The Principles Guiding Hospice Care in Islamic Law

Written by:  Dr. Aysha Wazwaz

The vast majority of hospices lack familiarity with the Islamic faith and lack practical experience in providing care to Muslim patients. As per the research conducted by the Pew Research Center, a considerable proportion of the American populace possesses limited to no knowledge regarding the Islamic faith. It can be posited that healthcare professionals may lack comprehension of Islamic doctrines and faith pertaining to end-of-life care, in light of the fact that approximately 50% of the American populace lacks basic knowledge regarding Islam.

Moreover, Muslim patients struggle finding the resources to fatwa as they are already helping their relative battle death. The psychological weight on both the patient and the family is extremely strong making it more complex to getting access to such resources. The family is struggling with a patient whose body is losing its ability to function is a lot to endure on the person and on the family. The expectations from hospice for most Muslim families is most of the times not understood.

Muslim patients, similar to their counterparts, may encounter challenges in accessing appropriate medical treatment for their ailments. In addition, individuals may encounter the realization that they lack access to treatment facilities and receive communication from professionals indicating that the available treatment resources have reached their maximum capacity. Consequently, individuals may find themselves confronted with severe medical conditions that necessitate their independent efforts to combat. 

Nevertheless, hospice care extends its services beyond the initial stages of the patient's illness, specifically during the advanced stages that typically span a duration of three to six months. 

It is plausible that Muslim patients and their families, who are currently under hospice care, may possess limited knowledge or awareness regarding the Islamic guidelines that dictate the end-of-life practices for Muslim patients. The individual experiences difficulty in processing the doctors' acknowledgment of their inability to provide treatment for the patient, leading to the recommendation of palliative care options, such as medication administration to alleviate pain. These services are commonly provided by hospice healthcare facilities and align with the principles emphasized by Islam regarding the patient's transition to the afterlife. 

This study aims to emphasize the significance of hospice care and elucidate Islamic guidelines pertaining to the utilization of specific pharmaceuticals, acknowledging that these therapies do not provide curative treatment for a disease but instead aim to enhance the quality of life during the end-of-life phase. Furthermore, this study aims to emphasize the significance of hospice care. This article provides a concise overview of the concept of hospice, its geographical locations, and the assistance it offers. However, the main focus of this study pertains to the regulations governing a diverse range of therapies or treatments commonly administered during a patient's hospice care. The interventions encompass the utilization of diverse pharmaceutical agents, such as analgesics for pain management, medications for anxiety and depression, antiemetics, antispasmodics, corticosteroids, and sedatives. Furthermore, this text explores a range of themes, encompassing topics such as do-not-resuscitate (DNR) directives, Artificial Nutrition and Hydration (ANH), euthanasia, suicide, and related subjects within the same overarching category.

Moreover, it provides a diverse range of alternative choices beyond the ones previously discussed in the context of hospice care.  

Myths about hospice care

Regarding hospice care, many Muslims harbor a lot of misinformation and conspiracy theories. The term "hospice" is often associated with social stigmas that suggest a sense of resignation, exclusivity to the elderly, and a means of hastening mortality. The prevalence of myths surrounding hospice care can complicate the process of accepting and utilizing such services. 

The term hospice is often associated with the notion of relinquishing hope or surrendering to an inevitable outcome. While hospice care does not provide medical treatment for illnesses, its primary objective is to offer patients who have not found a cure for their chronic illnesses comfort, support, and dignity. The objective is to offer assistance during the terminal phases of a disease rather than medical intervention for ailments. 

The notion that hospice care is exclusively intended for the elderly is erroneous. Hospice services are accessible to individuals of all age groups who have been diagnosed with a terminal illness and have a life expectancy of six months or less. 

A prevalent misconception among both Muslim and non-Muslim communities is that hospice care accelerates the dying process, leading to the belief that hospice hastens death. The principal objective of hospice care is to offer palliative measures, including pain management and symptom relief, to facilitate a tranquil end-of-life experience. It neither hastens nor prolongs the dying process. 

Hospice is often misconstrued as a physical location, leading to the assumption that it is a facility. Hospice care is typically administered to provide comfort and support and can be delivered in various settings, including a person's residence or other healthcare facilities. 

Hospice care entails significant financial costs: however, it is worth noting that hospice services are typically encompassed by the majority of insurance plans in the United States. The scope of this coverage encompasses a diverse array of services, including but not limited to pharmaceuticals, medical apparatus, and the comprehensive assistance of the interdisciplinary team.

The importance of chaplaincy during hospice care

The provision of religious chaplaincy is of utmost importance during pivotal phases of illness, as it serves as a poignant reminder to patients regarding the value of perseverance and the pursuit of divine blessings. The significance of placing trust in Allah (Tawakkul) over exclusive reliance on medications is underscored, given the possible adverse effects that patients may be incapable of articulating. Within this particular context, the promotion of "religious treatments" via the practice of ruqya (spiritual healing) assumes a notable degree of importance, given its capacity to furnish patients with spiritual and psychological sustenance, thereby bolstering their resilience during this pivotal period. This provision facilitates patients in expressing their faith by means of reciting the Shahada (the Islamic declaration of faith) and promotes a feeling of optimism in the clemency and pardon of the Divine Being. It is imperative to acknowledge that pharmacological interventions mitigate bodily discomfort, consequently enhancing cognitive focus and psychological acuity. Moreover, it is crucial to uphold the principle of patient autonomy and provide them with the option to decide whether or not to pursue medication, rather than enforcing such interventions upon them.

Hospice centers and facilities: 

There are numerous locations where hospice centers can be located, including:

Numerous institutions provide end-of-life care through hospice divisions or palliative care teams.

Some communities have distinct hospice institutions that specialize in providing all-encompassing end-of-life care. These facilities may provide inpatient or ambulatory services.

Long-term care facilities and nursing homes: Some nursing homes offer hospice services or collaborate with hospice organizations to provide specialized care for terminally ill residents.

Residential hospices are freestanding facilities designed specifically to provide hospice care in a home-like setting. They frequently provide care and support for patients and their families around-the-clock.

Additionally, hospice services can be supplied in the patient's own residence. Teams of nurses, physicians, social workers, and volunteers can travel to the patient's home to administer medical care, pain management, emotional support, and other services.

Medications used during hospice care: 

The selection of medications administered during hospice care is contingent upon the unique requirements and symptoms of each individual. The principal objective of medication administration in a hospice setting is to offer palliative care, mitigate pain, address symptoms, and enhance the overall standard of living. The following list comprises several frequently prescribed medications employed in the context of hospice care:

1. Analgesics, also known as pain medications, are substances used to alleviate pain. Opioids, including morphine, oxycodone, and fentanyl, are frequently prescribed for the purpose of managing pain that ranges from moderate to severe. These pharmaceutical interventions facilitate pain reduction and enhance overall comfort. Certain opioids fall into the category of non-synthetic narcotics, while others are classified as semi-synthetic narcotic analgesics. These medications are widely recognized for their efficacy in treating severe pain. For instance, fentanyl, a highly potent analgesic, is approximately 100 times more potent than morphine and 50 times more potent than heroin. However, it is important to note that these medications carry a significant risk of addiction and dependence. 

These medications are derived from the opium poppy plant or synthesized to mimic its effects. They work by binding to opioid receptors in the body, helping to relieve pain and promote comfort.

2. Anti-anxiety medications, such as lorazepam, diazepam, and midazolam, which fall under the benzodiazepine classification, may be prescribed in hospice settings to alleviate symptoms of anxiety, restlessness, and agitation in patients. These medications are classified as central nervous system (CNS) depressants within the realm of pharmaceuticals. They have the potential to facilitate the cultivation of a state characterized by tranquility and a reduction in stress.

It is noteworthy to mention that certain medications may be associated with potential side effects, including central nervous system (CNS) depression. These side effects may manifest as symptoms such as slowed or shallow breathing, shortness of breath, lightheadedness, dizziness, confusion, and difficulty maintaining wakefulness.

The individual experiences ideation of suicide or self-inflicted harm, a deteriorating emotional state, and a heightened sense of depression. 

In certain instances, individuals under hospice care may manifest indications of depression or anxiety, leading to the consideration of antidepressant medication. Pharmaceutical interventions such as selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) may be recommended by healthcare professionals to assist in the management of these symptoms.

