Health workers, like nurses are tasked to save the lives of their patients, however, there are instances in which health workers have to deal with difficult cases in taking a life, such as abortion. Scholars in the field of healthcare assert that abortion is morally justified if it is sought for health reasons. Nevertheless, there are a number of cases in which abortion is sought on other grounds other than health, such as the individual choice to do so. Can a nurse refuse to provide their professional service towards these people? This paper uses analytical and comparative methods to address ethical issues in abortion from the Islamic and conventional perspectives. Nursing implication: Since the nurses instruct and assist people in forming a decision as they engage in nursing care, utilising a comprehensive view of abortion based on Islamic sources would provide a foundation in Muslim perspectives as they interact with Muslim patients. The subject area to investigate the degree of knowledge among nurses regarding the Islamic moral judgement on this event is extremely recommended for future management.
According to the Concise Oxford English Dictionary, abortion means the deliberate termination of a human pregnancy1. The Black's Medical Dictionary states that abortion is the expulsion of a foetus before it is typically viable, usually before 24 weeks of pregnancy2. However, the definite period of viability is still disputable among scholars. Some books mentioned that the viability is within the 20th weeks of gestation3 or during the first 28 weeks4. Because of the different understanding of viability, the World Health Organization (WHO) has recommended two criteria in determining the viability, which are; a foetus is viable when the gestation period has reached 22 or more weeks, or when the foetus’ weight is 500 g or more5,6. Since these definitions have a variety of explanation and description, it can be simplified where the definition of abortion connotes the event of discontinuing a pregnancy. The foetus in a womb does not bear a chance to live outside since the surrounding factor has impeded their development. It is worth to note here that there are two types of abortion; spontaneous and induced. Miscarriage, which means an involuntary loss of the foetus, describes the former type7, where the intention to abort the child does not take place. While the latter denotes the will or intention of the pregnant women to abort the child, in which most scholars refer them as intentional abortion. For the purpose of this article, the author chooses to focus on the induced abortion only. Thus, throughout this discussion the term abortion will be employed to refer to induced abortion.
Basic concepts of abortionSince ancient civilisations, abortion has been practiced and the morality of its practises has been debated. The Greeks and Romans are the earliest known ancient cultures that have practised abortion. Most cases reported in these civilisations proved that abortion was done just for social causes, such as controlling the population and retaining the power8. The absence of modern medical technology at that time was possibly the reason that medical factors were not the primary cause of abortion. Meanwhile, abortion practices have always been resisted by certain groups of people. For example, the famous Hippocratic Oath taken by the physicians since its formation, which included the statement: “I will maintain the utmost respect for human life, from the time of conception”9 that reflects on the preservation of the spirit of life. Likewise, the early Christians showed their resistance towards abortion and indirectly influenced the Western world against all forms of birth control including abortion. However, this attitude has changed in 1973 where the Supreme Court of the United States reached a determination to allow the termination of pregnancy6. This decision has resulted in increasing frequency of abortion in the West.
Abortion has been made legal in many countries nowadays. The purpose of legalising abortion is to prevent women being involved in an unsafe abortion that could expose them to a higher risk of morbidity and mortality5. WHO defines the term unsafe abortion as the procedure performed by an unauthorised personnel who have a lack of skill and knowledge, or the environment is not met with the minimal medical standard, or both10. Some countries regard abortion as illegal such as Nigeria11 and Malaysia12. Nevertheless, there is an exception, whereby the physician, whom in good faith may justify their human actions with the appropriate medical reasons to induce abortion, hence, it is considered to be legal. Subsequently, the court needs to validate their good faith to be in compliance with the accepted medical practices13. For instance, as a general rule, abortion is illegal in Malaysia, but exclusion is made only for women who are suffering either physical or mental injury due to the pregnancy. Another example is when the pregnant mother of a rape case gets a severe mental distress, in which the physician believe that the condition would harm her, then abortion is allowed to be performed. For the exclusive ground of being a rape victim, abortion is not granted and both parties, including the mother and the physician, will be charged according to the Malaysian Penal Code under Act 5746. In most cases, the reason to save the life of the mother or known as the therapeutic abortion is morally justified. However, due to some women justifying abortion for a societal cause, such as unwanted pregnancy and gender selection, the pregnancy due to rape or adultery has become a subject that arouses passion and contention. Aside from that, legalising abortion has given women the option to decide to end a pregnancy. In that instance, nurses who are involved in this issue faced a moral dilemma because some times the choice of the pregnant women to abort the child may conflict with their personal belief.
