February 12, 2005

THE second half of the last century saw an avalanche of developments in medical and surgical techniques, bringing about interventions that brought many moral and ethical questions to the fore.

Blood groups were discovered in 1900 and blood transfusion took nearly 40 years to be accepted as a routine practice. Skin grafting and corneal transplant came later, followed by kidney transplant, which opened new doors to the practitioners of medicine.

Artificial insemination of yesteryear is responsible for numerous sperm banks which have sprung up all over the world today. In vitro fertilization and test tube babies of Patrick Steptoe have opened a new era in human reproduction. Tissue and genetic engineering have opened yet newer doors, which lead us to a world of questionable possibilities.

The new techniques have opened a Pandora’s Box as far as the theologians of the world are concerned. Clergymen have established a medical ethics committee to study the moral and ethical aspects involved.

Where Muslim physicians and scientists are concerned, even those who do care about religion largely fail to understand the immensity of the problem facing the Ummah. This is one of the reasons why not much progress has been made in this regard in the Muslim countries.

To start with, we must consider the motives behind organ transplantation, tissue engineering and genetic engineering. Briefly, the motives can be described as follows.

For the sake of humanity: This is the most valid and justifiable use of the technology and perhaps the main motive for average doctors and scientists. A majority of the procedures in the world are carried out by secular doctors and scientists.

The ever-weakening influence of religion has led to the totally unacceptable being accepted all over the world. Every day we hear of governments yielding to pressures from scientists, doctors and special groups. Abortion laws and human cloning are cases in point.

Scientific curiosity: This is a very potent source of scientific advances. Most research-minded scientists and doctors are always planning or attempting to venture into uncharted territories, to boldly go where no man has gone before.

As such, this is a healthy attitude but there are moral and ethical limits beyond which no one should be allowed to go, even in experiments featuring animals. An experiment successfully performed on animals today will most likely be carried out on humans tomorrow.

However, this is not necessarily a bad thing. Experiences gained during animal experiments help in finding better and cheaper technologies for use on humans. However, the fact remains that inbreeding and controlled breeding being carried out on animals often seems abhorrent and ethically unacceptable on humans.

Monetary gain: So often, this may be the prime motive for a particular procedure. However, for such procedures to be monetarily profitable they have to be successful clinically first. So, monetary considerations come into play only after there is a possibility of making money.

Mostly, these procedures are first carried out in a university department or a research centre. Once this is a success, the project is sold to a biotechnology firm. Sometimes, the firms fund and originate research on their own.

The rights to the human insulin, lactoferin, a growth hormone made by bacteria and transgenic cows and sheep, were all sold to biotechnology firms. The licences for these products could have been bought by WHO or other UN agencies and the patent could have been used for the sake of all humanity, but this was not to be.

I am told that it is possible to cure haemophilia by insertion of the missing gene, but then that would mean curing a patient and losing a buyer for an entire lifetime. Thus, economy overrides humanity.

Let us turn now to some procedures, which are already in clinical practice or in various stages of development.

Reproductive and fertility procedures

Choosing the baby’s sex: This is done by separating and using the required ‘X’ or ‘Y’ chromosomes for artificial or in vitro fertilization. Also, it is common practice these days to determine the sex of the baby by using ultrasound at the end of the first trimester or at tenth week by chorionic villous sampling. Then, only the desired sex, usually male, is allowed to proceed to full term.

Originally and perhaps morally justified was the use of in vitro fertilization in women who had blocked fallopian tubes and their husband’s sperms were used to create ‘test tube babies’. But, soon this took the form of the sperm of undeclared donors being used, which was akin to a child being conceived out of wedlock. In Europe and the US about 10 to 12 per cent of all white males have aspermia and today this is the method of choice for their wives, if they want to have babies.

This process is also being used in case the husband or wife has a genetically transmissible disease or occasionally when a woman wants the baby of a desired individual.

Surrogate mothers: Many cases have been in the news lately where the baby was implanted into some other woman after in vitro fertilization. Sometimes surrogate mothers have been grandmothers (sometimes even postmenopausal, whose uteri have been made receptive by hormonal replacement therapy).

Many such cases have led to courtroom battles, as the surrogate mother refuses to hand over the baby to the biological mother after childbirth.

