Global Bioethics

ISSN: 1128-7462 (Print) 1591-7398 (Online) Journal homepage: http://www.tandfonline.com/loi/rgbe20

Islam and palliative care

K. A. Choong

To cite this article: K. A. Choong (2015) Islam and palliative care, Global Bioethics, 26:1, 28-42,
DOI: 10.1080/11287462.2015.1008752

To link to this article: http://dx.doi.org/10.1080/11287462.2015.1008752

Published online: 09 Feb 2015.

Submit your article to this journal

Article views: 1340

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at

http://www.tandfonline.com/action/journalInformation?journalCode=rgbe20

Download by: [180.241.58.99] Date: 20 October 2017, At: 09:47

 Global Bioethics, 2015
Vol. 26, No. 1, 28–42, http://dx.doi.org/10.1080/11287462.2015.1008752

Islam and palliative care

K. A. Choong*

Lancashire Law School, University of Central Lancashire, Preston, UK

(Received 14 January 2015; accepted 14 January 2015)

Palliative care is experiencing an upsurge in interest and importance. This is driven,

paradoxically, by modern medicine’s increased ability to provide effective pain relief on the
one hand and an acknowledgement of its limitation in delivering a cure for certain diseases
on the other. With many Muslims suffering from such incurable diseases worldwide, they
Downloaded by [180.241.58.99] at 09:47 20 October 2017

too are now faced with the decision of whether to avail themselves of pain relief offered
within the framework of scientific medicine. However, while the general ethos of palliative
care which is to promote the quality of life of those facing life-limiting illnesses is
consistent with Islamic values, this paper explores whether the same can be submitted for
modern methods of pain control. The investigation will be steered by two overriding
questions. First, if pain and suffering could, as highlighted in the primary sources of Islamic
Law, lead to the expiation of sins, can pain relief be taken? Second, is it religiously
permissible to choose pain treatment options that could bring about iatrogenic addiction, the
hastening of death and the impairment or obliteration of consciousness?
Keywords: palliative care; end of life; Islam; Muslim patients; pain management; sedation;
medical ethics

Introduction
Dying, in Islam, is usually a time for reflection and repentance. It is a time for bringing oneself
closer to the Almighty by immersing in activities such as prayers and recitation of the Qur’an. It is
also a time for seeking forgiveness from fellow human beings for past transgressions. In addition,
Muslims are advised to be steadfast in dealing with any pain and suffering they are confronted
with, since such forbearance would not only lead to the expiation of sins, but would also be
rewarded in the afterlife (Qur’an 2:54, 4:146, 39:10, 99:7–8; Sahih Al-Bukhari, 1994). It was
for these reasons that I was particularly intrigued by the sight of a Muslim cancer patient who
was deeply sedated in a bed not far from the relative I visited in a hospital a few years ago.
The fact that he was rendered unconscious, albeit in a compassionate act to shield him from
having to experience excruciating pain and suffering, had then seemed at variance with what
would normally be considered a good death in Islam. This paper therefore seeks to investigate
how far the modern system of palliative care, which centres on pain management, is in conso-
nance with Islam.
The work will firstly chart the historical development of palliative care from its genesis
outside mainstream medicine where it was underpinned by a strong religious commitment, to
it eventually gaining recognition as a medical specialty in its own right. As palliative care

*Email: kachoong@uclan.ac.uk

© 2015 Taylor & Francis

 Global Bioethics 29

identifies itself more and more with the medical model, it will be highlighted that its philosophy
and practice also became more secularised. With death consequently identified as the end point of
human existence, a new ethos of pain-free and dignified dying saw the introduction of a range of
pain relief and symptom control methods. In investigating the extent to which Muslim patients
can avail themselves of these pain treatment options, the work takes a close look at what consti-
tutes a good death in Islam and explores how far this new medical specialty sympathises with the
Islamic outlook on death and dying. From there, it assesses the opportunities and challenges
which modern pain management and other aspects of palliative care present to Muslim patients.

The history and development of palliative care

Palliative care has been described by the World Health Organization (WHO, n.d.-a) as

an approach that improves the quality of life of patients and their families facing the problem associ-
ated with life-threatening illness, through the prevention and relief of suffering by means of early
Downloaded by [180.241.58.99] at 09:47 20 October 2017

identification and impeccable assessment and treatment of pain and other problems, physical, psycho-
social and spiritual.

Recognised in the West today as a distinct and important medical specialty, its conception and
earlier development nevertheless took place outside mainstream medicine. This part of the
work documents its journey from the periphery to the centre of Western medicine and highlights
the impact which this transition has on its ethos and remit.

Care of the dying: its religious roots

Although the term “palliative care” itself did not come into common use until 1974, the concern
over the quality of care provided to dying patients and their families has roots which extend back
to ancient times (Hallenbeckt & McDaniel, 2009; Humphreys, 2001). The concept was neverthe-
less thrust into social prominence with the advent of scientific medicine towards the end of the
nineteenth century. However, this was more as a critic of and a small rebellion against the
manner in which it dealt with dying patients (Clark, 1999; James & Field, 1992). This
stemmed from the fact that this system of medicine, which rapidly gained social and political rec-
ognition as the dominant model of health care, had focused predominantly on curing and rehabi-
litating patients (Bowler & Morus, 2005). Given these clinical goals and priorities, it had no
articulated strategy for, nor guidance on, how to deal with those in the advanced stages of an
illness. Deemed as “medicine’s failures”, patients who were certified as dying by doctors were
simply sent home with no further after-care offered (Clark, 1999; Humphreys, 2001). Many
died in pain and in appalling and unsanitary conditions. This led to what has been described as
a “cruel irony” in that those who are most in need of medical assistance are the ones who are
offered none in terms of the quality and quantity of care (Hamilton, 1995).
Their plight nevertheless garnered the sympathy of religious and charitable organisations.
Drawing on Christian traditions of care and philanthropy, small numbers of institutional homes
for the dying were established with care provided by nuns and untrained nurses. Their intention
was to provide such individuals with a place of peace, comfort and support to prevent them from
dying in a state of neglect (Clark, 1999; Humphreys, 2001). These homes began to be referred to
as “hospices” to evoke the blend of guest house and infirmary run by monks and nuns in medieval
times which offered food, shelter and care to the sick and travellers until they died or set out on
their journeys again (Putnam, 2002). Just as those endeavours were embarked on in the service of
God, these institutions deemed their efforts as religious duties towards the sick and dying.
 30 K.A. Choong

In furtherance of this commitment, their foremost aim was to provide spiritual care particu-
larly for those “whose souls had not yet been saved” (Humphreys, 2001, p. 154). However,
they soon realised that this ultimate goal of salvation could only be achieved by attending also
to the patients’ physical and mental suffering. It was, as they observed, “always hard in sickness
and pain to think of anything but one’s own discomfort and suffering” (Hostel of God Annual
Report, 1897, pp. 10–11). Besides, end of life also tended to provoke profound mental distress
as triggered by, among other things, loss of meaning and purpose, loss of independence and
frailty. The emotions they give rise to can take various forms. These can range from dishearten-
ment, despondency, despair and demoralisation to even suicidal thoughts. Against this back-
ground, care of the body and mind therefore became the necessary expression of, and a
complement to, spiritual care (Humphreys, 2001; Lloyd-Williams, Reeve, & Kissane, 2008).
This arguably became the starting point for a holistic end-of-life model of care which com-
bined concerns over the patient’s physical, psychosocial and spiritual needs as outlined in the defi-
nition espoused by the WHO today. It was also the first time that dying persons were viewed as a
group that require a specialised form of care that was best administered within an institutional
Downloaded by [180.241.58.99] at 09:47 20 October 2017

setting (Humphreys, 2001).

