<Home> <Bioethics> <Organ Transplantation> <The transplantation of nerve cells, with particular reference to brain cells>

Sheikh Muhammad al-Mokhtar al-Salami Mufti of the Republic of Tunisia

In the name of Allah, the Compassionate, the Merciful

This paper deals with organ transplant, which is one of the remarkable achievements of modern medical science in the treatment of disease. It is divided into five main parts:

1. Donated organs

2. The Donor:

- Destruction of fertilised eggs
- The embryo after the first stage
- Using aborted foetuses

3. The recipient

4. The Surgeon and his team

5. The objectives of organ transplant

6. Summary

7. Questions

8. References

1. Primary organs essential for life: only one, the heart
2. Secondary organs, essential for life such as the lungs and the kidneys
3. Secondary organs that are not crucial for life, such as hands, legs and eyes
4. Various parts of the body such as skin and other tissues.

Organs essential for the perpetuation of life cannot be removed as long as the owner remains alive, even if he is in his final death throes, the reason being that no one can determine for certain the moment the soul leaves the body. It is also not possible to predict if the would-be recipient, though outwardly in an improved condition, might not actually die before the donor. Nevertheless, advances in science have shown that although a donor may actually die, certain organs can continue to perform their function. This useful and very beneficial discovery has led to more research into the reality of death itself in order to determine exactly when a person could be considered dead. We may divide life into an indisputable total condition, without which a person is dead, and a limited one which might continue, even though the person may otherwise be considered dead. In this state, a person may bequeath but may not inherit, can be buried, and is no longer capable of sustaining the relationship of marriage. If the wife of such a person gives birth, she would be allowed to marry someone else, even if his heart, kidneys and lungs continue to function. The deciding factor between life and death is the death of the brain stem and its decay. If the patient is injected three times and the medicine does not spread through the body, and all instrument show that the body has started to decompose, then that would indicate the state of death, medically as well as religiously. This has led to considering the possibility and implications of transplanting the brain, a vital organ that cannot be replaced and without which there is no meaning to life. The state of this organ is the factor that decides between life and death. Dr Mokhtar al-Mahdi was correct when he said that the true meaning of brain transplantation is the killing of one human being in order to transfer his brain to another who is already dead. He further stressed that what is said about brain transplantation belongs to the world of science fiction and, if it were possible at all, it should be described as the body being transplanted to the brain, and not the other way round, since it is easier to achieve.(1)

Our focus goes beyond the brain to the nervous system, which is connected to the brain through nerves conveying signals and controlling movement, sensation and the various bodily functions, whether conscious or unconscious. These functions of the nervous system are common to all human beings, unless the system is damaged, but the important part of the nervous system is the brain which receives sensory input and classifies it. Individuals may react in different ways to the same stimulus, and this is what makes each person unique. From this point of view, the brain embodies the real personality of the person. Differences in the brain's responses determine the destiny of the person, whether he will be happy or sad, knowing or ignorant, intelligent or stupid, brave or cowardly. This, in my view, influences the distinctive features of every person and may even over-ride his or her genetic reality. I, therefore, believe that there are three different levels of ruling in relation to the brain: (a) that dealing with the centres of sensation and the nervous system allocated to them, (b) that dealing with the systems controlling the bodily functions and (c) that dealing with the part of the brain that is the centre of decision-making. Since the brain is an essential organ that cannot be replaced, any ruling applying to its removal must include not only total but also partial removal.

II. The Donor :

The donor may be in one of the following states:-
First: He is able to exercise free will, is in control of all his faculties, and is free to do one of the following:-

1. To donate his brain or parts of his nervous system without it affecting his own life, which is the property of God alone. No one has the right to donate his or her life to someone else. Nor does he have the right to donate an irreplaceable part of his body. Just as the donation of one's finger is not acceptable, so also, and even more so, is donation of parts of the nervous system. Since the death of the nervous system precedes that of other parts of the body, it is not possible to preserve these parts in a live state after the death of the brain stem.

2. To sell his organs for cash or in exchange for other organs of the body. The ruling outlined above applies here also. Any such contract is unlawful because a human being cannot sell what he does not own, since life and the human body in all its totality is the property of God.

Second: He is not responsible for his actions for one or other of the following reasons. Either he is not of sound mind and his fate must be decided by a guardian or the ruler, or he is under-age, in which case his guardian has no right to donate parts of his body, since the guardian is appointed to protect and preserve the body and interests of his charge, who is not capable of protecting himself.

