Key words : Behavior change, Bioethics, Organ transplant, Public discourse, Religion

Introduction

The issue of low rates of organ donation among Muslims has sparked much public conversation. In recent years, government authorities and lawmakers in both Muslim-majority and Muslim-minority countries have called attention to the problems of low rates of organ donation. In 2016, Ahmad al Saidi, Minister of Health of Oman, brought attention to the country’s “severe lack of organs,” implicating Islamic beliefs as a cause.¹ In 2015, Hans Hoogervorst, the Dutch Minister of Health, stated² that “Muslims in particular refuse to donate their organs” due to their beliefs, but controversially are “ready to accept an organ if they are ill.” Similarly, as politicians in the United Kingdom attempted to cement a presumed consent policy for organ donation into law, media reports noted that Muslim communities remain vehemently opposed to the proposed legislation and to donation in general.³

Studies that reported a prevalent lack of acceptability toward organ donation among Muslims support this public discourse. In 2011, a multi-national poll of more over 1000 participants indicated that 12.7% were registered donors, and fewer than half believed donation was acceptable with Islam.4 The study discovered greater rates of unwillingness among highly devout individuals, who cited religious texts as a deterrent.⁴ A comparable minority of Muslim people were found to be registered donors in a 2013 study from the UK of more than 500 South Asian people.⁵ Professionals’ perspectives on organ donation provide additional anecdotal support. A recent quality evaluation undertaken by the Washington Regional Transplant Community (WRTC) discovered that Muslim families often deny donation of organs from their loved ones, indicating religious reasons.⁶

Thus, the public and professional debate on organ donation presents a picture of Muslims, as a group, who are hesitant to donate, with this reluctance grounded in religious principles. As a result, various stakeholders have launched public and community-based initiatives to educate Muslim populations about (1) the social need for and advantages of organ donation and (2) religious perspectives that consider the act permissible.

In the late 1990s, the Birmingham Organ Coordination Team collaborated with the UK Muslim Council to support the passing of a new Islamic fatwa that proclaimed organ donation to be permissible and marketed that verdict broadly.⁷ It was believed that this program⁸ “would lead to a breakthrough in resolving the problem of low donor rates among Muslims.” In 2018 to 2019, the National Health Service undertook a similar approach by requesting an updated fatwa from Mufti Mohammad Zubair Butt, a National Health Service chaplain and highly respected Islamic jurist.^9,10 Several Muslim organizations, notably the British Islamic Medical Association, held workshops and seminars using the verdict to influence Muslim attitudes.¹¹ Similarly, in the United States, the WRTC collaborated with Islamic jurists, Muslim community leaders, and prominent organizations to furnish a national fatwa to reaffirm Islamic sanction for organ donation and launched an educational campaign to disseminate this view.¹² It is unclear how effective such efforts have been in changing Muslim attitudes toward organ donation, as scant research has occurred and commentators point out methodological flaws in such campaigns.^13,14

This paper examines the factual and normative underpinnings of this view of Muslims, Islam, and organ donation. We will specifically disrupt the narrative that (1) highly pious Muslims hold unfavorable attitudes regarding organ donation and (2) Islamic laws that consider organ donation as prohibited are misinformed and/or erroneous. We hope to build the groundwork for more successful and ethically balanced educational interventions and informative campaigns by nuancing narratives that connect Islam and Muslim organ donation behaviors.

Empirical Data: Muslim Attitudes Toward Organ Donation

The ensuing discussion of the empirical literature on Muslim organ donation attitude is limited to studies of Muslims living in the diaspora, because Muslims residing in Muslim-majority countries have a different decisional context given that official juridical bodies dictate the locally normative and state-sanctioned Islamic position on organ donation. In a minority setting, Muslims may have to resolve ethical questions about organ donation for themselves. Furthermore, access to organ donation and transplantation is regulated by different rules in the developing world than in the health care systems across Europe, the UK, and the United States.

Although organ donation is supported by over 95% of the American population, reported support among American Muslims is substantially lower.¹⁵ For example, a representative population-based study of 1016 Arab Americans living in southeast Michigan found that only 35% of respondents held that deceased organ donation was always justified, whereas 20% considered it to never be justified. Muslim Arabs were approximately 1.5 times less likely to support organ donation than Christians.¹⁶ In a smaller study of 93 American Muslims recruited through mosques in Michigan, only 39% believed that organ donation after death was justified.¹⁷ Another community-based survey of 227 Muslim Americans in Chicago found a similarly low rate of support, with only 51% of those polled willing to donate their organs.¹⁸ Studies of Muslims in Australia and the UK show similarly low rates of acceptance of organ donation.^4,5,19-22

In academic and public discourse, the poor acceptance of organ donation among Muslims is frequently linked to religion. Illustratively, an Australian study found that those with higher levels of religiosity were less likely to be organ donors and held fewer favorable opinions on the topic.²² Similarly, a sizeable transnational survey of Western Muslims reported that a higher degree of religiosity was associated with more unfavorable views toward donation.⁴ Islamic scriptures (76.5%) and advice from local mosques (70.2%) were cited as barriers to positive views toward donation.⁴ Other studies point to a lack of local religious leaders’ advocacy as a common barrier.^18,23

In summary, available empirical data suggest that Muslims in the diaspora favor organ donation at lower rates than their counterparts and that religion appears to have a negative impact on favorable attitudes toward organ donation.

