Hamza was a religious man as well as a businessman, a regular volunteer at the mosque, and well-known and respected in his local community. Hamza died of Covid-19 during the 'second wave' of infection in the UK. He was aged 65.
Hamza had been in hospital and on a ventilator for several weeks before he died. The hospital was allowing some visits from close family members, but had said that Hamza's wife, Faiza, should not attend because her own health problems meant she was in the category of people advised to 'shield' away from others. Their one son, Asim, had visited several times, including a few days before Hamza died, but then Asim tested positive for Covid-19 so could not visit again.
Asim contacted the mosque to let them know that his father had died. Even over the telephone, he could tell that the Imam was upset to hear of Hamza's death, but he was also kind and practically reassuring. The Imam said that a team from the Muslim Burial Society would collect Hamza's body from the hospital and be in touch with Asim about arrangements. The Imam himself would make sure he was there for the Salat al-Janazah (funeral prayers) and the burial, which might not be this evening, but he hoped would be no later than the next day.
Faiza told Asim she was worried that Hamza might not be able to receive the Ghusl (ritual washing) because he had died of Covid-19. Hamza had told her about a work colleague whose wife had died at the start of the first wave of the pandemic. The colleague remained distressed because he had learned after his wife's burial that she had not been taken out of the hospital body bag before being wrapped in shrouds. He was devastated that he and the broader community had not fulfilled their obligations to her as Muslims, even though his Imam had told him he need not worry about the implications for her soul of her body being buried unwashed because Allah would recognise the pandemic was an exceptional circumstance.
When Purdil from the Muslim Burial Society team contacted Asim a couple of hours later to confirm they had Hamza safely in a nearby mosque, Asim conveyed his mother's worry. Purdil reassured Asim that everything would be done correctly. He explained that they had set up a special facility at this mosque a few months after the pandemic started and that they now had several volunteer teams of men and women trained to perform the Ghusl and Kafan (shrouding) in a way that was fully approved by religious leaders and the Muslim Council of Britain, and that complied with public health requirements to minimise any risk of infection. Thanks to community donations, all the volunteers were given good personal protective equipment.
Purdil also told Asim that if he or another male relative would welcome the honour of contributing to the Ghusl and Kafan, the team could accommodate them, as long as they did not have Covid-19 or otherwise need to self-isolate. They would need to wear PPE and follow the team leader's instructions. Asim had to explain that he was Hamza's only son, and he had tested positive for Covid-19 only three days ago.
Asim felt hugely disappointed that he would not be able to honour his father by taking part in the washing of his body. This was literally a once in a lifetime opportunity, and for an act of filial kindness that his father would have thoroughly appreciated. Purdil was very sympathetic - it was such a difficult situation. He stressed again that he and all the team would take care to ensure all the rituals and prayers for Hamza were performed correctly. Asim thanked Purdil, but he could not help thinking that he had let his father down.
That evening, as Hamza was buried, Faiza and Asim sat in their respective isolation.
Suggested questions for reflection and discussion
- What, if anything, do you think is important when preparing the body of someone who has died for burial or cremation? Why?
- In what ways are your own beliefs and practices relating to death similar, or different from, those mentioned in this case story?
- What can be done to support someone who is unable to do what they think matters when someone they care for has died?
Commentaries
- An introduction to ritual care of the dead body in Islam, Judaism and Hinduism
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An introduction to ritual care of the dead body in Islam, Judaism and Hinduism
In this commentary, Jennie Riley outlines the rituals that are significant for Muslims, Jews and Hindus when someone dies.
The timely completion of rituals for a dead person's body and soul matter for a range of reasons in many religious traditions and communities. This commentary introduces beliefs and rituals in three religions - Islam, Judaism and Hinduism - in which there is often particular concern with completing rituals related to the body and soul and within set time frames.
