Elderly Health Care and Patient Autonomy in Islam Essay

Introduction

The concept of patients’ autonomy has gained much popularity during the last three decades. Currently, informed consent is recognized as a foundation of the medical practice across the globe. Islam reckons the underpinning value of the basic concept of patients’ autonomy. Nonetheless, differences emanate in their apprehension and practical application. The World Health Organization (WHO) reckons that the anticipation for autonomy is universal but also noted that there are cultural diversities in its understanding and applicability¹.

For instance, many health care associations have realized that patients have the right to choose an appropriate treatment from all available options. Medical practitioners as well as family members should respect patients’ autonomy through issuing essential information and motivating them to take control in the decision-making process.

According to Fry, Veatch, and Taylor, patients and medical practitioners in the Western society believe that the patients’ autonomy must be respected². The Western bioethics prioritizes the essence of the personal decision by arguing that patients should be left to make decisions about their life. While this is fundamental, most patients in the United States believe that it is necessary for the clinicians to be part of the decision-making process on consultative capacities.

On the other hand, Webster and Karen identified that in the Muslim society, patients’ autonomy is essential but it is the responsibility of the family, caregivers, and policymakers to ensure that the elderly needs are addressed appropriately³. This scholar claims that the Islam values regarding care for the elderly should not adopt the Western perspective that views the aged as problematic to the community. The elderly must be assisted in making decisions while respecting their dignity.

Therefore, this article will emphasize that stringent devotion to the Western-based structure of medical ethics and autonomy is inadequate to tackle ethical impasse in contemporary medicine. The Western bioethics advocates for autonomy that encourage choices covering all areas of social and individual life, an aspect ignored in the Islam cultures. In Islamic bioethics, besides autonomy, the essence of God, the society, and the patient are considered. However, this paper will adopt a more pliable perspective that incorporates cultural values in understanding patients’ autonomy and administering it in a highly modernizing society.

The predominant Western perspective vs. the Islamic perspective

According to Schultz and Levi, informed consent is defined as a discretional and precise agreement made by a person who is deemed competent to make an informed decision concerning a proposed act⁴. This research has indicated that the principle of patients’ autonomy has for a long time existed in Islam, only that its application may have differed to the secular model. Despite the functional differences in Western and Islamic bioethics, they are essentially common in the application⁵. The Western approach is a contemporary phenomenon developed in early the 1980s to examine issues in clinical practice and biomedical studies.

It was anchored in worldly philosophical factors basing on human reason and declined moral values related to religion. Islam and other non-Western models were seen as inferior and uninformed. The Western model was designed based on individual rights granted to individual to decide for his or her destiny. This approach encountered several challenges that called for moral considerations.

On the other hand, Webster and Karen suggest that the Islamic approach generates its resources from spirituality⁶. God (Allah) is the guiding force that helps people acknowledges moral concepts precisely applicable to health care. A common basis of belief and norms leads to a monotheistic culture focused on building harmony in one’s life, family, and community via adhering to the will of God.

According to Webster and Karen, in Islam, the bioethical decision-making is guided by religion since it describes the role of the self, family, and the healthcare providers. There is no event in Muslim society considered as completely secular. In the Western culture, the concept of autonomy facilitates individualism and self-control. These expectations block a third party from offering support unless the individual grants permission. This requirement indicates how respect of autonomy can hinder the Islamic principles to help the elderly.

Confucianism, for instance, is a profound cultural and philosophical phenomenon in Asia, which sees autonomy from a different perspective from Western traditions. Confucius view of humans takes two faces, the vertical and horizontal dimension. The vertical dimension views people as rational beings and independent while the horizontal views people as autonomous but also as relational since they have to participate in enhancing the welfare of others.

In this light, man is seen as born and civilized by education and experience to become a relatively autonomous being. Islamic bioethics is anchored on obligations to care for the elderly and social wellbeing for all. Individual considerations are subordinate to community interests. This claim contravenes the United Nations Educational, Scientific and Cultural Organization (UNESCO) declaration that comprehends that personal benefits should be put ahead of the interest of the family or community⁷.

