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Aligning Medical and Muslim Morality: An Islamic Bioethical Approach to Applying and Rationing Life Sustaining Ventilators in the COVID-19 Pandemic Era

In: Journal of Islamic Ethics
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  • 1 Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
  • | 2 Centre for the Study of Islam in the UK, School of History, Archaeology and Religion, Cardiff University, Cardiff, UK
  • | 3 British Board of Scholars and Imams, Dundee, Scotland, UK
Open Access

Abstract

The COVID-19 pandemic has spurred policymakers and religious leaders to revisit age-old questions about the ethics of pandemic control, the just allocation of scarce resources, and preparing for death. We add to these conversations by discussing the use of mechanical ventilation for COVID-19 patients. Specifically, we address the following: For Muslim patients/families when is it permissible to forgo mechanical ventilation? For Muslim clinicians, what circumstances justify the withholding or withdrawing of mechanical ventilation from patients? And for policymakers, is there an Islamically-justifiable rubric for allocating mechanical ventilation to patients in times of scarcity? Our Islamic bioethical analyses connect biostatistical data and social contexts with ethico-legal constructs to bridge the epistemic theories of biomedicine and the Islamic legal tradition. They reveal that forgoing mechanical ventilation is permissible for Muslims, that there are several conditions that allow for Muslim clinicians to justify withholding and withdrawing mechanical ventilation, and also several policy rubrics for ventilator allocation that would be justifiable.

Abstract

The COVID-19 pandemic has spurred policymakers and religious leaders to revisit age-old questions about the ethics of pandemic control, the just allocation of scarce resources, and preparing for death. We add to these conversations by discussing the use of mechanical ventilation for COVID-19 patients. Specifically, we address the following: For Muslim patients/families when is it permissible to forgo mechanical ventilation? For Muslim clinicians, what circumstances justify the withholding or withdrawing of mechanical ventilation from patients? And for policymakers, is there an Islamically-justifiable rubric for allocating mechanical ventilation to patients in times of scarcity? Our Islamic bioethical analyses connect biostatistical data and social contexts with ethico-legal constructs to bridge the epistemic theories of biomedicine and the Islamic legal tradition. They reveal that forgoing mechanical ventilation is permissible for Muslims, that there are several conditions that allow for Muslim clinicians to justify withholding and withdrawing mechanical ventilation, and also several policy rubrics for ventilator allocation that would be justifiable.

1 Introduction

Shortly after the year 2020 was rung in, the COVID-19 virus spread beyond China to become a global health issue. Months on, the prevailing questions occupying political minds and healthcare leaders are largely the same: What is the best way to keep disease rates low? How do we allocate and manage available healthcare resources? How do we safely allow people to work, learn, worship and play? Different socioeconomic and political contexts have spurred diverse responses to these questions, and in turn the health and economic burdens of the disease vary considerably across national boundaries (Macon-Cooney et al. 2020; Center for Systems Science and Engineering 2020). This paper presents a normative Islamic perspective1 on the use of mechanical ventilation upon COVID-19 patients at different registers. At the micro-level, we deliberate on the moral position of forgoing artificial ventilation and related COVID-19 therapies from the perspective of Muslim patients, providers and policymakers. At the meso-level, we connect biostatistical data and social considerations with Islamic ethico-legal constructs thus joining the epistemic theories of biomedicine and the Islamic legal tradition. We contend that such fusion is critical for the developing field of Islamic bioethics. Lastly, we comment on the wider-macro issues the example of forgoing ventilation and related therapies raises with regards to the craft of fatwā-making and deliberations of Islamic legists.

