Brain death revisited: it is not 'complete death' - Program on ...

Global medical ethics

Brain death revisited: it is not ‘complete death’ according to Islamic sources Ahmet Bedir,1 S xahin Aksoy2 1

Harran University, Faculty of Divinity, Department of Tafsıˆr (Islamic Exegesis), Sanliurfa, Turkey 2 Harran University, Faculty of Medicine, Department of Medical History and Ethics, Sanliurfa, Turkey Correspondence to Professor Sahin Aksoy, Harran University, Faculty of Medicine, Department of Medical History and Ethics, Harran University, Faculty of Medicine, Department of Medical History and Ethics, Dekanlik Binasi, Sanliurfa 63300, Turkey; [email protected] Received 14 September 2010 Accepted 14 November 2010 Published Online First 2 February 2011

ABSTRACT Concepts, such as death, life and spirit cannot be known in their quintessential nature, but can be defined in accordance with their effects. In fact, those who think within the mode of pragmatism and Cartesian logic have ignored the metaphysical aspects of these terms. According to Islam, the entity that moves the body is named the soul. And the aliment of the soul is air. Cessation of breathing means leaving of the soul from the body. Those who agree on the diagnosis of brain death may not able to agree unanimously on the rules that lay down such diagnosis. That is to say, there are a heap of suspicions regarding the diagnosis of brain death, and these suspicions are on the increase. In fact, Islamic jurisprudence does not put provisions, decisions on suspicious grounds. By virtue of these facts, it can be asserted that brain death is not absolute death according to Islamic sources; for in the patients diagnosed with brain death the soul still has not abandoned the body. Therefore, these patients suffer in every operation performed on them.

INTRODUCTION The notion of ‘brain death’ came into the medical scene following the practical application of organ transplantation practiced in accord with pragmatic and Cartesian premises; namely it does not arise due to ordinary causes. Aside from whether organ transplantation is objectionable or not, according to certain Islamic principles, in order to carry out this procedure it is important that person shall be certainly dead. According to scientific data that we are going to address later, it is very questionable that ‘complete death’ occurs with brain death. There are some scientific evidence and publication in medical field and in pertinent Islamic sources that, organ transplantation procedure before ‘complete death’ donors feel pain. Hence, the clarification of this matter is saliently important.

WHAT IS DEATH? Etymological meaning of death In Arabic, the word al-mawt means ‘death’. Lexically, it means ‘stopping of a thing; stagnating; calming down; insensitiveness’; as such it is the opposite of ‘life’.1 Al-mawât in Arabic denotes a thing without soul.1 Hence, the word al-mawt composed of the letters ‘mîm’, ‘wâw’, and ‘ta’ etymologically means ‘losing of power and force of a thing’. As for killing, it is an act that causes the spirit (al-nafs) leave body; this occurs through the disembodiment of the soul from body.2 In Arabic, there are many synonyms for the word al-mawt.3 For instance, the terms al-karb, sakarah 290

al-mawt (sakat al-mawt), ghamarât al-mawt means being on the brink of death (being close to death or death agony), or being close to dying. These terms also denote the meanings of al-ajal, ‘predestined time of death’, or al-hashraj al-sadr connoting the end of dying process.3 Meanwhile, patient who is in the process of death, but not died yet is called al-mayt or al-mâit.1

Terminological definition of death It is not possible to explain the real nature of death. The one who cannot understand the ‘real meaning’ of lifedthe opposite of deathddoes not comprehend the nature of death. ‘Knowing’ life is possible only by ‘knowing’ the reality of the soul and understanding its nature. However, speaking precisely about the soul is impossible, even for the Prophet who receives revelation from Allah.4 Death can be described by looking its effects before passing to its ‘real’ nature. Accordingly, death etymologically means separation of the soul from the body,5 6 and cessation of the signs of life.7 Separation of the soul from the body occurs via separation of the spirit from each and every tissue in of the body, showing no signs of vitality in any part of the corpse. In this regard, for al-Ghazzâlî (d 505 AH/1111 CE), an influential Islamic scholar, says that separation of the soul from the body is the end of its dominance over the body. Thence, the divine core in the body called ‘spirit’ cuts its relevance from the body.8 According to another Islamic scholar, death itself is a living entity; thus, the event of death occurs when life is separated from the body. That is to say, ‘death’ having a kind of life and a kind of existential body is translocated, changed with life that which has a kind of spirit.8Thus, the event of death is just a ‘change of state’.8 The fact pointed out by certain Qur’anic verses and hadiths (prophetic traditions) pertaining to this subject that death is not simply a type of change; but the soul separated from the body is either in a state of punishment, or in a mode of blessing.9 This situation explains why Ibn Sînâ (known as Avicenna in the West) (d 429 AH /1037 CE) writes: ‘We know with the language of attitude and behaviour, and of word that death is to be born from the world into Hereafter’.10 Thus, according to the mainstream Islamic understanding, death is an entity in opposition to life, like cold and hot.7