3. Antiemetics refer to pharmaceutical interventions designed to mitigate or manage the occurrence of nausea and vomiting, prevalent symptoms that can be associated with various etiologies, such as the adverse effects of other medications or the primary ailment itself. Some examples of medications that can be used are ondansetron, metoclopramide, and prochlorperazine. They work by blocking or reducing the activity of specific receptors in the brain that trigger these symptoms.

4. Antispasmodics, such as hyoscyamine or scopolamine, are pharmacological agents employed to mitigate symptoms associated with gastrointestinal spasms or excessive secretions, which may induce discomfort or distress.

5. Corticosteroids, such as prednisone or dexamethasone, are occasionally prescribed in order to effectively address symptoms associated with inflammation, pain, or respiratory distress. They work by suppressing the immune system and reducing the release of substances that cause inflammation.

Nonsteroidal anti-inflammatory drugs (NSAIDs): NSAIDs like ibuprofen and naproxen may be used in hospice care for managing pain and reducing inflammation. They work by inhibiting the production of certain chemicals in the body that cause pain and inflammation.

6. Sedatives, such as midazolam or phenobarbital, may be administered to alleviate symptoms of restlessness, insomnia, or agitation, thereby facilitating a state of tranquility and comfort.

It is imperative to acknowledge that the selection of medications and their respective dosages will be determined by the interdisciplinary hospice care team, comprising of physicians, nurses, and other healthcare professionals. The prescribed medications will be customized to suit the specific requirements of each individual and modified as needed to ensure the highest level of comfort and effective management of symptoms.

The inquiry at hand pertains to the permissibility of utilizing such medications, notwithstanding their inability to provide a cure for the patient but rather to alleviate specific symptoms.

Islamic rulings on using hospice medications: 

Substances in medications that may require attention: 

1. Ingredients: Certain medications utilized in hospice care may consist of ingredients such as pork, alcohol, or substances that typically result in intoxication. Some medications may contain constituents that are derived from porcine sources. However, it is imperative to recognize that the utilization of components derived from pigs can vary depending on the specific pharmaceutical product and the manufacturer.

Gelatin, a commonly utilized ingredient in pharmaceutical capsules and coatings, can be derived from various sources, including porcine origins. Therefore, it is conceivable that capsules or coatings made of gelatin could originate from porcine sources.

Moreover, it is important to acknowledge that specific pharmaceuticals may include excipients or inert constituents derived from porcine sources. The excipients employed in pharmaceutical formulations encompass a variety of substances including fillers, binders, stabilizers, and flavorings. The specific composition of the inert components may vary depending on the particular formulation and manufacturer of the pharmaceutical product.

2. Side effects: Another issue that may raise concerns regarding the use of such medications pertains to the potential side effects that arise as a result of their administration, specifically opioids such as morphine and oxycodone. The administration of opioids can lead to various adverse effects, including but not limited to constipation, nausea, vomiting, drowsiness, confusion, respiratory depression (characterized by reduced breathing rate), and the possibility of developing dependence or addiction with prolonged usage.

1. Anti-anxiety medications (such as lorazepam, diazepam): may result in drowsiness, dizziness, confusion, slowed breathing, and potential for tolerance or dependence with long-term use.

2. Antiemetics (such as ondansetron, metoclopramide): Side effects may include drowsiness, dizziness, constipation, dry mouth, and rarely, movement disorders.

3. Antidepressants:  Side effects can vary depending on the specific medication used and may include nausea, headache, sexual dysfunction, drowsiness, or activation of manic or hypomanic symptoms in individuals with bipolar disorder.

4. Steroids (such as dexamethasone, prednisone):  Side effects can include increased appetite, weight gain, mood changes, increased risk of infection, and fluid retention.

Scholars’ opinions regarding using medications that may contain impermissible substances: 

Muslim jurists generally had three different opinions in regard to using substances that may contain alcohol or impermissible substances for medical treatment. 

First opinion: The Maliki, Hanbali, Shafi'i, and Hanafi schools of thought maintain the perspective that the utilization of forbidden substances for medical purposes is impermissible. 

The argument presented is supported by evidence derived from the narration of Tariq ibn Suwaid al-Ju'fi, who inquired of the Prophet Muhammad (peace be upon him) regarding the utilization of alcohol for medicinal intentions. In response, the Prophet (peace be upon him) conveyed that alcohol is not a remedy, but rather a malady. Additional evidence can be found in the authentic narration ascribed to Ibn Mas'ud, which asserts that Allah has not ordained the remedy for your ailments in that which He has prohibited. According to Abu Huraira, it was reported that the Prophet (peace be upon him) issued a prohibition on the utilization of medication that is detrimental to one's health. According to the direct narration by Abu Darda, it is reported that the prophet, peace be upon him, stated that Allah has indeed sent down both illness and cure. Furthermore, it is mentioned that Allah has provided a remedy for every ailment. It is advisable to pursue appropriate medical intervention and refrain from seeking treatment through illicit methods.

These scholars adhere to the explicit interpretation of these narratives, which prohibits the utilization of forbidden substances for medical purposes, in accordance with the overarching prohibition. Ibn Taymiyyah provided a response to individuals inquiring about the permissibility of employing alcohol for medicinal intentions, wherein he unequivocally affirmed its prohibition. In addition, there is a lack of consideration regarding the inclusion of illness as a qualifying factor for the permissible use of substances that are otherwise prohibited. A distinction is made between the scenario of consuming the carcass as a means of survival in extreme circumstances, where the act of eating becomes imperative for preserving one's life, and the scenario of illness. In the latter scenario, it is unnecessary to utilize these prohibited substances for the purpose of facilitating the healing process. Hence, their stance asserts that the concept of necessity, as comprehended by them, remains unmet within this particular context.

Second opinion: The permissibility of utilizing substances that are prohibited for treatment is supported by proponents such as the Thahiri school of thought and certain jurists. The prevailing perspective within the Shafi'i school posits that the utilization of all impurities for medicinal purposes is permissible, with the exception of substances that induce intoxication. The rationale provided is that medical treatment is classified as a necessity, and necessities allow for acts that are otherwise prohibited. The proponents present their argument by referencing a specific verse from the Quran, which states that certain items are prohibited for consumption. These include deceased animals, blood, pork, and food offerings made to entities other than Allah. According to the Quranic verse {وَقَدْ فَصَّلَ لَكُمْ مَا حَرَّمَ عَلَيْكُمْ إِلَّا مَا اضْطُرِرْتُمْ إِلَيْهِ}, if an individual is compelled by circumstances beyond their control and does not have any desire or intention to violate the prescribed limits, then they are not held accountable for any wrongdoing.

The verse is interpreted by scholars as suggesting that actions driven by necessity are exempt from prohibition for individuals. The authors provide an instance where the Prophet Muhammad (peace be upon him) permitted the Bedouins to employ camel urine for medicinal reasons during times of illness. The proponents of this viewpoint additionally contend that the arguments put forth by opponents lack validity, as they assert that in situations of necessity, the utilization of prohibited substances for medical treatment is deemed permissible and does not carry the connotation of impurity. Consequently, proponents contend that categorizing it as a prohibited, impure, or forbidden substance is unwarranted.

The third opinion: This perspective advocates for the utilization of banned substances in medical treatment under the condition that their efficacy in promoting recovery is assured. Alternatively, the use of such substances for treatment is deemed impermissible. The aforementioned perspective is held by certain scholars of the Hanafi school, scholars of the Shafi'i school, and scholars of the Maliki school. The argument put forth by the proponents is grounded in the evidence that the Prophet Muhammad (peace be upon him) granted permission to the Bedouin community to utilize camel urine as a form of treatment, with explicit mention of its therapeutic attributes. Hence, proponents contend that the utilization of prohibited substances for medical purposes is justifiable in cases where a legitimate necessity exists, and the patient is unable to procure a lawful substitute capable of substituting the prohibited medication. The authors also underscore the significance of seeking guidance from a Muslim physician who adheres to principles of justice. This methodology facilitates the reconciliation between the prohibition mentioned in certain narrations and the narration that grants permission for Bedouins to utilize camel urine.

