Agenda on advance medical directives

Muslim scholars take the view that there is a limit to a patient’s autonomy in choosing the forms of treatment and care, as a doctor’s professional advice should also be considered.

FROM the perspective of the medical practitioner, an advance medical directive (AMD) is a proactive measure by an individual to help family members and next-of-kin decide the forms of treatment that must be provided when the individual has lost the ability to make his/her own decisions.

However, in Malaysia, there are no standardised guidelines on AMD to ensure that the care and management of patients who have lost their decision-making ability is ethically done, unlike some countries such as the United States, Australia, Holland, Germany, Italy, Switzerland, Canada, England and Wales in Britain, and Singapore.

In the Malaysian and Muslim contexts, discussions on AMD among community members outside the medical fraternity are still in their infancy. Because of this, public awareness on AMD is poor and consequently discussions on AMD from the Islamic perspective are very limited.

Even medical practitioners may not agree on the definition of an AMD. However, in simple terms, AMD includes aspects of care, treatment and disclosure of patient’s wishes after death. This may help the next-of-kin to make the decision when the time comes.

Modern medicine has enabled physicians to perform intervention in order to prolong one’s life, for example, by using a ventilator to mechanically assist or take over a patient’s breathing process.

Although such intervention is capable of “prolonging” one’s life, there are implications, such as ethical dilemmas, treatment costs, arguments between healthcare providers and family members, and possible violation of the patient’s wish in the choice of treatments.

This is so because modern medical practice emphasises patient autonomy, especially in making his/her own medical decision, shifting away from physician’s paternalism.

Patient autonomy is an important basis in modern medicine practice because the medical bioethics focus has started to shift from doctor’s benevolence to patient’s autonomy.

However, when a patient is unable to make his/her own decisions, doctors face difficulties deciding whether a particular course of treatment would be acceptable to the patient or not. Family members too face the same difficulties.

The bottom line is that everyone wants what is best for the patient. But who makes the final call? Would an AMD, made before the patient was not able to communicate his/her wishes, be the best thing to base the decision on?

AMD is a documentation method to keep the patient’s right to autonomy in making decisions, while helping family members and next-of-kin to choose the form of treatment which is agreeable to the patient in a situation where the patient has lost the ability to decide.

In developed countries, AMD has become part of a comprehensive approach to health care.

Although AMD is seen to be capable of empowering patient’s autonomy in decision-making, the document cannot be considered “complete” – that is, capable of expecting every probability that may happen, or even addressing the change of patient’s attitude.

The effectiveness of AMD as a tool to protect patient’s autonomy is also being questioned by certain parties as the document might be abused by irresponsible parties.

With regards to the Islamic perspective in Malaysia, there is not yet any specific view on AMD.

Previous discussions mainly focussed on issues outwardly related to AMD such as euthanasia, brain death, organ donation and body donation after death. Islamic jurists may not realise that these issues are related to AMD.

In fact the patient’s wish to continue or withdraw mechanical ventilation when diagnosed with brain death, and the desire of patients to donate or not to donate an organ or body after death can be articulated in the AMD document.

Generally, Muslim scholars take the view that there is a limit to patient’s autonomy in choosing the forms of medical treatment and care, as a doctor’s professional advice should also be considered.

This is because choices made to satisfy personal interests and satisfaction are contrary to Islamic values. The emphasis in Islam is more on public interest compared to personal interest.

Furthermore, Islam puts the emphasis on doctor’s efforts in saving lives.

However, Islam also recognises the limitation of human endeavour, and as such all efforts must be followed by tawakkal (perfect faith that Allah makes rules that will give humans everything they need).

Having said that, doctors should exhaust all possible avenues in order to save a patient’s life.

Realising that there are no specific guidelines on AMD, discussions on this issue have begun to take place.

In April, the Institute of Islamic Understanding Malaysia initiated preliminary discussions to identify issues pertaining to AMD that need to be looked at from the Islamic perspective. This is an on-going process which has received support from the stakeholders.

Involvement of stakeholders is important to ensure uniformity in providing guidelines on AMD which are applicable to all hospitals in Malaysia.

These guidelines must also take into consideration the religious and cultural aspects of the Malaysian community, and not just simply be adopted from other countries.

In discussing AMD within the framework of Islam, the aspect of maintaining and preserving life as outlined by maqasid al-shariah must be given priority. The challenge is to get medical practitioners and Islamic scholars to study this issue collaboratively and to understand each other’s point of view.

In this regard, Ikim plays the role as the “bridge” that links the two.

The outcome should be something that is practical, implementable and, most importantly, upholds the objective of saving a patient’s life while protecting his/her right to decide.

Dr Shaikh Mohd Saifuddeen Shaikh Mohd Salleh is Senior Fellow at Ikim’s Centre for Science and Environment Studies. The views expressed here are entirely the writer’s own.