Clinical Ethics and the Observant Jewish and Muslim Patient: Shared Theocentric Perspectives in Practice

Abstract

Patients from religious minorities can face unique challenges reconciling their beliefs with the values that undergird Western Medical Ethics. This paper explores homologies between approaches of Orthodox Judaism and Islam to medical ethics, and how these religions’ moral codes differ from the prevailing ethos in medicine. Through analysis of religious and biomedical literature, this work examines how Jewish and Muslim religious observances affect decisions about genetic counseling, reproductive health, pediatric medicine, mental health, and end-of-life decisions. These traditions embrace a theocentric rather than an autonomy-based ethics. Central to this conception is the view that life and the body are gifts from God rather than the individual and the primacy of community norms. These insights can help clinicians provide care that aligns Muslim and Jewish patients’ health goals with their religious beliefs and cultural values. Finally, dialogue in a medical context between these faith traditions provides an opportunity for rapprochement amidst geopolitical turmoil.

Introduction

Current geopolitical events have focused attention on conflict between Jews and Muslims. Yet, amidst the current turmoil, there is also an opportunity to explore elements of commonality and harmony between these faiths, particularly in the context of medicine. Within the folds of Abrahamic traditions, Judaism and Islam emerge not as adversaries but as kindred spirits, sharing more similarities than differences. In this study, comparisons of traditional Judaism and Islam highlight these common theological threads and urge a narrative shift towards understanding based on this shared lineage.

Judaism and Islam are two of the major Abrahamic faiths, along with Christianity. The term “Abrahamic” refers to the common ancestral origin through Abraham, father of Isaac, a patriarchal figure of Judaism, and of Ishmael who is considered a founder of the Arab nation and revered prophet of Islam. For Jews and Muslims, Abraham represents not only a patriarchal figure and shared genealogy but also a legacy of pioneering monotheistic faith, and a theocentric philosophy of human life as a project of utmost devotion to God.

Judaism and Islam share a deep reliance on their respective holy scriptures, namely the Torah and the Qur’an, as well as many similar beliefs, practices, and perspectives on healthcare and illness. Since Christianity is also an Abrahamic religion, it is important to explain why we do not include it in our study. Many Western Christian-majority nations have undergone profound processes of secularization which have accelerated in recent decades. These, in turn, have shaped Western societies’ perspectives towards medical issues such as reproduction, end of life decisions and mental health. Thus, observant Jews and Muslims might find themselves at odds with the dominant culture in those countries, because of their more traditional and theocentric worldview.

Importantly the range of beliefs and practices among Jews and Muslims vary considerably. Judaism for example has more progressive and modernized forms such Reform, Reconstructionist, and Conservative denominations, and more strictly devout, ones often described as Orthodox. Islam, also, encompasses several important traditions and religious philosophy. For example- within the realm of Islam, there are two distinct major groups: Shia and Sunni. While they traverse separate paths and uphold distinct values, practices, and historical perspectives, it is interesting to note that when it comes to medical reasoning, they often find themselves rooted in quite similar approaches. Therefore, in this paper, we aim to be inclusive of a wide variety of Muslims. That said, given that Sunni Muslims are the majority, and they prioritize the Quran and Sunnah with equal significance, we do include relevant Sunnah literature while recognizing that Shia has a different perspective.

In the context of this article, we focus on Orthodox Jews and devout Muslims who adhere strictly to religious teachings and traditions. These two faith communities are therefore often misunderstood and stereotyped, interfering with culturally competent medical care.

This paper aims to equip healthcare professionals with foundational knowledge to provide effective and culturally sensitive care in selected clinical settings to these religiously observant patients. As critically, by shedding light on shared values of Muslims and Jews, we hope to contribute to a larger discourse that promotes rapprochement between these two faiths communities.

1. Shared Origins: The Abrahamic Legacy

The common roots of Judaism and Islam extend into earliest antiquity. The Book of Genesis tells of Sarah, Abraham’s wife, who is childless, despite God’s promise to Abraham to be the father of many nations. She offers her servant, Hagar, as a surrogate of sorts to fulfill this goal. Hagar becomes pregnant, and tensions between the two women rise. Hagar flees the family home, then returns and gives birth to Ishmael. After Sarah gives birth to Isaac, the family is thrown into further turmoil. At Sarah’s behest Abraham casts Hagar and Ishmael off into the desert, where God saves them from death by showing them a water well. Isaac and Ishmael are later reunited after Abraham’s death and bury him together, in a sign of unity brought forth by mourning.

The story of Abraham and his two sons is one of confluences. In Islamic tradition, Ishmael, son of Ibrahim and Hagar, is revered: “And mention in the Book ‘O Prophet, the story of Ishmael. He was truly a man of his word and was a messenger and a prophet.” Qur’an (19:54).

In Islamic scripture Abraham is commanded by Allah to leave Hagar and Ishmael in an isolated place on the road to Mecca. Ishmael and Hagar settled in Mecca and were saved by finding water in the Well of Zamzam. In a story that parallels the Torah’s account of the binding of Isaac, Abraham attempted to sacrifice Ishmael, which is the basis for the holiday of Eid-al-Adha and the scared rite of Hajj (pilgrimage) in Mecca. ¹

Through the ages, Jews and Muslims lived together in Arabia, Egypt, Babylonia, Persia, the Levant, and North Africa. They shared cultural, religious, economic, and linguistic aspects of their lives. Early Medieval Jewish Scholars such as Rabbi Sa’adiah Gaon (882–942) wrote commentaries on the Torah and other works of Jewish religious philosophy in Arabic.