Further, although it was the patients who were ill, recognition was given to the fact that they
are a part of a wider network of family relationships. As such, the experience of death could
involve and affect family caregivers in various ways. Dying persons’ demoralised state, for
example, can be a contagious emotional state that is readily transmittable to them. The physical
pain experienced can also be a source of emotional, economic and spiritual challenge on their
families (Knight, Brand, Mchaourab, & Veneziano, 2007; Lloyd-Williams et al., 2008; Monroe
& Oliviere, 2007). This group of informal carers therefore have their own physical, psychosocial
and spiritual needs which are prompted by their dying relatives’ illness. For this reason, this
model of care viewed the patients and their families as the unit or object of care, and carers
worked with the family to solve problems and make decisions (Portenoy & Bruera, 2003).
The ethos by which it operates is fundamentally opposed to that espoused by the euthanasia
movement – another alternative solution which developed as a response to the poverty of terminal
care. The latter campaigned to allow dying patients to have control over their own death rather
than to undergo prolonged agony and loss of dignity. The aim was to enable them to secure a pre-
mature and voluntary death by being able to request their physicians to provide or administer them
with a lethal dose of narcotics (James & Field, 1992; Kemp, 2002). Such values and practices
clashed sharply with the Christian belief about the inherent value of life which underpinned hos-
pices’ work. The resolve to ensure that dying patients can have access to care that can improve
their quality of life and retain their dignity at the end of life, thereby obviating the need to
contemplate euthanasia, also provided an added impetus for the palliative care movement
(Dowbiggin, 2003; Payne, Seymour, & Ingleton, 2008).

From care and comfort to pain management

If the medical model had initially paid scant attention to care of the dying, this changed in the
1960s when a new discourse of terminal care developed within the oncology setting. Faced
with the reality that cure was still not within reach for many cancers, yet with 50–90% of sufferers
experiencing persistent pain in the late stages, major strides were made in pain and symptom man-
agement to alleviate the suffering of terminally ill cancer patients (Clark, 2002, 2007; Inter-
national Association for the Study of Pain, 2008). It is pertinent to observe that although
palliative care today has a wider remit than cancer care, the close association between the two
is kept to the present decade. The main contributing factors include the fact that the majority
of its service users are cancer patients and that most of the research in palliative care is conducted
 Global Bioethics 31

and published within oncology (Davies & Higginson, 2004; Gatrad & Sheikh, 2002; Kaasa &
Radbruch, 2008).
Importantly for all cancer and non-cancer patients, a wide range of pharmacological and non-
pharmacological pain control methods are now available for the whole spectrum of pain experi-
ence. For mild to moderate pain for instance, patients can be prescribed with orally administered
non-opioid analgesia (e.g. paracetamol and non-steroidal anti-inflammatory drugs) and mild
opioids (e.g. codeine). These can also be supplemented with transcutaneous electrical nerve
stimulation (TENS) and physiotherapy. For more serious pain, they can be given strong
opioids (e.g. morphine and methadone); or have a neurosurgical procedure performed on appro-
priate nerves. As for those with acute pain syndromes, they can be administered with a titration of
a continuous infusion of strong opiates (e.g. morphine, oxycodone, fentanyl, hydromorphone,
buprenorphine and methadone) that provide sustained pain relief. They can also be considered
for invasive analgesic techniques like nerve blocks and regional or neurodestructive blocks, or
for spinal delivery of opioids such as lignocaine, clonidine, midazolam and ketamine (Kahn,
Lazarus, & Owens, 2003; Laird, Colvin, & Fallon, 2008; NHS, n.d.; Vargas-Schaffer, 2010;
Downloaded by [180.241.58.99] at 09:47 20 October 2017

WHO, n.d.-b).
In situations where the patients’ pain cannot be relieved by ordinary levels of pain medication,
doctors may sometimes honour those patients’ request for pain relief by administering opioids in a
dosage so large that death is hastened. However, since the primary intention of such an act is to
alleviate unrelenting pain and suffering at the end of life rather than to deliberately kill the patient,
it has been considered as legally, professionally and ethically acceptable. In other words, where
the abbreviation of life is a necessary and foreseeable incident of pain relief medication, the
doctor’s action would not ordinarily be met by any legal liability, professional sanctions or
moral condemnation (Haugen, 1997; Nuccetelli & Seay, 2000). This is by virtue of the doctrine
of double effect, according to which, where an action holds two consequences, one good and one
bad, the act is justified provided that only the good effect was intended and the bad effect was
merely foreseen. The operation of the doctrine now allows doctors to administer whatever
dosage is necessary to accomplish the goal of pain relief (Haugen, 1997; Nuccetelli & Seay,
2000).
As for patients with a combination of uncontrollable and refractory symptoms, sedation as
highlighted at the outset, is currently a palliative medical treatment option. This involves a con-
scious decision to decrease the patient’s consciousness, through the use of sedating agent, to the
point where he or she no longer feels pain, air hunger or other distress. They are applied in excep-
tional circumstances where other measures are no longer helpful in relieving pain and other phys-
ical distress (Kahn et al., 2003; Materstvedt & Bosshard, 2009; Murray, 2008). As such, they are
usually referred to as a medical “last resort” or “last gasp” measure (Hasselaar, Verhagen, Reuzel,
van Leeuwen, & Vissers, 2009; Koh, Lee, & Wu, 2009). The depth and manner of the sedation
may differ. In the case of mild sedation, the patient’s unconsciousness is merely lowered. He is
otherwise awake and still able to communicate with minimum impairment. Where intermediate
sedation is applied, the patient is asleep but can be woken in order to communicate briefly. At
the other extreme, deep sedation may be carried out where the patient would be unconscious
and unresponsive (de Graeff & Dean, 2007; Nogueira & Sakata, 2012; Simon, Kar, Hinz, &
Beck, 2007). Although this artificially induced deep unconsciousness can be discontinued and
reversed, some attempts at discontinuation have been unsuccessful since the reduction of sedation
may sometimes result in renewed extreme suffering. Thus, depending on the circumstances,
doctors would implement it intermittently or carry out the sedation continuously until the patient’s
death. As regards the latter, this is sometimes combined with the withdrawal of life-sustaining
measures including clinically assisted nutrition and hydration (Curlin, Nwodim, Vance, Chin,
& Lantos, 2008; Materstvedt & Bosshard, 2009; Simon et al., 2007).
 32 K.A. Choong