The prevailing viewpoint asserts that the utilization of banned substances for medical purposes is justifiable in situations of necessity, as stipulated by these scholars' specified criteria. The permissibility of using camel urine for medicinal purposes among the Bedouin community, despite its general prohibition, can be attributed to the authorization granted by the Prophet Muhammad (peace be upon him) in certain instances of illness.

The Preponderant Ruling 

The preponderant opinion, and Allah knows best is the common opinion among scholars from the Hanafi and Maliki schools that the utilization of medications that may potentially contain impermissible substances is generally deemed permissible when seeking medical treatment. This perspective holds that the permissibility of such treatment is not contingent upon its ability to result in a complete cure, but rather extends to cases where it merely provides relief from symptoms.

Also, for what was narrated by Usama Ibn Shareek peace and blessings be upon him that the

"Some Bedouins asked: 'O Messenger of Allah (s.a.w) shall we treat (our ill)?' He said: 'Yes, O worshipers of Allah! Use remedies. For indeed Allah did not make a disease but He made a cure for it' - or - 'a remedy. Except for one disease.' They said: 'O Messenger of Allah (s.a.w)! What is it?' He said: 'Old age.'"

Ibn Abdeen had said: “It is permissible if one knows a cure in it and does not know another remedy. And in the medical field, it means what he - peace be upon him - said: 'Allah has not made your cure in what He has forbidden for you.' As narrated by Al-Bukhari, there is a cure in it that is permissible as drinking wine is allowed for the thirsty in necessity." It is worth mentioning that Hanafi scholars have also regarded experimentation in the pursuit of treatment as a valid source of knowledge in seeking medical remedies.

However, despite the potential lack of immediate relief provided by these medications for illnesses and pain, there may arise uncertainty regarding their effectiveness. In this regard, it is worth elucidating that Scholars affiliated with the Shafi’ee and some Hanbali scholars have asserted that the pursuit of medical treatment is advisable due to the presence of imperative language in the aforementioned Hadith. Supporters of this perspective have presented evidence indicating that the Prophet Muhammad, may peace be upon him, engaged in the practice of cupping therapy. This has prompted them to deduce that the Prophet's pursuit of medical treatment provides substantiation for the permissibility of seeking treatment, even in cases where medical professionals are uncertain about its effectiveness. Nevertheless, once it is verified that a specific treatment yields a remedial outcome, such as the implementation of a bandage on an injury, it becomes obligatory to employ said treatment in that particular situation.

Ibn Alqayyim had stated the following: “In authentic narrations, there is an emphasis on seeking medical treatment, and it does not contradict reliance on Allah (Tawakkul). It also does not contradict taking measures to alleviate hunger, thirst, heat, and cold with their respective remedies. In fact, the true concept of monotheism (Tawhid) is not fulfilled except by directly pursuing the means that Allah has established as necessary causes, both in terms of destiny and religious obligations. Disregarding these means undermines reliance on Allah, as well as undermines prudence and wisdom. Neglecting them weakens reliance on Allah, contrary to what some might think, abandoning them strengthens reliance. If abandoning these means leads to inability, it contradicts the true reliance that involves the heart's dependence on Allah in attaining what benefits the servant in their religion and worldly affairs, and in averting what harms them in their religion and worldly affairs. Along with this reliance, it is necessary to actively pursue the means. Otherwise, it would hinder wisdom and religious obligations. The servant should not make their inability an excuse for not relying on Allah, nor should their reliance become an excuse for their inability.” 

Preponderant Ruling on using analgesics and antiemetics

The practice of administering analgesics  and antiemetics and other pharmacological agents, commonly referred to as pain medications or medications that that prevent nausea and vomiting, is widely acknowledged and even advocated in situations where it is deemed essential to alleviate pain and provide solace to patients who are suffering from medical conditions or undergoing medical procedures.  Nausea and vomiting and other symptoms may manifest as clinical manifestations of diverse pathological states, adverse effects of therapeutic interventions, or consequences of other etiological factors. If a healthcare practitioner deems it necessary to alleviate symptoms of nausea and vomiting and enhance the overall health status of the patient, antiemetics are typically deemed permissible for use.

The legal maxim of removing harm places great emphasis on the principles of compassion, mercy, and the preservation of human life.

The Islamic legal maxims prioritize the elimination of harm and give significant weight to mitigating both physical and emotional suffering. The concept of "maqasid al-shariah" further highlights the importance of protecting life, promoting health, and preventing harm. Hence, when an individual experiences physical discomfort or distress, it is generally acceptable to administer analgesics or pain-relieving medications to alleviate their suffering.

It is crucial to recognize that the application of any pharmacological agent, including analgesics, should conform to medical guidance and instruction, given that certain medications may potentially interact with other drugs and elicit hazardous adverse reactions. It is advisable for Muslims to consult with licensed healthcare professionals, such as medical doctors and pharmacists, in order to obtain appropriate medication that is consistent with their distinct medical needs and situations.

It is crucial to consider the potential negative consequences or hazards associated with the use of analgesics and to attain a balanced equilibrium between pain relief and any potential adverse effects. The ethical principle of non-maleficence, which entails refraining from causing harm, and the holistic consideration of an individual's welfare, which involves taking into account all aspects of their well-being, should be given due consideration.

Ruling on using anti-anxiety medications: 

Quran, hadith and Muslim scholars have unanimously agreed on the significant emphasis on the preservation of five fundamental elements, namely faith, self-preservation, wealth, lineage, and intellect. Physical and mental health are widely acknowledged as fundamental elements, although their significance may vary. The concept mentioned above demonstrates a broad range of applicability and is supported by foundational principles that are inherent in Islamic legal theory. One of the most crucial principles consists of:

The ethical principle of non-maleficence, commonly referred to as the principle of non-harm, asserts that actions should not cause harm or have the potential to cause harm to oneself or others.

Surah Al-Baqarah 2:195 of the Quran serves as a demonstration of Allah Almighty's counsel to individuals, urging them to refrain from participating in activities that may result in harm to oneself. The verse explicitly articulates the admonition to refrain from engaging in self-destructive behavior. قوله تعالى: وَلاَ تُلْقُواْ بِأَيْدِيكُمْ إِلَى التَّهْلُكَةِ {البقرة:195}

 Additionally, it is important to acknowledge that Allah Almighty prohibits both suicide and homicide, as mentioned in the previously cited verse. Allah Almighty is quoted as stating 

قوله تعالى: وَلاَ تَقْتُلُواْ أَنفُسَكُمْ إِنَّ اللّهَ كَانَ بِكُمْ رَحِيمًا {النساء:29}

 The verse Surah An-Nisa 4:29 highlights the enduring benevolence of Allah towards individuals.

 Another principle that can be derived is that any substance or activity that has been empirically shown to have detrimental effects is deemed to be prohibited. This statement underscores the considerable importance attributed by Islamic jurisprudence to safeguarding the overall well-being of individuals.

This claim is substantiated by the hadith, in which the Prophet Muhammad (peace be upon him) prescribed that "when three individuals are together, two should refrain from engaging in private conversation, excluding the third party, until they involve themselves with others." 

The aforementioned hadith has received unanimous consensus and underscores the significance of safeguarding one's mental well-being by refraining from nurturing emotions such as enmity, hostility, and sorrow, which are widely acknowledged to have adverse effects on one's psychological welfare.

As per the narrative provided by Umm Kulthum bint Uqba, Prophet Muhammad (peace be upon him) proclaimed the prohibition of falsehood, except in three distinct circumstances: firstly, when a man employs it to appease his spouse; secondly, during periods of armed conflict; and thirdly, in order to facilitate reconciliation between individuals.

 This and other hadiths acknowledge the importance of prioritizing the mental well-being of a spouse. It suggests that if it is necessary to engage in deception in order to achieve this goal, it may be acceptable as long as it does not cause harm to any other person.

It is crucial to underscore that mental disorders trigger physical disorders and, therefore, require comparable considerations for treatment. As Psychological well-being holds equivalent significance to physical ailments.

The utilization of anxiolytic medications is generally deemed appropriate provided that they are prescribed by a duly licensed medical practitioner for the purpose of treating clinically diagnosed anxiety disorders or associated ailments. 

