His work as a counselor is also bolstered by his knowledge of Islamic theology, which has led people to sometimes call him a Sheikh, an honorary title given to Islamic leaders or clerics. With fluency in medicine, Islam, and English, he says, “I was able to communicate to people in terms of faith and in medical terms. I became a man that fits very much everywhere.”
In Islamic theology, in cases where neither the Qur’an nor Sunnah (the record of Mohammed’s teachings) offer clear guidance, Muslim scholars and ethical experts will exercise a system of Islamic jurisprudence known as Ijtihad. The term, which means “the utmost effort an individual can put forth in an activity,” refers to a way of working through textual grey areas to form legal opinions.
The case of Ezadin Mahmoud takes three days of careful Ijtihad.
Abdirahman believed Ezadin to be dead and suggested that they remove his oxygen, so that his family could bury him before the weekend, when the funeral home closed. (In Islam, the dead should ideally be buried before sundown on the same day of their death.) The family did not want to hear anything about the burial. The imams were equally at a loss for advice. They sat in the waiting room of Maine Medical, while combing the Qur’an and Sunnah for an answer. Although part of the Sunnah deals with the end of life, there was nothing that explicitly stated how to regard a brain-dead patient on life support.
Professor Abul Fadl Mohsin Ebrahim, a professor emeritus of philosophy at the University of Kwazulu-Natal in South Africa, summarizes the ethical dilemma of brain-dead cases: “The Qur’an informs us that death occurs when the nafs (the soul) is separated from the body. Thus the moment of death would be at the time when the soul is separated from the body,” he said. “But one has to concede that the Qur’an does not in any way tell us anything about the nature of the soul nor of its location in the human body.”
The key question in cases like Ezadin’s, then: Does the soul depart—and the life end—when the brain dies, or when the body does?
A 1968 report from Harvard Medical School on the same question concluded that irreversible coma should be the criterion for death. The Uniform Declaration of Death Act, drafted in 1981 by a President’s Commission Study on Brain Death, reached a similar conclusion: Death was “irreversible cessation of circulatory and respiratory functions; or irreversible cessation of all functions of the entire brain, including the brain stem.”
According to those criteria, Ezadin Mahmoud was dead. To the doctors at Maine Medical, he was uniformly and irreversibly dead, for all practical Western purposes. His organs were ready to be harvested. His life insurance could kick in.
To understand how the medical criteria for death fit with the Islamic faith, Abdirahman, Ezadin’s father, and the imams reviewed the opposing decisions of two group of Islamic experts. One of the ruling bodies was the Islamic Fiqh Council, a group of Muslim jurists and scholars who meet periodically to develop a more formalized public opinion around issues concerning Islam. In October of 1987, this group met in Mecca to issue an opinion on the permissibility of removing life support:
The life-support instruments which have been installed upon the body of patient can be removed from him, when all the functions of his brain have stopped working finally, and a penal of three medical specialists and experts decides that this situation of the brain is irreversible, though the heart and breathing are still continuing due to the life-support instruments. However, he will not be declared legally dead unless heart and breathing fully stop working after removal of the life-support instruments.
But separately, the Religious Rulings Committee of the Kuwaiti government resolved on December of 1981 that, “a person cannot be considered dead when his brain has died as long as his respiration and circulation systems are functioning, even if that life continues through mechanical aid.” Classical Muslim jurists tend to hold that consciousness or the brain is not the source of life, but rather “it is the body which is involved in determining life and death, because it is the body that actually moves.”