Islam
In Islam, shroud burial (kafan) is preferred, and takes place as soon as possible after a person has died - ideally within 24 hours. Burial is preceded by prayers for the deceased (known as salat-al-janazah) as well as ritual washing. The wash is usually conducted with water (ghusl mayyit) but in certain circumstances may be conducted in its dry form (tayammum) using sand or stone. Female family and community members traditionally carry out the ghusl when a female Muslim dies, and males when a male Muslim dies. The wash is one of purification, in keeping with the many forms of ritual ablution that Muslims perform in life. This final ghusl removes the impurity brought by death, rendering the deceased physically and spiritually clean for the soul's final journey. All Muslims are considered to deserve these rites as a marker of their human dignity, and all are considered equal in death. Conducting the death rites with gentleness and dignity and in a way which maintains the privacy of the deceased is important, as the soul is believed to linger near the body between death and burial. Participating in the ghusl and salat-al-janazah is considered an honour. It also accrues religious merit both for the deceased and for the living who take part, helping both to attain paradise when they die. Contributing to someone's death rites is also profoundly significant because it can be seen as a way of paying tribute and showing gratitude to the deceased, and of fulfilling an obligation or duty to reciprocate for what they have done. Family and community members participate in these rituals as they hope others will, in due course, do for them.
Judaism
Many Jewish communities similarly prioritise quick burial for the dead. Ideally burial takes place within 24 hours, though exceptions are made for the Sabbath and other festivals. A ritual washing for purification - the tahara - is undertaken, by way of honouring the deceased and marking the holy, sacred nature of the human body in Jewish religion. The tahara is typically undertaken by the chevra kadisha (which translates as 'holy society') a group of trained volunteers whose work is considered holy and privileged. Like in Islam, men prepare the bodies of men and women prepare the bodies of women. Following the tahara, the body is guarded by a shomer (male) or shomeret (female) until it is buried - this is known as shemira, and serves to protect the body from desecration. In Jewish tradition, the soul is believed to linger near the body until the body is interred, and spiritually speaking this is a very dangerous time. Once the body is buried, the soul departs. As in Islam, Judaism treats all Jews the same in death, and the death rites described here are conducted for all members of the community, irrespective of their commitment or status in life. Burial is also followed by a sequence of rituals, including sitting shiva, in which the family is supported and the deceased mourned and memorialised. Timing is important, and there are moments to mark at one week, one month and one year points. No headstones are erected on graves until at least one year has passed since the interment.
Hinduism
In Hinduism, when a person dies the concern with the progress of their soul, or life energy - atman - within the samsara cycle of life and death. A sequence of rituals prepare the deceased for the soul's release from the body during cremation. These rituals include the speaking of chants and mantras and various forms of preparing the body, including washing (with fluids including milk, ghee, honey and yoghurt), adorning with oils and garlands and either shrouding or smartly dressing it ahead of cremation. Close family members often visit the deceased multiple times between death and cremation, and the body is commonly brought home so that the wider family and community can visit. There is an important sense in which the time between death and cremation is used to emphasise and honour the deceased and their relationships. reaching the point of cremation quickly - ideally within three days or fewer - is important for the soul to move on and to help the bereaved come to terms with the continuous cycle of life and death.
After cremation, further rituals ensure the dead are provided with symbolic objects to aid them as they continue their journey through the samsara cycle. The timing of these rituals reflects beliefs about stages in the samsara cycle. The scattering of ashes, usually in the sea or a flowing river, is also a significant last rite for the deceased and an important obligatory marking of the end of physical life. When cremations were significantly delayed during the early waves of the COVID-19 pandemic, and when travel restrictions impacted the dispersal of ashes, people were sometimes worried about the implications for the journey of the soul.
All these Hindu rites are usually conducted with the help of religious leaders, but family members play significant parts and particular responsibility falls to eldest sons. Families derive comfort from knowing that the deceased have been provided with what they need as their atman moves on.