WHAT IS SOUL FROM ISLAMIC PERSPECTIVE? Lexical meaning of the soul Lexically, soul means ‘light breeze’, or ‘wind’. In the Qur’ân, it comes to denote such meanings as ‘the Qur’ân’, ‘divine revelation’, ‘Gabriel’, ‘name of an J Med Ethics 2011;37:290e294. doi:10.1136/jme.2010.040238

Global medical ethics angel’, ‘prophecy (nubuwwah), ‘Jesus’, ‘blowing out’ and ‘puffing out’, and so on.11

Etymological meaning of soul The nature of soul is not yet known. In the Qur’ân, it is asserted that its nature and mystery cannot be known except by Allah.4 Because of this, those who want to define the soul try to explicate its features. Consequently, in etymological terms, the soul is of living, conscious and beatific existence, and is a luminous entity; and the source of life itself. What is more, it is a divine gift that comes8 12 from the ‘realm of order’8 as a canon. At the same time, this entity is called as spirit11 (jân in Persian, cân in Turkish). And what is the possessor of the body and the genuine owner of the corpse is this spirit. This entity is named nafs by Muslim philosophers. According to general community among Muslim intellectuals, the soul is a luminous entity having ability to speak and understand what is spoken, and like water surrounding plants and trees, it surrounds every part of the body too, and is post-eternal; hence it never dies out.13 At the same time, it is a substance which does not pass away with the death of corpse14; thence it is not a matter, or an accident.15 Just as all religious orders are addressed to it, rewards and punishments of the ‘Hereafter’ are also inflicted upon it being a substance, not a matter, or an accident. What some scholars, such as al-Ghazzâlî, according to whom it is graded as al-nafs al-mutma’innah (‘reassured spirit’), al-nafs al-râdiyyah (‘contenting spirit’), al-nafs al-mardiyyah (‘contended spirit’), some Sufis for whom it is renamed as qalb (‘heart’), and philosophers, who name it as al-nafs al-nâtıqah (‘speaking spirit’) laid bare that the function of the substance of the soul/spirit consists of ‘mentioning’, ‘protecting’, ‘thinking’, ‘separating what is good from bad’ and ‘understanding the spiritual world’.16 Al-Jurjânî (d. 815 AH /1413 CE) evaluates the soul within _ three categories. These are: (a) ‘human’ (Insân); (b) ‘animal’ (Hayawân); (c) ‘supreme’ (A’zâm). He views that the human soul is a knowing and comprehending entity and uses the animal soul as ‘riding’, and cannot be known by any human intellect.17 This soul moves from time to time dependent and independent of the human body.8 The animal soul/spirit is also called18 as astral body,19 dedublo, or arua.20 This soul is also a luminous entity and is located in the corporal heart, and spread into the body through arteries. What is more, the corpse is a tool of the animal spirit, and the animal spirit is a tool of the human soul. As for the supreme soul, it is a human soul, and its nature can be known only by Allah. This soul is also known as al-‘aql al-awwal (‘the first intellect’), haqîqah Muhammadiyyah (‘the quiddity of Muhammad), al-nafs al-wâhidah (‘the first spirit’), and haqîqah al-Asmâ’ (‘quiddity of the Names [of Allah]’). Just as five sense faculties sense the outside world, so a human being has inner qualities for feeling the inner world. It is the soul that feels both inner and outer senses that succeed to the realm of isthmus along with its feelings by dying. Hence, the one whom we assume dead may not lose his sensations, such as knowing, hearing, seeing, and so on, by transposing from the realm of matter to that of souls, which is a station within the realm of order. Thence, with these sensations, he may be able to think all meanings and memories of this world in the next world.10 On the other hand, just as the aliment of the body is water, so the nourishment of the soul is air21; hence the body cannot live without water and the soul without air. Therefore, respiration is determinant evidence whether the soul leaves the body, or not. According to the mainstream Islamic notions in Islamic theology, the soul does not die, yet only the body does.8 The soul continues to live after disembodiment from its body. The fact J Med Ethics 2011;37:290e294. doi:10.1136/jme.2010.040238

that the soul does not die is confirmed also by the Qur’ân.22 In the hadiths, the souls of martyrs are alive and nourished in Heaven.23 Therewithal, the soul is a created entity; hence it is not pre-eternal. The spirits of those who die otherwise are waited until the decision made whether they will be in heaven, or in hell.24 And upon decision made about them they continue to live in their appropriate places (heaven, or hell). According to some Muslim theologians, since it is a nafs (‘self ’), the spirit will taste the agony of death; and upon the death of the body, it will die, as well.25

