5 Medicine, Health and Treatment

عَنْ أُسَامَةَ بْنِ شريكٍ، قَالَ أَتَيْتُ النَّبِيَّ صلى الله عليه وسلم وَأَصْحَابُهُ كَأَنَّمَا عَلَى رُءؤسِهِمُ الطَّيْرُ فَسَلَّمْتُ ثُمَّ قَعَدْتُ فَجَاءَ الأَعْرَابُ مِنْ هَا هُنَا وَهَا هُنَا فَقَالُوا يَا رَسُولَ اللَّهِ أَنَتَدَاوَى فَقَالَ

 ‏  تَدَاوَوْا فَإِنَّ اللَّهَ عَزَّ وَجَلَّ لَمْ يَضَعْ دَاءً إِلاَّ وَضَعَ لَهُ دَوَاءً غَيْرَ دَاءٍ وَاحِدٍ الْهَرَمُ “‏ ‏           

Usāma Ibn Sharīk narrated the following:

I came to the Prophet (ﷺ) and his companions were sitting as if they had birds on their heads. I said my greetings of salam and sat. The bedouins then came from all over, and they started asking the Prophet: Oh Messenger of Allah, should we seek medical treatment (if we are unwell)? He replied: “Seek medical treatment, for Allah has not made a disease without providing a cure, with the exception of one illness, which is old age.”

The physical body is entrusted by Allah to mankind and is a valuable gift that should be treasured. As such, Islam places great importance on health. One who is healthy does not only have a sound mind; good health helps a Muslim to perform duties and perfect worship. However, should a Muslim fall sick, whether due to negligence or other unavoidable factors, effort should be made to seek treatment for the illness.  This hadīth provides the basis for seeking treatment and medication:

إنَّ اللهَ أنْزَلَ الدَّاءَ والدَّواءَ ، وَجَعَلَ لكلِّ داءٍ دواءً ، فَتَداوَوْا ، ولا تَتَداوَوْا بالحَرَام

“Verily Allah has sent down illnesses and cures. And He has made (available) a cure for every illness. So seek treatment, but do not treat with what is prohibited.”[1]

This hadīth is a reminder that we must have proper understanding of how to seek treatment whilst observing the guidelines of treatment.

Taking medication and following a proper diet can relieve, treat, or even prevent diseases, in addition to improving one’s health. There are many available methods that serve as preventive measures or treatments of diseases, such as traditional herbs and modern medicine. Modern medicine typically uses drugs derived from scientific research to treat ailments. It also involves the use of vaccines to fight against pathogens or to protect the body from diseases. The production of these drugs often involves naturally-occurring chemicals and ingredients from animal sources.

As the awareness of health issues increase and Muslims are exposed to information on drug and vaccine production, an increase in questions on the permissibility of consuming medication containing alcohol or cells, fats or protein from non-halal sources, can be expected.

Islamic Principles on Medication

There are some key principles pertaining to medical ingredients as specified by Islamic law: (1) the concept of istiḥāla and istihlāk (2) the concept of emergency (ḍarūra) (3) preventing harm through treatment, and (4) the concept of maṣlaḥa. 

First: Istiḥāla and Istihlāk

The Fatwa Committee considers the principles of istiḥāla and istihlāk in relation to medication that are mixed with, or originated from, impure (najis) sources, thus undergoing the process of change or microfiltration until the impurity is changed or dissolved.  A more detailed explanation will follow in the discussions on related fatwas.

Second: The concept of emergency (ḍarūra) in seeking treatment

Emergency (ḍarūra) here means a situation in which the life or property of a person is exposed to harm.[2] A situation can be considered an emergency when a medication that has a prohibited substance(s) or a medical procedure is needed if

  • the main objective is the preservation of life, health and/or the physical body; and/or
  • in a situation where it is the only available medication or treatment suitable for the patient.

The basis for this state of emergency has to be established by medical experts before such a dispensation (rukhṣa) can apply.

Among the fiqh maxims observed in emergencies (ḍarūra) are:

A. Difficulties bring about ease. (المشقة تجلب التيسير)
This legal maxim allows for a difficulty to be resolved by way of flexibility in dire situations. The basis of this is the Qur’anic verse:

 يُرِيدُ اللَّهُ بِكُمُ الْيُسْرَ وَلَا يُرِيدُ بِكُمُ الْعُسْرَ
“Allah intends for you ease and does not intend for you hardship.”
(al-Baqara: 185)

This means that when difficulties arise in the observance of a ruling by the masses, a dispensation (rukhṣa) from the ruling can be considered. However, this is contingent upon the presence of harm. This principle, in turn, is related to the following legal maxim:

B. What is allowed during hardship, will be voided when it (the hardship) is removed. (ما جاز لعذر يبطل بزواله)

As mentioned above, all efforts to medicate from permissible substances must be exhausted. For example, where there are medications that do not contain prohibited substances in the future, such an emergency no longer exists and exceptions that have allowed for their use will be removed.

C. Emergency is limited to its rightful extent. (الضرورات تقدر بقدرها)

This maxim denotes that resorting to something prohibited (haram) is allowed up to the extent of what is required to remove the emergency. An example is a treatment for a disease, or to prevent it from worsening. However, this treatment cannot contain non-essential supplements or additives. This method reflects how Islam allows for facilitations to problems but within certain established parameters.

In Islamic jurisprudence, there are fixed rules known as ʿazīma, and concessionary rules known as rukhṣa. Muslims must abide by the rulings of ʿazīma as long as there is no concession allowing for dispensation (rukhṣa), such as the permissibility of breaking fast in Ramadan for those who are unwell. Among the reasons for dispensations include emergency, travelling, sickness and being placed under duress.

An emergency situation that warrants dispensation (rukhṣa) is specific. Dr Wahba Al-Zuhailī defines it as:

Emergencies occur to someone in dangerous situations, or in severe difficulties, or when there is a risk of injury or illness to life, limb, dignity, intellect, or property, and everything connected to it. In such a situation, it is permitted to resort to the prohibited, or to abandon or delay the compulsory in order to resist harm from occurring, while adhering to considerations within the boundaries of Islamic law.[3]

Similarly, Shaikh Yūsuf al-Qaraḍāwī in his al-Ḥalāl wa al-Ḥarām fi al-Islām, stresses that Muslims should not make light of the concessions given by the Lawgiver by using necessity as an excuse for not observing religious duties.[4]

Third: The Principle of Preventing Harm through Treatment

Another important principle in seeking treatment is that it should not cause harm or danger. This is based on the maxim that prohibits the removal of harm by inflicting a different type of harm based on a hadīth: “Do not harm or (reciprocate) harm” – Narrated by Ibn Mājah.[5] Imām al-Shāṭibī commented that although the status of the hadīth is weak (considered an uncertain hadīth i.e. ẓannī), its principle is certain (qaṭʿī) because harm and malice are known prohibitions in Islamic law.

Therefore, any medicine or treatment taken by a Muslim must be determined safe, not harmful nor poisonous, and does not endanger the patient’s health or those around him. This also forms the basis of seeking treatment from an illness. If there is a way to reduce pain, Sharīʿa encourages treatment, although it is not an obligation (as will be discussed later in the fatwa on Advanced Medical Directive).

Other maxims related to ḍarar (harm) are:

A. Harm cannot be removed by harm (الضرر لا يزال بالضرر) [6]
B. Harm is repelled according to one’s ability. (الضرر يدفع بقدر إمكان)
C. A more severe harm (ḍarar) can be removed by inflicting a less severe one. (الضرر أشد يزال بالضرر أخف)

This means that for a patient who has the option of either to undergo surgery (which is not without pain nor possible complications that may arise from the procedure) or to refuse the procedure and persevere with the illness, this maxim serves as a guide for him to choose the lesser of the two pains.

Fourth: Observing Maṣlaḥa

Classical jurists such as  Imām Mālik, Imām al-Shāfiʿī (d. 204H), Imām al-Ḥaramain al-Juwaynī (d. 438H) and  Imām Aḥmad Ibn Ḥanbal (d. 241H) accepted maṣlaḥa as a key doctrine and principle in Islamic legal thought. Whilst the guidelines developed by the classical scholars on the precedence of maṣlaḥa against harm are useful, ultimately one needs to assess every particular situation and balance between benefit and harm in his or her own unique circumstances. Whilst the guidelines developed by the classical scholars on the precedence of maṣlaḥa against harm are useful, ultimately one needs to assess every particular situation and balance between benefit and harm in his or her own unique circumstances. In the domain of jurisprudence, this is known as fiqh al-muwāzana. By taking into account both maṣlaḥa and mafsada, one must determine which maintains the maqāṣid al-sharīʿa. In relation to the topic at hand, undergoing a surgical procedure and providing treatment are considered essential to ensure that the live-preserving objectives of Sharīʿa are fulfilled. This is in accordance with a legal maxim that states “Any harm [or danger] should be eliminated”.

In his explanation of this maxim, Imām al-ʿIzz Ibn ʿAbd al-Salām divided maṣlaḥa into four:[7]

  1. Permitted maṣlaḥa
    An example of this is maintaining a healthy diet for someone who is in good health.
  2. Compulsory maṣlaḥa due to critical benefits
    An example of this is consuming prohibited food in order to preserve life.
  3. Recommended maṣlaḥa due to additional benefits
    An example of this is researching on supplements that can improve health of consumers.
  4. Disputed maṣlaḥa, yet the maṣlaḥa outweighs the mafsada.
    An example of this is praying in a state of impurity (without even performing tayammum) due to unavoidable circumstances and situations, as the priority is to conduct one’s prayer.

It must also be noted that maṣlaḥa does not necessarily include only matters that bring benefit. Jurists have categorised maṣlaḥa into several types: (1) maṣlaḥa muʿtabara (2) maṣlaḥa mursala and (3) maṣlaḥa mulghā.

1) Maṣlaḥa Muʿtabara (recognised good) refers to maṣlaḥa that has been clearly stated in the Qur’an and Sunnah, as a reason or purpose to be achieved with particular rulings. An example is maintaining individual honor and dignity by prohibiting adultery, or the prohibition of spreading allegation of adultery charges without any evidence.

2) Maṣlaḥa Mursala (unattested good) is a maṣlaḥa not explicitly mentioned but that needs to be achieved and maintained, and there is no specific scriptural basis for rejecting it. It can be understood as a maṣlaḥa that embodies the understanding of the purpose and spirit of Islam which must be preserved. Jurists have placed some conditions for maṣlaḥa mursala which include:

  1. The maṣlaḥa to be achieved must be definitive (ḥaqīqiyya) and not uncertain.
  2. The maṣlaḥa to be achieved must benefit the community in general (kulliyya) and not limited to individuals or certain groups.
  3. The maṣlaḥa to be achieved must not contradict one of the religious principles or values determined by religious evidences or ijmāʿ.[8]

3) Maṣlaḥa Mulghā (annulled good) refers to benefits which are clearly prohibited in the Qur’an or Sunnah.[9] An example of this is the prohibition of usury (ribā). Even if it might benefit certain parties, its maṣlaḥa is rejected by Sharīʿa in the verse:

وَأَحَلَّ اللَّهُ الْبَيْعَ وَحَرَّمَ الرِّبَا
And Allah has permitted trade and has forbidden usury.
(al-Baqara: 275)

Therefore, the maṣlaḥa one intends to secure from cosmetic surgeries might be deemed as maṣlaḥa that is mulghā (annulled), for two reasons:

  • It inflicts pain and harm on one’s limbs without valid reason, and this is prohibited by the religion
  • Such procedures differ from medical surgeries whose purpose is to maintain the health of the human body, which is considered one of the maṣlaḥa muʿtabara (recognised good).

The Status of Impurities (Najis) in Medication

The status of najis elements used in medication is a debated issue among jurists. For medicines containing alcohol, there are two main issues, namely (1) the status of najis, and (2) the prohibition against consuming intoxicants. For other najis substances, the discussions concern various other concepts as explained later in the relevant fatwas.

