Both women had lost two pregnancies and were not yet pregnant again. Rubina's first baby, a girl born at 40 weeks and of a good weight, had died after six days. In her second pregnancy Rubina had felt the baby was no longer moving at the beginning of the seventh month and was sent for scans that showed the baby boy was dead.
Samina's older sister and Samina's mother, who joined the interview part way through, also spoke about the value of prayer, particularly praying at the tombs of pir s saints, or holy men in Pakistan.
I should explain here that beliefs in the power of pir s to effect cures for a range of ailments are typically associated with South Asian Muslims of the Barelvi tradition.
And accessing pirs does not necessarily require travel abroad. When Samina became pregnant again, not long after our first interview, her family decided against the trip to Pakistan, considering it safer for Samina to avoid international travel and to have full medical surveillance of this pregnancy at the local hospital. Samina showed me the three cloth amulets she was wearing — one round her neck, one on her abdomen, and one at the top of her calf, just below the knee. Samina's mother also wanted her daughter to have full access to biomedical expertise, and could not understand why, in the light of the reproductive history, Samina's doctors were not keeping her in hospital for the entire duration of the pregnancy.
Yet the family also believed that all remedies, including Western medicine, had their limitations, and perceived God as the ultimate arbiter of successful or unsuccessful reproduction. It is her luck. And science, science cannot control everything. They [biomedical doctors] are not Gods. At the end of the day, we say it is in God's hands. The baby may be named at this point but final decisions about a name may be made later, sometime after relatives in Pakistan have offered their suggestions.
My interviewees mentioned several additional neonatal rituals performed during the early post-natal period to protect a vulnerable newborn baby from illness, evil spirits and even the malicious gaze of jealous neighbours. Indeed, my interviewees say, in the time between death and burial, the body and soul is especially vulnerable, and any bodily trauma is far more painful at this time than in life. Thus, post-mortems are not agreed to unless required by law, in which case in the UK the hospital will seek to return the corpse to the family for burial as soon as possible.
For the same reason, Muslim burials should take place as soon after the death as possible, ideally in the ground where the person dies. Preparation for a Muslim burial involves ritual washing of the body by close kin of the deceased or Muslim funerary services.
Men wash a male corpse and women wash a female corpse. The body is then wrapped in white unstitched cloth in preparation for relatives and friends to pay their final respects before the burial. Afterwards, visitors usually come to the home of the deceased to offer condolences to the bereaved family. Funerals are usually attended by a wide range of people who travel from near and far to acknowledge the loss of one of their community.
Despite the Islamic recommendation that a person be interred quickly after death, it has been customary since the early years of Pakistani settlement in Britain for bodies of deceased adults to be returned to Pakistan. First-generation migrants usually maintain it is important for relatives in Pakistan to view the deceased person and pay their final respects before burial. It is thought that relatives are more likely to remember the deceased person and pray for them if their grave is nearby.
The ideal place of burial, therefore, is near to the social body of the community, in a place that relatives will visit. Increasingly British Pakistani Muslims are being buried in the UK, in cemeteries or sections of cemeteries allocated for Muslims following negotiations with local councils.
Sometimes, adult children of pioneer-generation migrants decide not to return their parents' bodies to Pakistan, so that they can more easily visit their parents' graves. In the Muslim section of the cemetery in High Wycombe, the Muslim graves are distinctive because the tombstones all face in the same direction, in neat rows.
It is also striking that there is a roughly equivalent number of adult and of child graves, reflecting this history of burial practice. Some of these graves are unmarked grassy mounds of earth, not necessarily indicating neglect because a grave is in orthodox Islam supposed to be an unadorned, simply marked mound.
Others, however, have elaborately carved tombstones, some procured from specialist stone-carvers in Mirpur and carrying inscriptions that offer insights into aspects of the migration and settlement history of this community. This awareness of a child's life underpinned parents' concerns about the permissibility of facilitating death when considering medical abortion for fetal abnormality and when their consent was sought for the withdrawal of life-support from infants with fatal abnormalities.