Anxiety disorders have the potential to greatly affect an individual's overall well-being and their ability to perform everyday tasks. Islam places a significant emphasis on the preservation of mental well-being and underscores the significance of actively seeking solace from psychological anguish. Hence, when a healthcare practitioner deems anti-anxiety medications as essential for mitigating symptoms of anxiety and enhancing an individual's overall state of well-being, the prescription of such medications is typically sanctioned and subjected to equivalent regulatory protocols as other pharmaceutical substances. 

It is imperative to acknowledge that the utilization of any medication should adhere to medical advice and guidance. It is recommended that individuals seek guidance from licensed healthcare professionals in order to obtain a precise diagnosis and receive tailored medication that aligns with their specific requirements.

It is crucial to uphold strict compliance with the prescribed dosage and treatment regimen, while also exercising caution and awareness regarding potential negative effects or risks linked to pharmacological interventions for anxiety. The ethical and conscientious use of medications is encouraged by Islam, with an emphasis on the person's total well-being.

It is noteworthy to mention that the incorporation of psychological counseling or therapy in conjunction with pharmacological intervention can result in advantageous outcomes in the management of anxiety disorders. The legal maxims of Islam promote a comprehensive approach to the healing process, encompassing the identification and resolution of the root causes of anxiety, as well as the inclusion of psychological and spiritual assistance, in conjunction with the administration of medication.

Ruling on using Medications and opioids 

The jurists mentioned different types of treatment that were known among them at that time, especially with the advancement of medicine and medical studies. It became possible to determine the probability of the success of a medication more than before based on more advanced tests. Doctors in the past, based on their medical experience, mentioned that the types of treatment could be either through action or abstention, whether the patient takes specific medications or consumes certain foods, or by abstaining from certain foods or behaviors that studies or experts have shown to have a positive effect on those who have taken or abstained from them to the benefit of the individual.

(The Prophet (ﷺ) said), "Healing is in three things: A gulp of honey, cupping, and branding with fire (cauterizing)." But I forbid my followers to use (cauterization) branding with fire."

Ibn 'Abbas narrated that the Messenger of Allah (s.a.w) said: "Indeed the best of what you treat is As-Sa'ut, Al-Ladud, cupping and laxatives.' So when the Messenger of Allah (S.A.W) was suffering his companions treated him with Al-Ladud, and when they were finished he said: 'Treat them with Al-Ladud.' So all of them except Al-Abbas were treated with Al-Ladud."

Ibn Hajar had elaborated on the previous hadith saying: "And the Prophet, peace be upon him, did not limit [treatment] to these three [methods], for healing can be found in others as well. Rather, he drew attention to them as fundamental principles of treatment."

Meanwhile, Ibn Baz had stated the following: "As for the intoxicant that leads to euphoria and drunkenness, it is not permissible… However, if it is an anesthetic that relieves pain like anesthesia, there is no harm in it because it is used to alleviate and remove pain. This is permissible, as it benefits the patient. But if it intoxicates and alters one's mind, causing delirium and speaking inappropriately like other intoxicants, then it is not permissible."

Treatment failure and other options 

In the event of treatment failure, what are the next steps to be taken? Is it necessary to sustain all forms of medical intervention? Is it ethically acceptable to discontinue medication despite medical professionals advising that it lacks efficacy? 

Is treatment superior to patience? 

It is a widely acknowledged fact within the academic community of Islamic jurisprudence that the provision of medical treatment or care for illnesses is not deemed obligatory by the majority of jurists and imams representing various schools of thought. Instead, it can be categorized as within the scope of what is considered acceptable or allowed. According to certain companions of Imam Shafi'i and some Hanbalis, the notion of obligation is only upheld by a limited number of groups. However, Qadi Iyad asserted the existence of a consensus regarding the permissibility of refraining from seeking medical treatment.   

Indeed, there has been scholarly debate regarding the comparative merits of treatment and patience. There exists a line of argumentation suggesting that patience is a superior virtue, drawing upon the narration by Ibn Abbas in Sahih concerning a female servant afflicted with epilepsy. The female companion inquired  the Prophet (peace be upon him) to intercede on her behalf through prayer, to which he responded by suggesting that she may choose to exhibit patience, thereby securing her place in Paradise. If you desire, I can offer supplication to Allah for your healing. She expressed her intention to exercise patience, while acknowledging occasional episodes of distress, and requested prayers to Allah to prevent any potential vulnerability. He fervently beseeched for her to remain concealed.    

Furthermore, it is widely acknowledged that certain companions refrained from pursuing medical intervention, opting instead to endure illness. Prominent examples include Abu Ibn Ka'b and Abu Dharr (may Allah be pleased with them). It is noteworthy that these companions were not subjected to criticism for their decision to forgo medical treatment. 

The perspective of the jurists within the Ummah (Muslim community) pertaining to the provision of treatment or medical care for patients is as follows. The prevailing viewpoint holds that it is deemed permissible, albeit with a minority advocating for its recommendation and an even smaller subset asserting its obligation.

According to Qaradawi, it is deemed obligatory to administer medication in situations where the pain is intense, the medication is efficacious, and a positive outcome is anticipated, in accordance with the Sunnah of Allah Almighty.  

The prevailing viewpoint is that seeking treatment is highly regarded, as it is in accordance with the teachings of the Prophet (peace be upon him), who himself sought medical treatment and advised his companions to do the same. The reference to Ibn al-Qayyim's mention of this subject can be found in his renowned work "Zad al-Ma'ad," where he provides guidance on the actions and teachings of the Prophet Muhammad (peace be upon him). The minimum inference that can be drawn from this statement pertains to its level of recommendation.

Hence, in accordance with the laws of Allah pertaining to causality as understood by experts and medical practitioners, it is deemed advisable or obligatory to pursue treatment or medical intervention in cases where there exists a reasonable expectation of the patient's recuperation. Nevertheless, in the absence of any prospects for recuperation, as per the well-established principles and factors recognized by experts in this domain, it would be inappropriate for anyone to assert its desirability, let alone its necessity. 

Qardawi espoused the viewpoint that it is permissible to refrain from administering medication in situations where medical professionals recognize its futility in achieving a cure, but instead merely extending the duration of suffering. He abstained from categorizing it as "mercy killing" due to the fact that it entails abstaining from an action that medical professionals themselves acknowledge cannot yield a remedy. Hence, the issue at hand does not pertain to the disregard of a duty or a suggested course of action, and it would be inappropriate to assign blame to individuals for abstaining from it. 

 Islamic ruling regarding cannabis and other street drugs

Patients increasingly resort to self-medication as an alternative course of action following the failure of medical interventions. Many individuals view the use of various substances, including marijuana sold under various brand names such as Kratom or CBD, which may contain cannabis, as a last resort for therapeutic purposes or, at the very least, for inducing a state of tranquility. 

Notable is the fact that cannabis contains psychoactive compounds capable of altering a person's mental state and impairing cognitive abilities. Therefore, the use of this substance falls under the Islamic prohibition on intoxicating substances as a whole. Before discussing CBD as an alternative pain reliever, it is important to clarify drugs and drug categories. 

Substances derived from vegetation or synthesized chemically that exert measurable physiological effects upon consumption are referred to as drugs. These effects can manifest as sedation or stimulation, resulting in physical impairment or generating feelings of lethargy, sluggishness, and decreased activity. These substances can impair cognitive function similarly to intoxicating substances, although their intoxicating effects may be less severe than liquid intoxicants. 

There are numerous drug classifications.

According to their inherent characteristics, pharmaceutical substances can be categorized into the following groups:

1. Natural drugs are a category of substances derived from botanical sources, such as cannabis, opium, coca, and khat, among others.

2. Synthetic drugs are compounds that are synthesized from natural drugs through chemical processes in order to increase their efficacy and concentration. Examples include morphine, opium, cocaine, and a variety of other substances.

3. Synthesized through the synthesis of chemical substances, designer drugs exhibit similar effects to both natural and synthetic drugs. These substances are manufactured as capsules, pills, tablets, injections, beverages, and granules, among other forms. Certain medications, such as secobarbital capsules, function as sleep aides, whereas others serve as stimulants, such as amphetamine tablets, or tranquilizers, such as diazepam. LSD is a notable example of a substance that falls within the category of hallucinogens.

They can also be divided into two distinct categories according to their differing risk levels.

