Brain Death – An Islamic Perspective

Prof. Ibrahim B. Syed

President

Islamic Research Foundation International, Inc.

Louisville, Kentucky

E-Mail: President@irfi.org

Website: WWW.IRFI.ORG

Terri Schiavo,   a white female of Roman Catholic faith was  born  on 3^rd December 1963 in  Philadelphia, PA. She married  Michael on 10-11-84.

Terri Schiavo entered a vegetative state in 1990 after adopting an "iced tea diet" (related to her bulimia), resulting in a disastrous potassium deficiency that caused her heart to stop. She suffered  cardiac arrest on 25 February 1990 early morning and heart beat was revived after some delay.  By the time her heart was revived she suffered irreversible brain damage.  (WHEN THE HEART STOPPED, THE BRAIN DID NOT GET THE BLOOD SUPPLY WHICH NOURISHES THE BRAIN WITH GLUCOSE, OXYGEN AND MINERALS.  There is a popular belief that the brain "dies" after 4 to 6 minutes without oxygen. In some cases it may take 10 to 16 minutes. Within four minutes of the blood supply to the brain ceasing, the central nervous system is irreversibly damaged.). She lived  in different stages of unconsciousness and long considered in a ‘persistent vegetative state’ (PVP), in a Pinellas Park, Florida hospice. Severe brain damage which does not involve the brain stem may result in a persistent vegetative state. These patients breathe spontaneously, open and close their eyes, swallow and make facial grimaces. However, they show no behavioral evidence of awareness. In this persistent vegetative state she remained the last fifteen years of her life.  Neurological tests indicated that her cerebral cortex was principally liquid. The electroencephalogram (EEG) of someone who is brain dead shows no electrical activity, and an injection of mild radioactive isotopes into the brain reveals the absolute absence of blood flow. Death is now accepted as meaning brain stem death or brain death. The brain stem is a small area of the brain which controls respiration (breathing). If this area is dead the person will never be able to breathe spontaneously or regain consciousness.

She died shortly after 9 AM (EST) on March 31, 2005, nearly two weeks after the feeding tube was removed from her. Treatment  in an Intensive Care Unit costs $2000 per day whereas in Hospice its costs about $500/- per day. WHO WILL PAY?

Both Schiavo's doctors and her court-appointed doctors expressed the opinion that there existed no hope of rehabilitation. Her husband, Michael Schiavo, stated that it was his wife's wish that she not be kept alive through unnatural, mechanical means. Michael Schiavo wanted life support (her feeding tube) removed, after which Terri would slowly die of malnutrition and dehydration.

Politicians inserted themselves into the fray. The case was the catalyst for Florida's controversial "Terri's Law", which gave Gov. Jeb Bush the authority to have Schiavo's feeding tube re-inserted when a court ruled that her husband could have it removed. It was a tremendously sad family situation, undoubtedly painful for everyone involved (except, of course, the vegetable Terri Schiavo).

 In the legal battle, many court rulings and appeals took place (all the way to the US Supreme Court-6 times). There was  involvement of Florida State Governor (Jeb Bush), the State and  US legislature and the bills passed to save Terri Schiavo.

The U.S. Congress quickly passed legislation allowing federal courts to intervene, and President George W. Bush flew back to Washington to sign the bill into law. It should be noticed that this is the same George W. Bush who, as Governor of Texas, signed into state law the power of hospitals to remove a patient (in identical situations as Terri's) from life support -- a critical factor being the family's ability to pay the hospital bills -- even if such removal was against the family's objections.

House Majority Leader Tom DeLay  lied for national newscasts that Schiavo "talks and she laughs, and she expresses happiness and discomfort... It won’t take a miracle to help Terri Schiavo; it will only take the medical care and therapy that all patients deserve." But in 1988, DeLay had concurred in his own family's decision to withhold care for his comatose father.  (1)According to Schiavo's husband, "It is an invasion of the American people when you make a family matter public.

In a Muslim country, in a situation like this, the family of the patient would treat the patient at home and feed her thro' her mouth.  The patient would expire in 15 days.

