A Review of End-Of-Life Ethics in Critical Care and Iranian Cultural Perspective of Islamic Faith

Abstract

End-of-life care is an area of continuing development in light of new technologies that allow doctors to extend life beyond what was previously possible. With this ability come concerns over when it is appropriate to engage such life support measures. Unfortunately, there exists no universal guideline to end-of-life decision-making, and factors such as culture and religion further confound matters. Here we show that physician religious affiliation does indeed influence decision-making and we extrapolate this concept to the Shiite Muslim preponderance of physicians in Iran. We also demonstrate the need for reconciliation between medicine and religion in Iran so that patient care during the end of life can be improved.

Introduction

Death is recognized by end of life, however “dying and death” manifest incongruously from person to person, culture to culture, and country to country [1]. Sentiments about what might constitute a good and dignified death do, of course, differ among cultures, religions, and individual persons. Death includes various features such as clear communication among all parties involved, including the patient, patient’s family, and care team. End of life care (EOLC) is the providing of adequate preparation for death for patient, patient’s family, and care team [2]. There are a slew of confounding factors that make it difficult to ensure each parameter of death is fulfilled adequately such as prolongation of the dying process. Often times, blinded by a virtuous intention to heal, physicians fail to see the distinction between prolonging life and prolonging the dying process. Some undergo what we might classify as a good or pleasant death; in contrast, other perhaps not so fortunate patients might undergo a less desirable dying process, the attributes of which also are not unanimously agreed upon. Therefore, it is necessary for physicians dealing with the issue of EOLC to be cognizant of the various facets that death might encompass for the patient, patient’s family, as well as culture in big picture [3].

Patient vs. Physicians’ Role in End of Life

Autonomy refers to an individual’s right to make decisions for one, with an emphasis on the individual’s ownership of his/her own body and the right to do with it as he/she pleases .Advanced directives is to circumvent ambiguity in decision making in the event that the patient is for some reason incapacitated at the time a decision needs to be made, however, controversy still presents in many cases. Advanced directives prove to be particularly beneficial in the ICU setting, as it is outside of the means of up to 95% of patients to make decisions for themselves secondary to impaired states of consciousness from either illness or sedation. Currently there is no international consensus on when to limit EOLC if ever at all [4]. Widespread differences from person to person make it virtually impossible to standardize any one practice within and, especially, between countries. However, some countries such as the US have begun taking steps toward more specifically defining the physicians’ role in EOLC.

Islam vs. Secular View of End of Life

Secular utilitarian ethics and faith-based or religious ethics have various definitions of death. Use the definition of death in the Uniform Determination of Death Act (UDDA) - irreversible cessation of cardio pulmonary or the entire brain function- as an example of secular utilitarian ethics redefines western death. Time has proved the UDDA be both scientifically and legally flawed. On the other hand, definition of death grounded in 3 Abrahamic faiths (Judaism, Christianity and Islam) not only on the sanctity of life, but also on how dying or death occurs (assisting vs. allowing) is absolutely different from secular point of view [5].

Muslims do not view this life as the end, but only as the start of the next life; and the role of the current life is to determine the next life. Death is perceived differently in Western communities and Muslim patients and health care providers. In general, faithbased morality that rejects equating withholding vs. withdrawal of treatment especially when hastening the dying process do not accept distorted double-effect principle in secular morality . The distinction between assisting death and allowing natural death is fundamental in Islam including Sunni and Shiite. The former is absolutely forbidden.

In our approach to this controversial matter of EOLC, we find it prudent to begin with a brief summary of the ethical principles involved. There are 4 secular bioethical principles of Beauchamp and Childress in early 1970’s. Not realizing that these 4 principles are maninvented for society with the intention of building a firewall between secular ethics and traditional cultural-religious ethics. Time has proved that these secular bioethical (principles) are part of the root problems in the clinical practice of medicine, and behind irrational use of life/dying prolonging technology in terminal illness. A good example of the fallacy of secular bioethics is equating withholding vs. withdrawing treatment in clinical practice of medicine as morally equivalent, when in reality they are not. Influence of faith-based ethics on EOLC in clinical medicine has been described by Seal et al. Billings also described how secular ethics has twisted and bent the double-effect principle disguising assisted death as natural death; he succinctly opined “Trepidation about the improper use of the rule of double effect is also noteworthy, particularly whether it can be twisted to become a justification for evil acts” [6].

