Ethical Issues Of Resuscitation: Islamic Perspective - Research Proposal Example

Introduction: Islam is one of the primary great religions of the world and Muslims roughly constitute more than twenty percent of the total population. Even though the Muslim population is more concentrated in the Middle-East, some part of Asia, and Africa, followers are now spread out and found in all parts of the world. The growth is this religion is also great and it is no understatement to say that its influence in social and political spheres is enormous. This great religion has clearly laid out laws and edicts that are based on love, caring, morality and what is right and wrong for a true and devout Muslim. Modern medicine too has evolved over the years into the present state seen today and ethical practitioners and proponents of this branch of science believe in caring, cure, and scientific principles. But as with any science, certain practices may or may not be in accordance with religious laws found in various regions of the world. Examples where opinions differ include such diverse areas are stands on abortion, gay rights, genetic engineering and euthanasia. This paper is a review of the Islamic stand on the practices of cardio pulmonary resuscitation and the other extreme of do-not-resuscitate (DNR) in contrast with the medical practices and ethics. In the process, it will also look at other ethical and moral philosophies such as deontology, utilitarianism, and consequentialism. The purpose is to analyze whether there is a conflict in this area between Islamic laws and modern medicine. Basis of the paper: The paper is based on the treatment of Mr X who had been hospitalized with advanced pancreatic carcinoma. He was admitted to the ER primarily due to severe pneumonia with a DNR condition prescribed in the case sheet. But his family members requested the physicians to do everything in their care including resuscitation and keep him alive for a minimum of two days. Even though his condition was critical, family members wanted to ensure that he died during the month of Ramadan which was just a couple of days away. Dr M was in a quandary and this paper will find a solution for him regarding his ethical dilemma. The paper will conduct a literature review and methodology based on the following areas. 1- Address the point of ethical challenges since the evolution of modern medicine 2- Ethical issues related to the end of life 3- Ethical issues with resuscitation of incurable chronic diseases, do not resuscitate (DNR), consider the opinion of parents in a cardiopulmonary resuscitation etc. Literature review and methodology: It is proposed that both literature review and methodology be done using secondary sources from books, journals, and other relevant publications from acceptable bodies and organizations. Ethical challenges since the evolution of modern medicine: It appears from various viewpoints in literature that a proper definition of medical ethics is difficult. This is primarily because ethics is defined by religion, laws, culture, and other factors and as such will vary from country to country or even among different states within a country. According to Snyder, Candace, and Tong, ethical viewpoints may even differ among the different branches in medicine itself. So, “despite written directives for addressing common challenges, the practice of clinical medicine inherently will be fraught with unforeseen ethical dilemmas, since both the health care practitioner and the patient will bring their individual life experience and moral values to the clinical encounter. It is the job of the practitioner, to find a balance between fundamental ethical principles, the law, and respect for values for the patient (Snyder, Candace, and Tong 2008, 1).” For example, euthanasia of which DNR is a part of, is controversial in some countries while it is acceptable in others. In the United States, passive euthanasia which is characterized by ‘stoppage of treatment’ or palliative care is considered to be legal in most states. Only Oregon has introduced the Death With Dignity Act 1997 which allows physicians to take the life of patients with lethal injections under certain conditions (Death With Dignity Act). The challenges faced by medical ethics can also be seen from the criticism of the definition of euthanasia by the World Medical Association. The point made was that there is no differentiation between active and passive euthanasia which is critical to medical ethics in the United (Holm 2006). Medical ethics can primarily find its origins in the Hippocratic Oath, propounded by the father of modern medicine. Veatch, in his book ‘Medical Ethics’ confirms this observation by stating that “the Hippocratic Oath is often acknowledged by both physicians and lay people to be the foundation of medical ethics for physicians in the West” (Veatch 1997, 6). In the United States, there is a general consensus that the first official code of ethics was adopted in the country by the American Medical Association in 1847. Accordingly medical ethics was defined “as a branch of general ethics, must rest on the basis of religion and morality. They comprise not only the duties, but, also, the rights of a physician: and, in this sense, they are identical with Medical Deontology (Original Code of Medical Ethics 1847, 83). As mentioned earlier, religious beliefs can also matter with regard to how medical ethics is perceived. Veatch continues that Islamic teachings have strong views against the concept of killing as seen in euthanasia. Had the above mentioned case study taken place in Oregon, the doctor would have been at a loss as to follow the DNR order or the wishes of the family members. The Islamic Medical Association of United States (IMANA) is