HOW IS THE SOUL SEPARATED FROM THE BODY In the Islamic creed, the events, or phenomena that cannot be grasped by the five senses are knowable only through the information provided by the religious sources (Qur’ânic verses and prophetic traditions). Though in the prophetic traditions26 27 there is a knowledge about the beginning of granting life to human being in the womb28 that occurs after 40 or 45 days29 (or nights),23 or 120 days30 after implantation to the uterus; whereas there is no religious text regarding the ultimate separation of the soul from the body. Nevertheless, there are Qur’ânic verses and hadiths about how and where the spirit is separated from the corpse. The verse ‘why, then, when (the soul) cometh up to the throat (of the dying); and ye are at that moment looking’31 shows that the spirit/soul [cân/jân] comes out of the throat, and the time of death agony that leads to the departure of the soul from the body. Again in the following verses, the spirit comes out of the collarbone32 at the bottom of the neck towards arms: ‘Nay, but when the life cometh up to the throat; and men say: Where is the wizard (who can save him now)? And he knoweth that it is the parting.’32 What is more, according to one hadith, it comes out of the cheek.33 Thence, the spirit is taken out like a socket of shoulders, or cheek. This situation indicates also that the spirit comes out from feet to head with a movement. Upon the departure of the soul from the body, it is received by the angel of death.23 34 35 In the hadith explaining how the soul comes out, the soul is poured out of the body, like water drips from a water container.23 36 In the 27th verse of the Surah al-Qiyâmah (‘The Rising of the Dead’: ‘Resurrection’ that describes the departure of the soul, there is a ‘pause’/‘discontinuation’ (saktah) between the words man, and râq during recitation. This pause denotes two meanings: As for the situation concerns out topic under study, the verse is read with ‘pause’ (saktah); thus it implies that though breathing ceases, yet the soul that makes living continue departs. Accordingly, the spirit maintains its relation with the body via breathing. Therefore, only the end of respiration means the separation of the spirit from the body. In another prophetic tradition explaining the separation of the soul from the body, the deceasing person follows the soul separating from the body with his eyes as if he follows something material, staring at his front in a standing-on position.21 Thus, this implies ‘complete death’; and, depending on this state, shrouding and burial procedures can be permitted in Islam. In the hadiths explaining the departure of the soul, the soul is an entity spread to the entire body. In Islamic sources, the organs that manage to live are brain, heart and liver. It is obvious that the death of the brain implies the end of brain functions in the deceased person; for according to them all organs are subject to the brain. Yet for Ibn Sînâ, the heart and the soul are the components that start life.21 In the hadith, it is mentioned that the liver is also a source of life itself. Ibn Sînâ’s Qânûn talks about these two fundamental elements in 291

Global medical ethics human body. Here, at this juncture, even the brain is not mentioned in the first place. In the Islamic resources, the soul along with the heart and the liver are the basic sources of life. One hadith specifically emphasises that the liver is a source of life and essence of vitality.37

SYMPTOMS OF DEATH The symptoms of the death are sought through classical methods, or some classical medical knowledge in the periods when technical equipments are highly primitive. In our present time, medical advancements are considerably high, death can be ascertained through more accurate methods.

Death and symptoms of death according to classical knowledge In order to determine certain rights and responsibilities necessitate in favour of, and at the expense of heritors after the death of a legator, determining the complete death’ of an individual is saliently important in Islamic jurisprudence. Thus, this subject matter is evaluated within the categories and subcategories in the books written in the field of Islamic law (Fiqh). According to ‘ulâmâ’ (‘Muslim scholars’), it is not lawful to initiate the processes of shrouding and other funerary requirements before ‘complete death’ comes true. According to classical detection method, when one dies: one’s breathing is interrupted32; forehead becomes sweaty23; one’s feet release itself from their arthroses; feet may not be pulled up and down38; joints between arms and hands become released39; nose bends towards right or left, and twists40; skin wrinkles disappear, and facial wrinkles improve and become smooth41 42; temples come down inside43; in men testicles shrink with their skins sagging40; the body becomes cold; feet and nose turn to blue40; staring of the eyes becomes sharp44; lips remains apart45; in the elderly eye blackness is lost. Briefly, in order to judge one’s death all circumstantial evidences of life must be absent. The evidence above set forward by Muslim jurists to prove the occurrence of death does not take after the criteria of neither ‘brain death’, nor ‘cardiac death’. Amidst these, the greatest evidence for death is the termination of respiration.

