Ethical health promotion paper
ORIGINAL PAPER
Religious, Ethical and Legal Considerations in End-of-
Life Issues: Fundamental Requisites for Medical Decision
Making
Puteri Nemie Jahn Kassim •Fadhlina Alias
Published online: 10 January 2015 Springer Science+Business Media New York 2015
Abstract Religion and spirituality have always played a major and intervening role in a
person’s life and health matters. With the in uential development of patient autonomy and the
right to self-determination, a patient’s religious af liation constitutes a key component in
medical decision making. This is particularly pertinent in issues involving end-of-life deci-
sions such as withdrawing and withholding treatment, medical futility, nutritional feeding
and do-not-resuscitate orders. These issues affect not only the patient’s values and beliefs, but
also the family unit and members of the medical profession. The law also plays an intervening
role in resolving con icts between the sanctity of life and quality of life that are very much
pronounced in this aspect of healthcare. Thus, the medical profession in dealing with the
inherent ethical and legal dilemmas needs to be sensitive not only to patients’ varying
religious beliefs and cultural values, but also to the developing legal and ethical standards as
well. There is a need for the medical profession to be guided on the ethical obligations, legal
demands and religious expectations prior to handling dif cult end-of-life decisions. The
development of comprehensive ethical codes in congruence with developing legal standards
may offer clear guidance to the medical profession in making sound medical decisions.
Keywords End-of-life decisions Religious considerations Ethical dilemmas
Legal standards
Introduction
Technological and pharmacological advances in medicine have created more challenges to
healthcare professionals as modern medical interventions progress to increase life
P. N. Jahn Kassim ( &) Civil Law Department, Ahmad Ibrahim Kulliyyah of Laws, International Islamic University Malaysia, 53100 Kuala Lumpur, Malaysia e-mail: [email protected]
F. Alias Ahmad Ibrahim Kulliyyah of Laws, International Islamic University Malaysia, 53100 Kuala Lumpur,Malaysia
123
J Relig Health (2016) 55:119–134 DOI 10.1007/s10943-014-9995-z expectancy of terminally ill patients. These life-prolonging measures have made end-of-
life care an emerging aspect in the medical eld. Decisions at the end of life are no longer
con ned to clinical assessments as to what would be in the best interests of the patient from
a purely medical perspective, but involve due consideration of a patient’s religious beliefs,
customs and values, which ultimately have signi cant in uence on a patient’s response to
illness, suffering and dying. Furthermore, the decision-making process also affects
healthcare providers, particularly if the doctor and patient come from diverse cultural
backgrounds and adhere to different sets of values. The con icting ethical views and
developing legal standards in this area on matters concerning the sanctity and quality of
life, patient autonomy and medical paternalism have also made end-of-life decisions an on-
going debate (Agarwal and Murinson2012; Billings and Krakauer2011; Cantor2005;
Chin2002; da Rocha2009; Huxtable2002; Kuhse1981; Orentlicher1998; Rabiu and
Sugand2014). In any event, all affected parties carry with them their own individual life
experiences, values and beliefs to the decision-making process; accordingly, the event of
death itself, the manner in which it takes place, and the patient’s quality of life are
signi cant matters that have spiritual and psychological consequences for each of them.
The Importance of Ethics, Religion and Law as Guidance for Medical Decision
Making
Ethics is classi ed as a sub-branch of applied philosophy that is intrinsically related to
morality (Padela2007). The correlation between ethics and morality is that morality refers
to social norms that distinguish from right to wrong, while ethics describes moral conduct
based on the character and principles in each profession (Elsayed and Ahmed2009).
Medical ethics is a subdivision of ethics that is concerned with moral principles as they
relate to biomedical science in the clinical and investigational arenas (Padela2007).
Ethical principles are essential in helping to guide medical judgements that need to be
made and should be intrinsically linked to the application of clinical skills and knowledge,
which are used for delivering what is in the best interests of the patient (Tallon2012).
Accordingly, medicine and morality are thus very much interrelated, as the primary
function of medicine is not only ‘‘to cure illness…but to cure people of their illnesses’’
(Steinberg2003). The importance of observing medical ethics can be outlined as follows:
(1) ethical standards promote the aim of medical care; (2) medical care is built on the
communication, trust and respect between the medical team on the one side, and the patient
and/or family on the other side; (3) ethical standards help generate public support for
healthcare; (4) public awareness and support for healthcare will promote ethical conduct by
healthcare providers in the performance of their duties; and (5) ethical standards promote
moral and social values and facilitate cooperation and collaborative work between different
medical disciplines, leading to a healthy healthcare environment (Elsayed and Ahmed
2009). All existing medical codes of ethics directly and indirectly incorporate into their
provisions the fundamental principles which form the ethical basis of medical care, i.e.
autonomy, paternalism, non-male cence, bene cence and justice.
In recognition of the fact that culture and its components of religion and spirituality
constitute major social factors that greatly in uence the provision of medical care, espe-
cially at the end of life, some countries have also expressly included these components in
their ethical codes. For example, the Good Medical Practice: a code of conduct for doctors
in Australia issued by the Medical Board of Australia (‘‘GMC’’) contains provisions on
‘‘Culturally Safe and Sensitive Practice’’ which state that ‘‘good medical practice involves
120 J Relig Health (2016) 55:119–134
123 genuine efforts to understand the cultural needs and contexts of different patients to obtain
good health outcomes’’ which includes: (1) having knowledge of, respect for and sensi-
tivity towards the cultural needs of the community that one serves, including those of
indigenous Australians; (2) acknowledging the social, economic, cultural and behavioural
factors in uencing health, both at individual and population levels; and (3) understanding
that one’s own culture and beliefs in uence one’s interactions with patients (Medical
Board of Australia n.d.; Medical Council of New Zealand2013). Furthermore, in Clause
3.12 of the GMC, which deals with end-of-life care, respect and support for the values and
wishes of the patient and family members are emphasised, including ‘‘different cultural
practices related to death and dying’’ (Medical Board of Australia n.d.).
