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Editorial for the Journal of the Islamic Medical Association of North America 3rd November 2009 by Professor Omar Hasan Kasule Sr MB ChB (MUK), MPH (Harvard), DrPH (Harvard) Professor King Fahad Medical College Riyadh, Professor of Epidemiology and Islamic Medicine University of Brunei, and Visiting Professor of Epidemiology University of Malaya. EM omarkasule@yahoo.com WEB: http://omarkasule.tripod.com
Abstract
A DNR order would be a normal medical professional decision were it not be involving a host of ethico-legal considerations: certainty that further resuscitation is futile and is awast e of resources, informed consent by the patient or the proxies, and potential for abuse as a form of passive euthanasia. The author is of the view that a DNR order should be signed by an attending physician if 3 competent colleagues agree with his assessment of the need for it. It is preferable to get consent from the patient if competent and from family proxies if otherwise.
Key words: cardiopulmonary resuscitation, advanced cardiac life support.
The Do not Resuscitate (DNR) order is in essence a professional decision by the physician that no further intervention should be undertaken based on the doctrine of futility. It should not be based on a patient request without medical and scientific justification. DNR is however surrounded by so many related legal considerations that it ends up being highly controversial. These issues include: certainty about the futility of the resuscitation, waste of medical resources, what is the role of the family?, and the potential for abuse as a form of euthanasia. Additional issues arise in the technical details of the order: who makes the order, for how long is it binding?, and what is the exact technical formulation?. We shall analyze these issues using the Islamic Theory of Ethics based on the 5 Purposes of the Law, maqasid al shari'at[1], ethical principles based on the principles of the Law, qawa'id al fiqh[2], and other applicable Islamic legal provisions.
Certainty: A DNR order is legally valid if there is certainty that cardiopulmonary resuscitation (CPR) or advanced cardiac life support (ACLS) will have no nett benefit for the patient and that the patient will succumb again soon after the attempt. Islamic Law recognizes 4 levels of certainty the highest being absolute certainty, yaqiin, that is humanly difficult to achieve using existing knowledge and technology. The second highest legally termed as predominant conjecture, ghalabat al dhann, is the practical level at which decisions can be made. It is when there is preponderant clinical evidence that there will be no nett permanent benefit from the resuscitation. This evidence must be interpreted in the context of previous institutional experience that patients in such a condition had no nett and lasting benefit from CPR or ACLS. As an additional measure at least 4 specialist physicians familiar with such situations should concur before the attending physician signs the DNR order. Islamic Law considers 4 persons as a community, jama'at, so such a decision has the legal effect of being a binding communal consensus, ijma. or evidence that cannot be challenged.
Waste of resources:: Resuscitating a patient who will have no lasting nett benefit from the procedure is repugnant because it violates the 5th purpose of the Law which is preservation of resources, hifdh al mal. This is balanced against the second purpose of the Law that requires preservation of life, hifdh al nafs. In normal circumstances life takes precedence over resources but when the certainty of life is absent then consideration of preserving resources takes precedence.
Consent: DNR decisions are ordinary medical decisions by the attending physician that require informed consent by the patient or if incapacitated by a proxy decision-maker usually from the family. Informed consent is required under the principle of preventing harm, qa'idat al dharar, because only the patient and close relatives have the patient's best interests at heart. Patient consent and the DNR order need constant renewal preferably on a weekly basis. The order should be formulated according to guidelines set by each institution to be very exact in describing the conditions under which it will be applied. The family has an inherent interest in the welfare of the patient and can challenge the DNR order even if the patient consented. My view is that the family challenge should be respected. This should however never be interpreted to mean that the family have a right to impose a DNR order on an unwilling competent patient.
Abuse: The Islamic Law principle of intention, qa'idat al qasd, stipulates that actions are judged by the underlying intentions. A DNR order can be legal and permissible if the underlying intention is not to waste resources because of the futility of any further resuscitation. It is however illegal if based on other intentions such as when it is abused as an easy form of euthanasia by the patient, the physician, and the family. It may happen that all concur not to resuscitate a patient to save him or her from further suffering or pain which is euthanasia. Euthanasia is illegal because Islamic Law considers its active and passive forms as haram. It is however difficult to tell when the DNR order is genuine or is being used for euthanasia because the inner intentions and motivations of humans are knowable only to Allah. We as humans only judge by what we see or hear. If there is an expressed intention of committing euthanasia, then the DNR order become legally void and issuing or executing it becomes a legal infraction.
Conclusion: A DNR order is permissible in cases of a high degree of certainty that it resuscitation is futile and will not result in nett and lasting benefit for the patient.
[1] Imaam Abu Ishaq al Shatibi in his book. Al Muwafaqaat fi Usuul al Shari’at. Dar al Kitaab al ‘Aalamiyyat. Beirut. ? date
[2] Ali Ahmad al Nadawi. Al Qawa’id al Fiqhiyyat. Dar al Qalam Damascus 1412 Hijri / 1991 Nasrani