Enabling care for the deceased enables care for mourners
This comfort speaks to another important way in which religious rituals can matter. Many people believe participation in these rituals and their timely completion can contribute to healthy grieving. The bereaved feel more able to begin moving on knowing their deceased have been supported and cared for. A familiar, structured sequence provides, for many, a welcome sense of purposefulness in the earliest days and weeks following someone's loss. The communal nature of many of these rituals, and the practical community support which often mirrors them, can be a further source of support for people in their mourning.
The COVID-19 pandemic and the disruption it brought to funeral care in the UK impacted - and often inhibited - the timely completion of these important rituals. As the case of Hamza's funeral and further examples in this commentary illustrate, this generated concerns among the living about whether the body was properly prepared, and the soul properly equipped, for the deceased's onward journey. Being unable to participate in or facilitate rituals could bring distressing disappointment and guilt about not giving the deceased what they deserved, and many people felt profoundly the absence of the supportive structures usually provided by familiar rituals and the presence of community in completing them. Diverse religious beliefs and death rites need to be carefully considered in planning for future pandemics and disasters.
- Improving care in funerals: learning from international experience
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Improving care in funerals: learning from international experience
In this commentary, Dr Halina Suwalowska from the ETHOX Centre at the University of Oxford and Dr Voo Teck Chuan from the Centre for Biomedical Ethics at the National University of Singapore reflect on how the management of death in future emergencies could be improved by learning from previous experiences.
Globally, health emergencies arising from infectious disease outbreaks and natural disasters claim millions of lives, accompanied by human suffering that has lasting consequences. Research into what happened during the Ebola epidemic of 2014-2016 in Western Africa and after the Indian Ocean Tsunami of 2010 has revealed practical and ethical complexities related to restricting families from being present at the bedside of dying patients and to the safe management, including funeral arrangements, of deceased persons. The case story of Hamza's funeral illustrates that these challenges continued in the context of the COVID-19 pandemic.
Bad deaths and ambiguous loss: the importance of family presence
Hamza's wife was advised to shield away from others due to her health problems and as a result was not allowed to visit her dying husband. Similarly, Hamza's son Asim was not able to see his father as he tested positive for COVID-19 a few days before Hamza's death. Like many other families in similar circumstances, Hamza's family had no opportunity to say goodbye to him. They could be suffering emotional uncertainty from an 'ambiguous loss' because not seeing Hamza dead may impair their understanding of his death and their permanent loss. Both may result in unresolved grief. During the COVID-19 pandemic and other outbreaks, deaths similar to Hamza's, in which people died in isolation in hospitals with no loved ones present, have been perceived as 'bad deaths'. Some loved ones have derived some comfort from knowing that healthcare professionals acted as 'surrogate family' in bedside vigils. When the need for infection prevention and control precludes families from being physically present at the bedside of a dying patient, there need to be plans in place to ensure where possible that patients do not die alone. Careful use of technology such as video communication with family members, although not a perfect solution, may also help alleviate the practical and ethical challenges of these situations.
Respect for the dead
How the bodies of the dead are cared for can have significant public health implications. It also raises ethical dilemmas. Mismanagement of the dead can undermine public health efforts to contain diseases. It can also contribute to long-term trauma for survivors when they do not consider that the bodies of loved ones have been treated with respect.
The 2014-2016 Ebola epidemic in West Africa demonstrated the feasibility of managing a deadly contagion to ensure the safety of the living while being mindful of and showing respect for persons who died from it. During this epidemic, the World Health Organization promoted protocols for the safe and dignified burials of people who died from Ebola, and these protocols were widely accepted by local communities. Such an approach was not adopted in many countries during the COVID-19 pandemic, especially during its early stage. Hamza's case story discusses the distress of Hamza's colleague who learned that his wife, who died from COVID-19, was buried unwashed. Hamza's colleague regarded this as a failure of his and the broader community's obligations as Muslims. This example also shows that public health and other authorities often put undue emphasis on segregation of the infected and the non-infected when managing an outbreak. Their approach reflected a simplistic view of epidemic spread in populations as if these were merely collections of individuals rather than overlapping groups of individuals involved in complex social structures and practices. More attention needs to be paid to the ways in which valued funeral practices could be modified if necessary to mitigate risk of spread.
