Due to advancement and innovations in biotechnologies lunch genetic screening applications of stem cell in medicine and sophioticated life- support technologies, many bioethical challenges have been raised. Advances in medicine have greatly improved possibilities to treat seriously ill patients and to prolong life. Medical decision-making for patients with life-threatening diseases increasingly entails a balanced consideration of medical, ethical, psychosocial, and societal aspects.
Currently, end of life issues are one of the top 10 health care ethics challenges facing the public. Euthanasia, withholding and withdrawing treatments, physician-assisted suicide, do not resuscitate (DNR) orders, advance care planning, refusal of treatments, consent, quality of end of life care and advance directives are the main debates in this field.
In this paper, we have discussed briefly the main ethical issues of ending life in brief, including the religious. We have also applied a case-based approach to clarify Islamic perspective on the issues.
There are many complex ethical issues that can affect patients and families in the health care setting. Advances in medicine have greatly improved possibilities to treat seriously ill patients and to prolong life. However, their advances in modern medical technology have blurred many of the lines and distinctions that once seemed so clear; including life and death. Currently, end of life issues are one of the top 10 health care ethics challenges facing the public.1
End-of-life care also depletes 10%–12% of total health care costs in USA2,3.
Decision making in terminal care is a demanding and stressful duty for all involved that can take place in any setting in which patients die in hospitals, nursing homes, hospices, and at home. End of life care is an emerging field in all countries, irrespective of their economical, cultural, or religious backgrounds.
Studies of attitudes of medical professionals towards end of life decision-making have been undertaken in many countries.4,8 Currently, euthanasia is performed worldwide, regardless of the existence of laws governing it. The Netherlands and Belgium became the first countries in the world to enact a law on euthanasia.9,10 There are different policies and rules in this issue in some countries.11,13
In this manuscript, we intend to review the main ethical issues in the challengeable field of end of life, considering the Islamic viewpoints. For compilation of the article, we searched articles in Google and Ovid search engines, PubMed, and IranMedex sources by using appropriate keywords. We also referred to some English and Farsi books in this field and articles referenced in other sources. We have applied a case- based approach to clarify the issues according to Islamic perspectives.
Definition of Death
Human death definition was much easier in past eras than now. When our heart or lungs stopped working, we died. Sometimes our brain stopped before our heart and lungs did, sometimes after. But the cessation of these vital organs occurred close together in time.14 With advances in life support, the line between who is alive and who is dead has become blurred.15 Life support technologies introduced in the
20th century have generated a new kind of patient, one whose brain does not function, but whose heart and lungs continue to work. Thus, we need to define death in order to be able to declare a person physically and legally is dead.14 In the United States of America, the Uniform Determination of Death Act (UDDA), written in 1981, confronts the complexities concerning the declaration of death.16 The UDDA states that a person can be declared dead when either the heart and lungs or the brain and brain stem stop functioning permanently.16
Advocates working to improve care for dying patients try to determine what elements are necessary for a “good death” to take place. Common elements of a good death have been identified as the following.17,19:
- Adequate pain and symptom managements,
- Avoiding a prolonged dying process,
- Clear communication about decisions by patient, family and physician,
- Adequate preparation for death, for both patient and loved ones,
- Feeling a sense of control,
- Finding a spiritual or emotional sense of completion,
- Affirming the patient as a unique and worthy person,
- Strengthening relationships with loved ones,Not being alone.
- As mentioned, a good care for dying patients encompasses attention to spiritual issues at the end of life.20
MAIN ETHICAL CHALLENGES
Case 1: A middle-aged woman diagnosed with acute myelogenous leukemia has refused chemotherapy for her condition. She is educated, articulate and quite aware that she will certainly die without treatment. She is upset by her diagnosis, but is not depressed. Her close family wishes she would accept treatment because they do not want her to die, but even so, they honor her refusal. She understands that her death will likely be painful and may be prolonged and requests a supply of barbiturates that she might use to take her life when the appropriate time comes.
ªWhat is an appropriate course of action?
For people reaching and the end of life, continuing to suffer may appear worse than death. The suffering can be so great that the option of ending one’s life through either euthanasia or physician assisted suicide may appear to be a reasonable and merciful choice.14
Euthanasia and assisted suicide involve taking deliberate action to end or assist in ending the life of another person on compassionate grounds.7
There are some terms in this issue that are mentioned in Table 1. Euthanasia is an act where a third party, usually implied to be a physician, terminates the life of a person; either passively or actively.14 The modern concept of euthanasia came into being in the 20th century after the invention of life-extending technologies.14
With physician assisted suicide, a doctor provides a patient with a prescription for drugs that a patient could use to end his or her life.14 The main distinction between physician assisted suicide and active euthanasia is that the doctor is not the person physically administering the drugs.
Physician assisted suicide is only contemplated by patients who are conscious and capable of making their own decisions.14 Oregon is the only state in the U.S. that has a law that allows physician assisted suicide.14