Moral and legal dimensions of abortionIn the general outlook, the moral values of lifesaving and the sanctity of the human life sounds anti-abortion, yet today, abortion has been legalised in many countries around the world. For example, United States has gotten along without legalising abortion for 200 years. However, grounded from the case of Roe vs. Wade, the enactment in United States was changed allowing the women to terminate their pregnancies14. The Cornell University Law School discussed a case between Roe and Wade, whereby the court's decision was favourable to Roe and she was allowed to have the abortion15. The Roe vs. Wade case's decision indirectly gave the right for women to choose either to keep or terminate their pregnancies and has affected millions of poor girls like Roe that wanted to abort their child. For example, after this case, approximately 26 million legal abortions had been carried out worldwide in 199516. From 1973 to 2011, nearly 53 million legal abortions were performed in the United States, an average of almost 1.4 million abortions per year17. In fact, 40% of the world's population today exists in countries where abortion is permitted on request, and only 25% of them have taken into account whether the woman's life is in danger18. The statistics displayed are very surprising because billion of lives have been sacrificed for purposes that are morally debatable, and thus, should be given serious attention by everyone.
There are two opinions about the morality of abortion, namely pro-life, which argues against abortion, and pro-choice, which defends the morality of conducting an abortion. From the view of pro-life, the concern is on the sanctity of life, or when life begins19–22. Life is viewed as a valuable thing where it begins once the conception occurs19. In this regards, the foetus is conceived as an innocent human being. Thus, all forms of taking its life are rejected22, and are akin to murder23. This view has also been supported by two of the most prominent theologians in the Catholic tradition, St. Augustine and St. Thomas Aquinas, where they considered a foetus as a human being in the early stages of pregnancy24. Lopez wrote in his article entitled “Perspectives on Abortion: Pro-Choice, Pro-Life, and What Lies in between”, opines that whenever the foetus is regarded as a human being, the right and moral values of the foetus should be preserved. Therefore, termination of life violates the right of the foetus to be born or the right to life25, to some extent, abortion may be regarded as murder and is punishable by law26. However, some religious opinions, like the Catholics show flexibility on abortion in given cases; the permissibility of abortion should provide a good effect outweighs the bad effect in circumstances such as allowing women to abort the foetus if the pregnancy may harm the life of the female parent27.
The moral concern of pro-choice begins with the discussion about the beginning of life of the growing foetus or when the life began. Pro-choice views the beginning of life at the moment the child has been delivered. Thus, the foetus, which has not yet been born is considered as not a living organism, or a human being, and thus does not have any moral stance. Therefore, any forms of terminating the foetus are not morally wrong22. Boonin disputed the argument of those who say the foetus is a human being is not exact. If the foetus is said to be a human being, the concept of the beginning of life should be extended likewise to a zygote or ovum as well, and be given the same human rights. On the other hand, pro-life is only restricted to the foetus. This position absolutely holds no feeling of guilt and affect to the awareness of the sanctity of life because pro-choice views the termination of pregnancy does not take any life.
A moderate position between the two is to disagree with the above-mentioned pro-life and pro-choice arguments where their position is marked by a critical assessment of given cases. This group of ethicists holds that in principle, abortion is forbidden in the first place, but may be allowed if necessary and if controlled by strict demands and regulations.
Islamic perspectiveTo understand the Islamic perspective on abortion, a few things have to be clarified, including the Islamic understanding of life as well as the formation and the beginning of life.