Flexibility of rituals and the role of religious leaders
As Hamza's case story shows, the local Muslim Burial Society managed to modify death rituals for Muslims who died from COVID-19 to comply with public health requirements to minimise risk of cross-infection. Their approach was fully approved by religious leaders and the Muslim Council of Britain. This example, and the development of safe and dignified burial arrangements for Ebola victims during the recent outbreaks in West Africa and the Democratic Republic of Congo, and respectful mass burial ceremonies for victims of natural disasters, show that communities are often flexible where necessary and willing to adapt funeral rites to curb the spread of disease. Policies regulating care of the dead which are developed in consultation with relevant religious leaders and local community members are more likely to demonstrate respect for religious beliefs, and promote trust between religious leaders, bereaved families and burial teams. Trusted religious leaders may also be able to communicate why and how modifications to funeral practices comport with the values of the religion and with the significance of the original practice. They should therefore be involved, as well as families, in the planning and preparation of funerals for people who die during an infectious disease emergency, both to promote safety and to aid the grieving process for families who find meaning and strength in their faith.
Beyond the funeral
The case story does not discuss the aftermath of Hamza's burial. Asim felt hugely disappointed and that he let his father down by not being able to honour his father by taking part in the washing of his body. Asim and Faiza sat in isolation in the evening while Hamza was buried, which potentially exacerbated their grief and sadness.
In our view, policymakers need to develop compassionate and sustainable ways of supporting the people and communities who are bereaved during infectious disease outbreaks and other large scale crises. As well as family members and others close to those who die, consideration must be also given to healthcare professionals and the 'last responders' involved in addressing infectious diseases outbreaks and natural crises, including pathologists, body collection teams, funeral directors and other mortuary workers and volunteers who provide burial, cremation and bereavement support. Experience shows that mortuary workers and funeral directors can face stigmatisation and moral distress in situations in which they are being overwhelmed with dead bodies to manage. The management of deceased bodies is a key component of controlling a deadly infectious disease outbreak or dealing with another kind of large scale disaster. Society has a reciprocal obligation to the frontline workers and volunteers who undertake it to ensure they get the respect and support they deserve.
References
This commentary draws on the authors' published work and mentions guidance from the World Health Organization. If you would like to read more, you can find the details here:
- Suwalowska, Halina, Fatu Amara, Nia Roberts & Patricia Kingori (2021). Ethical and sociocultural challenges in managing dead bodies during epidemics and natural disasters . BMJ Global Health, 6(11), E006345.
- Voo, Teck Chuan, Mathavi Senguttuvan & Clarence C. Tam (2020). Family Presence for Patients and Separated Relatives During COVID-19: Physical, Virtual, and Surrogate . Journal of Bioethical Inquiry, 17(4), 767-772.
- Preparing a Body for Burial: A Jewish Perspective
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Preparing a Body for Burial: A Jewish Perspective
Heather L Munro considers how the preparation of Hamza's body might be different if he were Jewish.
There is much overlap between the rituals from Muslim tradition that appear in Hamza's story, and the rituals around death in Jewish traditions. There are also distinct areas of difference, including nuances which hospital staff and others caring for deceased Jewish persons need to be aware of.
Like in Hamza's story, it is important for the bodies of Jewish deceased persons to be buried as quickly as possible, and a ceremonial washing is also necessary. There are additional elements to be observed whenever possible in a Jewish case.