In June 2005, the Autopsy Report of Terri Schiavo indicated that her brain weighed half the normal size. Her brain was in a vegetative state with irreparable damage and that she was blind. Her husband did not abuse her.

In USA, Terri Schiavo lived for 15 years with modern medical technology and with a tube inserted to feed her nutritious food. This  is a testimony to the will and the technology to perform medical miracles -- the right-to-life resolve making demands of the technological sophistication.  Was the life of Terri Schiavo prolonged or  her death delayed? WHAT IS THE QUALITY OF LIFE OF A VEGETATIVE STATE PATIENT IN COMA?  A patient in coma is absolutely unaware of what is happening. In the US, there are thousands (30-40,000 according to some reports) in similar PVP, with hardly any fuss, but Schiavo’s case is now mired in a raging right-to-die debate, more precisely, the-right-to-die ‘in dignity’. The right-to-die in dignity does not necessarily mean euthanasia, mercy killing, assisted suicide, or deliberate ending of life of a person suffering from an incurable disease or a state that’s near impossible (given the medical resources available) to revert to normal life.

In Russia, euthanasia is illegal, but the reality seems more sympathetic. In Belgium, euthanasia has been legal since 2002. Same is the case in the Netherlands, where physician-assisted suicide is also legal. In these two countries alone, there are on the average 2,500 cases a year. Assisted suicide has not been illegal or a crime in Switzerland for nearly 60 years.
In Britain, there are laws against euthanasia and assisted suicides, but a few have been successfully challenged.  In treating the terminally-ill, and “when medical acts appear useless, disproportionate, or serve no other purpose than the artificial support of life, they can be suspended or not undertaken.” In France, the law specifies that artificial means of sustaining life (like feeding tubes etc.) can legally be withdrawn.

While the Catholic church remains opposed to euthanasia, many countries in Europe overwhelmingly support (about 80% according to some polls) the idea of euthanasia and assisted suicide. Other religions have different opinions. For instance, the Jewish law and tradition regard human life as sacred, and forbid doing anything that might shorten life. Active euthanasia is regarded as murder, without any exception, and it makes no difference if the terminally ill wants to die. Saving someone from pain is, according to the Jewish tradition, not a reason to kill them; nor is it lawful to kill oneself to save oneself from pain. However it does not require doctors to extend the state of dying.

Muslims are also against euthanasia and suicide: The Qur'an says, “Do not take life, which Allah made sacred, other than in the course of justice.” (Qur’an, Surah, Al-Isra' 17.33).:

“Do not take life, which Allah made sacred, other than in the course of justice.” (Qur’an, Surah, Al-Isra', 17.33).

5:32. On that account: We ordained for the Children of Israel that if any one slew a person - unless it be for murder or for spreading mischief in the land - it would be as if he slew the whole people: and if any one saved a life, it would be as if h e saved the life of the whole people. Then although there came to them Our apostles with clear signs, yet, even after that, many of them continued to commit excesses in the land.

The Qur'an says, “If anyone kills a person - unless it be for murder or spreading mischief in the land - it would be as if he killed the whole people.” (Qur’an 5.32); “When their time comes they cannot delay it for a single hour nor can they bring it forward by a single hour.” (Qur’an 16.61);

“And no person can ever die except by Allah’s leave and at an appointed term.” (Qur’an 3:145);

“Take not life which Allah made sacred other than in the course of justice” (Qur’an 6:151 and 17:33).

“Do not kill (or destroy) yourselves, for verily Allah has been to you most Merciful” (Qur’an 4:29).

To warn against suicide Prophet Mohammad said," Whoever kills himself with an iron instrument will be carrying it forever in hell. Whoever takes poison and kills himself will forever keep sipping that poison in hell. Whoever jumps off a mountain and kills himself will forever keep falling down in the depths of hell.”

