation described by the mustafti. Apart from the appeal to the principle of arura, the argument of the trustwor-93967_Ethical_Persp_10-4_07_VdBranden.indd 638 1/12/10 11:12639Ethical Perspectives 17 (2010) 4VANDENBRANDENANDBROECKAERT NECESSARYINTERVENTIONSthiness of the caregiver refers to the correct intention of the caregiver in administeringthemedication.Interestinglyenough,thisthirdIslamweb fatwamakesnoreferenceatalltoQuranicverses,propheticadithor Islamiclegalprinciples.Theoverallimpressionofthefatwaisthatitis writtenasaveryquickresponsetoanurgentquestionofthemustafti (Islamweb Anonymous 2004). Summarizingthethreefatwasthatdealwithsedation,weseethe same line of reasoning appearing: since it runs counter to Islamic prohi-bitions on using addictive or intoxicating substances, the use of sedatives isgenerallydismissedfromanIslamicpointofview.TheIslamiclegal principlestatingthatnecessitypermitsbreakingthelaw(Arab.:arura), however, can overrule this initial prohibition and permit the use of seda-tivemedication.Wealsonotethatthecasesthatrefertotheuseof sedatives do not contain situations of palliative sedation as a treatment decision.Onthelevelofcontent,itisstrikingtoseethathardlyany medical-ethical questions arise in these fatwas (e.g. ethical dilemmas con-nected to the use of sedative medication and the possibility of shortening thepatientslife-span).Whatwedofindareethicalelementsfromthe Islamic normative legal framework: we see that the question on sedative medicationisposedwithintheframeworkofthe(im)permissibilityof usingaddictiveorintoxicatingsubstances.Thereligiousnon-medical framework forms the basis for dealing with questions on the use of sed-ative medication stemming from a medical background. Pain ControlEnglishSunnie-fatwasviewsonpaincontrolprovidetwowaysof respondingtothequestionwhetherhighdosagepaincontrolistobe considered an ethical problem. The first type of response rejects the per-missibilityofusinghighdosagepainmedicationwithapossiblelife-shorteningeffect.Wefindthisresponseinfourfatwaspublishedon islamonline.net.Thesecondtypeofresponseisfoundamongauthors 93967_Ethical_Persp_10-4_07_VdBranden.indd 639 1/12/10 11:12640Ethical Perspectives 17 (2010) 4ETHICALPERSPECTIVES DECEMBER2010whoseenoproblematallwithusingheavypainmedication.Thistype of response is found in one fatwa issued on islamicity.com. On islamonline.net, the fatwas mostly contain theological arguments withoutreferencetothemedicalcharacteristicsofpaincontrol.We foundthreefatwasonthesaidwebsiteinwhichpaintreatmentisdis-cussed:onefatwaisissuedbyYusufal-Qaraawiandtwofatwasare issued by Muzammil Siddiqi. In the 2005 fatwa entitled Euthanasia: Types and Rulings, a mustafti named Fuess from Germany asks for clarification onthemanyrulingsonIslamsstanceoneuthanasia.Thefatwacon-tainsashortintroductionwithanetymologicalexplanationoftheterm euthanasia,afterwhichananonymouswriterquotesthefatwaonthe subject that was issued by the European Council for Fatwa and Research (ECFR).Togetherwithislamonline.net,theECFRisanorganthatwas createdbyitschairYusufal-Qaraawi.TheECFRissuedonefatwaon euthanasiaduringitseleventhordinarysession4,whichisquotedinits entirety in the fatwa Euthanasia: Types and Rulings as found on islamonline.net.Onthelevelofcontent,weseethattheECFRmakesadistinction between several types of euthanasia, presenting pain control as a form of euthanasia termed indirect euthanasia. We quote the full description of indirect euthanasia from the body of the fatwa.Indirect Euthanasia:This is done through giving the patient doses of tranquilizers or seda-tivestoabatetheseverepain.Withtimethedoctorwillhaveto increasethedosestocontrolthepain.Itisaprocedurepreferredby therapists,butlargedosesmayleadtodifficultiesinbreathingand dysfunction of the cardiac muscle, which