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Presentation
at the Muslim Health Professionals Ramadhan Seminar Mombasa August 3, 2013 by Dr Omar Hasan Kasule MB ChB (MUK), MPH (Harvard), DrPH
(Harvard) Department of Bioethics King Fahad Medical City Riyadh EM: omarkasule@yahoo.com. WEB: www.omarkasule-tib.blogspot.com
NATURE OF DEATH
·
Death is a process
and not an event
·
Death is
failure of the heart and lungs to deliver oxygen and nutrients to cells
·
The brain is
the most sensitive organ to oxygen and nutrient deprivation and is therefore
the first to die
·
Death of the
brain leads to death of the vital centers that control the respiratory and the
cardiovascular systems
·
Brain is
Command-communication-coordination (CCC) center; its death signals loss of body
integrity and coordination
·
Cyclic
chicken-and-egg situation with few exceptions
INDICATORS OF DEATH
·
Historically3
indicators of death: neurological, respiratory, and cardiac
·
Neurological
failure (consciousness and coma) always came first.
·
Recognition of
brain death as an early indicator is not new
·
New indicators
are able to detect the point of irreversible vital organ failure earlier
·
As new
knowledge and technology are developed death can be detected earlier
·
Clinical tests
relate more to brain stem death
·
Confirmatory
tests relate more to whole brain death
·
Is the dichotomy
brain stem death vs whole brain death relevant?
ETHICS AND LAW
·
Ethics is about
morality right vs wrong
·
Law is about
legality legal (can be done) vs illegal (punishable)
·
In Islamic Law
morality = legality because shari’at is positive law + morality
·
In secular law
some moral things may be illegal and some immoral things may be legal
·
Strictly
speaking we should not have a term for ethics because it is included in the
shari’at
MOTIVATION OF BRAIN DEATH CRITERIA
·
al umuur bi
maqasidiha
·
al ‘ibrat fi al
maqasidwa al ma’aani la al alfaadhwa al mabaani
·
Three
motivations for brain death criteria:
o
harvest
transplantation organs earlier
o
save intensive
care resources by earlier cessation of life support
o
obtaining
tissues for research before deterioration.
USE OF CRITERIA IN DETERMINING BRAIN DEATH
·
1968: Harvard
criteria: apneic coma with no evidence of brain stem or spinal reflexes and a
flat electroencephalogram over a period of 24 hours.
·
No consensus on
brain death criteria: variation by country and by institution
·
Brain death
criteria change with time with new knowledge and new technology
·
Criteria
development coincided with rise of organ transplantation? Causal link.
CRITERIA OF BRAIN DEATH: CLINICAL TESTS
·
Eliminate
causes of reversible coma
·
Identify a
plausible cause of brain death
·
Tests related
to the eyes and ears
·
Tests related
to motor response
·
Tests related
to the cough or gag reflex
·
The apnea test
·
Repeat of the
examination within 24 hours
CERTAINTY OF DEATH: CONFIRMATORY TESTS
·
No consensus on
confirmatory instrumental tests
·
Tests done to
confirm clinical diagnosis
·
Chemical tests
of blood oxygenation
·
Tests related
to brain electric activity
·
Tests related
to brain blood flow
APPROACHES TO AN ETHICAL ISSUE
·
1st
epoch: until ~1420H: direct reference to Qur’an and sunnah
·
2nd
epoch: 1420-14xx: use of qiyaas
·
3rd
era: Use of maqasid and qawa’id al shari’at in ijtihad
·
Maqasid are not
new pioneered by Shaikh al Haramain, Abu Hamid al Ghazzali, IbnTaymiyah, and
Ibn al Qayyim al Jawziyat, Abu Ishaq al Shatibi al Maliki al Andalusi
·
Derived from
the sources by induction they provide an intellectual frame work to reason out
difficult situations
·
Qawaid are
axioms of the Law that facilitate logical ethical reasoning
THE 5 PURPOSES OF THE LAW, maqasid al shari’at
·
Protection of
morality, hifdh al ddiin
·
Protection of
life, hifdh al nafs
·
Protection of
the progeny/family, hifdh al nasl
·
Protection of
the mind, hifdh al ‘aql
·
Protection of
resourcesmhifdh al maal
THE 5 PRINCIPLES OF THE LAW, qawaid al shari’at
·
The principle
of intention, qa’idat al qasd
·
The principle
of certainty, qa’idat al yaqeen
·
The principle
of injury, qa’idat al dharar
·
The principle
of hardship, qa’idat al mashaqqat
·
The principle
of custom, qa’idat al ‘aadat
INTRODUCTION
·
Ethical issues
relating to brain death are analyzable according to the purposes of the Law, maqasid
al shari’at, and principles of the law, qawa’id al fiqh, to reach
conclusions of practical importance.
·
3 Motivation to
declare death earlier:
o
harvest viable
organs earlier
o
save intensive
care resources
o
obtaining
tissues for research before deterioration.
PRINCIPLE OF INTENTION, qa’idat al qasd
·
Violation of
the principle of intention, qa’idat al qasd, which requires that actions
be judged by underlying intentions and that the end does not justify the means.
·
Are these ends
noble enough to justify early death declaration by brain death?
o
Save the life
of the organ recipient?
o
Save resources
wasted by futile medical intervention?
o
Medical
research to advance knowledge?
PRINCIPLE OF CERTAINTY, qa’idat al yaqeen
·
The requirement,
by the principle of certainty, qa’idat al yaqeen, of evidence-based
proof of death is partially fulfilled by brain death criteria, tests, and
examinations.
·
There is almost
unanimous consensus on clinical tests in determining brain stem death but no
such consensus exists for confirmatory instrumental tests.
·
An individual
practitioner in charge of the patient may not be convinced by the signs and
tests
PRINCIPLE OF CUSTOM, qa’idat al ‘aadat
·
innamayu’utabar
al ‘aadatidhaatradat aw ghalabat
·
al ‘ibrat li al
ghaalib al shai’u la al naadir
·
Consensus on
clinical signs as indicators of brain stem death
·
The principle
of custom, qa’idat al ‘aadat, is partially fulfilled because there is no
universal consensus on criteria of brain deat
·
Brain death criteria
vary by country, by institution, and over time.
OUTSTANDING QUESTIONS…1
·
Do we do brain
death testing routinely or are we selective?
·
Is repetition
of the testing needed after 6, or 24 hours?
·
How soon shall
we act after brain stem death is confirmed clinically?
·
Relevance of
cerebral death vs brain stem death difference?
OUTSTANDING QUESTIONS…2
·
Feasible?(a)
other causes of reversible coma (b) plausible cause of brain death
·
Protection of
life, maqsadhifdh al nafs, vs and mistakes in death determination
·
protecting
resources, maqsadhifdh al mal, vs delayed death determination
·
Pressure for
organ donation: specific individual vs. general public
·
Near death vs
dead
CONCLUSIONS
·
The criteria
and determination of brain death do not fully conform to principles of
intention, certainty, and custom.
·
Considerations
of organ harvesting, ICU costs, and research have been a driving force behind
development of brain death criteria.
·
These criteria
have been changing with development of knowledge and technology and have not
reached the level of universal consensus having variation by country and by institution.
·
There is
consensus about the reliability of clinical tests of brain stem death
RECOMMENDATIONS
·
Brain stem
death, determined by clinical examination with or without instrumental
confirmation, should remain the mainstay of death definition
·
The public
interest in organ harvesting and saving ICU resources overrides the doubts that
we may have about clinical criteria of brain death
·
Legal rulings,
fatwa, on brain death should be reviewed every 3 years to take into
consideration new developments in medical knowledge and technology.