However, as I shall show in what follows, this definition of life was insufficient to guarantee the recognition of Islamic personhood for miscarried and stillborn babies. Pakistan-born Sofia talked in some detail about her own experience of miscarriage. In Sofia's first pregnancy, at the week scan doctors had detected fatal abnormalities associated with a known recessive condition and offered a medical abortion.
The couple chose to continue with the pregnancy. Sofia had a surgical delivery at 38 weeks of a boy who died a few days later. He was named and buried in the Muslim cemetery. Sofia's next two pregnancies resulted in miscarriages at 10 and at 12 weeks. I flushed it down the toilet. I did not know then that the doctors would have liked to look at it. In the next pregnancy, when her second miscarriage started, Sofia immediately contacted a doctor and was admitted to hospital. This phrasing signals that Sofia considered these to be lost pregnancies rather than lost babies, miscarriages rather than stillbirths.
A pregnancy lost after fetal movements are felt is therefore recognized as the loss of a child, whereas an early miscarriage remains a lost pregnancy, a loss of blood or tissue. There is also an important distinction between miscarriages and medically induced abortion in local Urdu and Panjabi idiom.
By contrast, medical abortions are events that involve human agency. This difference in expression also reflects an underlying moral distinction between spontaneous pregnancy loss and medical induced abortion. My interviewees expressed considerable disquiet over the idea of medical induced abortion even where fatal abnormality in the fetus had been confirmed by ultrasound scans or genetic tests.
The dominant view was that abortion in such cases is murder, for which God will punish the murderer unless it is certain that the mother will die. Later, in Sofia's fourth pregnancy, similarly fatal abnormalities were confirmed after the gestational cut-off for abortion. A consequence of the dominant view that a medical termination of pregnancy is sinful is that when abortion is carried out, it may need to be concealed from some family members. Occasionally women who choose to terminate an abnormal fetus without the support of a husband or in-laws may arrange for the procedure to take place in a hospital away from the their home town, to reduce the risk of malicious gossip or other harm.
Older migrant-generation women tended to view the births of babies with disabilities as challenges sent by God, and which they should meet with patience sabar , endurance and a faith in Allah's will.
The two women among my interviewees who chose abortion did so with considerable ambivalence and, later, strong feelings of wrongdoing. British-raised Miriam expressed a personal view that medical abortion before 20 weeks might be acceptable. Miriam already had two healthy daughters when offered a medical abortion 20 weeks into her third pregnancy when scans showed a baby with fatal abnormalities. She did not justify this view with reference to Islam.
British-raised Shakeela sought unsuccessfully to find any authoritative Islamic support to enable her to end a first pregnancy shown on ultrasound to have multiple fatal abnormalities. Following her mother's advice to trust in God, and informed by books stating that medical abortion is wrong for Muslims unless the mother's life is in danger, Shakeela decided against a termination. She proceeded to have a traumatic surgical delivery of a fatally malformed baby, who lived less than an hour, was named and buried in the Muslim cemetery.
At the baby's funeral, however, Shakeela learnt from a woman offering condolences that some Muslim scholars have issued authoritative alternative interpretations of the Islamic position on abortion. These interpretations include fetal abnormality as a reasonable ground for abortion before days of conception, corresponding to about 19 weeks of the medical gestational calendar. Fatwa s to this effect have been issued in Kuwait, Saudi Arabia and Iran.
Exercising agency in facilitating the death of a child was also a concern for four couples who consented to the withdrawal of life support from infants in special care.
When I first interviewed Samina and Rubina they had each lost two pregnancies. Samina's first baby had died after 3 days; the second had died in utero and was induced at 40 weeks. Rubina's first baby had died after 6 days; the second had died in utero and was induced at 34 weeks. As I still looked puzzled over the distinction between burial upar and burial niche , Samina added some further explanation, in English:.
The big ones are the two babies who lived a few days. They are in the Muslim section of the [local hillside] cemetery, at the top of the hill. The little ones [she signed as she said this] are the babies who were born dead; they are buried in the Snowdrop Garden [the memorial garden for miscarried and stillborn babies, located at the bottom of the hill at the entrance to the cemetery].
