The Determination of Quality of Life and Medical Futility in Disorders of Consciousness: Reinterpreting the Moral Code of Islam

The Islamic moral code originates from two primary sources: the Quran and the Sunnah (Rady and Verheijde 2014a). Regardless of time and place, this code provides practical and comprehensive guidance on behavioral aspects in health and illness. In Western principlism-based bioethics, medical futility justifies withholding and withdrawing of life-sustaining treatment (LST) based on a subjective determination of an unacceptable quality of life (QOL). This contrasts with physiologic futility; withholding or withdrawing treatment because of physiologic ineffectiveness. The determination of treatment futility based on QOL remains medically, ethically, and legally controversial in disorders of consciousness (DOC) (Demertzi et al. 2014; Giacino et al. 2014). DOC includes several neurologic states, such as locked-in syndrome, unresponsive wakefulness syndrome (formerly known as vegetative state), minimally conscious state, brain death, and others. Padela and Mohiuddin (2015) propose a QOL definition of medical futility in DOC. The QOL is assessed with the “theological concept of accountability before God” (mukallaf) status: “the cognitive faculty to recognize God and thereby can benefit [a person's] afterlife by performing religious practices (worship) or other meritorious actions willfully”. They posit that acceptable QOL is “a clinical/physiologic state where one can perform willful actions while being cognizant of their potential after life ramifications”. They argue that brain death physiology has been accepted as the foundational concept of futility. Then they argue that absent consciousness equates to absent QOL in other states of DOC. In the Islamic moral code, the mukallaf status specifically pertains to the accountability for consequences of actions and deeds. When cognitively impaired, the non-mukallaf person is temporarily or permanently exempt from this accountability. The non-mukallaf status is not intended to judge the worthiness or quality of a human life. However, the authors link the non-mukallaf status to theologically unworthy QOL that warrants the denial of medical care based on the futility rationale. From this, they infer that medical treatment is futile in states of DOC. Padela and Mohiuddin translate higher brain death criteria into theological death in Islamic bioethics. We have outlined elsewhere how contemporary Islamic bioethics seeks closer alignment with Western principlism-based ethical decision making (Rady and Verheijde 2014a). Here, we outline scientific and theological arguments severing the links between non-mukallaf status, worthiness of life, and medical futility based on (1) the scientific challenge of brain death concept weakening the foundational definition of futility, (2) the confusion of obligation to provide medical treatment with the responsibility to provide compassionate care and the suggestion that end-of-life care (EOLC) may denote instrumentalizing another person's life, (3) the authors’ silence about what constitutes medical treatment versus basic humane care, (4) the argument that medical treatment is to restore cognition without defining the minimal threshold in theological worthiness of life, and (5) the role of autonomy when medical treatment is deemed futile.