will result in death that was intendedthoughanticipatedbeforehand(IslamonlineFatwaEditing Desk 2005b).Abriefintermezzoonthewordingoftheabovementionedparagraph isneeded.Althoughitlooksasifthepassageonindirecteuthanasia hasbeencopy-pastedfromtheECFRwebsite,acloserlookrevealsa 93967_Ethical_Persp_10-4_07_VdBranden.indd 640 1/12/10 11:12641Ethical Perspectives 17 (2010) 4VANDENBRANDENANDBROECKAERT NECESSARYINTERVENTIONSremarkableinaccuracy:whereasthelastsentenceoftheparagraphon indirect euthanasia in the ECFR fatwa reads: () which will result in deaththathasnotbeenintendedbyitselfthoughanticipatedbefore-hand(2008),thesametextpresentedintheislamonline.netfatwa Euthanasia:TypesandRulingsreads:()whichwillresultindeaththat wasintendedthoughanticipatedbeforehand.Thiscarelessnessresults inaquitedifferentinterpretationoftheindirecttypeofeuthanasia presented in the fatwa. One might wonder whether this change in inter-pretationwasintendedornot.Sincethefirsttypeofeuthanasiades-ignated in the fatwa as direct or deliberate euthanasia is evaluated as totally forbidden, the use of the term euthanasia while referring to pain controlwithalife-shorteningeffect,resultsintheimpressionthatthis treatment decision is equally forbidden for Muslims. Since Fuess ques-tiondoesnotconcernpaintreatmentspecifically,theislamonline.net fatwa issuer does not extract a clear ruling on pain medication from the islamonline.net fatwa. What is clear in the body of the fatwa is that the issuer acknowledges the idea that large doses of pain medication have a life-shorteningeffectandthattheprocedurewillresultinthedeathof thepatientthatdependingonthereadingisorisnotintended, thoughanticipatedbeforehand.Althoughtheintentionofthetreating physicianseemsofcentralimportance,thefatwadoesnotcontainany furtherethicaldeliberation,oraclearlyoutspokendecisionontheper-missibilityofthemedicaltreatment.Theterminologyusedandthe framework within which pain treatment is discussed clearly suggest that the act is impermissible. The fatwa contains only theological arguments and no reflections rooted in a clear case or a patients situation. The first fatwabyMuzammilSiddiqiisentitledIsEuthanasiaAllowedinIslam?. Thefatwawasissuedin2006byMuzammilSiddiqiasananswertoa questionposedbyMarianfromtheUSaskingwhethereuthanasia (mercykilling)isallowedinIslam.Siddiqistartswiththeideathat Islamconsidershumanlifesacredandthatitisneitherpermissible inIslamtokillanotherhumanbeing,noreventokillonesownself 93967_Ethical_Persp_10-4_07_VdBranden.indd 641 1/12/10 11:12642Ethical Perspectives 17 (2010) 4ETHICALPERSPECTIVES DECEMBER2010(suicide).Hethenwritesthatkillingahumanbeingispermissible according to Islamic law in the case of self-defence when under attack or in the case of a punishment for serious crimes such as premeditated murder.HethenclearlystatesthatthereisnoprovisioninIslamfor killing a person to reduce his pain or suffering from sickness. According to Siddiqis fatwa, adequate pain treatment is the most important step to be taken when confronted with physical suffering: It is the duty of the doctors, patients relatives and the state to take care of the sick and to do theirbesttoreducethepainandsufferingofthesick,buttheyarenot allowed under any circumstances to kill the sick person (Siddiqui 2006). Once again we observe that theological arguments take precedence here over the perspective of the patient in need of treatment. Whether or not the use of pain medication with a life-shortening effect gives rise to eth-ical debates is not discussed in the fatwa and thus remains uncertain. The secondofSiddiqisfatwasstemsfrom2005andisentitledCantheState Intervene to Determine the Life of Individuals? It is a response to Sofia from the US, who asks for an Islamic answer to the case of Terri Schiavo, the severely