Health Concerns for the BELIEVERS

ETHICAL DECISION MAKING IN PATIENT CARE: AN ISLAMIC PERSPECTIVE PDF Print E-mail
Written by Dr. Shahid Athar   

Islam, the meaning of which is peace and submission to the will of God, is not merely a way of worship but a way of life from womb to the tomb. We believe we have been created as humans and placed on this planet as a test from God, how we conduct ourselves .

In the Name of allah, the Beneficent, the Merciful
"Blessed is He in Whose hand is the Sovereignty, and He is Able to all
things, Who has created Life and death that He may try you, which of you
is best in conduct; and He is the Mighty, the Forgiving" (67:1-2).

In the absence of any ordained clergy in Islam, the role of decision making can be taken by the leader of a mosque, a religious scholar, a practicing Muslim physician or an elder in the family or community. However, he or she must consult the Quran, the Word of God, and the Sunnah, the sayings of the Prophet Muhammad (PBUH) before giving his or her opinion, and should not place his or her opinion above the opinion of God and the Prophet. "And it becomes not a believing man or a believing woman, when Allah and His messenger have decided an affair (for them), that they should (after that) claim any say in their affair,- and who so is rebellious to Allah and His messenger, he verily goes astray in error manifest" (33:36).

The guiding verse in Quran regarding the sanctity of life is, "If anyone killed a person, unless in lieu of murder or spreading mischief on earth, it would be as if he killed all of mankind. And if anyone saved a life, it would be as if he saved the lives of all mankind" (5:32).

Muslim patients understand that illness, suffering and dying are part of life and a test from God.

Be sure We shall test you With something offear And hunger, some loss In goods or lives or the fruits (Of your toil), but give Glad tidings to those Who patiently persevere (2:155).

Death is nothing but part of a joumey and transformation from one life form to another and component of their faith.

How can you reject the faith in God? Seeing
that you were without life, and He gave you
life; then will He cause you to die, and will
again bring you to life; and again to Him will you return (2:28).

Nor can a soul die
Except by God's leave.
The term beingfixed
As by writing. If any
Do desire a reward
In this life, We shall give it
To him; and if any
Do desire a reward

In the Hereafter,
We shall Give it to him.
And swiftly shall We reward
Those that (serve us with) gratitude (3:45).
Thus, belief in God and the hereafter establishes peace in their hearts.

Who say, when afflicted
With calamity: 'To God
We belong, and to Him
Is our retum' (2:156).

They seek God's help with patience and prayer.

0 you who believe! seek help
With patient perseverance
And prayer: for God is with those
Who patiently persevere (2:153).

The major roles of the ethicist in the patient care area are: a) Understanding the concerns of the patient and his family and transmitting them to physicians and others involved in the decision making process; b) interpreting the scripture as it applied to the specific concerns of the patient; c) consoling and comforting the patient and his family so that they can accept the present situation as a will of God and pray for a better life in the hereafter; and d) taking care of the needs of family (spiritual, emotional or even financial) after the death of the loved one.

The important principles used by Islamic ethicists are the preservation of faith, sanctity of life, alleviation of suffering, enjoining what is good and permitted, and forbidding what is wrong and prohibited, respecting patients' autonomy and couples' marriage, while achieving medical justice without harm and always being honest and truthful in giving information. He or she must consult the patient, the family, the physician and preferably another Islamic scholar, before giving a final opinion.

MEDICAL FUTILITY / ISLAMIC PERSPECTIVE

CASE PRESENTATION: BABY K

Baby K was born anencephalic (absence of all brain except for rudimentary brain tissue) in October, 1992. The baby breathes, sucks, swallows and coughs. The baby cannot see, hear, feel or think. The baby's mother, out of a firm Christian faith that all life should be "protected," insists that everything should be done for her baby, including mechanical and artificial ventilation. The Muslim physicians were asked the question as to whether or not mechanical ventilation in this situation was permissible, prohibited or uncertain.

Before discussing this case itself, there are several questions that come to mind about this particular issue.

