Health, Spirituality and Medical Ethics

Introduction
Heath and life are both created by God and serve as a means to test humanity [1]. In Islamic teachings, death is introduced as the birth of the soul, and with each breath, a person continues to live while simultaneously moving toward death (Hikmat 74) [2]. Throughout history, humans have tried to be immortal in various ways, and this human desire for immortality can be seen in the importance and progress of medical science to fight deadly and dangerous diseases, the quest to discover the elixir of youth, embalming corpses, and more. The most effective trick of Satan to deceive Adam is the promise of immortality [1].
Considering the importance of this issue, various fields of human sciences, including psychology, have dealt with the human concern about death. According to Yalom, “life and death” exist at the same time, and death is constantly moving under the skin of life. Death is the main and primary source of anxiety and the main source of mental abnormalities [3] affecting the quality of a person’s life [4]. Belsky (1999) defined death anxiety as the fears, feelings, and thoughts related to the final event of life that exceed the normal state of existence [5].
Death anxiety leads to the formation of different behaviors in different people [6]. Various studies have shown traces of death anxiety in anxiety disorders [5]. Also, death anxiety causes depression, suicidal thoughts, and a decrease in a person’s ability to do homework [4]. For this reason, psychopathology Therefore, the main goal of the current research is to carefully examine religious texts to extract targeted and structural mechanisms for the treatment of death anxiety and to present and develop a conceptual model to address death anxiety based on Islamic sources. Additionally, the researchers aim to utilize the findings of this research in the next stages to design a treatment package for death anxiety that aligns with God’s spiritual multidimensional treatment [5].
Death anxiety is a common experience among most people, and its relief can increase people’s quality of life [7]. Considering the importance of death anxiety, various treatment methods, including non-spiritual treatments [8, 9] and spiritual treatments [10, 11] have been designed to address this disorder. In recent years, spirituality has emerged as an important component in the theoretical and research literature aimed at increasing coping abilities and improving mental health [12].
Spirituality is attributed to beliefs and actions that exist in the transcendental dimensions (not physical) of life, placing individuals in a close and intimate relationship with God and a range of virtues within themselves [13]. Research has shown that spirituality plays an important role in mental health and is an important part of people’s quality of life. There is a significant relationship between spirituality and the development or reduction of depression, anxiety disorders, and suicidal thoughts [14, 15]. Also, research has shown that spiritual variables, such as spirituality [16], religiosity [17] reduce death anxiety.
God-oriented spiritual multidimensional therapy is a therapy with a spiritual approach that has attracted the attention of researchers in this field in recent years. In this treatment, instead of focusing on two perceptual domains (man and existence), the therapist focuses on four perceptual domains (origin, end, self, and existence), which consider the whole human being. This therapeutic model takes into account the heterogeneity of images (non-real perceptions) in relation to real concepts within the four general perceptual domains, which provides the context for psychological-spiritual damage. The treatment aims to help individuals distance themselves from these images (non-real perceptions) and move closer to the real concepts within their perceptual field. In this research, after analyzing the religious texts and discovering the effective components of death anxiety from these texts, the authors organized and categorized these components within the framework of the God-oriented spiritual multidimensional treatment. As a result, a conceptual model was obtained regarding death anxiety in the framework of God-oriented spiritual multidimensional treatment [18].
The spiritual treatment protocols for death anxiety in the research literature are mostly designed by Iranian researchers [10, 19]. However, most of them face the important issue that religious texts have not been qualitatively examined in any of them so that the mechanisms in these texts for the treatment of death anxiety should be identified, and based on that, a protocol should be designed that comprehensively and completely includes all dimensions of human existence. While research based on Islamic sources regarding death anxiety [7, 20] has been conducted, no study has been found that investigates and extracts effective mechanisms for the treatment of death anxiety from religious-Islamic texts.