Death and symptoms of death according to modern medicine According to modern medicine, death can be defined as: The cessation of respiratory and circulatory systems as well as brain functions irreversibly. This consists of the following four main elements.46 When the above features come true, respiratory and cardiac devices on patient are withdrawn; thence this mode of death is called ‘clinical death’. After the withdrawal of life support machines, blood circulation to the brain stops and thus brain cells die; thence this mode of death is named ‘biological death’. And the body cells and tissues decease gradually; thus the type of death is capsulated as ‘cellular death’. With this last type of death, the cells of the body die irreversibly.46e48 For the sake of generalisation, the symptoms of death in modern medicine look, by and large, like those of death in classical medicine.

WHAT IS BRAIN DEATH? As a clinical diagnosis, brain death is the cessation of brain functions wholly and irreversibly of the patients who are in coma due to trauma inflicting his skull caused by traffic accidents, and so on. At Harvard University in 1968, the ‘criteria for brain death’, which are highly specific and based on suppositions, were 292

specified and called the ‘Harvard Criteria for Brain Death’.44 Those that pursue this case have consensus on the issue described as ‘brain death’; yet not on the criteria that determine brain death.49 In the diagnosis of brain death, the conditions determining its cause cannot be ascertained and are not without speciousness.50 These criteria have been developed further by anaesthesiologists and biologists. And, with passage of time, every country, and every hospital began to set separate criteria. In the ANA and IAC medical committees, a table for the diagnosis of brain death was created, based on the criteria for the methods of brain death diagnosis.51 Upon increase in the criteria for the diagnosis of brain death, doubts and speculations around this concept grew more and more, that which has been treated as dubious since very beginning.52

CAN BRAIN DEATH BE REGARDED AS ‘COMPLETE DEATH’ FROM ISLAMIC PERSPECTIVE BASED ON CURRENT MEDICAL DATA? Brain death is not ‘complete death’, a concept which is unanimously adopted. All approaches in this regard are based on experimental observations. Yet the soul that makes life possible for human beings is not an entity based on experimental observations or empirical experiences. Those who diagnose brain death neglect, by and large, this aspect of the human being.51 Accordingly, the diagnosis of brain death is put forward with pragmatic and Cartesian logic. The concept of death, which is a determining fact in terms of social, legal, medical or religious duties and responsibilities regarding individuals, and us towards them, went through a drift of meaning caused by the concept of brain death put forward especially in the second half of the 20th century, and the adaptation of it by the masses. As described above, death is the complete separation of the soul from the whole body. In the case of brain death, however, it is doubtful that the soul is completely separated from the body. It is unknown whether the soul departed the body due to, even if artificial, the continuation of respiration, and flow of the blood in the arteries. Yet the most important evidence proving the separation of the soul is the absence of respiration. Accordingly, to relate one’s death to brain death means connecting religious provisions to non-related sources, or factors. Even though the cessation of brain is one of the signs of the separation of the soul, the heart functions; thus other symptoms of death do not appear. Therefore, the original provision remains as it was, since the individual is still alive. As the soul may be still in the body, then the person can suffer due to the processes inflicted on him. As mentioned in the previous section, the main source of aliment for the soul is air. There have been many errors in the apnoea tests conducted to ascertain the cessation of respiration, which is the most important proof for the separation of the soul from the body.53 On the other hand, the diagnosis of ‘brain death’ did not make any effect in accelerating organ transplantation.54 Scholars of Islamic jurisprudence have agreement on the idea that death happens via the separation of the soul from the body. Contemporary Muslim scholars have conflicting notions regarding such a person, who lives a limited life with the help of resuscitation devices, on whether his peduncle death is irreversibly death, or not. Some claims that absolute death cannot be come true only through brain death, without cardiac death. Whereas some others adduce that absolute death happens with brain death only, save for cardiac death. Unfortunately, these scholars form the majority in this matter. In the Muslim world, J Med Ethics 2011;37:290e294. doi:10.1136/jme.2010.040238