The pinnacle of the ties between Jews and Muslims was in Spain under Muslim rule, a period, referred to in Spanish as the “Convivencia,” literally living with each other. ² Two towering figures of this era were two physicians, philosophers, and religious scholars: A Jew, Moses Maimonides (the Rambam, 1138–1204) and a Muslim Ibn Rushd (Averros 1126–1198). As physicians who were deeply concerned with philosophy, we might even claim both Maimonides and Averros as proto-medical ethicists.

Maimonides was a great admirer of Ibn Rushd’s work on Aristotelian philosophy, and Muslims revered Maimonides as Ubayd Allah — a faithful servant of God.

“Both were quintessential citizens of Andalusia. Both wrote in Arabic. They both used reason and logic in appreciating faith and argued for the compatibility of the two. Their books were burned by members of their own community. They were exiled by the same dynasty…Maimonides promoted the work of Averroes among his students. Today both are recognized in the ranks of the greatest philosophers of history while their critics are lost in obscurity.” ³

One would never imagine such homologies of thought given the current political realities in the Middle East. Even more so since war erupted in October of 2023 in Israel and Gaza. This has pushed conflict to the foreground, creating a strong sense that religious tensions between Muslim and Jewish communities are the source of perpetual discord and struggle. This view of the relationship between the two religions is erroneous and ahistorical. It fails to capture the complexity and nuance of the lived experiences of Jews and Muslims and their religious traditions and joint inheritance. Before the recent war broke out, efforts to find reconciliation between Israeli and Palestinian communities have found that shared religious values ⁴ along with medical collaboration have helped members of these communities break through walls of mistrust and animosity. ⁵

We hope that by highlighting the shared values of Jews and Muslims that undergird their approach to medical ethics, we might improve care of patients from these traditions. As importantly, we hope to bring a bright light to this darkest hour and promote a future characterized by mutual understanding and peaceful reconciliation.

2. Decision-making and Sources of Moral Authority in Judaism and Islam

In this article, we map out the various junctures throughout the life cycle at which Orthodox Jews and observant Muslims need and seek religious guidance, whether through reading of scripture, religious law (known in Judaism as Halacha and Sharī’ah in Islam), or input from religious leaders regarding medical decisions. These decisions span the entire spectrum from marriage, sexuality, reproduction to end-of-life decision-making. In these faith traditions’ approach to healthcare decisions, biomedical facts, statistics, and evidence-based recommendations are just the first step in the deliberative process. Patients, families, and providers must reconcile medical information with moral and cultural values that influence how life, death, health, and well-being are experienced and perceived.

Before we turn to specific clinical areas, it is important to describe how decisions are made in these two religions. A key element are beliefs about human and divine agency. Unlike Western medical ethics, where the central tenet of autonomy devolves from the individual’s preferences, in the Abrahamic tradition, the individual is an inseparable part of a relationship between the self, family, the community, religious leaders and God. While individual choices certainly matter, the organizing principle is a faith-based duty for healing that must be upheld. This can be thought of as deontological obligation rather than a rights-based ethics.

For instance, Jewish scholars have asked whether it is even appropriate for doctors to intervene in illness, since healing originates with God. The prevailing view is from the house of Rabbi Ishmael that sees the Torah as giving permission for the physician to serve as God’s emissary in healing (Bava Kama 85b). The Midrash (Rabbinic exegesis on the Hebrew Bible) likens the physician’s work as akin to the farmer; God’s creation of water, soil and seeds still needs human toil. The Divine process of healing is similarly mediated by the physician’s practice (Shohair tov, Samuel 4:8).

Similarly, for Muslims, the decision-making process integrates medical information and opinions of physicians, consultations with religious authorities, and the view of divine agency as determinative for medical outcomes. Qur’an serves as the foundational book of Islam, from which all practices, norms, rules, and regulations are derived. It is considered a complete guide to a Muslim’s lifestyle. Additionally, the “Hadith” contains the sayings of the Prophet Mohammed (pbuh) and is known as the Sunnah. Anything not explicitly found in the Qur’an is encouraged to be sought in the Sunnah, as it encompasses religious practices. Hadith are interpretive guide for seeking wisdom and direction. The hadiths are coming from different sources, and they are ranked in order. ⁶

Additionally, Muslim religious beliefs and values are shaped by the Sharī’ah, representing Islamic moral law. Sharī’ah provides scripturally derived guidance on normative obligations. Islamic theologians and jurists have developed rules through moral theology (usūl al-fiqh), identifying sources of ethical and legal knowledge, laying down rules for clinical and juridical reasoning. This process culminates in fiqh (law). Usūl al-fiqh relies on material sources like the Quran and Sunnah, interpreted by trained jurists to derive contextualized rulings for the Muslim community. Formal sources include ijmā’ (consensus-based agreement) and qiyās (analogical reasoning). The four sources, while occasionally prioritized and applied in varying ways, are deemed fundamental in shaping moral law in Islamic bioethics according to the four existing Sunni schools of Islamic law. ^{7 , 8}

We will now turn to specific clinical challenges to illustrate the richness of these two traditions.

