Assignment: Ethical Health Promotion Paper

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Assignment: Ethical Health Promotion Paper

Assignment: Ethical Health Promotion Paper

Religious, Ethical and Legal Considerations in End-of- Life Issues: Fundamental Requisites for Medical Decision Making

Puteri Nemie Jahn Kassim • Fadhlina Alias

Published online: 10 January 2015 � Springer Science+Business Media New York 2015

Abstract Religion and spirituality have always played a major and intervening role in a person’s life and health matters. With the influential development of patient autonomy and the

right to self-determination, a patient’s religious affiliation constitutes a key component in

medical decision making. This is particularly pertinent in issues involving end-of-life deci-

sions such as withdrawing and withholding treatment, medical futility, nutritional feeding

and do-not-resuscitate orders. These issues affect not only the patient’s values and beliefs, but

also the family unit and members of the medical profession. The law also plays an intervening

role in resolving conflicts between the sanctity of life and quality of life that are very much

pronounced in this aspect of healthcare. Thus, the medical profession in dealing with the

inherent ethical and legal dilemmas needs to be sensitive not only to patients’ varying

religious beliefs and cultural values, but also to the developing legal and ethical standards as

well. There is a need for the medical profession to be guided on the ethical obligations, legal

demands and religious expectations prior to handling difficult end-of-life decisions. The

development of comprehensive ethical codes in congruence with developing legal standards

may offer clear guidance to the medical profession in making sound medical decisions.

Keywords End-of-life decisions � Religious considerations � Ethical dilemmas � Legal standards


Technological and pharmacological advances in medicine have created more challenges to

healthcare professionals as modern medical interventions progress to increase life

P. N. Jahn Kassim (&) Civil Law Department, Ahmad Ibrahim Kulliyyah of Laws, International Islamic University Malaysia, 53100 Kuala Lumpur, Malaysia e-mail:

F. Alias Ahmad Ibrahim Kulliyyah of Laws, International Islamic University Malaysia, 53100 Kuala Lumpur, Malaysia


J Relig Health (2016) 55:119–134 DOI 10.1007/s10943-014-9995-z

expectancy of terminally ill patients. These life-prolonging measures have made end-of-

life care an emerging aspect in the medical field. Decisions at the end of life are no longer

confined to clinical assessments as to what would be in the best interests of the patient from

a purely medical perspective, but involve due consideration of a patient’s religious beliefs,

customs and values, which ultimately have significant influence on a patient’s response to

illness, suffering and dying. Furthermore, the decision-making process also affects

healthcare providers, particularly if the doctor and patient come from diverse cultural

backgrounds and adhere to different sets of values. The conflicting ethical views and

developing legal standards in this area on matters concerning the sanctity and quality of

life, patient autonomy and medical paternalism have also made end-of-life decisions an on-

going debate (Agarwal and Murinson 2012; Billings and Krakauer 2011; Cantor 2005;

Chin 2002; da Rocha 2009; Huxtable 2002; Kuhse 1981; Orentlicher 1998; Rabiu and

Sugand 2014). In any event, all affected parties carry with them their own individual life

experiences, values and beliefs to the decision-making process; accordingly, the event of

death itself, the manner in which it takes place, and the patient’s quality of life are

significant matters that have spiritual and psychological consequences for each of them.

The Importance of Ethics, Religion and Law as Guidance for Medical Decision Making

Ethics is classified as a sub-branch of applied philosophy that is intrinsically related to

morality (Padela 2007). The correlation between ethics and morality is that morality refers

to social norms that distinguish from right to wrong, while ethics describes moral conduct

based on the character and principles in each profession (Elsayed and Ahmed 2009).

Medical ethics is a subdivision of ethics that is concerned with moral principles as they

relate to biomedical science in the clinical and investigational arenas (Padela 2007).

Ethical principles are essential in helping to guide medical judgements that need to be

made and should be intrinsically linked to the application of clinical skills and knowledge,

which are used for delivering what is in the best interests of the patient (Tallon 2012).

Accordingly, medicine and morality are thus very much interrelated, as the primary

function of medicine is not only ‘‘to cure illness…but to cure people of their illnesses’’ (Steinberg 2003). The importance of observing medical ethics can be outlined as follows:

(1) ethical standards promote the aim of medical care; (2) medical care is built on the

communication, trust and respect between the medical team on the one side, and the patient

and/or family on the other side; (3) ethical standards help generate public support for

healthcare; (4) public awareness and support for healthcare will promote ethical conduct by

healthcare providers in the performance of their duties; and (5) ethical standards promote

moral and social values and facilitate cooperation and collaborative work between different

medical disciplines, leading to a healthy healthcare environment (Elsayed and Ahmed

2009). All existing medical codes of ethics directly and indirectly incorporate into their

provisions the fundamental principles which form the ethical basis of medical care, i.e.

autonomy, paternalism, non-maleficence, beneficence and justice.