Clinical Context: Organ Donation and Its Subtypes

In studying organ donation attitudes, it is important to recognize the many different subtypes of organ donation, as it is not a singular entity. Each of these subtypes entails a specific decisional context based on the type of organ donated/transplanted, when it is donated/transplanted, its origin, and its potential benefit. To review, organ donation is defined as²⁴ “the process of surgically removing an organ or tissue from one person and placing it into another person.” This standard definition is not without ambiguity. For example, human blood is recognized as a tissue, yet blood donation is typically regarded as separate from and less contentious than organ donation, and thus it is frequently overlooked in community-based education and research on organ donation. Similarly, much of the bioethics literature examines contro-versies around organ donation rather than tissue donation.

Brain death is the biological marker that divides a living from a deceased donor, but this status is also fraught with debate, throwing another conceptual dividing line into controversy. Indeed, some Islamic authorities do not regard a person who meets the neurological criteria for death to be dead.^25,26 Scholars in secular circles similarly debate whether the dead donor rule applies to donations made after brain death certification, implying that such individuals are not dead.^27-29 Even among physicians, there is considerable controversy about the criteria and diagnosis of brain death. This ambiguity sur-rounding the conceptual basis and diagnostic criteria of brain death complicates the Islamic views on deceased donations, as religious scholars’ stance on when organ donation is permissible is intimately connected to their views on brain death. One must acknowledge the diverse views and ethical plurality among secular and religious views on brain death.

Additionally, organ donation can be divided into 2 categories based on the benefit it provides the recipient: life-saving or life-enhancing donations. Life-saving donations typically include organs that provide essential bodily functions and are critical to a person’s survival (eg, heart). Life-enhancing donations are not life-saving transplants but improve the recipient’s quality of life (eg, cornea). Here, the system of classification can be somewhat blurred. Kidney donation, for example, is commonly thought to be a life-saving intervention; yet, given that dialysis remains an obvious treatment option, whether a transplanted kidney increases the life expectancy over dialysis is dependent on patient-level circumstances. In some cases, instead of being a life-saving intervention, a donation could be considered a life-enhancing event. In sum, the multiplicity encompassed by the term “organ donation” must be addressed when conducting research or educating the public about organ donation.

The Normative Context: Islamic Ethicolegal Rulings on Organ Donation and Transplantation

Islamic sanction for organ donation is promoted in public organ donation campaigns and in bioethical literature. The “majority of shariah [sic] councils have concluded that organ donation is allowed, and indeed recommended, in Islam,” according to a leaflet produced by the official institution responsible for organ donation in Canada, Trillium Gift of Life Network.³⁰ In the United States, the WRTC reference guide to organ and tissue donation and trans-plantation quotes an Islamic studies professor, Abdulaziz Sachedina,³¹ declaring “the majority of the Muslim scholars belonging to various schools of Islamic law have…permitted the organ transplant as a necessity...” A similar inclination has been found in the bioethics literature, with an examination of internet-based Islamic edicts reporting that “all 70 fatwas allow for organ donation and blood transfusion.”³²

However, these broad statements conceal signi-ficant disagreements about the moral status of organ donation under Islamic law and fail to recognize the fundamentally plural ethicolegal tradition. When designing organ donation-related educational prog-rams and attitudinal interventions, these 2 elements of Islamic discourse are critical. First, it is important to acknowledge that organ donation is a novel matter that is not equivocally discussed by scripture. Given this, qualified Islamic jurists are tasked to conduct their own analyses, ie, carry out ijtih?d, and develop a nonbinding ethicolegal opinion, eg, fatwa, based on Islamic ethicolegal theory (u?ul al-fiqh). Accordingly, scholars can reach a variety of conclusions; each perspective is equally actionable as long as it correctly uses scriptural sources and is logically consistent. As a result, individual Muslims are free to select among the various opinions and determine which is more relevant to their circumstances and has the stronger argument. This plurality suggests that issues of majority versus minority opinions are irrelevant at the individual Muslim level and that any individual would not be judged to be sinful nor acting outside the bounds of Islamic law and ethics should they act upon any established view.³³

Against this backdrop, there are 3 general scholarly perspectives on organ donation, each of which is based on scripture and precedent.^34,35 The first normative view maintains that organ donation is impermissible because it violates human dignity (?urma and kar?ma),^36,37 the second holds that organ donation is impermissible in principle but permitted in circumstances of dire necessity (?ar?ra),³⁸ whereas the third view holds that organ donation is permissible because it serves a general public interest (ma?la?a).^32,39,40 These 3 views are commonly shared by Sunni and Shia denominations, yet, as previously stated, diverse views regarding brain death as the death of a human being complicates matters further. Some Islamic jurists, for example, do not view neurological grounds for death as sufficient to meet Islamic requirements for declaring a person dead and may refuse organ donation in such circumstances, even if they believe organ donation to be generally permitted.^9,41

It is worth noting that Islamic rulings often discuss organ donation and organ transplantation as a single matter. Sometimes this is because the question is stated as a singular issue or because the context of the question is unclear. It is also because of conceptual confusion. Factually speaking, organ donation carries a different moral significance than organ transplantation. The first moral context is one in which an individual seeks to provide a benefit to others by donation of an organ. In contrast, the second moral context is one in which an individual is worried about their mortality and quality of life and wishes to be the recipient of a donated organ. These different contexts lead to different moral responses. In the context of receiving an organ, the individual patient may be able to invoke dire necessity, given that they might die without the donated organ. Hence, normatively prohibited treatments can be permitted. On the other hand, with respect to organ donation, dire necessity considerations for the donor cannot be invoked since they are not facing a life threat. As such, organ donation and transplantation can be seen as different moral acts with different rulings.