3.1 Genetics Consultation

In the Abrahamic tradition reproduction represents not only a biological process but the continuity of the eternal relationship between humanity and God. The process of creation of a developing human being is viewed as sacred and represents a Divine plan for an individual’s life. An intervention that alters genotypic or phenotypic outcomes thus could be construed as interference in God’s will.

The Halachic approach to genetic testing is informed by the evaluation of individual risks. The small genetic pool, especially among Ultra-Orthodox Ashkenazi Jews poses concerns for monogenetic autosomal recessive disorders such as Tay Sachs or Gaucher diseases. ⁹ This elevated risk, along with a strong social norm of arranged marriage has prompted a novel approach by which prospective couples are screened for genetic disorders; if both individuals are carriers, then a match is discouraged. The prominent organization in this field, Dor Yeshorimm is credited with the near elimination of Tay Sachs disease and has contributed significantly to the genetics scientific literature. ¹⁰

Another area of concern is pregestational diagnosis (PGD), in which gametes and/or zygotes are analyzed for genetic variation and selected for certain traits (such as gender or the absence of genetic mutation) prior to implantation in the context of in vitro fertilization (IVF). The rabbinic approach to PGD, has been nuanced and complex and reflects hesitancy to interfere in the process of procreation which is believed to be Divinely devised.

The Talmud describes a conversation between the Prophet Isaiah and King Hezekiah who believed he should not father children because of his foreknowledge that some of his descendants will be wicked, to which the prophet responds:

“Why do you involve yourself with the secrets of the Holy One, Blessed be He? That which you have been commanded, the mitzva of procreation, you are required to perform, and that which is acceptable in the eyes of the Holy One, Blessed be He, let Him perform, as He has so decided. (Babylonian Talmud, Berachot 10a).

Halachic considerations in favor of PGD include the technology’s ability to help couples fulfill the commandment to be fruitful and multiply, which is believed to mean having both male and female children, which, in turn, gender selection by PGD can help achieve. A further benefit is its role in reducing the stress of couples at high risk for having children with severe genetic abnormalities. Halachic concerns include obtaining sperm from the prospective father, discarding gametes, and other issues. Overall, rabbis try to adopt a case-specific approach to PGD, considering the unique circumstances of each couple hoping to procreate. ^{11 , 12}

Islam mandates seeking treatment for diseases, in accordance with the Qaidah fiqh “ad-darar yuzal” (harm is put to an end). Islam acknowledges that Allah has created a treatment for every disease, except aging, and recovery is possible through proper therapy. The use of PGD to find treatments for genetic disorders is seen as consistent with Shariah. ¹³ Some scholars advocate for PGD, stating it can prevent genetic disorders in children. However, PGD for gender selection or personal traits enhancement is against the principles of Shariah ¹⁴ because any attempt to modify creation for non-medical purposes contradicts Islamic jurisprudence. Sex selection or enhancement would be non-medical and over-reaching and their use would question the Creator’s divine intent and his ability. ¹⁵

3.2 Family planning and Pregnancy

Contemporary secular societies do not necessarily consider child-rearing to be a duty; often, bearing and raising children are cast as matters of choice. Some even view human procreation as morally problematic given its perceived negative environmental impact. By contrast, fundamental importance is attached to marriage, children, and the expansion of the family in traditional Judaism and Islam.

In Judaism, procreation is said to be the very first commandment (Mitzvah) in the Torah. God commands Adam and Eve to:

“Be fruitful and multiply and fill the earth.” Genesis 1:28,

Rabbis interpreted this as an obligation to have at least one daughter and one son, with additional children being a further fulfillment of this Mitzvah.

Additional reasons for having large families include the memory of times when infant and child mortality was high, and the restoration of the Orthodox Jewish population that the Holocaust had nearly eradicated. The fertility rate among the ultra-Orthodox, accordingly, is very high, averaging 6–7 children, much higher than the Western average. ¹⁶

Views on contraception, assisted reproduction technology (ART) and prenatal testing are mixed. Contraception can be considered when: pregnancy could endanger a woman’s life or health; a couple needs time before having children for physical and/or emotional well-being; they have had as many children as they can handle. ¹⁷

Assisted reproduction for couples experiencing infertility is generally supported, to fulfill the Mitzvah to be fruitful and multiply. There are, however, significant Halachic issues with ART. Obtaining semen for IVF for example is subject to debate since masturbation and wasting of seed (Haschatat Zera Le-Batala) are forbidden. Alternative methods such as intercourse with the use of a condom that allows preservation of semen to be brought to the IVF lab have been suggested. Gamete donation raises questions of parenthood, the illegitimacy of children born in these circumstances and even adultery. Other issues include the fate of unused zygotes/embryo, and embryo selection when assisted reproduction results in multiple implanted embryos. ¹⁸ This issue, in fact, is now a matter of public debate in the United States following the Alabama Supreme Court ruling on the status of embryos following Dobbs. ¹⁹

Prenatal testing is another area where religious values influence preferences and choices. A study of ultra-Orthodox Jewish women who declined prenatal testing revealed that their decision was profoundly faith-based. Women believed that the outcome of their pregnancy would represent God’s plan for them and viewed endurance of undesirable outcomes as the highest level of religious devotion. Some even suggested that a special needs child is evidence of God’s confidence in the parents’ ability to withstand this challenge, a test of faith (nisayon). ²⁰

Similarly, in Islam, having offspring is a form of spiritual commitment, prompting Muslims facing fertility challenges to pursue parenthood fervently. Having large families has an added value by way of fulfilling one’s duty in increasing the population of faithful adherents of Islam who will carry its legacy into the future. ²¹ In fact, some scholars assert that contraception is not permissible within Islam. ^{22 , 23} This perspective views the act of having children assumes the nature of worship because it leads to the proliferation of followers of Islam worldwide. “My Lord! Grant me (offspring) from the righteous” [Qur’an 37:100].