The special volume on Islamic Ethics of Pandemics and COVID-19 of which this article is a part, gathers pieces on the pandemic from normative-Islamic, as well as social-Muslim, perspectives.2 It attempts to bring theory and practice into dialogue, and in so doing illuminate meta-ethical and practical ethics frameworks. Such work is timely as there have been multitudes of fatwās and juridical opinions related to the pandemic authored by Islamic authorities around the globe (BMA 2020; Nuffield Council on Bioethics 2020; al-Khaṭīb 2020; Saleh and Ghaly 2020; AMJA Resident Fatwa Committee 2020b; BBSI 2020b; BinṬāhir 2020; al-ʿAnqāwī 2020). At times religious scholars have gone at it alone (Shabbir 2020), but more commonly Islamic jurists and Muslim clinicians have worked together to justify the shutting of mosques, altering burial practices, and suspending religious obligations such as Friday prayer and even Ramadan fasting (BBSI 2020a; AMJA Resident Fatwa Committee 2020a; IMANA Ethics Committee 2020; ECFR 2020; Maravia 2020; al-Ṣabrī 2020). More recently, engagements have been around whether Muslims should take the COVID-19 vaccines (BBSI 2020c; AMJA Resident Fatwa Committee 2020c; Wifaqul Ulama 2020; Darul Ifta, Darul Qasim 2020), and the implications of these fatwās on the authority structures and fatwā-making (Zulfiqar 2020).

As researchers analyze the Islamic bioethics discourse related to COVID-19, we wager that they will likely disagree about what Muslims ought to do or should have done, debate how Islamic bioethical deliberation was or should have been undertaken, and offer different takes on what Muslim polities did or are doing. Indeed, Islamic theology, according to the muṣawwiba (correctionist) view, tells us that there can be no singular right ‘Islamic’ answer (al-Ghazālī 1993, 347; El Fadl 2003, 66). Additionally, observing social norms in different Muslim lands also leads to the conclusion that there is no unified Muslim practice (Anjum 2007; Geertz 1971). Recognizing this inherent plurality and multiplicity to Islamic/Muslim ethical discourse, we offer an Islamic moral perspective on three practical ethics questions related to COVID-19 and end-of-life care. Moreover, we model an approach to Islamic bioethical deliberation that aligns religious, biomedical, and social information.

Specifically, we will address the following three questions: At the Muslim patient-level, is it morally permissible to forgo mechanical ventilation and associated therapies when stricken with COVID-19? At the Muslim clinician/hospital-level, under what conditions is it morally justified to withhold mechanical ventilation and associated therapies from COVID-19 patients? And at the state policy-level, what is a justifiable rubric by which to allocate mechanical ventilation and associated therapies to patients in times of COVID-19 scarcity? We will address these questions by drawing on Sunnī uṣūl al-fiqh frameworks. References to scriptural sources will be made to clarify concepts rather than to represent different hermeneutical possibilities, and biostatistical data related to mortality risk and therapeutic efficacy will be referenced to nuance ethical arguments.

2 Our Deliberative Approach

Before attempting to answer the aforementioned questions, a few comments about our approach are in order.

2.1 Multilevel Analysis

In scoping out the problem-space it is important to recognize that the COVID-19 pandemic involves a constellation of considerations that bring into relief ethical questions involving the public, patients, clinicians, and policymakers. This constellation involves (i) patient-level clinical care concerns over optimal and effective care for COVID-19 considering a specific patient’s health status and comorbidities, (ii) healthcare system-level considerations about the infrastructure and resources needed to manage disease outbreaks and limit its morbidity and mortality, and (iii) social policy concerns focused on restructuring public spaces and economic programs in response to COVID-19 threat. Considerations at each of these levels are intimately connected to one another. For example, a bedside decision to apply or withhold ventilators is intimately connected to the existing supply of ventilators at a healthcare-system level, and both of these conditions result from policy-level decisions about social distancing and the device manufacture. While this example suggests a unidirectional upstream and downstream flow, in other words ‘higher-level’ societal decisions impact local challenges at the bedside, the reality is more complex. Illustratively, data from at the local level about scant community COVID-19 transmission may lead to the state level policies that remove economic incentives to manufacture ventilators, which may result in clinical decisions about ventilator use. Accordingly, the constellation of concerns is better viewed from a systems perspective with interconnections and multidirectional relationships (Elkins and Gorman 2014). In turn, a normative evaluation of the bioethics of COVID-19 must account for the ways in which the ethical questions at policy, provider, and patient levels relate to one another. Said another way, appropriately addressing questions requires multilevel analyses and a cogent meta-ethical framework that can be applied across the multiple levels.