If the baby breathes for a second, they can do it, but they have to do it quickly. In the Muslim section of the cemetery, the graves of babies are clearly distinguishable from the adult graves by being smaller.
Some of these small graves are simple grassy mounds, as are some of the adult graves. But many of them have elaborately decorated tombstones, some of them crafted by stone-carvers in Pakistan. These tombstones carry inscriptions that bear witness to the brevity of the child's life, noting a death that occurred a few moments, hours, days, or months of birth, or marking the short life of an older infant.
These brief biographies of named infants convey profoundly a sense of the loss experienced by the parents. In the Snowdrop Garden, by contrast, the Muslim graves are almost completely unmarked, although they are clearly recognizable because they are grouped together and all face the same direction. The non-Muslim graves are marked by flowers and inscribed tombstones while name plaques mark where ashes have been interred.
A few of the Muslim graves still carry numbers that would enable the hospital or the parents to identify the baby, through the system used by the local National Health Service Trust to allocate spaces in the memorial garden.
But these small mounds of earth are untended and overgrown with weeds, giving the impression that the Muslim parents of these babies do not visit. This recognized Islamic personhood is constructed locally through having a Muslim burial. Moreover, it provides social recognition to the bereaved parents of the fact that they have lost a child, a recognition made for example in the fact that neighbours will come to the home to offer condolences after the funeral.
Miriam who, as we saw, had declined an abortion, proceeded to a spontaneous labour and a normal delivery of a boy who had died in utero at 37 weeks. Miriam and her Pakistan-born husband named their stillborn baby, and took photographs of him in the arms of his parents and sisters, so that they would remember him. She showed me the number card by which they can identify his grave in the Snowdrop Garden.
Miriam said that she considered her son Muslim because he was born to Muslim parents. But in her wider family and community her son's personhood was not recognized:.
If he had drawn even one breath, then we would have had a funeral, all the family would have been there, and he would have been buried in the Muslim section of the cemetery.
But no, sometimes, it's like he never existed. One Pakistani couple, I heard, their baby was born dead, and they just left it in the hospital and went home. While Miriam had the support of her husband in creating a private memorial for her stillborn son, this was not the case for Qudsia.
A number of these questions were debated by Muslim theologians and legal scholars in the pre-modern world when considering contexts of abortion or issues surrounding paternity. In the modern world, these questions have grown to include in vitro fertilization and surrogacy amongst others.
Muslim scholars continue to grapple with these bioethical questions as the medical sciences grow more advanced and technology allows us to have ever more control over the basic aspects of reproduction, growth, and development. Per the question, When does human life begin? This is interesting for a number of reasons, not least of which is the possible change in perspective with regard to how religious authority is derived and its relationship to the medical sciences.
We might rephrase it as: When does a human being begin to exist? In other words, when do we consider this living thing to be properly human, part of the species homo sapiens? Establishing the point at which a human being comes into existence is important insofar as it is at that point that we would seriously consider that human life possesses some sort of special moral claim over and above other kinds of life in general.
Then We placed him as a drop of sperm, firmly fixed. Then We made the sperm into a clot of congealed blood, and of that clot We made an embryo; then We made out of that lump, bones, and clothed the bones with flesh. Then We developed another creation out of it. There is also an explication found in a Hadith—a verbal transmission or explanation from the Prophet.
He stayed there for about half an hour. I think he was disturbed by what he saw. He said he thought it would be wrong to make her die, but it would be wrong to increase her suffering. So I said to the doctors, just keep the tubes and medicines, but … no ventilator now.
It's up to her, we will see if she has the will to live … And … I could see … it was too much for her. Having discussed the matter with a religious authority whose opinion he could trust, Talib felt able to live with his decision; talking to his pir had lessened his burden. Moreover, in a subsequent interview he asserted that withdrawing life support is unconditionally wrong in his religion, and he asked for reassurance that his identity would not be revealed.
According to Muslim scholarship, the Qur'anic injunction against killing one's children 18 can be interpreted in historical context as a response to the pre-Islamic practices of burying alive female infants and thus as condemnation of mysogyny and infanticide, and not of such practices as the use of birth control.
