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ISLAMIC MEDICAL EDUCATION RESOURCES-03

0103-DEATH, (AL MAWT, AL MAMAAT)

Lecture for 1st year medical students on Friday 23rd March 2001 by Professor Omar Hasan Kasule, Sr.

OUTLINE

1.0 DEFINITION OF DEATH:

A. Moral/Spiritual Death

B. Legal Death

C. Biological Death

D. Qur'anic Terminology For Death

E. Temporary And Permanent Death

 

2.0 NATURE OF DEATH

A. The Life-Death-Life Cycle

B. Inevitability Of Death

C. Finality Of Death

D. Death As A Transition

E. Good And Bad Death

 

3.0 ATTITUDE TO DEATH

A. Death In The Hands Of Allah

B. Positive Attitude

C. Negative Attitude

D. Wishing For Death

E. Death As A Trial And A Test

 

4.0 PROCESS OF DEATH

A. Growth And Degeneration

B. Causes Of Death

C. Lifting The Ruh

D. Qur'anic Description Of The Last Moments

E. Reversal Of The Death Process

 

5.0 CRITERIA OF DEATH

A. Need For Criteria

B. Respiratory Failure

C. Cardiac Failure

D. Loss Of Consciousness

E. Brain Death

 

1.0 DEFINITION OF DEATH:

A. MORAL/SPIRITUAL DEATH

There are several possible definitions of death: moral, legal, and biological. Morally a person may behave so badly that he no longer has human life but has the life of animals or even worse. This denial of human life is akin to death. In practice moral death leads sooner or later to physical death. Abuse of alcohol leads to fatal motor vehicle accidents, racial prejudice leads to genocide. Promiscuity leads to fatal sexually transmitted diseases. Lack of purpose in life often leads to depression and suicide.

 

B. LEGAL DEATH

Legally several conventions are adopted by various countries and communities. These conventions change from time to time depending on the level of technological development and the underlying societal values. The sharia definition of death is guided by the fiqh concept of custom or precedent, aadat. Thus the shariat definition can change from time to time and also from place to place depending on the level of technological development. The current debate is about acceptance of brain death as a definition of death. Definition of death for the lost person, hukm al mafquud, can rely on the average expected life expectancy that varies by place, ethnicity, and socio-economic status.

 

C. BIOLOGICAL DEATH

 Biologically death is simply defined as irreversible damage of major organs. This is not an easy definition because the concept of reversibility is relative. New technologies are showing us that what was previously irreversible is now reversible. Many dead organs can now be replaced by transplantation. Multi-organ transplantation is now feasible and is becoming common. Preventive transplantation using cloned organs may become common in the foreseeable future. The moment of death is also difficult to ascertain with any degree of certainty. This is because the process of death in an interval and not a point event.

 

D. QUR'ANIC TERMINOLOGY FOR DEATH

The Qur’an uses several terms to refer to death such as gharq, halaaq, mawt, wafaat, firaaq. The Qur'an mentioned death by drowning (p. 960 18:71, 36:43). Drowning was mentioned as a form of punishment, al ‘iqaab bi al gharq (p. 861 7:64, 7:136, 8:54, 10:73, 10:90, 11:37, 11:43, 17:6, 17:103, 21:77, 23:27, 25:37, 26:64, 26:120, 29:40, 37:82, 43:55, 44:24, 71:25). The Qur’an uses the term halaq to mean death, al halaaq bi ma’ana al mawt (p 1291-1292 4:176, 5:17, 7:155, 8:42, 9:42, 12:85, 27:49, 40:34, 67:28). Mawt is used to refer to death (p. 1153 4:15, 17:75, 35:22, 36:43, 49:12, 52:30, 77:26). Wafaat is another Qur’anic term for death (p 1315 2:234, 2:240, 3:193, 4:15, 4:97, 6:61, 7:37, 7:126, 8:50, 10:46, 12:101, 13:40, 16:28, 16:32, 16:70, 22:5, 32”11, 37:42, 40:67, 40:77, 47:27). Firaaq is a term whose root word is separation. It is used to mean separation from the earth signifying death (p 887 7:28).