brain damaged American patient in a persistently vegetative state whose case whether to withdraw artificial nutrition became headline news across the globe in March 2005. Here we find the same reasoning that we encountered in Siddiqis first fatwa Is Euthanasia Allowed in Islam?. As in the former fatwa, Siddiqi uses the same words to stress the duty of doctors,patientsrelativesandthestatetotakecareofthesickandto reducetheirthepainandsuffering.Hementionsthesacrednessoflife by referring to Q.6:151. Then we find the idea of a reward in the afterlife forpatientlyenduringpainduringearthlylife:Thesickpersonalso shouldpatientlyendurethepainandshouldpraytoAllah.Ifhe/sheis patient, there will be a great reward and blessing for him/her in the eter-nal life (Islamonline Fatwa Editing Desk 2005a). It is clear that Siddiqi bases his argument here on the theological conviction relating to rewards intheafterlifeforenduringphysicalpain.InbothSiddiqisfatwas,we findnoreferencetothelife-shorteningeffectsofpainmedicationand 93967_Ethical_Persp_10-4_07_VdBranden.indd 642 1/12/10 11:12643Ethical Perspectives 17 (2010) 4VANDENBRANDENANDBROECKAERT NECESSARYINTERVENTIONShencenodiscussionofanethicaldilemmaconnectedtotheuseofthis typeofmedication.ApartfromthequotationofpartofQ.6:151inthe second fatwa, a striking element that is common to both Siddiqis fatwas on islamonline.net is the total absence of quotations, even references to Quranicversesorpropheticadith.TheveryfactthatSiddiqiwritesa fatwawithoutdirectreferencestoQuranicversesorpropheticadith mightbeconnectedtothehighstatusheenjoysasthepresidentofthe Fiqh Council of North-America.We found the second type of response to the question whether the useofhighdosagepainmedicationcanbeallowedinonefatwapub-lishedonislamicity.com.Theprimarycharacteristicofthistypeof response is its unconditional acceptance of pain medication. In the 1998 fatwaentitledIsEuthanasiaGoodinIslam?,weareconfrontedwithboth ananonymousmustaftiandananonymousfatwaissuer.Thefatwacon-tainsaveryclearreferencetotheeuthanasiadebateandtotheethical dilemma of using high doses of pain medication: Muslim scholars pro-hibit euthanasia for any person, including terminally ill people but allow the use of pain killing drugs even if they have negative side effects. The author takes very clear positions: such forms of medication are described as the best alternative for a worse alternative (euthanasia) and the eas-ing of pain for a peaceful and humane way of ending ones life is totally acceptable.Intheeventthatthepaincannotbereduced,theMuslim patient can only patiently accept his fate, knowing that pain endured dur-ingearthlylifewillberewardedintheafterlife(IslamicityAnonymous 1998).Astrikingfactinthisfatwaisthattheanonymousauthorstarts from the patients perspective and seems to have a realistic view of pain treatment as he writes that the modern advances in health care have con-siderably improved the possibilities of fighting forms of pain that could not be relieved before. The author also refers to the theological merits of patiently enduring the pain, but only in the event that the pain cannot be abated.Again,wefindnoreferencetoQuranicversesorprophetic adith.Althoughthisanonymousauthorreferstoanethicaldilemma 93967_Ethical_Persp_10-4_07_VdBranden.indd 643 1/12/10 11:12644Ethical Perspectives 17 (2010) 4ETHICALPERSPECTIVES DECEMBER2010connectedtothistypeofmedicaltreatment,itdoesnotseemtobean insurmountable problem. IV.CONCLUDING REFLECTIONSSummarisingtheargumentsonpaintreatmentandpalliativesedationin English Sunni e-fatwas, we note that no reference whatsoever was found to the expression palliative sedation and very little reference was made to theethicalissuesrelatedtotheuseofsedativemedication:theseissues were only referred to in three fatwas on