Third: He is an incomplete human entity such as a foetus or an embryo. This can be specified as being in a state of formation that extends from the point of fertilization of the egg up to 32 cells. Medical experts say that cells produced during this period are not specialised for specific functions and are therefore unsuitable for transplant.

Destruction of fertilised eggs
I have thought a great deal about the problem of surplus frozen fertilised eggs, whether it is permissible to destroy them and what use they can be put to.
Doctors treat women in order to make them produce a number of eggs which they remove (2) and fertilise in the laboratory, planting some of them and freezing the rest. Once they are certain that the planted egg has taken in the womb and has began to develop, they are faced with the dilemma of what to do with the rest of the fertilised eggs. These are now cells carrying their respective genes, each of which is in the very first stage of life. Can these living things be destroyed? It may be said that they are no longer of use, but can the loss of usefulness be used as a justification for destruction?

Muslim jurists have discussed whether an animal that is no longer of use can be destroyed. Al-Hattab reports al-Barzali as saying that when a cat was blinded and became of no use to its owner, Sheikh Ibn Arafah ruled that it should be fed and not killed. The same applies to creatures that have lost their usefulness due to old age or some kind of defect and also to young animals whose mother is not capable of providing them with enough nourishment. My own personal feeling is that this is permissible according to the principle advanced by the Prophet Muhammad of choosing the lesser of two evils. Izzudin bin Abdussalam was asked whether it was permissible to kill a destructive cat and his reply was that if its tendency goes far beyond normal cat behaviour and occurs repeatedly, it can be destroyed. Qualifications to this ruling are that the cat should not be killed if it is offered unclean meat and eats it, which is not normal for cats to do, or if it happens accidentally

Can animals who have become useless be killed to show mercy? My view is they should not, unless it is an animal whose skin can be used. (3)

In brief, then, any domestic animal should not be killed except for human use but if its flesh cannot be eaten or its skin cannot be used, it should not be killed unless it repeatedly shows harmful behaviour.

By analogy, it would seem more appropriate that the frozen fertilised egg be preserved and not destroyed. Dr Abdullah Hussain Basalamah has pointed out that at the point when a fertilised egg has reached stage 8 and has divided into 32 cells only, no limbs or organs are yet formed. He does not think that, at least at present, it is possible to use surplus eggs for organ transplant, although it is possible to use some of their cells. He believes that transplanting such cells is far better than destroying them, which would be comparable to infanticide.

Looking at the matter from both the religious and the medical point of view, the fertilised egg is not damaged, which would therefore argue for its being preserved. On the other hand, the number of surplus fertilised eggs will multiply with time and eventually there will be a huge number of them in existence. I understand they can be preserved for as long as 50 years. The convention is that fertilisation is not carried out until the parents have passed the age of 30, so that these eggs will live longer than the average age of either parent.

There is also a risk of eggs from different parents getting mixed, and that, as we know, would not be acceptable from the Islamic Shariah point of view. Another point is that 50 years is only an arbitraryfigure, and so we may ask: what time limit should be put on these eggs? Also, how great is man's need of these eggs and are they so scarce that they have to be stored for such a long time?

I believe that once the egg reaches 8/32 divisions and the parents no longer have a use for it, it should be destroyed. I also believe that it is risky for a doctor to transplant cells which can grow to a full human being, carrying all the properties and genes of a human being.

The embryo after the first stage
Once the foetus is attached to the wall of the uterus and begins to grow as God has intended, it could develop into a healthy normal being and be born as such. It could also separate from the womb much earlier, as in case of abortion. In the first case it would be a full human being accorded all rights and all its bodily parts are respected, while in the second case, it is dead and is of no use medically. The third case is the healthy foetus removed from the womb by the doctor during abortion. All scientists who respect human life are agreed that doctors should not have the right to separate the foetus from the womb, thereby killing it, for an unlawful purpose. There are, however, cases where the pregnancy is accompanied by certain complications that put the mother's life at risk, and where the baby's life is sacrificed to save that of the mother. These are case of necessity that should be considered and respected.

Using aborted foetuses
What is meant here is the foetus that has not taken on any faculties or distinct features such as crying, movement, sucking, sneezing etc. Scientists are agreed that no ritual washing or prayer is required for an aborted foetus less than 4 months old. Views vary, however, on those over 4 months old. If the foetus is delivered alive, it should be treated as a full human being. There is consensus among the experts that an aborted foetus within the first 4 months of life is not afforded the same human status as one coming after.