Alcohol in Medicine

Shaikh Yūsuf al-Qaraḍāwī explains in his book al-Ḥalāl wa al-Ḥarām fi al-Islām that Islam prohibits the consumption of alcohol in medicine as it might lead to addiction while its potential as a treatment is uncertain. His opinion was based on the opinion of Ibn Masʿūd that “Allah s.w.t. did not make a cure from what is forbidden.”[10] However, he made some exceptions in necessity, that is if there are no alternatives available.[11]

Some ‘ulamā consider intoxicating drinks such as liquor (khamr) as najis. As such, it cannot be used externally. The reason for the prohibition of intoxicants is found in the following verse:

يَاأَيُّهَا الَّذِينَ آمَنُوا إِنَّمَا الْخَمْرُ وَالْمَيْسِرُ والأَنصَابُ والأَزْلامُ رِجْسٌ مِنْ عَمَلِ الشَّيْطَانِ فَاجْتَنِبُوهُ لَعَلَّكُمْ تُفْلِحُونَ
Oh you who have believed, indeed, intoxicants, gambling, idol [worshiping], and divining arrows are but defilement from the work of Satan, so avoid it that you may be successful.” (al-Māʾidah: 90).

The second reason for this prohibition is the hadīth of the Prophet Muhammad (ﷺ) as narrated by Ibn ‘Umar r.a.:

كل مسكر خمر وكل خمر حرام[12]
All that intoxicates is khamr, and all khamr is prohibited.”

As liquor (khamr) contains alcohol, this causes intoxication. However, alcohol as a substance is a product of a chemical reaction. There are several types of alcohol. The alcohol contained in liquor is known as ethyl alcohol. It is formed by the fermentation of sugar and yeast, and can be produced from either organic ingredients or through a synthetic process. Ethyl alcohol, among the other types of alcohol, is found in medication.[13]

Therefore, when discussing medication containing alcohol, one should distinguish between synthetic alcohol and alcoholic drinks known as khamr, because both have been used in the production of medication. If a medicine contains the second type, i.e. khamr, it is considered impure (najis) and is prohibited based on the hadīth above. However, if it contains synthetically-produced alcohol, then it is not deemed as najis.

Alcohol has many medical uses. For centuries, alcohol was the main component of European pharmaceutical products. Roger Bacon, an English philosopher in the 13th century and also a medical writer, wrote that among the benefits of alcohol is that it helps to protect the stomach from acid. Some pre-modern theories argued that consuming gin could ward off a plague.[14] Islamic history itself has revealed some examples of the use of alcohol to treat patients, such as those carried out by the physician al-Zahrāwī.

Early American explorers, who found it difficult to get hold of clean water sources and relied on water filtration methods, often used alcohol and opium for medical purposes.[15]In modern times, there are various views on the use of alcohol in medicine. In 18th and 19th century Europe and America, organisations promoting moderate alcohol use tried to change public opinion on using alcohol for medical purposes.[16] In 1917, the American Medical Association adopted a resolution declaring that alcohol and other stimulants are not necessary in the treatment of diseases.[17] This was later followed by a ban on alcohol across the United States in the 1920s and 1930s. However, to this day, alcohol remains an essential ingredient in medication, especially in cough medication.[18]

Fatwa Decision 29/7/1981
TAKING MEDICATION THAT CONTAINS ALCOHOL

Question:

What is the ruling on taking medications containing alcohol?

Answer:

Taking medication containing alcohol is allowed only if there are no other drugs that can replace it. This is like treating an illness by taking medicines containing najis substances [which is allowed], and not like taking liquor only [which is not allowed, as it intoxicates without healing].

The basis for allowing the consumption of medication from najis substances is a hadīth narrated by Al-Bukhārī: From ’Abu Qilabah from Anas, he said: “There are some people of ‘Ukl and Urainah, who came to visit Medina. The Prophet (ﷺ) sent some of his companions to give them camels full of milk, so that they drink its urine (for treatment) and as well as its milk…” until the end of the hadīth.

There is another hadīth narrated by Abu Dardā’ which diverges from the hadīth used in the fatwa above, which prohibits treatment with najis substances. How can we then reconcile these two hadīths?

Among the factors that may cause a medicine to become prohibited are as follows:

  • It contains substances from non-halal animals or animals not slaughtered according to Islamic law
  • It contains substances deemed as najis
  • It contains substances from human origin

As earlier explained, for medicines containing alcohol, two questions arise: whether alcohol is najisnajis, and whether consuming liquor is prohibited.

In the hadīth narrated by Anas r.a. in Jāmiʿ al-Tirmīdhī, in which the Prophet explained that Allah s.w.t. did not create treatment from prohibited substances, a possible meaning, as offered by Shaikh Al-Mubārakfūrī, is that the hadīth forbids using prohibited substances for medication when there are other halal options (ikhtiyār) for treatment. Where such options are unavailable, then it is considered a necessity in which the use of prohibited substances is permitted.[19] This is consistent with the injunction in Surah al-Anʿām:

وَمَا لَكُمْ أَلَّا تَأْكُلُوا مِمَّا ذُكِرَ اسْمُ اللَّهِ عَلَيْهِ وَقَدْ فَصَّلَ لَكُم مَّا حَرَّمَ عَلَيْكُمْ إِلَّا مَا اضْطُرِرْتُمْ إِلَيْهِ ۗ وَإِنَّ كَثِيرًا لَّيُضِلُّونَ بِأَهْوَائِهِم بِغَيْرِ عِلْمٍ ۗ إِنَّ رَبَّكَ هُوَ أَعْلَمُ بِالْمُعْتَدِينَ
And why should you not eat of that upon which the name of Allah has been mentioned while He has explained in detail to you what He has forbidden you, except which you are compelled to consume. And indeed many do lead [others] astray through their [own] inclinations without knowledge. Indeed, your Lord – He is most knowing of the transgressors.” (al-An’ām: 119)

This principle is also further illustrated in the case of using pig skin grafting as discussed next.

Surgery

One way to treat skin damage is through surgery. Unlike vaccinations or drugs, some people regard skin grafting as a cosmetic procedure rather than a life-saving medical procedure. This is inaccurate as human skin is the body’s largest organ and performs many important functions. It protects the body, regulates body temperature, and produces protein and Vitamin D.[20]

The outer layer of the skin (epidermis) forms a waterproof coating while the inner layer (dermis) contains nerve endings, glands and hair follicles. The subcutaneous layer contains fat and protects the body from heat and cold.[21] Healthy skin helps to heal internal trauma such as in some medical conditions and in cases of burns.[22] The procedure involves taking healthy skin from areas of the body that are not damaged, to be grafted onto the injured skin. This method also reduces the problem of DNA incompatibility and promotes faster recovery.

In Singapore, this procedure has been used since the 1930s to help victims of acid attacks and burns.[23] A special burns unit offering skin grafts and plastic surgery was established at the Singapore General Hospital (SGH) in 1959.[24] As early as 1963, doctors planned to set up a human tissue bank for skin grafts, followed by the launch of a ‘skin farm’ in SGH in 1991.[25] Although research was conducted on the possibility of developing artificial skin, skin grafting remains the most viable treatment until now.[26] From attempting to develop artificial skin, the ‘skin farm’ now aims to grow healthy skin. This is done by taking small pieces of skin from a patient’s body before it is grafted so that the skin can be used to treat those suffering from serious skin injuries.[27] Within 3 years of its opening, at least seven patients with severe burns have benefited from this technology.[28]

There are also situations where patients suffer an injury so severe that no skin on the patient’s body was deemed suitable to be grown. In this situation, animal skin was used as an alternative skin source. It was found that there are many similarities between human skin and pig skin; both contain 95% collagen and 2% elastic fibers in the external cells.[29] Furthermore, pig skin is also used to treat heart defects, specifically to patch a hole in the heart.

A question related to this procedure was posed to the Fatwa Committee in 1988. In the fatwa, the use of pig skin was allowed if no other alternative source is found. This method also carries a higher risk as compared to grafting the skin of the patient unto himself, as the human body tends to reject foreign objects from other species.[30] However, the ruling took into consideration the harm that a patient faces from his current injuries, as well as the harm that a patient might face should he be deprived of the surgery.

Fatwa Decision  15/11/1988
USING PROHIBITED (HARAM) ITEMS (PIG SKIN) IN TREATMENT (THROUGH SKIN GRAFTING)

Question:

My niece is suffering from a congenital heart defect (hole in the heart) and according to the doctors, the hole must be sealed using pig skin. What would the ruling be if a Muslim uses pig skin as a treatment to an illness and what would be the impact on his responsibilities as a Muslim as defined in the Sharīʿa?

Answer:

There are several things which have been specified as haram by Allah s.w.t. to protect mankind from their ill effects and as a safeguard for the well-being of mankind.  These items include alcohol, carcasses, pork and several others. Allah explains in detail in surah al-Māʾidah verse 90:

يَاأَيُّهَا الَّذِينَ آمَنُوا إِنَّمَا الْخَمْرُ وَالْمَيْسِرُ والأَنصَابُ والأَزْلامُ رِجْسٌ مِنْ عَمَلِ الشَّيْطَانِ فَاجْتَنِبُوهُ لَعَلَّكُمْ تُفْلِحُونَ

 “O you who believe! Intoxicants and gambling, idol [worshiping], and (divination of) arrows, are defilement from Satan’s handiwork; so avoid it that you may be successful.

In surah al-An‘am verse 145, Allah explains:

ُقُلْ لا أَجِدُ فِي مَا أُوحِيَ إِلَيَّ مُحَرَّمًا عَلَى طَاعِمٍ يَطْعَمُهُ إِلا أَنْ يَكُونَ مَيْتَةً أَوْ دَمًا مَسْفُوحًا أَوْ لَحْمَ خِنزِيرٍ فَإِنَّهُ رِجْسٌ أَوْ فِسْقًا أُهِلَّ لِغَيْرِ اللَّهِ بِهِ فَمَنْ اضْطُرَّ غَيْرَ بَاغٍ وَلا عَادٍ فَإِنَّ رَبَّكَ غَفُورٌ رَحِيمٌ

Say: ‘I find nothing in what has been revealed to me that forbids any one to eat of any food except the dead, running blood, and the flesh of swine for these are unclean and that which has been hallowed in its slaughter to other than Allah. But whoever is constrained to eat of any of these, not intending to sin or transgress, then your Lord is Forgiving, the Most Merciful.

 

The last statement in this verse implies that in a critical situation where there exists no other alternatives, such actions can be forgiven, as Allah has stated in surah al-Baqarah verse 173:

إِنَّمَا حَرَّمَ عَلَيْكُمْ الْمَيْتَةَ وَالدَّمَ وَلَحْمَ الْخِنزِيرِ وَمَا أُهِلَّ بِهِ لِغَيْرِ اللَّهِ فَمَنْ اضْطُرَّ غَيْرَ بَاغٍ وَلا عَادٍ فلا إِثْمَ عَلَيْهِ إِنَّ اللَّهَ غَفُورٌ رَحِيم

He has only forbidden you dead meat, and blood and the flesh of swine and that on which any other name has been invoked besides that of Allah. But if one is forced by necessity without willful disobedience, nor transgressing due limits – then is he guiltless. For Allah is Oft-Forgiving, Most Merciful.”

 

This verse implies that whilst in normal situations these items will remain haram, there are exceptions to the rule in extreme situations where there exists no other recourse to save a life or to protect one’s health and prevent an illness than to consume these prohibited items. In such situations, their consumption is allowed.

In a situation of extreme thirst where there exists no water or other alternative liquid save alcohol, Islamic law permits the consumption of the alcohol with the intent of saving a life. The same goes for the consumption of items that are haram or najis for medicinal purposes. Islamic scholars have unanimously agreed that it is allowed to use haram or impure items for medicinal purposes to remove a life-threatening illness. [1] The scholars have, however, attached two conditions to this. Firstly, the relevant doctors must be trustworthy and honest with a credible background and experience in the profession. Secondly, it must be ascertained that no other alternative forms of treatment are available so that it cannot be said that the medication with haram components was intentionally taken.

As the illness suffered by your niece is considered critical and as the doctor has determined that there are no alternative treatments that can be used other than utilising pig skin for grafting, the treatment is thus allowed and there is no sin for doing so. There are also no restrictions placed upon the person in fulfilling his ibadah such as the prayer, etc.

Source:
1. Wahba al-Zuhailī, Fiqh Perundangan Islam (Malaysia: Dewan Bahasa dan Pustaka, 1995), Vol. 3, 593.

The fatwa above explained the concept of overriding necessity (ḍarūra) with more detail and scriptural evidence. The issue raised by the questioner was that the procedure involves using pig skin – which is categorised as ‘major impurity’– to permanently patch the heart. Hence, the question is not only whether the procedure is permissible, but relates as well to the acts of worship performed by the patient after undergoing skin-grafting.