1. The term "major drugs" refers to a class of substances that exhibit a high level of inherent danger thereby posing substantial risks to those who use and abuse them. Opiates, morphine, cocaine, and other substances are examples of such substances.

2. The term "minor drugs" refers to substances that pose a lower degree of danger than "major drugs." A substantial proportion of pharmaceuticals used in medical treatment contain substances that, despite their therapeutic benefits, have the potential to cause dependence, addiction, and physical damage in patients.

In addition, substances can be classified based on the negative health and psychological effects they produce, which include:

A) Depressants, encompassing:

• Morphine, heroin, and similar substances are administered through injection or inhalation.

• In medical practice, sedative analgesics, such as narcotics, are commonly employed.

• The topic of discussion is tranquilizers and sedatives.

• Volatile solvents, including adhesives and similar substances.

B) A variety of stimulants, including cocaine and crack cocaine.

C) Hallucinogens including mescaline, cannabis, and others.

D) Cannabis, including reproductive structures such as flowering branches and blooms, in addition to the resinous form known as hashish.

E) Khat is a psychotropic plant that is commonly ingested in certain global regions.

F) tobacco 

The general rule In the Qur'an, is that intoxicants are described as "an abomination of Satan's handiwork" (Surah Al-Ma'idah, 5:90).

The Prophet, peace be upon him, said: "Every intoxicant is wine, and every intoxicant is forbidden. Whoever drinks wine in this world and dies while addicted to it, without repenting, will not drink it in the Hereafter."Muslim (2003).

It was also narrated by Bukhari (4087) and Muslim (1733) that Abu Musa said: "The Prophet, peace be upon him, sent me and Mu'adh ibn Jabal to Yemen. I said, 'O Messenger of Allah, we have a drink in our land called "mizr" made from barley, and a drink called "bita" made from honey.' He said, 'Every intoxicant is forbidden.'"

Furthermore, Ibn Umar, may Allah be pleased with him narrated that Umar, may Allah be pleased with him, said on the pulpit of the Prophet, peace be upon him: "O people! It has been revealed that wine is prohibited, and it includes five things: grapes, dates, honey, wheat, and barley. And wine is that which clouds the mind."

"Whatever intoxicates in large quantities, a small quantity of it is also prohibited" 

Drawing upon various Hadiths it is widely agreed among Islamic scholars that the utilization of cannabis and any drug that leads to intoxication, change in behavior or mental state, particularly for recreational objectives, is deemed impermissible. This encompasses activities such as smoking, ingesting edibles, or any other method of cannabis consumption that leads to intoxication or hinders cognitive abilities.

Ibn Hajar had inferred from the absolute statement 'Every intoxicant is prohibited' that anything that causes intoxication is prohibited, even if it is not a drink. This includes cannabis and others. 

Al-Nawawi and other scholars have unequivocally asserted the significance of discussing hashish and other narcotic substances known for inducing intoxication and . Given that these substances elicit behavioral modifications akin to those induced by alcohol, resulting in comparable sensations of pleasure and ecstasy, individuals tend to develop habitual and engrossed tendencies towards them, rendering their usage impermissible.

And if it is assumed that it is not intoxicating, it is established in Abu Dawood that 'every intoxicant and imitator is prohibited.' And Allah knows best."

Al-Khattabi said, "The imitator (al-muftir) is every drink that causes degeneration, weakness in the organs, and numbness in the limbs. It is the precursor to intoxication, and its consumption is prohibited to prevent it from becoming a means to intoxication."

And Shaykh al-Islam Ibn Taymiyyah, may Allah have mercy on him, said, "Anything that clouds the mind is prohibited, even if it does not bring about ecstasy or pleasure. Clouding the mind is unanimously prohibited among Muslims. As for the use of anesthesia that does not cause intoxication or cloud the mind, it is subject to disciplinary measures."

It is obvious through the general prohibition mentioned in the Quran and hadiths that all intoxicants or substances that lead to  physical or psychological impairment are prohibited.

Ibn Taymiyah expounded upon the inherent peril of substances by emphasizing the extent to which they induce alterations in consumer behavior: "The hashish made from cannabis leaves is also prohibited, and its user is subjected to the same punishment as the drinker of alcohol. It is even worse than alcohol because it corrupts the mind and temperament, leading to effeminate behavior, promiscuity, and other forms of corruption. Alcohol is worse in that it leads to disputes and fighting, and both of them divert a person from the remembrance of Allah and prayer. Some later jurists have debated the prescribed punishment for its use, suggesting that its user should be punished with something less severe than the prescribed punishment, as they consider its effect on the mind to be similar to anesthesia. However, we have not found the earlier scholars expressing such views. On the contrary, its users become intoxicated by it and crave it more than alcoholic beverages. It diverts them from the remembrance of Allah and prayer when they indulge in it excessively, in addition to the other harms it entails such as promiscuity, effeminate behavior, corrupting temperament and mind, and other consequences."

The preceding discourse predominantly focuses on the behavioral and recreational ramifications, neglecting to acknowledge the inhibitory impact of pain on an individual's memory and cognitive abilities, particularly in instances of medical conditions. Furthermore, under specific circumstances, the capacity to recall and focus may serve as the only avenue for certain individuals to attain even momentary respite from their pain. The experience of pain can significantly impair an individual's functioning capacity.

In this particular field, a wide range of scholarly perspectives can be identified, comprising a total of five distinct viewpoints. 

First perspective: Some jurists base their ruling on the use of drugs in medicine on whether they are intoxicating or not. Those who consider them intoxicating do not permit their use for treatment, regardless of the small dosage used. This is based on numerous hadiths that prohibit the use of alcohol for medication and consider it a disease, not a cure.

Second perspective: other scholars believe that the prohibition is based on the harm or the impairment of one's intellect. They permit the use of a small quantity of drugs for treatment if the intention is purely for medicinal purposes. This is because the reason for prohibition, which is harm and impairment, no longer exists.  They draw an analogy to the permissibility of consuming carrion (dead animals) for someone in a state of necessity, as mentioned in Surah Al-An'am, verse 145.

Third perspective: while other jurists believe that the use of drugs such as opium, anesthesia, and perfume for medical treatment is permissible under two conditions:

1. There is a genuine need for their use in treatment, and there is no alternative available.

2. There is no substitute that can fulfill their purpose. 

The evidence supporting these two perspectives includes the following:

The statement of the Prophet Muhammad (peace be upon him) regarding alcohol: "It is not a cure." However, the effectiveness of drugs in medicine is subject to experimentation. Experiments have shown the benefits of many drugs in the field of medicine, as determined by experts in the field.

The dosage used in medicine does not cause addiction if used appropriately. Necessity permits the consumption of prohibited substances that alleviate harm threatening one's life. Therefore, using a small amount of drugs in medical treatment is permissible based on this principle.

Fourth perspective: Its proponents believe that if a prohibited substance becomes necessary for medication and it loses its intoxicating properties, its use is permissible. The prohibition is removed because the substance transforms from impure to pure or from forbidden to permissible, as its original qualities are altered. However, if the prohibited substance remains intoxicating, its use is only permissible within the aforementioned conditions.

Some scholars believe that the removal of prohibition does not affect the permissibility of medication, and it is only permissible within the mentioned conditions.

Fifth perspective: Medications derived from drugs can be categorized into two situations:

1. The medication is derived from a drug where the intoxicating substance has been removed naturally. If the removal occurs naturally, the ruling on such medication is the same as that of permissible medicines. However, if the removal is due to human intervention, the ruling is similar to that of substances whose prohibition is lifted due to human intervention. There is a difference of opinion regarding the permissibility of using alcohol in such cases.

2. The medication is derived from a drug where the intoxicating substance has not been eliminated. If the drug is purely intoxicating, it is ruled as alcohol according to those who consider drugs as intoxicating substances. If it is a combination of intoxicating and non-intoxicating substances, if the effect of the intoxicating substance is eliminated, the ruling is the same as that of substances whose prohibition is lifted due to human intervention, according to those who consider them as intoxicating substances. However, if the effect remains, the ruling is the same as that of pure alcohol in medication, according to those who consider drugs as intoxicating substances.

The preponderant viewpoint regarding the utilization of cannabis for medicinal intentions. 