Global medical ethics scholars, such as Yusuf al-Qaradawî, Ahmad Sharafaddin, Muhammad ‘Ali al-Bâr and others advocate this view.55 The patients diagnosed with brain death are kept on lifesupporting equipment; their urinary actions are monitored; in case of infection, they are given antibiotics; even cardiac massage is done if their hearts stop.56 If anaesthesia is applied, the patients diagnosed with brain death may able to respond to the strokes of scalpel; and their blood pressure and heartbeat markedly increase.53 Organs taken from the patients diagnosed with brain death are received from them, who are still ‘alive’, whose heart beats, breathe even, if, whose blood circulation continues, carry the warmth of a human being and even may suffer from pains.57 Proven scientific studies have shown that the patients, who respond positively to neurological tests, and to the extant clinical criteria used in the diagnosis of brain death, are not expected to lose all brain functions. That is, the diagnosis of the cessation of all brain functions cannot be come true with the current standard diagnostic tests.58 Now, it has clearly emerged that the concept of ‘brain death’, which is a prognostic indicator like kidney failure or liver failure, is a big artifice through which the living persons are declared dead.59 On the other hand, the phrase ‘brain death’ carries different meaning apart from the meaning expressed with the word of ‘death’. In the form of noun phrase, it is understood that this concept implies ‘a kind’ of death. That alone is a matter of criticism, as well. In this case, there is no difference between brain death, cardiac death, kidneys death, and so on. All of these indicate that brain death is not ‘complete death’, and there are dozens of suspicions regarding it. According to Islamic law, there are universal rules based on the Qur’ânic verses and prophetic traditions. Two of such rules regarding the issue under study are ‘authentic knowledge may not disappear with suspicion’59 and ‘it is essential that thing remains as it has been’. When this subject is evaluated according to these two precepts the following predicates can be asserted: what is essential for the patient diagnosed with brain death is his life? And his relation with death is laid down with the diagnosis of brain death. In fact, in the criteria for the diagnosis of brain death, there are various decisions, and greater suspicion as mentioned before. Namely, the subject is controversial. Thus, there are various results and findings that change from hospital to hospital, from one country to another country, from device to device through which pertinent analysis is made. All of these problems constitute a complete doubt. Accordingly, if there is a doubt in the decision to be made, then the original situation is left as it has been. The issue is returned to the previous mode or state. This is because, with suspicion, the truth over which full conviction is realised cannot be eliminated. To illustrate this: It is forbidden to kill someone unjustly. Then the logic continues as follows: the patient who is diagnosed with brain death is still alive. While respiration is provided with respirator or ventilator, its heart beats and respiration continues. In this case, it is in sheer doubt that the patient who breathes with the aid of a respirator lose his soul. Thus, it can be argued that dissecting the individual whose blood circulates by heart beating and whose lungs are functioning by artificial respiration is equivalent to killing a human being. According to another principal Islamic rule, the terminology of ‘brain death’ emerged during the time when organ transplantation was performed successfully, and has been used for this end. Nevertheless, in accord with these rules, such as ‘no harm shall not be removed via its equal’ and ‘constraint does not repeal other’s right’59 one’s harm does not necessitate to harm J Med Ethics 2011;37:290e294. doi:10.1136/jme.2010.040238

others, or one’s difficult situation cannot justify the annulment of another ’s right. Therefore, the person who is diagnosed with brain death is still ‘alive’, and suffering from the agony of death near death, or in the process of dying. In order that the patient who is in need of a healthy organ to live, that person diagnosed with brain death cannot be sacrificed in favour of the former.

