130101P - CONCEPTS OF LIFE AND HEALTH IN RELIGIOUS SPIRITUAL SUPPORT FOR PATIENTS

Presentation at the Spiritual Support Conference held at the King Fahad Medical City Riyadh 1-3 January 2013 by Prof Omar Hasan Kasule Sr MB ChB (MUK), MPH (Harvard), DrPH (Harvard) Department of bioethics Faculty of Medicine King Fahad Medical City, Riyadh Saudi Arabia.

Life from the tauhidi-based holistic integrative Islamic paradigm, shumuliyat al Islam, is a complex phenomenon with biological, chemical, and spiritual components. The relations among the components are governed by the physical laws, sunan al kawn, of balance, mizan, equilibrium, i’itidaal, and reciprocal action-reaction, tadafu’u. Humans share biological life with plants and animals and share spiritual life with angels. They are the only creation to have both biological and spiritual life at the same time. Human life devoid of spirituality is like animal or plant life.

Health (sihhat, raahat, ‘aafihat), is a positive and holistic state of well-being and not mere absence of disease or illness. It includes spiritual, physical, psychological, emotional, and psychological dimensions in holistic balance and equilibrium. The spiritual component is the most important and its impairment adversely affects all the other components. Holistic measures of quality of life and health must incorporate all the dimensions above.

The soul, ruh, the permanent and eternal essence of each human life, was created before Adam. Ensoulment, nafakh al ruh, occurs in intra-uterine life. It is a spiritual event that also sustains biological life; desoulment, naza’u al ruh, is followed rapidly by biological death. The limited knowledge of humans about the ruh is only from revelation, wahy. The Qur’an used several terms that seem to be referring to various manifestations of the same essence of human life: ruh, nafs, aql, naasiyat, lubb, dhihn, fuad etc, These can be mapped by experts in tafsir al Qur’an to spiritual, psychological, cognitive, emotional, and social modalities that professionals use in providing holistic spiritual support to patients.

Spiritually patients should be supported to reach calmness devoid of fear anxiety by accepting death as a transitional event from inferior life temporary on earth, hayat al duniyat, through the interregnum, hayat al barzakh, to the superior and eternal life in the hereafter, hayat al akhirat. Death is not a terminal event and neither does it break the reassuring direct communication between the human and the Creator.

Psychologically, the patient should be supported to ascend from the evil-inclined soul, nafs al ammarat, through the self-conscious soul, nafs lawaamat, to the high levels of the calm soul, nafs mutmainnat. At this level the patient bravely faces the suffering and pain of illness.

Cognitively the patient should be supported to appreciate illness as just one minor phenomenon in the wide and expanding spatio-temporal dimension of the universe and to appreciate that illness can have beneficial aspects such as forgiveness of sins and bringing out the best in the human who can overcome pain and suffering and stay calm and composed.

Emotionally the patient’s self-worth, self-esteem, and self-confidence to face the challenges of illness should be enhanced based on the superiority of human creation that overcomes innate weakness such as evil-doing fisk, and spilling blood, safk al dima, to become a vicegerent, khalifat, who with limited control of the universe, taskhiir, is able to build a material civilization, imarat al ardh.  

Socially the patient should be given support to live the remaining life with the highest quality of social relations with the family and the wider community.

130101P - CONCEPTS OF LIFE AND HEALTH IN RELIGIOUS SPIRITUAL SUPPORT FOR PATIENTS (Word Slides)

Presentation at the Religious Spiritual Support Conference held at the King Fahad Medical City Riyadh 1-3 January 2013

by Prof Omar Hasan Kasule Sr MB ChB (MUK), MPH (Harvard), DrPH (Harvard) Department of bioethics Faculty of Medicine King Fahad Medical City, Riyadh Saudi Arabia.

LIFE, hayaat

·         Life, from the tauhidi-based holistic integrative Islamic paradigm, shumuliyat al Islam, is a complex phenomenon with biological, chemical, social, psychological, and spiritual components.

·         The relations among the components of life are governed by the physical laws, sunan al kawn, of balance, mizan, equilibrium, i’itidaal, and reciprocal action-reaction, tadafu’u.

·         Humans share biological life with plants and animals and share spiritual life with angels.

·         Humans are the only creation to have both biological and spiritual life at the same time.

·         Human life devoid of spirituality is like animal or plant life.

HEALTH, sihhat, raahat, ‘aafihat

·         Health is a positive and holistic state of well-being and not mere absence of disease or illness.

·         Health includes spiritual, physical, psychological, emotional, and psychological dimensions in holistic balance and equilibrium.

·         The spiritual component is the most important and its impairment adversely affects all the other components.

·         Holistic measures of quality of life and health must incorporate all the dimensions above.

SOUL, ruh

·         The ruh, the permanent and eternal essence of each human life, was created before Adam.

·         Ensoulment, nafakh al ruh, occurs in intra-uterine life. It is a spiritual event that also sustains biological life; Desoulment, naza’u al ruh, is followed rapidly by biological death.

·         The limited knowledge of humans about the ruh is only from revelation, wahy.

·         The Qur’an used several terms that seem to be referring to various manifestations of the same essence of human life: ruh, nafs, aql, naasiyat, lubb, dhihn, fuad etc,

·         These terms can be mapped by experts in tafsir al Qur’an to spiritual, psychological, cognitive, emotional, and social modalities that professionals use in providing holistic spiritual support to patients.

SPIRITUAL SUPPORT, al da’am al ruhi

·         Patients should be supported to reach calmness devoid of fear or anxiety by accepting death as a transitional event

·         The transition is from inferior and temporary life on earth, hayat al duniyat, through the interregnum, hayat al barzakh, to the superior and eternal life in the hereafter, hayat al akhirat.