The question is: could its brain cells be used for transplantation to save or improve the life of someone else, as outlined on page 70 in Dr Mokhtar al-Mahdi's paper? However, he also points out that, although it is theoretically possible, scientists are still trying to achieve this in the laboratory as well as in real life applications. Making use of aborted foetuses is only possible, however, if the required organs are removed within minutes of the death of the foetus. The solution is to operate on the mother and remove the cells before the foetus is aborted. I find no objections to this being done, provided the parents' consent is obtained and the abortion is lawful and justified as outlined above and provided that the parents do not know the identity of the recipient, in order to eliminate the commercialisation of these operations. Otherwise, it would not be acceptable and should be debated. It is thought that foetal cells could be used to reinvigorate the brain and the hormones to overcome ageing, but this seems to be nearer to science fiction than to reality. In fact I am sure of that because overcoming ageing to fight death is a futile pursuit.

Fourth: The donor is a fully-grown adult whose life is no longer respected or protected, such as convicted prisoners sentenced to death, according to the Shariah, in clear-cut cases of murder. The Qur'an allows mercy to murderers if the next-of-kin of the victim grant a pardon: "In the law of equality, there is (saving of) life to you O ye men of understanding; that ye may restrain yourselves." (Surah I, 179) However, in cases where the victim's next-of-kin have not forgiven him, would it be it lawful to use parts of the brain or nervous system or cells of such criminals for transplantation purposes? Could this be justified under conditions of necessity as outlined by the jurists? [Here, it may be useful to consider what constitutes necessity in the case of the consumption of human flesh.]

1. What is necessity?
According to Al-Nawawi, the ulema have agreed that in cases of starvation and where there is inability to walk, ride or move, and there is the fear of being left behind or of contracting a threatening disease, and death may take place otherwise, then there may be justification for the consumption of human flesh. The Imam of al-Haramain says that this danger does not have to be imminent; the mere threat of it is sufficient. It is enough for the victim to perceive the threatened danger. (4)

2. To whom does this apply?
According to Al-Nawawi there is total agreement that, in the above circumstances, an enemy or an apostate may be killed and his flesh eaten. Regarding those convicted of adultery, piracy, or neglect of prayer, there are two views, the stronger of which, endorsed by Imam al-Haramain, al-Musannif and the majority of the ulema, says it is not permissible because we are not allowed to kill such people. Any such action must be left to the authorities to ensure they are not falsely accused. Such justification does not prevent the action once necessity is established. However, if the one in need has the right to kill someone as punishment for a crime, he would be justified to eat his flesh, whether with the permission of the authorities or not, as already pointed out, and according to al-Baghawi and others.

3. Can non-Muslims use organs of Muslims condemned to death?
According to Al-Nawawi, there are two views on this matter cited by al-Baghawi but he does not endorse either of them. On the basis of this, it does not appear that it is allowed in Islam. (1) From this we conclude that the one under duress must have a strong conviction that he would die or would suffer a serious chronic illness. In certain cases, therefore, the judgement would allow consumption of the flesh of those condemned to death, and in others only with consensus of Shafeai ulema. There is thus a difference of opinion regarding the use of organs of Muslims by non-Muslims.

If the consumption of human flesh is allowed, then it follows that the use of organs and tissues for transplantation would also be allowed. They would have to be removed from those rightly condemned to death shortly before execution, but with full precautions being taken to avoid torture or suffering.

Fifth: On page 7 of Dr Mokhtar al-Mahdi's paper, he points out that organ transplantation began with transplanting the cells of animals within their own bodies, such as cells taken from the suprarenal gland which produces dopamine. Is it permissible, therefore, to transplant organs or tissues of the same person within his own body, in which case, the donor is also the recipient?

Al-Zurqani says that it would be possible to allow someone to eat his own flesh in order to survive. He referred to the case of someone stung by a scorpion in the hand who could only survive by cutting it off (5). Al-Zurqani used this analogy to justify eating one's own flesh since, in both cases, limbs have been dispensed with to preserve life. Since it is acceptable to amputate a limb for that purpose, then it would similarly be permissible to transfer a limb or parts of it from one part of the body to another.

III. The recipient
We have pointed out that Muslims can benefit from one another's organs within the conditions already outlined. There is a difference of opinion with respect to non-Muslims and there is the view that a Muslim cannot donate his organs to a non-Muslim.

IV. The surgeon and his team
This would include all members of the medical team. Once a patient's life becomes in all probability dependent on surgery being performed, members of the medical staff are obliged, provided the conditions cited in this paper are satisfied, to carry out the operation, and in fact they would be rewarded. Any negligence on their part would be condemned and considered religiously sinful. The Shariah stipulates corporal punishment for such negligence. Where the patient's condition is not critical, then the surgeon's role would be to relieve pain and this would be considered commendable and worthwhile.