With regard to the 3 camps, organ donation is prohibited in the first normative view because it violates human dignity, which is further dissected into 2 parts: inviolability (?urma) and sanctity (kar?ma).^36,37 Kar?ma, derived from the Arabic root k-r-m, imparts the meaning of honor, and refers to the special status of humankind above all of God’s creation. The Qur’an grounds this notion by stating, “We [God] have honored (karamna) the sons of Adam… and conferred on them special favors, above a great part of our creation” (Chapter 17:70). ?urma, derived from the Arabic root h-r-m, conveys the meaning of sacredness and prohibition. The Qur’an grounds this concept by stating “Nor take life, which Allah has made sacred (?arramullah), except for just cause” (Chapter 17:33). This position of imper-missibility, based on notions of inviolability and sanctity, was first described in 1966 by the late Mufti Muhammad Shafi and has been reinforced by numerous subsequent scholars.³⁴

This group claims that organ donation reduces the human body into a collection of replaceable body parts and diminishes the intrinsic honor bestowed on the human by God.³⁵ The illegal black markets for organs exemplify this concern and have been highlighted by many, including the late grand Mufti of Egypt, Shaykh Ali Guma’a, who stated,³⁵ “here a human being has been relegated to the status of a spare part that can be bought and sold; a person has been rendered into something that is cut up, whose parts are distributed…No, this is not permitted.” Additionally, any incision into an individual’s body disrupts its intactness, and if that intrusion is not directly beneficial to them, then it is considered mutilation.⁴² Mutilation also extends to the corpse, as both the dead and the living are equal in ?urma. Prophet Muhammad once said,³⁴ “breaking the bones of the dead is akin to breaking the bones of the living.” As such, organ donation can be considered a violation of human dignity.

In the second normative view, organ donation is permissible in the context of dire necessity (?ar?ra). The Islamic Fiqh Academy of India supports this viewpoint, which maintains that life-saving organ donations are held to meet the standard of dire necessity.³⁸ The permissibility of organ donation is contingent on a firm conviction that the patient would otherwise perish, and that no alternatives are available. Scholars that hold this viewpoint support their position with multiple Qur’anic verses in which God allows forbidden items in circumstances of dire necessity. For example, a verse of the Qur’an states, “He has only forbidden you carrion, blood, pig’s meat, and animals…if anyone is forced to eat such things by hunger, rather than desire or excess, he commits no sin: God is most merciful and forgiving” (Chapter 2:173). Such guidance encourages scholars to conclude that necessity permits the prohibited, and it follows that organ donation is permissible under life-saving circumstances.

The third perspective views organ donation as permissible because it promotes a human public interest (ma?la?a), namely duration and quality of life. The former rector of Al-Azhar University (Sayyid al-T?ant?awi, who died in 2010), the former head of the European Council for Fatwa and Research (Yusuf Al-Qarad?awi), and the UK Muslim Council 1995 all agreed with this position.^7,34 In 2018, the Fiqh Council of North America (FCNA) agreed with this view,⁴³ stating that organ donation is permissible in principle and when “done with a good intention, organ donation may be regarded as a rewarded act of charity.” Proponents of this argument claim that saving a life is a legitimate interest that is explicitly mentioned in the scriptural source-texts; therefore, because organ donation is a means to secure this interest, it should be considered morally permissible.³⁵

Several requirements must be met for organ donation to be regarded as religiously licit, whether on account of public benefit or dire necessity. These include the donor’s consent and authorization (in some cases, family permission is considered sufficient), the donation of a vital organ cannot be made while the donor is alive, and the harm to this donor must be minimal or negligible. Given the differing contexts and many requirements stated by jurists, it is essential for both the potential donor and their advisors to review the stipulations set forth by the ruling upon which they desire to act.

From these details, it can be gleaned that the Islamic rulings on organ donation are plural, replete with nuanced criteria under which permissibility is sanctioned, and mediate between scriptural principles and societal contexts. As biomedical technology develops and societal contexts change, Islamic jurists will have to reexamine their analyses.

Righting the Narratives: Islam, Muslims, and Organ Donation Attitudes

We have briefly reviewed the empirical data and gained insights from the clinical and normative contexts, and what follows is our critical assessment of the narratives and our recommendations for corrective actions.

Narrative 1: Increased religiosity among Muslims is associated with more negative views of organ donation

As previously mentioned, some evidence points to religious values and concerns as barriers to organ donation. For example, interviews with 141 Muslims in West London revealed that religious notions such as the sacredness of the human body and concerns about moral accountability for actions committed by the recipient of a donated organ fuel reticence toward organ donation.²⁰ Focus groups with Muslim women in Chicago echoed these themes where the perceived risk of the exposure of a woman’s ?awra (part of the body religiously required to be covered) in violation of religious modesty requirements during the organ donation process was a concern.⁴⁴ Similarly, moral accountability for the actions committed by the organ recipient enhanced uncertainty toward organ donation.⁴⁴

However, religious values may also motivate (rather than discourage) organ donation, as it is considered a meritorious activity worthy of reward in the afterlife. Muslims are encouraged to help their fellow human beings, “Whoever helps another will be granted help from Allah in the hereafter,” as Prophet Muhammad once said.⁴⁵ Similarly, the Qur’an states, “Whosoever saves a life, it would be as if he saved the life of all mankind” (Chapter 5:32). Organ donation is viewed as a charitable act by many scholars.^32,43 Therefore, it is reasonable to conclude that Muslims are supportive of organ donation and are driven by religious ideals. According to a study of 402 Muslim participants, most (78.1%) Muslims who approved of organ donation felt that it was a means of saving lives and was a tremendous reward in accordance with their religious views.⁴⁶ Other studies have also shown that Muslims believe that organ donation is consistent with the overarching Islamic obligation to preserve human life.⁴⁴ As such, qualitative research suggests that religious values can both promote and detract from organ donation. Hence, increased religiosity could be linked to both positive and negative attitudes regarding organ donation.