Iran, Shiite and End of Life Care

Up to this point, there have been very few positions published delineating the Iranian Shiite perspective on EOLC for many reasons. Essentially, EOLC law has not well defined in Iran medical ethics. Therefore, EOLC has yet to be acknowledged or defined as a separate entity of care in Iran, secondary to the austere restriction of limiting life support measures in accordance with Shiite Islamic law. Due to the Iran constitutional law Iranian jurisprudence is based on Islam. In other words, Sharia (Shiite rules) has a key role to play in establishing the legal statutes naming life and death [7].

According to Shiite verdicts there is a key difference between withholding medical treatment from a person who has entered a stage of dying and withdrawing life support already in place such as mechanical ventilation. A precise Shiite verdict by Grand Ayatollah states that “save Muslim life is necessary, however compulsory precaution could be made to ask from a cleric in each questionable case” [8].

Due to its fledgling nature, many areas of critical care medicine have yet to be addressed by Iranian religious leaders (Grand Ayatollahs or Mujtahids); therefore, legal verdicts (fatawa) on matters relating to EOLC and support measures are lacking at present. For instance, Do Not Resuscitate (DNR) and Do Not Intubate (DNI) orders are not practiced in Iranian medical laws and ethics. In fact, Any and all life support measures are to be executed in the attempt at preserving life until which point the patient ultimately expires [9].

Cancer Care and Hospice

Iranian hospitals have no hospice wards or teams. Therefore the terminally ill cancer patient must choose between dying at home in an arguably unpleasant way or being admitted to the ICU and being maintained until which point the cancer ultimately overcomes all the support measures. Furthermore, if our hypothetical cancer patient is admitted, there will be great cost for both the hospital and patient, as the patient could very likely be maintained on mechanical ventilation and artificial feeding for an indefinite period of time. In Iran, neither the hospital nor patient can afford such costs. Lastly, ICU beds in Iranian hospitals are highly coveted [10].

Organ Harvesting for Transplant

Although Iran is lagging in many aspects of EOLC, there has been some recent progress made with regards to organ harvesting for transplant purposes. About six years ago, the religious leaders released a fatawa justifying organ harvestation in brain dead patients. Currently, a patient’s liver, kidneys, lungs, or heart are permitted to be harvested if the proper consent is obtained. This hierarchy of consent comes foremost from the patient’s parents, regardless of the age or marital status of the patient [11]. If parents are unavailable, the next tier is comprised of the patient’s spouse and children. Also, Iran presently offers its citizens the option of registering to be an organ donor in the event of brain death; however, consent according to the aforementioned hierarchy is necessary in addition to this patient registration. The system being such, the patient’s wishes can be overridden at a later time [12].

Discussion

While it might be tempting to conclude that regional variation in practice is attributable to religion, those differences should not be attributed to religion as a whole. Since the majority of Islamic publications come from Sunnite countries, Shiite point of problem should also be discussed thoroughly. There is copious room for development in the field and propose that attempts be made at reaching a unified agreement on EOLC practices based on a respect for the Muslim-dominated culture of the region. Religion remains an influential factor in medical decision-making according to Iran constitutional law [13].

It is possible that EOLC in religious countries like Iran is under influence of Shiite Islamic rules more than medical ethics. Another alternative explanation is the fact that medical system have not been in close contact with grand ayatollahs to pronounce such sophisticated issue, although one should not rule out economics scale, culture, and other elements. The problems on EOLC in countries like Iran can be solved by “medical experts and scholar clerics (Grand Ayatollahs or Mujtahids) come together and devise an approach”. Only when such a multi-disciplined strategy is employed will we likely see advancement that could eventually contribute to a decrease in costs and increase in quality of life perception associated with EOLC [14]. We believe medical and Islamic rules reform has the potential to dramatically improve the quality of EOLC in religious countries such as Iran and simultaneously reduce costs of care with some relatively simple and straightforward steps.

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