  1. Does the quality of life modify decision-making?
  2. When the resources are scarce, who takes precedence, the individual or the community?
  3. When the physicians and family vs. patients' views clash, whose view should be taken into account?
  4. How does a Muslim physician deal with a "firm Christian belief" of his patient and the patient's relatives?

As far as Baby K itself is concerned, the chances of this child's survival without mechanical ventilation are very small. The cost of maintaining him or her on long-term ventilation, either in the hospital or in a home situation, is extremely high, and it places tremendous pressure on parents in caring for such a child without improving any quality of life. However, their emotional attachment, as well as their faith perspective, should be taken into account and respected.

Let me explain some of the principles of biomedical ethics:
1) Respect for autonomy: People are autonomous to the extent that they are able to understand and make decisions for themselves that are intentional and voluntary. The principle of respect for autonomy places importance on allowing persons to make important decisions for themselves. The right of patient self-determination is based on this principle .

2) Beneficence: The principle of beneficence obliges persons to benefit or help others. This principle requires positive action: to prevent what is bad or harmful; to remove what is bad or harmful; and to do or promote what is good or beneficial.

3) Nonmaleficence: This principle obliges persons to refrain from harming others, including to refrain from killing them or treating them cruelly.

It is one of non-intervention. It also requires persons to exercise due care so that they do not unintentionally harm others through actions such as reckless driving or careless surgical procedures.

4) Justice: This principle requires a fair distribution of benefits and burdens. Justice requires that persons receive that which they deserve or to which they are entitled. This principle is involved in decisions to allocate scarce health care resources. The specifics of how to implement this principle remain controversial in many situations.

Each patient should be discussed under these guidelines for the final conclusion. We, the physicians, cannot remain aloof from such situations as we are intimately involved in patients' care and outcomes.

1) We, the physicians, must understand the religion of our patient because the religion of the patient influences his feeling and thus affects the patient's decision and compliance with a prescribed treatment.

2) A physician is seen as a secular priest. Therefore, a patient who is indecisive about his care may seek not only medical but also spiritual advice from the physician.

3) Sickness precipitates questions in the patient and drives him closer to God. Therefore, he may have to reflect upon his past and make some decision based on his own spiritual growth during illness.

4) Finally, the physician's own belief may influence his treatment options offered in the patient's outcome. For example, a physician who is totally against abortion will never advise his patient to undergo abortion, or a physician who does not care about the sanctity of life may become "a suicide doctor."

We conducted a survey of Muslim physicians about Baby K (Chart A). Twenty-nine of them, or twenty-four percent, thought it was permissible to institute mechanical ventilation for Baby K. However, seventy- nine of them, or sixty-five percent did not feel that way. At the same time, fourteen or eleven percent were not sure.

The true role of physicians is to alleviate suffering and give comfort to the patient and the relatives, improving the quality of life, the terms of which have been fixed. The physician should not perform heroic measures in the care of a hopelessly ill patient. Technically, a patient in a vegetative state can be kept alive for months and years, like Karen Quinlan's case, eventually to die anyway. It may also be very painful for the relatives to see one of their loved ones being in a vegetative state for such a period of time and cost to the family of such care can be over $100,000. Nor at the same time, should physicians hasten the process of death by pulling the plug or withdrawing nutritional support.

Therefore, the decision in such cases cannot be an individual decision by either the family or the physician but should be a decision of all those concemed or who are involved in the care of the individual patient. The team should include not only the physician and relatives but also a Muslim clergy for the interpretation of the Shariah.

 

CHART A

Survey of Muslim Physicians about Baby K's Mechanical Ventilation
                                     Males                                          Females

Age
Groups of Permissible Prohibited Not Sure Permissiblo Prohibited
Physicians

20-30 2 16 2 0 0 0

30-40 4 8 3 1 2 0

40-50 9 25 3 4 4 1

50-60 7 17 1 0 6 1

60 2 1 2 0 0 1

------------------------------------------------------------------------------------------------------------------------

Total 24 67 11 5 12 3


1. Permissible: 29 or 24%
2. Prohibited: 79 or 65%
3 Not Sure: 14 or 11%
 
IMANA.ORG