Parents' responses in these situations reflected the dominant family and local community opinion about what is right as well as customary practice. Some also experienced private unease or guilt that they had done wrong, or felt compelled to conceal their decision for fear of disapproval from relatives and other community members, even if their decision had been a responsible one that balanced different potential harms.
Having more information about the circumstances in which Islam permits abortion and withdrawal of life support from infants in special care, and having more open discussion of the emotional and social significance of public recognition of stillbirth or miscarriage would be helpful for parents and health-service providers supporting parents in making fully-informed decisions. Sometimes, medical personnel do not raise the topic of prenatal testing and abortion with Muslim patients, believing that there is no point in doing so because abortion is forbidden in Islam.
Patients should have the opportunity to consider all their reproductive options, and to make informed choices about their use. These choices may or may not take their faith into account. This paper has identified several areas in which more information on the Islamic positions regarding abortion and the withdrawal of life support would help parents and families in making fully informed decisions.
I thank the Wellcome Trust UK, who awarded me a grant GRMA for the fieldwork from which this paper draws; the relevant NHS local research ethics committee, for prospectively reviewing and approving the research and colleagues at the Regional Hospital who issued an honorary clinical contract to me to facilitate the research.
I am grateful to colleagues in the Regional Genetics Service for their support, most especially Dr. Jane Hurst, my co-applicant on the grant to the Wellcome Trust, for access to the patients who participated in this study and for the great privilege of working with her closely on the clinical aspects of the research. Above all, I thank the families who participated in this study. I also wish to acknowledge comments from participants at the 3rd International Conference on Islam and bioethics, held in Turkey on 14—16 April , in response to my presentation of a shortened version of this paper, especially from Abul Fadl Mohsin Ebrahim.
I also thank Mohammad Akram of the Oxford Centre for Islamic studies for discussing with me details of Muslim burial practices as these are discussed within Islamic scholarship. I am also grateful to the two anonymous reviewers for their helpful suggestions. Any errors and shortcomings are my own responsibility. Her research interests are medical anthropology, ethnicity and health, with particular reference to British Pakistani families with whom she has conducted extensive fieldwork.
Negotiating risk: British Pakistani experiences of genetics. Oxford: Berghahn Books; A. J Genet Couns , ; 17; 4: —; A. Ethn Health , ; 14; 2: — The arranged transnational cousin marriages of British Pakistanis: critique, dissent and cultural continuity.
Contemp South Asia , ; 15; 2: — The medical and social costs of consanguineous marriages among British Mirpuris. South Asia Res ; 29; 3: — Islamic Bioethics: Problems and Perspectives.
The Netherlands: Springer: 91—; —; L. Reprod Health Matters ; 15; 2: 75—84; K. Therapeutic abortion in Islam: contemporary views of Muslim Shiite scholars and effect of recent Iranian legislation.
J Med Ethics , ; 32; —; V. The right not to be born: Abortion of the disadvantaged fetus in contemporary fatwas. Muslim World , ; 89; 2: —; V. Islamic Medical Ethics in the Twentieth Century.
Leiden: Brill: 8. Islamic Biomedical Ethics: Principles and Application. Oxford: Oxford University Press: Family planning, contraception, and abortion in Islam: undertaking khilafah. In Sacred Rights: the case for contraception and abortion in world religions. Maguire, ed. Oxford: Oxford University Press: ; see also A. Al Aqeel. Islamic ethical framework for research into and prevention of genetic diseases.
Nat Genet ; —; V. Rispler-Chaim, , op cit. Biomedical issues: Islamic perspective. Family Planning in the legacy of Islam. London: Routledge: See also Atighetchi, op. Contemporary Muslim Ethics of Abortion in J. Brockopp, ed. Columbia: the University of South Carolina Press: 51— The pregnancy cannot be terminated if the period of opportunity has been missed, and the anomalous foetus must be carried to term. Anecdotal evidence suggests that a missed opportunity to end a pregnancy for foetal anomaly has the potential to culminate in maternal morbidity or even mortality.