2.2 Using Biomedical Data to Inform sharʿī Rulings

Employing scientific data (both social and natural) to service Islamic rulings is not to interject modern ‘alien’ epistemologies into sacred law-finding activities, rather it has precedent. For example, in his discussion of embryology through Islamic scriptures and Galenic medicine, Ghaly (2014) maintains that Islamic scholars were aware of, and employed, medical knowledge of the time to arrive at religious verdicts (al-ḥukm al-sharʿī) on abortion. His investigation noted that medieval scholars such as Shihāb al-Dīn al-Qarāfī (d. 684/1285) and Ibn al-Qayyim al-Jawziyya (d. 750/1350), as well as their modern counterparts, mitigated perceived tensions between the truth claims of scripture and of the natural sciences. They did so by either (i) metaphorically interpreting religious texts in order to accommodate medical views, or (ii) giving primacy to the religious sources and underscoring the inherent uncertainty of medical knowledge (Ghaly 2014, 57). The jurists’ deliberations demonstrate that the deliverables of medicine were part and parcel of Islamic rule finding activities. Similar tensions between the natural sciences and scripture is noted by Stearns in his study of the bubonic plague and Islamic scholars’ responses to it (Stearns 2008). Ibn al-Khaṭīb (d. 776/1374) the vizier of Granada and a theologian wrote a scathing response to religious scholars denying contagion on the basis of Prophetic reports. He argued that the Prophetic reports had to succumb to the empirical evidence that proved human transmission of the plague. In contrast, his teacher Ibn Lubb (d. 782/1381) maintained the view extrapolated from Prophetic statements that diseases are not contagious and to believe otherwise was to assign causation to other than God. Again, we see classical scholars striving to incorporate, or alternatively marginalize, the truth claims of biomedicine.

While some classical jurists were able to indifferently disregard biomedical data, we hold that it is no longer tenable to overlook clinical knowledge, biostatistical data, and social scientific understandings when penning religious views on health behaviors or bioethical policy. While this may seem obvious, some scholars advise against relying on medical science for the purpose of a presumed greater good. For example, some contemporary scholars believe that organ transplantation technology is a cultural imposition upon Muslims and must be rejected despite its clinical merits (Ali and Maravia 2020, 8). Moreover, Islamic jurists often advocate that clinical medicine and physicians should defer to scripture and scholarly precedent when defining concepts, e.g. death, that have clinical, social, and religious dimensions (Stodolsky and Kholwadia 2021; Hamdy 2013).

2.3 Resolving Truth Claims by Evaluating Epistemic Certainty

So how is one to navigate between scripture and the natural or social sciences? While there have been tomes dedicated to this topic by classical jurists and theologians, most notably, by al-Ghazālī (d. 505/1111) (tangentially in his Tahāfut al-Falāsifa (2000) and more directly in Qanūn al-Taʾwīl (1993)), Ibn Rushd (d. 595/1198) (in his Faṣl al-Maqāl (1997)) and Ibn Taymiyya (d. 728/1328) (in his Darʾ al-Taʿārud (1991)), these of course made reference to what was considered science at the time – natural philosophy. Though each of these scholars reached different conclusions, the level of precision and certainty of modern science is arguably far beyond what they conceptualised. Thus, making direct reference to their works is a potentially misleading endeavour not germane to our cause. Rather, a more contemporary tie in – founded on the same epistemic principles evinced by these medieval figures – is found in an essay by Kamaluddin Ahmed.3 A basic description of Ahmed’s typology of perceived conflict between the natural or social sciences and scriptural claims and how resolution is to be effected is provided below. At base, any form of knowledge is graded on a hierarchy from apodictic certainty (qaṭʿ) to speculative (wahm). Thereafter, potential conflict is dealt with as follows:

  1. A matter can be purely scientific and one where scripture make no claims. For example, identifying the best form of massage to relieve tension from muscles. Since there is no competition with the Sharīʿa here, empirical findings will be treated as actionable, though probabilistically established, knowledge (ẓann).