 

E. TEMPORARY and PERMANENT DEATH

Death could be permanent, mawt, or temporary, nawm. Permanent death is irreversible until the day of resurrection. The Qur'anic reference to death is usually to the permanent death. The Qur’an has described sleep as a form of death. In this case death is reversible and is temporary. In some cases people pass away during their sleep (p 1258 39:42; p 1316 6:60). Animal biology can throw more light on the phenomenon of temporary death associated with sleep. Animals like amphibians can hibernate for long periods when their body metabolism is reduced to the minimum needed to preserve life. They can revive and resume normal activity when weather conditions allow. Medical research has yet to research the phenomena of temporary death and how it can throw light on the phenomenon of permanent death.

 

2.0 NATURE OF DEATH

A. THE LIFE-DEATH-LIFE CYCLE

CYCLIC PHENOMENA

There is a continuous cycle involving life and death. Life arises from death and vice versa, ikhraaj al hayat mina al mawt (p 1953 3:27, 6:95, 10:31). Modern scientific knowledge enables to understand this cyclic phenomenon in more detail at the cellular and molecular levels. Inanimate matter in the form of atoms and molecules becomes the basis for the physical component of human life. They eventually return to their inanimate nature when they are excreted or on death of the human. When you study the ecosystem and the food chains you realize that life of some living things is sustained because of the death of others. There is continuous recycling of matter between the organic and inorganic. There is also recycling between the organic and the living.

 

DEATH SIGNALING THE END OF THE HUMAN MISSION

All human endeavors cease with death, intiha al ‘amal bi al mawt, inqitau al ‘amal bi al mawt (p 839 4:18, 6:27-28, 7:53, 23:99-100, 23:107-108, 32:12, 35:37, 99:7-8, p 1154 23:99-100, 23:91-100, 63:10). There are only three exceptions a righteous offspring who prays for the parent, waladu salihu yad’u lahu; knowledge that benefits others, ‘ilm yuntafau bihi; and charity of continuous benefit, sadaqat jariyat.

 

CLOSURE OF THE LIFE-DEATH CYCLE ON THE LAST DAY

Death is followed by burial in the grave, qabr (p. 1158 90:21). There may be reward or punishment in the grave. Barzakh (p 189 23:100) is a transitional phase between life on earth and life in the hereafter. On the last day humans will be resurrected back to life, ba’ath (p 196 6:36, 7:29, 7:57, 10:4, 10:34, 11:7, 16:38, 17:49-52, 17:99, 18:48, 21:103, 22:7, 23:16, 23:100, 26:87, 28:85, 29:19-20, 30:11, 30:25-27, 30:50, 30:56, 31:28, 32:10-11, 34:7, 36:12, 36:32-36, 36:51-52, 36:78-83, 37:16-21, 36:33, 56:47-50, 58:6, 71:18, 75:3-4, 83:4-6, 86:8-10). Resurrection will be bringing the dead back to life, ihya al mawta, which will be life after death al hayat ba’da al mawt (p 1155 2:28, 2:56, 2:73, 2:154, 2:243, 2:259, 2:260, 3:49, 3:169, 5:110, 6:36, 6:122, 7:25, 7:57, 11:7, 16:21, 16:38, 19:15, 19:33, 19:66, 22:6, 22:66, 23:35, 23:37, 23:82, 26:81, 30:40, 30:50, 36:12, 37:16, 37:53, 41:39, 42:9, 44:35, 45:26, 46:23, 50:3, 56:47, 75:40, 80:21-22). The Qur’an has not provided details about this life whether it will be exactly like that on earth or there will be some differences. The Qur’an makes it clear that it will be physical life with physical bodies. On resurrection people will be gathered; all generations and all geographical areas will be together, al hashr ba’da al mawt (p23-24 2:203, 2:281, 3:158, 4:87, 5:48, 5:105, 5:109, 6:21, 6:22, 6:72, 6:128, 6:164, 8:24, 9:94, 10:28, 10:45, 14:21, 14:47, 15:25, 17:97, 18:47, 18:99, 19:85-86, 19:95, 20:108, 20:124, 25:17, 27:83, 34:26, 34:40, 36:29-32, 36:51-53, 37: `19-23, 40:16, 41:19, 42:15, 50:44, 64:9, 67:24, 70:43-44, 77:38, 99:6, 100:9-10). Those who committed transgressions will be punished in hell for a limited time with the exception of those who committed shirk who will be condemned to stay in hell forever. Paradise, jannat, will be the permanent abode of the righteous. There will be no more death in the hereafter (p 1158 14:17, 20:74, 35:36, 44:56, 87:13).

