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Background material by Professor Omar Hasan Kasule Sr. for Year 2 Semester 1 Med PPSD session on 20th August 2008
1.0 CLINICAL PRACTICE GUIDELINES
Each hospital should have written guidelines on initiating, withholding, and withdrawing life support, conventional treatment, nutrition and hydration. The guidelines should specify what to do in cases of brain stem death and higher brain. In the presence of guidelines, the attending physicians will then have only the task of ascertaining the clinical and laboratory evidence before taking the necessary action. In cases of doubt and if there is time, 3 trusted specialist physicians should be consulted about the interpretation of the guidelines and the clinical and laboratory evidence. They should also be consulted if there are no written guidelines in the hospital. If there is doubt it is better to take the more conservative course of initiating and continuing the measures.
2.0 INITIATING ARTIFICIAL LIFE SUPPORT
Initiating life support can be obligatory (waajib), recommended (manduub), or undesirable (makruh). Initiating life support is waajib if there is net benefit to the patient. It is manduub if the benefit may be temporary and the patient will eventually succumb. In practical terms this means that life support can be started only for patients with intact brain stem function with a reasonable chance of recovery. It would be makruh to initiate life support for any reason not related to the patient’s medical condition such keeping the patient ‘alive’ to give time for organ harvesting or to delay declaration of legal death for personal or public interest.
3.0 WITHHOLDING ARTIFICIAL LIFE SUPPORT
Withholding life support may be permitted (jaiz), offensive (makruh), or prohibited (haram). Withholding life support is jaiz if there is clinical and laboratory evidence that it will produce no nett benefit to the patient. This helps avoid the later problems of withdrawal because withholding is psychologically easier than withdrawing. Under the Law the distinction between the withholding and withdrawal is minor because the intention and the consequences are the same. In practical terms life support should be withdrawn in cases of brain stem death. It should also be withdrawn in cases of imminent death to avoid waste of resources. It is makruh to withhold life support on the basis of poverty or advanced age of the patient. It is haram to withhold life support on the basis of discrimination according to race, caste, religion, or political beliefs. Life support cannot be withheld from an infant born with severe congenital disease on the grounds that even it survives it will not lead a normal life. The ruling on withholding life support for a persistently vegetative patient requires further discussion.
4.0 WITHDRAWING LIFE SUPPORT
Withdrawing life support can be permitted (jaiz) or prohibited (haram). Life support withdrawal is jaiz in case of clear death. If the brain stem is dead continuing life support is a waste of resources. Withdrawal of life support in such a case will free an intensive care bed for the next needy person. Withdrawing life support from a patient with a functioning brain stem on the basis of sparing him further pain and suffering is euthanasia and is clearly haram.