islamweb.net. Apart from the fact that the expression palliative sedation is a recently coined term in West-ern medical ethical literature (Broeckaert 2002), one would have expected theethicalissuesconnectedtotheuseofsedativemedicationforpain treatmenttobeofcentralimportance.Evenwhenthetermsedationis used,orwhenreferenceismadetotheuseofsedativemedication,the term/expression is more often used in relation to pain treatment than the reduction of the patients consciousness. Authors reasoning about reduc-ingthepatientsconsciousnessusetheprincipleofnecessity(Arab.: arura) as the general argument: only a case of necessity can overrule the initialIslamicprohibitiononusingsubstancesthatalteronesstateof consciousness.Whenitcomestoargumentsontheuseofpainmedica-tionwithalife-shorteningeffectinEnglishSunnie-fatwas,wefindthat someauthorswoulddescribepaintreatmentasaformofeuthanasia, while at the same time not forbidding it. As such, it is unclear whether or nottheuseofheavypainmedicationcanbecondoned.Othershave arguedthatenduringpainisrewardinginspiritualterms,thatkillinga personisneverallowedinIslamandthattheuseofheavypainmedica-tion can be condoned in very pressing cases if the intention of the physi-cianistoalleviatepainandnottokillthepatient.Themajorityofthe fatwasmakenomentionwhatsoeverofaprobleminusingheavypain medication.Generallyspeaking,theoftenreferredtoprincipleofarura 93967_Ethical_Persp_10-4_07_VdBranden.indd 644 1/12/10 11:12645Ethical Perspectives 17 (2010) 4VANDENBRANDENANDBROECKAERT NECESSARYINTERVENTIONSprovidesroomforallowingapatienttochoosepaintreatmentwhileat the same time being in line with the Islamic normative-ethical framework. Fromtheresultsofourstudyitisclearthattheideathattheuse of morphine in high doses entails the risk of ending a patients life, delib-eratelyornot,canstillbefoundintheargumentationusedinEnglish Sunnie-fatwas.Thischaracteristichastobeplacedinabroaderframe-work:itevenappearstobecommononaninternationallevelamong healthcareprovidersingeneral(Deliensetal.2000;Sprungetal.2008; VanderHeideetal.2000;Vincent1999).Inspiteofthiscommonper-ception, the effects of administering high doses of morphine, Hanks et al. describe how hypoventilation the best known lethal side effect of high doses of morphine use seldom occurs in cancer patients. Furthermore, theyindicatethatrespiratorydepressionalmostalwaysoccurstogether withothersignalsofanegativeeffectofthemedicationonthecentral nervoussystem,suchassedation,deliriumandconfusion.Bybeing attentivetothesesignals,deathbyrespiratorydepressionifitoccurs can be averted (Hanks, Cherny and Fallon 2005). Wilson et al. studied theorderingandadministrationofsedativesandanalgesicsduringthe withholding and withdrawal of life support from critically ill patients and concludedthatalthoughlargedosesofsedativesandanalgesicswere ordered, death was not hastened by administration of the drug (Wilson et al. 1992). In their 1999 study, Bercovitch et al. likewise demonstrated that hypoventilation or any other life-shortening effect did not occur in their twoyearstudyoftheuseofhighdosesofmorphineinIsraelicancer patients (Bercovitch, Waller and Adunsky 1999). Thorns 2000 study also points in the same direction (Thorns and Sykes 2000).ItisclearfromouranalysisthatEnglishSunnie-fatwasonend-of-lifeethicsareverymuchinlinewithRoysanalysisofthevirtualumma: the fatwas are very eclectic in nature often only referring to the Quran and to the Sunna (adith) and are quite uniform. The fatwas found on islamweb.net, however, form a major exception: in each of the three fat-was found on the said website, we encountered references to one central 93967_Ethical_Persp_10-4_07_VdBranden.indd 645 1/12/10 11:12646Ethical Perspectives 17 (2010) 4ETHICALPERSPECTIVES DECEMBER2010principleinIslamicjurisprudencebeingappliedtotheuseofsedative