What is the ruling on mistreating elderly patients in the course of their treatment? My maternal aunt is elderly and has dementia. Her children treat her harshly because she sometimes harms herself, and they are afraid that they may incur sin by doing so. However, they have found no other means of controlling her. Would they be considered sinful for treating her this way?

Islamic law has made dutifulness to parents and treating them with kindness one of the greatest means of drawing closer to Allah Almighty. It is among the most important acts of obedience and one of the foremost objectives of Islamic law. Numerous texts from the Noble Quran and Sunnah affirm the rights and honor due to parents. Allah Almighty says, “Worship Allah and associate nothing with Him, and to parents do good, and to relatives, orphans, the needy, the near neighbor, the neighbor farther away, the companion at your side, the traveler, and those whom your right hands possess. Indeed, Allah does not like those who are self-deluding and boastful” (Quran, 4:36).

Dutifulness towards parents is likewise one of the manifestations of excellence, as Imam al-Razi explains in his Tafsir (10:76), “[Children] should attend to their parents’ needs, not raise their voice at them or speak to them harshly. They should strive to fulfill their requests and provide for them to the fullest extent of their filial duty.”

Dutifulness to parents is an individual obligation upon their children, reflecting their exalted status and the importance of the rights they are owed. It is also a non-delegable obligation, as articulated by jurists from the four schools of Islamic jurisprudence and affirmed in their works. More than a moral virtue, it is an integral part of worship and a right enshrined in Islamic law. Parents are the means through which their children come into existence. They play a fundamental role in instilling virtues of all kinds, both religious and worldly. The obligation to be dutiful to parents is even greater and more strongly emphasized when they reach old age, become frail, or fall ill, at which point Islamic law accords them special consideration. Allah Almighty says, “And your Lord has decreed that you not worship except Him, and to parents, good treatment. Whether one or both of them reach old age [while] with you, say not to them [so much as], "uff," and do not repel them but speak to them a noble word. And lower to them the wing of humility out of mercy and say, "My Lord, have mercy upon them as they brought me up [when I was] small” (Quran, 17: 23-24).[1]

 

Warning against mistreating elderly and ill patients during medical treatment

The obligation to be dutiful to and care for a parent suffering from dementia is even more binding when the parent becomes frail or afflicted with a debilitating illness after having been in good health. According to the World Health Organization dementia is a condition caused by a range of diseases that affect the brain, such as Alzheimer’s disease, resulting in neurodegeneration and, typically, a decline in cognitive function (i.e., the ability to think), memory, and the ability to perform everyday activities. The condition worsens over time, becoming more severe than would ordinarily be expected as part of the natural aging process.

Dealing with individuals with dementia requires a thorough understanding and a high level of awareness of the nature of the condition and its medical and psychological effects. It also requires caregivers to exercise great compassion and patience. Consequently, children of a parent suffering from dementia may face considerable difficulties and challenges in fulfilling their duty of filial piety, which requires them to treat their parent with kindness and refrain from harsh treatment. Abu Huraira (may Allah be pleased with him) narrated that the Messenger of Allah (peace and blessings be upon him) said, “The Prophet said, “May he be disgraced! May he be disgraced! May he be disgraced!” When asked who, he replied, “The one whose parents, one or both of them, reach old age during his lifetime and he does not enter Paradise [by serving them]” (recorded by Muslim). Mistreating a parent under such circumstances constitutes prohibited disobedience toward parents, which includes causing them harm out of stinginess, frustration, impatience, a desire to retaliate, or contempt, unless the parent is acting unreasonably. Ibn Hajar al-‘Asqalani noted in Fath al-Bari (10: 406), “Filial disobedience refers to anything a child says or does that causes a parent harm or distress, except where the matter involves polytheism or disobedience [to Allah], provided that the parent is not acting unreasonably. Ibn ‘Atiyya described it as the obligation to obey one’s parents in permissible matters, whether by doing or refraining from something. Obedience in recommended acts and communal obligations is likewise encouraged.”

Regarding the case in question, if treating the inquirer’s aunt gently would result in considerable harm, such as the risk of self-harm or danger, then a firm approach may be necessary to prevent such harm. Though Islamic law permits necessary precautionary measures to prevent harm, the manner, means, and extent of such measures are to be determined by the attending physician and relevant specialists, depending on the patient’s condition. In advanced dementia, a stern approach to caregiving, even when intended to protect the patient, may contribute to psychological deterioration or severe depressive episodes.

Though the necessity of preserving the life and safety of the inquirer’s aunt may warrant preventing her from engaging in certain actions, in accordance with the Islamic legal maxims “Necessity renders prohibited things permissible” and “Harm is to be removed,” this is nevertheless subject to the maxim that states, “Harm is not to be removed by harm.” It is therefore impermissible to prevent potential harm that the mother in question may cause to herself by inflicting actual and prohibited harm; rather, filial piety in such circumstance requires meticulously following the instructions of the attending physician. However, if it becomes necessary to physically prevent her from doing something harmful, firmness may be exercised to protect her from harming herself or to aid her recovery, using the mildest means deemed appropriate by the relevant specialists. Such measures should protect her from harm without resorting to harsh treatment that undermines her dignity or causes her physical or psychological harm.

If the nature of the disease gives rise to situations in which the caregiver is unable to speak gently to the patient due to episodes of agitation that impair the patient’s ability to understand speech and respond to verbal de-escalation, this does not in any way waive the duty to adopt the gentlest practical approach available. This combines the duty of protection with the obligation of filial piety and gives effect to the Islamic legal maxim, “That which is easy cannot be waived due to what is difficult.”[2] Accordingly, the mother must be treated as a trust placed by Allah in her children’s care, not as an opponent who is resented or held accountable for her actions; a person with impaired mental faculties should be cared for, not punished or reprimanded. Any aggression or unusual behavior that the patient may exhibit does not constitute disrespect that warrants a stern response; rather, it is a manifestation of illness that calls for compassion and mercy. In this reversal of roles, the parent needs the child just as the child once needed the parent.

To uphold their filial duty and show the utmost compassion, the children must educate themselves on how to care for people with dementia, following the Islamic legal maxim that states, ‘That without which an obligation cannot be fulfilled, is itself an obligation.’ They should therefore attend specialized training courses, conduct an in-depth study of this matter, or consult regularly with psychiatrists, physicians, and relevant specialists. Such education is not a luxury but a practical necessity that enables them to provide proper and safe care that preserves their mother’s dignity, reduces her suffering as well as their own, and prevents them from making mistakes for which they may be held accountable under Islamic law despite their sincere intentions. However, if the children are unable to fulfill this role to the best of their ability, they must seek the assistance of a qualified and specialized healthcare provider, in order to relieve themselves of hardship and protect their mother from harm.

 

The ruling

Based on the above, dealing with individuals suffering from dementia requires a thorough understanding and a high level of awareness of the nature of the condition and its medical and psychological effects. It also requires caregivers to demonstrate great compassion and patience, and to exert their utmost to support and assist these individuals. Any firmness necessary to protect them from harming themselves or to aid their recovery should be proportionate to the need. The children in question should therefore not subject their mother to any verbal or physical harm and should follow medical guidance on the proper way to care for her. These obligations apply when caring for any patient, but are even more binding upon children when caring for their parents.

Egypt’s Dar al-Ifta advises family members of dementia patients to educate themselves about the proper way to care for them. If a family caregiver feels unable to fulfill this role to the best of their ability, they should seek the assistance of a qualified caregiver or specialized healthcare provider.

And Allah Almighty knows best.