The Islam society believes that in cases where the patient is incapacitated by a disease to make decisions, the physician or a family member may be needed to identify what the patient would want or what could be his preferred course of action. In Islam, if an individual act of autonomy has potential to cause risks to self or others, it is the obligation of the physicians or the society to prevent such acts since they undermine collective wellbeing.

For instance, hazardous lifestyle and actions that threaten personal and public well-being such as substance abuse and environmental pollution are restricted in Muslim society. Contrary, in Western society, these activities are enclosed within the spectrum of individual autonomy and are thus viewed as a personal decision. Islam society undermines personal autonomy if the consequences are detrimental to others. According to Sachedina, ethics is believed to be the basic segment of every act of a Muslim. Consequently, the physician-patient interactions and ethical values are better safeguarded in Islamic approach as opposed to Western approaches⁸.

Ethical dilemmas

Modern geriatric care is growing increasingly multicultural and diversified. The geriatric care is far more complex than merely taking care of the elderly patients. Due to the diminished level of competence among the elderly people, the patient unit in Islam societies is extended to cover the patients’ family, cultural, and religious factors. Consequently, physicians meet patients from a variety of cultural and religious foundations of their practice and must cross various barriers to offer sensitive care. The Islam community is not an exception since value and belief differences between the physician and the patient often cause ethical conflicts.

However, since the aging population is more vulnerable to a terminal and complex ailments, this portion will analyze various ethical dilemmas that include euthanasia, the right to decline, lying to patients, and use of resources.

The argument to commit a mercy killing still revolves on if or not patients have the right to die when they feel they cannot fight anymore. Unlike in the Western society, where patients might be given the opportunity to commit euthanasia, the Islam society believes that life is a sacred gift to humanity by God, and only Him has the authority to take one’s life. Most of these elderly patients are terminally ill and weak to fight illness thus it is necessary to let them die if they wish to die. Contrary, the Islamic ethics advocate that geriatric care is about facilitating quality care and assisting the elderly live longer through available resources and nursing care towards the aged. Islam bioethics advocates for practices that encourage the patients to stay strong and look forward to achieving their health goals.

In the Islamic society, people are granted the right to make choices, but it becomes a dilemma when such choices influence individual’s health or threaten death. Anorexia is a highly used eating disorder by patients who want to starve themselves to death by eating very little. Dealing with such challenges becomes increasingly difficult for a physician. According to the Islam society, it is a moral obligation of the physician to override the freedom of choice for the patient and intervene in the best interests of the welfare of the patient. Essentially, it is always desirable to give the patient hope since it generates believe to see life from a positive perspective.

Requests to uphold the truth about a patient’s condition are very common from family members of the elderly patients. It is also possible for clinicians to provide false details by telling a patient that their conditions are worse than they are. Lying to patients might be acceptable in cases where the decisions favor the well-being of the patient⁹. For example, dealing with alcoholism or substance abuse among the aged patients is very challenging.

Research shows that giving warning to substance addicts regarding their health can substantially help them avoid substance use. Clinicians understand that at some point in life addiction will result in terminal illness such as cancer or even death. The ethical dilemma arises whether addicts should be made to believe that they are dying soon. Dobrof, Disch, and Moody refute such claims by arguing that lying cannot be of any benefit to the patient or rather they should be told the truth and left to make decisions regarding one’s life¹⁰.

Use of resources is a common ethical dilemma faced by practitioners every day. Resources are described as inputs used to enable patient care. In the U.S for instance, the aged population is viewed as a burden to the economy since they require many health care resources yet they are not productive.

These resources include funding, bed spaces, and human labor. The question of how clinicians should deal with patients who utilize these resources while other patients who can utilize them better arises. Many aged people are seen as a group that is ailing thus; there is diminished importance for them to stay on life support machines while such resources can be channeled to young patients with higher chances of survival. Contrary to this claim, the Islamic society does not view one’s life more important than others do regardless of age, gender, religion, or race¹¹. The few mentioned examples are ethical challenges that physicians encounter every day while handling geriatric care in Islamic societies.

