AMA Journal of Ethics^®

Case

Mr. Abdullah had just been admitted to the ICU at a major academic medical center. He had traveled there to undergo surgery recommended by his doctor back home in Damascus, Syria. Shortly after his arrival, Mr. Abdullah suffered a heart attack and went into cardiac arrest. His son, who had accompanied him on the trip, called 911, and Mr. Abdullah received CPR for 18 minutes on the way to the hospital. Although his pulse returned, Mr. Abdullah was breathing on a ventilator and comatose on exam.

Neither Mr. Abdullah nor his son spoke English, so Dr. Kramer, the ICU physician, communicated through an interpreter. She explained what had occurred and ordered a neurology consult to evaluate the degree of hypoxic-ischemic injury to his brain and determine whether he was likely to regain consciousness. The consult concluded that Mr. Abdullah was unlikely to regain any significant neurological function.

During their conversation about Mr. Abdullah’s prognosis, Dr. Kramer stated that there was a risk that he might code again and advised that a DNR order be written. Mr. Abdullah’s son agreed that this was appropriate, and the order was written. The following day, however, the son asked that the DNR order be rescinded, saying that he had spoken with his older brother back in Syria and that his brother, who stood at the head of the family in their father’s stead, thought the DNR was inappropriate. Confused by this sudden reversal, Dr. Kramer asked if any other family members had weighed in with their opinions. The son replied that they had not, nor had they been asked to; he and his elder brother were their father’s only sons, and the feelings of their mother and sisters were irrelevant in this case.

“In fact,” the son explained through the interpreter, “our mother has not been told about what has happened to our father since his arrival because my brother did not wish to upset her.”

Dr. Kramer knew from previous experience that, by law, if a patient had not designated someone to exercise power of attorney for health care, the responsibility for decision making on the patient’s behalf fell first to his wife. If he had no wife or if she declined to act as surrogate, then it fell to the majority decision of adult children. She explained this legal requirement to Mr. Abdullah’s son and asked him to help her act accordingly. The son refused, upset by the doctor’s apparent disrespect for his culture.

Commentary 1

Proper case management of Mr. Abdullah, a Muslim patient from Damascus, Syria, who has suffered a severe hypoxic brain injury requires the services of several experts to ensure the best possible care for him and his family. Barriers to good care include language, culture, and religious differences and the physical distance that separates Mr. Abdullah from most of his family members. The services of a qualified interpreter are needed, as is the guidance of a physician who is knowledgeable in Islam and Islamic medical ethics. Finally, the assistance of an Islamic religious leader such as an Imam or an Islamic scholar will help achieve an outcome with which everyone involved can feel comfortable.

Since the patient is Muslim, Islamic law and Islamic medical ethics are important governing factors in decision making. Islamic law is derived from the Qur’an, the Muslim holy book, and from the Hadiths, the traditions of the Prophet Muhammad (peace be upon him). Islamic medical ethics is based on Islamic law as well as statements of Islamic scholars. The Ethics Committee of the Islamic Medical Association of North America (IMANA) offers clarification in the management of patients and has published a position paper that covers many medical and ethical dilemmas [1].

In this particular case, the prognosis for neurological recovery is poor. If Mr. Abdullah survives, he is unlikely to recover neurologically and will remain in a persistent vegetative state (PVS). IMANA does not endorse prolonging the misery of a patient who is dying of a terminal illness when death is inevitable or of a patient in a PVS. In such cases, IMANA’s position is that the patient should be allowed to die without unnecessary procedures while at the same time receiving nutrition, hydration, antibiotic treatments, and palliative care [2, 3]. No additional attempts should be made to sustain life with artificial life support. If the patient is on mechanical support, this can be withdrawn with the consent of the patient’s family members [1-4]. IMANA is, however, opposed to euthanasia and assisted suicide [2]. Initiating a DNR order is appropriate for Mr. Abdullah, according to IMANA’s position [2-4]. IMANA also recommends that all Muslim patients have a living will and an advance directive to assist physicians in understanding the wishes of patients who are in situations akin to that of Mr. Abdullah [1].

One strategy for overcoming these language, culture, religion, and physical distance barriers is to call on the services of an Imam or Islamic religious leader or scholar. Although Muslims are a diverse group of people with many different cultures and languages, they share universal respect for the knowledge and guidance of an Imam. The Imam’s expertise along with the physician’s medical explanations would be most effective in conveying the patient’s status in Islamic terms to the family in the United States and the family overseas. In this case, for instance, an Imam could help the family understand that initiating a DNR order does not mean their decision resulted in Mr. Abdullah’s death. The spiritual implications that accompany a family’s DNR decision for a loved one can be addressed by the Imam in religious terms. He can explain that accountability for the loved one’s death does not rest on the shoulders of family members who do not request futile attempts at sustaining their loved one’s life. The Imam can help family members understand that letting go does not equal responsibility for Mr. Abdullah’s death.

Another matter of concern in managing this particular patient appears to be the role of gender in Islam. The Qur’an at 2:187 states that men and women are each others’ garments or each others’ protection [5]. Muslim women have the right to marry men of their choice, divorce, obtain education, spend their earnings as they wish, and raise their family with their husband’s support. The equal status of the sexes is not only recognized, but insisted upon. The Qur’an at 3:195 cites that any good deed done by a male or female is never wasted, for one is the offspring of the other [6]. Independent and strong Muslim women are not foreign concepts in Islam. In fact, Khadija, the first wife of the Prophet Muhammad (peace be upon him), was a wealthy business woman who proposed to Muhammad (peace be upon him) and lived happily with him until her death at the age of 65. Khadija was the first person to accept Islam after it was revealed to her by Prophet Muhammad (peace be upon him) [7]. This example of an independent and strong woman in Islam is reflected doctrinally in the right of women to make decisions mentioned above.

Despite many examples of the equal status of women in Islam, various cultures label Muslim women as weak and lacking the strength to make important decisions—particularly decisions about life and death. Such notions are culturally based, arising from the beliefs that prevail in the woman’s country of origin as well as the level of education the woman had obtained.

Pakistan, Indonesia, and Bangladesh all have had Muslim women as heads of state. Many Muslim women are also highly educated and succeed in the professional ranks while assuming the traditional roles of wife and mother. Prophet Muhammad (peace be upon him) has stated that paradise lies under the mother’s feet—indicating the great respect due to mothers in Islam [8].

In this case, Mr. Abdullah’s wife is the most appropriate figure to make a decision regarding her husband’s life. Her sons seem to be protective of their mother and do not think it necessary to burden her with such a difficult decision. Perhaps they do not think she is strong enough to hear difficult news or decide upon the DNR order. Here, the Imam or an Islamic scholar can assist in conveying the difficult news to the patient’s wife, but with or without an Imam’s help, Mr. Abdullah’s wife should have been informed and given the opportunity to decide upon the DNR order.

This particular case reflects several medical, cultural, and ethical issues that must be handled by a team of experts. The use of a physician knowledgeable in Islam and Islamic medical ethics is preferred, an interpreter should be employed, and an Imam or religious leader who can effectively communicate with the family will be most helpful.