The sensitive subject-matter of how to determine the best course of action with regard to the treatment, or other options, for a patient who is reaching the end of their life, who may be terminally ill or have an irreversible medical condition that is no longer responding to medical treatment, will always present great difficulties for medical practitioners. It requires great skill, care, medical and ethical judgment to balance the needs of the patient and their families, alongside what is medically ‘doable’, what should be done or should not be done, either from a medical or ethical stand-point, and, of course, to take into consideration what actions or decisions are permissible under the law. In the Gulf Corporation Council (‘GCC’) states, these already difficult decisions are over-layered with religious and cultural beliefs that must also be at the forefront of the mind of the care pathway decision-makers.
In some circumstances, it is not appropriate to continue to treat a patient, for example, at an end-of-life stage, perhaps with a terminal illness, or where a cardiac condition would mean that repeated attempts at resuscitation (‘CPR’) would be futile. The concept of withdrawing active intervention medical treatments is now accepted under both Islamic principles and under country-specific state laws. In this article we examine the current status of the law.
There are a number of significant ‘concepts of care’ that must be balanced when dealing with a patient at the end-of-life stage, these are:
- the over-arching duty to treat;
- futility of continuing to treat;
- whether to attempt or continue to attempt CPR;
- how to determine the moment when a patient has died (for example, ‘brain dead’); and
- whether the organs of a deceased patient may be taken to benefit a living patient.
The Islamic perspective
The laws that govern end of life stage care in the GCC are rooted in Islamic principles. Islam considers that life is sacrosanct and that efforts to treat a patient should be continued. Historically, the thinking was that treatment options should continue notwithstanding that the end result would be that the patient would eventually die. A physician could be accused of terminating the life of a patient if all treatment options were not pursued with vigour. There has been a significant change in this approach in recent times.
There is now a great deal of support for the concept of the ‘natural death’, that it would be appropriate to withdraw active intervention for some patients to allow them to spend the last few weeks of their life peacefully, and that further intervention or life support is not required if it prolongs agony and suffering. In such cases, the patient would be allowed a natural death, while feeding, hydration and comfort treatments would be continued.1
The concept of ‘futility’ now extends to patients not only at an end-of-life stage due to terminal illness, but also to cases where a patient suffers from a cardiac condition, or has been involved in a serious accident, and life support treatments by mechanical means become necessary. Under certain laws, CPR may be discontinued for a patient where three physicians agree that such resuscitation attempts would be futile. In the Kingdom of Saudi Arabia, for example, do not resuscitate (‘DNR’) orders can be put in place by way of an advance directive. Where no such DNR order has been made, CPR can be discontinued where three physicians agree that continued attempts would prove useless to improving the patient’s condition. 2
A question that has vexed Islamic scholars and medical practitioners alike, is to determine at what point the patient has actually died. The point at which the patient dies is very important from a religious, spiritual and family perspective, but also in medical terms, because the diagnosis of death then potentially enables other decisions to be made, such as whether organs can be harvested for the benefit of living patients.
There are numerous ways to define the point of death, including:
- the irreversible loss of capacity to breath;
- irreversible cessation of cardiac and respiratory function;
- brain death (whole-brain death, and brainstem death); and
- the departure of the soul from the body.
Islam is not wholly agreed on the concept of brain death, but, on balance, the agreement favours whole-brain death. There is general support for an Islamic legal definition of brain death when the following conditions are met:
- total cessation of cardiac and respiratory functions, ruled as irreversible; and
- total cessation of all brain functions, and experienced specialised competent doctors have ruled that this is irreversible, and that the brain has started to disintegrate. 3
The diagnosis of brain death permits the physician to disconnect mechanical life support treatment. The difficulty, and a matter that does not nave full agreement under Islamic principles, is the agreed process for testing the patient to determine the cessation of all brain functions, or the evidence for the deterioration of the brain. If a strict approach is taken, in many situations, the diagnosis of brain death cannot be made, and this means that an organ cannot be harvested and transferred to a living patient.
While organ transplantation is permitted in the GCC , the transplant process is dependent upon having a brain-dead donor. By decision of the GCC Council of Health Ministers, GCC 4 states are required to establish uniform organ transplant laws and a GCC referral centre for transplants in the Kingdom of Saudi Arabia 5 whose responsibility will lie with the Saudi Center for Organ Transplantation.
GCC Federal laws
The principles for the rulings under Islamic laws have had a trickle-down effect into the laws of the GCC states. The current status of the laws are best illustrated in table A.
Significant steps have been taken towards coming to a consensus by Islamic scholars and under GCC State laws to ensure that patients’ wishes at the end-of-life stage of their care are taken into account to ensure their needs are met and at the same time providing legal protection for those medical practitioners at the forefront of dealing with these difficult cases.