  2. Science makes a claim about something and scripture makes a contrasting claim. Both claims are probabilistic (ẓannī) and do not yield certain (yaqīnī) knowledge. For example, knowledge of neurology reveals that emotions are created in the brain whereas Islamic scripture asserts that the heart is the seat of emotions. Ahmad suggests that hermeneutical strategies that harmonize and reconcile between these different truth claims must be employed.

  3. Science makes a claim which contradicts a clear unequivocal scriptural evidence (qaṭʿ/yaqīnī) for example the accounts given by both of the origins of the human species. Ahmed maintains that if science itself accepts that this claim is probabilistic, then scriptural knowledge will take preference. However, if the scientific knowledge is equally certain based on its own methodological principles, then for the likes of al-Ghazālī and Ibn Rushd such conflict is not rationally possible. Both advocate tweaking the truth claims of each science until the contradiction no longer remains (Ahmed 2021, 333–336).4

While Ahmed’s typology does not detail the mechanics of resolving tensions, he asserts (and we agree) that natural and scientific theories can be plotted on the same epistemic gamut employed by Islamic scholars in order to classify sources of knowledge. These include ‘certain knowledge’ (yaqīnī) which yields full confidence in the knowledge imparted. This is followed by ‘highly probable knowledge’ (ghalabat al-ẓann) where the scale is tilted towards confidence but not as strong as ‘certain knowledge’, and ‘probable knowledge’ (ẓann) when the scale is above 50% certitude. Most of Islamic law and Islamic bioethical deliberations operate in the probabilistic zone. The third category is doubt (shakk). This is when the degree of confidence is 50:50 and the scale is not tilted towards any one position. Highly uncertain (wahm or mawhūm) follows suit when the level of confidence is below 50%.

Another way of looking at certainties is that with yaqīn, no alternative view is possible; with ghalabat al-ẓann, alternative views are discounted; with ẓann, alternative views are considered but deemed less likely; with shakk, no judgment is possible (tawaqquf); and wahm can be ignored even in the absence of an alternative view. The implications of this classification of knowledge will become apparent later in the article.

Islamic verdicts on biomedicine often hinge on assessing benefit (maṣlaḥa) and harm (mafsada) inherent to an action; where benefits outweigh harms judgements of ethico-legal permissibility are rendered, and the opposite for when harms outweigh benefits. In our view, however, neither harm nor benefit can be appropriately ascertained and specified without recourse to biomedical data. This melding of biomedical with the Islamic is epistemically valid. Indeed, reasoning exercises within fiqh validate the status of ratiocination, ʿaql, in both deriving values from the scriptural sources, as well as on furnishing views on the ethical in cases where the scriptural texts are not univocal. Similarly, Islamic law’s recognition of human convention, ʿurf, as a source of moral knowledge and as a grounding for ethical practice provides sufficient space for social and natural scientific data to be used in Islamic ethico-legal decision-making (Ahmed 2021). As Ahmed and others (Qureshi and Padela 2016) note a biostatistical approach to harm (ḍarar) and fear (khawf) is a valid form of knowledge accumulation in the Sharīʿa.

2.4 Gaps between Islam and Muslims

Finally, as we lay out our arguments we acknowledge that between the Islamic and Muslim,5 and theory and practice, there are wide gaps. Our ethico-legal analyses requires further nuancing to context before it is implemented by patients, providers, and policymakers confronting the COVID-19 pandemic.

