Ethical Obligations and Clinical Goals in End-of-Life Care: Deriving a Quality-of-Life Construct Based on the Islamic Concept of Accountability Before God (<i>Taklīf</i>)
Authors: Aasim Padela, Afshan Mohiuddin
Journal: The American Journal of Bioethics (2015)

AbstractEnd-of-life medical decision making presents a major challenge to patients and physicians alike. In order to determine whether it is ethically justifiable to forgo medical treatment in such scenarios, clinical data must be interpreted alongside patient values, as well as in light of the physician's ethical commitments. Though much has been written about this ethical issue from religious perspectives (especially Christian and Jewish), little work has been done from an Islamic point of view. To fill the gap in the literature around Islamic bioethical perspectives on the matter, we derive a theologically rooted rubric for goals of care. We use the Islamic obligation for Muslims to seek medical treatment as the foundation for determining the clinical conditions under which Muslim physicians have a duty to treat. We next link the theological concept of accountability before God (taklīf) to quality-of-life assessment. Using this construct, we suggest that a Muslim physician is not obligated to maintain or continue clinical treatment when patients who were formerly of, or had the potential to be, mukallaf (the term for a person who has taklīf), are now not expected to regain that status by means of continued clinical treatment.Keywords: end-of-life issuesIslamic bioethicslife-sustaining treatmentmukallaf FUNDINGAIP's time-effort was partially supported by the University of Chicago's Program on Medicine and Religion Faculty Scholars Program funded by the John Templeton Foundation. AM received a Fentress Fellowship at Pritzker School of Medicine, University of Chicago to help support this project.ACKNOWLEDGEMENTSWe thank Shaykh Mohammed Amin Kholwadia, Shaykh Humza Maqbool and Dr. Omar Hussaini from Darul Qasim Islamic Institute, as well as Taha Abdul Basser, for working with us to clarify the argument in this article. We also are grateful to Dr. Dan Sulmasy for his helpful edits and clarifying discussions related to this target article and the response to commentators. This article was presented in partial form at the 11th annual Critical Islamic Reflections Conference at Yale in April 2012, and at the Inaugural Religion and Medicine Conference hosted by the University of Chicago in May 2012.Notes1 . Fatawa (singular: fatwa), nonbinding ethical/legal Islamic opinions by a qualified Islamic jurist consult or committee of such scholars; qararat (singular: qarar), Islamic opinions issued by a committee of Islamic jurists.2 . This gradient ranges from obligatory (farḍ or wājib) to recommended (mandūb or mustaḥab) to permitted (mubāḥ) to discouraged (makrūḥ) and, finally, to prohibited (ḥarām). For more information, see Table 1.3 . Alibhai reports that withdrawal of life-sustaining treatment is not permissible, according to Ayatollah Sistani and al-Khu'i. Lack of improvement does not justify withdrawal of life-sustaining treatment. See Jaffer and Alibhai (2008).4 . While our discussion has thus far pertained to the Muslim patient, our rubric can be extended to cover non-Muslims by considering them as potential mukallafs. In our view, Muslim clinicians should seek to maximize quality of life for all patients irrespective of religious affiliation and should consider each patient's values (religiously rooted or otherwise) regarding quality of life when making treatment decisions. For the Muslim clinician motivated by Islamic bioethical guidelines, extending our rubric to cover non-Muslims as we suggest may be helpful and indeed demonstrates the robustness of our theory.5 . Although it is accepted that (all other things being equal) every competent patient has the right to accept or reject any intervention, the appropriate decision-making process for mentally incompetent patents who do not have advance directives remains under debate. The most accepted solution is that others ("surrogates") may make decisions on behalf of incompetent adult patients (surrogate decision making). Depending on whether the patient preferences are known or inferable, a surrogate may either use "substituted judgment" or "best-interest" standard to make the decision.6 . Two of the fatawa do encourage forgoing life support in certain condition for unspecified reasons, but it is clear that they are only recommendations and not obligations to forgo treatment. IOMS says that "treatment of patients whose condition has been confirmed to be useless by the medical committee should not be commenced," (italics mine) and interestingly, Yusuf Qaradawi says that it may be in some circumstances recommended to suspend medical treatment.7 . Although relatively recent functional magnetic resonance imaging (fMRI) studies have shown that a small proportion of patients in a vegetative state have brain activation reflecting some awareness and cognition, the level of awareness and cognition is far from that required by the 'aql criteria for mukallaf.