Medical impairment and pain can have a significant impact on an individual's functioning, similar to the effects of intoxication on the human mind and body. By examining the legal principles of sharia, we can observe that the general legal maxim is to enhance focus and prevent harm. Consequently, if there are no alternative means to alleviate harm except through the use of cannabis, it may be permissible to use it, albeit with restrictions to ensure appropriate usage for its intended purpose. 

In situations where cannabis or its derivatives are prescribed by a qualified medical practitioner for the purpose of mitigating severe medical conditions or alleviating pain, certain scholars may endorse its utilization under stringent supervision and within prescribed parameters. The underlying foundation of this methodology is rooted in the concept of necessity (darurah) as delineated in Islamic jurisprudence. This principle grants the flexibility to make exceptions to established prohibitions in situations of extreme urgency or dire need. 

Such an opinion is supported by the following: 

Ibn Hajar Alhaytami said: “He may seek cure in matters, even if intoxication occurs. If two just physicians tell him that there is no remedy for your ailment except Him."

This was the fatwa that was stated by Sheikh Abdulaziz bin Baz, Sheikh Abdulrazzaq Afifi, Sheikh Abdullah bin Ghudayan, Sheikh Abdullah bin Qu'ud: "If no other permissible substances are known to be used to alleviate the patient's pain except for these two substances, it is permissible to use each of them to alleviate the pain when necessary, as long as their use does not result in greater harm or an equivalent harm, such as addiction to their use."

 It was also mentioned in the "8th Medical Jurisprudence Conference": "Narcotic substances are prohibited and should not be consumed except for necessary medical treatment, in the quantities determined by physicians, and they are considered pure."

Restriction to ensure the proper usage for medical purposes should be within the following guidelines: 

1. Meeting the patient's need for that medication should be limited to absolute necessity.

1. A trustworthy physician should testify that the narcotic drug contains benefits for the patient that other tested medications have failed or are at least not as efficient for treatment or healing. 

Although physicians may not be capable of fully testifying that such drugs maybe helpful, it is enough to consider the probability of such help in such cases. As Al-Shatibi said in Al-I'tisam: "Ruling based on preponderance of probability is a fundamental principle in legal judgments." Regarding the incident of the two women whose child was taken by a wolf, it is mentioned: "Some jurists have stated that in this incident, there is permission to judge based on preponderance of probability." And according the Malikis preponderance of probability is equivalent to certainty in rulings. As Allah, the Most High, says: "And if you know them to be believers, then do not return them to the disbelievers." There is no way to attain certainty in this matter. It is narrated from Umm Salamah that the Prophet (peace be upon him) said: "I am only a human being, and the disputants come to me. It is possible that one of them presents his case more eloquently than the other, and I may consider him to be truthful and rule in his favor."

1. The medication should be administered only to the extent required by necessity. Therefore, substances that are known to cause addiction and mental collapse cannot be used as a treatment for any illness, such as cocaine and meth. Cannabis and other known CBDs that may contain pain-relieving properties continue to be the focus of our research.

2. This “medication” should be specifically designated for use, so that there are no permissible or less prohibited alternatives.

3. This “medication” should not cause the patient harm that exceeds or equals the benefit it provides, and one of the greatest harms to the patient is becoming addicted to the narcotic drug.

Withdrawal of life-sustaining treatment

The topic of a "Do Not Resuscitate" (DNR) status or directive is a broad and delicate matter that necessitates meticulous examination, given the absence of a definitive legal ruling on DNR status in jurisprudence literature. The application of certain principles derived from Maqasid Alsharia, which are Islamic legal maxims, can offer valuable guidance in the context of decision-making pertaining to end-of-life care and resuscitation.

A) The preservation of life is widely recognized as a fundamental value, and efforts to uphold and perpetuate life are commonly advocated, as evidenced by the presence of numerous references in ayat (verses) and hadiths. 

The recommendation for pursuing life-sustaining treatment typically arises in cases where it is deemed medically essential and holds a reasonable probability of enhancing the individual's health and overall state of being. Promoting the adoption of medical interventions and advancements to effectively preserve and restore health to the highest degree possible.

Prognosis and the ineffectiveness of treatments meant to prolong life are taken into account in the medical sector. In situations where professionals ascertain that the administration or continuation of a particular treatment would not result in significant advantages for the individual's well-being or overall life satisfaction, it may be considered justifiable to abstain from or terminate said treatment. The limitations of medical interventions do not necessitate the continuation of treatments that are considered medically ineffective.

In situations where life-sustaining medical interventions impose an excessive burden on individuals or their families, whether it be physical, emotional, or financial, and there is no reasonable prospect of substantial health improvement, it may be justifiable to consider the possibility of withholding or withdrawing such treatment. The key is to prioritize a balance between the potential benefits and drawbacks of these interventions.

Al-Qaradawi's perspective aligns with the notion that the cessation of treatment devices for patients with severe brain damage ought to be regarded as a discontinuation of medical treatment, rather than a deliberate facilitation of death. Individuals afflicted with this particular ailment undergo a state of unconsciousness and insensitivity as a result of the severity of their cerebral impairment. Sustaining vital functions for these patients results in superfluous economic encumbrances and monopolizes resources that could be allocated to other individuals requiring medical attention.

The significance of quality of life is recognized, and in cases where life-sustaining interventions would merely extend the dying process and result in undue distress, without substantially enhancing the individual's general welfare, it may be ethically acceptable to prioritize the provision of palliative or supportive care.

The concept of Advance Directives and Consent is acknowledged, which upholds the significance of autonomy and acknowledges the entitlement of an individual to make informed decisions concerning their medical treatment. Advanced directives, such as living wills or durable power of attorney for healthcare, can offer direction concerning an individual's preferences for life-sustaining treatment in the event of incapacity.

The determination regarding life-sustaining treatment is contingent upon the specific circumstances and the medical condition of the individual in question. The prevailing consensus among scholars is that the cessation of resuscitation devices is generally considered ethically impermissible unless the patient has reached a state of clinical death. However, there exist differing perspectives, such as that of Al-Qaradawi, who argued that if reputable medical professionals affirm that the patient's condition is beyond recovery, it is permissible to discontinue the use of such devices. The Fatwa issued by the Permanent Committee for Scientific Research and Fatwa offers additional insights regarding the permissibility of terminating patient resuscitation in certain circumstances.

1. If the patient arrives at the hospital already deceased, there is no need to use resuscitation devices.

2. If the patient's condition is deemed unsuitable for resuscitation by the testimony of three trustworthy specialized doctors, there is no need to use resuscitation devices.

3. If the patient's illness is incurable and death is confirmed by the testimony of three trustworthy specialized doctors, there is no need to use resuscitation devices.

4. If the patient is in a state of incapacity, mental lethargy with a chronic illness, advanced-stage cancer, or chronic heart and lung disease with repeated cardiac and respiratory arrests, and this is confirmed by the testimony of three trustworthy specialized doctors, there is no need to use resuscitation devices.

5. If the patient shows evidence of irreparable brain damage, confirmed by the testimony of three trustworthy specialized doctors, there is no need to use resuscitation devices due to the lack of benefit.

6. If cardiopulmonary resuscitation is futile and inappropriate for a specific condition, according to the opinion of three trustworthy specialized doctors, there is no need to use resuscitation machines. The opinion of the patient's guardians regarding the use or removal of resuscitation devices should not be considered, as it falls outside their jurisdiction. This concludes the fatwa.

The preponderant ruling regarding DNR

Islam expressly prohibits active euthanasia and includes a statement prohibiting medical professionals from taking affirmative steps to terminate the life of a patient. Yet, the terminal condition of the patient is characterized by the absence of recovery prospect. This is commonly referred to in medical contexts as "la yurja buruh." While brain-dead individuals are deemed alive from an Islamic perspective, it is acknowledged that they are in the process of dying and cannot be brought back to a stable state of life (hayat mustaqirra ). 

While advocating for the preservation of life, the physician is required to recognize and respect their limitations. If there is a scientific certainty that restoring life is impossible, it would be futile to sustain the patient's vegetative state through artificial resuscitation or other artificial means. Rather than prolonging the duration of the dying process, the primary objective is to preserve the continuity of life.