Therefore, the main goal of the current research was to carefully examine religious texts to extract targeted and structural mechanisms for the treatment of death anxiety and to present and develop a conceptual model to overcome death anxiety based on Islamic sources. Also, the researchers aimed to utilize the findings of this research in the next stages to design a treatment package for death anxiety that aligns with God’s spiritual multidimensional treatment.
Methods
In this research, a mixed exploratory research method (quantitative and qualitative methods) was used. In the qualitative part, the collection of texts was done using the method of semantic domains, and the analysis of texts was performed using the method of qualitative content analysis within the inductive content analysis framework. In the quantitative part, the method of evaluating the opinions of experts was utilized and in the quantitative part, the method of evaluating the opinions of experts was used [21].
The textual community for the research was the Holy Quran and narrative sources. To facilitate the search process, statements from 29 chapters of the book Mizan al-Hikmah (chosen to structure the studies) were collected in connection with the concept of death anxiety through targeted sampling. The review was then continued in the main texts. The studied sample was selected based on the principle of saturation in sample size. Saturation in qualitative research refers to the point where data collection continues until no more data can be found to expand the characteristics of the category [22]. The statistical population in the quantitative section consisted of specialists in psychology and seminary sciences with higher education (Ph.D. in psychology and seminary education at levels three and four). In the first qualitative part, using the strategy of “lexical search” in Islamic sources (Jamae al-Tafaseer, Jame al-Hahadith and Mizan al-Hikmah software) and using ten words (“al-Mut”, “vaseeat”, “Ajl”, “Tul Amal”, “Dunya”, “Tobeh”, “Tvfi”, “Tamni al-Mut”, “Takhaf Man Al-Amut”, and “Amal”), 226 expressions related to death were extracted.
Then, using the principle of synonymy, semantic contrast, and lexical domain from the principles of linguistic semantics, 16 other related words were considered in several rounds between Islamic sources and dictionary books: “Amal”, “Akhrat”, “Haeat”, “Ghabr”, “Fana”, “Bagha”, “Ghabzeh roh”, “Baqiyat al-Salahat”, “Zekre Al-Mut”, “Shogha Leghae Allah”, “Halat Al-Mut”, “Ghamrat Al-Mut”, “Sakrat Al-Mut”, “Trada Al-Mut”, “Hasrat”, and “Hazar Al-Mut”.
A total of 323 other expressions were extracted from these words. In total, 549 religious propositions were collected using 26 related words. Subsequently, these propositions were examined, and duplicate data as well as data that were only marginally related to the research topic were removed. At this stage, 374 propositions were removed and 175 religious propositions were selected as the final selected text for analysis. In this section, Meiring’s qualitative content analysis was used. Thus, a systematic process with controlled analysis of the texts was conducted, bringing the researcher closer to forming a conceptual model. Also, because the research literature on the subject was limited, the inductive content analysis method was used. This approach avoided preconceived categories, allowing for the discovery of categories directly from the data [23]. The method of data analysis based on the coding process takes place in three stages: Open, central and selective [24]. In this process, three basic elements “component”, “category” and “theme” are determined. Several codes that refer to the common aspects of a phenomenon are called components. A “category” is formed from the combination and juxtaposition of several components. When the main categories are compared and related to each other in various ways during the axial coding stage, a “theme” is formed [25]. Brown and Clark’s approach was used to analyze the texts and discover the themes [26].
In the quantitative part of the research, to achieve the “reliability” criterion of the data and its quantification, the evaluation method of experts’ opinions, along with the content validity index (CVI) and content validity ratio (CVR), were used to achieve the “reliability” criterion of the data and its quantification. In this research, the validity assessment was done by 12 experts using the purposeful sampling method [21]. The minimum required score for the CVI is 0.79 [21]; otherwise, the concept of validity is not attained, and the item is removed. Thus, the initial findings of the research were presented to 12 experts in the field of psychology and religious sciences and their corrective opinions were applied. Finally, 63 sub-components, 17 categories and eight themes were extracted.