In Islam procreation is confined to the sacred institution of marriage between a man and a woman. In the context of in vitro fertilization (IVF), specific conditions must be met to align with Islamic principles. The IVF procedure must exclusively involve a married couple, with the husband’s sperm and the wife’s eggs. This process must occur within the bounds of a valid marriage ^{24 , 25}.

The pursuit of a solution for infertility is not only permitted but actively encouraged. Islamic law sanctions all assisted reproductive technologies (ARTs), given that the sperm, ovum, and uterus are sourced from parents legally married to each other. The involvement of any third party in the sacred realms of marital intimacy and procreation is expressly prohibited. Furthermore, the practice of cryopreserving surplus fertilized embryos is permitted, allowing for their transfer to the same wife in subsequent cycles, as long as the marriage remains intact. ²⁶ Surrogacy, in particular, is not deemed acceptable in Islam and all forms of procreation outside of marriage is not sanctioned. In fact, adoption is even discouraged in Islam. ^{27 , 28}

The enormous importance of procreation for Orthodox Jews and Muslims underscores the challenges faced by couples striving to fulfill their religious obligations while navigating high risk pregnancies, ART and other scenarios. Providers need to appreciate that procreation is an act of devotion in these faith traditions to understand why families persist in these efforts despite the high-cost expense and risk of complications.

3.3 Childbirth and Fetal Rights

Contemporary Western reproductive ethics view abortion primarily through the prism of maternal bodily autonomy. The right to make choices regarding pregnancy and abortion is given primacy, while the personhood of the fetus is debated. Ongoing political and legal struggles surrounding abortion further sharpen the fault lines between conservative and liberal worldviews. The Abrahamic faiths have a less dichotomous view. They emphasize the status of the fetus as a being with at least a potential of personhood, while still recognizing maternal interests as significant.

The Orthodox Jewish approach to abortion and fetal status is characterized by an effort to balance the sanctity of human life as it applies to the fetus with the mother’s physical and emotional health. Some early commentators have considered the verse:

“He who sheds the blood of a person in a person, by a person shall his blood be shed,” (Genesis 9:6), as a prohibition against abortion.

The key phrase is “a person in person” which can be interpreted as a fetus (Babylonian Talmud, Sanhedrin, 57b).

As in Islam, full personhood of the fetus comes about gradually. Rabbi Yehuda HaNasi in his conversation with the Roman emperor Antoninus agreed that the soul of the fetus is created at conception.

Rabbi Yehuda HaNasi said: Antoninos taught me this matter… that it is from the moment of conception [pekida] that the soul is preserved within a person. (Babylonian Talmud Sanhedrin 91 b).

Other sources, however, refer to the embryo until day forty as “merely water” or maya be’alma (Babylonian Talmud Yevamot 69; b:10).

Several texts prioritize the mother’s life over the fetus’ even during birth, leading some to interpret that in Judaism personhood begins with fetal crowning during labor.

“If a woman is having trouble giving birth, they cut up the child in her womb and brings it forth limb by limb, because her life comes before the life of [the child]. But if the greater part has come out, one may not touch it, for one may not set aside one person’s life for that of another.” (Mishna Ohalot 7:6).

“When a woman has difficulty in giving birth, one may dismember the child in her womb, either with drugs or by surgery, because it is like a pursuer seeking to kill her. Once its head has emerged, it may not be touched, for we do not set aside one life for another; this is the natural course of the world” (Maimonides Hilkhot Rotzea/:1 U’Shemirat Nefesh 1: 9).

Rabbi Shlomo Yitzhaki (Rashi), the great Medieval commentator even goes so far as to deny the personhood of the unborn fetus in this context:

“The entire time that it has not gone out into the air of the world, it is not [considered] a life, and [so] it is permissible to kill it and to save its mother. But when its head came out, we cannot touch it to kill it, as it is like a born [baby]; and we do not push off one life for the sake of another.” (Rashi on Sanhedrin 72b).

Importantly, this discussion is closely tethered to a situation where there is risk to the mother’s life and does not necessarily extend to an elective abortion for other reasons. Thus, abortion is contextualized against a threat to maternal wellbeing and could be viewed as a proportionality argument.

Along these lines contemporary rabbinic rulings strive to balance maternal and fetal rights and interests. Many rabbis continue to view risk to the mother’s life as a clear reason to allow abortion. Things get more complicated in the case of major fetal abnormalities that do not directly affect the mother’s physical health, such as Down Syndrome. While many rabbis categorically forbid abortions in these circumstances, others (most notably Rabbi Eliezer Waldenberg) have allowed the consideration of abortion in extreme cases. These include the risk of severe psychological trauma to the parents, family break-up, etc. ²⁹ Importantly, no major orthodox Posek (a rabbi who holds scholarly and moral authority to rule on matters of Halachah) allowed abortion based on economic hardship or social circumstances (such as a child born out of wedlock) per se.