Cultural competence, i.e. the acquisition of the knowledge and skills that enhance the
management of cultural issues in the clinical environment requires skilled verbal and non-
verbal communication as a means of appreciating differences (Carey and Cosgrove2006).
Better healthcare especially at the end of life can only be achieved if these factors are given
due consideration as medicine does not merely deal with elements of pure science, but also
major and intrinsic humanistic and ethical components (Steinberg2003). In Part 3 of the
End of Life Care Strategy issued by the Department of Health in the UK (UK Department
of Health2008), guidelines are provided to address the spiritual needs of patients nearing
the end of life. This is complemented by the NHS Chaplaincy (UK Department of Health
2003), which acts as a guidance to those involved in the provision of chaplaincy-spiritual
services. It is submitted however that the content of the End of Life Care Strategy and NHS
Chaplaincy, while respecting and recognising the importance of religious and spiritual
considerations in end-of-life care, is not intended to speci cally provide an understanding
of the different values and beliefs on end-of-life issues. It is noteworthy that the
Queensland Health Multicultural Services in collaboration with the Islamic Council of
Queensland has published a series of handbooks for healthcare providers in attending to
Muslim, Hindu and Sikh patients, respectively (Queensland Health and Islamic Council of
Queensland n.d.,2010,2011). Speci c areas covered in the handbooks include religious
approaches to end-of-life issues, pain management and the concept of death and dying.
These are intended to support healthcare providers by building their knowledge of the
diverse needs of their patients, noting that ‘‘those who display cross-cultural capabilities in
their work use self-re ection, cultural understanding, contextual understanding, commu-
nication and collaboration to provide culturally appropriate, responsive and safe health
care’’ (Queensland Health and Islamic Council of Queensland n.d.,2010,2011).
In addition to the above, an integrated effort to develop a codi ed religious-based
system of ethical conduct can also be seen in the form of the Islamic Code of Medical
Ethics (First International Conference on Islamic Medicine1981) (‘‘Islamic Code’’), which
was drawn up and adopted at the First International Conference on Islamic Medicine in
1981. The Islamic Code aims to provide a guideline to Muslim doctors in understanding
the tenets of Islam, which are relevant to the performance of their duties. The Islamic Code
cites authorities from theShari‘ahand provides the Islamic perspective on an array of
subject matters concerning medical care, including end-of-life issues such as the preser-
vation of life, the refusal of a patient to a prescribed plan of treatment, medical inter-
ventions and futile therapy. In addition, the duty to respect the autonomy of the patient, as
well as the obligation to ensure that harm is prevented (non-male cence), and medical
decisions are made to the bene t and best interests of the patient (bene cence), are inherent
ethical values in the Islamic Code. The extent of application of the Islamic Code in
healthcare policies and legislation of countries populated by Muslims, however, are of
varying degrees from one country to the next.
J Relig Health (2016) 55:119–134 121
123 In general, the majority of Arab countries emphasise the importance of healthcare
professionals to respect human dignity, provide the best care available to patients and their
families, as well as protecting their rights, safety and con dentiality (UNESCO Cairo
Of ce2011). Countries such as Jordan, Libya and Indonesia have gone further in their
efforts to take steps to include guidelines pertaining to certain end-of-life decisions in their
regulatory framework (Majelis Kehormatan Etik Kedokteran Indonesia2001; UNESCO
Cairo Of ce2011), while in other countries such as Malaysia and the UAE, the extent of
application of Islamic principles in the same area is uncertain, as speci c provisions on the
subject matter have yet to be incorporated in their respective laws or ethical codes
(Malaysian Medical Association2002; UNESCO Cairo Of ce2011).
The intervention of law in the area of medicine has been regarded as pivotal, particu-
larly in offering clear guidance in issues that raise ethical, philosophical and religious
dilemmas. The law has been seen as a means of controlling the medical profession in the
interests of the community as a whole. As advocated by Lord Hoffman in Airedale NHS
Trust v Bland (‘‘Airedale NHS Trust v. Bland’’1993), ‘‘…medical ethics [is] to be formed
by the law rather than the reverse’’ (‘‘Airedale NHS Trust v. Bland’’1993). However, legal
intervention in itself may cause problems particularly when the courts may nd themselves
drawn in to act as mediators in complex and frequently distressing clinical matters. In any
event, judges have to make decisions to protect public policy and do justice to both the
patient and the doctor.
The judicial courts in Malaysia have yet to decide on issues involving end-of-life
decisions; thus, at the moment, such matters are considered to be purely medical decisions
(Kassim and Adeniyi2010; Talib2002). As the law in this area has yet to reach its fullest
extent, the developments in countries such as the UK and the USA have been able to shed
light on how con icting ethical principles are resolved by the courts and the application of
different tests in their decisions. Accordingly, their experience would provide invaluable
lessons for Malaysia to develop holistic ethical codes that are in congruence with devel-
oping legal standards. This is because by virtue of section 3 of the Civil Law Act 1956, due
to the lacunae in Malaysian law on end-of-life decisions, English common law and the
rules of equity would be applicable as a source of reference for the courts.