By undergoing the surgery, the patient is putting himself in a situation considered religiously as impure. To understand the answer provided in the fatwa ruling, the classification of ‘needs’ and ‘emergencies’ must be scrutinised. Carrying or implanting a non-halal substance for medical reasons – as in the case mentioned above – should not be compared to someone using and wearing something prohibited (haram)as detailed in the following hadīth narrated by Muslim:

عن أبى هريرة رضى الله عنه قال  قال رسول الله صلى الله عليه وسلم: إِنَّ اللَّه تعلى طَيِّبٌ لاَ يَقْبَلُ إِلَّا  طَيِّبًا وَإِنَّ اللَّه أَمَرَالْمُؤْمِنِينَ بِمَا أَمَرَبِهِ الْمُرْسَلِينَ فَقَالَ تَعَالَى:  يَـأَيُّهَا الرُّسُلُ كُلُوا مِن الطَّيِّبَاتِ وَاعْمَلُوا صَالِحًا، وَقَال تعالى: يَأَيُّهَا الَّذِ ينَ آمَنُوا كُلُوا مِنْ طَيِّبَاتِ مَارَزَقْنَاكُمْ. ثُمَّ ذَكَرَ الرَّجُلُ يُطِيلُ السَّفَرَ أَشْعَثَ أَغْبَرَ يَمُدُّ يَدَيْهِ إِلَى السَّمَاءِ: يَارَبُّ يَارَبُّ وَمَطْعَمُهُ حَرَامٌ وَمَشْرَبُهُ حَرَامٌ وَمَلْبَسُهُ حَرَامٌ وَغُذِىَ بِالْحَرَامِ فَأَنَّى يُسْتَجَابُ لَهُ.

Abu Hurairah r.a. related that the Messenger of Allah (ﷺ) said: “Allah is Pure and, therefore, accepts only that which is pure. Allah has commanded the believers as what He has commanded upon His Messengers by saying: ‘O Messengers! Eat of the good things, and do good deeds.’ And He said: ‘O you who believe! Eat of the lawful things that We have provided you.” Then the Prophet (ﷺ) mentioned about a person who travels for a long period of time, his hair is dishevelled and covered with dust. He lifts his hand towards the sky and makes the supplication: ‘My Lord! My Lord!’ But his food is unlawful, his drink is unlawful, his clothes are unlawful and his nourishment is unlawful, how can, then, his supplication be accepted?

It must therefore be noted that the meaning conveyed in this hadīth differs from the issue being discussed at hand. First, nutrition and clothing must be halal, pure and free from doubt (shubhah).[31] As such, it not only refers to prohibited physical substances, but also to how the food and clothing were obtained, that is, whether they were obtained through forbidden or doubtful means. Secondly, the hadīth considers food and clothing as part of a person’s property. There is clearly a difference between clothes and items used as a treatment or as an implant in the body. Therefore, a patient undergoing this treatment should not worry about the validity of his worship, or that he might be categorised among those whose prayers are not accepted due to the presence of prohibited substances in his body. The reason for this is that these substances were not arbitrarily added, but only used for treatment, based on necessity and dire need.

Apart from drugs or surgical treatments, there are also other preventive measures made available through vaccination. As a vaccine enters the bloodstream, the issue of whether its ingredients are halal become important. The Fatwa Committee issued fatwas on two types of vaccinations with questionable ingredients, namely the Meningitis and Rotavirus vaccines.

Vaccines

The use of enzymes and bacteria derived from animals in vaccines originated from the invention of world’s first vaccine by Edward Jenner, who invented the smallpox vaccine where inoculation is done using cowpox matter.[32] Later, many human drugs and vaccines used cow, monkey or swine enzymes in the production process. This could be done directly where the enzymes become part of the vaccine itself (as in the case of the smallpox vaccine) or indirectly where the enzymes help to cultivate the necessary ingredients but is not inherently present in the vaccine (for example, the Rotavirus vaccine).  Such enzymes were initially thought to be non-pathogenic, although some new research have shown otherwise.[33]

History of Vaccine Use

In Southeast Asia, vaccination largely came through programs implemented by colonial powers. Vaccination was a key component of the Dutch Ethical Policy program in the then Dutch East Indies from 1901 while the British-made smallpox vaccination was compulsory in Malaya in 1891.[34] Such attempts by colonial powers to improve public health were not necessarily well received and village headmen often had to help to round up their constituents to receive the vaccination shots. Early opposition to such programs was not due to the content of the vaccine but suspicion of the procedure itself and the colonial authorities’ intrusion into the bodies of their colonial subjects.[35] Much later, in the new millennia, controversial studies emerged suggesting a possible link between vaccinations and childhood autism.[36] Although these findings were highly contested, it catalysed opposition to vaccines for children.[37] Furthermore, some conservative religious groups in the United States oppose mandatory vaccinations for sexually transmitted diseases like human papilloma virus (HPV) although they support vaccination on the whole.[38] Muslims generally do not oppose vaccination on religious grounds. Sometimes, ostensibly religious reasons lead communities to decline vaccination but this reflects personal beliefs rather than theological rules.[39]

Vaccination Programmes in Singapore

In Singapore, there is currently a vaccination program in place to inoculate children called the National Childhood Vaccination Program which started in the 1980s. Introduced in stages, it currently vaccinates children against tuberculosis, hepatitis B, pneumococcal, diphtheria, tetanus, poliovirus, measles, mumps, rubella and pertussis.[40] These vaccinations were done at scheduled years during childhood and carried out in primary schools. Vaccination against measles and diphtheria are compulsory by law while the rest are optional. Before the advent of vaccines, disease prevention generally focused on ensuring the cleanliness of public and private spaces to minimise infectious contact.[41] Letters to the press prior to 1947 about the dangers of infectious disease also stressed the importance of controlling the environment such as controlling milk supply rather than prevention through medical intervention.[42]

The benefits of a vaccination program can be seen through the example of tuberculosis immunisation. In 1908, French scientists Albert Calmette and Camille Guerin discovered a tuberculosis vaccine in 1908 and named it ‘bacillus of Calmette and Guerin’, better known by its acronym BCG.[43] The vaccine’s success rate in countries such as Denmark and Russia was very high but doubts arose about its safety when 73 babies in Germany died after being given the vaccine in 1930. It was later found that that culture was contaminated with a highly virulent strain of tuberculosis.[44] Medical authorities for Singapore started examining the feasibility of adopting the vaccine for Singapore in 1947, years after the safety concerns had died down. At the time, the high incidence of tuberculosis was a source of major concern in Malaya and Singapore. The Sultan of Johore had died of the disease in 1895[45] and it was one of the top two causes of death in 1910.[46] The situation abated slightly before the war years but the rate appeared to spike during the Japanese Occupation and tuberculosis was the number one killer in Singapore in 1950.[47] The cost of tuberculosis relief that year exceeded $20000 per month.[48]

The introduction of mass BCG vaccinations in Singapore was received well by the public. The take-up rate for tuberculosis vaccination in Singapore was even higher than that in Britain itself in 1949.[49] By 1969, the disease was on a decline[50] and the number of deaths from T.B only numbered about 450 in 1975.[51] Besides vaccination, improved housing and sanitation also helped the situation.[52] Today, the disease is virtually eradicated here although there was a slight rise in recent years.[53]

The Fatwa Committee issued fatwas on two types of vaccinations with questionable ingredients from the perspective of Islamic law, namely the Meningitis and Rotavirus vaccines. Among Muslims in Singapore, opposition to vaccines because of how they were produced seemed to first arise only in 2002, following a high-profile case in Malaysia. By this time, communities here are largely in favour of vaccination as a means of fighting disease and have supported compulsory vaccination programs. However, in that year, a Malaysian doctor went to the press to point out that the vaccine used for meningitis had “bovine and porcine” elements used during its production.[54] This became a major issue as the Saudi Arabian government had mandated meningitis vaccinations for pilgrims entering the country for the Haj in that same year.[55] Therefore, Haj-bound pilgrims could not avoid it. The Saudi government’s decision was due to concern about the rising number of meningitis cases.

This led to an unintended consequence: a rise in the demand for the vaccine worldwide and closer scrutiny of its ingredients. There were actually two types of meningitis vaccines available: one made from vegetable-based fat (Mercevex) and the other from animal-based fat (Menomune). Government hospitals and clinics in Malaysia generally used a quadrivalent vaccine known as ACYW-135 based on Mercevex while some private clinics in Malaysia opted to vaccinate using the Menomune form when higher worldwide demand reduced stocks of Mercevex.[56] Given the medical need for such a vaccination and the fact that the fats were transformed into a chemical form, the Malaysian Medical Society opined that the Menomune vaccine was halal.[57] This was disputed by Malaysia’s religious authorities later that year when they ruled only the Mercevex version is halal.[58]

This debate in Malaysia, extensively reported in Malay-language newspapers here, appeared to lead to a greater sensitivity to the contents of vaccines. In 2003 and 2013, the Singapore Health Sciences Authority (HSA) asked Muis to rule whether using vaccines derived from small quantities of porcine elements is permissible before rolling out the vaccines to the public.  This seemed to be a pre-emptive move to prevent an uproar similar to what happened in Malaysia. The Meningitis vaccination requirement remains a point of contention: as late as 2010, Indonesia was still protesting the requirement because many available vaccines used porcine enzymes.[59] However, as long as the need for vaccine remains, the ruling outlined in fatwas is still relevant and applicable.

Fatwa Decision 21/10/2003
VACCINES DERIVED FROM PORCINE SOURCES

Question:

What is the ruling on vaccines derived from porcine sources?

Answer:

The Fatwa Committee views that, in principle, treatments with substances containing impurities (najis), namely pork, is allowed in an emergency (ḍarūra) if there are no other drugs that can replace it.

This fatwa, in particular, refers to vaccinations that contain prohibited ingredients, which are deemed permissible only with the condition that there are no other available alternatives that fulfils the same function. This fatwa also applies in cases where halal-certified vaccines run out, and re-stocking would take time. In particular, this fatwa continues to provide guidance for haj and umrah pilgrims, or individual Muslims who need to travel to countries that require vaccination. This is so that they can use whatever available vaccine, without having to wait for halal vaccines to become available in Singapore.

In 2013, the HSA asked the Fatwa Committee about another vaccine called the Rotavirus vaccine, which also contained religiously-prohibited ingredients. Before the development of the Rotavirus vaccine in 1984, rotavirus had killed approximately one million children a year by causing acute diarrhea[60] although no deaths from the virus has ever occurred in Singapore.[61] HAS posed the question in order to respond to queries and to address concerns by Malay-Muslim patients and parents, rather than instituting compulsory enforcement of it. In addition, the Rotavirus vaccine is not among the vaccines recommended by the World Health Organization that is compulsory for children in Singapore.

Fatwa Decision 28/2/2013
THE ROTAVIRUS VACCINE

Question:

What is the ruling for the Rotavirus Vaccine on babies?

Answer:

The Fatwa Committee has received a question from the Health Science Authority (HSA) on the Rotavirus vaccine.
Rotavirus infection can cause vomiting, dehydration, fever, and in some cases, death. At present, the Rotavirus vaccine remains the best way to tackle the disease. Information received from the HSA states that at one stage of manufacturing, enzymes from pig pancreas (trypsin) was used to separate and transfer the cells of the vaccine

Islamic Principles on Medicine and Treatment

Islam strongly encourages each individual to seek treatment for diseases. This is because the preservation of life is among the main objectives of the Sharīʿa (maqāṣid sharīʿa), and seeking treatment fulfills this purpose. There are many hadīths in which the Prophet (ﷺ) encouraged his people to seek cure.

From Usāma bin Sharik, an Arab Bedouin once asked the Prophet (ﷺ):
ياَ رسول الله أَلَا نَتَدَاوَى؟ قال: (تَدَاوَوْا، فَإِنَّ اللهَ لَم يَضَعْ دَاءً إِلاَّ وَضَعَ لَهُ شِفاءً أَو قَالَ دَوَاءً إِلاَّ دَاءً واحداً) قالوا: يا رسول الله وما هو؟ قال: الهرم

O Rasulullah, do we need to seek treatment? The Prophet  said: ‘Seek treatment, because Alllah does not place a disease, except that He placed a cure for it, except one (of which there is no cure).’ They asked: And what is it? The Prophet said: ‘Old age.’”