In the Islamic faith, the fetus is regarded as a potential life, with the soul becoming fully realized approximately 120 days after conception, when the fetus attains the status of a living human being. There are some other views that consider 40 days after conception and when the heartbeat is detected.

“Each one of you is constituted in the womb of the mother for forty days, and then he becomes a clot of thick blood for a similar period, and then a piece of flesh for a similar period. Then God sends an angel who is ordered to write four things. He is ordered to write down his deeds, his livelihood, the date of his death, and whether he will be blessed or wretched. Then the soul is breathed into him…” (Sahih al-Bukhari 3036).

Drawing from this text and other passages within the Holy Quran and Sunnah, Muslim scholars concluded that fetal ensoulment occurs at 120 days after conception. ³⁰ Once the soul is “breathed into” the fetus, it is considered a human with almost full rights under Islamic law, making abortion prohibited. ³¹

Similar to Judaism, this prohibition can be overridden after 120 days if the mother’s life is at risk and takes priority over the potential life of the fetus. However, the definition of harm to the mother’s life is not explicitly defined and is subject to circumstantial consideration. Those who violate this principle could face spiritual consequences, as Muslims hold the belief that such an act may not be forgiven by the Creator. In fact, any abortion after 120 days will be viewed as killing. ³²

“And do not kill the soul which Allah has forbidden, except by right.” (Qur’an 6:151).

In Western secular societies, these beliefs and practices can indeed lead to cultural and religious clashes, as the perspectives on fetal development and rights may differ. It is important for individuals and communities to engage in respectful dialogue and understanding to bridge these differences.

3.4 Pediatric Decision-making

An autonomy-centered approach generally affords children extensive protections because their decision-making capacity is not yet established. Parental decisions are expected to adhere to a best interest standard defined by the child’s health outcomes. But whereas children gain autonomy as they become capacitated adults, the effects of maturation take a different shape in the Abrahamic traditions. There, a duty-based ethic sees children as increasingly subject to religious imperatives and parents as educators obligated to impart religious rites to their offspring and bring them into the fold. ³³ Adherence to religious precepts not autonomy becomes the operative norm.

One area where religious obligation comes into conflict with a child’s eventual self-determination as an adult is ritual circumcision. Neonatal male circumcision has encountered ethical challenges in recent years based on the view that circumcision should be a personal decision and that a male child might not desire it when they have the capacity to make an autonomous choice. Consequently, performing circumcision without the child’s agreement could be seen as violation of his autonomy. Some contend that circumcision should be deferred until a later time, and then done with the individual’s consent. ^{34 , 35 , 36}

In Judaism, ritual male circumcision (usually at the age of 8 days) is considered a foundational mitzvah of utmost importance. In Genesis chapter 17 God speaks to Abraham about the everlasting covenant between Him and Abraham and his descendants and of circumcision as its immediate and most tangible manifestation. Abraham then circumcises himself at the age of ninety-nine, his son Ishmael at the age of thirteen, and later his son Isaac at the age of 8 days. Circumcision has come to symbolize the covenant of the Israelites with God at Sinai. ³⁷

Rabbinic commentators described circumcision as equal in importance to all other mitzvot combined, equal to the entire Torah.

“So great is the act of circumcision that without it, Heaven and Earth would not exist”. (Menorat HaMaor iv).

Decrees against circumcision have been traumatic events in Jewish history as early as the Hellenistic period when Antioch the Fourth forbade circumcision on penalty of death (Maccabees 1,1 48–49) and into the Twentieth century when circumcision was effectively banned in the Soviet Union. A 2007 poll that found no less than 97% of Israeli Jews (the majority of whom are not strictly observant) intend to or have had their male children circumcised. ³⁸

Lack of consent and concern about violating children’s’ bodily integrity has prompted some American Jewish parents to avoid circumcising their children. An additional concern is a practice in some ultra-Orthodox community called Metzitzah b’peh (MB). This refers to the person performing the circumcision (mohel) orally sucking blood from the baby’s circumcision wound. This practice has been linked to serious Herpes Simplex Virus (HSV) infections, severe neonatal illness and death. In the US, the New York City Department of Health has highlighted alternatives to MB approved by some religious authorities such a glass tube attached to a rubber bulb used to suction blood. If MB is performed, recommendations include ensuring that mohelim rinse their mouth with alcohol-containing mouthwash immediately before performing direct oral suctioning. The New York City Commissioner of Health has forbidden mohelim identified as having infected a baby with HSV-1 from performing MB. (NYC Health).

In Islam, male circumcision holds symbolic importance for Muslims, and certain scholars deem it a mandatory practice, all though not majority. Male circumcision (Khitān) is not explicitly addressed in the Qur’an, but various passages of the Sunnah, which encompasses the teachings and actions of the Prophet Muhammad, highlight the importance of male circumcision, and presents it as a commendable practice. Some scholars even consider it obligatory. ^{39 , 40} It is worth menmtioning that circumscision is a culturely driven act and it is a belief in the Muslim practices that circumscisison reduced infection, which is scientifiaccly not proved based on recent data. There is a continuos debate about its mandare or level of encouragement in the Muslim scholar community.