It is emphasised that the anguish endured by the affected women is real. The ineffectiveness of the current available laws or edicts on TOP is readily evident from the distressing outcomes endured by the Muslim populations of the world due to foetal anomalies [ 2 — 29 ], including even those residing in developed nations [ 2 , 4 , 5 , 10 , 16 , 20 , 21 , 23 — 29 ].
This article will review the views of both schools of thought. It will attempt to highlight and discuss differences of opinion with regard to TOP between these two sects. Only a few countries apply Islamic principles as the basis of laws viz: Saudi Arabia and Iran. In these countries, the religious edicts issued by an authorised council are considered law.
In the remaining countries, even if Islam is the official religion, the laws are made by a parliament or the royal court, which may or may not conform to religious edicts. The religious edicts issued by an Islamic council of scholars in individual Islamic countries are applied, but such edicts are not law until passed by their parliament or an equivalent authority.
The edicts issued in Saudi Arabia have far-reaching consequences and implications. The Muslim nation looks towards Saudi Arabia for guidance in all matters pertaining to religion. Therefore, this paper will focus on Saudi rulings.
This article is intended to assist healthcare providers, decision makers, would-be parents, and health administrators to address or make decisions regarding this very controversial subject. The dreadful outcome of not performing TOP in a timely manner must be addressed and eliminated in the 21st century.
The issue of TOP past days of pregnancy must be revisited, debated and resolved to prevent suffering. All Abrahamic religions and indeed all religions forbid the taking of a life [ 31 — 33 ]. In Islam, in the context of the embryo, the question arises whether it is a living entity?
Logically a lifeless entity feels no pain nor is it sensitive to its environment, and therefore, the ethics of its externally engineered demise is less debatable and therefore less questionable and more permissible than if the entity is a living individual and the need to abort is a necessity. In all Abrahamic religions and in most religions, the question of the soul is pmount [ 34 ].
A living individual not only has a physical body but also has a soul. Therefore, it follows that an embryo is not an individual until it has a soul. This, in Islam, is generally believed to take place at approximately days after fertilisation [ 3 , 15 , 34 , 35 ] although some schools of thought may argue that life begins the moment the sperm fertilises the egg.
On the basis of the Hadith, Muslims a ssume the former to be correct. It is noteworthy that one school of Islamic thought allows embryo research up to 14 days post fertilisation for the benefit of the advancement of science [ 19 ]. An embryo becomes an individual with the full rights of a living person only after it is bestowed a soul, prior to which, it is just an entity, soulless and hence, lifeless as it were, to most Islamic scholars; therefore, it has limited rights but is not devoid of rights.
In consideration of these points, the general belief in Islam is that the embryo begins life following ensoulment at day after fertilisation [ 3 , 15 , 34 , 35 ]. The Madhabs are neither clans nor sects but only schools of thought. Verily the killing of them is a great sin. While the Maliki and Hanbali schools state that abortion is permissible at the request of both the parents for up to 40 days with a legitimate cause, this is principally prohibited from day 40 onwards [ 37 , 38 ].
Past and contemporary Islamic scholars opine that abortion is totally forbidden at any stage of a pregnancy. However, some scholars consider it allowed during the stage of nutfah i. Others consider TOP allowed in the stages of nutfah and alagah i. Still others consider it allowed during all stages of the first four months provided that there are reasonable grounds for the abortion [ 39 — 44 ]. The Egyptian Grand Sheikh of Al-Azhar, the highest Islamic council in Egypt, issued a religious edict in and permitting unmarried women that are victims of rape access to abortion even after days [ 45 , 46 ].
The termination of a pregnancy for a foetal anomaly is also allowed after days if three specialists document these severe anomalies and both parents consent [ 47 ]. Its members are representatives of individual countries where Islam is the predominant religion. They are chosen by their respective governments as the senior-most Islamic scholars of their respective countries.
Their main task is to meet on a regular basis to discuss current debatable issues affecting Muslims and to formulate rulings for resolving such issues. If proven by a committee of at least two competent and trustworthy medical experts on the basis of medical examinations with the use of appropriate equipment and laboratory findings before days of pregnancy that the foetus has serious anomalies that will be present at birth, only then is it permissible to abort after the request of the parents.
