Transcript Biomedical Ethics

Principles in Biomedical
and Islamic Medical Ethics
Shahid Athar, MD,FACP
Past Chair, Medical Ethics
Islamic Medical Association of North America
www.IMANA.org
Presented at
IMANA/ Hofstra University
Sept.18 , 2010
The Disclaimer
1. I am on speaker’s bureau of several
pharmaceutical companies, however, this
CME presentation is not financially
supported by any of them.
2. I am not a mufti (Islamic scholar qualified
to give fatwa or religious decree).
“Blessed is He, in Whose Hands is the
Sovereignty , and He is able to all things.
Who has created death and life that He
may test you ,which of you is best in
conduct and He is the Mighty and the
Forgiving.”
Quran 67: 1-2
Presentation Objectives
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Principles of Biomedical Ethics
Principles of Islamic Medical Ethics
IMANA’s position on End of Life issues
An interfaith perspective on EOL issues
Case presentations and discussions
End of Life Concerns …..
• When can we stop medical care?
• Life support of patients on dialysis,
chemotherapy and ventilators?
• Withholding of tube feeding and TPN?
• Organ donation and transplantation?
• Palliative care (pain medications,
sedation) in terminally ill patients?
• Need for Living Will and Advance Directive
What is Medical Ethics?
“Medical Ethics is a decision making
process , not all black or all white, or all
right or all wrong, but in gray areas,
choosing a better option over a worse one.
The difference between what can be done
and what should be done is the reason for
Medical Ethics”
Questions in Ethics
• Ethics vs. Morality – are both same?
• Religious vs Secular Ethics
• If the patient is unable to speak for
himself- then who guards his interest?
(family, MD, State)
• When the family and caregiver’s views
clash –whose views be taken?
• When caregiver and the patient have
different faith/ values- how do they
reconcile?
The Principles of Medical Ethics
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Preserve life
Promote and restore health
Alleviate suffering
Respect patient’s autonomy
Distributive justice
Tell the truth
Do no harm
Some Ethical Terms Explained…
• Respect for autonomy:
“ people are autonomous in decision making
for themselves if they are able to
understand the options and do it
voluntarily. This principle requires informed
consent”
Beneficence
• This principle obliges persons to benefit or
help others. It 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.
Nonmaleficence
• This principle obliges persons to refrain
from harming others, including to refrain
from cruelty and torture.
• This is a principle of non-intervention. It
requires persons to exercise due care that
they do not unintentionally harm others
through their actions such reckless
interventions or procedures.
Distributive Justice
• This principle requires a fair distribution of
benefits and burdens. It requires that
persons receive that which they deserve.
This principle is involved in decisions to
allocate scarce health resources such as
use of ICU beds and ventilators in case of
a pandemic.
Some Arabic (Islamic) Terms..
• Darura (necessity): over rides prohibition
• Fitra : (the built in good human nature)
• Istihsan :(juristic preference between two
or more valid judgments .
• Maslaha (public good)
• Marsalih al mursala (public good derived
from reasoning)
• Sunnah (traditions of Prophet Mohammad)
The Place of Ijtehad (reasoning)
“ Moaz ibn Jabal (r) was asked by Prophet
Muhammad (p) before sending him to Yemen
,“on what basis he will judge cases ?”, he replied
“Quran”. The Prophet asked ”and if you cannot
find the answer in Quran, then ?”, Moaz said “
the sunnah of the messenger of Allah”. The
Prophet asked" and if you cannot find the
answer there either”, Moaz said , “Then I will
make every attempt with my own opinion to
make a right decision”. The Prophet (p) was
delighted and said “ Praise be to Allah who has
guided the envoy of the messenger of Allah”
Goals of Shariah (Islamic Laws):
• Preservation and protection of life
• Preservation and protection of mind
• Preservation and protection of private
ownership
• Protection of the freedom of religion
• Protection and preservation of progeny
Rules of Islamic Medical Ethics
• Necessity overrides the prohibition
• Accept the lessor of the two harms if
both cannot be avoided
• Public interest overrides individual
interest
• Harm has to be removed
The rule of “No harm, no harassment”
(la dararar was la dirar fi al- Islam)
• Actions are judged on intentions- hadith
• Hardship necessitates relief
• One needs certainty: how was the present
doubtful situation resolved in the past?
• Harm has to be removed/ take lesser of
two evils
• Local customs determine the course of
action
End of Life issues
An Interfaith Perspective
“Most Religions believe in life and health as
gifts from God and uphold the sanctity of
human life as well as dignity for the dying
person” (Lancet Sept.2005)
Diversity is the recognition
and respect for the values of the Other
“Our first task in approaching another
people, another culture and another
religion is to take off our shoes first for the
place we are approaching is holy, else we
may find ourselves treading on another’s
dream. More seriously still, we may forget
that God was there before we arrived”
End of life-the Buddhist view
• Death is an integral part of life by virtue of belief
in incarnation
• Death is an experience that everyone will go
through many times.