The Scope of End-of-Life Care
End-of-life care refers to the health and social care system required to address the physical,
social, spiritual and emotional needs of patients who are in the nal stages of their lives as
well as those who are af icted with terminal illnesses (Colello et al.2011; Tallon2012).
From the healthcare perspective, end-of-life care encompasses both palliative care and
hospice care, which aim to provide a comfortable environment to restore and improve
patients’ quality of life as far as it is practically possible (Centre for Bioethics2005; Chater
and Tsai2008; Tallon2012). The World Health Organization de nes palliative care as ‘‘an
approach that improves the quality of life of patients and their families facing the problem
associated with life-threatening illness, through the prevention and relief of suffering by
means of early identi cation and impeccable assessment and treatment of pain and other
problems, physical, psychosocial and spiritual’’ (World Health Organisation n.d.).
Although both palliative care and hospice care share the same objectives, these two
areas should not be confused with one another. Palliative care focuses on reducing the
severity of disease symptoms for patients who are seriously ill, and can be delivered along
with curative treatment at any time during the course of the patient’s illness (Centre for
122 J Relig Health (2016) 55:119–134
123 Bioethics2005; Colello et al.2011). In addition, palliative care is not restricted to patients
near the end of life and can be used in both acute and long-term settings (Centre for
Bioethics2005). Hospice care on the other hand is focused on terminally ill patients, who
no longer seek curative medical treatment, and is generally offered when the patient is
expected to live for 6 months or less (Colello et al.2011). A salient similarity between
palliative care and hospice care is that both involve the mobilisation of an interdisciplinary
team of professionals comprising doctors, nurses, social workers and psychologists, with
the assistance of chaplains, nutritionists, pharmacists and others (Centre for Bioethics
2005; Colello et al.2011).
The Ethical Considerations in End-of-Life Care
Con icting ethical values between healthcare providers and patients may impede the
decision-making process in end-of-life care (Carey and Cosgrove2006; Chater and Tsai
2008; Mazanec and Tyler2003). On the part of the healthcare provider, respecting the
patient’s autonomy in the decision-making process may at times be inconsistent with the
performance of their ethical obligations of bene cence and non-male cence. Ethical
challenges are further compounded in cases where the patient is incapable of interaction
and deciding for himself, whereby family members would stand in as proxy to decide what
would have likely been the wishes of the patient pertaining to a certain course of action.
The ethical considerations in end-of-life care which have raised ethical dilemmas can be
looked at from three aspects:
Withholding and Withdrawal of Medical Interventions
Medical interventions such as resuscitation, ventilators and the use of antibiotics in cases of
infection may operate to save and prolong the life of a terminally ill patient. However, such
treatments may run counter to the patient’s wishes who may request that the same be
withdrawn or refuse them altogether. For example, some patients may view cardiopul-
monary resuscitation as a death-delaying act, which contradicts with their values and
beliefs that one should not alter the course of nature (Markwell2005; Mazanec and Tyler
2003; Sachedina2005). In cases where the condition of the patient necessitates respiratory
therapy, some patients and family members may view it as a non-bene cial treatment
which only serves to impede in what they believe should be the natural process of dying
(Centre for Bioethics2005). Consequently, such patients or their family members may
seek a do-not-resuscitate order from their doctor. In such circumstances, doctors are
confronted with ethical dilemmas on whether to adhere to the patient’s and family
members’ wishes or to decide on what is the best course of action for the patient. For
example, if the decision to withdraw treatment is carried out and death is thereby hastened,
would this action violate the ethical principal of non-male cence which demands that
actions taken must prevent harm to the patient? Nevertheless, it has also been argued that it
is permissible to withhold or withdraw treatment and allow the disease process to progress
to a natural death for the patient (Kinsella and Booth2007). However, any decision to
withhold or withdraw treatment should be based upon the expectation that the patient can
no longer bene t from that treatment, it is medically futile and the doctor’s intention when
doing so must be to relieve the patient of the burdens associated with that treatment
(Kinsella and Booth2007).
J Relig Health (2016) 55:119–134 123
123 Withdrawing medical treatment has always been seen as acceptable as there is a clear
distinction between positive acts and omissions. According to the acts–omissions dis-
tinction, ‘‘in certain contexts, failure to perform an act, with foreseen bad consequences of
that failure, is morally less bad than to perform a different act which has the identical
foreseen consequences. It is worse to kill someone than to let them die’’ (Glover1977).
Thus, acting to kill a patient even for good reasons may seem wrong, whereas omitting to
act by withholding life-saving treatment may seem right in certain compelling circum-
stances. It follows that permitting an illness to progress naturally, as opposed to making
something happen by acting intentionally, appears to be more acceptable legally and
ethically (Glover1977; McLachlan2008).
Medical Futility
Medical futility is described as an intervention that will not be able to reach the intended
goal of the intervention (Cavalieri2001). This usually occurs during assessments on
whether to forego or withdraw life-sustaining treatments (Centre for Bioethics2005). The
determination of medical futility raises ethical concerns, particularly, on the reasons for
considering the treatment as futile. The fact that such decision rests solely in the hands of
the healthcare providers may lead to possibilities of the discretion being exercised arbi-
trarily. For instance, medical treatment may be discontinued not only because it no longer
bene ts the patient, but such continuation may be considered futile in order to save cost
(Centre for Bioethics2005; Zahedi et al.2007). Further, discontinuation of life-sustaining
treatments particularly arti cial nutrition and hydration causes a great deal of ethical
tension and emotional burden, especially to the family members of a dying patient (al-
Shahri and Al-Khenaizan2005;Bu¨
low et al.2008). Food and water are considered to be
the basic sustenance of human survival, and denying them to a patient may be viewed by
family members as starving their loved one to death (Noah2006).