This ability to effectively control physical pain and other symptoms (like nausea, depression,
shortness of breath, distress, vomiting, fatigue and alopecia) transformed terminal care. It now
holds enormous potential to relieve patients’ suffering and improve their quality of life (Unroe
& Meier, 2011). Hospitals, armed with good practices and principles learnt from the care of
the dying in hospices, became major providers of palliative care (Hart, Sainsbury, & Short,
1998). Further, since pain and symptom management became scientifically complex and required
skills no less demanding than in well-established areas of medical practice, palliative medicine
was soon recognised as a specialty in its own right. This gives it a significance which is equivalent
to that of other medical specialties (Bentur, Emanuel, & Cherney, 2012; James & Field, 1992).
Hospices too readily embrace these skills and resources to assist their patients. In so operating,
they not only allowed themselves to be subjected to mainstream influence, but in effect integrate
with the mainstream health system. Thus, just as palliative care is now provided in hospitals, care
provision in hospices resembles hospital care. The process blurred the ideological boundaries and
oppositional practices of the past (Hart et al., 1998; James & Field, 1992).
Palliative care and the hospice movement are now an accepted part of mainstream medicine.
Downloaded by [180.241.58.99] at 09:47 20 October 2017

Inevitably, the ethos and secular nature of other areas of medicine have also permeated this speci-
alty. A new philosophy of pain-free dying is now subscribed to. Death itself is not deemed as a
transit to another world. Rather, it represents the end point of human existence, with God excised
from any spiritual understanding of death (Bradshaw, 1996; Engelhardt, 2012; Hillier & Wee,
2012). Against this background, there is nothing redeeming or ennobling about pain and suffer-
ing. Wherever possible, these should be lessened or eliminated. This is so, even where the pain
relief used may compromise consciousness to various extents and even where the dosages used
could lead to the abbreviation of life. All these led to a considerable reorganisation of how end-of-
life decision-making and the ethics of palliative care are now understood.
For one, death became medicalised and now happens predominantly outside the home in hos-
pices or hospitals (Goodhead, 2010; James & Field, 1992). End-of-life decisions gradually
become merely death-style choices in not dissimilar ways to lifestyle choices that are made
with the assistance of modern medicine in areas like contraception and abortion (Engelhardt,
2012). Much of the carers’ time is taken up by explaining the pain relief options available and
the significance of medication routines to patients and their families (McNamara, Waddell, &
Colvin, 1994). Equipped with this information, patients are thereby then encouraged to, in discus-
sions with their families, make a decision on what they regard as “an acceptable style of living
while dying” (Hart et al., 1998, p. 66). The “medical good death” is consequently one where:
they are fully aware of their prognosis and make their own choices as regards their care in the
last days and months, and doctors manage a pain-controlled dying with dignity (Hart et al.,
1998; Walter, 2003).
Amidst all the changes, palliative care still preserves its opposition against euthanasia. In fact,
medicine’s current ability to treat pain should help to allay the public’s concerns of a prolonged
and painful death – fears that have served as the impetus for the euthanasia and physician-assisted
suicide movements. More importantly, it has also retained its holistic concern with the physical,
psychological and spiritual dimensions of end-of-life experience. This is in recognition of the
roles that these play, both on their own or in an accumulative and interactive way, to patients’
as well as their family members’ suffering (Limonero & Gil-Moncayo, 2014). There is neverthe-
less a tendency to focus significantly more on physical care over the psychosocial and spiritual
aspects of care. Indeed, as pointed out by Bradshaw (1996, p. 414), drugs became “a solution
and a first and last resort”. Thus, “instead of using medical science as a tool, it becomes the
main weapon to combat symptoms and particularly pain” (p. 414). Where the psychosocial
dimension is now addressed, there is widespread use of psychotherapeutic and counselling tech-
niques. Thus, where previously love and compassion were shown in silence and quiet by just
 Global Bioethics 33

being with the patients and their families, facilitation is now provided to encourage them to get in
touch with their feelings by expressing these verbally and/or through other means of self-
expression (Bradshaw, 1996). Where the spirituality dimension is attended to, the traditional
emphasis of the human being’s relationship with God has been replaced by a conception of spiri-
tuality as a personal and existential search for meaning. There is thus a distancing of religion from
spirituality. The redefined spirituality aims to help patients and their families transcend pain and
suffering by connecting with something deeper within the self (Bradshaw, 1996).
The care of these different dimensions requires the involvement of a multidisciplinary team of
formally trained carers, which include doctors, nurses, pharmacists, social workers, chaplains,
physiotherapists, psychologists, and art and music therapists (Barnard, Towers, Boston, & Lam-
brinidou, 2000). These characteristics – namely, concerns over the patients’ emotions and spiri-
tuality rather than just their bodily well-being; the inclusion of family members as focus of care
and co-decision-makers rather than the usual patient-centred structures that characterise clinical
practice in the West; and the involvement of numerous carers including those trained outside
the medical model – make palliative medicine unique among all medical specialties.
Downloaded by [180.241.58.99] at 09:47 20 October 2017

Modern pain management and Muslim patients

In order to ascertain how far this new medical speciality holds relevance for Muslims, this part of
the discussion will firstly explore the extent to which its philosophical outlook coheres with the
Islamic perspective on death and dying. From there, the opportunities and challenges which
modern pain management and other aspects of palliative care present to Muslim patients will
be investigated.

Dying and death from an Islamic perspective

Muslims subscribe to the belief that health is a gift from the Almighty and that illness takes place
only through His will (Al-Shahri & Al-Khenaizan, 2005). When the latter occurs, there are certain
expectations placed upon others towards the care and welfare of the sick. Relatives and friends,
for example, are strongly encouraged to visit. This is for the purposes of: honouring the patient;
praying for their welfare; mutual seeking of forgiveness for wrongdoings that have been know-
ingly and inadvertently committed in the past; and offering support in various means wherever
possible (e.g. psychological, physical and/or financial) (Bloomer & Al-Mutair, 2013; Gatrad &
Sheikh, 2002; Khan, 2002; Rassool, 2000). This can be particularly comforting for those who
are suffering from a life-limiting illness as they struggle with a wider range of physical, emotional
and spiritual challenges than others who are merely ill. In addition to those highlighted previously,
these include: changes in social and family roles; fear of the disease process; disconcerting feel-
ings about being a burden on others; resentment at being pitied by others; a fractured sense of
dignity; diminished ability to work and the anxiety over the financial pressures this may cause;
feeling of being unproductive at professional and personal levels; concerned about the afterlife;
worried that family members are worrying about them; and concerned about the dependants they
are about to leave behind (Doumit, Abu-Saad Huijer, & Kelly, 2007; McClement & Chochinov,
2008; Sheehan, 2005).
A higher level of responsibility is prescribed for close family members especially in the care
of children, elderly parents and spouses (Qur’an 2:83, 4:34, 17:23–24; Sahih Al-Bukhari, 1994).
When this is performed in the context of care at the end of life, it is with the aim of encouraging
and supporting the dying, and to cement firmly their relationship with the Almighty before death
(Gatrad & Sheikh, 2002). It has been observed that their physical presence is important to the
patients’ physical, emotional and spiritual well-being. This provides assurance to the patient
 34 K.A. Choong