Parsing through the empirical literature exposes limitations that cast doubt on the narrative that increased religiosity is linked with negative attitudes toward organ donation. To begin, the very few studies to directly measure religiosity and test its association with Muslim attitudes about organ donation have conflicting results. For example, Sharif and colleagues developed a transnational survey that used a single-item self-rated measure that rates individuals on a religiosity scale from nonreligious to extremely religious and found that those who considered themselves religious or moderately religious were less likely to agree with organ donation than those who identified as slightly religious.⁴ Religiosity, on the other hand, was not found to be an independent predictor of organ donation.⁴ Another survey of mosque-going American Muslims incorporated psychological measures of religiosity combined with a self-reported measure and discovered no association between the self-reported measure and attitudes toward deceased organ donation.¹⁷ Further downstream to attitude, no studies directly link elements of religiosity to organ donation behaviors.

Relatedly, generic inquiries about organ donation do not account for the many different contexts in which organ donation occurs. Although some studies distinguish between living and deceased donation in their surveys, religious ambiguity regarding a spectrum of distinct types of donation (such as donation after brain death) could cause variability of interpretation by respondents with regard to these distinctions. Additional detailed assessments of the various types of organ donation are required to fully understand how religiosity influences Muslim organ donation-related attitudes and behaviors.

Beyond the ambiguous relationship between religion and organ donation attitudes, empirical studies have revealed that religious concerns are not the only factors, and may not even be the most important factors, of Muslim attitudes toward organ donation. Alkhawari and colleagues stated that distrust of the health care system and lack of awareness of the societal need for organ donation were strongly linked to negative attitudes.²⁰ Distrust of the health care system was also mentioned as a barrier to organ donation in the survey published by Sharif and colleagues.⁴ Focus groups with Muslim women in Chicago revealed that concerns about organ trafficking and the personal medical risk associated with organ donation were another barrier.⁴⁴ Furthermore, numerous surveys show that the percentage of individuals who believe that Islam permits organ donation is lower than the percentage who believe that organ donation is justified/acceptable (the numbers from the survey by Sharif and colleagues are 39.3% and 68.5%, respectively), which suggests that Islamic ethicolegal permissibility may not be the primary determinant of organ donation attitudes.4 Given the diversity in the types of organ donations mentioned, the populations investigated, and the lack of a specific analytic focus on elucidating which determinants are primary and which are secondary to organ donation attitudes and behaviors, one cannot assert that religion is less important than other factors. Our point here is to suggest that allaying religious concerns is unlikely to result in changes in attitudes or behavior. To be sure, both theoretical and empirical data point to the limitations of interventions intended to persuade Muslims to accept the religious permissibility of organ donation.^8,14,18,47

More research is needed to understand the relationship between Islamic religiosity and Muslim attitudes toward organ donation. Indeed, inter-pretations that “religious ideology [is] a source of misinformation relating to organ donation” or that religious interpretations are substantial obstacles to organ donation may be somewhat misguided, given that religious values can legitimately support both sides of the debate, ie, affirmations to donate and refusals to donate.^4,48 Moreover, portraying religion as a barrier to be overcome betrays an instrumentalist view of religion, in other words religion is a means to promote health. Health is undoubtedly beneficial, but it is neither the only benefit nor the ultimate good in the lives of religious individuals. Instead, at least according to Islamic moral theology, health is subservient to religious ends. As a result, assertions that “good” religiosity corresponds with the good of organ donation, whereas “bad” religiosity is the contrary, are extremely troublesome. Those who seek to plan public health interventions must be wary of such rhetoric, for it is neither theologically accurate nor empirically grounded. Furthermore, inter-ventions that seek to “correct” community views that organ donation is religiously impermissible by highlighting existing permissible rulings may risk fostering mistrust of organ donation professionals and the health care system in general and is contrary to the persuasion models that facilitate the central processing of information.⁴⁹

Narrative 2: Islamic edicts of impermissibility are ill-informed and/or unfounded
This narrative reinforces extant interventions. Most educational programs and campaigns promote the religious permissibility of organ donation by creating local fatwa and/or referencing juridical bodies that have deemed organ donation to be permissible. Religious scholars who find organ donation to be impermissible are viewed⁵⁰ as a “key aspect of this [organ donation] problem.” As with the public, organ donation experts interact with these religious scholars to better inform these scholars of the biomedical and societal perspectives of organ donation and transplantation in the hopes that they may change their negative view of organ donation. The assumption is that deficits of religious, biomedical, or societal knowledge may promote the perspective of impermissibility, and biomedical and societal imperatives predominate over religious ethicolegal assessment.

Although such efforts are honorable, it is inappropriate to assert that Islamic verdicts are misinformed with regard to the religious impermis-sibility of organ donation. As discussed above, the basis of this impermissibility is grounded in the notion that the human body is inviolable and that organ donation hinders its sanctity. These ideals are supported by various statements of Prophet Muhammad that stipulate the sanctity of the human body persists after death.