CONCLUSIONS Those who define the soul, though its real nature cannot be fully known, try to describe it via its effects; thence they ignore its metaphysical aspects. All approaches in this subject are within the boundaries of the positivist perspective based only on experimental observations and empirical experiences. Nevertheless, the soul that makes life possible in a human being is not definable through experimental observations or empirical experiences. Those who put forward the diagnosis of brain death always neglected one aspect of human life. Accordingly, the diagnosis of brain death has been set forth with a pragmatic and Cartesian logic. Those who accept the diagnosis of brain death have not been able to concur on the criteria for identifying such diagnosis. In the diagnosis of brain death, the speciousness determining this diagnosis cannot be averted. The concept of brain death is to be discussed at academic level and in public as well as in the platforms where opposing views are welcome; and legal arrangements should be made accordingly. By the way, it should be accepted that there have not been any codes unanimously adopted during legislative amendments in this issue. In Islamic jurisprudence, the diagnosis of ‘complete death’ is clear. Those who believe in the acceleration of organ transplantation decided on the diagnosis of brain death that is not accepted unanimously as ‘complete death’ are not saved from the oppositions and contrariness posed by the members of Islam, and of other heavenly religions. In Islam, as in other legal provisions, the provisions concerning human life cannot be built on suspicions. The diagnosis of brain death is then a decision entirely based on doubt. On the other hand, no one in Islam can be sacrificed for another one. Human life is respected wholly and fully; and until self-delivering the soul, his life is guaranteed. According to the Qur’ân and Sunnah of the Prophet, the main sources of Islamic legislation, the aliment of human body is water, and the pabulum of the soul is air. Just as in the absence of water the body collapses, so with the cessation of air the spirit goes out. The patient whose life is wanted to be prolonged for organ transplantation through artificial respiration is still breathing and continues his life. Succinctly, it is obvious that as long as therein exists air, or breathing, the spirit is still therein. Hence, be it via artificial respiration, or via self-respiration, the patient who continues to breathe is accepted as alive in Islamic jurisprudence. This fact, for the sake of generalisation, negates the diagnosis, and also claim of brain death as ‘complete death’. Provenance and peer review Not commissioned; externally peer reviewed.

REFERENCES 1. 2. 3. 4. 5. 6.

Al-Mısrıˆ Muhammad B, Mukarram B. Manzuˆr Lisaˆn al-‘Araˆb, Vol. 2, Beirut: Daˆr Sadır: 92, No publication date. [in Arabic]. Al-Bahuˆtıˆ, Mansuˆr B, Yuˆnus Kashshaˆf al-Qınaˆ. ed. by Hilal Musaylihıˆ, Vol. 5. Beirut: Daˆr al-Fikr, 1402 AH eAfter Hicrah- (Islamic lunar calender): 504. [in Arabic]. Al-Farahidıˆ, Abuˆ ‘Abdurrahman al-Halil B. Ahmad Kitaˆb al-‘Ayn by Mahdi al-Mahzuˆmıˆ: Daˆr wa Maktabah al-Hilaˆl. No publication date or place. [in Arabic]. The Meaning of Glorious Qur’an, Trans. by Marmaduke Pickthall. New York: A.A. Knopf, 1930. Chapter Al-Israˆ’, 17/85. Qayyıˆm al-Jawziyyah Ibn, Muhammad B, ed. Abuˆ Bakr Shifaˆ’ al-‘Alil lby Muhammad Bedruddin. Beirut: Daˆr al-Fikr, 1398 AH: 92. [in Arabic]. Nawawıˆ A, Abuˆ Zakariya Muhyiddin Yahya B. Sharaf al-Majmuˆ‘ Sharh al-Muhazzab, Vol. 5. Beirut: Daˆr al-Fikr, 1996:94. [in Arabic].

293

Global medical ethics 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33.