However, medical opinions vary on this issue. Some argue that continuing arti cial
nutrition and hydration prevents suffering to a certain extent, while others claim that it is an
unnecessary burden with no clear symptom bene t (Olsen et al.2010). There are also those
that hold the view that nutrition and hydration treatments are palliative care that ful l a
basic human need and should not be denied at the end of life (Centre for Bioethics2005;
Zahedi et al.2007). However, in some circumstances, the continuous supply of nutrition
and hydration may not be bene cial to a dying patient and may in fact be distressing as the
patient’s gastrointestinal function deteriorates (Kahn et al.2003). It is therefore suggested
that the principle of proportionality be applied with regard to life-sustaining treatments at
end-of-life care. Nutrition and hydration may thus be ethically withheld or discontinued if
the dying patient suffers burdens that outweigh the life-prolonging bene t, irrespective of
whether death will be the result (Centre for Bioethics2005).
Pain Management/Terminal Sedation
Terminal sedation is used in end-of-life care to relieve severe suffering. It refers to the use
of medications to induce decreased or absent consciousness to the extent that the patient
will no longer feel pain, air hunger or other forms of distress (Kahn et al.2003; Olsen et al.
2010). In the practice of euthanasia, a lethal injection is administered in an amount that is
certain to bring about and ultimately intended to cause the death of the patient, while
terminal sedation differs from euthanasia in that the dose of medication is maintained
rather than increased once sedation is achieved; the intent being not to hasten death but to
124 J Relig Health (2016) 55:119–134
123 relieve suffering (Kahn et al.2003). Several ethical concerns have been raised, particularly
on the unknown effect that terminal sedation may have on hastening death, and the
potential abuse of patients who are rendered unconscious during the process, in which right
to autonomy is inhibited (Centre for Bioethics2005; Kahn et al.2003).
On the risk of exposing patients to a premature death, two major arguments have been
forwarded to justify and dispel this notion: rstly being the doctrine of double effect. The
double effect doctrine, as applied in medicine, is based on two basic presuppositions: the
doctor’s motivation is to ease suffering, and the treatment must be proportional to the
illness (Malik2012). The doctrine applies if (1) the desired outcome is judged to be good,
e.g. relief of suffering and is not in itself immoral; (2) the bad outcome, e.g. death of
patient is not intended even if it is foreseen; (3) the good outcome is not achieved by means
of the bad; and (4) the good outcome outweighs the bad (Malik2012; Markwell2005).
Secondly, it has been argued that the fear that palliative sedation hastens the dying process
is unfounded since studies have shown that sedatives administered appropriately and
proportionately are able to prolong the chances of survival and improve the quality of life
(Centre for Bioethics2005; Olsen et al.2010; Tallon2012).
Further, the effects of pain management also give rise to ethical dilemmas in terms of
the patient’s cognitive perceptions. Since critically ill patients who are sedated are put
into a state of reduced consciousness, this results in the loss of their social interaction.
This not only hampers their ability to effectively communicate and partake in any further
decision-making process regarding their medical care, but also affects the emotional state
of their loved ones. The idea of being put into a deep sleep may not be well tolerated
with certain patients and their families whose spiritual belief includes that one should
face death with a clear, alert and unclouded state of mind (Keown2005; Zahedi et al.
2007).
Religious and Spiritual Considerations in End-of-Life Care
In end-of-life care, religion and religious traditions serve two primary functions, namely
the provision of a set of core beliefs about life events and the establishment of an ethical
foundation for clinical decision-making (Daaleman2000). Spirituality, on the other hand,
revolves around a sense and purpose of life, which may not necessarily involve religious
beliefs and practices. Both religion and spirituality support a person’s sense of security
and belonging, and can be especially signi cant in end-of-life care, offering the patient a
way to nd meaning in dying as in life (Chater and Tsai2008; Daaleman2000; Mazanec
and Tyler2003). Clinical assessments on quality of life involve the examination of how
a patient’s illness and well-being are in uenced by the patient’s physical, social and
psychological conditions (Tallon2012). Thus, the inclusion of measures of religiousness
and spirituality into such framework will enable doctors to have a better understanding
of patients’ beliefs, values, expectations and needs and at the same time facilitate a
dynamic interaction between patients, family members and healthcare professionals.
Religion and spirituality can potentially mediate quality of life by enhancing a patient’s
well-being through social support, stress and coping strategies (Daaleman2000). The
following paragraphs outline the different ethical considerations relating to end-of-life
care from the Roman Catholic, Jewish, Buddhist and Islamic perspectives in issues such
as sanctity of life, withholding and withdrawing of medical interventions and pain
management.
J Relig Health (2016) 55:119–134 125
123 The Roman Catholic Perspective
There are two basic human values underlining Catholic bioethics, that is, human dignity,
and interconnectedness of every individual to promote a just social order (Markwell2005;
Padela2006). The value of human dignity stems from the fundamental belief that life is
sacred as Catholics believe that they are mere stewards of their human bodies and are
therefore accountable to God for the life that they have been given (Markwell2005; Padela
2006). The value of interconnectedness relates to the relationship and responsibility that
each member of society holds towards one another. These two central elements of Catholic
bioethics in uence end-of-life decisions in the following manner. Firstly, the dignity of the
human person, as one who is oriented towards God, requires him or her to make choices for
the good within a free and informed conscience; and secondly, the interaction between
doctor and patient must take the form of a mutual relationship of trust and respect: the
patient trusts that the doctor’s intentions and acts are carried out in good faith, and the
doctor seeks to understand what the patient’s wishes might be (Markwell2005).