Wholeness
Hamza died while on a ventilator in the hospital. From a Jewish perspective this is significant because it can be assumed that Hamza had a tube down his throat and was likely hooked up to intravenous drips of some kind, and possibly catheterised. Blood and tissue can collect in these tubes and associated machines. It is important according to Jewish Law to gather all parts of the body, which can include residual tissues and amputated body parts, to bury with the body of the deceased. This is based on the belief that only fully intact Jewish bodies will be made whole again, resurrected and reunited with the soul, at the time when the messiah comes. Volunteers with the chevra kadisha [burial society] are specially trained to attend Jewish people who have died, including to remove medical apparatuses and collect any blood or tissue which has been left on them. Thus, when someone Jewish dies in hospital while hooked up to machines of these types, a respectful response involves leaving the body with the apparatus in place and summoning the chevra kadisha [burial society] as soon as possible.
Purity
When the chevra kadisha have the body in their care, they bring it to a special room at the mikveh [ceremonial bath house], where it is washed using water from the ceremonial bath. This washing is known as the commandment of tahara [purity], and unlike in Hamza's story, it is not usually done by family members. The chevra kadisha has both male and female groups, and the deceased person's body is prepared by chevra kadisha members of the same gender. It is important to Jewish communities to do the washing and preparation of the bodies as a kindness for the family of the person who has passed. It would be extremely unusual to have a family member, particular a close family member (child, parent, sibling, spouse) attend the tahara, and a family member usually would perform tahara only if there is no one else to do it. This is for two reasons: first, to do with modesty, because part of the intention of tahara is to maintain the dignity of the deceased; and secondly, because the intention of those performing tahara must be upon the transition of the soul of the deceased from this world to the next, and this is seen as a difficult intention to maintain for those who are consumed by grief.
Once washed, the body is dressed in either respectable clothing, or tachrichim, a special garment which is made of either muslin or linen. In most cases today, the choice of the tachrichim indicates a stricter level of Jewish religious observance. Men are often buried with a tallit [prayer shawl] with the knots cut off. The knots represent the 613 commandments in Judaism, and their removal signifies the freedom from having to fulfil these in death. Women are sometimes buried with their siddur [prayer book].
Safeguarding
After washing, the period of shmira [guarding] begins, in which either one person or multiple people on a rota become the shomer [guard, keeper]. The body must not be left alone until burial. The reasons for this are to show respect, guard the body against desecration, and to help the soul of the person depart. Many Jews believe that this is a dangerous time for the transition of the soul, and the shomer helps the soul to find comfort and leave the body. The shomer often recites Tehillim [the book of Psalms] while keeping watch and say the daily prayers at the appropriate times.
Expediency
Under strict Jewish Law, the body must be buried within 24 hours. Exceptions to this are when death occurs on or right before the sabbath or a religious festival, as mourning and burial cannot happen during these times. In these cases, burial will have to happen as soon as possible after the end of the holy day. Jewish bodies need to be buried in ground which has been consecrated as a Jewish cemetery. Jewish caskets are usually simple, unadorned, and made of wood. Sometimes, there is a funeral service at either a synagogue or funeral home, but these are not required.
Many of the rituals discussed above became impossible to observe during the Covid-19 pandemic. Although as in Hamza's story, chevra kadisha volunteers could wear protective gear and be specially trained to take additional precautions when conducting cleansing rituals, they were not permitted into Covid-19 ICUs and could not collect the blood and tissue left behind on tubing and needles because these were considered contagious biohazard by the medical establishment. During this period, many Jewish relatives and burial societies faced long waits to receive the bodies of deceased persons, delaying burial beyond the usually accepted norms.
This information about preparing a body for burial applies to strict Orthodox Jewish interpretation. In the general Jewish population of the United Kingdom, there is a wide range of variation in level of religious observance and adherence to tradition. However, death practices do seem to have a high level of adherence even among those Jews in the UK who generally are less strictly religious in their daily lives. When the level of observance of the family is unknown, it may be best practice to wait to speak with the next of kin before taking any action concerning the body.
Further Resources