First, in Islam, life is a gift that is very sacred and priceless. In chapter 5 verse 32, the Qur’an states that: “On that account: We ordained for the Children of Israel that if anyone slew a person unless it is for murder or for spreading mischief in the land it would be as if he slew the whole people: and if anyone saved a life it would be as if he saved the life of the whole people”. In this verse, the sanctity of life is confirmed, whereby the murder of one life is like killing all humankind. All forms of life taking are prohibited, including homicide, suicide, abortion and many more, while all types of life are believed to be sacred, including that of adults, teenage, children and infants.
Secondly, in moral debates on abortion, some scholars have raised concerns about the beginning of life for the growing embryo. This is because in the eyes of these scholars, if the beginning of life is determined, the issues of life determination can be solved, whereby abortion before the beginning of life may be permissible, and will not be permissible after life begins. In the prophetic tradition from the compilation by the Imam Abul Hussain Muslim Ibn al-Hajjaj, narrated by Abdullah in hadith number of 6723 mentioned that the creation of man goes through three stages, including nufah, calaqah, and mughah, whereby each stage approximately consumes 40 days, thus constituting to a total of 120 days. In an article entitled “Abortion from an Islamic Ethical Point of View”, written by Serdar Demirel, he concluded that the scholars came to an agreement that the ensoulment will only take place after all the three stages have been through completely. So, based on this hadith, the majority of scholars agree that the ensoulment occurs immediately after 120 days of conception or within the following ten days28. In other words, the beginning of life begins after the 120th day.
Islamic views on abortionPreservation of life is one of the primary objectives of the Islamic Divine Law (maqasid al-shari’ah). Besides preservation of life, Islamic shari’ah also aims to preserve religion, intellect, honour (family lineage) and property. Conducts and behaviours that are deemed to violate these aims are prohibited, while conducts that are set to achieve these aims are considered morally right. In this case, since abortion involves the termination of life, it is considered as immoral; thus the general perspective of Islam about abortion is as not permissible unless it is done to save the mother's life, which should be carried out before the ensoulment takes place29. The Muslim scholars had achieved a consensus in the prohibition of abortion after the ensoulment takes place12. However, a dispute among scholars regarding at which stage the abortion should be allowed should not be obviated. Regarding this matter, the President of the Islamic Research Foundation International, Ibrahim B Syed, unveils the opinion of the four leading schools towards the permissibility of abortion. The Shafie School allows abortion up to day 120. On the contrary, the Hanafi School views abortion to be permitted until the end of the fourth month. A pregnant woman is permitted to abort her pregnancy without the husband's consent if the reason is morally justified. Whereas, the Maliki School believes abortion is only permitted up to day 40 with the agreement of both parents. Last but not least, the Hanbali School holds the opinion that abortion is prohibited from day 40 onwards.
In addition, the Egyptian Fatwa Institution (Dar-al Ifta Misriyyah) also detailed the prohibition criteria and the tolerance in this issue. Grounded along the public inquiry on abortion towards this institution via its formal website, the author summarises few points as an overall conclusion of this argument. Some of which are as follows: a) abortion is completely prohibited whether it is taken before or after the ensoulment except for any legal necessity; b) the abortion is forbidden if the ground merely due to congenital malformation, the medical test has shown some malformation, low likelihood for a normal delivery or unplanned pregnancy, and c) abortion is permissible to carry out before 120 days of pregnancy if the doctor confirmed the presence of a foetal malformation or the foetal is in lethal condition. The only acceptable reason to abort the foetus is if the pregnancy would threaten the mother's health and life after seeking an opinion from a trustworthy Muslim physician30.
Likewise, the discussions of the Fatwa Committee of the National Council for Muslim Affairs of Malaysia, presiding time to 90 on 1st of March 2010 also agreed and decided a few matters connected to abortion. For couples who are legally married:
- 1.
Abortion between the ages of one to 40 days is discouraged if it is not harmful to the mother and the procedure is required to obtain the consent of both husband and wife.
- 2.
Abortion before the age of 120 days is granted if the foetus is deformed and diseased that can threaten the life of the female parent.
- 3.