Taking vaccines serves as a preventive treatment from diseases. A person who wants to prevent himself from contracting a particular disease can be vaccinated before he is infected. Preventive treatment is also highly recommended in Islam. It was narrated from the Prophet (ﷺ):

مَنْ تَصَبَّحَ بِسَبْعِ تَمَرَاتٍ عَجْوَةٍ لَمْ يَضُرَّهُ ذَلِكَ الْيَوْمَ سَمٌّ وَلَا سِحْرٌ

He who eats seven Ajwah dates every morning, will not be harmed by poison and magic on that day.” -Muttafaq Alaihi

Elements of Najis in Medication

In principle, Islamic law prohibits seeking treatment from najis or prohibited sources. However, when there are no halal alternatives and the patient’s life depends on the medication, the Sharīʿa allows for medication with that which is najis or prohibited. Allah s.w.t. says:

 وَقَدْ فَصَّلَ لَكُم مَّا حَرَّمَ عَلَيْكُمْ إِلَّا مَا اضْطُرِرْتُمْ إِلَيْهِ

“… and He has explained in detail to you what He has forbidden upon you, except that to which you are compelled.” (al-An’am: 119)

 

Fatwa Committee Decision

After examining the manufacturing process of the vaccine, the Fatwa Committee found that a solution which contains enzymes from pig pancreas (trypsin) was used to transfer the developed vaccine cells to other instruments. Based on the information received from the HSA, the trypsin solution – for now – is the safest way to ensure that the transfer of cells reach the desired amount. The solution is not used in subsequent processes. The vaccine cells also go through repeated filtration and purification processes to ensure that the final product is free from the trypsin solution.

The Fatwa Committee also notes that the elements derived from pig enzymes in the trypsin solution is very small (0.001%). Based on the concept of istihlāk, the Fatwa Committee views that the miniscule amount of najis element was mixed with large amount of pure elements. The trypsin solution is thus regarded as pure because it goes through the dissolution process by being added to other pure ingredients. The dissolution process by addition is known in Islamic jurisprudence as istihlāk bi al- Mukāthara.

In addition, the official information obtained by the Fatwa Committee from the HSA also indicates that ingredients derived from pig enzymes (trypsin solution) are not contained in the rotavirus vaccine. This enzyme is in fact used as a tool to transfer the vaccine cells, and these cells will be cleansed several times. These processes show that the pork enzyme is not contained in the vaccine. The resultant vaccine also undergoes filtering, cleansing and purifying processes repeatedly until no element of the pig enzyme is left in the final product. Based on these considerations, the Fatwa Committee is of the opinion that the Rotavirus vaccine is halal and pure, as there are no elements of najis in it.

Concepts of Istiḥāla and Istihlāk

In contrast to the 2003 fatwa, the focus of the fatwa on Rotavirus above was not to address the dire need for such vaccine, but to shed more light on the ingredients and contents of the vaccine itself. As part of the research which the Committee conducted, the technical information that was provided by the health authorities was closely studied, especially the manufacturing process of the vaccine.

The Committee learnt that the impure substance (najis) was dissolved as a result of several levels of filtration and purification of the vaccine. Hence the istihlāk (decomposition) method was applied for the content of the vaccination to be considered pure and halal. The issue of whether taking an immunisation is a necessity which reaches the level of an emergency no longer arises, because it is already classified as pure through the process of istihlāk al-tām (full decomposition). The issue of whether taking an immunisation is a necessity which reaches the level of an emergency no longer arises, because it is already classified as pure through the process of istihlāk al-tām (full decomposition). Thus, even in non-emergency situations, such vaccination can be used.

The concept of istihlāk is further refined in another fatwa ruling on the drug heparin (see fatwa below) which contains a prohibited substance in its production. Heparin is an anticoagulant. It is not a vaccine but a medication given to patients suffering from cardiovascular diseases and only in critical condition. The key ingredient in heparin that dilutes blood is glycosaminoglycan. The base material in processing heparin is taken directly from animal sources, usually from bovine liver or pig intestines. [62]Bovine heparin was withdrawn from the market due to worries that it could be contaminated with bovine spongiform encephalopathy (mad cow disease).

Just like the fatwa ruling on the Rotavirus vaccine, a detailed study was carried out on heparin, including obtaining clinical information from medical experts on the production process of the drug and its use in treatment. Two main points that the Fatwa Committee considered in their discussions were (1) the level of necessity and emergency which requires urgent administration of the medication, and (2) its production process.

For the first consideration, the administration of the drug is used in an emergency situation to avoid blood from clotting. This will save lives and prevent harm on a patient suffering from heart or kidney diseases.

Although such dire circumstances call for the administration of heparin, the Fatwa Committee considered other aspects in its deliberations, specifically on the non-halal ingredient in the product, as there are several types of heparin drugs available in the market. While animal enzymes were used as a starting material in heparin production, the drug is later mixed with other ingredients. This differed from the Rotavirus vaccine in which the impure elements were only used in the early stages as a method to transfer the vaccine cells, and not as one of the key ingredient, after which, the vaccine is filtered until no traces of the impure substance is left in the final product.

Clinical tests on heparin conclude that most types do not have any trace of animal cells in the final product, although a small number of samples still contain a small residue of animal content. The fatwa ruled that the drugs have been through the process of istihlāk bi al-Mukāthara (dilution), which means that the impure content had dissolved despite being present in the early stages of production. From this ruling, there is a noticeable development in fatwa thinking, specifically in relation to the use of impure substances in medicines. The fatwa takes into consideration the needs of patients, in addition to the level of scrutiny, in both the manufacturing process and in the end product. This development in fatwa thinking is important, as the pharmaceuticals market is expected to grow rapidly as medical research becomes increasingly diversified.

Fatwa Decision 27/10/2015
FATWA ON DRUG HEPARIN

Background

  1. The Fatwa Committee received a question from the Health Sciences Authority (HSA) and the National University Hospital (NUH) Heart Centre on 23 July 2015 on using heparin for treating Muslim patients. The Fatwa Committee was informed that heparin is a drug used to reduce or prevent blood clots. It is commonly used for patients undergoing treatments such as dialysis, heart surgery and blood transfusion. The drug is also effective in preventing complications that might occur after heart attacks.1
  2. Among the main ingredients of heparin is a substance that prevents blood coagulation. This ingredient is glycosaminoglycan. The information shared with the Fatwa Committee shows that glycosaminoglycan is derived from pig enzymes and is taken directly from pig intestines. The question posed to the Fatwa Committee is whether the use of heparin is allowed on Muslim patients, as all heparin drugs in Singapore contain ingredient derived from pig enzymes.2

Source of Heparin

  1. There are essentially two main sources for producing heparin. It can be derived from either animal enzymes or synthetic chemicals.3
  2. Heparin produced from animal enzymes is either derived from the liver of bovines, or from the inner surface of pig intestines. However, due to the mad cow virus that spread around the 1990s, companies which produce heparin no longer source it from bovine enzymes. To ensure patient safety, heparin is produced only from pig intestines.

Seeking Treatment with Pure Substance

  1. Islam commands its followers to seek treatment with elements that are pure, and to avoid the prohibited and unclean. In a hadīth narrated by ’Abū al-Dardā’, the Prophet (ﷺ) said:

    إِنَّ اللَّهَ أَنْزَلَ الدَّاءَ وَالدَّوَاءَ ، وَجَعَلَ لِكُلِّ دَاءٍ دَوَاءً ، فَتَدَاوَوْا وَلَا تَدَاوَوْا بِحَرَامٍ

    Verily Allah has sent down illnesses and cures. And He has made (available) a cure for every illness. So seek treatment, but do not treat with what is prohibited.” (Hadīth narrated by Abū Dāud)

  2. Imām al-Bukhārī also narrated in his ahīh from Ibn Mas‘ūd as follows:

    إنَّ اللَّهَ لَمْ يَجْعَلْ شِفَاءَ أُمَّتِي فِيمَا حَرَّمَ عَلَيْهَا
     “Allah does not make a cure for my people from what He made forbidden on them.” Narrated by al-Bukhārī

  3. In the 2013 fatwa on Rotavirus vaccine, the Fatwa Committee stated that the Sharīʿa principally prohibits someone from seeking treatment from najis or prohibited sources. However, when no other halal alternatives are available, and the patient’s life depends on the treatment, then the Sharīʿa allows treatment with substances that are najis or prohibited

Drug Production and Najis Element

  1. The information shared with the Fatwa Committee stated that heparin is derived from pig intestines in various stages of extraction,4 so that the resulting heparin is safe for medical use. At the same time, heparin is also mixed with other substances such as liquid sodium.
  1. Several laboratory tests on the drug found no traces of porcine DNA in low-concentration heparin. However high-concentration heparin was found to contain very low traces of porcine DNA.
  1. The Fatwa Committee is of the opinion that the process of istihlak5 has occurred on low-concentration heparin. Since the product has undergone a dilution process through which other pure ingredients are added to it, it no longer contains any trace of porcine DNA. As such, it is considered pure and permitted to be used as a treatment.
  1. As for high-concentration heparin with traces of najis, the Fatwa Committee examined a number of Sharīʿa texts to determine its ruling. For example, in a hadīthnarrated by Imām al-Bukhārī, the Prophet (ﷺ) himself prescribed camel urine as a remedy for illness. The hadīth states: “That a group of eight people from `Ukl came to the Prophet (ﷺ) and pledged allegiance to him. But the climate of Medina made them fall sick, so they complained to the Messenger of Allah (ﷺ) and he said to them: “Why don’t you go with our herdsman to his camel, and get its milk and urine…(Hadīth narrated by al-Bukhārī and Muslim).
  1. In addition to the hadīth above, the Prophet (ﷺ) also allowed the use of non-najis yet originally prohibited elements as treatment. For example, Prophet (ﷺ) allowed ‘Abd Raḥmān Ibn ‘Auf and al-Zubair al-‘Awām r.a. to wear silk due to a disease they were suffering from, which provides the analogy for using najis in emergencies.6 The Prophet (ﷺ) also permitted Arfajah ibn Asad r.a. to put on a nose made of gold because of necessity.7
  1. The Fatwa Committee believes these evidences demonstrate that if there is a need,8 then high-concentration heparin is allowed as treatment for certain patients.

Decision

  1. Based on the evidences and arguments set out above, the Fatwa Committee views that low-concentration heparin derived from pig enzymes is permitted, as it has gone through a process of istihlāk which completely eliminates all traces of najis. As for high-concentration heparin, the Fatwa Committee also views that it is permitted when certain patients require it, in order to avoid danger and harm. This is based on the verse of the Qur’an:

وَلَا تُلْقُوا بِأَيْدِيكُمْ إِلَى التَّهْلُكَةِ وَأَحْسِنُوا إِنَّ اللَّهَ يُحِبُّ الْمُحْسِنِينَ
 “Do not throw [yourselves] with your [own] hands into destruction. And do good; indeed, Allah loves the doers of good.” (al-Baqara:195)

Source:
Some other health complications that can be managed and prevented through heparin includes DVT and pulmonary embolism.

Some porcine-sourced heparin brands commonly used in Singapore are Clexane, Tinzoparin and Fraxiparin.
3 Synthetically-produced heparin does not contain animal enzymes. However, it is not safe for some patients, especially those suffering from chronic kidney disease.
4 Heparin production involves several stages to remove an essence from pig intestines, and later processed to remove heparin from the essence, before finally filtered to isolate heparin from other elements.
5 Istihlāk: The term istihlāk is derived from the Arabic phrase (هلك) which means: destoyed. Therefore, istihlāk refers to a process of destruction. In this context, it refers to the destruction or elimination of najis substances. There are several processes for eliminating najis, a common example given by fuqahā’ is by mixing a drop of liquor to large quantities of water (istihlāk bi al-Mukathāra). Istihlāk means mixing a small amount of prohibited or najis substance with a large amount of pure and halal substance, until the characteristics of the prohibited substances (such as its colour, odor and taste) are eliminated. This transforms the characteristics of najis, therefore changing the najis status of the substance according to Sharīʿa. See: az-Zuhaily, Qaḍāyā al-Mu‘aira, Damascus:Dar al-Fikr, 1428H/2007, p.72.
6 Narrated by al-Bukhārī and Muslim.
7 Narrated by al-Tirmīdhī, Abu Dāwud and al-Nasā’ī.
8 Based on information provided by the health officer, high-concentration heparin is needed by certain patients immediately after surgery, in which physicians need to make sure there is no blood clotting. Low-concentration heparin was found to be inadequate to meet these needs.