 

B. INEVITABILITY OF DEATH

All humans will eventually die, shumuliyat al mawt (p 1156-7 3:154, 3:154, 3:168, 3:185, 4:78, 4:10, 21:35, 23:15, 29:57, 39:30, 55:26). There can be no exceptions now or at any time in the future. Even prophets have to face death (p 1157 3:144, 19:15, 19:33, 21:34, 34:14, 39:30, 3:168, 3:185, 4:78, 4:10, 21:35, 23:15, 29:57, 55:26). All death is by Allah's permission (p 1258 3:145). Humans fear death, gadhar al mawt (p 1155 2:19, 2:243). In view of the inevitability of death, hatmiyyat al mawt, it is futile to attempt to avoid death or think of its removal, istihalat daf'u al mawt (p 1154 3:154, 3:156, 3:163, 4:78, 33:16, 62:8). The human and death have inevitably to meet, liqa al mawt (p 1045 3:143, 62:8). However much the humans try to escape it, death catches up with them, lihaaq al mawt bi al insaan (p 1156-7 3:154, 3:154, 3:168, 3:185, 4:78, 4:10, 21:35, 23:15, 29:57, 39:30, 55:26). No human endeavor can prevent death, isthalat man’i al mawt (p. .). Modern biotechnology discoveries of artificial life support, cloning, and frozen embryos are not in essence prolongation of life as will be discussed in later sections of the manual. Death will come to all humans and all living things, shumuul al mawt kulla shay’I (p 1156 73:154, 5:26).  The concept of death also includes non-living things for example the Qur’an talks about death of the earth, mawt al ardh (p 1153 2:164, 7:57, 16:65, 25:49, 29:63, 30:19, 30:24, 30:50, 35:9, 36:33, 43:11, 45:5, 50:11, 57:17).

 

C. FINALITY OF DEATH

Human death has finality to it. Each human has only one death. There is no reincarnation. There is only resurrection in the hereafter. There will be no more death after the day of Judgment (p. 158 14:17, 20:74, 35:36, 44:56, 87:13). Life after the Day of Judgment will be eternal (p 1158 14:17, 20:74, 35:36, 44:56, 87:13). Humans in their arrogance and folly find it difficult to accept the finality of death. They try various means to achieve some form of immortality. Some as an attempt at achieving immortality strive to have children who will carry part of the biological heredity and family name into the next generation. Some humans endeavor to leave behind physical monuments that will remind future generations of their achievements like the pyramids of the pharaohs and the Aztecs. Many human acts are motivated by the desire to achieve fame or notoriety in order to enter the books of history. Belief in ghosts in superstitious societies can also be seen as a form of prolonging human existence on earth after physical death.

 

D. DEATH AS A TRANSITION

Death could be looked at a transitional event or rite de passage. Death is a transition to life after death. There is another life after the earthly one al hayat ba'da al mawt (p. 1155-6 2:28, 256, 2:73, 2:154, 2:243, 2:259, 2:260, 3:49, 3:169, 5:110, 6:36, 6:122, 7:25, 7:57, 11:7, 16:21, 16:38, 19:15, 19:33, 19:66, 22:66, 23:35, 23:37, 23:82, 26:81, 30:40, 30:50, 36:12, 37:16, 37:53, 41:39, 42:9, 44:35, 45:26, 46:33, 50:3, 56:47, 7:40, 80:21-22 & 80:21-22, 22:66, 26:81, 30:40).  The only way to life after death is through physical death on earth. Life in the hereafter is better than earthly life. Death could therefore be a welcome event for good people who look forward to a better life in the future.