that he is still valued and has not been abandoned (Adeniyi, 2013; Al-Mutair, Plummer, &
Copnell, 2012; Al-Muzaini, Salek, Nicholls, & Alomar, 1998). In the event where the patient’s
condition does not enable him to express his preferences in relation to treatment and care
options, family members can be a source of valuable background information (particularly regard-
ing the relevance and influence of religion and spirituality specific to the patient) in communi-
cations with health care professionals (Carey & Cosgrove, 2006; Owen & Jeffrey, 2008).
They would also, if the patient is no longer able to read the Qur’an themselves, recite the
Qur’an by the dying patient’s bedside. This would help imbue their terminally ill relative with
peace, serenity and a sense of closeness with the Almighty (Bloomer & Al-Mutair, 2013).
Further, since prayers remain obligatory irrespective of illness, and adjustments are allowed if
the patient can no longer pray in the prescribed way, family caregivers would need to provide
the necessary assistance to ensure that these can be carried out. Family members would addition-
ally seek to ensure that the dying patient recite the syahadah (which reads “I bear witness that
there is no God but Allah, and that Muhammad is the Messenger of Allah”) as they take their
last breath. This, which is a testimony of their faith, consolidates the dying person’s expectation
Downloaded by [180.241.58.99] at 09:47 20 October 2017

that death does not represent the end, and that he is now entering another state of existence
(Schultz, Baddarni, & Bar-Sela, 2012). If the dying person is not able to say the syahadah
himself, family members will whisper it into his ear.
It is important to note that irrespective of how severe or seemingly unbearable a person’s pain
and suffering may be, Islamic jurisprudence does not recognise a right to die voluntarily. This
stems from the belief that life is a divine trust and is sacred. Each and every moment of life is
therefore precious and must be cherished and preserved. Muslims are, in line with this, forbidden
from ending their lives by committing suicide (Aramesh & Shadi, 2007; Clarfield, Gordon, Mark-
well, & Alibhai, 2003; Qur’an 2:164, 4:29, 15:99, 17:33, 31:17, 39:42). Nor should Muslim
doctors and family caregivers render any assistance to bring about their death. The sanctity of
life is such that the taking of one life without just cause is considered as tantamount to the
killing of all of mankind (Qur’an 5:32, 17:33). The precise moment as to when death will
occur is a matter of Divine decree rather than one determined by human beings (Qur’an 3:145,
3:154, 16:61, 29:57, 39:42). Muslims are expected to be resolute in facing the hardships and
tests that are sent their way. Instead of taking their own lives, they are advised to pray to God
for strength and help in dealing with the trial (Qur’an 31:17; Sahih Al-Bukhari, 1994; Shah &
Chandia, 2010). These two aspects, caring for the sick and not ending lives prematurely, are there-
fore common characteristics shared by both Islam and palliative care.
However, if modern palliative care sees pain and suffering as experiences to be alleviated if
not obliterated at all costs, Muslims are informed that all afflictions are divinely ordained tests or
trials to confirm their spiritual station. Viewed from this perspective, pain and suffering when
endured with patience can lead to spiritual and moral development. It can purify the soul,
atone for one’s sins and is expected to yield rewards in the afterlife (Laird, Amer, Barnett, &
Barnes, 2007; Pew Research Center, 2013; Qur’an 2:153–157, 39:10; Sachedina, 2012; Sahih
Al-Bukhari, 1994). In acknowledging a life beyond this worldly existence, death is thereby
deemed as the transition point from one state of existence to the next. With the latter believed
to be eternal where the deeds and misdeeds done during one’s earthly sojourn are rewarded
and punished, the end of life is therefore a particularly significant and meaningful time. This
period, in view of how death is the point at which actions in this life are sealed, represents a
Muslim’s final opportunity for spiritual connection and refinement (Bloomer & Al-Mutair,
2013; Qur’an 29:7, 99:7–8; Sheikh, 1998). Crucially, it is also a time for repentance which, if gen-
uinely sought can, Muslims believe, mitigate the effects of sins committed during one’s lifetime.
Forgiveness and reconciliation may likewise be sought during this period for excesses committed
against fellow human beings (Qur’an 4:18; Sheikh, 1998; Smith & Haddad, 2002).
 Global Bioethics 35

Thus, if end of life choices in the secular framework are evacuated of any ultimate or enduring
meaning or importance (Engelhardt, 2012), Islam attaches value and a higher purpose to pain and
suffering. Moreover, if the goals of palliative care are not directed to a reality beyond the worldly
life (i.e. to judgment before God), Muslims seek reward from the Almighty for enduring the pain
and suffering and are mindful of the significance of death as the door to eternal life. Further, if the
end of life choices in palliative care are deemed as possible last opportunities to exercise self-
determination and to preserve human dignity (Engelhardt, 2012), Muslims equally see these as
their last opportunities for repentance, to avoid God’s wrath and to seek God’s approval.
Hence while contemporary palliative care is shaped and governed by the ideal of dying well –
with dignity, self-affirmation and comfort (Engelhardt, 2012) – end of life in Islam has a focus
on existence beyond this ephemeral world. Because of this, the emphasis is on repentance and
not dignity. In view of these conflicting philosophies, does modern pain management go well
together with the Islamic worldview?
Downloaded by [180.241.58.99] at 09:47 20 October 2017

Palliative medicine: opportunities and challenges

Having compared and contrasted the philosophical underpinnings of secular palliative care with
the Islamic notion of death and dying, several important questions come to the fore. First, if pain
leads to the expiation of sins and has a higher purpose, can pain relief be taken? If so, the second
question that arises is whether the substance used (i.e. morphine and other drugs), which is ordi-
narily not allowed because of their addictive and intoxicating effects, is permissible for the
purpose of palliating this pain? Further, if Islam forbids acts that terminate life prematurely,
what if the pain medication carries with it the potential to abbreviate life? In addition, can the
patient be sedated when emphasis is placed on optimising their final days? This part of the dis-
cussion assesses the potential opportunities and challenges that modern palliative care poses to
Muslim patients.