Bursawıˆ IH. Tafsıˆr Ruˆh al-Bayaˆn, Vol. 10. Istanbul: Maktabah al-Mahmuˆdiyyah. 75. No publication date. [in Arabic]. Al-Ghazzaˆlıˆ, Abuˆ Hamıˆd Muhammad B. Muhammad Ihyaˆ’ ‘Uluˆm al-Dıˆn, Vol. 4. Beirut: Daˆr al-Ma‘rifah: 493e95. No publication date. [in Arabic]. ˆyi al-Qur’aˆn, Vol. 1. Beirut: Al-Tabarıˆ, Muhammad B. Jarıˆr Cami’ al Bayan ‘an T’awil A Daˆr al-Fikr, 1405. AH: 189. [in Arabic]. Erzurumlu Yesxilzaˆde Mehmed Salih Ruh ve Mevt [the Soul and Death]. Istanbul: Burhaneddin Publishing, 1940:62. [in Turkish]. Firuzabadıˆ, Abuˆ al-Taˆrıˆkh Majd al-Dıˆn Muhammad b. Ya‘kuˆb b. Muhammad al-Okyanuˆs al-Basıˆt fıˆTarjumah Qaˆmuˆs al-Muhıˆt. Trans. by Mu¨tercim Asım Efendi, Vol. 1, Istanbul: Cemal Efendi Publication, 1304 AH: 472. [In Ottoman Turkish]. Nursıˆ, BS So¨zler (The Words), Vol. 1. Istanbul: Nesil Publication, 1996:231. [in Turkish]. Al-Shirbıˆnıˆ, Muhammad B. Ahmad al-Hatıˆb Mughnıˆ al-Muhtaˆj ilaˆ Ma ‘rifah Alfaˆz al-Minhaˆj, Vol. 1. Beirut: Daˆr al-Fikr:329. No publication date. [in Arabic]. Muhammad Munıˆr B. ‘Abduh al-Ithaˆf al-Saniyyah bi al-Ahaˆdith al-Qudsiyyah. Beirut: Daˆr Ibn Kathıˆr:146. No publication date. [in Arabic]. ¨lu¨m ve ¨otesi: Gazaˆlıˆ ¨uzerine bir arasxtırma. [The Soul, death and beyond: Yazıcı R R. O An Investigation on al-Ghazzaˆlıˆ]. Istanbul: _Iz Publication, 2007:41. [in Turkish]. Al-Ghazzaˆlıˆ, Abuˆ Hamıˆd Muhammad B. Muhammad Majmuˆ ‘ah Rasaˆil al-Imaˆm al-Ghazzaˆlıˆ Proofreader: Ibrahim Emin Muhammad. Cairo: al-Maktabah al-Tawfıˆqiyyah: 242. No publication date. [in Arabic]. Al-Jurcaˆnıˆ, ‘Ali B. Muhammad Ta‘rifaˆt. Beirut: Daˆr al-Kutub al- ‘Ilmiyyah, 1988:112. [in Arabic]. Gu¨len MF. Varlıgın Metafizik Boyutu [Metaphysical Dimension of Existence]. Istanbul, 2008:50. Nil Publication. [in Turkish]. Walker DP. The Astral Body in Renaissance Medicine. J Warburg Courtauld Inst 1958;21:119e33. Mufti AR. The Aura of Authenticity. Social Text 2000;18:87e103. Ibn S, Abuˆ ‘Ali Husayn B, ‘Abdullah B. ‘Ali Belkhıˆ(Avicenna) al-Qaˆnuˆn fıˆ al-Tıb, Vol. 3 (Manuscript, composition date 1020 AH, Haydarabad, number. A1000), waraq/ “leaf”: 210. [in Arabic]. ˆl-i ‘Imraˆn, 3/169. The Meaning of Glorious Qur’an A Ahmad B. Hanbal Musnad, Vol. 1: 265. No date or place of publication. [in Arabic]. Al-Bukhaˆrıˆ: “Kitab al-Janaˆiz” 90. [in Arabic] No date or place of publication. Al-Mawsuˆ ‘ah al-Fikriyyah al-Kuwaytiyyah Ruh [Soul] Vol. 39. Kuwait: Wizaˆrah al-Awqaˆf wa Shuuˆn al-Islamiyyah, 1404. AH: 250. [in Arabic]. Ibn Qayyıˆm al J, Muhammad B. Abuˆ Bakr Shifaˆ’ al-‘Alıˆl. Cairo: Maktabah Daˆr al-Turath: 39. No date or place of publication. [in Arabic]. ¨niversitesi _Ilahiyat Bedir A Kur’an ve _Ilim. [The Qur’aˆn and Science]. Harran U Faku¨ltesi Dergisi. J Faculty of Divinity 1996;2:296e7. [in Turkish]. Al-Bukharıˆ “Kitaˆb al-Qadar” 1. No date or place of publication. [in Arabic]. Al-Muslim “Kitaˆb al-Qadar”, 1, 2, 5. No date or place of publication. [in Arabic]. Al-Bukharıˆ “Kitaˆb al-Bad’ al-Khalq” 6. [in Arabic] No date or place of publication. The Meaning of Glorious Qur’an Al-Waˆqi‘ah, 56/83e4. The Meaning of Glorious Qur’an Al-Qiyamah, 75/26. Tabaraˆnıˆ A, Sulayman B, Ahmad B. Ayyuˆb al-Mu ‘jam al-Kabıˆr. In: Hamdi B, ed. Abdulmecid, Vol. 10. Mosul: Maktabah al- ‘Uluˆm wa al-Hikam, 1983:90. [in Arabic].

34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59.