 

E. GOOD and BAD DEATH

Good death is to die in Islam, al mawt ala al Islam (p 1157 2:132, 3:102). The best of death is to die when struggling in Allah’s way, al mawt fi sabilillahi (p 1156 4:100, 22:58, 33:23). Death in unbelief, al mawt ala al kufr (p 1156-7 2:161, 2:217, 3:91, 4:18, 9:55, 9:85, 9:125, 47:34) is bad death. Death while committing a major sin is bad death because iman is temporarily lifted from a person engaged in sin. It may not be possible to tell whether a person lived a righteous life by the manner of death, demeanor or attitude of the dying person. However empirical observation of the death of many righteous persons, salihiin, shows that they generally die in a calm way. 

 

3.0 ATTITUDE TO DEATH

A. DEATH IN THE HANDS OF ALLAH

Death and its occurrence are in the hands of Allah, taqdiir al mawt mina al llah (2:243, 2:258, 3:273, 3:27, 3:145, 3:156, 6:95, 6:162, 7:158, 9:116, 10:31, 10:56, 15:23, 22:66, 23:80, 25:3, 26:81, 30:19, 30:40, 39:42, 40:11, 40:68, 44:8, 45:26, 53:44, 56:60, 57:2, 67:2, 76:28). The believer surrenders all matters pertaining to death to the Lord.

 

B. POSITIVE ATTITUDE

The attitude to death varies according to the spiritual well being of those involved. The good people welcome death as a rite de passage to a better existence in the hereafter. They look forward to death, al shawq ila al mawt as a happy event. The Qur'an challenged the non-believers to wish for death if they were sure of a good life after death. The approach of death is an opportunity for repentance, tawbat (p. 1158 4:18, 23:99). Death is an occasion for reminding and remembering the hereafter. It makes the good prepare better by doing more good deeds.

 

C. NEGATIVE ATTITUDE

Humans are apprehensive about death, al hadhr mina al maw and often fear it, khawf al mawt (p 1155 2:19, 2:243). This is basically the human fear of the unknown. It is useless to fear an event that is inevitable and over which a human has no control. Fear of inevetible death itself in illogical but anxiety about the manner and circumstances of death is reasonable and is expected from a normal human. Death may be feared because of leaving behind beloved ones.

 

D. WISHING FOR DEATH

Wishing for death, isti’ijaal al mawt, tamanni al mawt, in desperation with severe painful illness is discouraged. The wish for death, tamanni al mawt (p 1154 2:94-95, 3:143, 19:23, 62:6-7) can be negative for the escapist who looks to death as a relief from present psychological or physical distress Committing suicide, qatl al nafs & intihar, is definitely forbidden and puts someone outside the fold of Islam.

 

E. DEATH AS A TRIAL and a TEST

Death is a trial, ibtila’a bi al mawt (p 1153 21:35, 77:2) and is a calamity, musibat al mawt (5:106). This trial involves both the person dying and the relatives and friends left behind. Death is a calamity for the relatives, friends, and the society but not the deceased. If he is good he is going earlier to his Lord. If he is bad he has no more time to do bad; however he might have made tawbat and improved his situation had he lived longer. Death is a test for humans (p 382 67:2). The test for the deceased is to be aware of death and prepare for it by doing good work, amal hasan. For the relatives and loved ones death is a calamity calling for patience and forbearance.

 

4.0 PROCESS OF DEATH

A. GROWTH and DEGENERATION

Human cells show signs of ageing and metabolic processes get weaker with time. Thus humans have both degenerative and regenerative processes at the same time. Death overwhelms them when the degenerative forces have the upper hand. Death has got its own appointed time, ajal al mawt  (p. 1153 7:34, 10:49, 15:4-5, 16:61, 17:58, 35:45, 63:10-11, 71:4). Humans have no way of knowing the ajal (p 1155 71:34).