Opportunities
In dealing with the first question, Muslim scholars have highlighted that recognition of an inherent
value and larger meaning in pain and suffering should not overshadow nor in any way prevent
Muslims from seeking pain relief. In fact, not only are they allowed to avail themselves of
such assistance, efforts in this direction are obligatory and regarded as highly virtuous (Al-Shahri
& Al-Khenaizan, 2005; Sachedina, 2012). As emphasised by Sheikh (1998, p. 138), undue pain
and suffering “has no place in Islam”. Muslims should accordingly seek to benefit from pain relief
methods that are available to help lessen their pain and suffering.
Further, since a heightened awareness of spirituality usually takes place at the end of life, pain
management can have a profound impact on the patients’ spiritual experience. Importantly, it
could enable them to engage in acts of worship and remembrance of God in ways that would
otherwise be severely compromised had they been in excruciating pain (Al-Muzaini et al.,
1998; Mitchell, 2007). It would also allow them to carry on with important “illness work” like
sorting out their wills and other unfinished businesses; and mending strained relationships
(Murray, Kendall, Boyd, Worth, & Benton, 2004). This is especially more so since the lowering
of pain intensity would also generally lead to a reduction in emotional distress (Fainsinger &
Nekolaichuk, 2008). Therefore, pain relief would provide them not only with added physical
strength but also with a better clarity of mind to concentrate at such a crucial stage in their spiritual
journey. Pain relief would also help retain their belief in God. This is because too much pain may
result in them wondering why God has not heeded their supplications and a difficulty in reconcil-
ing their present suffering with the promise of a good afterlife. This could have a denigrating
 36 K.A. Choong

effect on faith by making them question the benevolence or even the existence of God. Such
thought patterns carry with them a risk of capitulation which can be tempered or obviated
through the enhancement in their quality of life (Murray et al., 2004; Puchalski & O’Donnell,
2005; Worth et al., 2009).
Moreover, given the interdependency and mutual care commended in Islam, the inclusion of
the family within palliative medicine’s remit of decision-making and care can also be beneficial.
Firstly, it supports many Muslim communities’ family-centred approach to care planning and
medical decision-making. Secondly, in view of the centrality of family within Muslim commu-
nities, the patient’s suffering could easily lead to disequilibrium within the household and a
radical reconstruction of everyone’s life (Bloomer & Al-Mutair, 2013; Daaleman, Usher, Wil-
liams, Rawlings, & Hanson, 2008; Murray et al., 2004; Omari, 2009). Identifying and addressing
affected family members’ physical, psychosocial and spiritual needs could help optimise their
well-being and coping capability. This would in turn enable them to continue providing
comfort and more effective care to their critically ill family members (Al-Hassan & Hweidi,
2004; Al-Mutair, Plummer, Clereham, & O’Brien, 2013; Omari, 2009). Another positive effect
Downloaded by [180.241.58.99] at 09:47 20 October 2017

on the dying patients is that it would prevent them feeling like a burden on their families,
thereby lessening the thought of radical options like suicide or euthanasia (Adeniyi, 2013;
Murray et al., 2004) both of which as discussed earlier, are strictly forbidden in Islam.

Challenges
However, if pain management can have faith-enhancing and faith-preserving qualities, there are
challenges that require scrutiny. As Muslims are not generally allowed to consume intoxicating
mind-altering substances like alcohol and narcotics (Khan, 2003; Sahih Al-Bukhari, 1994) can
these otherwise prohibited substances be taken for the relief of pain and symptoms especially
when they can induce addiction and sedation, or even accelerate death?
Here, it is important to note that for individuals who are not mentally disabled, Islam places a
premium on mental alertness. This is to ensure that they maintain God-consciousness at all times
and be accountable for their acts and omissions. It is for that reason that it forbids the consumption
of addictive, inebriating and mind-altering substances as these can impair reasoning, perception,
discernment, moral sensitivity and will-power (Al-Qaradawi, n.d.; Qur’an 5:90–94). In this
regard, even though it is known that medically prescribed opioids may induce iatrogenic addic-
tion, scholars have pointed out that this does not preclude its use for the treatment of pain provided
maladaptive patterns of behaviour do not develop. These are when the person became preoccu-
pied with using opioids despite adequate analgesia, and where it entails persistent over-sedation
(Rahimi-Movaghar, Rakhshani, Mohammadi, & Rahimi-Movaghar, 2004).
Before looking at the latter, namely, persistent over-sedation, what if a hastened death is a
foreseeable consequence or side effect of the pain and symptoms relief administered? As noted
earlier, Muslims are not allowed to avail themselves of any forms of assistance that would
bring about a premature death. Responding to this dilemma, commentators have opined that
since the interventions are primarily aimed at reducing pain and suffering, they would be accep-
table provided death was definitely not the intention of the doctor (Gatrad & Sheikh, 2001;
Schultz et al., 2012). Thus, the foresight/intention distinction epitomised by the doctrine of
double effect finds approval in Islam (Abrahm, 2005). The large dosage of opioids must,
however, be prompted by a pressing need since necessity negates prohibition (Qur’an 2:173,
6:145). Further, the amount given must not transgress that which is needed to bring about the
relief required (Malik, 2012).
Returning to the issue of persistent over-sedation which as mentioned above is generally pro-
scribed under Islam, some scholars have stressed that since the aim of the Shariah is always the
 Global Bioethics 37

welfare of human beings, medication-related sedation would be permissible on the grounds of

necessity (Al Qaradawi, n.d.; Al-Shahri & Al-Khenaizan, 2005). This is on the condition that
no other medicines are available to be used as substitutes, and that the concession is strictly
limited to that quality which is deemed essential, that is, to stave off excruciating pain which
is intractable to other forms of pain control that does not compromise or obliterate consciousness.
The depth and duration of the sedation should thereby be proportional to the patient’s symptoms
(Hasselaar et al., 2009; Khan, 2003). In addition to proportionality, the intention behind the seda-
tion must clearly be palliation and not euthanasia (Koh et al., 2009). However, basic hydration and
nutrition cannot be discontinued during sedation. This is prohibited in Islam as it would have the
effect of starving the patient to death (Bulöw et al., 2008).
At the same time, this concern to relieve the pain and suffering via sedation needs to be
balanced against the significance of maintaining a level of consciousness as close to normal as
possible so as to enable the patient to observe prayers and other forms of worship or remembrance
of God for the longest time possible before death (Al-Shahri & Al-Khenaizan, 2005). This is
especially important since Muslims nearing the end of life, as emphasised previously, would
Downloaded by [180.241.58.99] at 09:47 20 October 2017

like to optimise the time left to gain as much spiritual growth as possible and to prepare for
the hereafter. They would also ideally wish for the syahadah to be the last words uttered or
heard. However, it may not be easy to maintain a state of equilibrium allowing for optimal
pain control and a normal level of consciousness (Al-Shahri & Al-Khenaizan, 2005). The
ability to think clearly and to communicate well may be compromised in most situations
where sedating agents are administered. Moreover, certainly in cases where deep sedation is
used, this will obliterate consciousness to the point where the patient’s life is purely biological.
They have no self-awareness and are not able to perform any act of worship, nor steep themselves
in remembrance of God. Neither can they, in that state, have any contact or ability to interact with
their family (Cherny, 2009; Materstvedt & Bosshard, 2009).
All these underline the necessity of a detailed explanation of the levels and mechanics of sedation,
and their benefits and side effects to dying patients and their families. It may well be the case that they
may refuse the intervention, preferring instead to endure the pain so as to maintain a better level of
consciousness when it is clear that death is imminent. Indeed some would find this more desirable
than to have a clouded sensorium or even a complete lack of awareness of the moment of death
(Al-Shahri & Al-Khenaizan, 2005; Kemp, 2005; McCulloch, Comac, & Craig, 2008). Alternatively,
they may choose a level of sedation that brings some but limited pain relief, so as to enable them to still
prioritise their religious commitments and values (Olsen, Swetz, & Mueller, 2010). As for patients for
whom deep and continuous palliative sedation seems to be the only viable option and where there is
no intention to bring them back to consciousness before they die, they could be advised to say their
final farewell to family and friends, and to recite the syahadah before the sedating agent is adminis-
tered (Materstvedt & Bosshard, 2009). All in all, health care professionals should be prepared for dis-
cussion about pain relief at the end of life to revolve around concerns of how their Muslim patients can
best fulfil their religious duties and good deeds over the limited time that remains. In line with that, the
decision of what option(s) should be pursued should ultimately belong to the patient and his family as
they are often best placed to know which approach would best allow them to serve God (Schultz et al.,
2012).