Although there are many clear societal benefits to donation, the assertion of impermissibility is bolstered by the greater virtue assigned to prevention of harm versus acquisition of benefits, a concept aligned with the overarching Islamic ethicolegal maxim known as (dar? al-mafa?sid awla? min jalb al-mas?alih?).⁵¹ This ethos is further maintained by a Prophetic command that there should be no harm.⁵² The act of cutting open the body, whether living or dead, to procure an organ is an act that disturbs bodily integrity and is therefore classified as a harm that must be avoided. Thus, data in support of biomedical and societal benefits are of secondary concern. Additionally, although some level of individual harm may be tolerated when required to deflect a greater harm or to obtain a more significant benefit (eg, surgery for appendicitis), jurists in the impermissibility camp argue that the donor is afforded no direct benefit from the act of organ donation, particularly in the case of deceased donation (the posited afterlife reward notwithstanding). In further support of this argument, religiosity asserts that the individual does not own their organs. In this viewpoint, donation is only permissible if the action is by the owner of donated material/product/goods. Based on multiple scriptural texts, God is the owner of all human bodies, and it is God who grants temporary stewardship/custodianship to individuals. Consequently, any directive that allows an individual to approve the donation of organs is deemed invalid. Again, this line of reasoning would not be disrupted by biomedical or societal data.

It is true that the previously mentioned assertions are debatable and that alternative and equally legitimate perspectives exist. Namely, some Islamic jurists argue that individual-level harms can be tolerated as these harms result in a greater general societal benefit. Others reframe organ donation authorization in the context of the religious sanction for an individual to partake in a contract to supply physical labor; this established precedent permits a person to contemplate organ donation authorization as an act of distribution of organ function rather than an act of ownership transference. Our point here is that misunderstandings of the societal context and biomedical processes involved with organ donation are not the conflicts upon which these lines of argument turn. Instead, these alternative lines of reasoning are founded on various readings of scripture and different constructs and devices within Islamic law, not on a “better” interpretation of societal context and biomedical processes.

One may argue that biomedical and societal data are considered by the camp that holds organ donation to be contingently permissible due to necessity. Indeed, determining whether a dire necessity exists requires interrogating whether the potential organ recipient faces a threat to life without organ transplantation and whether there are valid alternatives to transplantation. However, those who adhere to the view of impermissibility would argue that such determinations must be made at the individual level and not at the societal level and that the morality of organ transplantation should not be equated to the morality of organ donation. Furthermore, even those who consider organ donation to be permitted based on dire necessity state that the base ruling regarding organ donation is one of impermissibility. In other words, although organ donation may be permissible for an individual on account of dire necessity, to undergo organ trans-plantation and even solicit organ donation from others is the exception, not the rule.

Organ donation advocates must recognize that Islamic law on the subject is plural. Each of the 3 camps mentioned above offer legitimate perspec-tives, and each stance is morally actionable. Individual jurists and juridical bodies should better understand the societal contexts and biomedical processes surrounding organ donation so that their perspectives may be finely tuned. Organ donation professionals and stakeholders must educate these religious leaders and dispel any myths they may hold. However, at the end of the day, if it is determined that a particular type of organ donation is prohibited, then that decision should be respected.

A situation in which the opposite scenario took place serves as a cautionary tale. From 2016 through 2020, the WRTC launched an extensive educational effort to bring Islamic jurists in the United States into consensus regarding the Islamic stance on organ donation.^6,12 They specifically asked FCNA to issue an “American fatwa” on the matter. Eventually, FCNA judged organ donation to be permissible with conditions. Among these conditions were that “deceased donation must occur after cardiac determination of death” and that “the consent and authorization of the donor” is obtained.⁴³ The edict rules out deceased donation and familial authorization for organ donation. It is disingenuous then for WRTC to highlight that⁶ “[although FCNA] is still seeking clarity among its 19 members on the issue of brain death…this point of internal debate does not conflict with or supersede, its ‘Permissible’ ruling on organ donation.” The FCNA ruling explicitly prohibits deceased donation because they were concerned about brain death as a valid marker of death in Islam.⁴¹ Organ procurement organizations have an ethical mandate to assist individuals in making informed choices, and as part of that mandate, they must accurately portray the plurality of Islamic views.

Designing More Effective and Ethical Educational Interventions

Finally, we highlight design considerations that might improve the effectiveness and ethicality of educational interventions. These characteristics account for the facts that (1) religiosity does not entirely drive individual decisions regarding organ donation, (2) organ donation comes in a variety of forms and settings, and (3) Islamic perspectives on the subject differ. Rather than focusing on convincing people to donate, equipping people with the knowledge they need to make an informed decision about whether to donate is critical.

Accordingly, educational programs must target the informational needs of Muslims related to organ donation. First, empirical data reveal various fallacies about organ donation that are pervasive in the Muslim community. One common misconception is that organs can be procured from comatose patients who have not yet been pronounced deceased. A study surveyed 400 Iranian students and found that 52% were not interested in being donors because of a fear of organ donation before brain death was declared.⁵³ This misconception due to lack of procedural knowledge may promote hesitancy. It is vital to emphasize that potential organ donors undergo multiple tests to assure that neurological criteria for death are met before organ procurement is initiated.⁵⁴ Another point of contention for many Muslims is the manner by which the body is treated during donation. A process that provides reassurance to patients and families that organ procurement is undertaken with care and respect to both donor and recipient and that the process of donation rarely leads to disfigurement can help mitigate these concerns.⁵⁵ Last, potential disruptions to burial rituals are of significant concern to many Muslims, because religious requirements indicate quick burial following death, and lengthy organ retrieval procedures may be alarming to some.^56,57 However, this concern is primarily curbed by the time-sensitive nature of organ donation and transplantation.⁵⁵

Muslims require specific process knowledge and education to resolve this knowledge deficit will increase self-efficacy and perceived behavioral control. Many Muslims are also likely to be unaware of organ donation disparities in the community; therefore, detailed data should be presented where feasible.