Hence, the ongoing debate on whether to circumcise male infants involves tension between individual autonomy and religious values and norms. Medical professionals and caregivers should be mindful of these factors when interacting with the Muslim community.

Interestingly, Jews and Muslims in some European countries have also stood together against efforts to restrict or ban ritual male circumcision, citing both religious freedom and the concern about xenophobia, Islamophobia and Anti-Semitism in this context.

3.5 Mental Health Stigma

Modern understanding of mental health and illness in the twentieth century has incorporated psychodynamics and an expanding psychopharmacology increasingly predicated upon a biological knowledge of neuropsychiatric conditions. In contrast, traditional Abrahamic views mental health as closely intertwined with spiritual challenges and metaphysical influences on the psyche.

Ultra-Orthodox Jews approach psychology, psychotherapy and psychiatry with ambivalence⁴¹ The key to happiness and mental well-being is generally considered to be observance and the study of the Torah. Resorting to a medical solution to existential problems may be viewed as devaluing the power of Judaism to address life’s struggles. ⁴²

At the same time, there is recognition that religious devotion requires significant emotional work and fortitude:

“As for sadness connected with Heavenly matters, one must seek ways and means of freeing oneself from it… For this one must set aside opportune times, when the mind is calm.”(Rabbi Schneur Zalman of Liadi, Sefer HaTanya, Chapter 26).

In a society where marriages are usually arranged by parents and matchmakers, a diagnosis of mental illness can significantly impact the marriage prospects of an individual, and his or her siblings. ⁴³ However, when overt mental illness is present, Ultra-Orthodox Jews will turn to the secular-professional world of psychiatry for help. Referral is often mediated by a rabbi. The process is characterized by negotiation and qualification, reflecting the conflicted nature of this outreach and the need to balance the need for professional help with assertion of rabbinic authority. ⁴⁴ Rabbinic medication also serves to assess the psychiatrist’s trustworthiness and ability to comprehend Ultra-Orthodox values. ⁴⁵

Interestingly, the meaning of mental crisis among the Ultra-Orthodox can be seen in both a negative and positive light: is it a result of a profound spiritual flaw or an opportunity for spiritual elevation? The mystic and false messiah Shabtai Zvi, for example, described moments of profound religious elevation alternating with spiritual crisis, in what today might be seen as manifestations of bipolar disorder. ⁴⁶ Although Freud observed distinguished obsessive actions from religious practice ^{47 , 48} in orthodox Judaism Obsessive-compulsive behavior may be understood as manifesting a scrupulous adherence to religious ritual, making obsessive thoughts about morality, sin difficult to distinguish from extreme piety. ⁴⁹

In an interview-based study of 18 psychiatrists caring for ultra-Orthodox patients, investigators identified 12 challenges in providing mental healthcare to this population and 11 strategies to overcome obstacles to care. Emerging themes included community stigma, an extended family-patient-community team, cross-cultural communication, culture-related diagnostic complexity, transference/countertransference, and conflicts between Jewish law /community norms and treatment protocol. ⁵⁰ One particularly interesting strategy was appealing to the very same religious values that the ultra-Orthodox community uphold, such as the notion of God’s “helping through the doctor,” thus utilizing a patient’s religious faith as a therapeutic tool.

Similarly, Muslims may avoid admitting or seeking treatment for mental health concern, mainly because of cultural stigma and a limited awareness of mental health care. ^{51 , 52} Mental health is unfortunately often neglected and overlooked among the Muslim population. There are two strongly held beliefs that significantly influence perceptions of mental health: the “Evil Eye” and “Spirit Possession,” both rooted in social and cultural traditions. These beliefs do not originate directly from the Quran and Sunnah and are somewhat interpreted or explained by scholars. Nevertheless, they can pose barriers to mental health and contribute to increased social stigma around mental health.

The concept of the Evil Eye refers to a belief that a repeated gaze of jealousy can cause harm, even leading to illness in the object of envy. It can be intentional or unintentional harm caused by one person to another. Consequently, the root causes of the mental health issues may go unnoticed, attributed instead to the influence of the Evil Eye. ⁵³

“The influence of an evil eye is a fact; if anything would precede the destiny it would be the influence of an evil eye, and when you are asked to take bath (as a cure) from the influence of an evil eye, you should take bath.” (Sahih Muslim 2188).

Belief in “Spirit possession” holds that a person’s body can be inhabited by a malevolent entity known as a “Jinn,” which can cause various psychological symptoms. In the Qur’an, there is a dedicated chapter on Jinn. Muslims sometimes connect mental health conditions to Jinns and often turn to the Quranic healing method known as “Ruqyah”—seeking refuge in Allah and using remembrance and supplications from the holy book. Ruqyah is used for physical diseases as well. These practices are an integral part of their approach to mental health challenges. ^{54 , 55}

“The Prophet ordered me or somebody else to do Ruqya (if there was danger) from an evil eye.” (Sahih al-Bukhari 5738).

Muslims may therefore be less comfortable accepting conventional mental health treatment; the stigmatization is deeply rooted as a form of evil. Furthermore, engaging a secular therapist or psychiatrist for treatment can be seen as disconnecting from religion. ⁵⁶ Thus, the Muslim community is often less likely to encourage someone to seek professional help, which further deepens the already established stigma around mental health among religious Muslims.