Ruling on discontinuation of artificial nutrition and hydration (ANH)

The Islamic viewpoint on the discontinuation of artificial nutrition and hydration (ANH) is dependent on various contextual factors and the individual's health condition. The decision to discontinue artificial nutrition and hydration (ANH) should be based on a comprehensive assessment of the individual's overall well-being, medical prognosis, and in collaboration with knowledgeable Islamic scholars or experts in Islamic jurisprudence. 

Undoubtedly, the importance of protecting life and ensuring the provision of necessary sustenance and assistance to individuals is inherent in the legal principles of upholding life within the Islamic tradition. However, there are situations in which the continuation of ANH (Artificial Nutrition and Hydration) may not lead to favorable consequences or may cause excessive harm, thus making it justifiable to discontinue it. There are several important considerations that must be taken into consideration. Specifically, in situations where the administration of artificial nutrition and hydration (ANH) is deemed medically unnecessary due to an irreversible condition and the absence of potential benefits or improvements in quality of life, the discontinuation of ANH may be considered permissible as determined by healthcare professionals.

The cessation of artificial nutrition and hydration (ANH) may be deemed ethically defensible under circumstances where it is deemed medically futile, meaning that it does not provide substantial nourishment or hydration, or if it induces excessive physical or emotional suffering for the individual without a reasonable probability of yielding positive outcomes.

Islam acknowledges the importance of quality of life. In situations where an individual is experiencing a prolonged vegetative state, with no foreseeable chance of recovery, and the administration of artificial nutrition and hydration (ANH) merely extends the dying process without offering substantial advantages, it may be ethically defensible to prioritize the delivery of palliative care.

The inclusion of an individual's will is crucial in all deliberations concerning the cessation of Artificial Nutrition and Hydration (ANH), specifically in relation to informed consent and the determination of the individual's best interest, while also considering the relevant contextual factors. Moreover, it is crucial to establish a consensus by engaging in a collaborative process involving the patient's family members, healthcare professionals, and Islamic scholars. This approach should consider the well-being of the individual as well as their commitment to their personal beliefs and values.

Ruling on suicide and euthanasia 

Suicide is generally considered forbidden and prohibited. Taking one's own life is seen as a major sin and a violation of the sanctity of life, a second major legal maxim in Islam. 

There are several evidence from the Quran and Hadith that indicate the prohibition of suicide:

It is forbidden for the patient to use anything that causes mortality, including medication or other means. This is regarded as suicide, which is one of the seven deadly crimes. Based on the Quranic verse, "And do not kill yourselves [or one another]." The Quranic verse from Surah An-Nisa, 4:29-30 asserts that Allah is consistently merciful towards individuals.

Allah is indeed ever merciful to you" (Surah An-Nisa 4:29-30).

لقوله تعالى : ( وَلَا تَقْتُلُوا أَنْفُسَكُمْ إِنَّ اللَّهَ كَانَ بِكُمْ رَحِيمًا . وَمَنْ يَفْعَلْ ذَلِكَ عُدْوَانًا وَظُلْمًا فَسَوْفَ نُصْلِيهِ نَارًا) النساء/29، 30 .

Abu Hurairah (may Allah be delighted with him) narrated that the Prophet (peace be upon him) said: "Whoever launches himself off a mountain and murders himself will be in the Hellfire eternally, hurling himself into it. Whoever drinks poison and commits suicide will eternally have the poison in his hand and consume it in Hell. Whoever commits suicide with a weapon will eternally hold that weapon in his grasp and wound himself with it in the Hellfire. ”.  

Thabit bin Ad-Dahhak (may Allah be delighted with him) narrated that the Prophet of Allah (peace be upon him) said, "Whoever kills himself in this world with something will be punished with it on the Day of Resurrection."

  Jundub ibn Abdullah (may Allah be delighted with him) narrated that the Prophet of Allah (peace be upon him) said, "There was a wounded man among those who arrived before you. He sliced his hand with a dagger after becoming overwhelmed by the situation. The bleeding continued until his death. Allah, the Supreme Being, stated, "My servant hastened his own demise." I have prohibited Paradise for him.”

 It is impermissible for a physician or organization to assist, promote, or facilitate the suicide of a patient. Allah states in the Quran, "And cooperate in righteousness and piety, but do not cooperate in sin and aggression, and fear Allah; indeed, Allah is severe in penalty" (Surah Al-Ma'idah, 5:2).

قال تعالى: (وَتَعَاوَنُوا عَلَى الْبِرِّ وَالتَّقْوَى وَلَا تَعَاوَنُوا عَلَى الْإِثْمِ وَالْعُدْوَانِ وَاتَّقُوا اللَّهَ إِنَّ اللَّهَ شَدِيدُ الْعِقَابِ) المائدة/2 .

Ruling on euthanasia 

The act of offering assistance in euthanasia, which entails deliberately terminating an individual's life in order to alleviate their suffering, is widely considered to be illicit and prohibited. This behavior is considered to be an accomplice to illegal actions and represents a direct violation of the fundamental value placed on human life. The Islamic religion places considerable emphasis on the preservation and sanctity of human life. The deliberate act of causing the demise of another individual is widely recognized as a grave transgression.

 The act of granting consent for euthanasia or actively facilitating a patient's pursuit of it, along with the creation of literature and resources related to this topic, is widely regarded as a morally reprehensible act, a grave transgression, and may lead to legal consequences both in the present life and the afterlife. 

As per the "Fatwa of the Permanent Committee for Scientific Research and Fatwa" (25/85), individuals who support the idea of fulfilling a patient's wish to end their life and actively assisting in this process, whether through medical practitioners or alternative methods, are committing a violation and are implicated in aiding a criminal act.

The deliberate termination of an individual's life with the intention of alleviating their distress is widely regarded as morally and legally impermissible. 

There are several justifications for the prohibition of euthanasia within the Islamic faith.

1) The Islamic religion holds the belief that human life is a sacred and bestowed gift. The Islamic religion requires the protection and preservation of human life, and any intentional action leading to the termination of another person's life is considered contradictory to this core principle.

2) Individuals are instructed by Allah Almighty to place their faith in Allah's decree, which affirms that the authority to determine matters of life and death resides exclusively with Allah. In accordance with Islamic doctrine, adherents are entrusted with the responsibility of their own lives and are encouraged to place their faith in the wisdom and decree of Allah regarding the duration and nature of the challenges they face throughout their existence.

3) Islam recognizes that the human condition encompasses a diverse range of afflictions, tribulations, and hardships. Muslim individuals are encouraged to exhibit resilience and endure these challenging circumstances, drawing strength from their religious beliefs, engaging in supplication, and seeking support from their community.

4) The Islamic religion promotes the provision of compassionate care to individuals who are either in the advanced stages of an illness or experiencing severe pain, commonly known as palliative care. Furthermore, the religious doctrine places significant emphasis on the value of demonstrating compassion towards individuals of this nature. Islam advocates for the provision of palliative care, pain management, and interventions aimed at alleviating suffering. The emphasis is placed on providing comfort and support, rather than hastening the dying process.

Spiritual therapy 

When an individual is approaching the threshold of mortality, it is advisable to adhere to the subsequent protocols:

Prompting shahada: One approach to encourage the individual nearing the end of their life to utter the phrase "La ilaha illallah" (There is no God worthy of worship but Allah).  According to numerous narrations, the Messenger of Allah (peace be upon him) advised his companions to encourage those who are close to death to utter the phrase: "La ilaha illallah". 

Abu Dawud, a prominent narrator, has also transmitted, through a reliable chain of narrators, a statement attributed to Mu'adh ibn Jabal (may Allah be pleased with him) wherein the Prophet (peace be upon him) asserts that whoever concludes their final utterances in this worldly existence with the declaration of "La ilaha illallah" will gain admission to Jannah (Paradise).

The act of prompting becomes essential in cases where the dying individual is incapable of independently articulating the testimony of faith. If individuals possess the capability to articulate their thoughts or opinions without external assistance, there is no necessity for any form of prompting. Prompting should be administered when an individual is in a state of consciousness and possesses the ability to articulate verbally. Prompting is not feasible if the individual is experiencing delirium. In the event that an individual is incapable of verbal communication, they have the capacity to internally reiterate the testimony within their cognitive faculties. 

Scholars have recommended against maintaining a steadfast insistence in such circumstances. It is advisable to refrain from instructing a dying individual to recite the phrase "La ilaha illallah" due to concerns that they may become irritated and utter inappropriate expressions. 