Accordingly, Christianity prioritises the signi cance of patient autonomy and veracity in
ethical decision-making. The doctor is under an obligation to provide the patient and
family members with the requisite medical information, advice and analysis, but it is
ultimately the patient who will decide which treatment or course of action is best aligned
with his personal values and beliefs.
In terms of withholding and withdrawing of futile therapy, the Catholic Church allows
this to be done if it is burdensome, dangerous, extraordinary or disproportionate to the
expected outcome (Bu¨
low et al.2008). Likewise, the same principle is adopted in cases of
pain management or palliative sedation (Bu¨
low et al.2008; Markwell2005). While the
issue of pain and suffering is important to Catholic bioethics as an opportunity to induce
personal growth and gain closeness to God, this belief does not imply that pain relief
should be withheld in order that a patient might come to understand the redemptive nature
of suffering (Markwell2005). Christianity allows for the administration of analgesia and
sedation to alleviate terminal suffering if this does not, by obtunding consciousness, take
away a nal chance for repentance (Zahedi et al.2007). The aforesaid views of the
Catholic Church take cognizance of the applicability of the doctrine of double effect in
bioethical issues (Bu¨
low et al.2008; Malik2012; Markwell2005), and it is considered to
be one of the ‘‘most signi cant principles proposed by all Catholic medical ethicists’’
(Curran2008; Malik2012). Withdrawal of arti cial nutrition and hydration from patients
at the end of life and for people in a persistent vegetative state, however, is a controversial
issue in the Christian faith. In 2004, the then Pope John Paul II issued a pronouncement
stating that the cessation of nutrition and hydration resulting in death by starvation
amounted to euthanasia which is strictly forbidden (Bu¨
low et al.2008; Noah2006). This
view has been met with criticism by most bioethicists and medical ethics organisations, as
it contradicts much of the Catholic doctrine on matters of end-of-life care (Noah2006).
The Jewish Perspective
There are three main principles in Jewish medical ethics: life is of utmost value; ageing,
illness, and death are a natural part of life; and improvement of the patient’s quality of life
is a constant commitment (Padela2006). When applied in the context of end-of-life care,
the Jewish position is that dying is a natural part of life’s journey that should be addressed
with dignity and compassion (Loike et al.2010) and human beings have both the per-
mission and the obligation to heal (Zahedi et al.2007). The principle of sanctity of life
126 J Relig Health (2016) 55:119–134
123 connotes that any decision that may directly or indirectly result in hastening death is
prohibited. However, Jewish law recognises that ‘‘if situations necessitate foregoing certain
rules and regulations for a higher purpose, for example, that of saving life or improving
quality of life or avoiding harm, then one is allowed to do so’’ (Padela2006). According to
the Jewish legal system orHalacha(which to those of the Jewish faith represents a
comprehensive guide to human life, regulating all aspects of behaviour through assigning
moral values to actions as well as determining sacred law), there are several basic
guidelines related to end of life that distinguish between: (a) acts of omission and acts of
commission; (b) treatments pertaining to the dying process (or illness) and treatments
unrelated directly to the dying process; (c) treatments that are continuous in nature in
which withdrawing of such treatments is considered an act of commission and treatments
that are cyclic in nature in which the withholding of the next cycle of treatment is con-
sidered an act of omission; and (d) patients who are expected to die within 6 months and
those patients with less serious medical conditions (Loike et al.2010).
Based on the above, on the issue of withholding and withdrawing life-sustaining
treatment, Jewish law allows for such act or omission to be carried out only if such
treatment is of a recurrent nature and provided that the patient has clearly consented to it.
This includes withholding any life-prolonging activities such as intubation, surgery, che-
motherapy or dialysis, even after initiation of the same, because such action is viewed as
omitting the next treatment rather than committing an act of withdrawal (Bu¨
low et al.
2008). If the same constitutes a continuous form of life-sustaining treatment, for example, a
respirator or cardiac pacemaker, then such withdrawal is forbidden. The strictest position
in Judaism restricts permission to withdraw or withhold treatment to cases where doctors
assume that the patient will die within 72 h (Dorff2005; Zahedi et al.2007). Patients and
doctors are allowed to withhold or withdraw clinical treatment in cases where the patient is
diagnosed with incurable terminal illness, as long as it is within the patient’s best interests.
Further, theHalachaconsiders oxygen, food and uids to be essential components of life
to which every human being is entitled. Accordingly, a dying patient cannot be denied
these basic needs, and withdrawal of arti cial nutrition and hydration is not allowed as it is
seen as an act leading to death. However, in cases where the continuance of arti cial
nutrition and hydration cause suffering and complications to a patient who is approaching
death, such support may be withdrawn upon the request of the patient or if it can be
ascertained that that was the patient’s wish (Bu¨
low et al.2008). The Conservative
Movement’s Committee on Jewish Law and Standards adopted a somewhat dissimilar
view in classifying arti cial nutrition and hydration as medicine, permitting their removal
where there is not likely to be any reasonable prospect for recovery at the end of life
(Zahedi et al.2007). It is suggested that when the decision is made to discontinue arti cial
nutrition and hydration, the focus of communication should be on ‘‘what will be done to
demonstrate respect for the patient, rather than on emphasising what will be withdrawn or
withheld’’ (Gillick2001; Loike et al.2010). With regard to palliative sedation, there is a
general agreement in Jewish law that this is permitted in spite of the risk that the
administration of such drugs may shorten life, based on the principle of double effect
(Bu¨
low et al.2008; Loike et al.2010).