In recognition of the fact that culture and its components of religion and spirituality

constitute major social factors that greatly influence the provision of medical care, espe-

cially at the end of life, some countries have also expressly included these components in

their ethical codes. For example, the Good Medical Practice: a code of conduct for doctors

in Australia issued by the Medical Board of Australia (‘‘GMC’’) contains provisions on

‘‘Culturally Safe and Sensitive Practice’’ which state that ‘‘good medical practice involves

120 J Relig Health (2016) 55:119–134

Assignment: Ethical Health Promotion Paper

genuine efforts to understand the cultural needs and contexts of different patients to obtain

good health outcomes’’ which includes: (1) having knowledge of, respect for and sensi-

tivity towards the cultural needs of the community that one serves, including those of

indigenous Australians; (2) acknowledging the social, economic, cultural and behavioural

factors influencing health, both at individual and population levels; and (3) understanding

that one’s own culture and beliefs influence one’s interactions with patients (Medical

Board of Australia n.d.; Medical Council of New Zealand 2013). Furthermore, in Clause

3.12 of the GMC, which deals with end-of-life care, respect and support for the values and

wishes of the patient and family members are emphasised, including ‘‘different cultural

practices related to death and dying’’ (Medical Board of Australia n.d.).

Cultural competence, i.e. the acquisition of the knowledge and skills that enhance the

management of cultural issues in the clinical environment requires skilled verbal and non-

verbal communication as a means of appreciating differences (Carey and Cosgrove 2006).

Better healthcare especially at the end of life can only be achieved if these factors are given

due consideration as medicine does not merely deal with elements of pure science, but also

major and intrinsic humanistic and ethical components (Steinberg 2003). In Part 3 of the

End of Life Care Strategy issued by the Department of Health in the UK (UK Department

of Health 2008), guidelines are provided to address the spiritual needs of patients nearing

the end of life. This is complemented by the NHS Chaplaincy (UK Department of Health

2003), which acts as a guidance to those involved in the provision of chaplaincy-spiritual

services. It is submitted however that the content of the End of Life Care Strategy and NHS

Chaplaincy, while respecting and recognising the importance of religious and spiritual

considerations in end-of-life care, is not intended to specifically provide an understanding

of the different values and beliefs on end-of-life issues. It is noteworthy that the

Queensland Health Multicultural Services in collaboration with the Islamic Council of

Queensland has published a series of handbooks for healthcare providers in attending to

Muslim, Hindu and Sikh patients, respectively (Queensland Health and Islamic Council of

Queensland n.d., 2010, 2011). Specific areas covered in the handbooks include religious

approaches to end-of-life issues, pain management and the concept of death and dying.

These are intended to support healthcare providers by building their knowledge of the

diverse needs of their patients, noting that ‘‘those who display cross-cultural capabilities in

their work use self-reflection, cultural understanding, contextual understanding, commu-

nication and collaboration to provide culturally appropriate, responsive and safe health

care’’ (Queensland Health and Islamic Council of Queensland n.d., 2010, 2011).

In addition to the above, an integrated effort to develop a codified religious-based

system of ethical conduct can also be seen in the form of the Islamic Code of Medical

Ethics (First International Conference on Islamic Medicine 1981) (‘‘Islamic Code’’), which

was drawn up and adopted at the First International Conference on Islamic Medicine in

1981. The Islamic Code aims to provide a guideline to Muslim doctors in understanding

the tenets of Islam, which are relevant to the performance of their duties. The Islamic Code

cites authorities from the Shari‘ah and provides the Islamic perspective on an array of

subject matters concerning medical care, including end-of-life issues such as the preser-

vation of life, the refusal of a patient to a prescribed plan of treatment, medical inter-

ventions and futile therapy. In addition, the duty to respect the autonomy of the patient, as

well as the obligation to ensure that harm is prevented (non-maleficence), and medical

decisions are made to the benefit and best interests of the patient (beneficence), are inherent

ethical values in the Islamic Code. The extent of application of the Islamic Code in

healthcare policies and legislation of countries populated by Muslims, however, are of

varying degrees from one country to the next.

J Relig Health (2016) 55:119–134 121

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