Dignity in the care of the elderly vs. clinical practice

Dignity is the state of feeling important, honored or acknowledged. Despite the devotion and growing focus on dignity within the Asian health policy and professional codes of practice, dignity proves hard to transform into action particularly in geriatric care. Respect for the dignity of patients has to be balanced with respect for practitioners’ self-respect. This scholar indicated some of the common practices that amount to the lack of integrity for patients. These cases include leaving patients in poor conditions, pushing and handling patients in a rough and unsympathetic manner resulting in pain.

Elderly patients need a lot of attention, and if they are not seen regularly or talked to, they feel that they have not been recognized. Sachedina pointed out that with permission from the patient, personal space, for instance, can be entered with no loss of dignity¹². When permission is sought, the patient does not feel humiliated, but when personal life is invoked, it results in potentially damaging emotion.

In clinical practice, an array of research has proven that dignity and care have diminished. Most research has found that this deterioration of dignity has emerged from the change in clinical education and lack. However, such claims are very usual and yet there is little evidence to prove that dignity was at one time highly upheld¹³. Dignity entails the obvious things, but that are crucial such as keeping hygiene and getting a timely response from the nurses.

Currently, there has been emerging tendency to reduce the cut on the burden of the health care provision based on individual human rights. Patients are concerned with making decisions on their health unlike in the past were testing, and isolation of patients was done based on suppressing the rights of the few for the benefit of the larger population. This act is not morally acceptable in not only the Islamic States but also elsewhere in the world. This aspect was an act of lack of dignity for patients suffering from various diseases targeted in this approach. For instance, discrimination for patients infected with HIV/AIDS was common until the United Nations policy prevented isolation for those patients.

The diminished principle of autonomy

The bioethical challenges in the contemporary Islam society have emanated from clashing lines of thought, offering diverse human interests and responses. Current bioethics emerged from the West with a background of non-compliance with the church values, and it was seen to be founded on a materialistic perspective. Religion forms an integral part of the Islamic culture and thus Islam offers the model for thinking and making meaningful decisions.

On the contrary, Schultz and Levi declare that religion was merely a way of denying the freedom to make own decisions¹⁴. Various arguments supporting the need for autonomy concerning patients’ care have been met with high criticism. For example, the end-of-life decisions, which are widely endorsed in the West, are highly refuted in most non-West countries that belief in life after death. For Muslims, helping the elderly to attain good health care and avoiding death is an obligation of everyone in the society. The wellbeing of the aged population is viewed as a moral obligation to the physicians and the society.

The caring of the elderly is considered an essential undertaking that should be prioritized while respecting one’s autonomy. However, in some cases when elderly patients wish is to terminate their lives, physicians and members of the society are supposed to offer a motivating message. Such practices infringe the wishes of the patient thus compromising with the principle of personal autonomy. Most of the elderly population is vulnerable to terminal diseases and treatment might not be sufficient to better the situation. In most Western countries, the physicians are allowed to abide by the patient’s wish to facilitate death.

Contrary, Muslim law suicide or assisted death is not allowed. Since telling the truth is an ethical requirement, physicians are supposed to apply their knowledge when revealing undesirable diagnosis to guard their patients against thinking of terminating their lives. In the Muslim society, advocating for something spiritual and enhancing social care is a way of diverting stressful feelings.

In some parts such as Asia, social and family practices influence personal autonomy. The West view such influence as primitive and inferior because personal views are in most cases accorded a subordinate role. Asian culture perceives the family as a sociocultural entity that pursues both individual and familial autonomy. Family interventions are seen as a moral intervention from God, and thus they cannot be excluded in decision-making regarding the health care of the elderly. While Islam views the best ethical practices as those that consider family considerations in decision-making, researchers such as Sachedina believe that these family-based practices infringe personal autonomy¹⁵.

Nevertheless, this view is considered of the Islamic belief as unacceptable as autonomy. This argument is based on the understanding that very few aged people are competent to autonomous decisions. A physician is justified to reject a patient’s request for a diagnosis procedure if it is deemed harmful to one’s well-being. In such situations, the family should assist the physicians in persuading patients from unwise choices and propose what they believe is meaningful for the patient.