The Islamic Code of Medical Ethics endorsed by the First International Conference on Islamic Medicine (Islamic Organization of Medical Sciences, Kuwait, 1981, p.65) includes: “Mercy killing, like suicide, finds no support except in the atheistic way of thinking that believes that our life on this earth is followed by void. The claim of killing for painful, hopeless illness is also refuted, for there is no human pain that cannot be largely conquered by medication or by suitable neurosurgery...”
On pain, suffering and endurance, Islam has special consideration: “Those who patiently persevere will truly receive a reward without measure” (Qur’an Surah, Zumar, 39:10).

39: 10. Says: "O ye my servants who believe! Fear your Lord, good is (the reward) for those who do good in this world. Spacious is Allah's earth! those who patiently persevere will truly receive a reward without measure!"

 “And bear in patience whatever (ill) maybe fall you: this, behold, is something to set one’s heart upon” (Qur’an, Surah, Luqman,  31:17).

31:17. "O my son! establish regular prayer, enjoin what is just, and forbid what is wrong: and bear with patient constancy whatever betide thee; for this is firmness (of purpose) in (the conduct of) affairs.

Prophet Mohammad taught “When the believer is afflicted with pain, even that of a prick of a thorn or more, God forgives his sins, and his wrongdoings are discarded as a tree sheds off its leaves.”
Islamic Medical Ethics

The introduction of newer technology in medicine in areas of life support in terminal patients, abortion, organ transplantation, biotechnical parenting, and care of AIDS patients has posed Muslim physicians and patients some new questions of ethics. Islamic medical ethics are based on the principles of the sanctity of human life and safeguarding its values, taking the lesser of the two evils.
Life, though short as it may look on this planet, is still a precious gift from God. Since we did not create our life, nor are the owners of it, we should not have the absolute power over it either. The guiding principle in Islamic medical ethics which is mentioned in Quran  is saving life. However, the question that we are faced with, in terms of saving life, is at what cost and what quality. Does the quality of life modify our decision-making process and when resources are scarce, who takes precedence, the individual or the community?

Islam  emphasizes  on preserving life and the quality of life, promoting and restoring health, alleviating suffering, respecting patients' autonomy, doing medical justice, telling the truth, and doing no further harm.

Another rule is nonmaleficence. This principle obliges persons to refrain from harming others including refraining from killing them or treating them cruelly. It is one of the non-intervention.

In the question of the right to live or die, the question is, should one prolong the life or the misery?. Who determines (the unconscious patient, the family, or the doctor), that the plug should be pulled and the life support system stopped? What is the definition of death, acceptable to both the medical technology and Islamic jurists? Is a living will justified? Is stopping the life support system an act of mercy, a medical decision, a murder, or a financial decision?

While Islam gives importance to saving life, it also makes it clear that dying is part of the contract with God and part of the journey on this planet. The final decision of the term is up to God. The quality of life is equally, if not more important than the life span on this planet.

Physicians and the family should realize the limitations of medical technology and should not attempt to do heroic measures for a terminally-ill patient who is in a vegetative state and cannot be resurrected to a quality of life acceptable to him/her. The heroic measures taken at the beginning of life like saving a premature baby are more justifiable than at the end of the life span. Muslims  consider euthanasia an act of murder.

Medical Ethics: An Islamic Perspective

Muslim Physicians are not encouraged to artificially prolong the misery in a vegetative state, however, they are ordained to help alleviate suffering. Quran says, "Anyone who has saved a life, it is as if he has saved the life of whole mankind" (5:32). Prophet Muhammad (PBUH) emphasized this by saying, " O Muslims, seek cure, since God has not created any illness without creating a cure."
The financial cost of maintaining the incurably ill is very high. It  becomes a financial burden on society, and society decides either to  discard the maintenance  abruptly or allow the patient  to die naturally, gradually and peacefully? Islamically, when individual means cannot cover the needed care, it becomes a collective responsibility of the society. To meet this objective, the society has to reshuffle its values and priorities and divert funds from those spent on alcoholism, drug abuse, teenage pregnancy, and other such "pursuits of happiness" to providing health care for those who are hopelessly ill and allowing them to live with quality and die in dignity.