This decision must be based on the opinions of at least two competent and trustworthy medical experts in the field. First, the foetus must be less than four months of age, that is, before ensoulment. Second, the foetus must be suffering from profound developmental delay or profound deformations or malformations.
Third, these fetal problems must be the cause of extreme suffering or hardship for the mother or the foetus. Fourth, the life of the mother should be in danger. Fifth, both the mother and the father must give their consent to the procedure. Islam, in general, has provided broad guiding principles that could be utilised to overcome any dilemma that may arise in life. The first guideline asks one to consider whether a particular action fulfils the basic objectives of jurisprudence. These objectives include the i preservation of religion, ii preservation of life, iii preservation of genealogy or parentage, iv preservation of the mind and health, and v the preservation of property.
The second guideline seeks to prevent a detriment that takes priority over the fulfilment of a benefit or interest [ 3 , 15 , 34 , 35 ]. With scientific advancement it is inevitable that healthcare workers will be presented with new and ever progressing knowledge and indeed will be confronted with novel medical and scientific techniques and methods on a continuous basis, all of which can be utilised for the good, to ward off detriment, harm and difficulty.
It is incumbent upon every Muslim to seek knowledge and to seek a cure for diseases because for every disease there is a cure - well documented Hadith. In the years to come, the technologies at our disposal will provide enormous opportunities to help prevent serious health disabilities.
It is crucial that Muslims remain open to new treatment modalities that could help avoid situations that could result in lifelong disability and suffering for the affected individual and that pose a serious difficulty to the immediate family members and a burden on the healthcare system. These edicts are considered law in Saudi Arabia if the edict is signed by the majority of the committee members. In Saudi Arabia, there has been continuous debate on abortion, and the laws have evolved only marginally over the last few decades.
Abortion of a malformed foetus after days of conception or 19 weeks of gestation following ensoulment is permissible if the pregnancy is certain to cause the death of the mother. Abortion of a malformed foetus before days or prior to ensoulment is permissible if it is certain that the foetus will die following birth or if it has severe incurable disabilities. Abortion of the foetus at any stage of pregnancy is permissible if intrauterine death was confirmed.
Abortion shall not be permissible under any circumstance without a medical report from a specialised and trustworthy committee composed of at least three competent physicians following written informed consent of both parents or the mother alone if the pregnancy and its continuance was affecting or will affect her health. The consent can be provided by persons delegated by the parents if the parents are not able to provide the same for any valid reason.
The signed consent must be retained in the medical records of the mother [ 49 ]. Although the Islamic stance on the abortion of malformed foetuses has remained mainly unaltered, the current edict from the SC of Saudi Arabia provides a large margin of comfort to treating physicians as it removes guilt if they were to pursue a course of treatment involving abortion of a malformed foetus prior to ensoulment.
Rule number two above states that abortion is permissible prior to ensoulment if the malformed or defective condition of the foetus is incurable. A large number of foetal anomalies are considered incurable and thus may be amenable to therapeutic abortion. More importantly, under this edict the mothers are empowered to decide on their own whether to proceed with TOP, which provides significant freedom to the mother to safeguard her well-being irrespective of external influences.
The freedom is further extended to assist mothers and parents in making decisions through the delegation of authority so that if for any reasons the mothers or parents are not able to make the decision the delegated individual s can make the decision to proceed with TOP. Religious edicts, in general, are not law in most Islamic countries except in Saudi Arabia and Iran Table 2.
In all other countries edicts are merely guidelines unless their parliaments rule it be made a law. There is a need to streamline this issue. Edicts must be debated by relevant authorities and made law if justified or abandoned if found unsuitable. A recent cross-country study reporting on TOP in Muslim countries from by Shapiro [ 50 ] showed that abortion is acceptable in all countries when there is a threat to the life of the pregnant mother and if days of pregnancy has not lapsed; however, there is considerable heterogeneity in regards to other circumstances such as social or economic situations, the preservation of physical or mental health, foetal anomalies, and rape, in addition to the gestational development of the foetus.
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