Humans are aware of their end from childhood. Our awareness that one day, not knowing when and how, we will die poses a challenge for us. Different societies, religions, and cultures have provided ideas and attitudes to deal with the ever-present idea of death.
Yet, the attitudes and behaviours towards death do not remain unaffected by cultural and medical advances. Religion also has a strong influence on how humans deal with thoughts of death. But as living conditions change, new religious interpretations emerge, fostering new outlooks. Present times, with their intellectual, technical, and medical advances, are bringing up new ideas of death. How are Muslim societies, more relevantly for us in Pakistan, being affected by changes in attitudes towards death occurring across the world? This question needs close examination.
To find how attitudes are evolving, we must first look at what they have been and are, specifically in Pakistan. Generally, our belief in the afterlife is consoling—that the end is not the end. Yet, death itself is scary. This duality plays out in life. Most people struggle to postpone death by seeking intercessions of prayers, pirs, and shrines, in addition to affordable medical interventions.
Culturally, it was a custom in my childhood in the walled city of Lahore that the death of an old person was celebrated for his/her long life by serving chickpea pulao, in contrast to dry naan and pakoras for a young person after burial. A high rate of child mortality was accepted with resignation. Yet, crying and wailing were common at a death as an open expression of grief.
These customs have begun to wear out among urban middle classes. The faith in foreign doctors and treatment abroad is widespread for potentially fatal ailments, though only a few can afford those. Yet, these are efforts to avert looming death. When nothing seems to bring solace, it is common to pray for a sick person’s deliverance from suffering, which is an indication of acceptance of the inevitable.
Medical Assistance in Dying (MAID) is the newest medical procedure being adopted in the Western world. It is another step towards accepting and dealing with death to reduce its fear and uncertainty for incurably suffering persons
Here, a brief recounting of my own experiences may be illustrative. My father’s untimely death (43 years of age) was preceded by a long and agonising illness, making this strapping and strong man gasp for breath. We tried specialists’ treatments, visiting divines and shrines (despite ancestral affiliations with Deobandis), sacrificing goats, and getting amulets against a relative identified by a spiritual psychic (falsely) to have done black magic for a property dispute, but he kept on deteriorating and suffering. So painful was it all that I, a child of 13, blurted out that he may be better off dying—a thought that made me feel guilty for ages. Yet, the inevitable happened.
It was a common belief, enunciated in Friday sermons, that non-believing Westerners are terrified of the approaching death. At the deathbed, they realise their folly of irreligiosity. When I came for graduate studies to the US in the mid-1960s, I found that death was not much talked about, even in the media. The affected relatives and friends took it with grief, but a community’s and church/synagogue’s support offered relief. A typical American child learnt of death from movies, books, and the passing of pets. I saw no evidence of extraordinary terror afflicting Americans at the time of death.
The Vietnam War and the body bags coming into communities across the US brought death as a topic into everyday discourse. TV news, discussions, and dramas brought the scenes of people dying into living rooms. A major change came when doctors’ ethics changed, requiring them to truthfully tell patients about their life prospects. Death was no longer an unspoken topic.
The next major change in public attitude came with advances in medicine, which enabled a person to be clinically alive with aggressive interventions such as tube feeding, ventilators, and heart stimulation. Yet, the patient could be unconscious and unresponsive. This possibility has led many persons to leave instructions for not being resuscitated. People started to record such preferences in wills and with their caretakers/doctors. This is a preference for death over being alive in a vegetative state. Individuals choose the form, if not the moment, of death.
Mr Ghamidi, a renowned Islamic scholar, in one of his YouTube videos, can be seen approving this practice. I know of a Pakistani-Canadian whose brain aneurysm left him completely unresponsive, but he was kept breathing with a ventilator and tubes for years because his family did not consent to turn off the sustaining equipment. Finally, after some Imam shopping, they got a fatwa that turning off his support system was permissible.
These changes in attitudes and practices have forged palliative care as a formal medical procedure and have given rise to hospices as institutions for the care of the terminally ill. Recently, (former) US President Carter, a devout Christian, survived almost a year under hospice care at home, opting to discontinue any medical treatment for his illness.
The acceptance of death has changed customs of mourning. Now, in North America, the death of a relative or friend is more commonly memorialised in a reception recalling the deceased’s achievements, humour, and quirks, with some tearful goodbyes. The ceremony is beginning to be called a celebration of life.
Medical Assistance in Dying (MAID) is the newest medical procedure being adopted in the Western world. It is another step towards accepting and dealing with death to reduce its fear and uncertainty for incurably suffering persons. It is a controlled and consented form of euthanasia. Though rules vary, generally, a person has to be an adult in their right mind, required to give consent twice at different times. An independent board of doctors and lawyers/ethicists has to judge a MAID request as acceptable to terminate an incurable and grievous condition.
Switzerland has been offering MAID since 1942. Now, about 16 countries—mostly Western, though Colombia from the south—have legalised MAID. Eight states of the US have also legalised MAID. The UK remains an exception. Canada is fully MAID-compliant. In 2023, 15,343 MAIDs were performed in Canada. I know of two academic colleagues who had chosen MAID. Recently, a long and close friend of my wife, suffering from advanced Parkinson’s, has chosen to undergo MAID.
Like most medical practices originating in the West, MAID will also come, illegally or legally, to Pakistan and other Muslim countries. I have a mixed reaction, but the thought crosses my mind that if we accept medical interventions to prolong life, then why not those to end the suffering of an impending death? Maybe this could be the divinely ordained way of when and how death comes? There should be national discussions about MAID led by medical experts, Islamic scholars from universities and seminaries, and the public at large. It should not be left to the knee-jerk reactions of conventional mullahs. Thinking back, I wonder if my father may have chosen MAID, given his prolonged agony.