Lastly, studies show that Muslims are unaware of the underlying rationale for the various Islamic edicts on the matter.^18,53,58-60 Accordingly, this information must also be widely distributed with an ethically balanced approach. Because of the inherent and legitimate nature of plurality in this topic, all educational interventions should adequately recount each view and its underlying ethicolegal reasoning. Thereby, the target audience will be encouraged to reflect on each perspective and discern for themselves which position is most sound. This will also allow additional personal and contextual factors to receive appropriate consideration. This method has additional advantages. First, transparency enhances trust between organ donation stakeholders and Muslim community members. Members of the target audience are likely aware that Islamic scholars have a plethora of views; a lack of acknowledgment or lack of elaboration upon that as part of any educational intervention could seed distrust.

Second, acknowledgment that individual Muslims remain steadfast to the faith, whether they approve or disapprove of organ donation, reduces the possibility of divisiveness and tension among communities. Finally, recognition of plurality allows both scholars and community members to further clarify or alter their views as organ donation technology advances and societal conditions change.

Conclusions

This review aimed to “right” the narratives surrounding Islam, organ donation, and Muslim attitudes to facilitate the creation of more effective and ethically balanced interventions. Our inspection plunged into organ donation’s empirical, clinical, and normative realms to dispel social narratives that Islam is a barrier to organ donation. More specifically, we focused on reports that suggested that increased religiosity leads to more negative attitudes towards organ donation and that religious edicts that prohibit organ donation are misinformed or poorly reasoned. Limitations in the literature preclude the narrative that religiosity is a barrier to organ donation, and the various Islamic ethicolegal rulings on organ donation are well-grounded and legitimately plural. We recommend that educational interventions in Muslim communities seek to facilitate informed decision-making by dispelling myths and by accepting the plurality of Islamic ethicolegal perspectives on organ donation.

References:

1. Al-Mukrashi F. Oman launches organ donor programme. Gulf News. March 22, 2016. https://gulfnews.com/world/gulf/oman/oman-launches-organ-donor-programme-1.1695454
   CrossRef - PubMed
   
2. Peeperkorn M. Hoogervorst wants priority for organ-donor: standpoint of Muslims concerning transplantation ‘wrings’. De Volkskrant. March 4, 2005.
   CrossRef - PubMed
   
3. Organ donation: Jewish and Muslim presumed consent worries. BBC News. November 5, 2012. https://www.bbc.com/news/uk-wales-20182517
   CrossRef - PubMed
   
4. Sharif A, Jawad H, Nightingale P, et al. A quantitative survey of Western Muslim attitudes to solid organ donation. Transplantation. 2011;92(10):1108-1114. doi:10.1097/TP.0b013e318231ea17
   CrossRef - PubMed
   
5. Karim A, Jandu S, Sharif A. A survey of South Asian attitudes to organ donation in the United Kingdom. Clin Transplant. 2013;27(5):757-763. doi:10.1111/ctr.12189
   CrossRef - PubMed
   
6. Daniels J. Organ donation permissible for American Muslims. Washington Regional Transplant Community; March 20, 2019. https://www.beadonor.org/organ-donation-permissible-for-american-muslims/
   CrossRef - PubMed
   
7. Badawi, Z. Organ Transplant Fatwa. World Islamic Mission. 1995.https://muslimdonorsuk.wixsite.com/moduk/forum/published-research/zaki-badawi-1995-organ-transplant
   CrossRef - PubMed
   
8. Razaq S, Sajad M. A cross-sectional study to investigate reasons for low organ donor rates amongst Muslims in Birmingham. Internet J Law Healthcare Ethics. 2006;4(2):1-5. https://print.ispub.com/api/0/ispub-article/13225
   CrossRef - PubMed
   
9. Butt M; Institute of Islamic Jurisprudence (Bradford). Organ donation and transplantation in Islam: An opinion. June 18, 2019. https://nhsbtdbe.blob.core.windows.net/umbraco-assets-corp/16299/organ-donation-summary-fatwa.pdf
   CrossRef - PubMed
   
10. National Health Service. Blood and Transplant. New fatwa to clarify Islamic position on organ donation. June 19, 2019. https://www.organdonation.nhs.uk/get-involved/news/new-fatwa-published-to-clarify-islamic-position-on-organ-donation/
    CrossRef - PubMed
    
11. Ali O, Ahmed S, Bashir A, et al. Discussing organ donation with Muslim families: the effect of educational interventions on the opinions of Muslim and Black, Asian and Minority Ethnic (BAME) communities. Anaesthesia. 2020;75(Suppl 3):10-106. doi:10.1111/anae.15157
    CrossRef - PubMed
    
12. International Institute of Islamic Thought. Reaching consensus on organ donation: a call to the Muslim American community. 2016. https://iiit.org/en/reaching-consensus-on-organ-donation-a-call-to-the-muslim-american-community/
    CrossRef - PubMed
    
13. Rasheed S. Organ donation among Muslims: an examination of medical researchers’ efforts to encourage donation in the Muslim community. Thesis. University of Michigan; 2011. https://deepblue.lib.umich.edu/bitstream/handle/2027.42/85315/sarashee.pdf
    CrossRef - PubMed
    
14. Rasheed SA, Padela AI. The interplay between religious leaders and organ donation among Muslims. Zygon. 2013;48(3):635-654. doi:10.1111/zygo.12040
    CrossRef - PubMed
    