The Buddhist Perspective
The two most fundamental values in Buddhism are compassion and respect for life (Keown
2005). According to the Buddhist faith, life ‘‘begins at conception and ends at death: in the
interval between these events, the individual is entitled to full moral respect, regardless of
J Relig Health (2016) 55:119–134 127
123 the stage of psycho-physical development attained or the mental capacities enjoyed’’
(Keown2005). The manner of dying and death is of particular signi cance in Buddhism;
death with an unclouded mind is believed to lead to a better rebirth in the next life (Keown
2005; Zahedi et al.2007), and death is an experience that will recur many times. Con-
sequently, this concept has signi cant bearing on end-of-life issues such as palliative
sedation and pain management, as the concern would be to maintain a mental and sensory
clarity at all times. In terms of arti cial nutrition and hydration, the Buddhist perspective
maintains that such life-sustaining support cannot be discontinued, even from patients in a
persistent vegetative state (Keown2005; Zahedi et al.2007). This stems from the notion
that in Buddhism, damage to the brain is not differentiated from injury to any other part of
the human body when considering the ethics of treatment (Keown2005).
The above does not, however, mean that there is a moral obligation in Buddhism that
life must be preserved at all costs. The ethical validity of an act or omission in Buddhism is
measured against the aim or motive of such conduct. If a patient ‘‘makes death his aim’’,
then the refusal of medical care is considered to be an offence; declining further treatment
due to the patient’s acceptance that recovery is grim and death is inevitable, is on the other
hand legitimate (Keown2005). It follows that proceeding with futile treatment goes against
the teachings of Buddhism; ‘‘to seek to prolong life beyond its natural span by recourse to
increasingly elaborate technology when no cure or recovery is in sight is a denial of the
reality of human mortality, and would be seen by Buddhism as arising from delusion and
excessive attachment’’ (Keown2005).
The Islamic Perspective
TheShari‘ahor Islamic law is based on two primary sources, the HolyQur‘an(the Holy Book
which Muslims believe to be the word of God Almighty) (Al-Qur’an2:2) and theSunnahof
Prophet Muhammad (peace be upon him) (his words, conduct and tacit approval) (Al-Qur’an
4:59). The secondary source of theShari‘ahis found inijtihad(deductive reasoning) (Su-
laiman2008, Sunan Abu Dawud, Book 24, Hadith no. 3585). The guiding principles, rules
and regulations in the main sources govern the Islamic way of life and, together withijtihad,
provide a comprehensive moral and juridical framework to address and accommodate issues
relating to human conditions (Gatrad and Sheikh2001). In Islamic jurisprudence, each
deliberation towards resolving any given issue must observe the following ve fundamental
principles which are known asmaqasid al-shari‘ah: preservation of life, protection of an
individual’s freedom or belief, maintenance of intellect, preservation of honour and integrity,
and protection of property. Congruently, end-of-life issues in Islamic bioethics involve
ethical considerations on the sanctity of human life. This ruling is ordained in the HolyQur’an
in the following verse: ‘‘Do not take life which God has made sacred except in the course of
Justice’’ (Al-Qur’an6:151). It is accordingly forbidden for anyone to deliberately end a life:
‘‘Whosoever takes a human life, for other than murder or corruption in the earth, it is as if he
has taken the life of all of mankind’’ (Al-Qur’an: 5:32).
The saving of a life is considered one of the highest merits and imperatives in Islam
(Zahedi et al.2007). Doctors must do everything they can to prevent a premature death.
However, this does not come at all costs; when death is inevitable, and clinically evaluated
treatment is obviously futile, it ceases to be mandatory (Khan2002). Islam recognises that
there are times in which human beings need to recognise their own limits and let nature
take its course (Al-Qur’an39:42); resorting to futile treatment in order to put off death is
not acceptable in Islam (Zahedi et al.2007). Muslim jurists agree that it is possible for a
collective decision to be reached between the attending doctor, patient and family members
128 J Relig Health (2016) 55:119–134
123 to refuse medical interventions and discontinue life-sustaining treatments if such proce-
dures will in no way improve the condition or quality of life, on the basis of informed
consent (Bu¨
low et al.2008; Sachedina2005; Zahedi et al.2007). However, if invasive
treatment has been intensi ed to save a patient’s life, Muslim jurists have ruled that life-
saving equipment cannot be switched off unless the doctor is certain about the inevitability
of death (Sachedina2005).
Islam maintains the position that patients should not be denied their basic human rights
of nutrition and hydration even at the end of life. This is due to the fact that withdrawal of
such needs would hasten death, which is forbidden in Islam (Bu¨
low et al.2008; Gatrad and
Sheikh2001; Khan2002). However, administering analgesia to lessen suffering in end-of-
life care is permitted even if in the process, death is hastened, based on the Islamic teaching
that ‘‘actions are to be judged by their intentions’’ (Bu¨
low et al.2008; Gatrad and Sheikh
2001; Sachedina2005; Zahedi et al.2007). It follows that the intended purpose of palli-
ative sedation is not to facilitate death, but rather to save a patient from severe discomfort,
which renders it ethically legitimate from the Islamic viewpoint.