The IMA (Islamic Medical Association) holds the view that when the treatment becomes futile, it ceases to be mandatory. This would reflect on the administration or continuation of medical treatment (including the respirator).

The IMA follows the current policy about DNR (do not resuscitate), where treatment is deemed futile. Brain death, including the brain stem, is an acceptable definition of death, with all the consequences pertaining to cessation of animation or the procurement of vital organs for transplantation.

IMA(Islamic Medical Association)  suggests  advance directives as  part of all hospital and office medical records of a patient.

The objectives of Islamic Shariah (Laws) is for the protection of individual life, religion, mind, property and family. In difficult cases, the rules are:

 a) take the lesser of the two evils,

 b) necessity overrides the prohibition.

The following Questions and answers  took place at ISNA Convention of 1997(2)

QUESTION (1): Is CPR (Cardio Pulmonary Resuscitation) part of the mandate to maintain life. What is the status of DNR (DO NOT RESUSCITATE) and code "C"?
ANSWER: When the treatment becomes  scientifically  futile (i.e. hopeless), it is no more mandatory to maintain life, and DNR would be acceptable. If a patient is placed on life support and the doctors see no improvement in the patient’s health conditions, and the doctors indicate that artificial resuscitation has become useless, then with due consideration and care and by collective decision of medical experts, family members and religious scholars, it would be permissible to decide to switch off the life support machine and to allow nature to take its course.

QUESTION (2). Is it OK to withdraw the life support system for example: ( A Ventilator for a patient who has no cerebral function and is in a vegetative state)? Or Feeding Tube.
ANSWER: Same answer as question 1. If there is no hope of treatment, you may withdraw the life support equipment. In an attempt to prolong life without quality, one must not prolong the misery at a high cost.  In a patient like Terri Schiavo, it is permissible to remove the Feeding Tube.

If  a number of medical experts determine that a patient is in a terminal condition, and there is no hope for his/her recovery and all medications have become useless, then it permissible for them, through a collective decision, to stop the medication.

Question (3). What is the definition of "death" when do you say it is OK to turn the machine off when the patient is dead? Is brain death and brain stem death the same thing?
Answer: Brain death is not synonymous with brain stem death and does not mean death. Brain death including brain stem death, means death. The brain stem contains the centers for breathing . Thus brain stem death fulfills the requirements of Cardio-pulmonary death.  Muslim medical experts have defined death in the following way: An individual is considered dead in one of the following two situations: A) Complete irreversible cessation of respiratory and cardiovascular systems. B) Complete irreversible cessation of the functions of the brain including the brain stem. This should be confirmed by the accepted medical standards. In case of brain death it is required to have the presence of a reliable medical specialist well experienced in the clinical diagnosis of brain and brain stem death and the various implications of such diagnosis.  The team comprises two specialists with experience in diagnosing brain death.  One of the two doctors of the team should be a specialist in neurology, neurosurgery or intensive care.

Question 4. If a person is in a vegetative state on artificial life support but he/she is not brain dead but his/her survival chances are minimal, are physicians' allowed to turn off the machine at this point?
Answer: If "minimal" means hopeless upon scientific assessment, one may turn off and withdraw life support.

Advanced Directives -Preparing the will- and THE LIVING WILL: The Prophet - peace be upon him - urged all Muslims to prepare their will. It is always good to have an Islamic will. The way the situation is changing and the increasing involvement of the governments and courts in this matter, makes it even more urgent and necessary that we carefully think how to preparer our Islamic will, not only for the distribution of inheritance, but also for our medical treatment in case of coma or other complications and also for our proper Islamic burial. This is called the Living Will.

If a Living Will and Durable Power of Attorney for Health Care is not made out in life, then  at the time of serious decision making if the patient is not competent, the legal system in the United States gives that power to the spouse.

REFERENCES:

1.  http://www.nndb.com/people/435/000026357/   

2. " Medical Ethics Questions From the Audience During the Medical Ethics Symposium at  ISNA Convention, 1997 and answers by Dr. Hassan Hathout
and compiled by Dr. Shahid Athar