 

B. CAUSES OF DEATH

Death is inevitable; it will occur. What are called causes are actually associated factors. These may be trauma, infections, metabolic impairment, and neoplasms. Humans may not be able to ascertain the immediate cause of death in some cases.

 

C. LIFTING THE RUH

The process of death is long. It starts with the humanly understood causes like infection or trauma. The body progressively fails until a point of no return is reached. There is a point during this process when the angels take away the ruh thus separating the essence from the body, al malaika wa qabdh al arwaah, malak al mawt (p 1145 4:97, 6:61, 6:93, 7:37, 8:50, 16:28, 16:32, 32:11, 47:27).

 

D. QUR'ANIC DESCRIPTION OF THE LAST MOMENTS

The Qur’an has described the process of death using terminology such as sakrat al mawt (p 1156 6:93, 33:19, 47:20, 50:19, 56:83-85, 75:26-30, 79:1), ghashiyat al mawt (p 1157 33:19 and 47:20) and ghamrat al mawt (p 1157 6:93).

 

E. REVERSAL OF THE DEATH PROCESS

The process of terminal death following Allah's laws, sunan al llaah, can not be reversed except in exceptional cases of divine intervention such as when Allah gave the prophet Isa (PBUH) the ability to revive the dead, ihyaa al mawta (p 858 3:49, 5:110-115, 19:29-33).

 

5.0 CRITERIA OF DEATH

A. NEED FOR CRITERIA

In general death is defined as irreversible loss of the integrated functioning of the organism as a whole. For most of human history, death has been defined in a more subjective way with little attention being given to objective criteria. There were not legal or practical necessities for early diagnosis of certification of death. They had the luxury of waiting until all signs of life disappeared before pronouncing death. The earliest criteria of death that humans used were respiratory arrest. The Qur'an and sunnat describe death mostly in terms of respiratory failure. Later circulatory/cardiac arrest as absence of a heart beat or a pulse was also used. Unconsciousness was another criterion used and it related to the brain. Technological developments in intensive care units have blurred the demarcation between life and death that was taken for granted before. Many brain-dead people can be kept apparently alive on artificial respirators. The increase in transplantation has given momentum to the need to develop new criteria for death. This is because organs have to be harvested quite early in the death process to prevent them from further degeneration.

 

B. RESPIRATORY FAILURE

The main purpose of the respiratory system is to deliver oxygen to the tissues. Oxygen is necessary for tissue metabolism. Tissues cannot survive prolonged hypoxia. Thus respiratory failure is followed by death of tissues due to oxygen deprivation.

 

C. CARDIAC FAILURE

In cardio-vascular failure, tissues are not perfused sufficiently with blood that carries food and oxygen as well as takes away tissue metabolic waste. The brain is more sensitive to circulatory failure than other tissues of the body.

 

D. BRAIN DEATH

Brain death is quite an early event and was first proposed as a criterion for death by an adhoc committee of the Harvard Faculty that redefined death as brain death in 1968. Use of brain death as a criterion gives rise to ethical and legal problems because in cases of brain death, many other organs and functions of life are still alive. There are also controversies about the definition of brain death as a pathological entity. There is controversy whether it is death of the whole brain or specific parts of it. It is not yet possible to agree on what constitutes irreversible brain death. There is also disagreement whether criteria used for adults can be used for children. Brain death is assessed clinically and by use of laboratory and electrical assessments. Clinically brain death is indicated by: absence of pupillary reflexes, dilated pupils, absence of the corneal reflex, absence of eye movements, absence of spontaneous respirations, absence of cephalic reflexes, absence of motor response to pain, absence of the cough reflex, and absence of the gag reflex. These clinical criteria are considered less accurate that laboratory measurements. They also are sometimes too late for purposes of declaring death to enable harvesting organs for transplantation. Laboratory assessment are considered confirmatory and include: electrocorticogram measurements, electo-retinography, cerebral blood gas analysis, cerebral angiography to show cerebral circulatory arrest, retinal fluoroscopy, assessment of brain stem auditory responses, and the orbicularis oculi reflex.

Professor Omar Hasan Kasule August 2006