Issues of Modesty (aurat) in Seeking Treatment

Apart from discussions on the halal status of ingredients in medicines, other issues that were discussed by the Fatwa Committee on health matters include aurat (modesty) between patients and those who treat them. A fatwa issued in 1984 concerns surgery to restore a part of female genitalia. Although revealing the aurat is prohibited, the text of the fatwa explains that there are other equally important considerations, such as the purpose of a surgery and its level of emergency.

The hymen and virginity is regarded as important in many societies. From the religious standpoint, it is vital to protect the genitalia from illegal sexual intercourse, known as zina. It is one of the basic laws of Sharīʿa to safeguard the dignity of Muslims and preserve lineage. This is based on the verse in surah al-Muʾminūn:

وَالَّذِينَ هُمْ لِفُرُوجِهِمْ حَافِظُونَ ۝  إِلَّا عَلَىٰ أَزْوَاجِهِمْ أَوْ مَا مَلَكَتْ أَيْمَانُهُمْ فَإِنَّهُمْ غَيْرُ مَلُومِينَ ۝ فَمَنِ ابْتَغَىٰ وَرَاءَ ذَ‌ٰلِكَ فَأُولَـٰئِكَ هُمُ الْعَادُونَ
And they who guard their private parts; except from their wives or those their right hands posses, for indeed, they will not be blamed. But whoever seeks beyond that, then those are the transgressors.” (al-Mu’minūn: 5-7)

Generally, the physical aspect of virginity is being emphasised through the good structure of the hymen. This has led to social stigma against many prospective brides and their families, who are embarrassed by torn hymen although this could have been caused by natural and non-illicit causes. So much so, that in some societies, bleeding during intercourse is taken as an important proof of virginity.[63]

Hymen surgery is known by various names, such as hymen repair, hymen reconstruction, hymenoplasty or devirgination.[64] In most cases, these are aesthetic surgeries to repair or recreate the hymen, which is what the fatwa below refers to. If there is confirmation from a qualified medical expert that such a procedure is required, only then is the surgery deemed as an emergency. Otherwise, hymen surgery is not permitted.

The position of the Fatwa Committee on hymen restoration also shows how, despite customs and social norms being a basis of Islamic law, they can – at times – also be modified by Islamic law. This is especially so if the custom is not consistently practised or if it is impractical and can lead to harm. As such the fatwa states that it is not a religious obligation to restore the hymen to prove virginity, especially since there is no medical urgency. This signals that the practice of proving virginity through the hymen should not persist, not only because it can lead to suspicion among newlyweds, but also because it can have a negative effect on the couple’s relationship and their families. This is one example when a fatwa may subtly change the norms and customs of society.

Fatwa Decision 23/8/1984
RULING ON HYMEN RECONSTRUCTION SURGERY

Question:

Can a woman go for hymen reconstruction surgery?

Answer:1

Ustaz Ahmad Sonhadji views that the ruling on the matter may be based on the following hadīths:

إِنَّمَا الأَعْمَالُ بِالنِّيَّاتِ 
 “Verily, actions depend upon intentions.” Narrated by al-Bukhārī

إِذَا لَمْ تَسْتَحِ فَاصْنَع مَا شِئْتَ
If you do not feel shame, then do as you please.” Narrated by al-Bukhārī

Because this action involves elements of deception, and also the exposure of aurat without any needs recognised by the Sharīʿa, it is thus deemed prohibited.

The doctors who perform the surgery is also involved in enjoining the prohibited, because it is unlawful to get involved in anything forbidden.

Source:
1 Even though this is based on the opinion of Ustaz Ahmad Sonhadji, it obtained the agreement and consensus of other Fatwa Committee members and therefore became a fatwa. This is because each fatwa has to be issued on a collective agreement and based on a unanimous decision by the Fatwa Committee members. If no consensus is reached, then a fatwa cannot be issued.

A consequential rule to this fatwa is that since the purpose of hymen restoration is not religiously accepted, the woman is not allowed to expose her aurat to foreign (i.e. non-mahram) men for the surgery. However, in situations where a life is endangered or where a medical need establishes itself, it is not prohibited for a person to seek treatment from a non-mahram doctor or nurse of the opposite gender.[65] This exception is clear from the Islamic principle that acknowledges the “needs recognised by the Sharīʿa, which is a condition clearly stated in the fatwa above. This is especially as hospitals or treatment centres, in addition to administering medical needs, do not necessarily have enough staff of the same gender to attend to any particular patient.

When weighing the harm of exposing one’s aurat to a non-mahram for treatment, and the harm of avoiding treatment that may make a condition life-threatening, then the preservation of life is prioritised. This is interpreted from the fiqh maxim that deals with the weighing of different types of harm as mentioned above.

Euthanasia and Advanced Medical Directives (AMD)

Active euthanasia is prohibited by law in Singapore but the choice on whether to prolong or curtail treatment that could artificially support life remained at a patient’s and his family’s discretion. Accordingly, apart from the discussing the need for treatment, the Fatwa Committee had also looked into the issue of whether a Muslim could choose to avoid treatment. This issue revolves around the Advanced Medical Directive (AMD) bill proposed by the government.[66]

The law allowing AMD in Singapore was introduced in late 1995.[67] It was initially proposed as a ‘living will’ but was later passed as First Directive.[68] The AMD is a bill in which a patient declares to the doctor that he does not wish to subscribe to life-prolonging treatments, especially for critical illnesses with little or no chance of recovery. It was approved after the National Medical Ethics Committee (NMEC), a body appointed to study the matter for a year, published its 21-page report. The NMEC had consulted various groups and religious representatives in Singapore. In these discussions, it received the feedback from more than twenty religious and professional groups. Fourteen of the groups supported the recommendation to adopt the proposed legislation, while seven others disagreed.[69] The NMEC concluded that in order to pass the bill, doubts surrounding the intention of the patient should be clarified before he is in a coma and unable to communicate.[70]

In Singapore, the directive can only be done by those who are of sound mind, aged 21 years and above. Two witnesses, including the doctor treating the patient, must be present when the order is signed. The witnesses must also be honest and not be beneficiaries (i.e. do not stand to gain any benefits upon the patient’s death).

The availability of such directives is necessitated by rapid technological advances that prolong life without actually treating the patient. One example would be the use of a ventilator, which takes over the body’s natural respiratory system.[71] The AMD is different from euthanasia; patients invoke the AMD to withdraw from prolonged treatment while euthanasia accelerates a patient’s death. Also, the AMD is legally allowed in Singapore while euthanasia is not.

There are many groups, especially religious bodies, that continue to have concerns about the AMD. Even some Members of Parliament were concerned that if the law was passed, it might cause patients to give up and stop their treatment.[72] Groups that opposed the AMD include the Catholic Medical Association, the National Council of Churches and the Family Council. Some fear that the bill will pave the way for allowing euthanasia as AMD is considered as a form of “passive euthanasia”.[73] The bill was finally passed in December 1995 after it was debated in Parliament.[74] It should also be noted that the law does not make the AMD compulsory.

Although the debate often focuses on legislative issues, some groups view that the recommendation to allow the living will is associated with economic motives. Hospital costs have increased since the 1980s, and caring for patients with respiratory support equipment require substantial financial resources.[75] For example, the National Council of Churches of Singapore, in voicing their opinion on the bill, stated that they are aware that the recommendation for the AMD was first voiced in Parliament in the debate on the affordability of health care. However, the NMEC Chairman, Dr. Chew Chin Hin, clarified that the AMD is not motivated by economic motives, and stressed that cost is not a determining factor in making a diagnosis on a patient, whether he is suffering from terminal illness or not.[76]

Among the Malay-Muslim community, there were great efforts to publicise the fatwa permitting the AMD in 1994. This fatwa was issued by the Fatwa Committee before the bill was passed. There were also at least three articles published in the Malay newspaper that explained the position of the Fatwa Committee. Among others, it stated that the AMD is allowed but not compulsory. The explanation also pointed out that if a patient wants to persevere and face death naturally without relying on breathing apparatus, he should be allowed to do so.[77] In other Muslim countries, the principles of these rulings were discussed by the Islamic Fiqh Academy in Mecca in 1987.

As the law does not make the AMD obligatory, not many Singaporeans took up this option. Only 650 people made the AMD in 1999, most of whom were in good health.[78] Ten years after the law was introduced, this number increased to 2,645. Furthermore, with the improvement of hospice care in Singapore, many people do not see the need to make the “Will of Life”.[79] This trend changed when the case of Terri Schiavo received worldwide coverage. A year after the Schiavo case, the number of those who made the AMD in Singapore rose sharply; 1,328 people signed up in that year, bringing the total number of Singaporeans who registered for the AMD to almost 4,000 people in 2006.[80] click here to see the case of Terri Schiavo.

Health Minister at the time, Mr Khaw Boon Wan, announced that the government would focus on providing more information on living wills to the public over the next five years in order to facilitate their decision-making.[81] This effort included encouraging doctors to discuss the option more openly with their patients so that they have a more thorough understanding on the AMD. The government will also create a portal for patients to write their AMDs online.[82]

Fatwa Decision 20/9/1994
ADVANCED MEDICAL DIRECTIVE

Question:

The National Medical Ethics Committee (NMEC) proposed a law whereby each Singaporean is given the right to make advance medical directive in their own will.

The law will allow the patient to give instructions and allow a doctor to stop treatment should the patient has no more chance to live. The law will also allow an individual who is above 21 years of age and is mentally stable to draft a will anytime.

The will can only be executed when an individual is so ill that he ‘has no chance to live or the only chance of survival is via a life-support system’. What is the Committee’s opinion on this matter?

Answer:

The Committee is of the opinion that if a person has made a conscious decision not to be attached to a life-support system when he is terminally ill – then the Islamic position is that this is permissible. It can be considered that he has chosen to be patient and allow himself to die naturally because he is confident that one will eventually die when his time has come.

This is allowed because the majority of Islamic scholars have agreed that the Islamic position on seeking medical help is not compulsory although Islam highly encourages it. This is based on a hadīth narrated by Bukhārī which tells the story of a woman who has fallen ill and asked Prophet Muhammad (ﷺ) to pray for her. The Prophet then told her:

إن شئت صبرت ولك الجنة، وإن شئت دعوت الله أن يعافيك”  فقالت : أصبر
If you are patient, the reward that awaits you is heaven. Or if you would rather I pray to Allah for your recovery.” The women then replied: “In that case then I would want to be patient.1

 

Furthermore, a life-support system serves to act as a human body’s organ, not to alleviate the illness of the patient, especially when the patient is terminally ill. However, we are thankful that in NMEC’s proposal, normal treatment will still be carried out for the patient.

Medical ethics stipulates that all possible efforts to cure, including the use of a life-support system to continue the life of a patient, should be observed.  The Fatwa Commitee is of the opinion that the life-support system can be detached from the patient only if the patient is in a coma and the machine serves no other functions for him. However, this is applicable only under the following conditions:

If three doctors certify that the patient has no more hope to live. When a differing opinion arises, then the matter should be brought to the attention of an independent committee of experts as suggested by NMEC.

The same matter has been debated by the Islamic Fiqh Academy in its convention in Mecca on 17 October 1987, whereby three decisions were made:

It is permissible to detach the life-support system from the patient, even though his heart is still functioning with the help of the machine, if three doctors certify that he is brain-dead and the condition is irreversible.2

As mentioned in the proposal papers of NMEC, euthanasia or “mercy killing” is illegal in Singapore, as much as it is also prohibited in Islam.

As the advance medical directive is a new initiative, we also suggest that NMEC ensures that there is no abuse. We also support the fact that the directive is only effective if it is made willingly or by choice.

Source:
Fatḥ al-Bārī Bi al-Syarḥ aḥīḥ al-Bukhārī. 5220. addition:
‏ألا أريك امرأة من أهل الجنة قلت بلى قال هذه ‏ ‏المرأةالسوداء ‏ ‏أتت النبي ‏ ‏صلى الله عليه وسلم ‏ ‏فقالت إني أصرع وإني أتكشف فادعالله لي قال ‏ ‏إن شئت صبرت ولك الجنة وإن شئت دعوت الله أن يعافيك فقالت أصبرفقالت إني أتكشف فادع الله لي أن لا أتكشف فدعا لها
http://hadith.al-islam.com/Display/Display.asp?Doc=0&Rec=8448
2 Refer to Majallah Al-Majma‘ al-Fiqh al-Islāmīy Li Muktamar al-Fiqh al-Islāmīy al-‘Adad al-Thalith. 1987. Vol.2, 767.