V. The objectives of organ transplant
The rulings with regard to organ transplant are dependent on the objective. Transplantation could be done for cosmetic reasons such as adjusting nose or chin size or enhancing one's looks. It could be done to change the identity by criminals or fugitives running from the law. These do not apply to brain or nervous system transplant because of their special role in giving a person his human qualities. Their transplantation must only be allowed for genuine psychological or physiological reasons of restoring health and normality to the body and psychological balance to the person. Thus, such transplantation is permissible within the conditions outlined earlier and when a good chance of recovery exists.

Summary
Organ transplant is a means whereby doctors overcome illness, pain and mutilation and is therefore a form of treatment.
There are five elements underlying this treatment:
The donated organ
The donor
The recipient
The surgeon
The purpose of the transplant

The transplant organ
This would only be of use if still alive. An organ may continue to live after the death of its owner whose brain stem is dead. It may or may not be a life-saving organ. Since the brain is a unique and vital organ, it must not be wholly or partly removed from anyone capable of sustaining life.

The donor
Donors fall into 4 categories:
1. Adults whose life is respected and their organs cannot be removed voluntarily or for remuneration.
2. Minors or individuals of lower mental ability whose guardians have no right to dispense with their organs.
3. The foetus, when or before the cell has divided into 32 units. Since the cells have no distinct functions up to this point, they would not be suitable for transplant. I am of the opinion of destroying these fertilised eggs as soon as they become redundant. After the tenth week, if the foetus was unlawfully aborted, its use would not be permissible; otherwise, if the mother gives her consent, use can be made of some of its organs and tissues even if their removal requires operating on the mother.
4. Adults whose life is not protected according to Islam i.e. those whose blood can be shed. Their organs may be used as of necessity, as when the recipient's life is threatened with death or a long, debilitating illness.
It is permissible to transplant parts of the body within the same body.

The recipient
Within the areas outlined, there is full agreement that transplantation is permissible from one Muslim to another and from a non-Muslim to a Muslim. Transplanting Muslim organs into those under Muslim protection is a matter of some disagreement, while the transplant of Muslim organs into non-Muslims is not permitted.

The surgeon
If the patient's life is in danger, the transplant, under the above conditions, would be obligatory and the medical team would be rewarded. If the condition is not critical, the operation would be commendable in God's eyes, as long as the surgeon does it for the sake of pleasing God Almighty.

The objective of the transplant
If the reason is a physical or psychological need it is permissible. If it is for the purpose of eluding the law, it would not be so, and the majority opinion is that it would not be allowed for cosmetic purposes.

Questions
I have followed closely the work produced by Dr Mokhtar al-Mahdi, Mamoun al-Hajj Ali Ibrahim and Abdullah Hussain Basalamah, all of whom are to be commended for their excellent effort. I have benefited a great deal from their work on which I have based many of my own findings. However, certain points continue to cause concern and confusion:

On page 65 Dr Mokhtar al-Mahdi refers to "the hormones affecting sexual glands and the ability to ovulate again." Medical literature I have read indicates that females store a finite number of eggs which are released during ovulation. How do hormones bring about ovulation again?

On page 67, we read: "transplant inside the brain does not affect the personality." Since brain cells are responsible for behaviour and choice, how could transplanted foetal cells not affect the personality of the recipient if they carry their own genes and complete genetic codes.

On page 70 he lists the cases in which nervous tissue was transplanted, but what is important in my view is the rate of success. He seems to underestimate the use of the foetus aborted in the 11th week, which is the period just before the soul is blown into the body. My question is: Does medicine differentiate between the four months and the period preceding them, and is what is happening a development of the first creation or development complementary to the first creation?

On page 199 of Dr Mamoun al-Hajj Ali Ibrahim's paper, he asks whether dead organs could be transplanted, which begs the question whether limbs and organs on their own are alive or dead. A dead organ cannot be made alive again in this world.

On page 185 of Dr Abdullah Hussain Basalamah's paper, he states that a foetus in the first eight weeks has no organs or tissues that are of any use, but adds that foetuses taken out of the womb after the fourth month are suitable for transplant purposes. I have not been able to reconcile this with what Dr Mokhtar al-Mahdi says on page 7 of his paper that sexual cells are taken between weeks eight and ten of pregnancy.

REFERENCES
(1) Page 2
(2) The Arabic word 'shafat' is used by medical experts but it is not in the dictionary.
(3) Mawahib al-Jalil, vol3, page 236
(4) Al-Majmoua, vol. 9, page 44
(5) Al-Zurqani: Sharh al-Khalil, vol. 3, page 28