the body that provides ethical guidelines for these regarding Sharia in the country. It can be seen that there is no clash of ideologies with regard to the aspect of care and curing, but in certain areas, the organization does not have the same viewpoint as the general medical community and statutes in the United States. For example, the IMANA states that genetic research is allowed if it is specifically for cure, but is not allowable in other instances. According to the organization, “We believe that each individual is born with unique qualities and genetic makeup. Islamically, a child should be born out of marriage between husband and wife and the lineage of the child should be maintained. Therefore, human reproductive cloning is not permitted in Islam” (Islamic Medical Ethics: The IMANA perspective n.d., 9). It should be noted that the IMANA specifically states that their guidelines should not be regarded as Fatwa that are binding on believers. In other words, if any Fatwa is introduced which is not agreeable to the views of the IMANA, the former will prevail. On the whole, it can be seen that ethical challenges do exist and are related to religion, law, experience, and beliefs of the stakeholders, especially for the doctor, the patient and his or her family. The one way to overcome this problem is to take all of them into consideration and decide depending on the unique factors present in individual situations. Ethical issues related to the end of life: Advancements in modern medicine have led to many breakthroughs in treatment and cure of diseases. Another factor is that it is now possible to prolong the life of a patient through life support systems even though the disease itself might be fatal. The concept of treatment at the end of life stage has now given rise to much ethical confusion among healthcare providers and patients and their families. The main question would be with regard to continuation of treatment and palliative care. Even though there is no law or statute that orders a particular course of action to be taken, there are statutes that provide the patient with a right to die with dignity. A landmark statute in this regard is the Patient’s Self-Determination Act (PSDA) of 1991. This Act provides a patient with the right to take informed decisions regarding continuation or non-continuation of treatment especially in end-of-life situations. “The principle of justice relates to the fair, equitable, and appropriated treatment or use of resources in light of what a patient needs, weighed against the needs of others” (Andrews & Boyle 2007, 410). In other words, the wishes of the patient can supersede what is wished by the physician or family members in end-of-life situations. The patient can communicate this with the healthcare authorities though advance directives, living wills, or a durable power of attorney. Islam does have strong views on the concept of suicide, and is considered to be the gravest of sins either to kill or to take one’s own life. In that sense passive euthanasia can be seen as a form of suicide and hence a sin. But scholars who have interpreted Islamic laws and the Quran have certain concessions in specific instances. According to an article on end-of-life issue, “Islam recognizes that death is an inevitable part of human existence. Thus, treatment does not have to be provided if it merely prolongs the final stages of a terminal illness as opposed to treating a superimposed, life-threatening condition” (Zahedi, Larijani & Bazzaz 2007, 11). There are more directives regarding adhering to the patient’s wishes from the Administration of Islamic Research and Ifta, Riyadh, KSA, in their Fatwa No. 12086. The Fatwa states that “if three knowledgeable and trustworthy physicians agreed that the patient condition is hopeless; the life-supporting machines can be withheld or withdrawn. The family members opinion is not included in decision making as they are unqualified to make such decisions” (Takrouri & Halwani 2008). Both these directives clearly provide the patient with the right to informed directives regarding stopping of treatment in such situations. In the case of Mr. X, it is not clear who had provided the directive or even whether he is in a critical no-recovery stage. If both factors are present, the he has the right to request DNR without committing religious mistake. In this instance, it also appears that the family members do have the right to ask the doctor to extend life since both the directives only provide a choice and not a command to die. In other words, the Sharia does not prohibit extension of life but only termination (with exceptions mentioned above). But if the doctor listens to the family members, he could be held liable under the PSDA if the patient himself had directed the DNR. The doctor can comply with the wishes of the family members if he ensures that no legal action will be taken by them. But he will be held liable if it happens even in spite of assurances. Taking into consideration, the religious sentiments, it is safe to assume that no such action will take place. Another factor to be noted is that PSDA primarily involves organizations that receive federal grants. It is not mentioned here whether Mr. X was admitted in such a hospital. If not the doctor is perfectly safe both morally, ethically, and legally safe if the patient was in a critical no-recovery condition to either course of action. Another instance of religious and ethical dilemma is mentioned here for reference. A man afflicted with Crohns disease is admitted for surgery. He was bleeding profusely and an emergency total colectomy is required. The patient (who is alert) and family members refuse blood transfusion because they are Jehovah’s Witnesses. The surgeon and anesthetist