Cases of animal surrogate mothers have been reported in animal experimentation. Even cows have been suggested as surrogate mothers for human babies because the size of their uteri are adequate for human babies and their natural gestation period is the same as humans.

In vitro pregnancy: This is so far limited to animal experimentation. But, human zygote has been developed for up to 8 weeks outside the womb before implantation into the uteri. Also, babies now can be delivered at 28 weeks instead of 40, thus shortening the gestation period from 40 weeks to only 20 weeks.

Attempts are being made to extend this period for the entire term of gestation, thus obviating the need for uteri altogether. Combine this with cloning and imagine what lies ahead.

Duplication of zygotes: Human zygotes have been grown to 8-16-cell stage, then cleaved to obtain several zygotes. The embryos can be kept on hold in a frozen state. The DNA pattern can be carried out on one or two of them and thus the complete genetic makeup of these zygotes can be determined before implantation.

Zygotes carrying diseases are destroyed and only healthy ones are used to produce babies. Through use of drugs multiple eggs are formed. These can be harvested in one cycle or eggs from different cycles can be collected. Zygotes are then made with desired sperms. These are analysed and only healthy ones used for implantation.

On Dec 31, 2000, 5,000 frozen embryos were destroyed in the UK. This evoked much emotion and debate about the rights of the frozen embryos. Are they humans or mere objects? The European Union holds that all defective zygotes be destroyed and the healthy ones be used within five years, thus preventing life in limitless limbo.

Cloning: ‘Dolly’, the cloned sheep, caught newspaper headlines far and wide and made cloning a household term. Mice, goats, cows, sheep and pigs have already been cloned and rumours are rife that some unscrupulous scientists have even begun cloning humans, though this is not legal in most countries.

At the moment, apart from legal implications, the main constraint in this procedure is that the age of the DNA and RNA, at the time of the birth of clone, will be the same as that of the individual from whom the cells are taken. This is so because they have not gone through the process of meiosis and rejuvenation achieved by the DNA and RNA during natural reproduction. But after complete mapping of the human genome and once the genes of aging and cancer come under control, the process is likely to become a reality. Cloning has recently been made legal in the US.

Organ transplantation

Organ transplantation began as skin grafting. Corneal grafting and kidney transplants are common practice nowadays. Liver, pancreas and lung transplants have also become common all over the world.

Apart from skin, bone, kidney and bone marrow transplants, nearly all organ transplants are cadaveric. That is, the source of the organs is a dead person or in some cases animals (xeno-graft). In Russia, blood and other organs of healthy people dying in accidents, heart attacks and electric shocks are taken out with the permission of the authorities.

Blood, after initial clotting, becomes liquid due to fibrinolysis and then is collected without any anticoagulant. Every year more than 100,000 units of blood are collected from these cadavers. In the West, this is thought to be abhorrent and no blood or organ is taken out unless prior permission has been obtained from the deceased or the relatives.

The opinion of the secular world towards cadaveric organ transplantation may be, and perhaps is, considerably different from what is allowed in Islam. Most ulema believe that a person is supposed to be the owner of his property and his body. Therefore, he can donate any part of his body to others as long as it does not cause his own death. So, our ulema have no objection to organ donations.

Tissue engineering

Stem cells: Cells from placentas, live aborted foetuses or fresh stillbirths are being used to provide stem cells, which can be manipulated to produce tissues and even organs. Pleuripotent stem cells or even committed cells of particular organ, such as endoderm, can be directed towards development into the desired organ by careful guidance using hormones and gene controlling substances. Very recently, the British parliament legalized these procedures.

In humans: In vivo use of genetic engineering has been used for some time. Autologus and Allogenic bone marrow transplants are the most common examples. Now non-vascular tissues, like cartilage, and less vascular tissues, like bones, can be grown in subcutaneous tissues or in peritoneal cavity.

The required organ for replacement may be grown from the cells of the patients themselves (Autologus) or other matched individuals (Allogenic) or from animals (Syngenic). Success in this field would obviate the need for organs from other individuals, thus removing many of the objections that are being raised at present.

In animals: At first, the transgenic animals were used to produce many human proteins. This great feat encouraged the scientists to make the required organs in animals. Most commonly used animals are rats, mice, goats, sheep, pigs and cows.