In Islam, pain is believed to be a form of trial from God to test a Muslim’s faith and
spiritual standing (Al-Qur’an2:153–7). Muslims should thus endure pain with patience and
perseverance, but this does not mean that they are forbidden to seek a means to alleviate
the suffering. The HolyQur’anstates that ‘‘surely the good deeds will drive away the evil
deeds [which cause suffering]’’ (Al-Qur’an11:114); inferentially, this implies the per-
missibility for a person’s endeavour to overcome pain (Albar2007; Sachedina2005). This
precept is further substantiated by other verses in the HolyQur’anand theSunnahthat
encourage Muslims to remove harm and dif culty (Al-Qur’an2:185, 5:6 and 94:28; al-
Bukhari1997(Book 2, Hadith no. 38)). In Islamic ethics, an individual’s welfare is
intimately linked with his or her family and community (Sachedina2005). Hence, neither
autonomy nor paternalism is the determining factor in deciding a course of action in
matters relating to end-of-life decisions, but rather, a joint decision made by all parties
associated with the patient, which may require the involvement of religious authorities, if
needed (Sachedina2005).
The Developing Legal Standards
Decision making at the end of life must necessarily take into account the courts’ standing
on such issues and the legal implications that would ensue. In order for a comprehensive
ethico-legal framework to exist where medical codes of ethics are af rmed as good
practice, the latter must be compatible with current developments of the law. In the UK,
when decisions are made on behalf of a patient, the principle of ‘‘best interests’’ has
consistently been the determinative principle in legal cases. A responsible decision by a
team of medical experts to withdraw life-sustaining treatments and withhold further
medical interventions which have been determined to be futile and would not be in the
patient’s best interests is permissible under the law and would not subject healthcare
professionals to criminal proceedings. This principle was enunciated in the landmark case
of Airedale NHS Trust v Bland (‘‘Airedale NHS Trust v. Bland’’1993), where the House
of Lords discussed its legal justi cation in relation to the principle of sanctity of life and
patient autonomy.
The case concerned one Anthony Bland, a victim of the disaster at the Hillsborough
Football Stadium who suffered irreversible damage to his cerebral cortex which rendered
him in a persistent vegetative state. He was fed arti cially and mechanically with a
J Relig Health (2016) 55:119–134 129
123 nasogastric tube and showed no cognitive response to his surroundings. All his natural
bodily functions had to be operated with nursing intervention, requiring 4–5 h of nursing
attention by two nurses daily. After three and a half years of remaining in this condition, a
court declaration was sought by Bland’s attending doctor to cease further treatment, which
involved extubation, i.e. withdrawal of arti cial nutrition and hydration and withholding of
antibiotic treatment in case of infection. The declaration was based on a clinical assessment
by medical experts that there was absolutely no hope for recovery for Bland and thus any
medical intervention would be futile and not in the best interests of the patient. In arriving
at its judgement, the court ruled that the principle of sanctity of life was not absolute; ‘‘it
must yield to the right of self-determination’’ (per Lord Goff in Airedale NHS Trust v
Bland (‘‘Airedale NHS Trust v. Bland’’1993at p. 866). The principle of self-determination
requires that the patient’s wishes be respected to the extent that if a patient of sound mind
refuses to consent to a medical treatment which would prolong his life, the doctor
responsible for his care must abide by the former’s wishes, regardless of the fact that such
refusal is unwise.
In the case of an insensate patient like Bland who lacked the capacity to validly consent
or refuse medical treatment, the lawfulness of such medical treatment depended upon
whether it was in the best interests of the patient (per Sir Thomas Bingham in Airedale
NHS Trust v Bland (‘‘Airedale NHS Trust v. Bland’’1993at p. 843). The court further held
that doctors were not under an unquali ed duty to prolong life at all costs; accordingly, the
duty to provide medical care ‘‘ceases when such treatment can serve no humane purpose’’
(per Lord Hoffman in Airedale NHS Trust v Bland (‘‘Airedale NHS Trust v. Bland’’1993
at p. 856). In Bland’s case, the futility of the treatment in providing him any quality of life
ethically justi ed its termination (per Lord Goff in Airedale NHS Trust v Bland (‘‘Airedale
NHS Trust v. Bland’’1993at p. 870).
A patient’s right to autonomy was reiterated in Ms B v An NHS Hospital Trust (‘‘Ms B
v An NHS Hospital Trust’’2002). Here, the case involved a patient who was mentally
competent and had repeatedly yet unsuccessfully requested for the withdrawal of medical
therapy to which she was subjected. Ms B suffered a spinal cavernoma, which necessitated
neurological surgery to remove it. During the course of her hospitalisation and treatment,
she executed a living will stating that if at any point of time, she was incapable of giving
instructions, she wanted treatment to be withdrawn if she was suffering from a life-
threatening condition, permanent mental impairment or permanent unconsciousness.
Unfortunately, as a result of the surgery, Mrs B became completely paralysed from the
neck down and was treated with a ventilator to ease her respiratory problems. She even-
tually regained some movement in her head and was able to speak, pursuant to which she
requested to her clinicians on several occasions to have the ventilator removed. The
clinicians were not prepared to do so as they considered it to not be in her best interests, i.e.
it would inevitably lead to her death. In allowing Mrs B’s claim for a declaration that the
hospital had been treating her unlawfully, the court upheld the principle of self-determi-
nation, referring to the judgements delivered by the bench in Airedale NHS Trust v Bland
(‘‘Airedale NHS Trust v. Bland’’1993) on the interface between the two con icting
principles of autonomy and preservation of life. It was accordingly ruled that the principle
of ‘‘best interests’’ was not applicable in cases where the patient had the mental capacity to
make relevant decisions about her medical treatment, and therefore, a doctor was under an
obligation to respect the wishes of the patient, even if it was plain to all parties, including
the patient, that death would ensue.