know that the patient may die during surgery if transfusion is not given. In spite of their warnings the patient and family members refuse transfusion (Gaffney, Galvin & Stilwell 2002, 2) Ethical issues with resuscitation of incurable chronic diseases, do not resuscitate (DNR), consider the opinion of parents in a cardiopulmonary resuscitation etc.: An overview of Islamic religious laws and traditions: There are primary and secondary sources on which Islamic law is based. The primary ones are the holy Quran and the Sunnah and the former supersedes any other source (Izz al-Dīn 2004, 36). The Quran is considered by every believer to be the direct word of God and is more directive rather than as a book of law. The Sunnah is based on tradition or norm. In other words, they are what has been accepted and practices by Muslims over the years. Secondary sources include the Ijma and Qiyas. Ijma, which means consensus, is also considered to a book of law while the Qiyas means analogy (Visser 2009, 11). Allowing or disallowing euthanasia is not specifically mentioned in the Quran, probably because it is a relatively modern concept. But as mentioned earlier, suicide or even mercy killing, is specifically forbidden. But the Quran also says that in a critical state, a person can pray that “Oh God! Let me live as long as life is good for me and let me die if death is good for me” (Sachedina 2009, 149). Since the holy Quran is the ultimate Sharia, it can be purported that Mr X had the right to request DNR if he is in a critical condition. The Ijma is the result of the Prophet’s direction that believers should not agree upon something that is an error. Hence this could be used as a guide when new technology, practices, and beliefs develop over a period of time. Mostly, decisions are arrived at after common discussion by scholars upon a new matter of concern. An article by, Dr Omar Hasan Kasule, a professor of epidemiology, with regards to Ijma and Qiya on medical ethics finds no mention regarding denying the right to DNR if the factors (like imminent death) are present. According to him, “Valid consent must be voluntary, informed, and by a person with capacity to consent. It involves explaining the procedure contemplated, making sure the patient understands, and offering the patient a choice. Consent is limited to what was explained to the patient except in an emergency” (Kasule 2007). Moreover, this appears to be in agreement with the legal and medical perceptions on DNR in the United States. CPR is mostly an invasive method to revive the heart in emergency conditions and can be considered to be an action towards life sustenance. In the same vein, DNR is a deliberate option not to provide this life sustaining treatment. Hence DNR can be considered to be passive euthanasia (Hill & Howlett 2004, 352). But all this may not be agreed to by many devout Muslims and controversies and disagreements may continue on this topic in the future also. For example, a study by Aramesh and Shadi in the Iran Journal of Asthma Immunology, observes that euthanasia in all forms are forbidden in Islam. The authors state that life support systems can be withdraws in hopeless cases by informed consent and consultation with family members (Aramesh & Shadi 2007, 38). Another way to look at this is to consider DNR as a case of withdrawal of life support. But even so family consent should be there which is not so in the present case. Hence the physician in this case has no choice but to go in for CPR if the need arises irrespective of the patient’s DNR request or the family member’s need to prolong life. There is another factor that can create ethical challenges to physicians and other stakeholders with regard to the effectiveness of CPR. The article titled ‘Ethical issues of resuscitation: An American perspective’ states that survival and success rates of CPR is ranges between zero and sixteen percent with most cases leaning towards the no success rate (Marco 2005, 609). Moreover, it is very costly and in all instances an emergency procedure. Unless a DNR is previously specified there is practically no chance of asking the opinion of the patient because of his or her physical condition. It will be left to the doctors and in some instances, the family members to decide on what should be done. It is also worthwhile to provide some more general and legal views on passive euthanasia in the country. Euthanasia cannot be allowed unless that patient repeatedly requests for it over a period of time and the physician is sure that the patient is sincere in his or her requests. There should also be no medical, psychological or other means of relief from the insufferable pain. The request of the patient was done with total free consent and not coerced of forced in any way. The patient should also be aware of the facts regarding the disease. All forms of treatment possible have been done and have not resulted in bettering life or curing the patient. The final condition is that the physician who primarily treats the patient should consult a colleague (or any other competent physician) regarding this before taking a decision. There are many who oppose euthanasia under any circumstance. The American Medical Association does not support euthanasia as of date. They are of the opinion that “Euthanasia is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks” (Code of medical ethics 1994). The book ‘Ethics - Theory and Contemporary Issues’ mentions the views of professor of philosophy Gay Williams who is against euthanasia. According to him euthanasia is wrong due to three primary reasons. He says that human beings are naturally inclined to living and not dying. The second contention is that death is irreversible. A mistake with regard to prognosis will result