A “good” fatwa

The word “fatwa” has come to have a rather sinister meaning in many Western countries. This misconception has arisen, in large part, as a result of one author and his work and the publicity given to a resulting fatwa. A fatwa is simply a legal opinion in Islam given by a mufti or other religious leader on a specific issue, and this account describes one with which I was involved.

In 1990 I was appointed chairman of surgery at a large hospital in Riyadh, Saudi Arabia. Most of the surgical patients had cancer, and many major and often futile resections were performed in patients who were really in need of good palliative care—there was no non-surgical alternative available at the time. The hospital's chief executive officer was made aware of the problem and asked me to explore the possibility of inviting an authority in palliative care to visit Riyadh to give advice. Dr Derek Doyle from St Columba's Hospice agreed to visit, and, as a result of his report, a palliative care service was established in the hospital in 1992.

In 1999 the European School of Oncology sponsored a symposium at the hospital. During the symposium a workshop was organised to address the problem of the availability and the distribution of narcotics to patients with advanced symptomatic cancer.¹ Many country-wide problems were identified. The goal of allowing patients with advanced cancer to die in dignity and without pain was identified as a worthy one, and one that would be appreciated by patients, their relatives, carers, and religious leaders. One of the obstacles to attaining this goal, however, related to the religious beliefs of patients and family members, which made the introduction of the “analgesic ladder” unacceptable to them. It was suggested that the religious acceptability of the appropriate use of pain relieving drugs in patients dying of cancer should be established through the Committee of the Leading Ulam'a (council of religious scholars).

One of my patients was a senior and respected imam and a member of the committee. We discussed the workshop and its findings, and he agreed to support a letter to the committee explaining the need to give parenteral opiates on a regular basis to patients with advanced cancer. He further agreed to invite the committee to issue a fatwa approving the use of parenteral opiates in patients with advanced cancer. About a year after the letter was sent, I received a fatwa from the Mufti General and President of the Committee of Leading Ulam'a. It stated that “there is no objection against using these analgesics [opium and other analgesics] in advanced cancer patients, because this is a necessity.”

This fatwa will surely benefit many patients both within Saudi Arabia and in other parts of the Muslim world and is perhaps my most important contribution, surprisingly non-surgical, to patient care. I may be the first non-Muslim Westerner to have gained such a fatwa. It was certainly not a negative fatwa.