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Lecture given by Prof Omar Hasan Kasule at FOM KFMC on 18th April 2011
1.0 DEFINITION OF DEATH
Traditional definition of legal death: Death was traditionally defined as cessation of respiration, cessation of the heart beat, and loss of consciousness. It was possible to wait until these criteria of death manifested in a clear irreversible way. It is no longer possible to use those three criteria in the modern situation because of the pressure to declare legal death quickly in order to remove organs for transplantation or remove artificial life support equipment.
Irreversible brain stem death as a definition of legal death: Consensus has been reached in the medical profession that the death of the brain stem is an irreversible indicator of death. There is no record of even one case of recovery after irreversible brain stem death was diagnosed. When the brain stem dies, essential physiological functions of the body like respiration and blood circulation can only be maintained artificially. It is permissible to stop artificial life support if there is certainty, yaqiin, that the brain stem is dead irreversibly. There are clinical and laboratory criteria that can be used to diagnose brain stem death. To be sure at least 3 specialist doctors must confirm death of the brain stem before artificial life support is withdrawn. Artificial life support may be delayed in a brain stem dead person to prevent organs from deteriorating while preparing for transplantation. It may also be delayed to give a fetus more time to grow and be viable. There is no justification for delaying it for social or legal reasons. There is no difference in Law between withholding and withdrawing artificial life support in case of brain stem death, however withholding is psychologically more bearable than withdrawing.
Irreversible death of the higher brain: There is no consensus yet about definition of death as irreversible death of the upper brain. The upper brain’s functions are intellect, memory, sensory perception, and control of voluntary movements. These functions are lost irreversibly when the higher brain dies but the essential life functions of breathing, blood circulation, and nutrition can be maintained if the brain stem is still functioning either on its own or assisted by artificial life support. According to present-day medical technology nobody with irreversible death of the higher brain has ever recovered and death eventually ensures. There is however no consensus yet on withdrawing artificial life support in cases of unconscious people with dead upper brains but with other physiological functions intact. Cases of doubt should be referred to the judge for decision.
2.0 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.
3.0 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.
4.0 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.
5.0 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.
CASES ON LIFE SUPPORT IN TERMINAL ILLNESS
Case #22: A patient with brain stem death is kept on artificial life support at the insistence of the family because announcing the death immediately will have an adverse effect on the values of the family business on the stock exchange.
Case #23: The family took an unconscious man to hospital reluctantly because they believed he was dead. He was admitted to the ICU and was put on artificial life support. For a period of 4 weeks the family insisted on withdrawal of life support because they would be ruined financially by the high ICU costs. The physicians refused withdrawal of life support because his brain stem was functional. The patient woke up in the 5th week.
Case #24: A patient is brought to the emergency room after a car accident. The examining doctor found some signs of life but refused to institute life support because he was convinced it was futile. The patient died a few minutes later. The accompanying family members were furious and accused the doctor of negligence. They threatened to sue. The doctor advised them to wait for results of the postmortem examination that would show that death was inevitable. They refused to have any postmortem because it was against their religious beliefs.
Case #25: A patient admitted to the ICU after a car accident was confirmed by 3 specialist surgeons to be in a persistent vegetative state. The doctors wanted to discontinue life support but the family refused because there were signs of life like reflex flexion of joints and blinking of the eyes. The hospital decided to seek a court injunction after keeping the patient in the ICU for 6 months without any obvious improvement.