Notably, the under-utilization of modern psychiatric care for these populations is associated with a significant health disparity that have significant consequences for those suffering from severe mental illness. Clinicians should become familiar with the perspectives of these traditions to bridge this divide and make modern therapeutics both available and acceptable to these communities.

3.6 End-of-life

The final transition in the cycle of life, namely dying and death is seen in the Abrahamic tradition as a time of spiritual significance. Duty to God continues through this period and thus mitigation of pain and suffering must be balanced against the sanctity of life and recognition of God’s ultimate authority on when life in this world ends. Death in both religion is seen as a transfer from one life to the another.

Orthodox Jews generally promote continuing life-sustaining treatment (LST) even in the context of poor prognosis. ⁵⁷

“Every moment of life, even if accompanied by the worse suffering is the greatest gift that a person can have”(Rabbi Hayim Kanyevski, zt”l).

This vitalist approach is by no means absolute. Rabbi Moshe Feinstein, for example held that in some cases of terminal illness associated with suffering a patient may have the right to refuse certain treatments. ^{58 , 59} A key concept is that of “goses” (dying): a moribund, actively dying patient expected to expire within 3 days. Such a patient may not be disturbed, for fear of hastening death, invasive procedures and diagnostics may be avoided in many circumstances, while comfort measures and hygiene should be maintained.

Importantly, the concept of goses dates to Talmudic times. As such it does not account for modern medical advancements that may treat acute life-threatening conditions that in antiquity would inexorably lead to death, its application in clinical practice is complex and requires inquiry and clarification in each individual case. There is also clear distinction between withholding treatment in the context of imminent, unavoidable death and withdrawing treatment, which from a Halachic perspective is far more problematic. ^{60 , 61}

Once death occurs, there is a highly prescribed sequence of observances to help the family and community respond to loss. ⁶² These include preparation for the funeral by the family of the deceased (Aninut), producing a tear in one’s clothes as a sign of mourning, (Kriah), purifying the body, and timely burial, followed by a structured and staged process of grief. There are different rules and customs for the first week (shiv’a), the first month (shloshim), the first year and beyond. ⁶³ The symbolic meaning of these laws amounts to a twofold psychological process: quick separation from the physical body of the dead followed by a slow process of transition from the presence of the deceased person to the legacy of their hallowed memory. The process is one of closure, acceptance, commemoration, faith in the afterlife and affirmation of life for the survivors, as they are embraced by their community. ⁶⁴

In Islam, most fatwās, except one, permit the withdrawal or withholding of life support in Islam under specific conditions, considering factors like the futility of therapy, depressed neurological status, and compounding harms from continued care. When considering the cessation of “futile” treatments, some scholars distinguish between life support (e.g., mechanical ventilation) and what are perceived as obligatory measures, such as nutrition, hydration, pain control, antibiotics. The consensus in fatwās addressing this distinction is that while life support treatment may be stopped, these other treatments should continue. ⁶⁵

A central aspect of dying in Islam is the utterance of the Shahadah: “There is no god but Allah; Mohammed is the Messenger of Allah.” ⁶⁶ This recitation is the last that a Muslim says before dying and failing to recite this declaration before death may raise doubts about one’s place among the righteous. For this reason, certain religious scholars argue that dying peacefully, without the aid of mechanical ventilation, holds great importance. ⁶⁷

Similar to Judaism, the Islamic faith emphasizes the belief in God as the ultimate authority, wielding power over life and death. The end-of-life phase is viewed as a transitional period preceding an everlasting afterlife. In the later stages of life, adherents of both Islamic and Jewish faiths often intensify their connection to their religious beliefs, seeking comfort and assurance.

3.7 Brain Death

Ultra-Orthodox Judaism and Islam approach brain death with trepidation about a premature determination of death. The question of whether respiratory arrest is sufficient to define death or whether the continuation of cardiac function renders one alive even if brain death criteria are met is a subject of intense debate among rabbinic scholars. Beyond these biomedical considerations, however, resistance to acceptance of brain death stems from mistrust of the medical profession’s moral commitment to upholding the sanctity of human life. Certain jurisdictions with a large Orthodox Jewish population, in US states such as New York and New Jersey allow varying degrees of accommodation of religious objection to brain death. However, protracted brain death disputes can have an adverse effect on the well-being of surviving family members. ⁶⁸ A productive strategy to mediate disputes is to attempt to engage Orthodox families within halaka and not as a question of the secular versus the religious. For example, one can address the halachic challenge of balancing the obligation to preserve life versus the mandate to not disturb a goses (see above) with medical interventions. ⁶⁹

There are ongoing discussions among Muslim scholars regarding whether neurologic criteria can be used to determine death, and who holds authority in defining death, religious scholars, or medical experts.