3 Question 1: At the Muslim Patient-Level, Is It Morally Permissible to Forgo Mechanical Ventilation and Associated Therapies When Stricken with COVID-19?

COVID-19 is a viral illness with significant respiratory manifestations. Individuals infected by the disease commonly develop a cough, shortness of breath and fever, and many lose their sense of smell and taste, muscle aches, and diarrhoea. There is a spectrum of disease from no symptoms, to mild common cold-type symptoms, and to overwhelming illness and death (Wu and McGoogan 2020). Critical illness resulting from COVID-19 principally involves individuals struggling to breathe and oxygenate tissues. Given this challenge, the morality of applying mechanical ventilators along with ancillary treatments is a key issue.

To resolve an Islamic perspective on the matter, the first step is to consider the general ethico-legal stance on seeking clinical treatment.6 Classical Sunnī law, as espoused by the prevailing opinions within the four Sunnī schools determine seeking healthcare to be a permitted act (mubāḥ) (Ghaly 2010; Al-Bar 2007). Importantly it is not an obligation, meaning that moral censure is not attributed to the individual who forgoes medical treatment. This view is espoused by scholars such as Ibn Taymiyya and al-Ghazālī, and is recorded within the classical legal works of all four schools (Padela and Qureshi 2017). Detailing the scriptural and legal reasoning undergirding these rulings is beyond the scope of this paper. Suffice it to say, however, that an ontology/theology of illness and cure residing with God as noted in the Qurʾān and ḥadīth, and practices of the early community were reconciled to furnish these views. Contemporary thinkers note that these views must be cautiously implemented given that medical treatment differs greatly today from when these opinions were advanced (Ghaly 2010). Notably, healthcare is much more efficacious today than it was fifty years ago, and most definitely is more effective than it was a millennia ago.

At the same time, some classical scholars, as well as contemporary Islamic authorities, delineate conditions under which seeking medical treatment becomes obligatory. This evaluation turns on the notion of treatment efficacy and life threat. Where therapies are known to remove illness-related harms, meaning that there is certainty (yaqīn) or near certainty (ghalabat al-ẓann) of such, and the harm to be avoided is death, jurists lean towards there being an obligation to obtain that treatment (Padela and Qureshi 2017; Padela and Mohiuddin 2015). Contemporary discussions further expand the zone of obligation. In 1992 the International Islamic Fiqh Academy (OIC-IIFA), an affiliate of the Jeddah based Organization of Islamic Conference (OIC) which includes Sunnī jurists from all four schools of Islamic law as well as Shia jurists, revisited the classical views. In accounting for modern-day treatment efficacy they declared that seeking medical care is obligatory when neglecting treatment may result in (1) the person’s death, (2) loss of an organ or disability, or (3) if the illness is contagious and a harm to others (OIC-IIFA 2000).

These classical and contemporary perspectives are relevant to the ethico-legal status of ventilator assistance for COVID-19 patients as they setup thresholds for making ventilation assistance obligatory. The first threshold condition is whether such assistance is surely life-saving, and second is to consider whether not obtaining treatment harms others.

3.1 Is a Ventilator along with Ancillary Therapies When Applied to COVID-19 Patients Life-Saving?

As noted above, severe COVID-19 disease leads to respiratory problems and for some respiratory failure. In cases of primary respiratory failure there are but a few clinical therapies to stave off death: non-invasive or invasive assisted ventilation. Non-invasive methods involve using machines that deliver positive pressure and oxygen to the lungs to assist with ventilation while the patient is awake. These technologies do not enter the patient’s body cavity, e.g. respiratory tract, and are externally applied. Invasive ventilation, on the other hand, requires the insertion of an apparatus into the oral cavity of a patient (a respiratory tube) so that positive pressure and oxygen can be delivered and requires the patient be unconscious. In common vernacular this latter type is called intubation and being placed on a ‘breathing machine’ Intubation is a risky procedure in that it is not always successful and patients can die from its complications. In the context of COVID-19 it also increases risk of disease transmission to staff involved (Yao et al. 2020; Brown III et al. 2015).