Abortion during 120 days or more is not allowed except that of abortion is to save the life of the mother due of severe disability6.
- 1.
When the foetus completes 120 days, then it is not permissible to abort it, even though the medical diagnosis shows that it is physically deformed. Still, if it was proven by the report of a medical panel of the trusted and specialised medical scientists that there is a definite danger to the life of the mother, then it is only permissible to abort the baby whether it is physically deformed or not, in order to avoid the worst of the two harms.
- 2.
It is permissible to abort the foetus on the request of the parents before the foetus’ completion of 120 days, only if it was proven by a report of trusted and specialised medical panel and by a medical check-up based on a thorough technical investigation using the proper laboratory instruments, that the foetus is seriously deformed and it could not be treated, and if it remained to grow into term and was delivered on its due date, the baby's life will be bad and would continue to be in agony throughout its life31.
Nevertheless, in the event of pregnancy due to rape, incest, and adultery, some scholars state that abortion is permissible during the first 120 days of gestation32. Other scholars, nonetheless, never permitted abortion for such causes.
If there are any healthcare providers involved in the procedure of abortion after the four months that violates the Sharicah's guidelines, both the healthcare provider and mother are required to pay blood money to the heirs of the foetus, but his killer (mother) should not take any of it33. They are also expected to recompense for the sin of killing the foetus by fasting for two consecutive months as kaffarah. If the procedure is performed before the fourth month, they should pay the compensation money to the baby's heir34.
Nursing implicationAbortion violates the traditions and values that exist in nursing35, whereby from the perspective of nurses, protecting both of the patient and the foetus is a priority. On the contrary, nurses who participate in abortion procedures indirectly helping to end one life. Some studies demonstrated that nurses are accompanied with the emotional burden, conflict of values and belief36,37, and depression38,39 whenever this dilemma is handled inefficiently.
In the abortion process, nurses play a vital role starting from helping in decision-making40–42, participating in abortion procedures, and providing post-care after abortion42 where the controversy in the termination of life only takes place in the first two roles. In the decision process, nurses are responsible for informing the pros, cons, and the effects of each decision taken by the patient. During this time, nurses do not act as the decision-makers, but more as the facilitator40. The second task requires nurses to make a moral judgment whether or not to participate in the abortion procedure. Therefore, the nurses may require additional education or updates about the laws regarding end-of-life treatment43, to help them in forming their moral judgments and preparing them with the relevant information. The knowledge that emphasises on this matter should be offered in the ongoing education and continuing the professional development education because it will help nurses address the issue of abortion more effectively, whether regarding the professional guideline, law, or morals39.
The findings of this study can aid the growth of related knowledge among nurses and leads towards the enrichment of the existing body of knowledge in nursing, especially the Islamic position on the permissibility of abortion. The nurses put much concern whether or not to take part in abortion procedures. Even though, the policies and law allow nurses to refuse. However, Lachman44 argues that the reason for declination should not be based on self-interest, discrimination, or prejudice, but must only be based on moral judgment, which is also supported by the religious and secular views. In this regards, Islamic views on this issue give a clearcut idea on the condition for Muslim nurses either to proceed or decline in participating in the abortion procedure.
Studies have shown that the perspective of religion on the arising issues play a major role among the patients to make a related decision11,45–47. Indeed, a local study carried out among outpatients at the University Malaya Medical Centre, Malaysia showed the majority of the patients, mainly Muslims pointed out that every health plan needs to be in line with their religious views48. Since the nurses instruct and assist individuals in making a decision as they engage in nursing care, using a comprehensive view of abortion based on Islamic sources would provide them with some information as they interact with Muslim patients. As holding a role of an advocate, nurses must be fitted with an excellent understanding and knowledge of abortion to educate the patients. However, insufficient explanation to the patient regarding this issue may put a patient in doubt and confusion that may lead to an interruption in the decision-making process. For the future direction of this study, it is highly recommended to investigate and explore the knowledge of Islamic moral judgment on this issue among nurses.
Conflicts of interestAll authors declare that they have no conflicts of interest.
