Bioethics and Organ Transplantation in a Muslim Society, by Farhat Moazam

Dr. Farhat Moazam, author of Bioethics and Organ Transplantation in a Muslim Society, set out in her fieldwork – consisting of interviews, observations, narratives, and statistical data recovery – to demonstrate how shared beliefs, value systems, and socioeconomic realities informed and framed ethical dilemmas, mediated interactions, relationships, and decision making processes between the patient, family, and medical staff within the busiest transplant institute in Pakistan when the survival of a family member is at stake. This paper will be sectioned off into three parts, the first will examine how Moazam defends her thesis. The second will attempt to explain why she was unsuccessful in discussing, considering, or implementing Islamic metaphysics, bioethics, or other pertinent aspects of Islam in her work. And the third section will be an attempt to prove that Moazam’s underlying concern was with women’s rights and equality in regards to the family decision making process and donor issues. Due to my lack of knowledge in Islamic metaphysics I will be unable to provide vital evidence which could have assisted Moazam in her shortcomings in implementing Islamic metaphysics in her work.

Proving Her Thesis

One socioeconomic reality that has framed the decision making process of the family is poverty. The cost of transportation and all the hospital/clinical/pharmaceutical fees are extremely expensive. Even though most medical facilities are free, the financial worries of transportation, lodging, food, etc. was still an issue. Some families were forced to sell almost all of their possessions in order to make ends meet and be able to stay at the hospital. Family members would even camp out on hospital grounds. Those who are less fortunate cancel the treatment in hopes of finding a donor and leave the hospital because, for them, traveling back home with a sick family member is cheaper then traveling with a dead one.

Another issue is illiteracy and lack of education on the family’s side. This is amplified when little is done by the government and most hospitals to teach the people on such topics as renal transplantation. With the fear of surgery, increased illness, and the like, many people believe the hospitals is where you go to die. And after twenty years of kidney transplants in Pakistan there is still a mystery and misconception with the people in regards to what truly happens at a medical facility. Because of these misconceptions families are reluctant to even step foot in a public hospital let alone donate an organ.

Trustworthiness is also an issue at times, particularly when families first go to private practices. Due to a weak economy, and the primal instinct to survive, a dishonest and deceitful approach from the staff occurs whereby they lie to the family in saying that additional tests are required in order to lure more money from them. The family leaves the practice, financially and emotionally drained with doubts on who they can trust. And when they arrive at the institution it is difficult for the staff to earn their trust, build a relationship and ultimately convince the family to donate, because they have come this far and have been told so many different stories they simply do not know what or who to believe.

Due to the obstacles presented above, and the difficulties of overcoming them, the institution is fortunate to have a staff of individuals with the same shared beliefs and value systems as most of the families who walk into their building. The ability to relate on such a level allows for a relationship to form which would relatively make the conversation of convincing a reluctant family member to donate easier. Although the staff would lie with empty threats of ending dialysis if no donor would volunteer, they would also get emotionally and personally involved with the entire family engaged in seeing their kin receive a kidney. Even though these are seen by many in the medical profession as ethical dilemmas, it could be argued that since the staff is seen as an elder member of the family and thus deserving of respect and adherence, they are intruding and lying in order to help the family. Every staff member believes that there is a common moral obligation from everyone to help the patient.

The staff’s approach towards everyone regardless of economic status and their stubbornness for refusing payment shows their compassion and humanity. With this mind set, a connection can be made of the hopeful movement to lead by example, that giving is essential and perhaps the family members will see, hear, and learn of such a gesture and help out their kin.

What about Islam?

Aside from quoting patients and family members saying inshallah, Alhamdulillah and a few other Islamic terms, Moazam does little to capitalize on these moments which could have opened up a variety of questions in which she could have made a connection to Islamic metaphysics and bioethics.

One example comes from pages thirty one and thirty two, where Moazam provides a brief over view on how (through the Quran, Hadith, Sharia, ijma, qiyas, maslaha, istislah, and istihsan) and why (issues of live and cadaver renal donation) fatawas are formulated and also states that with no equivalence to a central “church” in Islam, there are a multiplicity of views and therefore an array of fatawas which although do carry a considerable amount of influence, are none the less not regarded as legally binding on all Muslims.

Because of the possibly countless number of fatawas as well as the lack of legal authority behind them, one could argue on behalf of Moazam why she did not pursue this issue further. Considering the fact that her field work was to consist within the walls of the institute, thus possibly leaving her no time to interview any “Islamic holy men” – whether they are ulema’s, muftis’, fuqaha’s, etc.  – either outside the institute or within. Nevertheless, the interviews she did conduct with over 100 patients, families, and staff members could have seen some connection, reference, or attention to Islamic metaphysics or bioethics.

On page thirty seven she mentions how the indigenous culture is deeply influenced by Islam. She provides a handful of examples of how the culture affected and influenced the families’ decision making. One of the examples was how the people viewed the doctors as hakims, as God’s medical instruments. The doctors were held with high regard, on a hierarchal status equal to that of the eldest in one’s family, and shown much respect due to their title and knowledge. This level of respect is seen by many families as an Islamic importance and yet little is discussed by Moazam, and no connection is made to any metaphysical significance.

Another example is the importance of family, especially in a country where almost everyone lives together. Therefore, there is no sense of individualism but rather a strong hierarchical, interdependent, traditional and collectivistic group. With this type of mentality, deciding who will donate depends on the entire family and who at that juncture can donate and not be a second liability to the family. Furthermore, the interaction between the family and staff is larger because the doctors will have to deal with the entire family, not just the patient.