A minority of COVID-19 patients suffer from respiratory failure to such an extent that they need non-invasive or invasive ventilatory assistance, but when they do the prognosis is generally poor. Given that COVID-19 is a novel disease, studies on its natural course and mortality are ongoing. Yet the available global data suggests that less than one half of individuals with COVID-19 who require intubation can be weaned off the therapy and survive to discharge (Ñamendys-Silva 2020). For example, in a clinical case series of approximately 300 COVID-19 patients presented to two hospitals in Manhattan between March and April, 33% of COVID-19 patients required mechanical ventilation, and only 33% were able to be weaned off this therapy and breathe successfully on their own (Goyal et al. 2020). Data from the US state of Georgia echoes these findings with 33% of individuals requiring intubation dying (Auld et al. 2020). A larger case series of over 5700 patients from around New York City revealed that over 20% required mechanical ventilation, of which 25% died and only 3% were discharged alive (Richardson et al. 2020). Many of these studies can be considered ‘incomplete’ in the sense that a large proportion of patients remained on ventilator support at the time of publication without having died or been extubated, hence the full mortality rates remain to be ascertained. Nonetheless international data fills in some gaps as a Chinese case series from Wuhan noted that over 90% of individuals who required mechanical ventilation died (YLiu 2020), while Italian data from Milan and Lombardy found that about a quarter of patients requiring mechanical ventilation died (Zangrillo et al. 2020). It bears mention that these data come from healthcare systems with robust capacity to care for patients in intensive care units and with sufficient mechanical ventilators. Mortality in regions without such technical capacity is expected to be much worse. For our purposes, these data support the idea that mechanical ventilation is not a certain cure; only a minority of patients on whom it is applied survive to discharge and a great number require continued intubation for an unknown and prolonged time period. This latter fact compounds societal resource scarcity and leads to its own health risks.

Consequently, ventilation assistance is life-saving for only a minority of patients. Said another way there is no certainty, and the probability is not high, that intubation will save the life of a COVID-19 patient, either because the respiratory failure does not respond to this therapy or because the illness effects other organs and bodily functions which are unresponsive to remedies. As research continues, we may be able to predict which patients will benefit from invasive ventilation and which will not. However, at present and for all comers, Islamic scholars must grade the therapy as doubtful (mawhūm) to bring about benefit and resolve its moral status accordingly.

3.2 Is Not Being Treated for COVID-19 a Credible Harm to Others?

The threshold set by the OIC-IIFA that the lack of treatment to be a credible harm to others is somewhat difficult to resolve in the context of a COVID-19 patient with respiratory failure. Firstly, there is no known treatment for the disease. Hydroxychloroquine and other purported ‘cures’ have not proven to be effective cures, though some medications may reduce the duration of disease (Geleris et al. 2020; Magagnoli et al. 2020). Given the lack of a clinical cure, the public health focus has been on reducing the transmission of the disease by implementing social distancing measures, masking protocols, and curtailing aspects of public life. In a narrow sense such measures are not cures, but in the context of public health and social medicine, these preventive measures curtail risk of individuals becoming infected.