15. US Department of Health and Human Services, Health Resources and Services Administration, Healthcare Systems Bureau, Division of Transplantation. 2019 National Survey of Organ Donation Attitudes and Practices: Report of Findings. 2020; https://www.organdonor.gov/sites/default/files/organ-donor/professional/grants-research/nsodap-organ-donation-survey-2019.pdf.
    CrossRef - PubMed
    
16. Padela AI, Rasheed S, Warren GJ, Choi H, Mathur AK. Factors associated with positive attitudes toward organ donation in Arab Americans. Clin Transplant. 2011;25(5):800-808. doi:10.1111/j.1399-0012.2010.01382.x
    CrossRef - PubMed
    
17. Padela AI, Zaganjor H. Relationships between Islamic religiosity and attitude toward deceased organ donation among American Muslims: a pilot study. Transplantation. 2014;97(12):1292-1299. doi:10.1097/01.TP.0000441874.43007.81
    CrossRef - PubMed
    
18. Hafzalah M, Azzam R, Testa G, Hoehn KS. Improving the potential for organ donation in an inner city Muslim American community: the impact of a religious educational intervention. Clin Transplant. 2014;28(2):192-197. doi:10.1111/ctr.12296
    CrossRef - PubMed
    
19. Ahmed M, Kubilis P, Padela A. American Muslim physician attitudes toward organ donation. J Relig Health. 2018;57(5):1717-1730. doi:10.1007/s10943-018-0683-2
    CrossRef - PubMed
    
20. Alkhawari FS, Stimson GV, Warrens AN. Attitudes toward transplantation in U.K. Muslim Indo-Asians in west London. Am J Transplant. 2005;5(6):1326-1331. doi:10.1111/j.1600-6143.2005.00814.x
    CrossRef - PubMed
    
21. Sheikh A, Dhami S. Attitudes to organ donation among South Asians in the UK. J R Soc Med. 2000;93(3):161-162. doi:10.1177/014107680009300324
    CrossRef - PubMed
    
22. Wakefield CE, Reid J, Homewood J. Religious and ethnic influences on willingness to donate organs and donor behavior: an Australian perspective. Prog Transplant. 2011;21(2):161-168. doi:10.7182/prtr.21.2.2071rgn834573152
    CrossRef - PubMed
    
23. Ali A, Ahmed T, Ayub A, et al. Organ donation and transplant: the Islamic perspective. Clin Transplant. 2020;34(4):e13832. doi:10.1111/ctr.13832
    CrossRef - PubMed
    
24. Cleveland Clinic. Organ donation and transplantation: how it works. Updated 2021. https://my.clevelandclinic.org/health/articles/11750-organ-donation-and-transplantation
    CrossRef - PubMed
    
25. Rady MY, Verheijde JL. Brain-dead patients are not cadavers: the need to revise the definition of death in Muslim communities. HEC Forum. 2013;25(1):25-45. doi:10.1007/s10730-012-9196-7
    CrossRef - PubMed
    
26. Mohammed AM; The Institute for the Revival of Traditional Islamic Sciences. Harvesting the Human: Traditional Sunni Islamic Perspective. December 30, 2017. https://www.irtis.org.uk/wp-content/uploads/2020/01/organs.pdf
    CrossRef - PubMed
    
27. Fost N. Reconsidering the dead donor rule: is it important that organ donors be dead? Kennedy Inst Ethics J. 2004;14(3):249-260. doi:10.1353/ken.2004.0030
    CrossRef - PubMed
    
28. Sade RM. Brain death, cardiac death, and the dead donor rule. J S C Med Assoc. 2011;107(4):146-149.
    CrossRef - PubMed
    
29. Shewmon AD. The brain and somatic integration: insights into the standard biological rationale for equating “brain death” with death. J Med Philos. 2001;26(5):457-478. doi:10.1076/jmep.26.5.457.3000
    CrossRef - PubMed
    
30. Trillium Gift of Life Network. Islam and Organ Donation. https://www.giftoflife.on.ca/resources/pdf/Islamic%20Brochure%20EN%202019.pdf.
    CrossRef - PubMed
    
31. Harris D; Washington Regional Transplant Community. The Islamic faith and organ donation. November 30, 2021; https://www.beadonor.org/islam/
    CrossRef - PubMed
    
32. Van den Branden S, Broeckaert B. The ongoing charity of organ donation. Contemporary English Sunni fatwas on organ donation and blood transfusion. Bioethics. 2011;25(3):167-175. doi:10.1111/j.1467-8519.2009.01782.x
    CrossRef - PubMed
    
33. Padela AI. Islamic bioethical positions on organ donation and transplantation: stressing rigor and caution in fatwa reviews. Transplant Direct. 2020;6(8):e586. doi:10.1097/TXD.0000000000001023
    CrossRef - PubMed
    
34. Ali M, Maravia U. Seven faces of a fatwa: organ transplantation and Islam. Religions. 2020;11(2):99. doi:10.3390/rel11020099
    CrossRef - PubMed
    
35. Padela AI, Duivenbode R. The ethics of organ donation, donation after circulatory determination of death, and xenotransplantation from an Islamic perspective. Xenotransplantation. 2018;25(3):1-12. doi:10.1111/xen.12421
    CrossRef - PubMed
    
36. Shafi M, Muhammad M. Islam on Grafting and Transplantation of Human Organs. Darul-Ishaat; 1995.
    CrossRef - PubMed
    
37. Moosa E. Transacting the body in the law: reading Fatawa on organ transplantation. Afrika Zamani Annu J Afr Hist. 1998;(5-6):292-317.
    CrossRef - PubMed
    
