How can we improve the rate of autopsies among Muslims?

Among Muslim people in Britain the uptake of autopsies in general, and perinatal and paediatric autopsies in particular, is low. Family members may decline consent for an autopsy for several reasons: they believe that Islam doesn't allow autopsy; they see no need for an autopsy because of their belief that death is God's will; advances in medical knowledge mean that everything is already known about the case and hence an autopsy isn't necessary; they fear that the body will be desecrated; and they worry that an autopsy will prevent the body from being buried as soon as possible, an Islamic requirement. Are these reasons justified?

Islamic law is derived from three sources: the Koran, the Sunnah—which includes the teachings, whether by word or deed, of Mohammed—and ijtihad, the process of deductive logic. The laws set by the Koran and Sunnah are obligatory for all Muslims and cannot be disputed. Ijtihad opinion is formulated by a single scholar or group of scholars who reach a consensus. The ruling, called a fatwa, is not binding. It can be right or wrong and can be debated and modified, so a range of views on a given question is possible.

Although death is God's will there is no reason why we cannot do autopsies

Although most Muslims believe that Islam doesn't allow autopsies, neither the Koran nor the Sunnah has actually addressed the issue. The belief is based only on the ijtihad of scholars and on cultural beliefs wrongly attributed to Islam. Muslims used to believe that organ transplantation was not permitted in Islam. In 1952 the supreme head of the Islamic School of Jurisprudence in Egypt issued a fatwa that if anything was of “good” for humanity then “necessity allows what is prohibited” (BMJ 1994;309: 521-3). The ruling allowed organ transplantation in certain circumstances, and now many Muslims see organ donation as a charitable act. In Britain a collaborative effort led to a fatwa allowing Muslims to donate organs and carry donor cards.

Building on the 1952 ruling, a fatwa committee in 1982 found that the benefits of autopsies outweighed the drawbacks if they increase the knowledge of medical students and doctors, help control contagious diseases, and serve the cause of justice. The main reason for hospital autopsies is to help the family understand what went wrong and in perinatal cases to identify problems that can be avoided in future pregnancies. Also, autopsies benefit medical science, so there is no reason why they cannot be permitted.

Figure 1.

Body politics: autopsies need not delay burial

Credit: BIB NAT PARIS/CHARMET/THE BRIDGEMAN ART LIBRARY

The belief among Muslims that autopsies are unnecessary because everything, including death, happens according to God's will is illogical. Illness also happens through God's will, and no Muslim would argue against treating sick people. The guiding principles of Islamic law include the maintenance of life and of the intellect. The first verse of the Koran revealed to Mohammed commanded him to read (to learn), and countless teachings of the Prophet encourage Muslims to learn and apply their knowledge for the benefit of all. Autopsies are essential to increase our understanding of disease processes, to determine accuracy of clinical diagnoses, and to assess effectiveness of treatments. Although death is God's will there is no reason why we cannot do autopsies, learn from them, and apply our knowledge for the benefit of all.

With advances in diagnostic tests and imaging techniques, clinical diagnoses have become increasingly accurate. This has resulted in a perceived decline in the value of the autopsy among doctors and the public. Yet studies have shown that new information was gathered in a quarter of autopsies (BMJ 2002;324: 761-3). Perinatal mortality among Pakistani mothers in Britain is twice the national average, indicating a need to investigate underlying causes in this group. Furthermore, irrespective of medical advances, the autopsy remains valuable in the counselling of families after the loss of an infant, as it can help in the grieving process, improve parents' understanding, and alleviate concerns.

Islam forbids the disfigurement or desecration of dead bodies. This has been taken literally by many Muslims as pertaining to autopsies. But Mohammed said that deeds depend on the intentions behind them. As the intention behind autopsies is the benefit to the family, medical science, and society, and if they are carried out according to the law of the land and pathologists' guidelines, then they should be regarded not as desecration but another medical procedure. An empathetic explanation to the family about an autopsy's purpose and that the body is treated with great respect would allay many concerns. Family wishes, such as not examining the head and returning all tissues back to the body, can also be accommodated.

With respect to burying the body, this should be done as soon as practically possible. Many Muslim families send their loved ones back to their original countries for burial, a process that can take up to a week. If pathologists are informed that the dead person is a Muslim they should be happy to do the autopsy as soon as possible. This is the current practice at the Royal London Hospital.

So what can we do to improve the rate of autopsies, including perinatal and paediatric autopsies, in the Muslim population? The “three Cs” of Toronto Hospital for Sick Children's paediatric autopsy service are relevant: communication (by experienced professionals who have some knowledge of the religious and cultural beliefs of Muslims and can explain to families the procedure and potential benefits of autopsies), compassion (showing families that their concerns are understood), and compliance (changing the protocol and timing of the autopsy as needed and if possible).

Most religious objections to autopsy derive not from the principles of the faith but from personal interpretations and anxiety. Most can be alleviated by knowledge, understanding, and respect.