Results
The vocabulary search yielded the following words: “Al-Mut”, “Vaseeat”, “Ajl”, “Tul Amal”, “Dunya”, “Tobeh”, “Tvfi”, “Tamni al-Mut”, “Takhaf Man Al-Amut”, “Amal”, “Akhrat”, “Haeat”, “Ghabr”, “Fana”, “Bagha”, “Ghabzeh roh”, “Baqiyat al-Salahat”, “Zekre Al-Mut”, “Shogha Leghae Allah”, “Halat Al-Mut”, “Ghamrat Al-Mut”, “Sakrat Al-Mut”, “Trada Al-Mut”, “Hasrat” and “Hazar Al-Mut”.
By examining these cases and after the formation of the basic contents, the mechanisms related to the treatment of death anxiety were obtained separately in eight main axes of discovery and their conceptual schema. By examining the opinions of the experts, it was found that 11 components did not meet the required scores in the CVR and CVI, while the remaining items obtained an acceptable score. The results related to documentation, inferential content, and components are shown in Table 1 and the validity of the findings is shown in Table 2.
After specifying the conceptual dimensions and mechanisms of death anxiety treatment and validating the findings, the conceptual model of death anxiety treatment structures was drawn and modeled (Figure 1).
Discussion
This research aimed at presenting and developing a conceptual model of effective structures in the treatment of death anxiety based on religious texts. The findings related to the vocabulary search and the analysis of the themes and expressions led to the extraction of effective structures in the treatment of death anxiety from these expressions, and finally, a conceptual model was developed to overcome death anxiety.
The approved constructs in the conceptual model of death anxiety treatment after validation are: “Purposeful regulation”, “emotion regulation”, “desire regulation”, “action and communication regulation”, “imagery regulation”, “monotheistic attitude”, “consciousness-raising” and “de-conceptualization of death”. Based on the findings, it seems that if attention is paid to and these eight structures are regulated in the affected individual, death anxiety can be reduced.
According to the findings of the research, “purposeful regulation” is one of the effective structures in the treatment of anxiety in terms of religious texts. This finding is consistent with the findings of studies on the effect of meaning and meaning therapy on death anxiety [42, 43], because the existence of meaning and the search for meaning contribute to making human life purposeful. Researchers believe that the meaning of life is fundamentally cognitive in nature and includes people’s beliefs about the existence of an ultimate goal in life [11]. It means that increasing the sense of meaning in life will make life more purposeful, thereby reducing the anxiety associated with death.
According to the next finding of the research, the structure of “emotion regulation” can also help reduce death anxiety. This research finding is consistent with another study [44].To explain the effectiveness of this structure in reducing death anxiety, it can be said that emotion regulation strategies in a positive way, such as acceptance and re-evaluation, can reduce anxiety because the use of these strategies makes a person evaluate events with a different perspective and pay attention to the positive aspects and possible benefits of that event. In anxiety-provoking issues, such as death, accepting the issue and considering how to deal with this stressful event, rather than resorting to catastrophizing, rumination, denial, or avoidance, can help alleviate the anxiety associated with it resorting to catastrophizing, rumination, denial, or avoidance, can help alleviate the anxiety associated with it.
By examining religious texts, “regulation of action and communication”, one of the effective structures in reducing death anxiety, was introduced. This finding is in line with the other studies on the effect of religious practices [45] and social support [46] on death anxiety reduction. By performing religious duties, people take a step toward mental refinement by releasing their emotions and emptying themselves of impurities and negative thoughts, resulting in improved mental health Engaging in religious acts and regulating one’s actions can foster a sense of peace and security by establishing a connection to an infinite, powerful source. When people adjust their actions based on gaining God’s pleasure reaching heaven and striving to achieve a “good life” (Sura An-Nahl/97) [1], they experience less fear and worry. At the time of death, they consider God to be pleased with them in proportion to their efforts and long for heaven, approaching the divine “Dar al-Salaam”, (Surah Yunus/25) [1] with desire and happiness, free from anxiety about death. These people fulfill divine rights and regulate their relationship with others in such a way that they do not infringe upon anyone’s rights. By regulating their actions and communication with others, they cultivate hope for God’s mercy and forgiveness, as well as the satisfaction and prayers of those around them, which can contribute to the alleviation of death anxiety.