Moreover, some choices are complex and hard for even competent patients to make informed choices on their own. Following negotiations, a patient’s decision to adopt the physician’s choice might not necessarily mean infringement of personal autonomy¹⁶. In cases when a patient makes questionable wishes or s/he is incapacitated to come up with an autonomous decision, the family or the physician should be advised to respond to patient’s preferred interests. Provided there is a mutually agreed goal among all stakeholders, recommendations should not be seen as interfering with patient’s autonomy.

The role of dignity and respect for autonomy

The concept of dignity is rooted in the Islamic religion and that it plays a great role in improving patient’s self-actualization. Treating older patients with dignity helps enhance self-respect, empower them to make choices and encourage them to stay positive. Older people feel honored and needed when they are treated with dignity. This feeling is essential since it triggers positive experiences and increase the urge to live long. Even though the Islamic society encourages assisting old people to make decisions, it does is essential to let them know the truth about their conditions. Since it is their life, they should be allowed to know everything but assisting them to come to a solution is necessary. When old people are treated with dignity, they generate a view that they are handled as adults but not children and the same as others.

Age and gender inequality and the effect on dignity and respect for autonomy

The traditional thinking about human beings presupposes that all people should be accorded the respect, dignity and rights to make own decisions. The Universal Declaration of Human Rights echoes this segments by recommending that people be accorded the freedom to make personal decisions. However, these traditional conceptions of human dignity are disputed by the contemporary bioethics dilemmas. For instance, Lesser questions how the dignity and respect for the autonomy of a fetus or severely handicapped patients can be accorded¹⁷. Therefore, it becomes a challenge determining if humans at all ages should be accorded equal dignity and rights. Many philosophers have challenged this viewpoint. In modern bioethics, Leners declares that a person is a rational agent able of making personal decisions¹⁸.

A person is defined as possessing qualities such as a sense of self-consciousness and rationality. Nonetheless, it should be noted that people at their tender age are not yet developed to make competent decisions thus they should be directed in the process of decision-making. Similarly, the elderly people are associated with aging disorders such as memory loss, agitation, and poor communication skills. For these individuals, the conception of personhood may not necessarily lead to self-control and autonomy.

Moreover, not all cultural practices share a common conception of humanity. This aspect has an implication for the application of dignity and respect for autonomy across different genders. Women in the Islamic communities have struggled for gender equality and fundamental rights. Guido argues that patriarchy and religious traditions have colluded with against the women around the Middle East¹⁹.

Currently, across the Islamic community, women’s rights are one of the most contentious issues in the nursing practice. The development of women autonomy and respect for dignity has not been smooth due to its collision with cultural and religious norms. Due to the diminished place of a woman in the Islamic world, such reduced importance has been reflected in the clinical practice. Women are denied the opportunity to participate in decision-making regarding their health. Women needs in the hospital are not given enough attention compared to their male counterparts who have the power to make personal decisions.

Language barriers

Effective communication is essential to respect for dignity and patient’s autonomy. In a bid to offer quality care, good communication should be facilitated between older patients and health care providers. Effective communication skills mark the process entailed in assessment and care provision for the older people. Since communication relies upon a common language, this pre-requisite may not be present in many elderly patients. Due to the high rate of globalization, the medical sector has been dominated by the mobility of labor and trade goods. This aspect means that caregivers in most of the care centers in Islamic nations might not necessarily be familiar with the local language. Besides, language proficiency among the aged people might be influenced by age-related disorders such as memory loss and psychiatric conditions.

Limited ability in English is a major communication barrier in Islamic societies. The elderly people are less likely to be proficient in English since it is a second language that has gained access to the Islamic world in recent years. For instance, most health care providers in Saudi Arabia are migrants from nations such as the US, the United Kingdom, and other nations with different cultural backgrounds.