Conclusion
As highlighted above, although palliative care is a relatively new area of medicine, it has managed
to transform end-of-life care through the introduction of a range of effective pain management and
symptom control techniques. It has nevertheless been reported that Muslims in the West have not
availed themselves of hospice and palliative care services in proportion to their numbers (Gatrad
 38 K.A. Choong

& Sheikh, 2002; Harford & Aljawi, 2013). This low uptake is partly attributable to the fact that the
shift of focus from cure to care with the aim of enhancing quality of life is not a concept which
readily registers with the Muslim psyche, there being no direct equivalence to the term “to palli-
ate” in the language of Muslim communities. In addition, there is also the perception that since the
philosophy and practice of palliative care are based on the secular Western model of health care,
the interventions offered do not cohere with religious norms (Gatrad & Sheikh, 2002). However,
as the preceding discussion demonstrated, not only does the idea of pain relief correspond to
Islamic teaching on the care of the sick and the dying, pain management also holds faith-enriching
potential. It is therefore important that this lack of awareness and general understanding be
addressed so that more people from this faith group will access and benefit from palliative care.
As for Muslims who live in other parts of the world, palliative care services are still not widely
available. Yet these are regions where the majority of Muslims reside, in which the preventative
and curative treatment for cancer and other serious diseases are also still underdeveloped (Harford
& Aljawi, 2013). As a consequence, an exceptionally large number of patients present themselves
for medical attention at advanced stages of their disease. Since they are mainly incurable at the
Downloaded by [180.241.58.99] at 09:47 20 October 2017

point of diagnosis, the provision of palliative care would seem the most humane, realistic and
appropriate approach (Stjernsward et al., 2007). However, despite the fact that their need for
pain management is proportionally greater, palliative care services and programmes are currently
only available in a small number of Muslim-majority countries (Al-Shahri, 2002; Harford &
Aljawi, 2013; Wright, Wood, Lynch, & Clark, 2008). The vast majority of such patients are there-
fore not receiving pain relief and are undergoing unnecessary and preventable pain and suffering
(Daher et al., 2002). For that reason, training, capacity building and the integration of palliative
care into the health care system need to be prioritised. Understandably, issues such as poverty, the
sheer number of patients to be served, inadequate health infrastructure and the need to compete
with other priorities like primary health care, education and defence means that the provision of
multi-professional teams may not be a realistic goal in many countries (Chaturvedi, 2008). At the
very least, however, they should concentrate on the provision of pain relief as a starting point, for
reasons emphasised earlier. However, since pain management itself is a moving field (Magnus-
son, 2006), continuous discussion is called for in relation to how far new techniques would be
suitable for implementation and utilisation in the future.

Acknowledgements
An earlier version of this work was presented at the UNESCO Chair in Bioethics 9th World Conference held
in Naples between 19 and 21 November 2013. I am grateful to the participants of the conference for their
helpful comments. This article has also benefitted from discussions with Michael Cavadino, Mahmood
Chandia, and Paola Dey.

Disclosure statement
This work is not funded by any parties and the author does not anticipate any financial interest or benefit
arising from the direct application of the research.

References
Abrahm, J. L. (2005). A physician’s guide to pain and symptom management in cancer patients. Baltimore:
Johns Hopkins University Press.
Adeniyi, O. B. (2013). Euthanasia as a contemporary issue in the jurisprudence of rights: The position of
Islamic law. Yonsei Law Journal, 4(2), 85–112.
 Global Bioethics 39

Al-Hassan, M. A., & Hweidi, I. M. (2004). The perceived needs of Jordanian families of hospitalized, cri-
tically ill patients. International Journal of Nursing Practice, 10(2), 64–71.
Al-Mutair, A. S., Plummer, V., & Copnell, B. (2012). Family presence during resuscitation: A descriptive
study of nurses’ attitudes from Saudi Arabia. Nursing in Critical Care, 17(2), 90–98.
Al-Mutair, A. S., Plummer, V., Clereham, R., & O’Brien, A. (2013). Needs and experiences of intensive care
patients’ families: A Saudi qualitative study. British Association of Critical Care Nurses, 19(3),
135–144.
Al-Muzaini, A. S., Salek, M. S., Nicholls, P. J., & Alomar, B. A. (1998). The attitude of health care pro-
fessionals toward the availability of hospice services for cancer patients and their carers in Saudi
Arabia. Palliative Medicine, 12(5), 365–373.
Al-Qaradawi, Y. (n.d.). The lawful and prohibited in Islam. Retrieved from http://www.dartmouth.edu/~
dcare/pdfs/yusuf.pdf
Al-Shahri, M. (2002). The future of palliative care in the Islamic world. Western Journal of Medicine, 176(1),
60–61.
Al-Shahri, M., & Al-Khenaizan, A. (2005). Palliative care for Muslim patients. Journal of Supportive
Oncology, 3(6), 432–436.
Aramesh, K., & Shadi, H. (2007). Euthanasia: An Islamic medical perspective. Iranian Journal of Allergy,
Asthma & Immunology, 6(suppl. 5), 35–38.
Downloaded by [180.241.58.99] at 09:47 20 October 2017