Seeking Treatment in Islam

In deliberating the AMD issue and whether a medical treatment should persist, the focus is on the Islamic principle of preserving life. Islam gives great emphasis on the protection of life, as evident in the verses of the Qur’an and hadīths of the Prophet (ﷺ). In the surah al-Isrā’, Allah s.w.t. mentions the elevated status of humankind:

وَلَقَدْ كَرَّمْنَا بَنِي آدَمَ وَحَمَلْنَاهُمْ فِي الْبَرِّ وَالْبَحْرِ وَرَزَقْنَاهُم مِّنَ الطَّيِّبَاتِ وَفَضَّلْنَاهُمْ عَلَىٰ كَثِيرٍ مِّمَّنْ خَلَقْنَا تَفْضِيلًا

 “And We have certainly honoured the children of Adam and carried them on the land and sea and provided for them of the good things and preferred them over much of what We have created, with [definite] preference.” (al-Isrāʾ: 70)

There are also restrictions against hurting oneself and engaging in acts that put someone in danger. This is based on the following verse:

وَأَنفِقُوا فِي سَبِيلِ اللَّهِ وَلَا تُلْقُوا بِأَيْدِيكُمْ إِلَى التَّهْلُكَةِ ۛوَأَحْسِنُوا ۛ إِنَّ اللَّهَ يُحِبُّ الْمُحْسِنِينَ

 “And spend in the way of Allah and do not throw [yourselves] with your [own] hands into destruction. And do good; indeed, Allah loves the doers of good.” (al-Baqara: 195)

Islam recognises the preservation of life and the well-being of the physical body. This is based on the following verse:

 وَلَا تَقْتُلُوا أَنفُسَكُمْ ۚ إِنَّ اللَّهَ كَانَ بِكُمْ رَحِيمًا
And do not kill yourselves [or one another]. Indeed, Allah is to you ever Merciful.”  (an-Nisā’:29)

The ruling also includes the prohibition against suicide. This is due to the dignity of human life, and the right of Allah s.w.t. – who commands its protection – that supersedes a human’s right to end his/her own life.

Here, the main consideration in deciding whether AMD is permissible is whether it is mandatory to seek treatment from a religious viewpoint. The religious opinion in seeking treatment for a Muslim patient suffering from terminal illness – with no hope of recovery – is guided by the dominant view among jurists that it is not mandatory. The religious opinion in seeking treatment for a Muslim patient suffering from terminal illness – with no hope of recovery – is guided by the dominant view among jurists that it is not mandatory.

The basis for this is found in a hadīth of Ibn ‘Abbās mentioned in the fatwa. The woman mentioned in the narration was reported to have been suffering from ṣarāʿ or epilepsy. As its cure was unknown at the time, this would be analogous to someone suffering from a terminal illness. This interpretation is also a form of conciluation (al-jam’u) between this hadith and others that encourage seeking treatment, such as that narrated by Bukhārī and Muslim:

ما ورد عن النبيِّ صلى الله عليه وسلم حين قال :  ما أنزلَ اللهُ مِنْ داءٍ إلا أنزلَ لَهُ شِفاءً
Verily Allah has not sent down an illness, except that (He also) sends down a cure for it.

The hadīth emphasises that Allah s.w.t. makes a cure available for any diseases, and encourages Muslims to seek treatment. Yet, this must be accompanied by the understanding that medical development occurs in stages, and the ability of the human mind to know is limited, as mentioned in surah al-Isrā’:

وَمَا أُوتِيتُم مِّنَ الْعِلْمِ إِلَّا قَلِيلًا
And humankind have not been given of knowledge except a little.” al-Isrā’:85)

Therefore, the fatwa ruled that euthanasia – be it by a patient deliberately committing an action such as taking poison, or asking someone else to commit an action leading to his death – is prohibited. This prohibition includes actions committed by the patient himself, or by a doctor with or without the patient’s request.

Meanwhile, the living will or the Advanced Medical Directive is not the same as euthanasia, as the patient chooses not to seek treatment in a situation that recovery is unlikely, and instead chooses to surrender completely to the will of Allah s.w.t. Various fatwas on the use of modern treatment to prolong a patient’s life were also issued by other fatwa bodies much after that issued in Singapore.

  • The Dār al-Iftāʾ in Egypt issued a fatwa on 3 January 2006, which states that:
    It is permitted, with the advice of a physician, to disconnect the medical ventilator from a patient who has no hope of recovery, when the machine is used to prolong his life without treating his health. However if the machine is used for other purposes, such as removing fluid to help the patient’s breathing, then it is not allowed (to disconnect the machine).[83]
  • The Jordanian Fatwa Council issued a fatwa on 11 October 2006, which states:
    The Council believes that there is no Sharīʿa prohibition for not using a medical ventilator or dialysis machine, if a group of physicians believe that it has no benefit (medically) to be gained from its use. This is provided that the decision is made by three physicians, at the very least, who are competent, fair, and credible. This is based on the principle that the use of these devices do not bring benefits in removing the disease, and that the death of a person cannot be delayed or accelerated.[84]
  • The National Fatwa Council of Malaysia issued a fatwa during its session held in December 2011 on the removal of the medical ventilator. The Council decided:
    [I]n cases where physicians have decided that a patient has no hope of recovery and is allowed to be sent home, then stopping the main treatment and only continuing with palliative treatment is allowed in Islam, as it does not fall within the prohibited practice of euthanasia or mercy killing. However if the treatment/life support system is used for other purposes such as removing fluid to facilitate breathing, then disconnecting/stopping it is not allowed.[85]

While permitting the removal of the life support system, the additional condition in this fatwa – that the device should not be used for other purposes that aid the patient – is similar to the Egyptian Dār al-Iftāʾ fatwa.

  • The Permanent Committee for Islamic Research and Fatwa in Saudi Arabia also ruled on the use of resuscitation equipment during cardiac arrest, or when the heart stops, in patients suffering from diseases with no hope of recovery. The Committee decided the following:
    It is permitted to use resuscitation equipment if the patient could recover. However, if the patient’s heart can only function when using the equipment, and ceases to function without it, then it is better not to use it because the patient is actually lifeless.[86]

Kidney Dialysis

Apart from issues concerning the permissibility of medical treatments, there are also questions on the effects of a treatment on acts of worship. This relates to kidney dialysis and its effects on fasting.

Fatwa Decision 13/2/2001
KIDNEY DIALYSIS IN DAY TIME RAMADAN

Question:

On 7 December 2000, Berita Harian published a Saudi Arabian fatwa that says kidney dialysis nullifies fasting in Ramadan. The reason given was that dialysis removes impurities in blood, and after cleaning and mixing it with chemicals and nutrition, the blood is then pumped back into the patient. What is the opinion of the Fatwa Committee on this matter?

Answer:

After its deliberation, the Fatwa Committee noted that dialysis is a process that removes impurities in blood and replaces it with cleansed blood into the patient’s body through the kidney dialysis machine.

Before dialysis, kidney patients will usually feel weak and frail. This treatment will steadily improve the health of kidney patients for several days until they undergo another dialysis treatment.

The Fatwa Committee also considered the use of injection needle in the month of Ramadan among the contemporary issues not discussed in detail by ‘ulama of the past. Evaluated from the medical standpoint, the injection needle which is inserted into a patient is divided into two types:

  1. Injection that contains no nutrition, and
  2. Injection that contains nutrition

An injection into the bloodstream that contains no nutrition does not invalidate the fast, because these injections do not contain nourishment that reaches the stomach.

However, for injections that contains nutrition, there is a difference of opinion (khilāf) among the ‘ulamā:

  1. The injection invalidates the fast
  2. The injection does not invalidate the fast

Those who hold the view that the injection breaks the fast reasoned that nutrition directly goes into the bloodstream.

Those who hold the opposing view – that the injection does not break the fast – argued that fasting is invalidated by putting something into the body through its open orifices, such as the mouth, ears, and nose, which then reaches the stomach and causes a person to feel full. They viewed that these injections merely entered the bloodstream and do not directly reach the stomach.

Having examined the different views of the ‘ulamā and their arguments, the Fatwa Committee is of the opinion that injections containing nutrition in the month of Ramadan do not invalidate the fast. However, as a precautionary measure (الِاحْتِيَاط) especially for kidney patients, dialysis should be delayed until after sunset. If it cannot be delayed, and the patient still intends to fast, then his fast is not invalidated by the dialysis as long as it does not cause harm. If the dialysis is harmful because of the fast, then breaking the fast or not fasting is better than enduring harm.

In considering this ruling, the Fatwa Committee consulted the opinion of jurists on the types of injections that break a fast. This study also required an accurate understanding of the dialysis process and its effects. In selecting the strongest opinion given the circumstances of the problem (tarjih), the Fatwa Committee adopted the view that accommodates the needs of a patient who cannot undergo dialysis at night. The Fatwa Committee also took into consideration patients who cannot suspend treatment throughout Ramadan. At the same time, the fatwa also contains advice and guidance for Muslim patients: that if fasting during dialysis causes harm, then harm should be removed, and therefore the patient should not fast.

Smoking

Smoking is defined as the practice of inhaling smoke obtained from burning a stimulant or hallucinogen. It has been a common practice since ancient times, as seen in temple carvings and old manuscripts from ancient Egypt, Greece, Babylon, India, China and the Peruvian Andes which depict people smoking. Often associated with religious ritual in the past in civilizations such as the Maya, the Aztecs and the Chinese, smoking probably originated from the burning of incense, later adopted for pleasure. Hallucinogens were  also used to achieve trances or to contact the spirit world. Their central role in the ancient Aztec religion is symbolized by the goddess Cihuacoahuatl whose body was made of tobacco.[87]

There are many different substances and methods of smoking. The most common today is tobacco but prior to the 19th century, many people from various parts of the world smoked opium and cannabis legally. These substances were also considered to have medicinal properties as they dulled pain. The ancient Chinese, for instance, used cannabis as a panacea for rheumatic pain, intestinal complication and malaria, while Assyrians used it in treatments for impotence and kidney stones.[88]

Opium was widely used in Asia up to the twentieth century, particularly among the poor, although it had an adverse health effect. Both cannabis and opium are illegal in many countries today, partly because these substances caused many social and economic problems. This leaves tobacco as a legal and most widely used substance being used today.

The main active ingredient in tobacco is nicotine. Its genus, nicotiana, most likely originated from South America and was named after Jean Nicot, the consul of the King of France in the 17th century who brought the plant over to Europe.[89] French scientists later developed methods of extracting pure nicotine from the tobacco plant and experimented to find out its properties.[90] Early scientific investigation of its properties showed that pure nicotine was highly toxic and would be lethal if ingested even in small amount. However, diluted nicotine could be incorporated into products like snuff, chew, cigar and later, cigarettes where inhalation of the smoke produced when burned has comparatively less severe physiological impact. Click here for further reading on tobacco and culture.

 Science and health risks of smoking

The twentieth century – which had seen the rise of widespread smoking in the form of cigarettes – also generated scientific interest and research on this practice. Such research, however, were sometimes commissioned by the big tobacco companies themselves and this compromised the integrity of their results. For example, up to the 1940s, doctors in the United States routinely appeared in cigarette advertisements attesting to the safety of these products.[91] However, in the 1940s, scientists began seeing a link between cancer and the use of nicotine. By 1959, Alan Rodgman, a scientist working in a research laboratory of R.J Reynolds – a huge tobacco company – reported that cigarette smoke contains polycyclic aromatic hydrocarbons that can cause cancer.[92]  In response, the tobacco companies also funded research aimed at reducing the amount of carcinogens in their products and sought to suppress public knowledge of these health concerns, each competitively advertising that their products were safer.

However, more and more research emerged showing the adverse effect smoking had on health. The tide against smoking turned with the discovery that passive smoke can cause lung cancer, thus putting non-smokers at risk.[93] This meant that the issue went beyond personal choice but impacted public health. Furthermore, there emerged more scientific evidence about the addictive nature of nicotine.[94] Prolonged nicotine consumption could change the circuitry of the brain and nervous system to make it dependent on this product.[95] This element of addiction called to question the idea that smokers could stop any time they wanted to, and highlighted the similarity of cigarettes to banned substances such as opium and cannabis. Such information became public knowledge in a series of highly public trials of cigarette companies, particularly from the mid-1990s.[96]

Today, there is much greater regulation on smoking. Cigarettes are still freely available in countries around the world but many countries now mandate that cigarette packages carry a health advisory and ban smoking from certain public places such as restaurants in order to reduce public exposure to passive smoke.