in wrongful killing. This will ultimately be against the interest of the individuals in the society. The third factor is that regular practice of euthanasia can even corrupt in the sense that doctors, the patient and family members may not try hard enough and look at euthanasia as an easy option. But Williams has different views on passive euthanasia and seems to be supportive regarding this. “In such cases, the person involved is not killed (the first essential aspect of euthanasia), nor is the death of the person intended by the withholding of additional treatment (the third essential aspect of euthanasia). The aim may be to spare the person additional and unjustifiable pain, to save him from the indignities of hopeless manipulations, and to avoid increasing the financial and emotional burden on his family” (Williams 1996, 168). Other philosophical outlooks on this scenario: Deontology states that any action should be dependent on its moral significance. Hence it will vary from individual to individual. If a physician or a nurse feels that it is morally wrong to refuse resuscitation, he or she may go ahead with it in spite of a DNR order. The reverse scenario can also take place depending on the healthcare provider’s moral and religious outlook. Utilitarianism advocates a balanced outlook and judgment taking into account the pros and cons of the action and its results. If the physician feels that a DNR is more practical (if resuscitation only results in leaving the patient in a vegetative state), he might leave the patient alone. Consequentialism is based on a broader outlook and a decision which results in the greatest good to the greatest numbers should be acted upon. If the patient is critical with no hope of recovery or normal life, then the DNR option could be taken. This is because it will be beneficial to family members in terms of removal of prolonged distress, and the financial and other resources involved. All these philosophies only provide guidelines and any action will be dependent on the values and belief systems of the people involved in decision making. So in the present case, the doctor will act out depending on whether what is best for the patient, the family members and his own beliefs and value systems. Discussion and conclusion: In the case study the doctor is facing an ethical challenge between the DNR order and family request to resuscitate. Legally, the doctor is bound to refuse and opt for DNR. Under Islamic laws, the concept of euthanasia (DNR) in any form is sin. But if the patient has an incurable disease or is in a critical or no-recovery stage, withdrawal of treatment is permissible. Hence he may be correct under Sharia to opt for DNR. On the other hand, the doctor is also bound by duty, ethics and by Sharia to save a life. His decision will depend on the following factors. If Mr. X had requested the DNR after informed consent, then Dr M is bound to honor it in the United States. If he takes religious considerations into effect, he is bound to provide all assistance to prolong and save a life. It is only when the patient is in a stage of no-recovery can the doctor opt for DNR. In this case, the request is to prolong life for just two more days till Ramadan begins and not for an indefinite period. Hence, the doctor can bow to the wishes of the family members in an effort to see that if death does occur, it can be during this holy period. But he should ensure that no legal action with regard to non-compliance of DNR takes place. In the second case also the doctor should operate even without transfusion, otherwise the patient will surely die. In case of an operation (without transfusion) there is a chance that the patient’s life will be saved. These two decisions are also in accordance with religious, legal factors, other philosophies, and the physicians’ own moral and belief systems. So the doctors can comply with the wishes of the family members in both cases. References Andrews, M.M. & Boyle, J.S. 2007. Transcultural concepts in nursing care 5th ed., Lippincott Williams & Wilkins.   Aramesh, K. & Shadi, H. 2007. Euthanasia: An Islamic perspective, Iranian Journal of Allergy, Asthma, and Immunology, vol. 6, no. 5, pp. 35-38 Code of medical ethics. 1994. 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Islamic law: from historical foundations to contemporary practice, Edinburgh University Press. Kasule, O.H. 2007, The legal and ethical basis of medical practice, Islamic Medical Education Resources, Viewed 27 September 2009, http://omarkasule-04.tripod.com/id1318.html Marco, C.A. 2005. Ethical issues of resuscitation: An American perspective, Postgraduate Medical Journal, vol. 81, pp. 608-612 Original Code of Medical Ethics. 1847. American Medical Association, Viewed 26 September 2009, http://www.ama-assn.org/ama/upload/mm/369/1847code.pdf Sachedina, A.A., 2009. Islamic Biomedical Ethics, Oxford University Press US.   Snyder, J.E., Candace, C. C. & Tong, R. 2008, Evidence-based medical ethics: Cases for practice-based learning, Springer Takrouri, M. & Halwani, T. 2008. An Islamic Medical and Legal Prospective Of Do Not Resuscitate Order In Critical Care Medicine, The Internet Journal of Health, vol. 7, no. 1, Viewed 26 September 2009, http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijh/vol7n1/dnr.xml Veatch, R.M. 1997. Medical ethics 2nd ed., Jones & Bartlett Publishers.   Visser, H., 2009. Islamic Finance: Principles and practice, Edward Elgar Publishing.   Williams, J.G. 1996, Intervention and Reflection: Basic Issues in Medical Ethics, 5th ed., Ronald Munson (ed.), pp. 168-171 Zahedi, F., Larijani, B. & Bazzaz, J.T. 2007. End of Life Ethical Issues and Islamic Views, Iranian Journal of Allergy, Asthma and Immunology, vol. 6, no. 5, pp. 5-15 Read More