Some scholars believe that brain death fulfills the Islamic legal requirements for declaring death, thus involving medical science in determining death criteria. Others argue that traditional signs such as the cessation of cardiopulmonary function should remain the primary indicators of human death, as they are both medically and religiously valid. They, consider the cessation of these functions as the criteria upon which a declaration of death should be based because the path towards bodily decomposition has been set irreversibly. ⁷⁰ However, the majority of fatwas view brain death as a valid justification for allowing the discontinuation of life support or mechanical ventilation. ⁷¹

3.8 Physician Aid in Dying

Both religions view life as sacred, bestowed by a divine gift from God. Halacha forbids deliberate infliction of bodily harm on oneself or others. ⁷² As such, physician aid in dying (PAD) is regarded within Orthodox Judaism as an “act of murder.” ⁷³

Adam the first man was created alone, to teach you that with regard to anyone who destroys one soul the verse ascribes him blame as if he destroyed an entire world, as Adam was one person, from whom the population of an entire world came forth (Mishnah, Sanhedrin, Chapter 4).

Within Islamic teachings, the Quran declares the profound power of Almighty Allah in the lives of Muslims and how their faith is rooted in the belief of God’s control over their existence.

“Allah decides how long each of us will live When their time comes, they cannot delay it for a single hour, nor can they bring it forward by a single hour.” (Qur’an 17:33).

The sanctity of life in Islam centers around the belief that the soul originates from God and belongs to Him, and the ultimate decision of life and death is Allah’s divine decree. ^{74 , 75} The concept of autonomy and individual choices is mitigated by the sanctity of human life and the detrimental impact of killing on society. ^{76 , 77}

“If anyone kills a person -unless it is for murder or spreading mischief in the land – it would be as if he killed the whole people” (Qur’an 5:32).

In Islam, it impermissible for a terminally ill patient in great pain to request the end of their life, stating that assisting such a patient in death would be a sin for a physician. ⁷⁸

While Islam promotes the alleviation of suffering, the virtues of patience and forbearance in the face of hardship are extoled making the invocation of the doctrine of double effect challenging. ^{79 , 80} Muslims firmly believe that Allah will test them through their health and wealth. In facing these trials, they hold steadfast and endure.

“…those who patiently persevere will truly receive a reward without measure!” (Qur’an 39:10).

In both Judaism and Islam, the intrinsic value of life is paramount, reinforcing the notion that decisions about its end rest solely in the hands of a higher power, guiding adherents to seek solace in faith and patience during times of suffering.

4. Conclusion

We set out on a comparative study of Orthodox Jewish and Muslim approaches to medical ethics. We sought to highlight common values shared by these two-faith tradition and to provide guidance for professionals who care for these communities. Going through the life cycle from prenatal to end-of-life care we identified common beliefs that distinguish the Abrahamic traditions from mainstream secular medical ethics.

Orthodox Judaism and Islam employ theocentric rather than anthropocentric moral reasoning. Both faiths prioritize Divine Law in organizing and guiding human life. Individual autonomy is mitigated by a duty-based ethical framework in which personal preferences are superseded by a moral obligation to God’s Law. This is exemplified in hesitancy to employ genetic interventions in reproductive care that could be seen to interfere in God’s work. Similarly, considerations of consent and capacity are overridden in circumcision of infants. Furthermore, Orthodox Jews and Muslims will often look to their religious leaders for guidance in decision-making, rather than simply exercise their autonomy to voice their personal preferences and views. This deference to religious authority can seem intrusive and challenge mainstream perceptions of personal autonomy. Nonetheless, it is important to not view this delegation of authority as an abdication of the self but rather as the expression of a belief system to which individuals adhere.

A related theme is the sacred status of human life originating in Divine creation. Importantly, this contests the modern notion that one has dominion over oneself, and that life belongs to the individual. This distinction from the secular is perhaps best manifested in end-of-life-care which is informed primarily by a duty to preserve life rather than realize one’s self-determination or make determinations about quality of life. This can complicate the provision of palliative care in the face of suffering and a poor prognosis.

A further consideration is the role of communal structures and norms. Patients in an Orthodox Jewish or traditional Muslim community are embedded in a social web that is both supportive and expectant of adherence to religious and cultural norms. This can create challenges as in the case of the provision of mental health care which carries a considerable stigma and can affect social standing. ^{81 , 82}

An overarching theme across the life cycle was the limited ability of a biomedical model to explain illness or provide consolation to members of these traditional communities. An example is the futility of probabilistic models at the end-of-life to paint a dire prognosis and discount the possibility of a divine cure or to view mental illness metaphysically as a demonic possession, a moral failing, or the mystical manifestation of the divine. Given the richness of these possibilities, clinicians need to remain curious about alternative ways of understanding illness to provide effective care to culturally diverse patient populations.

Even as we summarize our findings and, it is important to avoid simplistic generalizations and to recognize that individuals can have values and priorities that conflict with the religious codes of their communities. In fact, tensions between community expectations and personal perspectives related to lapses of faith, a person’s sexual orientation, or desire to overcome traditional gender roles can contribute to emotional or even physical symptoms. Medical professionals must first and foremost understand an individual patient’s own view of their illness and care before they seek to understand the religious and cultural context of their lives.

Our hope is that the insights and perspectives we offer can extend beyond the realm of medicine at this time of war and suffering. The common themes shared between two religions often cast as being at odds with each other reminds us of their common origins, shared ethos and the possibility of reproachment. Finally, we offer our collaboration as Muslim and Jewish authors as a model for convivencia–Spanish for “living together”–as the basis for substantive conversation against a tragic backdrop of war and despair. We hope the discussions we have had, and that this essay might engender, might serve as foundations upon which a more peaceful future can be built.