A language barrier can also arise when a sender speaks too quickly for the receiver to comprehend. Additionally, providing too many details or addressing the individual harshly can result in a language barrier. Using a commanding tone can destroy a patient’s self-esteem and cause communication failure. According to Fry, Veatch, and Taylor, the aged are very vulnerable to demeaning emotional tone and a body language that does not support a positive implication²⁰. Cognitive and physical impairments can damage several elements of communication, and huge care should be considered to ensure that language proficiency is accounted for during any exchange.

Stereotypes also affect the way caregivers communicate to the elderly patients. The stereotyped sentiments that are socially attached to people relating to their age and health status can cause health providers to act dismissively when dealing with aged individuals. Besides, the lack of awareness about certain stereotypes can create a damaging impression. Non-verbal communication such as gestures, body language, eye contact, or facial expressions often transmits messages before one speaks. However, it is desirable for care providers to develop awareness of their body language since they can pass an unfavorable message.

The communication environment is a critical factor while handling aged patients. Most of the geriatric care systems in the Islamic countries are still yet to be fully developed compared to the Western countries²¹. The level of development is still low, and funding for health resources is difficult. This aspect implies that residential aged care resources and hospitals are always busy zones, and thus the chance to converse quietly and privately may be unrealistic. This situation places aged people at a disadvantage since they are controlled in their conversation. Regardless, the Islam traditions expect the service provider to work to the best interest of the aged and provide a private place. When an aged person is placed in an unfamiliar environment may become stressed. Patients often speak faster when experiencing stress and this can cause misunderstanding.

Isolation and loneliness

Isolation and loneliness are frequent challenges that face older people in Islamic countries and pose a significant detrimental effect on health. Research shows that social isolation and loneliness have negative implications for both mental and physical wellbeing of the aged²².

The effects of isolation and loneliness can lead to premature death and cardiovascular complications. On the other hand, the physiological implications of social engagement and keeping social bonds can maximize body functioning and reduce diseases related to exposure to stress. The Islamic doctrine encourages physicians and families to take the responsibility of ensuring the needs of the aged are met adequately. Furthermore, the Islam community believes that social relationships are critical during old age, and those patients who have a network of interpersonal ties experience better health as opposed to those who are socially abandoned.

Elderly access to health care

In Islamic countries, everyone is accorded the right to quality healthcare. Besides, the Qur’an pays huge concern to the way the elderly are treated. However, since most of the Muslim nations are less developed, the access to health care and catering for social demands for the elderly is problematic. Some of the health services are not provided in the public clinics in the Arab region. For instance, mental health services are covered to a limited extent forcing patients to seek treatment in the private sector. Even though Islam advocates for equal rights across all ages, there is a tendency to streamline resources to younger patients, while mentally retarded aged people tend to be disadvantaged.

Conclusions

The phenomenon of a universal standard of medical ethics appears unrealistic. Bioethics needs to adjust its perspective and realize cultural diversities and moral practices of non-Western cultures. Even though personal autonomy remains a vocal point of bioethics, it should not be the consummate right of the individual but rather a joint obligation between the physician, patient, and family. Such sharing of responsibility should not be seen as undermining patient’s autonomy but rather enhancing a patient’s ability to make decisions.

Final decisions should be based on mutually accepted goals factoring the patient’s spiritual, cultural, and psychological demands. This mutual understanding is attained through effective communication between patients and health care providers. Quality elderly care relies on good relationships that facilitate discussions leading to adherence to medical procedures.

Bibliography

Dobrof, Rose, Robert Disch, and Harry Moody. Dignity and Old Age. Hoboken: Taylor and Francis, 2013.

Fry, Sara, Robert Veatch, and Carol Taylor. Case Studies in Nursing Ethics. Sudbury, MA: Jones & Bartlett Learning, 2011.

Guido, Ginny. Legal and Ethical Issues in Nursing. Upper Saddle River: Pearson/Prentice Hall, 2006.

Leners, Jean-Claude. “Euthanasia, Palliative Care, Hospice and Elderly in Luxembourg. Ethical and Numerical Considerations Over 3 Years”. European Geriatric Medicine Journal 4, no. 38 (2013): 7-124.