·         Death is not a terminal event and neither does it break the reassuring direct communication between the human and the Creator.

·         Of all links and relations that a human can have, it is only the link with Allah that persists after the disappearance of parents, siblings, children, spouses, friends, and enemies

PSYCHOLOGICAL SUPPORT, al da’am al nafsaani

·         The patient should be supported to ascend from the lowest to the highest levels of the nafs

·         From the evil-inclined soul, nafs al ammarat to the self-conscious soul, nafs lawaamat

·         From the self-conscious soul, nafs lawaamat to the high levels of the calm soul, nafs mutmainnat.

·         Nafs mutmainnat is described as raadhiyat, mardhiyat, qanuu’at

·         At this level the patient bravely faces the suffering and pain of illness.

COGNITIVE SUPPORT FOR THE PATIENT, al da’am al ma’arifi/al fikri

·         The patient should be supported to appreciate illness as just one minor phenomenon in the wide and expanding spatio-temporal dimension of the universe ‘aalamiin

·         The patient should be guided to appreciate that illness can have beneficial aspects such as forgiveness of sins and bringing out the best in the human who can overcome pain and suffering and stay calm and composed.

EMOTIONAL SUPPORT, al da’am al ‘aatifi

·         The patient’s self-worth, self-esteem, and self-confidence to face the challenges of illness should be enhanced

·         The patient should be aware of the superiority of human creation that overcomes innate weakness such as evil-doing fisk, and spilling blood, safk al dima, to become a vicegerent, khalifat, who with limited control of the universe, taskhiir, is able to build a material civilization, imarat al ardh.  

SOCIAL SUPPORT, al da’am al ijtima’e

·         The patient should be given support to live the remaining life with the highest quality of social relations with the family and the wider community.

·         Members of the family should be welcome as partners in patient care and should be treated as honored guests of the hospital with all the rights of the visitor, huquuq al dhaif.

·         The patient should be enabled to stay in contact with the outside community and not be confined to the 4 walls of the hospital room: news, visits, participation in radio talks etc

PHYSICAL SUPPORT, al da’am al maadi

·         The spiritual support professional cannot ignore the physical needs of the patient

·         The primary necessities, dharuraat, are those needed to preserve life like basic staple food and water

·         The needs, haajiyaat, bring emotional satisfaction like favorite dishes served in an attractive way

·         Embellishments, tahsiinaat, and complementaries, mukamillaat, are what are beyond the necessities and needs

CONCLUSION

·         Islam has concepts of life and health than can guide spiritual support for the patient

·         The multi-dimensional manifestations of the ruh require that spiritual support consider spiritual, psychological, emotional, social, and physical modalities of patient welfare

·         Little research has been carried out on spiritual support from the Islamic perspective

·         Because of its multi-dimensional aspects, spiritual support should be recognized as a separate profession that goes beyond religious guidance, irshaad diini.

130110P - BRAIN DEATH: CRITERIA, SIGNS, AND TESTS (Word Slides)

Presented at the Faculty of Medicine Bayero University, Kano, Nigeria on 10^th January 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

CASE #1:

·         A 60-year old comatose accident victim suffering from severe multi-organ traumatic injury and with a signed organ donation card was evaluated in the ERof a remote rural hospital. There was no other plausible cause of reversible coma or of brain death.

·         Clinically: no pupillary reflexes, fixedly-dilated pupils, no corneal reflex, no eye movements, no blink reflex, no vestibule-ocular reflex, no cranial reflexes, and no gag reflex. Findings were equivocal regarding the apnea test, cephalic reflexes, and motor response to pain.

·         Investigations: jugular vein partial oxygen pressure could not be determined. The EEG was isoelectric. Bedside trans-cranial Doppler showed no cerebral circulation.

·         Family members with the exception of the mother were certain of death and asked the physician not to institute any life support and to call the organ harvesting team. The doctor was not sure what to do he however convinced the family to start life support to keep the organs viable until the transplant team arrived by helicopter.

·         While walking along the corridor, a nurse overheard members of the family talking about a 15-year old cousin of the victim lying in a hospital in the capital waiting for a kidney transplant.

CASE #2:

·         A 40-year old billionaire stage 4 cancer victim with multi organ failure in ICU and on artificial life support

·         Determined clinically dead on the basis of clinical signs repeated after 6 hours (pupillary reflexes –ve, fixedly-dilated pupils, corneal reflex –ve, eye movements –ve, blink reflex –ve, cold water test –ve, cranial reflexes –ve, apnea test –ve, cephalic reflexes –ve, motor response to pain –ve, gag reflex –ve).

·         All confirmatory tests were also negative (jugular oxygen partial pressure -ve, EEG=0, CT angiography).

·         Family members begged the physicians not to withdraw life support and not declare death until his beloved last daughter arrives from London. She might die from shock if she does not see him alive before death. They were willing to pay for the extra days of ICU stay.

CASE #3

·         A 90-year old deeply comatose man with multiple organ failure was admitted to the last available ICU bed and was put on artificial life supportminutes when the family refused a DNR order.

·         A few minutes later ambulances started bringing in over 100 casualties from an air crash site. The head of the ICU carried out a rapid assessment of the comatose man showed equivocal clinical signs of brain death;some indicating death and others not. None of the confirmatory tests was positive.

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

3.0 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

·         1^st epoch: until ~1420H: direct reference to Qur’an and sunnah

·         2^nd epoch: 1420-14xx: use of qiyaas

·         3^rd 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 are 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.