Ibn AbıˆShaybah, Abuˆ Bakr ‘Abdullah b. Muhammad Musannaf. Kamaˆl Yuˆsuf al-Huˆt, ed. Vol. 3, Riyadh: Maktabah al-Rushd, 1409 AH: 54. Tayaˆlisıˆ A, Sulayman B. Daˆvud Musnad Tayaˆlisıˆ. Beirut: Daˆr al-Ma‘rifah:102. No publication date. [in Arabic]. Maˆlikıˆ A, Ahmad B. Ghunaym al-Fawaˆkih al-Dawwaˆnıˆ, Vol. 1, Beirut: Daˆr al-Fikr, 1415. AH: 283. [in Arabic]. Al-Bukharıˆ Kitab al-Mazaˆlim 23. [In Arabic] No date or place of publication. Al-Shaˆf‘ıˆ, Muhammad b. Idrıˆs al-Umm, Vol. 1, Beirut: Daˆr al-Ma‘rifah, 1393 AH: 274. [in Arabic]. Mardawıˆ A, ‘Alau¨ddin Abuˆ al-Hasan B. Sulayman al-Insaˆf fıˆ Ma ‘rifah al-Raˆjihi min al-Kkilaf ‘alaˆ Madhhab Imaˆm Ahmad b. Hanbal, Vol. 2. Beirut: Daˆr Ihyaˆ’ al-Turaˆth, 1419. AH: 328. [in Arabic]. ‘Atiyyah B. Muhammad Saˆlim Sharh Bulugh al-Maraˆm: 113. No date or place of publication. [In Arabic]. Al-Nasaˆ’ıˆ Sunan, “Kitab al-Janaˆiz”: 10. [In Arabic] No date or place of publication. Al-Jawıˆ, Muhammad b. ‘Umar Nihayah al-Zayn, Vol. 1, Beirut: Daˆr al-Fikr: 148. No publication date. [in Arabic]. Al-Maˆlikıˆ, ‘Ali al-Saidıˆ Haˆshiyah al-‘Adawıˆ In: Yuˆsuf al-Shaykh Muhammad al-Bikaˆˆ,ı ed. Vol. 1, Beirut: Daˆr al-Fikr, 1412 AH: 512. [In Arabic]. ˆbidıˆn Haˆshiyah Ibn ‘A ˆbidıˆn, Vol. 1: 189. No date or place of publication. Ibn ‘A [In Arabic]. Mohandas A, Chov SN. Brain death: A clinical and pathological study. J Neurosurg 1971;35:211e18. Capron AM, Lynn J. Defining Death. Science 1982;215:612. Anon. Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death, A Definition of Irreversible Coma. JAMA 1968;205:337e40. Korein J. The problem of brain death: development and history. Ann N Y Acad Sci 1978;315:19e20. Wijdicks EFM. Determining brain death in adults. Neurology 1995;45:1003e11. De Tourchaninoff M, Hantson P, Mahieu P, et al. Brain death diagnosis in misleading conditions. QJM 1999;92:407e14. Joralemon D. Organ wars: the battle for body parts. Med Anthropol Q 1995;9:335e56. Lizza JP. Persons and death: what’s metaphysically wrong with our current statutory definition of death? J Med Philos 1993;18:351e74. Machado C, Kerein J, Ferrer Y, et al. The concept of brain death did not evolve to benefit organ transplants. J Med Ethics 2007;33:197e200. Al-Baˆr M. Ajhizah al-Inaˆs Majallah Majma‘ al-Fıqh al-Islaˆmıˆ 1(2):457. No publication date. [In Arabic]. Kerridge IH, Saul P, Lowe M, et al. Dying and donation: organ transplantation and the diagnosis of death. J Med Ethics 2002;28:89e94. Han SG, Kim GM, Lee KH, et al. Reflex movements in patients with brain death: a prospective studyin a tertiary medical center. J Korean Med Sci 2006;21:588e90. Cantor NL. The real ethic of death and dying. Mich Law Rev 1996;94:1718e38. Al-Suyuˆtıˆ, ‘Abdurrahman b. Abuˆ Bakr al-Ashbaˆh wa al-Nazaˆir. Daˆr al-Kutub al-‘Ilmiyyah, 1403 AH: 86. No publication place. [In Arabic]. Jam ‘iyyah al-Majallah, Majallah Najib Hawawinıˆ. ed. Kaˆrkhaˆna Tijarah Kutub: 19. No publication date. [In Arabic].

Journal of Medical Ethics View our active blog now live at JME online. blogs.bmj.com/medical-ethics

294

J Med Ethics 2011;37:290e294. doi:10.1136/jme.2010.040238