Clarification on Islamic Jurisprudence and Transplantation

We read with interest the article by Padela et al¹ on Islamic jurisprudence, organ transplantation, and the recent Fiqh Council of North America ruling.² Transplantation has long been contentiously discussed in Islamic medical ethics communities. In such dilemmas where the Qu’ran or Hadīth do not clearly describe the proper course of action, principles including ijtihad (independent legal reasoning),^3,4 istihsan (preferential reasoning of jurists), al-urf (local customary precedent), and al-masalih al-mursalah (public interest or welfare) may offer guidance.^5,6 Ijtihad-generated rulings (fatawa), however, are case specific and not globally binding.^5,7,8 Jurist disagreements (ikhtilaf) are common and key to understanding the Islamic legal tradition.⁹ This means that a jurist’s ruling on 1 case (eg, transplantation) is not by default invalidated or reversed by an opposite finding by a different jurist on a different case of the same topic.^10,11 This may in part be because the merits, context, and participants in each case differ. A Muslim scholarly saying states: our opinion is a right one with the possibility of being wrong, and others’ opinions are wrong ones with the possibility of being right.¹⁰ Failure to understand this concept may generate uncertainty, confusion, and aid conflict.

Important theological elements for understanding Islamic views toward transplantation include the sacredness of life (Qur’an 5:32), respect for the human body and its use (Qur’an 17:36,70) and Hadīth of the Prophet Muhammad (‘alayhi as-salām).^i12,13 Accordingly, some may believe that organ transplantation/donation is prohibited; however, several Islamic jurisprudential principles have allowed others to determine its permissibility including (1) necessity-breaks-the-law (darūra); (2) working for the public interest or wellbeing of society (al-masalih al-mursalah); and (3) altruism (al-ithar). Darūra may allow for exceptions to general rules, while al-masalih al-mursalah and al-ithar may allow arguments that overrule the individual in favor of greater society.¹⁴

Disagreements exist regarding transplantation fatawa. Of 42 identified fatawa (Table 1), 23 were Sunni (13 permissible, 7 conditional, 3 prohibited), 16 were Shi’a (4 permissible, 11 conditional, 1 prohibited), and 3 were joint Sunni/Shi’a (1 permissible, 2 conditional). Thirty-six (86%) of fatawa permit organ donation conditionally or unconditionally. Autologous transplantation is widely accepted if performed for medical indication (ie, not cosmetic), success is likely, and it carries no mortality risk.¹⁴ Proposed restrictions to allogeneic transplantation including (1) donor has full mental capacity; (2) donor consent (may be granted postmortem by closest relatives)¹⁵; (3) adult (preferable >21 y);^15,16 (4) medically determined to be lifesaving or able maintain the recipient’s quality-of-life without suitable alternative; (5) recipient benefit exceeds donor harm and some stipulate; and (6) live donation only of nonvital (ie, self-renewing) or nonsingular organs (eg, hematopoietic cells, skin, kidney, lung, liver).¹⁴ Gonad transplantation is forbidden; however, other internal sex organs (eg, uterus) may be permissible.¹⁴

TABLE 1.

Summary of Islamic fatawa regarding the permissibility of transplantation

Given the quantity, language, and timeline of rulings, topic knowledge of individual religious leaders may vary. Public awareness of transplant fatawa is suboptimal.^9,55–61 Fatawa have limitations and are case specific; context is important. A dissenting ruling arising within 1 context, time, or location is not necessarily binding on those in another, and vise-a-versa. Accordingly, transplant permissibility may justifiably vary by circumstance, time, location, and context.