With these cultural influences on the family’s decision making and Moazam’s statement of Islamic inspiration on the indigenous culture leads one to believe that if time is dedicated to discuss the cultural importance then that same dedication should be implemented in the root cause of what formed that culture, in this case being Islam. In other words, if the families, patients, and medical staff are making decisions based on their cultural beliefs, and these beliefs were and are structured with the influence of Islam, then these decisions are also based on their Islamic beliefs. And it is here that Moazam falls short of describing or explaining these Islamic influences and making a correlation with metaphysics.

At least through her presentation of Islam, it appears Moazam’s knowledge on the religion was somewhat mediocre. She admits that her education and life experience in Pakistan was uncharacteristic in comparison with the norms of the country – which in regards to education has a great deal of emphasis on Islam and Arabic. She specifically emphasized gender as one of the topics learned but mentioned nothing of Islam.

Although she did attend the University of Virginia to learn bioethics, Arabic, and enhance her knowledge of Muslim History she was already in her 50’s. And she states herself that she began this research at a mature stage of her life (by my calculations she was in her late 50’s early 60’s) with decided views and opinions already set. It has been successfully argued by many psychologists that the older humans become the more difficult it is to change. And perhaps for Moazam it was too late in incorporate Islam – a field she knew relatively little about –  into a field (medicine) in which she has been so dominate in for many decades. That is why, I believe, Moazam had reservations when it came to discussing and addressing Islam.

One example of Moazam’s, either, lack of knowledge or interest in Islam comes on page thirty five when she was discussing the reasons of whether or not to donate cadaver kidneys. She stated: “I suspect that these reasons are complex and multifaceted rather than purely religious in nature.” Of course the possibility of these reasons not being solely religious is very likely, notwithstanding, it is still an integral ingredient in the recipe for discovering the ethical issues of live or cadaver donations as well as other medical concerns. Another example was when she also realized that there are moments when one does not “consider rational ethical principles or philosophical arguments about autonomy and rights”; you just go with your gut when it comes to trying to convince a family member to donate a kidney (101). What about an Islamic approach? This would have been a perfect time to discusses the metaphysical principles or arguments in one’s efforts to convince a family member to donate.

Moazam also offers statistical data that suggests highly educated individuals are more likely to donate than others. She contributes this to their “greater faith in modern science, medicine and technology” (128). One’s greater faith in modern science, medicine, and technology is no different than one’s greater faith in God and Islam. This was also another great opportunity for Moazam to expand on these ideas. The last example comes from page 135 and the story of Tufail and Zarina and how Zarina did not choose to donate her kidney, rather, there were no other option. Moazam states that Zarina “did not mention any religious metaphors or beliefs” when it came to her decision to donate her kidney to her husband. With this example in particular as well as the others mentioned above, one can arrive at two conclusions. Either a) Moazam intentionally and deliberately excluded Islam from her work, which would be difficult to believe given her genuine acknowledgments to the religion. Or, what I believe to be the case, b) on a more unconscious level she overlooked this issue and became more and more fascinated with women’s rights.

Women’s Rights

Although she never clearly explains what specific issues she will or will not be discussing, enough evidence shows that her main area of concern is not bioethics but a focus on women’s rights as the ‘other’ potential victim, as Moazam puts it, in regards to being coerced to donate or presented as a “willing” possible donor. She states how the patriarchy of the family sometimes forces the female members to donate. In particular, the single females are more prone to donate and end up with some degree of difficulty in getting married. The females according to Moazam are “helpless in the androcentric Pakistani culture and open to coercion when a family member needed a kidney” (108). These females were also considered as “victims” and therefore needed the protection of the hospital staff in this case it was Dr. Fatima and Ms. Azra.

Dr. Fatima looked after the married women and Ms. Azra watched out for the single women because for them there was a great deal of difficulty in getting married due to misconceptions about the aftermaths of donating. Between the two of them (and Dr. Badar) as the gate keepers, as Moazam calls them, the women are definitely looked after and protected from their male counterparts. 

Moazam narrates a very interesting story of Fehmida and how Moazam’s distress for her as a woman trapped by cultural norms and Moazam’s commitment as a researcher not to contaminate her data by influencing events in the field leads one to a sense of curiosity as to when exactly this observation took place during her fieldwork and to what extent – if any – did it have an influence in the way she conducted her research from then on. It seems as if this story could have had an influence on Moazam in regards to her focus on gender equality and not Islamic bioethics or metaphysics. It could be argued that it was unlikely for this type of influence to take place due to Moazam’s professionalism. However, the counter factual is also plausible given the number of stories of how Moazam stopped being an observer and automatically became a physician or even an individual who emotionally became involved.

There were also moments throughout the book that also showed her interest in women’s rights. She admitted that it was mostly the situations concerning the women that troubled her the most. Also, her conversations with Azra were often about the women. Furthermore, Moazam stated that she felt that Azra and Fatima were happy with the fact that now there are three people to “protect the oppressed women”. These examples to raise concerns that Moazam quite possibly was more concerned with women’s rights then with bioethics or even Islamic metaphysics. Interesting enough, Moazam talks about the shrewd women who control the members of their family and dictate many of the decisions, for example the female in-laws who control the wives. But she refers to these women as not being members of the feminist movement and not looking out for their fellow females.

By my calculations Moazam offered thirty one stories, nineteen of which were about women and of those sixteen were about how women were being mistreated and misrepresented. Of those sixteen, two were narrated at the end of chapter four, which was where she confessed her reasons why she had to leave the field due to personal distress and emotional involvement with both girls. Furthermore, of the 226 page book, 30% consisted of issues pertaining to women. Thus in closing, I would argue that Moazam’s book is more about women’s rights within the medical world of kidney transplants, specifically in Pakistan, than on Islamic metaphysics and bioethics; which is obviously fine because this is a great book, just somewhat misleading.

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