By: Albar MA & Chamsi-Pasha H
Advance Directives (in: Contemporary Bioethics: Islamic Perspective By: Albar MA & Chamsi-Pasha H)
Death is an inevitable phenomenon which strikes at any time during a person’s infancy, youth, or old age. But, one cannot overlook the fact that before the inevitable (i.e., death) does take place a person may become a victim of a terminal illness, or may lapse into an irreversible coma, or (PVS) . The contemporary sophisticated medical care of terminally ill patients increasingly utilizes life support technologies and procedures that many individuals prefer to avoid when they reach that stage .
The Living Will (Advance Medical Directive) is a document in which a healthy person explains in writing which medical treatment he/she would accept or refuse at that critical juncture when he/she may not be in a position to express his/her wishes in case of emergencies, terminal illnesses, and situations where they may be incapable of making decisions. In other words, this document assists the attending physician to withhold or withdraw certain medical procedures and allows the patient to die naturally.
There are two types of advance directives: a living will and a durable or medical power of attorney. Living wills and advance directives, which are legal documents in the United States, are used to make decisions regarding the person’s type of care to receive in situations in which they cannot speak for themselves.
A durable power of attorney for health care is acceptable for Muslim patients. Patients not capable of making healthcare decisions can call upon an authorized representative to express their wishes and make treatment decisions on behalf of their best interests .
The question that arises here is whether it is permissible for a Muslim to include an advance medical directive in his/her wasiyyah? Attention should be drawn here to the fact that the Living Will cannot form part of the wasiyyah, since what is incorporated in the wasiyyah will be executed only after one’s demise.
Prophet Muhammad (PBUH) asked his wives, when he was ill, not to pour medicament in the side of his mouth (Ladood) if he became unconscious, but his wives did. When he came around, he scorned them and asked them to do the same for themselves.
The following may be incorporated into the living will:
Request to discontinue treatment
A terminally ill Muslim patient can request that treatment be discontinued if the treatment would not in any way improve his/her condition or quality of life based on the Islamic juridical principle of la darar wa la dirar (no harm and no harassment). The intention here is not to hasten death, but the refusal of “overzealous” treatment. However, “palliative” care in maintaining personal hygiene and basic nutrition should not be discontinued.
Instruction to switch off the life-support equipment
A healthy Muslim may instruct that should he/she, as a result of a terminal illness or massive head injury, be diagnosed as brain dead, then the life-support equipment should be switched off. In this regard the International Islamic Fiqh Academy of the Organization of the Islamic Conference, during its third session held in Amman–Jordan from 8 to 13 Safar 1407 Hijri/11–16 October 1986, resolved that a person whose brain activity has ceased and the physicians confirm that such a cessation is irreversible and that the brain has entered the state of decomposition, under such circumstances the ventilator could be stopped even though some organs of his body, like the heart, continue to function artificially with the help of life-support equipment . Other Fatwas on this issue allowed stopping the ventilators whenever brain death was diagnosed. They have been discussed in the Chap. 14.
• Inclusion of organ donation (Please refer to the chapter on Organ transplantation).
• Power of attorney (wakalah)
In the alternative Living Will it would be prudent on the part of a Muslim to entrust someone with the power of attorney and mention that person by name in his/her Living Will. This would safeguard that should he/she become noncompetent, then his/her wishes as stated in the Living Will would be expressed by his/her wakil  (authorized representative) to family members and the attending physicians. The document should be dated and signed by the person giving the advanced medical directive, his/her wakil, and that of two witnesses.
Muslims may draw up an alternative Living Will and include in it instructions pertaining to the cessation of treatment, switching off the life-support equipment, and organ donation. The wakil (authorized representative) would be morally bound to express and convey the wishes of the person concerned to members of the family and the attending physicians. If none of the clauses of the Living Will contradicts the broad teachings of the Qur’an and Sunnah of Prophet Muhammad (PBUH) there would be no justification to ignore the directives given therein .
A prototype of an Islamic Living Will has been developed by the Ethics Committee of the Islamic Medical Association of North America (IMANA). It was published in The Journal of the Islamic Medical Association of North America, Volume 37, Number l, July 2005. p.37.
46.Ebrahim AF (2000) The living will (Wasiyat Al-Hayy): a study of its legality in the light of
Islamic jurisprudence. Med Law 19(1):147–60. [PubMed]
47.Ebrahim AF. The living will (Wasiyat Al-Hayy): a study of its legality in the light of
Islamic jurisprudence FIMA Year Book 2005–2006. Jordan Society for Islamic Medical
Sciences in Collaboration with Federation of Islamic Medical Associations (FIMA) [PubMed]
48.Babgi A (2009) Legal issues in end-of-life care: perspectives from Saudi Arabia and United
States. Am J Hosp Palliat Care 26(2):119–27. [PubMed]
49.Resolution No. (5) of the third session of the council of the Islamic Fiqh Academy in
Organisation of the Islamic Conference’s Islamic Fiqh Academy—Resolutions and Recommendations. Jeddah. Matabi` Shirkat Dar al-`Ilm li al-Tiba`ah wa al-Nashr. 1406– 1409H/1985-1989, p 30.
50.For an account as to who can be appointed as the wakil see Kitab al-Fiqh `ala al-Madhahib al-Arba`ah, vol 3, pp 170–171. 51.Ebrahim AF (2005–2006). op.cit.