“De-conceptualization of death” is another important construct extracted from religious texts to reduce death anxiety in this study. This structure can be considered equivalent to cleaning the mind from cognitive errors. In line with this research finding, we can refer to studies that have investigated the effect of thought regulation and cognitive therapy on reducing death anxiety [47]. To explain this finding, it can be said that based on the cognitive approach, the events and circumstances surrounding individuals do not inherently cause tension and anxiety; rather, it is their beliefs about these events that lead to tension and anxiety, making their lives more difficult. Irrational belief leads to negative emotions (feelings of anxiety, depression, etc.) [48]. This issue is more severe and complicated in the context of death, as the imperceptible nature of death makes it difficult to know it correctly. Only by relying on and believing in religious teachings can a person gain a clearer understanding of death [49].
The “consciousness-raising” construct introduced in this research as one of the constructs extracted from religious texts to reduce death anxiety, can be considered equivalent to mindfulness and interventions based on it. This finding is consistent with the findings of a study on the effect of mindfulness [50] on reducing death anxiety. To explain this finding, it can be said that living in a conscious and mindful way causes people to be more aware of themselves, their abilities, and their surroundings, and as a result, they have more hope and optimism in life. People with wandering minds lose the ability to perceive reality accurately, focusing instead on their weaknesses and the darker aspects of life, which can result in unpleasant emotions such as depression and anxiety. In contrast, individuals with high awareness are more conscious of their activities, become more familiar with the automatic features of their minds, and develop moment-to-moment awareness. Consequently, people who are high in alertness and mindfulness experience less stress and lower levels of death anxiety [48].
“Desire regulation” is another structure that can reduce death anxiety based on the findings of this research. By searching the authors, no research was found that addressed this issue. Religious texts can be used to explain the effect of this structure on death anxiety. In religious texts, asceticism can be equated with the regulation of desire, and the concept of asceticism is the change of desire, not the elimination of desire. Islamic traditions state that a person’s desire should be directed toward the hereafter, while aversion should be directed toward this world. Understanding this important issue depends on the correct and deep knowledge of this world and the hereafter; until a person understands the nature of these two, he/she cannot practice asceticism toward one while desiring the other. According to traditions, desire for the world is a sign of ignorance and asceticism is a sign of human consciousness [51]. Research has identified one of the causes of death anxiety in religious texts as human attachment to the world and the preference for worldly matters over the hereafter [7]. According to this finding and the explanation of asceticism and desire, if the desire is regulated and a person’s focus shifts from this world to the hereafter, their anxiety about death will be reduced.
The “monotheistic attitude” is another structure that the content of religious texts suggests can be effective in creating and reducing death anxiety. The meaning of the monotheistic attitude is the belief that one God created the world and that all affairs are in His hands. The intellectual foundation of Islamic psychology is based on the assumption that humans are naturally inclined to know God. If this knowledge evolves in a natural direction during the course of intellectual evolution, it strengthens the individual’s psychological and belief systems. However, if it diverges from this natural path due to limited, materialistic ideas influenced by parents, it can create a basis for religious and psychological harm [18]. In line with this research finding, there are studies that have investigated the image of God [52] and showed that a person’s perception of God affects how he/she copes with events.
It seems that people who have a better mental image of God, maintain a positive view of events, exhibit more acceptance of death, and experience less death anxiety. The major religions of the world all provide guidance for preparing for death, and as a result, people who have positive religious beliefs and a better relationship with their Lord find meaning in their lives. They perceive death as a natural process, and this meaning leads them to accept death rather than experience anxiety about it [53].