Transgenic pigs have also been produced which make human blood. However, most interestingly the pig’s heart, with human antigens of the required HLA type, has been developed. This would prove extremely valuable in human heart transplantation, since the size and haemodynamics of the pig’s heart are nearly identical to that of humans.

Genetic engineering

The transgenic technique was first used to synthesize human insulin by bacteria. But soon transgenic animals like mice, rats, goats, sheep, pigs and cows were developed to produce human milk, human factor IX, human lactoferin and growth hormones. The possibilities are endless.

Many biotechnology firms have sprung up that lead in this cutting edge technology and are reaping rich dividends. The advantage of using milk is that large amounts of various substances can be collected simultaneously from the milk of these transgenic animals.

There is no need to sacrifice them and their offspring would also carry the genes. A cow during one lactation can produce up to 8000 liters of milk and despite longer gestation periods and only one to two calves in each gestation, has edge over pigs and sheep, which produce 10 to 20 times less.

A step ahead of cloning, and changing the whole set of DNA, this is a new technology. It is now possible to add or remove a single (particular) chromosome, an arm of a chromosome or even a single gene or codon. It will soon be possible to put a particular gene in its natural locus instead of inserting it randomly within the nucleus.

This has opened a new door to the cure of many genetic disorders, both inherited and acquired, as a first generation mutation. Presently disorders like haemophilia, thalassaemia, cystic fibrosis and several other diseases can be detected in the embryo at 8 to 10 weeks gestation and all the babies carrying the defective genes can be aborted.

It will soon be possible to add the missing gene or delete the deleterious gene in the bone marrow stem cells of these individuals and use corrected cells to populate the bone marrow through bone marrow transplantation.

However, is it a single gene, multiple genes, the whole arm, the entire chromosome or a number of chromosomes? At what point can we say that we have changed the individual?

One can argue that when we change 51 per cent of the genes we create a new person. But interestingly, all genes are not of equal importance. Genes in humans and chimpanzees are 95 per cent identical. It is only the remaining 5 per cent of the genes, which make all the difference.

This was a glimpse from the daring, but not so ethical, new world. What starts as an animal experimentation today may be used in humans tomorrow. And what is therapeutic and life-saving now will most certainly be used for monetary exploitation later.

Let me turn now to some important questions. Is it in tune with the Islamic sense of humanity that an organ be allowed to rot and decay, instead of providing relief to other human beings? This would be like throwing away precious water instead of letting it quench the thirst of a badly dehydrated man.

It is often said that a procedure, which is therapeutic in the beginning, may be used for cosmetic reasons later. Or, an operation done for humanity today will be undertaken for commercial reasons tomorrow. I believe that it is not the sword or the gun itself that is Haram but the way it is used which makes it so.

To be sure, I am not a Mufti but just another practising Muslim. I can only point out what appears to be in tune with the Islamic spirit. Here are some guidelines, to the best of my knowledge and understanding.

A procedure is likely to be permissible if it is life saving; alleviates pain and suffering; helps in removing permanent disability; is carried out to make a person socially acceptable, such as repair of gross disfigurement; and, helps people in earning their livelihood.

Cosmetic procedures done just to enhance beauty are to be shunned. However, I am not sure if this can be declared un-Islamic.

Procedures carried out for scientific advancement, with the intention of saving human lives both now and in the future, should be permissible. Many procedures appear to be born out of scientific curiosity at first but if the intention is to learn new techniques, this should be allowed.

Procedures carried out purely for monetary gain are not acceptable. Inbreeding experiments on humans is not acceptable. In human reproduction procedures, all sperms and ova must be from men and women married to each other and not from outside wedlock. Surrogate human mothers should carry the same sanctity in our society as the Razai (milk) mothers.

There are many other situations requiring guidance in the light of Islam. All such cases have to be studied individually and carefully in detail, both medically and in the light of the Holy Quran and Sunnah.

Dr M. Ali Albar in his article “Organ transplantation and the Islamic perspective,” which was published in Contemporary Topics In Islamic Medicine, has mentioned several edicts from the Grand Muftis of Egypt, Saudi Arabia, Kuwait and Malaysia who spoke in favour of organ transplantation. It is interesting to note that in all these countries a majority of the people follow one school of thought.

The writer is the CEO of a chain of pathological laboratories

Please Visit our Sponsor (Ads open in separate window)