Smoking in Singapore

In Singapore, efforts to stamp out smoking paralleled global trends. Opium and cannabis are banned. From 1950, when there was a record number of opium seizures from smugglers caught trying to bring the substance into the country,[97] Singapore generally enforced a tight ban on these drugs. Cigarettes are legal, both in the past and today. Public disapproval of the practice became evident fairly early, with letters decrying smoking appearing in the Singapore press as early as 1950, when the deleterious health effect of smoking was only beginning to be publicized.[98] However, the key message then was to smoke in moderation, with some doctors claiming “ten cigarettes a day are without any ill effect for an average adult.” [99]

Since then, there was a gradual movement to ban smoking in public places. It was first banned in buses, cinemas and theatres in 1970. This was followed by a ban on smoking in public indoor locations such as malls in 1977. Smoking was also banned from mass rapid transit (MRT) trains since its inception in 1987 due to fears of fire.

The space for smokers was further restricted in 2005 when cigarettes were banned in bus interchanges and bus stops, as well as public toilets and swimming complexes. This extended to coffeeshops, hawker centres, entertainment nightspots, night clubs (except in pre-defined smoking areas), children’s playgrounds, exercise areas, markets, ferry terminals and jetties, offices and lift lobbies when bans were imposed successively from 2006 to 2009.

Smokers also found their freedom to smoke in their own neighbourhoods curtailed when the ban was extended to linkways, corridors, stairwells and multi-purpose halls in 2013, although this proved difficult to enforce especially during wakes and funerals. Those found flouting these rules faced a minimum fine of $200. In addition, cigarette packs in Singapore carried mandatory health warnings and, from 2004, graphic pictures of diseased organs.[100]

The discourse in the media about smoking highlighted deep divisions among proponents of the freedom to smoke and those who wished to see smoking banned completely. With the institution of each successive regulation or restriction, letters protesting such a move or reports of business owners unhappy with these rules appeared in the local press. Nightspot owners in particular found these rules onerous and bad for their business. On the other side, many non-smokers in Singapore supported the bans, to the extent that some groups set up an online Tobacco-Free Singapore campaign in 2010, which sought to prevent the sale of tobacco to millennials and thus, stamp out the practice completely.

Among Malay Muslims, this issue was also equally divisive. Some Muslims sought advice about it from a religious perspective through the Malay press, and the general response to these questions throughout the 1970s and 1980s was that smoking was not haram or forbidden although it is makruh or practice that was highly disapproved of and better to abstain from. If the habit resulted in fatal disease, continuing the habit could also be haram. Such a stance was not agreed on by all schools of Muslim thought.

In 1993, Pertapis, a Muslim charitable organization in Singapore, issued a stand stating that the smoking was haram according to the Shafi’i school of law. This meant that the act of smoking is considered as sinful as that of consuming pork or liquor.[101] This hardline stance caught the attention of the English press and led to more debate about the Islamic ruling on smoking. Some Muslims pointed out that the accepted rule on smoking here was that it was makruh, and that even religious leaders in the Malay Muslim community smoke regularly. Haji Abu Bakar Hashim, then-president of Singapore Religious Teachers Association (Pergas) and President of Sharīʿa Court tended to side with the Muis stand but emphasized that the ruling depended on situation and could be haram for habitual smokers who endangered their health but makruh for social smokers.[102] There were also calls in the Malay press for clarification and a unified stand on the issue.[103]

Globally, there also exist similar disputes about this issue in the Muslim world. In 1995, Malaysia’s opposition Islamic party Parti Islam SeMalaysia (PAS) also issued a similarly hardline opinion against smoking. In 1994,Shaikh Yūsuf al-Qaraḍāwī opined that it was haram to smoke if it can be proven that smoking slowly kills.[104] Mosques in Singapore also began to enforce informal bans on the practice in their compounds. There were suggestions mooted to create a smoking zone in mosques, however, this was not implemented as the existence of such a zone could be interpreted as condoning the practice.[105]

Although a common consensus is lacking about precisely how strongly Islam discouraged smoking, there was a general agreement that the practice was bad for health, in accordance with all the emerging scientific evidences. When the Singapore government tightened the bans on public smoking, there were a few renewed calls by Muslims for a fatwa to ban the practice.[106] However, education appeared to be the method of choice for Malay Muslims to tackle the problem, with regular campaigns against smoking as well as celebrities and leaders setting the example by publicly giving up smoking.[107]

Fatwa Deliberations Regarding Smoking

Fatwa Decision 13/9/1993
RULING ON SMOKING

Question:

The Fatwa Committee has been asked to explain the ruling on smoking. The issue was raised after a news article appeared in The New Paper, in which Pertapis was reported to have said that smoking is prohibited. The report also mentioned that smoking is a sin, similar to other sinful acts such as eating pork and drinking alcohol.

Answer:

After discussion, the meeting agreed with the opinion that generally, smoking is discouraged (makruh). If smoking is verified to cause harm to an individual, then it is prohibited for him. Also as there are evidences on the harm of smoking, then it should be avoided, in line with the Islamic legal maxim meaning “avoiding harm is prioritised over obtaining benefit”.

 

Fatwa Decision 20/4/2006
FATWA ON SMOKING

Question:
What is the opinion of the Fatwa Committee on smoking?

Answer:
Fatwa Committee agrees that smoking is prohibited because the harm on the smoker and the people around him is clear and definite.

In deliberating the ruling on smoking, the principle of rejecting harm is observed. There is also a gradual and incremental approach in the fatwa positions (described as al-tadarruj fī al-taṭbīq al-Ḥukm), as the fatwa on smoking changed from makruh to being forbidden. In the period between the two fatwas, the content of cigarettes did not change. The only difference is the medical and scientific information available on the dangers of smoking, studies that proved the negative effects of smoking, as well as tighter regulations. Greater awareness on the danger of smoking can be cited as a reason why it was ruled as forbidden.

This goes back to the aforementioned incremental or gradual application of Islamic law (tadarruj) in the ruling, which was an approach taken by Prophet Muhammad (ﷺ) and his companions in the history of Islamic law. An example is the prohibition of liquor at the time of Prophet Muhammad (ﷺ). The first revelation in this context proclaims its sinfulness despite recognising there are benefits associated with it. However, there was no explicit prohibition on liquor in this verse of the surah al-Baqara:

  ۗيَسْأَلُونَكَ عَنِ الْخَمْرِ وَالْمَيْسِرِ ۖ قُلْ فِيهِمَا إِثْمٌ كَبِيرٌ وَمَنَافِعُ لِلنَّاسِ وَإِثْمُهُمَا أَكْبَرُ مِن نَّفْعِهِمَا
They ask you about wine and gambling. Say, “In them is great sin and [yet, some] benefit for people. But their sin is greater than their benefit…” (al-Baqara:219)

It was reported that liquor was still consumed after the revelation of this verse until a companion of the Prophet led a Maghrib prayer and recited the verses of the Qur’an in the wrong order. Following this, the following verse in surah al-Nisā’ was revealed:

يَا أَيُّهَا الَّذِينَ آمَنُوا لَا تَقْرَبُوا الصَّلَاةَ وَأَنتُمْ سُكَارَىٰ حَتَّىٰ تَعْلَمُوا مَا تَقُولُونَ
O you who have believed, do not approach prayer while you are intoxicated until you know what you are saying.”  (an-Nisā’:43)

Later, a clear pronouncement that completely prohibited liquor was revealed in the surah al-Māʾida:

يَا أَيُّهَا الَّذِينَ آمَنُوا إِنَّمَا الْخَمْرُ وَالْمَيْسِرُ وَالْأَنصَابُ وَالْأَزْلَامُ رِجْسٌ مِّنْ عَمَلِ الشَّيْطَانِ فَاجْتَنِبُوهُ لَعَلَّكُمْ تُفْلِحُونَ
O you who have believed, indeed, intoxicants, gambling, [sacrificing on] stone altars [to other than Allah], and divining arrows are but defilement from the work of Satan, so avoid it that you may be successful.”  (al-Mā’ida:90)

Conclusion

In conclusion, the main deciding factors for the use of prohibited substances in medication are: key ingredients, production process of these ingredients, benefits and effects of the medicine, and the availability of alternatives. The same considerations are applied for medication containing ingredients from alcohol and animals, as have been previously elaborated.

It is also important to note that preserving life is one of the objectives of the Islamic Sharīʿa (maqāṣid al-sharīʿa) which needs to be observed at all times. In circumstances that can result in great harm, this principle should take precedence. This must be also be seen together with the Islamic teaching that encourages the seeking of treatment.

 