Barnard, D., Towers, A. M., Boston, P., & Lambrinidou, Y. (2000). Crossing over: Narratives of palliative
care. New York: Oxford University Press.
Bentur, N., Emanuel, L. L., & Cherney, N. (2012). Progress in palliative care in Israel: Comparative mapping
and next steps. Israel Journal of Health Policy Research, 1(1), 15–17. doi:10.1186/2045-4015-1-9
Bloomer, M. J., & Al-Mutair, A. (2013). Ensuring cultural sensitivity for Muslim patients in the Australian
ICU: Consideration for care. Australian Critical Care, 26(4), 193–196.
Bowler, P. J., & Morus, I. R. (2005). Making modern science: A historical survey. Chicago: University of
Chicago Press.
Bradshaw, A. (1996). The spiritual dimension of hospice: The secularization of an ideal. Social Science and
Medicine, 43(3), 409–419.
Bulöw, H. H., Sprung, C. L., Reinhart, K., Prayag, S., Du, B., Armaganidis, A., … Levy, M. M. (2008). The
world’s major religions’ points of view on end-of-life decisions in the intensive care unit. Intensive Care
Medicine, 34(3), 423–430.
Carey, S. M., & Cosgrove, J. F. (2006). Cultural issues surrounding end-of-life care. Current Anaesthesia
and Critical Care, 17, 263–270.
Chaturvedi, S. K. (2008). Ethical dilemmas in palliative care in traditional developing societies, with special
reference to the Indian setting. Journal of Medical Ethics, 34(8), 611–615.
Cherny, N. (2009). The use of sedation to relieve cancer patients’ suffering at the end of life: Addressing
critical issues. Annals of Oncology, 20(7), 1153–1155.
Clark, D. (1999). Cradled to the grave? Terminal care in the United Kingdom, 1948–1967. Mortality, 4(3),
225–247.
Clark, D. (2002). Between hope and acceptance: The medicalisation of dying. British Medical Journal, 324,
905–907.
Clark, D. (2007). From margins to centre: A review of the history of palliative care in cancer. The Lancet
Oncology, 8(5), 430–438.
Clarfield, A. M., Gordon, H., Markwell, H., & Alibhai, S. M. (2003). Ethical issues in end-of-life geriatric
care: The approach of three monotheistic religions – Judaism, Catholicism, and Islam. Journal of the
American Geriatrics Society, 51(8), 1149–1154.
Curlin, F. A., Nwodim, C., Vance, J. L., Chin, M. H., & Lantos, J. D. (2008). To die, to sleep: US physicians’
religious and other objections to physician-assisted suicide, terminal sedation, and withdrawal of life
support. American Journal of Hospice and Palliative Medicine, 25(2), 112–120.
Daaleman, T., Usher, B., Williams, S., Rawlings, J., & Hanson, L. (2008). An exploratory study of spiritual
care at the End of life. The Annals of Family Medicine, 6(5), 406–411.
Daher, M., Tabari, H., Stjernswärd, J., Ammar, W., Nabhan, T. A. Khalil, M. B., … Mansour, Z. (2002).
Lebanon: Pain relief and palliative care. Journal of Pain and Symptom Management, 24(2), 200–204.
Davies, E., & Higginson, I. J. (Eds.). (2004). Palliative care: The solid facts. Milan: WHO.
De Graeff, A., & Dean, M. (2007). Palliative sedation therapy in the last weeks of life: A literature review
and recommendations for standards. Journal of Palliative Medicine, 10(1), 67–85.
Doumit, M. A. A., Abu-Saad Huijer, H., & Kelly, J. H. (2007). The lived experience of Lebanese oncology
patients receiving palliative care. European Journal of Oncology Nursing, 11(4), 309–319.
 40 K.A. Choong

Dowbiggin, I. (2003). A merciful end: The euthanasia movement in modern America. New York: Oxford
University Press.
Engelhardt, H. T. (2012). Suffering, dying, and death: Palliative care ethics “after God”. European Journal of
Science and Theology, 8(2), 5–13.
Fainsinger, R. L., & Nekolaichuk, C. L. (2008). Cancer pain assessment – Can we predict the need for
specialist input? European Journal of Cancer, 44, 1072–1077.
Gatrad, A. R., & Sheikh, A. (2001). Medical ethics and Islam: Principles and practice. Archives of Disease in
Childhood, 84, 72–75.
Gatrad, A. R., & Sheikh, A. (2002). Palliative care for Muslims and issues before death. International
Journal of Palliative Nursing, 8(11), 526–531.
Goodhead, A. (2010). A textual analysis of memorials written by bereaved individuals and families in a
hospice context. Mortality, 15(4), 323–339.
Hallenbeckt, J., & McDaniel, S. (2009). Palliative care and pain management in the United States. In R. J.
Moore (Ed.), Biobehavioral approaches to pain (pp. 493–514). New York: Springer.
Hamilton, J. (1995). Dr Balfour Mount and the cruel irony of our care for the dying. Canadian Medical
Association Journal, 153(3), 334–336.
Harford, J. B., & Aljawi, D. M. (2013). The need for more and better palliative care for Muslim patients.
Palliative and Supportive Care, 11(1), 1–4.
Downloaded by [180.241.58.99] at 09:47 20 October 2017

Hart, B., Sainsbury, P., & Short, S. (1998). Whose dying? A sociological critique of the “good death’”.
Mortality, 3(1), 65–77.
Hasselaar, J., Verhagen, S., Reuzel, R., van Leeuwen, E., & Vissers, K. (2009). Palliative sedation is not con-
troversial. The Lancet Oncology, 10(8), 747–748.
Haugen, P. S. (1997). Pain relief for the dying: The unwelcome intervention of the criminal Law. William
Mitchell Law Review, 23, 341–343.
Hillier, R., & Wee, B. (2012). From cradle to grave: Palliative medicine education in the UK. Journal of the
Royal Society of Medicine, 94(9), 468–471.
Hostel of God Annual Report. 1897. (cited in C. Humphreys, 158).
Humphreys, C. (2001). “Waiting for the last summons”: The establishment of the first hospices in England
1878–1914. Mortality, 6(2), 146–166.
International Association for the Study of Pain (IASP). (2008). Psychological aspects of cancer pain.
James, N., & Field, D. (1992). The routinization of hospice: Charisma and bureaucratization. Social Science
and Medicine, 34(12), 1363–1375.
Kaasa, S., & Radbruch, L. (2008). Palliatice care research – Priorities and the way forward. European
Journal of Cancer, 44, 1175–1179.
Kahn, M. J., Lazarus, C. J., & Owens, D. P. (2003). Allowing patients to die: Practical, ethical, and religious
concerns. Journal of Clinical Oncology, 21(15), 3000–3002.
Kemp, C. (2005). Cultural issues in palliative care. Seminars in Oncology Nursing, 21(1), 44–52.
Kemp, N. D. A. (2002). Merciful release: The history of the British euthanasia movement. Manchester:
Manchester University Press.
Khan, A. (2003). Islam, Muslim, and America: Understanding the basis of their conflict. New York: Algora
Publishing.
Khan, F. A. (2002). Religious teaching and reflections on advance directive – Religious values and legal
dilemmas in bioethics: An Islamic perspective. Fordham Urban Law Journal, 30(1), 267–275.
Knight, K. H., Brand, F. M., Mchaourab, A. S., & Veneziano, G. (2007). Implantable intrathecal pumps for
chronic pain: Highlights and updates. Croatian Medical Journal, 48(1), 22–34.
Koh, Y. H., Lee, O. K., & Wu, H. Y. (2009). “Palliative” not “terminal” sedation. Journal of Pain and
Symptom Management, 37(4), e6–e8. doi:10.1016/j.painsymman.2008.11.005
Laird, L. D., Amer, M. M., Barnett, E. D., & Barnes, L. L. (2007). Muslim patients and health disparities in
the UK and the US. Archives of Disease in Childhood, 92(10), 922–926.
Laird, B., Colvin, L., & Fallon, M. (2008). Management of cancer pain: Basic principles and neuropathic
cancer pain. European Journal of Cancer, 44, 1078–1082.
Limonero, J. T., & Gil-Moncayo, F. (2014). Importance of psychological research in palliative care: Barriers
in its development. Palliative Medicine and Hospice Care Open Journal, 1(1), 1–3.
Lloyd-Williams, M., Reeve, J., & Kissane, D. (2008). Distress in palliative care patients: Developing patient-
centred approaches to clinical management. European Journal of Cancer, 44, 1133–1138.
Magnusson, R. S. (2006). The devil’s choice: Re-thinking law, ethics, and symptom relief in palliative care.
Journal of Law, Medicine and Ethics, 34(3), 559–569.
 Global Bioethics 41