The last mechanism extracted from religious texts to reduce death anxiety is “imagery regulation” toward death. The researchers of this research believe that if the person’s image of death and its accompanying events is corrected and formed based on reality and what is depicted in religious texts, death anxiety will decrease. Imagery regulation can be considered equivalent to guided visualization in psychological therapies. In line with this finding, in another research [54], the effect of guided visualization on reducing patients’ anxiety was discussed. To explain this finding, it can be said that people have created false images of death due to their false ideas about God and their false and irrational beliefs about death, and this problem increases the anxiety of death. However, if this image is adjusted by focusing on what is presented in the verses and traditions mentioned, death anxiety can be reduced [55].
The abovementioned structures can also be explained based on God-oriented spiritual multidimensional psychotherapy. According to this model, humans are purposeful beings, and choosing a meaningful goal is valuable as it can provide meaning to human behavior and effectively address basic human needs. This approach embodies the characteristics of monotheism and integration, which are of great importance [56]. Purposeful regulation creates unity by providing a single direction for different human activities, paying attention to both the regulation of partial actions and the regulation of final goals, which effectively positions resurrection as the culmination of actions. Also, through purposeful regulation, individuals establish a meaningful relationship with both the beginning and end of their actions, leading to a true understanding of the meaning of death in human perception.
Also, by using the second round of this treatment, which deals with adjusting the perceived origin, it is possible to find the person’s false images of God that caused death anxiety and correct them, thereby reducing this anxiety. Using the spiritual identity round and perceived existence therapy, the individual’s desires, emotions, and actions are regulated, allowing life and the world to regain their true meaning while helping clients realize their spiritual identity. If a person can deconceptualize his/her identity and base his/her actions on authentic experiences, due to the right relationship with possessions, his/her anxiety about death will decrease due to a healthier relationship with possessions, as living actions provide a sense of purpose. Also, using the perceived end treatment round, it is possible to correct the person’s image of death and the afterlife, as well as their relationship with this aspect of their destiny. By fostering accurate knowledge about death and the afterlife, a proper understanding is created, leading to a reduction in death anxiety.
Conclusion
There are effective structures in religious texts to overcome death anxiety, which can significantly improve this issue if they are acknowledged and applied. In a review of the literature and treatment packages for the treatment of death anxiety, no protocol was found that addresses all these factors. While some of these aspects have been investigated separately in various studies or have been included in different treatment protocols, the researchers of this study did not find a protocol that encompasses all of these elements. Therefore, creating a treatment package that takes into account all of the aforementioned factors in the treatment of death anxiety will be effective in improving the symptoms of death anxiety.
Limitations
One of the limitations of this research is that, due to the limitation on the number of words in the journal, it was not possible to comprehensively report the documents. Another limitation of this research is that the search for hadiths was lexical, as well as a review of related chapters in narrative books, while a study of all religious texts could potentially yield more comprehensive results.
In conclusion, it is suggested that all the religious books be studied in future research to ensure that all the components have been considered in this field. It is also suggested that due to the lack of a treatment package that considers and uses all the cases introduced in this conceptual model for the treatment of death anxiety, a treatment package should be designed and implemented accordingly.
Ethical Considerations
Compliance with ethical guidelines
This article did not require any special ethical considerations due to the lack of clinical research and manipulation of human subjects.
Funding
The present article was extracted from the PhD dissertation of Fatemeh Ghanavi, approved by Research Institute Hawzah and University, Qom, Iran.
Authors' contributions
Writing, study concept and design: Fatemeh Ghanavi; Study supervision: Masoud Janbozorgi; Statistical analysis: Seyed Kazem Rassolzadeh Tabatabayi.
Conflict of interest
The authors declared no conflict of interest.


Acknowledgments
All authors express their gratitude for the invaluable collaboration the unique of the Hazwa Research Institute, Qom University and the respected Ayatollah Gharavi.