Ethical Decision-Making and the Muslim Patient
By Dr Shahid Athar
Indiana
In crucial times of our lives, when a Muslim ethicist is not available, the leader of a mosque, a religious scholar, a practicing Muslim physician or an elder in the family or community can take a leadership role in ethical/medical decision-making for the patient.
God tells us: "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).
However, in forming his opinion, the advisor must consult the Qur’an and the Sunnah of the Prophet Muhammad (salla Allahu ‘alayhi wa sallam): "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 God and His messenger, he verily goes astray in error manifest" (33:36).
The Quran’s guidance about the sanctity of life is well known, "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 death are part of life and a test from God who while giving “glad tidings to those who patiently persevere,” tells us that He “shall test you with something of fear. And hunger, some loss in goods or lives or the fruits (of your toil)” (2:155).
In 2:28, He warns that death is a part of a journey and transformation from one life form to another and component of their faith. And stresses that no one can die except by His leave, “The term being fixed by writing” (3:45).
Thus, belief in God and the Hereafter establishes peace in Muslim hearts, who, when afflicted with calamity, say: “To God We belong, and to Him is our return” (2:156). He seeks God's help with patience and prayer (2:153).
The ethicist’s major roles in patient care area are: a) Understanding the patient and his family’s concerns and conveying them to physicians and others involved in the decision-making process; b) interpreting the scripture as it applied to the patient’s specific concerns; c) consoling and comforting the patient and his family so that they can accept the situation as a will of God and pray for a better life in the Hereafter; and d) taking care of the family’s spiritual, emotional or even financial needs after the loved one’s death.
Muslim ethicists work under the principles of preservation of faith, sanctity of life, alleviation of suffering, enjoining what is good and permitted, and forbidding what is wrong and prohibited, respecting the patients' autonomy and couples' marriage, while achieving medical justice without harm and always being honest and truthful in giving information. Thus, before giving a final opinion, they must consult the patient, the family, the physician and preferably another Islamic scholar.
Medical Futility – A Case Presentation:
Baby K, who was born anencephalic (absence of all brain except for rudimentary brain tissue), breathes, sucks, swallows and coughs but cannot see, hear, feel or think. The 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 whether or not doing mechanical ventilation in this situation was permissible, prohibited or uncertain.
Questions and discussions: Does the quality of life modify decision-making? When the resources are scarce, who takes precedence, the individual or the community?
When the physicians and family vs. patients' views clash, whose view should be taken into account?
How does a Muslim physician deal with his patient and the family’s "firm Christian belief"?
Baby K’s chances of survival without mechanical ventilation are very small. The cost of maintaining the baby on long-term ventilation, either in the hospital or at home 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.
Some of the principles of biomedical ethics:
1) Respect for autonomy: The right of patient self-determination is based on the principle that people are autonomous to the extent that they are able to understand and make decisions for themselves that are intentional and voluntary.
2) Beneficence: The principle of beneficence that obliges persons to benefit or help others, 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) Non-maleficence, which obliges persons to refrain from harming others, including refraining from killing them or treating them cruelly, is one of non-intervention, 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 requires a fair distribution of benefits and burdens, where persons receive that which they deserve or to which they are entitled. It also involves decisions to allocate scarce health care resources. However, 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. Physicians cannot remain aloof of such situations, as they are intimately involved in patient outcome. They should know the patient’s ethical values as religion influences the patient's decision and compliance with a prescribed treatment.
A physician is seen as a secular priest. Therefore, a patient who is indecisive about his care may seek not only the physician’s medical but also spiritual advice. Sickness precipitates questions in the patient and drives him closer to God. Therefore, he may have to reflect upon his past and make decisions based on his own spiritual growth during illness.
Finally, the physician's own belief may influence his treatment options offered in the patient's outcome. For example, a physician who is against abortion will never advise his patient to undergo one, or one who does not care about the sanctity of life may practice euthanasia.
A physician’s true role 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 sick patient. Technically, a patient in a vegetative state can be kept alive for months and years, like Karen Quinlan's case, eventually to die. 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 while cost to the family of such care can be prohibitive because insurance coverage has its limits. However, a patient in coma in a vegetative state is still alive and should not be deprived of nutrition and hydration. Physicians should not hasten the process of dying 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 who are involved in the patient’s care. The team should include not only the physician and relatives but also a Muslim imam or scholar for the interpretation of the Shariah.
(Shahid Athar, MD, FACP, FACE is a physician, former chair of medical ethics of Islamic Medical Association of North America. IMANA’s position paper is on line at www.imaa.org )