Malik, M. M. (2012). Islamic bioethics of pain medication: An effective response to mercy argument.
Bangladesh Journal of Bioethics, 3(2), 4–15.
Materstvedt, L. J., & Bosshard, G. (2009). Deep and continuous palliative sedation (terminal sedation), clini-
cal-ethical and philosophical aspects. Lancet Oncology, 10, 622–627.
McClement, S. E., & Chochinov, H. M. (2008). Hope in advanced cancer patients. European Journal of
Cancer, 44, 1169–1174.
McCulloch, R., Comac, M., & Craig, F. (2008). Paediatric palliative care: Coming of age in oncology?
European Journal of Cancer, 44(8), 1139–1145.
McNamara, B., Waddell, C., & Colvin, M. (1994). The institutionalization of the good death. Social Science
and Medicine, 39(11), 1501–1508.
Mitchell, D. (2007). Spirituality and cultural issues at the end of life. Medicine, 36(2), 109–110.
Monroe, B., & Oliviere, D. (Eds.). (2007). Resilience in palliative care: Achievement in adversity. Oxford:
Oxford University Press.
Murray, S. A. (2008). Continuous deep sedation in patients nearing death. British Medical Journal, 336
(7648), 781–782.
Murray, S. A., Kendall, M., Boyd, K., Worth, A., & Benton, T. F. (2004). Exploring the spiritual needs of
people dying of lung cancer or heart failure: A prospective qualitative interview study of patients and
their carers. Palliative Medicine, 18(1), 39–45.
Downloaded by [180.241.58.99] at 09:47 20 October 2017

NHS. (n.d.). TENS (Transcutaneous Electrical Nerve Stimulation): Overview. Retrieved from http://www.
nhs.uk/conditions/tens/pages/introduction.aspx
Nogueira, F. L., & Sakata, R. K. (2012). Palliative sedation of terminally ill patients. Revista Brasileira de
Anestesiologia, 62(4), 580–592.
Nuccetelli, S., & Seay, G. (2000). Relieving pain and foreseeing death: A paradox about accountability and
blame. The Journal of Law, Medicine and Ethics, 28(1), 19–25.
Olsen, M., Swetz, K., & Mueller, P. (2010). Ethical decision-making with end-of-life care: Palliative sedation
and withholding or withdrawing life-sustaining treatments. Mayo Clinical Proceedings, 85(10), 949–
954.
Omari, F. H. (2009). Perceived and unmet needs of adult Jordanian family members of patients in ICUs.
Journal of Nursing Scholarship, 41(1), 28–34.
Owen, R., & Jeffrey, D. (2008). Communication: Common challenging scenarios in cancer care. European
Journal of Cancer, 44, 1163–1168.
Payne, S., Seymour, J., & Ingleton, C. (Eds.). (2008). Palliative care nursing: Principles and evidence for
practice. Berkshire: Open University Press.
Pew Research Center (2013). Religious groups’ views on end-of-life issues. Retrieved from http://www.
pewforum.org/2013/11/21/religious-groups-views-on-end-of-life-issues/
Portenoy, R. K., & Bruera, E. (2003). Issues in palliative care research. New York: Oxford University Press.
Puchalski, C. M., & O’Donnell, E. (2005). Religious and spiritual beliefs in end of life care: How major reli-
gions view death and dying. Techniques in Regional Anesthesia and Pain Management, 9(3), 114–121.
Putnam, C. E. (2002). Hospice or hemlock? Searching for heroic compassion. Westport: Praeger Publishers.
Rahimi-Movaghar, V., Rakhshani, F., Mohammadi, M., & Rahimi-Movaghar, A. (2004). Opioid Use in
patients presenting with pain in Zahedan, Islamic republic of Iran. La Revue de Sante de la
Mediterranee Orientale, 19(1–2), 82–89.
Rassool, G. H. (2000). The crescent and Islam: Healing, nursing and the spiritual dimension. some consider-
ations towards and understanding of the Islamic perspectives on caring. Journal of Advanced Nursing,
32(6), 1476–1484.
Sachedina, A. (2012). Islam. In M. Cobb, C. M. Puchalski & B. Rumbold (Eds.), Oxford textbook of spiri-
tuality in healthcare (pp. 55–62). Oxford: Oxford University Press.
Schultz, M., Baddarni, K., & Bar-Sela, G. (2012). Reflections on palliative care from the Jewish and Islamic
tradition. Evidence-Based Complementary and Alternative Medicine, 2012. doi:10.1155/2012/693092
Shah, A., & Chandia, M. (2010). The relations between suicide and Islam: A cross-national study. Journal of
Injury and Violence Research, 2(2), 93–97.
Sheehan, M. N. (2005). Spirituality and the care of people with life-threatening illnesses. Techniques in
Regional Anaesthesia and Pain Management, 9(3), 109–113.
Sheikh, A. (1998). Death and dying – A Muslim perspective. Journal of the Royal Society of Medicine, 91
(3), 138–140.
Simon, A., Kar, M., Hinz, J., & Beck, D. (2007). Attitudes towards terminal sedation: An empirical survey
among experts in the field of medical ethics. BMC Palliative Care, 6, 4. doi:10.1155/2012/693092
 42 K.A. Choong

Smith, J. I., & Haddad, Y. Y. (2002). The Islamic understanding of death and resurrection. New York:
Oxford University Press.
Stjernsward, J., Ferris, F., Khleif, S. N., Jamous, W., Treish, I. M., Milhem, M., … Alwan, A. (2007). Jordan
palliative care initiative: A WHO demonstration project. Journal of Pain and Symptom Management,
33(5), 628–633.
Unroe, K. T., & Meier, D. E. (2011). Palliative care and hospice: Opportunities to improve care for the sickest
patients. Notre Dame J.L. Ethics and Public Policy, 25, 413–428.
Vargas-Schaffer, G. (2010). Is the WHO analgesic ladder still valid? Twenty-four years of experience.
Canadian Family Physician, 56(6), 514–517.
Walter, T. (2003). Historical and cultural variants on the good death. British Medical Journal, 327, 218–220.
WHO. (n.d.-a). Definition of Palliative Care. Retrieved from http://www.who.int/cancer/palliative/
definition/en/
WHO. (n.d.-b). WHO’s Cancer Pain Ladder for Adults. Retrieved from http://www.who.int/cancer/
palliative/painladder/en/
Worth, A., Irshad, T., Bhopal, R., Brown, D., Lawton, J., Grant, E., … Sheikh, A. (2009). Vulnerability and
access to care for south Asian Sikh and Muslim patients with life limiting illness in Scotland: Prospective
longitudinal qualitative study. British Medical Journal, 338, 183. doi:10.1136/bmj.b183
Wright, M., Wood, J., Lynch, T., & Clark, D. (2008). Mapping levels of palliative care development: A
Downloaded by [180.241.58.99] at 09:47 20 October 2017

global view. Journal of Pain and Symptom Management, 35(5), 469–485.