38. India Islamic Fiqh Academy. Organ Transplant II. 1989.
    CrossRef - PubMed
    
39. Ghaly M. Religio-ethical discussions on organ donation among Muslims in Europe: an example of transnational Islamic bioethics. Med Health Care Philos. 2012;15(2):207-220. doi:10.1007/s11019-011-9352-x
    CrossRef - PubMed
    
40. Albar M. Organ transplantation: a Sunni Islamic perspective. Saudi J Kidney Dis Transpl. 2012;23(4):817-822. doi:10.4103/1319-2442.98169
    CrossRef - PubMed
    
41. Padela AI, Auda J. The moral status of organ donation and transplantation within Islamic law: the Fiqh Council of North America’s position. Transplant Direct. 2020;6(3):e536. doi:10.1097/TXD.0000000000000980
    CrossRef - PubMed
    
42. Rashid R. Organ Transplantation: An Islamic Perspective to Human Bodily Dignity and Property in the Body. Doctoral dissertation, Master’s thesis. University of Manchester; 2018.
    CrossRef - PubMed
    
43. Auda J, Badawi J, Padela A; Fiqh Council of North America. On organ donation and transplantation. October 6, 2021. https://fiqhcouncil.org/on-organ-donation-and-transplantation/
    CrossRef - PubMed
    
44. Duivenbode R, Hall S, Padela AI. A mosque-based qualitative study on American Muslim women’s organ donation beliefs. Prog Transplant. 2020;30(1):56-62. doi:10.1177/1526924819893933
    CrossRef - PubMed
45. National Health Service. Blood and Transplant. Organ donation and religious beliefs: a guide to organ donation and Muslim beliefs. 2012. https://nhsbtmediaservices.blob.core.windows.net/organ-donation-assets/pdfs/islam_and_organ_donation.pdf
    CrossRef - PubMed
    
46. Tas F, Selcuk Tosun A, Akgul Gundogdu N. The effect of Islamic belief and spiritual well-being on organ donation in Turkey: a descriptive-relational study. J Relig Health. 2022;61(3):2121-2140. doi:10.1007/s10943-021-01252-3
    CrossRef - PubMed
    
47. Bilgel H, Sadikoglu G, Goktas O, Bilgel N. A survey of the public attitudes towards organ donation in a Turkish community and of the changes that have taken place in the last 12 years. Transpl Int. 2004;17(3):126-130. doi:10.1007/s00147-003-0680-5
    CrossRef - PubMed
    
48. Krupic F, Westin O, Hagelberg M, Skoldenberg O, Samuelsson K. The influence of age, gender and religion on willingness to be an organ donor: experience of religious Muslims living in Sweden. J Relig Health. 2019;58(3):847-859. doi:10.1007/s10943-018-0670-7
    CrossRef - PubMed
    
49. Petty RE, Cacioppo JT. The elaboration likelihood model of persuasion. In: Communication and Persuasion. Springer Series in Social Psychology. Springer; 1986:1-24.
    CrossRef - PubMed
    
50. Tarhan M, Dalar L, Yildirimoglu H, Sayar A, Altin S. The view of religious officials on organ donation and transplantation in the Zeytinburnu district of Istanbul. J Relig Health. 2014.
    doi:10.1007/s10943-014-9851-1
    CrossRef - PubMed
    
51. Ibn Nujaym, Z. Al-Ashbah wa-l-Na?air. Umayrat Z, ed. Dar al-Kotob al-Ilmiya; 1999.
    CrossRef - PubMed
    
52. Sachedina A. “No Harm, No Harassment”: major principles of health care ethics in Islam. In: Guinn DE, ed. Handbook of Bioethics and Religion. Oxford University Press; 2006:265-290. doi:10.1093/0195178734.003.0013
    CrossRef - PubMed
    
53. Afzal Aghaee M, Dehghani M, Sadeghi M, Khaleghi E. Awareness of religious leaders’ fatwa and willingness to donate organ. Int J Organ Transplant Med. 2015;6(4):158-164.
    CrossRef - PubMed
    
54. Mayo Clinic. Organ donation: don’t let these myths confuse you. 2021. https://www.mayoclinic.org/healthy-lifestyle/consumer-health/in-depth/organ-donation/art-20047529
    CrossRef - PubMed
    
55. Organ Procurement and Transplantation Network. The basic path of organ donation. September 17, 2014. https://optn.transplant.hrsa.gov/news/the-basic-path-of-organ-donation/
    CrossRef - PubMed
    
56. Gatrad AR. Muslim customs surrounding death, bereavement, postmortem examinations, and organ transplants. BMJ. 1994;309(6953):521-523. doi:10.1136/bmj.309.6953.521
    CrossRef - PubMed
    
57. Oliver M, Woywodt A, Ahmed A, Saif I. Organ donation, transplantation and religion. Nephrol Dial Transplant. 2011;26(2):437-444. doi:10.1093/ndt/gfq628
    CrossRef - PubMed
    
58. Gauher ST, Khehar R, Rajput G, et al. The factors that influence attitudes toward organ donation for transplantation among UK university students of Indian and Pakistani descent. Clin Transplant. 2013;27(3):359-367. doi:10.1111/ctr.12096
    CrossRef - PubMed
    
59. Darr A, Randhawa G. Public opinion and perceptions of organ donation and transplantation among Asian communities: an exploratory study in Luton, UK. Int J Health Promotion Educ. 1999;37(2):68-74. doi:10.1080/14635240.1999.10806098
    CrossRef - PubMed
    
60. Keten HS, Keten D, Ucer H, et al. Knowledge, attitudes, and behaviors of mosque imams regarding organ donation. Ann Transplant. 2014;19:598-603. doi:10.12659/AOT.891370
    CrossRef - PubMed