Applying Advanced Medical Directive

Islam allows its application in end-of-life decision-making, but there may be issues which have to be addressed

THE act of saving lives is considered one of the highest merits and imperatives in Islam. Doctors must do everything they can to prevent premature deaths.

But it ceases to be mandatory when death is imminent, and the available therapies are evaluated as futile. Islam recognises that there are times when a doctor needs to realise his own limits and let death take its natural course.

However, a few medical cases overseas, such as that of Karen Ann Quinlan and Nancy Cruzan, have shown that determining whether or not a patient should be disconnected from life support equipment is not an easy task. It leads to many ethical and moral disputes, especially when dealing with the patient’s family.

In order to address this challenge, a legal document known as the Advance Medical Directive ( AMD) was introduced in countries like the United States, Australia, England and Singapore to allow an individual to predetermine his or her future healthcare. It reflects one of the bioethical principles in healthcare, which is to respect the patient’s autonomy and self-determination.

AMD informs both the health care professionals and family members about an individual’s wishes and the type of care they wish to receive in case they cannot express themselves. This may help healthcare attendants in assessing the patient’s wishes should the patient later become mentally incompetent.

Therefore, AMD is expected to repel any disputes that may arise in the future should the patient lose his mental capacity or face permanent or prolonged unconsciousness. This is because AMD functions in specifying limitations concerning terminal care, including the withholding of cardiopulmonary resuscitation.

In the tradition of Prophet Muhammad, there are some instances that imply the legality of AMD. As narrated by al-Bukhari, when the Prophet was ill, he gave a directive that would conform to the concept of advance directive.

He instructed his wives not to give him a medicine known as ladood orally should he become unconscious, but his wives disobeyed. When he came around, the Prophet was upset with what they did.

This prophetic tradition points out two important matters. Firstly, Muslims are permitted to not receive a particular treatment, especially when they are suffering from an incurable illness.

Secondly, individuals who look after the patient should not force him to take a certain treatment, more so if he already expressed his refusal. The second point can be further elaborated in another prophetic tradition.

As narrated by al-Bukhari, a female companion came to see Prophet Muhammad and asked him to pray to God to cure the illness that she was suffering from. Prophet Muhammad said: “If you choose to be patient, then the reward for you is paradise, and if you want to be healed, I will pray to God to heal you.” The woman then said, “Then I will be patient.”

This prophetic tradition underscores the fundamental idea that each individual has autonomy in deciding whether he wants to be treated or to refuse treatment.

In general terms, Islam does not disapprove the application of AMD in end-of-life decision-making. However, the application of AMD may have certain limitations that must be addressed.

Islam grants freedom to Muslims to deal with their healthcare affairs based on what they believe to be in their best interest, but freedom is not granted in exercising the right to die. The manifestation of the right to die through unlawful acts such as mercy killing and physician assisted-suicide is strongly prohibited in Islam, as both acts are regarded as killing. Killing is a serious crime in both Islamic and conventional laws.

Besides that, respecting autonomy via AMD should not diminish the physician’s role in decision-making as an expert in the medical field. Many Islamic views stress the necessity of taking the judgment of experts into account.

Before any medical procedure is executed, it must undergo thorough medical evaluation and judgment of experts. Therefore, patients must consult doctors before they can carry out their right to self-determination.

There are many other challenges that require meticulous discussions among medical doctors, ethicists and jurists. They include the discussion on the patient’s mental capacity to make his healthcare choices. AMD requires a competent individual to make decisions on his future healthcare choices.

However, there are some cases where people have consented to medical procedures without clearly understanding the reasons and the effects of those procedures. Therefore, further research on AMD from every related aspect, including religion, must be carried out to engage these challenges.

For a country like Malaysia, if AMD is to be implemented, proper understanding and awareness should be created among the public. At the same time, religious and cultural sensitivities must also be addressed.

The role and expert view of the physician is crucial in providing the necessary information to patients or family members to allow them to make informed decisions in the best interest of the patient.

It is also equally important to have a standardised guideline for hospitals and doctors to apply AMD, should it be implemented. Acknowledging the fact that AMD will be a development that will impact healthcare in the future, Ikim has taken the initiative to conduct research since 2016 to provide the necessary Islamic input to stakeholders.

It is hoped that this research endeavour will assist in addressing the various ethical dilemmas pertaining to AMD. Mohammad Mustaqim Malek is a research officer with Ikim’s Centre for Science and Environment Studies. The views expressed here are entirely his own.