  1. Hadīth narrated by Abū Dāwūd, 4: 217; al-Shawkānī, Nayl al-Awṭār, 9: 93.
  2. In the chapter on Organ Transplant and Donation, the concept of emergency (ḍarūra) was discussed in a narrow scope, i.e. treatment through organ transplants. This chapter meanwhile discusses the concept in more general terms.
  3. Waḥba Al-Zuhailī, Naẓariyya al-Ḍarūra al-Sharīʿa (Beirut: Muassasah Risalah, 1979), 73.
  4. Al-Qaraḍāwī, The Lawful and the Prohibited In Islam, 46.
  5. Hadīth narrated by Ibn Mājah, Kitāb al-Aḥkām, Bab Man Banā Fī Haqqihi, No. 2332.
  6. Jalāl al-Dīn Al-Ṣuyūṭī, al-Ashbāh wa al-Naẓāir fī Qawāʿid wa Furūʿ al-Shāfiʿiyya, (Dar as-salam, 1998), Vol. 1, 214.
  7. Al-ʿIzz Ibn ʿAbd al-Salām, Qawāʿid al-Ahkām fī Masālih al-Anām, Vol. 1, 84.
  8. Kamali, Principles of Islamic Jurisprudence, 344-347.
  9. Ibid.
  10. Yūsuf al-Qaraḍāwī, The Lawful and the Prohibited in Islam (Malaysia: Islamic Book Trust, 2013), 75.
  11. Ibid.
  12. Ṣaḥīḥ Muslim, No. 2003.
  13. USDA, (2015) "Organic Production/Organic Food: Information Access Tools," Alternative Farming Systems Information Center. United States Department of Agriculture National Agricultural Library. Available online at http://www.nal.usda.gov/afsic/pubs/ofp.ofp.shtml. Accessed 23 July 2015.
  14. "Alcohol therapy: medicinal drinking through the ages," BBC News. Accessed on 23 July, 2015, http://www.bbc.com/news/health-25712005
  15. Caroline J. Acker and Sarah W. Tracy (eds.), Altering American Consciousness: The History of Alcohol and Drug Use in the United States, 1800-2000 (Amherst, Mass.: University of Massachusetts Press, 2004), 3-5.
  16. Ibid.
  17. "Alcohol as Medicine." Malayan Saturday Post, June 1925, 17.
  18. Singapore health authorities do not provide a list of medicines that contain alcohol. The US Food and Drug Administration has a list of which can be found at http://pubs.niaaa.nih.gov/publications/Medicine/medicine.htm. Retrieved on July 24, 2015.
  19. Refer to Tuḥfa al-Aḥwāzi Sharh Jāmiʿ al-Tirmīdhī, 244.
  20. Gottschlich M.M., “Fat-Soluble Vitamins and Wound Healing”, in Molnar, J.A. ed. Nutrition and Wound Healing, (Boca Raton: CRC Press; 2007), 156.
  21. Kathi C. Madison,"Barrier Function of the Skin: "La Raison d'Etre of the Epidermis," Journal of Investigative Dermatology, (2003) 231-238. A brief explanation on skin functions can also be found in the following article: "Only skin-deep," The Straits Times, November 2004, 7.
  22. “Covers dead, burnt skin,” The New Paper, October 2000.
  23. See “Malay Disfigured for Life,” The Straits Times, January 1934; “Farzana’s boyfriend was once burnt too,” The Straits Times, November 2000; “SGH discharges Bali blast victims”, Today, October 2003.  
  24. "Burns Unit opens at General Hospital," The Straits Times, February 1959, 4 and "Unique skin farm set up in SGH to grow grafts for burn victims," The Straits Times, March 1991, 3.
  25. "Doctors plan a 'human tissues' bank," The Straits Times, February 1963, 11.
  26. See “Developing Natural Skin,” The Straits Times, January 1982 and “Aussies Claim Skin Success,” The Straits Times, June 1990 which explained several alternatives to the regular grafting treatment.
  27. "Skin can be grown at 'farm' and grafted onto burn patients," The Straits Times, February 1992, 19.
  28. "Life-saving skin farm," The Straits Times, February 1994, 15.
  29. Heinrich W, Lange PM, Stirtz T, Iancu C, Heidemann E. Isolation and characterization of the large cyanogen bromide peptides from the alpha1- and alpha2-chains of pig skin collagen. FEBS Letters, 1971;16(1):63–67.
  30. "The Soul Barrier," The Singapore Free Press, December 1960, 4. There is also extensive scientific research on organ transplant rejection.
  31. Al-Nawawi, Sahih Muslim, (Cairo: Dar al-Salam, 1996), Kitāb al-Zakāh, hadīth No. 1015.
  32. Derrick Baxby, “Edward Jenner’s Inquiry: A Bicentenary Analysis,” Vaccine, 17:4, (1999) pp. 301-7. See also Ian Bailey, “Edward Jenner (1749-1823); naturalist, scientist, country doctor, benefactor to mankind.” Journal of Medical Biography 4:1, (1996), pp. 63-70
  33. See for instance, Tuija Kekarainen, Laura Martinez-Guino and Joaquin Segales, “Swine Torque teno virus detection in pig commercial vaccines, enzymes for laboratory use and human drugs containing components of porcine origin.” Journal of General Virology, 90:3, (2008), pp. 648-53.
  34. For the history of vaccination in British Malaya, see Lenore Manderson, Sickness and the State: Health and Illness in Colonial Malaya, 1870-1940, Cambridge University Press (2002).
  35. For more about indigenous resistance to vaccination in British colonies, see Atsuko Naono, “Inoculators, the Indigenous Obstacle to Vaccination in Colonial Burma” Journal of Burma Studies,Vol. 14, (2010), pp. 91-114 and David Arnold (1993), Colonizing the Body: State Medicine and Epidemic Disease in Nineteenth Century India, (Berkeley, CA: University of California Press),
  36. See Hileman, Bette, “Vaccines and Autism”, Chemical and Engineering News, 82:8, 2004 and Jan Poling, “Vaccines and Autism Revisited” The New England Journal of Medicine, 359:6, 2008.
  37. See Michael S.W Lee, Mike Male, “Against Medical Advice: The Anti-Consumption of Vaccines” The Journal of Consumer Marketing, 28:7, pp. 484-490.
  38. Sprigg P “Pro-family, pro vaccines but keep it voluntary”, Washington Post, 15 July 2006.
  39. John D. Grabenstein, “What World Religions Teach, Applied to Vaccines and Immune Globulins” Vaccine, 31:6, 2013.
  40. Details about the program and schedule for vaccination can be found at Health Promotion Board (2013) "Immunization for Primary School." Health Promotion Board Singapore. Available online at http://www.hpb.gov.sg/HOPPortal/health-article/630. Accessed on July 20, 2015.
  41. For more information see Manderson (2002), Sickness and the State.
  42. See among others, "Communication of Disease," Eastern Daily Mail and Straits Morning Advertiser. 18 April 1906, p. 2; "Sanitation of Singapore," The Straits Times, 12 June 1907; "Milk Supply Scandals," The Straits Times, 15 September 1908, p. 7.
  43. "BCG - Tuberculosis Defence," The Straits Times, 8 April 1947, p. 6
  44. Ibid.
  45. "The Sultan of Johore," Mid-Day Herald, 2 July 1895, p. 2. and "Details on the death of the Sultan of Johore," The Straits Times, 2 July 1895.
  46. "Tuberculous Disease," The Singapore Free Press and Mercantile Advertiser, 15 July 1910, p. 8.
  47. "T.B still No. 1 killer in Singapore." The Straits Times, 17 January 1950, p. 4
  48. "T.B relief bill 000 a month," The Straits Times, 14 January 1950
  49. "S'pore leads Britain in BCG work," The Straits Times, 9 January 1950, p. 3.
  50. "Many infectious TB cases still in Singapore," The Straits Times, 21 January 1969, p. 6.
  51. "Better housing tends TB a beating," The Straits Times, 17 March 1975, p. 5.
  52. Ibid.
  53. "T.B cases on the rise here." Today, 23 March 2009, p. 4.
  54. ‘Suntikan vaksin sebelum kerjakan haji didakwa kandungi lemak babi’ Berita Harian, 16 June 2002.
  55. Ibid.
  56. ‘Vaksin Jemaah Haji, unmrah disahkan halal’, Berita Harian, 23 June 2002
  57. ‘Ubat pelali dari lemak babi dibenarkan’ Berita Harian, 14 October 2002.
  58. ‘Fatwa: Hanya suntikan vaksin ACYW 135 yang dibolehkan untuk jemaah’ Berita Harian, 1 December 2002.
  59. “Indonesian clerics ask Saudi to drop Hajj vaccine” Al-Arabiya news. (online). Available: http://www.alarabiya.net/articles/2009/06/08/75297.html. Accessed 20 May 2015.
  60. ‘New vaccine can fight virus that causes diarrhea deaths’, The Straits Times, 12 November 1984 and ‘Rotavirus punca utama cirit birit serius di kalangan kanak-kanak’, Berita Harian, 30 March 2003
  61. ‘No ordinary diarrhea’ The Straits Times, 25 June 2009
  62. Robert J. Lindhart, et al, “Production and Chemical Processing of Low Molecular Weight Heparin” in Seminars in Thrombosis and Hemostasis (1999), Vol. 25, 5-16.
  63. See Ruzy Suliza Hashim, “Meniti duri dan ranjau: Pembikinan gender dan seksualiti dalam konteks dunia Melayu [Exploring a thorny issue: The creation of gender and sexuality in the Malay world]”, Sari, (2006), Vol. 24,15-34.
  64. Ahmadi A., “Ethical issues in hymenoplasty: Views from Tehran's physicians”, J Med Ethics, (2014), Vol.  40, 429–430 
  65. Among the fatwa bodies issuing similar view is Dar al-Ifta, Egypt in 2008. http://www.dar-alifta.org/ViewFatwa.aspx?ID=366&LangID=5&MuftiType=2 . Accessed on 26 October 2016.
  66. More information can be obtained from https://www.moh.gov.sg/content/moh_web/home/legislation/legislation_and_guidelines/advance_medical_directiveact.html.
  67. “Living wills law to be introduced later this year,” The Straits Times, July 1995.
  68. “Wasiat Hayat tukar jadi Arahan Awal, [Living will changed to Advance Medical Directive]” Berita Harian, December 1994.
  69. “Living wills law to be introduced later this year,” The Straits Times, July 1995.
  70. “Law needed to clarify doubts,” The Straits Times, July 1995. Also see “When a patient is dying and unable to speak, family members get very emotional. It is difficult to make the decision not to take heroic measures. A directive will help them,” The New Paper, 28.
  71. Singapore follows the life-sustaining treatment policy of the United States Uniform Rights of the Terminally Ill Act. See “Living wills law to be introduced later this year,” The Straits Times, July 1995.
  72. “MP fears seriously ill may lose hope and see easy way out,” The Straits Times, August 1995.
  73. “Clearing the air on advance medical directives,” The Straits Times, June 1997.
  74. “Advanced directive Bill up for scrutiny,” The Straits Times, December 1995.
  75. “Health - focus shifts from cost to ethics,” The Straits Times, March 1995.
  76. “Clearing the air on advance medical directives,” The Straits Times, June 1997.
  77. See “Harus sebab mudahkan pesakit nazak temui ajal [Permitted because it enables terminal patient to die],” Berita Harian, September 1994. “Fatwa kaitan wasiat hayat [Fatwa on living will],” Berita Harian, September 1994. “Wasiat Hayat tukar jadi Arahan Awal [Living will changed to Advance Medical Directive],” Berita Harian, September 1994.
  78. “The Advanced Medical Directive,” The New Paper, February 1999.
  79. “Quality Hospice Care,” The Straits Times, April 1999 and “Dying patients can turn to hospice care,” The Straits Times, April  2001.
  80. “Nearly 4000 had signed living wills,” The Straits Times, March  2006.
  81. “MOH to focus on living wills for the next five years,” The Straits Times, October 2006.
  82. “Living Wills to be made easier,” The Straits Times, October 2008, 35.
  83. http://www.dar-alifta.org/ViewFatwa.aspx?ID=405&LangID=1
  84. http://www.aliftaa.jo.Decision.aspx?DecisionID=119
  85. http://www.e-fatwa.gov.my/fatwa-kebangsaan/hukum-eutanasia-atau-mercy-killing    
  86. Fatāwā al-lajna al-dāima, al-majmū‘a al-ūlā, 25: 71-78, Fatwa no. 8926.
  87. Francis Robiscek, "Ritual Smoking in Central America," in Smoke: A Global History of Smoking, ed. Sander Gilman and Zhou Xun (London: Reaktion Books, 2004), 33-35.
  88. Antonio Waldo Zuardi, "History of cannabis as a medicine: a review," Rev Bras Psiquiatr 2nd ed., (2006), Vol. 28,153-157.
  89. Allan Brandt, The Cigarette Century (New York: Basic Books, 2007), 20.
  90. Hewitt Grenville Fletcher Jr. "The History of Nicotine," in Journal of Chemical Education (1941), 303-307.
  91. Brandt, The Cigarette Century, 201.
  92. Ralph Nader, "Perspective on the Tobacco Settlement: Marlboro Man Still in the Saddle," Los Angeles Times, November 1998.
  93. Joaquin Barnoya dan Stanton A. Glantz "Cardiovascular effect of secondhand smoke nearly as large as smoking," in Circulation (2005), Vol. 111,2684-2598 and P. Brennan, P.A Buffler et al. "Secondhand smoke exposure in adulthood and risk of lung cancer among never smokers: a pooled analysis of two large studies," in International Journal of Cancer, (2004), Vol. 109,125-131.
  94. Neal L. Benowitz, "Pharmacologic aspects of cigarette smoking and nicotine addiction," The New England Journal of Medicine (1988), 1318-1330.
  95. Ibid., 1319-20.
  96. Brandt, "The trials of Big Tobacco," in The Cigarette Century, (2007), 401- 445.
  97. "Record number of opium seizures in Singapore," The Straits Times, October 1950, 9 and "Opium runner hard hit", The Singapore Free Press, June 1950, 7.
  98. "The smokers," The Straits Times, May 1950, 9.
  99. "Warning to the Lovers of Lady Nicotine," The Singapore Free Press, February 1950, 2.
  100. Information on smoking policies in Singapore can be obtained from the Ministry of Environment and Water Resources (Singapore) “Public Health Policies: Smoking Ban.” Government of Singapore. http://mewr.gov.sg. Accessed on 4 September 2015. See also “Going smoke free: a step forward,” National Environment Agency of Singapore (2014). http://www.nea.gov.sg. Accessed on 4 September 2015.
  101. “Smoking sinful for Muslims,” The New Paper, September 1993, 12.
  102. Ibid.
  103. “Benarkah rokok haram [Is smoking really haram]?” Berita Harian, September 1993, 7. See also “Merokok: Hukum masih dikaburi asap [Smoking: Ruling still clouded by smoke].” Berita Harian, November 1993.
  104. “Ulama: Merokok bahaya [Ulama: Smoking is dangerous],” Berita Harian, November 1994.
  105. “Akan datang: sudut khas bagi perokok di masjid [Coming soon: Smokers’ corner in mosques]?” Berita Harian, April 2000, 6 and “Saran dibatal ura-ura [Suggestion to cancel proposal],” Berita Harian, April 2000, 27 and “Patut susahkan bukan mudahkan [Should make it harder not easier],” Berita Harian, May 2000, 7.
  106. “Syor haram merokok [Recommend to prohibit smoking],” Berita Harian, July 13, 2001, 16.
  107. “Tidak wajar biarkan Muis saja tangani isu [Not right to let MuiS tackle issue alone],” Berita Harian, August 2006, 35 and “Kesedaran harus dipupuk melalui didikan Islamiah [Awareness should be fostered through Islamic education],” Berita Harian, October 2006, 26 dan “Apabila Imam setuju berhenti merokok [When Imam agrees to quit smoking],” Berita Harian, June 2007.

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