Secondly, applying the metric of credible harm from a COVID-19 patient with respiratory failure not being treated is difficult. Even if we take the view that public health measures are treatments, these are not readily applicable to the patient with respiratory failure. Certainly, the patient can be masked but social distancing is not appropriate in the clinical environment where the patient is in need of urgent medical treatment. Masking is an effective means of reducing disease transmission and thus can be morally sanctioned. However, the clinical treatments, invasive and non-invasive ventilation, do not prevent harms to others. Rather, these treatments increase the risk of disease transmission to bystanders and clinical professionals. The reason for this increased risk is that COVID-19 spreads primarily through respiratory droplets, and when positive pressure is applied these can be aerosolized and broadcast into the ambient air in the patient’s room. Non-invasive treatments such as continuous positive pressure ventilation (CPAP) continuously aerosolize droplets into the surrounding air, while intubation reduces such transmission since the respiratory circuit is a closed system (the tube in the lungs connects to a machine). Nonetheless, the process of intubation aerosolizes droplets and in so doing attributes disease risk to the personnel involved in the procedure. While the relative risk of disease transmission is modest, it is not negligible and thus a potential harm to treating clinicians and staff (Brewster et al. 2020; Yong and Chen 2020). Forgoing therapy also increases risk to others as respiratory droplets from the infected patient are spread in the community, and airborne as well as fomite transmission may also occur to close contacts. In order to weigh which action conveys greater harm to others, we must also appreciate the time factor. Intubation is generally a short procedure and droplets are contained within the circuit once the patient’s lungs are connected to the machine via an endotracheal tube. However, a patient who is suffering from respiratory failure also does not have long to live as the patient will likely die within minutes or hours if he/she is not provided ventilation support. At death droplet production would cease.

In consideration of the above, a patient with COVID-19 suffering from respiratory failure, is in complex moral conundrum. There is no definitive therapy given that survival is less than 50% even if intubated and placed on a ventilator. Additionally, applying such therapies increases the risk of COVID-19 transmission to healthcare professionals involved with intubation and post-intubation care. At the same time, forgoing therapy conveys risk of transmission of the disease to others and the patient would die. Yet it would seem odd, from an Islamic moral perspective or otherwise, to suggest that all COVID-19 patients with respiratory failure be intubated and quarantined so that disease transmission risk is mitigated. For one intubation and ventilation is not certainly beneficial to the patient and may indeed harm the patient given the risks of ventilator-associated pneumonia, bed sores, and other nosocomial infections that hospitalization in an ICU carries (Koulenti, Tsigou, and Rello 2017; Manley 1978). Secondly there are resource issues to consider. There simply are not enough hospital beds, ventilators, and support staff to make such a policy actionable. We will take up this point in the next section, but it is worth underscoring the connection between the moral evaluation of individual patient care and society-level resources.

Although the moral calculus of risk-benefit is hard to quantify accurately, and is multifactorial, the forgoing suggests that it is morally permissible for a Muslim patient to forgo mechanical ventilation and associated therapies when stricken with COVID-19 because these do not assuredly benefit him or her. Secondary considerations about which state, a non-intubated patient with respiratory failure at home or in the hospital, or an intubated patient in the hospital, is less harming to others is not clear. The data on risk is not readily available, and the category of harms expands beyond biological to encompass social, psychological and ethical harms. We hazard that forgoing treatment would remain permissible because of this ambiguity.7

4 Question 2: Clinician-Level: Under What Conditions (Both Societal and Patient-Level) Is It Morally Justified to Withhold Mechanical Ventilation and Associated Therapies from COVID-19 Patients?

Clinicians have a privileged position in Islamic moral theology as they are charged with preserving one of the overarching objectives of the Sharīʿa: life (nafs). Al-Shāfiʿī (d. 204/820) mentions that there are two professions of people who are indispensable to the community. They are the ʿulamāʾ whose duty extends to the preservation of religion (dīn) and who tend to the spiritual welfare of the community, and physicians who are charged with attending to the community’s physical wellbeing and preserve individual life (cited in al-Bārr and Shamsī-Bāshā 2004). Similarly, ʿIzz al-Dīn ibn ʿAbd al-Salām (d. 660/1262) finds that the practice of medicine and of Islamic law are similar is that they both seek to maximize benefit and reduce harm (cited in al-Bārr and Shamsī-Bāshā 2004, 7). Before answering the question, ‘Under what conditions is it morally justified for clinicians to withhold mechanical ventilation and associated therapies from COVID-19 patients?,’ we preface the answer with some general Islamic principles related to the ethics of a Muslim physician. These broad principles will assist in conceptualizing a nuanced answer.