• Brain death is not accepted by all Buddhists
especially Japanese
• Nutrition and hydration should continue in
persistent vegetative state
• Euthanasia is rejected by most Buddhists
• Withdrawal of intervention when end is near is
not immoral
End of life-a Hindu view
• Life is a transition between previous one and next one
• Karma explains inequity and suffering in this life and
affects next life.
• A good death is on right time , in right place , prepared
and mind on God
• The family has a sacred duty to help the dying before
and after death.
• Suicide is frowned upon but voluntary euthanasia for
spiritually advanced is accepted
• Involuntary euthanasia is justified to prevent extreme
suffering
End of life- a Jewish perspective
• The body belongs to God
• Humans have both permission and obligation to heal.
• Humans have no right to commit suicide or enlist the aid
of others in the act.
• A patient has a right to pray to God for death to end
his/her suffering
• Criteria for death is cessation of breathing and heart
beat.
• Heroic measures are allowed if there is hope for cure ,
comfort care must continue
• Visiting the sick is an obligation.
End of life –a Catholic view
• Life is a sacred gift from God and has an
intrinsic worth
• Understanding of sickness and death is
grounded in belief that Jesus suffered, died and
was resurrected
• Human dignity and interdependence are of
supreme value
• The value of stewardship and creativity holds us
accountable to God
• The value of charity demands us to respond to
others in need especially the poor.
End of life issues-a traditional
Christian view
• The pursuit of eternal life through
repentance and pursuit of holiness through
humble submission to God
• Values within traditional Christians are
diverse
• Intending and causing death is not allowed
• Salvation through Jesus is a core belief
End of life- a secular view
• Atheists regard God as a human creation
• Care is directed towards need of the
individual
• Ignoring need is a form of discrimination
• This life is all there is and death is the end
of life
• Keep religion out of health care and
hospital environment
Case 1: DNR and family conflict
(JAMA 2009 ;11:582-588)
• A 63 year old visitor from Lebanon here for an
elective surgery had MI and coded. He is on MV
now. The neurologist does not think he will
recover. His son signs a DNR but his elder
brother back home does not agree and wants
full code. Patient’s wife back home is not
informed of what is her husband’s condition.
• What should his (non Muslim) physician do?
Case : 2
• 70 year old lady had surgery for a ruptured
appendix 2 years ago
• Diagnosed 1 month earlier with poorly
differentiated adenocarcinoma of the right lung
with significant bilateral paratracheal
adenopathy
• She elected no chemo or radiation therapy
Case 2 continued.
• Properly executed a DNR form stating no tubes
in throat and no Mechanical Ventilation
• Copy placed on chart
• Presented with fever, tachycardia, abdominal
pain, significant abdominal distension
• Mechanical intestinal obstruction
• Surgeon recommended immediate laporotomy
Case 2 continued
• Anesthesiologist: patient would require GA,
intubation and likely MV; possible treatment of
arrhythmia and hypotension – i.e. resuscitative
measures
• Surgeon: problem is temporary and can be
corrected
• How should we respond to the conflict between
anesthesiologist and surgeon?
• How should we address patient’s autonomy?
Case # 3- Who can consent?
DM , a 25 year old , pregnant immigrant
woman , is brought to ER in acute abdominal
pain. She is examined in the presence of her
husband and a tubal pregnancy is
diagnosed.
Although , she can speak English , her
husband answers all the questions and when
it comes to taking consent before the
treatment (operation vs medical) , he insists
he should give the consent saying “ I speak
for her ”
Q. After a massive brain hemorrhage, my
mother is in a coma and is on artificial life
support. Her physician says there is no
hope of survival and wants to pull the plug.
We love her very much. What should we
do?
Question from a physician .
“ As a physician, when I find out that my
patient has a terminal illness and will die
very soon. should I tell the truth to my
patient and his family as soon as I know
myself?”. My patient is from Middle East
where they do not tell diagnosis to an
elderly dying person
Q, My grandfather never took care of his
diabetes. Now he has developed
gangrene in his foot. Doctors recommend
amputation to save the rest of his leg. He
refuses. What should we do?
For the wind that blows the sail is the mind
But the faith in the heart is the compass to guide
And what is the eyesight if heart is blind?
Lo! We all look so good. But what is inside?
Who is right? Who is wrong? Only God will decide
Late Dr. Hassan Hathout, the Islamic ethicist
“To Allah belongs the East & the West”
Selected References
3. Hassan Hathout , “Reading The Muslim Mind”
4. Abdulaziz Sachedina: Islamic Biomedical Ethics
5. Shahid Athar, “Islamic Perspectives in Medicine”
6. Shahid Athar, “Health Concerns for Believers”
7. Islamic Code Of Medical Ethics (IOMS-Kuwait)
8. 2002 year book on Ethics published by FIMA.
Websites for Islamic Medicine
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www.imana.org
www.IIIM.org
www.islamset.com (IOMS website)
www.islamonline.net
www.islamicmedicine.org
www.islam-usa.com
([email protected])
The Disclaimer
I am on speaker’s bureau of several
pharmaceutical companies, however, this
CME presentation is not financially
supported by any of them
Shalom (Salaam, Peace)