Lesser, Harry. Justice for Older People. Amsterdam: Rodopi, 2012.

Padela, Aasim. “Medical Ethics in Religious Traditions: A Study of Judaism, Catholicism, and Islam”. Journal of Islamic Medical Association 38, no. 3 (2006): 38-43.

Rathor, Mohammad, Mohammad Rani, Azarisman Shah, Islah Leman, Uddin Akter, and Ahmad Omar. “The Principle of Autonomy as Related To Personal Decision Making Concerning Health and Research from an ‘Islamic Viewpoint’”. Journal of Islamic Medical Association 43, no.1 (2011): 46-57.

Sachedina, Abdulaziz Abdulhussein. Islamic Biomedical Ethics. Oxford: Oxford University Press, 2009.

Schultz, Marcus, and Marcel Levi. “Prescription Of Rh-APC Differs Substantially Among Western European Countries”. Intensive Care Medicine 32, no. 4 (2006): 630-631.

Tadd, Win, Alex Hillman, Sian Calnan, Mike Calnan, Tony Bayer, and Simon Read. “Right Place ‐ Wrong Person: Dignity in the Acute Care of Older People”. Quality in Ageing and Older Adults 12, no. 1 (2014): 33-43.

Webster, Carole, and Karen Bryan. “Older People’s Views of Dignity and How It Can Be Promoted in a Hospital Environment”. Journal of Clinical Nursing 18, no. 12 (2011): 1784-1792.

Footnotes

1. Mohammad Rathor, Mohammad Rani, Azarisman Shah, Islah Leman, Uddin Akter, and Ahmad Omar, “The Principle of Autonomy as Related To Personal Decision Making Concerning Health and Research from an ‘Islamic Viewpoint’”, Journal of Islamic Medical Association 43, no.1. (2011): 46-57.
2. Sara Fry, Robert Veatch, and Carol Taylor, Case Studies in Nursing Ethics, (Sudbury, MA: Jones & Bartlett Learning, 2011), 67-72.
3. Carole Webster and Karen Bryan, “Older People’s Views of Dignity and how it can be promoted in a Hospital Environment”, Journal of Clinical Nursing 18, no. 12 (2011): 1784-1792.
4. Marcus Schultz and Marcel Levi. “Prescription Of Rh-APC Differs Substantially Among Western European Countries”. Intensive Care Medicine 32, no. 4 (2006): 630-631.
5. Abdulaziz Sachedina, Islamic Biomedical Ethics, (Oxford: Oxford University Press, 2009), 88.
6. Webster and Bryan, 1784-1792.
7. Sachedina, 42.
8. Ibid, 62.
9. Rose Dobrof, Robert Disch, and Harry Moody, Dignity and Old Age (Hoboken: Taylor and Francis, 2013), 23-41.
10. Ibid, 23-41.
11. Webster and Bryan, 1792.
12. Sachedina, 101.
13. Win Tadd, Alex Hillman, Sian Calnan, Mike Calnan, Tony Bayer, and Simon Read. “Right Place ‐ Wrong Person: Dignity in the Acute Care of Older People”. Quality in Ageing and Older Adults 12, no. 1 (2014): 33-43.
14. Schultz and Levi. 630-631.
15. Sachedina, 77-83.
16. Aasim Padela, “Medical Ethics in Religious Traditions: A Study of Judaism, Catholicism, and Islam”, Journal of Islamic Medical Association 38, no. 3 (2006): 38-43.
17. Lesser, Harry, Justice for Older People (Amsterdam: Rodopi, 2012), 12-34.
18. Jeane-Claude Leners, “Euthanasia, Palliative Care, Hospice and Elderly in Luxembourg, Ethical and Numerical Considerations Over 3 Years”. European Geriatric Medicine Journal 4, no. 38 (2013): 7-124.
19. Ginny, Guido, Legal and Ethical Issues in Nursing, (Upper Saddle River: Pearson/Prentice Hall, 2006), 44-56.
20. Fry, Veatch, and Taylor, 67-72.
21. Padela, 39.
22. Dobrof, Disch, and Moody, 23-41.