medication. This principle states that necessity permits breaking the law: in the event that the person has looked for alternative treatments and no otheralternativeisavailable,theuseofheavypainmedicationwitha possiblelife-shorteningeffectcanbecondoned.Byusingthisclassical principle from Islamic jurisprudential thinking, the authors of the fatwas on islamweb.net do not merely uphold the Islamic sources of Quran and Sunna,theyalsoaddanelementfromtraditionalIslamicjurisprudence. OnemightwonderwhetherthescholarlybackgroundofAbdullahal-Faqih, the head of the group of scholars issuing the fatwas published on thewebsite,hashaditsinfluenceonthemeticulousnessofthefatwas published on the website. Another element regarding the fatwas issued on these websites is the anonymity of the mustafti and/or the mufti. Given the way these fatwas are conceived and bearing in mind the channel through which they are com-municated, the anonymity of the mustafti and/or the mufti can be explained byreferringtotheuniversalscopethefatwasenjoy.Theyclearlydonot contain any indication of geographical limitation, but are published rather as a form of Islamic normative guidance and through a channel that can beaccessedbypeoplethroughouttheworld.Atthesametime,wefind norestrictionsconcerningtheIslamicschoolsoflawfromwhichthese fatwas are issued. This again adds to the idea of the global scope of these fatwas.Ofcentralimportancefromareligiousstudiesperspectiveisthe impact of this anonymity. Roys analysis of the fundamentalist character ofthesefatwasonlyreferringtoQuranandSunnaandtheeaseof publishing online fatwas resulting from the Internets anonymity, create a situation of democratization in deliberating on Islams normative sources. Thisevolution,however,alsoputsthefatwarequestersespecially minoritiesinnon-Muslimcountriesinavulnerableposition,opening themtobeingcontrolledbyorganisationswithhiddenagendas.The evolutiontowardsaformofuniversalisationinfatwaissuing,theemer-gence of access to the sources by each and everyone, and the vulnerability 93967_Ethical_Persp_10-4_07_VdBranden.indd 646 1/12/10 11:12647Ethical Perspectives 17 (2010) 4VANDENBRANDENANDBROECKAERT NECESSARYINTERVENTIONSresulting therefrom, demonstrates the importance of integrating this type of Islamic normative material into the study of Islamic/Muslim attitudes towards pain treatment and (palliative) sedation.The analysis of the fatwas shows how Islamic jurisprudence is aimed at the wellbeing of the patient: the principle insisting that necessity per-mits breaking the law in extreme situations safeguards the physical well-being of the patient. 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JAMA 267: 949-953.Box 1.Q.6:151Say:ComeIwillrehearsewhatAllahhath(really)prohibitedyoufrom: joinnotanythingwithHim;Begoodtoyourparents:killnotyourchildren onapleaofwant;providesustenanceforyouandforthem;comenot nightoshamefuldeeds,whetheropenorsecret;takenotlife,whichAllah hath made sacred, except by way of justice and law: thus doth He command you, that ye may learn wisdom.NOTES1.This in-depth study of the views of Islamic scholars on pain control and palliative seda-tion, as they can be found in English Sunni e-fatwas, is part of the research project Religion and Ethics at the End of Life. A Study of the Influence of Religious and Ideological Affiliation and WorldviewonAttitudestowardsEnd-of-lifeDecisions(promoterBertBroeckaert),sponsored by the Research Foundation Flanders.2.http://www.islamonline.net/servlet/Satellite?cid=1118742803189&pagename=IslamOnline-English-Ask_Scholar%2FCollection%2FFatwaCounselorsE3.http://www.islamweb.net/ver2/archive/article.php?lang=E&id=130464.Islamic Centre, Stockholm, Sweden, 1-7 July, 2003.93967_Ethical_Persp_10-4_07_VdBranden.indd 651 1/12/10 11:12