The approach to the issue on end of life adopted by the US courts is not entirely
dissimilar to the law in the UK (it is noted that although the House of Lords in Airedale
130 J Relig Health (2016) 55:119–134
123 NHS Trust v Bland (‘‘Airedale NHS Trust v. Bland’’1993) declined to apply the test of
‘‘substituted judgment’’ used by the US courts in the case of an incapable patient, Lord
Hoffman at p. 857 noted that such principle, to the extent that it pays respects to what most
likely would have been the patient’s views, ‘‘may be subsumed within the English concept
of best interests’’). In the absence of the expressed wishes of a patient (be it in the form of
oral statements or advance directives), decisions are based on the patient’s presumed
wishes (Meisel2008). This is known as the doctrine of ‘‘substituted judgement’’. Under
this doctrine, a surrogate appointed by a patient is legally authorised to make decisions on
behalf of the patient, or where there is no surrogate, the patient’s family members, based on
the patient’s values and beliefs. This practice marks the difference between the USA and
the UK positions; in the UK, it is not a legal requirement for relatives to assent on behalf of
a patient who is unable to give consent (per Lord Goff in Airedale NHS Trust v Bland
(‘‘Airedale NHS Trust v. Bland’’1993at p. 872). Discussions with relatives are never-
theless of utmost value because they assist in providing indications about the patient’s own
attitudes and values concerning treatment (Kinsella and Booth2007).
The proli c Florida case of Theresa Marie Schiavo (‘‘Schiavo ex rel. Schindler v.
Schiavo’’2005) is noteworthy not only to illustrate the application of the ‘‘substituted
judgement’’ test, but also due to the controversial intervention of the executive body and
conservative groups in the dispute surrounding her medical care, which attracted intense
media coverage. Theresa Schiavo was in a persistent vegetative state for 15 years, fol-
lowing a cardiac arrest. Although she suffered from irrevocable cerebral cortex, she was
able to breathe on her own and was kept alive through arti cial nutrition and hydration
which was delivered by way of a tube implanted in her body. After having accepted the
grim medical prognosis that his wife’s incapacity was permanent, Michael Schiavo
attempted to seek the court’s permission for the removal of her feeding tube so that she
could die peacefully, stating that it would have been against Theresa’s wishes and values to
have her life prolonged in a vegetative state with no hope of recovery. Since Theresa
Schiavo had not appointed a surrogate, in accordance with Florida law, her husband was
authorised to act as the proxy decision-maker, ahead of her other family members (‘‘FLA.
STAT. § 765.401(1)’’2005; Noah2006). In an ensuing series of intense court battles over a
period of 7 years, including the controversial intervention of the US Congress, Theresa
Schiavo’s parents, Robert and Mary Schindler, fought against Michael Schiavo’s desig-
nation as legal surrogate and his request to withdraw the life-sustaining treatment from his
wife. Despite immense pressure from political groups, all state and federal courts which
heard the case ruled in favour of Michael Schiavo’s application.
In 2004, in what is seen to have been a response to Theresa Schiavo’s case, a pro-
nouncement was made by the then Pope John Paul II concerning the impermissibility of the
withdrawal of arti cial nutrition and hydration (Bu¨
low et al.2008; Noah2006). This was
relied on by the Schindlers, arguing that since their daughter was a practising Catholic, she
would have been inclined to abide by the papal decree (Noah2006). Although the courts
recognised the relevance of a patient’s religious af liations, no proper inference could be
made as to Theresa’s personal understanding and level of adherence to Catholic principles,
and thus, it was dif cult to form a decision in that respect (Noah2006). This highlights the
need for a more effective mechanism to facilitate religious and spiritual awareness in end-
of-life care, so that ethical and social implications can be ‘‘anticipated and acted upon in
advance rather thanpost factum’’ (Steinberg2003). On that note, it is argued that the legal
system is not the most appropriate platform to cope with the different ethical dilemmas
created by the dynamic changes in the medical world; instead, multidisciplinary ethic
committees may prove to be more ef cacious in developing and recommending policies
J Relig Health (2016) 55:119–134 131
123 and procedures to resolve ethical con ict (Steinberg2003), which are more pronounced at
the end of life.
Conclusion
In a world of increasing cultural pluralism and multi-faith societies, there is an undeniable
need for those involved in health services to have increased awareness and understanding
of the various and distinct value and belief systems of the patients whom they attend to.
Sensitivity towards cultural and religious differences leads to increased trust between
doctor and patient, resulting in a compassionate and improved end-of-life care environ-
ment. Further, aspects of end-of-life care such as withholding and withdrawal of medical
interventions, futile treatments and palliative sedation involve a manifold of ethical
dilemmas, necessitating a structured approach into the different value systems of each
individual patient. It is thus important that healthcare providers inquire into and evaluate a
patient’s religious and spiritual beliefs as well as his personal attitude towards end-of-life
issues such as illness, pain and death. This may accordingly be facilitated through the
formulation and implementation of ethical codes which give due consideration to the
characteristics of religion, culture and locality. The importance of adequate and effective
communication between doctor and patient must also not be underestimated, as it plays a
crucial role in minimising misunderstanding and resolving con ict, as well as promoting a
mutual and collective approach to decision-making.
AcknowledgmentsThis paper was funded by the Ministry of Higher Education Malaysia and presented at
the Asian Conference on Ethics, Religion and Philosophy 2014 (ACERP—Osaka 2014).
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