Alternatively, it is recommended that the individual vocalize their words in close proximity to the terminally ill individual, ensuring audibility and comprehension.

In the event that an individual who is nearing death has already expressed their testimony of faith, it is unnecessary to reiterate the prompt, unless they proceed to articulate additional words subsequently. In such a scenario, it would be advisable to reiterate the prompt in order to ensure that it becomes the final statement uttered by the individual.

The prevailing consensus among scholars is that the invocation is restricted to "La ilaha illallah" due to the explicit interpretation of the Hadith. Nevertheless, there exists a viewpoint among scholars that advocates for the simultaneous recitation of both testimonies, namely "La ilaha illallah" and "Muhammad Rasul Allah." This perspective posits that the intention behind this practice is to reinforce the concept of Tawhid, which encompasses the acknowledgment of both statements.

Facing Qibla: Scholars held differing perspectives regarding the practice of aligning the terminally ill individual towards the Qibla. 

 The hadiths do not make any mention of the prophet himself redirecting while he was on his deathbed.

 Nevertheless, it is important to acknowledge that scholars belonging to the Hanafi, Maliki, Shafi’ee, and Hanbali schools of thought generally concur that it is advisable to orient the terminally ill person towards the Qibla. This viewpoint is derived from a hadith transmitted by Abu Qatadah, wherein the Prophet Muhammad (peace be upon him) inquired about Bura' ibn Ma'rur (may Allah be pleased with him) upon his arrival in the city of Madinah. praised the companion for providing assistance to him in aligning himself with the Qiblah during his final moments. Subsequently, the Prophet Muhammad (peace be upon him) proceeded to partake in an act of supplication on behalf of the individual, fervently beseeching: "O Allah, bestow upon him forgiveness, bestow upon him Your mercy abundantly, and grant him entry into Your eternal abode of Paradise." 

 Albani contended that there is a lack of authoritative narrations concerning the Prophet, may peace be upon him, that can be considered as reliable in relation to the subject under discussion.

Reading Surah Yasin and surah Al-an’am: Based on the narrations attributed to Maqil ibn Yasar (may Allah be pleased with him), it is reported that the Messenger of Allah (peace be upon him) advised the recitation of Surah Yasin for individuals in the process of passing away. Yet, scholars differed in regards to reading Surah Yasin due to the weak narrations in that regards, amongst such scholars Imam Malik. Yet, other scholars have considered it a sunnah or recommended the least to mention based on the hadith that Ibn Hajar had regarded it as a considerable (hassan) hadith The scholars informed me that they attended the funeral of Ghudayf ibn al-Harith al-Thumali (a companion) when his  illness became intense. He said, "Is there anyone among you who can recite Surah Yasin?" Salih ibn Shurayh al-Sakuni recited it, and when he reached the fortieth verse, Ghudayf passed away. The scholars used to say, "When Surah Yasin is recited in the presence of a deceased person, it eases their situation."

According to those that have regarded the aforementioned statement and other hadiths as acceptable narrations specifically directed towards individuals who are in close proximity to death, rather than those who have already passed away. 

Covering the deceased: In accordance to what was reported that the Prophet (peace be upon him) encountered Abu Salamah (may Allah be pleased with him) upon his passing, observing that his eyes remained open. The Prophet (peace be upon him) proceeded to gently close Abu Salamah's eyes, remarking that upon the departure of the soul, the sense of sight naturally ceases.

The act of covering the deceased's body serves the purpose of safeguarding it from exposure and concealing any alterations in its physical appearance from visual observation. Aisha,  recounted that upon the demise of the Prophet Muhammad, peace be upon him, his countenance was veiled by a cloth adorned with stripes.

There is a consensus among scholars from the four schools that it is permissible to engage in the act of kissing the deceased. The Prophet Muhammad (peace be upon him) demonstrated an act of reverence by kissing the deceased Uthman ibn Maz'un. Similarly, Abu Bakr, upon the Prophet's demise, expressed his respect by kissing him between the eyes and addressing him as "O Prophet, O dear one."

Preparing the corpse for burial, shrouding and funeral: One important aspect involves:

1. Softening the joints to make moving the limbs around during washing and shrouding easier. 

2. Fastening the jaws to avoid the entrance of air on water to the corpse during washing and shrouding. 

3.  Promptly initiating the preparation of the deceased upon confirmation of their demise, expediting the processes of washing and burial, driven by apprehension towards any potential alteration in their state. The narration is attributed to Abu Dawood, who reports the account of Husayn ibn Wahb. According to Husayn ibn Wahb, Talhah ibn al-Bara' became ill, prompting a visit from the Prophet Muhammad (peace be upon him). During the visit, the Prophet remarked, "I perceive that Talhah is in the grip of death." Please notify me promptly upon his demise, as it is deemed inappropriate for a Muslim to procrastinate in making necessary arrangements for the deceased.

Recommendations and advocacy for Muslim patients in hospice: 

With the increasing Muslim population, there is a corresponding rise in the need for Muslim palliative care. Consequently, it becomes increasingly imperative for Muslims to enhance awareness and allocate the necessary resources to facilitate the provision of comfort during the final stages of life for dying Muslims. The following recommendations outline potential strategies for the Muslim community to effectively safeguard its rights and ensure the provision of necessary services.

The topic of education and training is of great significance in academic discourse. The importance of ensuring that employees and volunteers in hospice centers possess sufficient education and training, as well as a comprehensive understanding of Islamic beliefs, practices, and end-of-life rituals, cannot be overstated. The acquisition of a comprehensive comprehension of the Islamic viewpoint on palliative care, the notion of a dignified death within Islam, and the religious and cultural responsibilities of Muslim individuals pursuing medical intervention is imperative in this context. 

Developing a thorough understanding of successful approaches to interacting with Muslim patients enables the delivery of essential services that are customized to meet their unique needs. 

The proposed initiative seeks to facilitate cooperation between Muslim communities and hospice institutions with the objective of establishing chaplaincy services that are specifically designed to cater to the unique needs of Muslim patients. These services encompass a variety of forms of support, including the provision of spiritual guidance, emotional assistance, and the facilitation of religious practices. Furthermore, these programs can also assist in alleviating spiritual isolation. They have the capacity to provide support to patients and their families through the practice of reciting prayers, formulating supplications, and addressing any religious or spiritual difficulties that may arise.

- Enhancing Service Delivery for Muslim Patients: Streamlining the Process of Identifying Suitable Resources for Individuals Seeking Fatwas, Taking into Account the Multifaceted Information Required to Address Their Religious, Social, and Spiritual Requirements. 

- Providing relevant information to hospice institutions to support the integration of appropriate accommodations for Muslim patients. The aforementioned criteria encompass a range of elements, including religious provisions such as prayer rugs, Qurans, materials facilitating wadu, halal food, gender segregation and modesty, as well as a tranquil environment conducive to prayer and reflection.

To enhance the provision of essential support to Muslim patients, it is recommended to initiate communication with hospice centers and subsequently share relevant information with nearby Islamic centers. This will facilitate the acquisition of knowledge and resources by Islamic centers, thereby enabling them to effectively address the unique requirements of Muslim patients. This document presents a comprehensive set of guidelines regarding Islamic funeral and burial customs, as well as provisions for grief counseling and support services designed to assist individuals in managing the emotional distress associated with the passing of a beloved person.

In situations where Muslim patients are present, it is necessary for Islamic centers to establish communication with hospice centers and assisted living institutions in order to acquire references. 

The utilization of mosques as educational platforms will facilitate the dissemination of knowledge concerning the provision of care for terminally ill patients within the Muslim community. Furthermore, individuals working in hospice settings will receive lectures on this particular subject matter. 

Respect for Religious Observances: Should the patient indicate a wish to partake in religious observances, such as observing fasting rituals during Ramadan or conducting religious rituals, it is crucial to exhibit reverence for these practices and endeavor to support their implementation to the fullest extent possible. Establishing and maintaining effective communication channels with healthcare professionals is of utmost importance in order to facilitate the requisite modifications in treatment plans, including adjustments in medication dosing, when deemed appropriate.

*References within this Article are available upon request: drayshawazwaz@gemsoflight.com