A Muslim physician is duty-bound to restore health and save lives so long as she remains faithful to the dictates of the Sharīʿa related to her craft. Some of these conditions relate to the doctor’s ability to practice, whilst others relate to how the doctor practices her profession. The most obvious of these is the competency of the doctor to practice medicine. This is adjudicated today by the plethora of certifications and licenses that practicing medicine requires. However, during the Prophet’s era there was no such guild as charlatans, pseudo-physicians and mendicant doctors were prevalent. Thus, it is reported in a ḥadīth that the Prophet said, “Whoever practices medicine without learning is liable” (al-Tirmidhī 1996).

Aside from practicing within her zone of competency to preserve human life, the moral ethos of a physician, at least theologically, requires that she recognize that health and illness are part of God’s sapiential plan. Moreover, she must reflect that a human’s life is ‘owned’ by God and a fair usage policy applies when seeking to restore or enhance human health (al-Bukhārī 1997; Ali 2019). Implicitly then humans do not have the right to forgo living as this life does not belong to them. Hence the preservation of life is an absolute principle which cannot be violated due to secondary attributes (such as age, health, social status etc.). This idea is based on the Qurʾānic verse, “On account of [his deed], We decreed to the Children of Israel that if anyone kills a person – unless in retribution for murder or spreading corruption in the land – it is as if he kills all mankind, while if any saves a life it is as if he saves the lives of all mankind” (Q 5:32).

Another Sharīʿa principle related to the profession of medicine is that of equity, as in a physician will should not privilege one patient over another without valid and justifiable rationale (some of which are discussed below). Finally, the principal duty of physician is to ward off harm and maximize benefit as gleaned from legal maxims such as deflecting harm takes precedence over procuring benefit (darʾ al-mafāsid awlā min jalb al-maṣāliḥ) and a personal harm is tolerated in order to deflect a public harm (yutaḥammal al-ḍarar al-khāṣṣ li-ajl dafʿ al-ḍarar al-ʿāmm) (Ibn Nujaym 1999, 74, 78). One may incorrectly surmise from these legal maxims that Islam is utilitarian in its outlook and that a benefit (maṣlaḥa) driven approach to the Sharīʿa is consequentialist in nature. This is not accurate (Kenney and Moosa 2014).8 Islam is an eclectic blend of deontological moral imperatives (such as the absolute sacredness of life) tempered by consequentialist (maṣlaḥa-oriented) precepts. For example, if two people are competing for the same medical resource and by allocating it to the one who is in dire necessity (certain death without the intervention), the deprived patient experiences excruciating, but not life-threatening, pain, this is to be tolerated as the sanctity of life itself over-rides all other considerations. This is enshrined in the legal maxim, ‘when there is a competition between two harms, the least damaging is to be privileged’ (idhā taʿāraḍa mafsadatān rūʿiya aʿẓamuhumā ḍararan bi-irtikāb akhaffihimā) (Ibn Nujaym 1999, 76; al-Sarīrī 2020)

These are broad principles that the physician must follow. However, beyond these general conditions, are there other ethical norms that the physician needs to abide by? The polymath scholar al-Suyūṭī (d. 911/1505) mentions that if something is not clearly mentioned in scripture, and the language does not accommodate it, one can resort to common practice (ʿurf) to decide on the matter (cited in al-Bārr and Shamsī-Bāshā 2004). By way of example, God says in the Qurʾān that humans are dignified (Q 17:70). However, the actualization of this dignity is not spelled out in the Qurʾān or by Prophetic practice. Hence it is left largely to the society to decide how dignity is to be defined (Butt 2019, 40; Raḥmānī 2010, 48). Based on this principle, Rabīʿ b. Sulaymān (d. 270/870) quotes al-Shāfiʿī saying,

If someone asks another to let his blood, or to circumcise his son, or to treat his horse, as a result of which loss occurred then the situation is as follows: if the person did what is done by the people in the trade in such circumstances which is considered beneficial then