Iranian Journal of Medical Ethics and History of Medicine

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Brain death is a subject in our society which can be mistaken with coma or other types of life status similar to death. To assess the legal status of a brain dead patient, it is necessary to determine whether a person afflicted with brain death is dead or alive. Do they meet the criteria for biological death? Or in precise words, do Islamic laws for the dead apply to them? Several questions arise in this regard, which give more importance to this issue from the viewpoint of Islamic jurisprudence and law, and all answers depend on our definition of brain death, and whether we find brain death an instance of the separation of body from soul. There has been much research around this issue and the laws in many countries and religions, including Christianity and Judaism, have been disambiguated. In Iran, however, brain dead patients are considered alive, while brain death should be legally considered absolute death like in many medically advanced countries (UK, Germany, France, and USA). The authors aim at examining this issue from the viewpoint of Fiqh and law, and its disambiguation.

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The aim of this study was to explore experiences of family members of patients confronting brain death diagnosis and the request for organ donation.
A qualitative study was designed focusing on content analysis. Data collection process included 38 unstructured in- depth interviews with relatives of 26 brain death patients who were candidate for organ donation and field notes. Sampling method began as purposive and continued as theoretical until saturation.
Five main themes were extracted from the current dataset that indicated family experiences and perceptions of brain death concept while being informed. The themes were included internal conflict, internal barriers against external realities, imminent sense of loss and grief, surrender and acceptance.
The results showed that facing the diagnosis of brain death for relatives and family members is a condition surrounded by many challenges, ambiguities and conflicts that is become more complicated when emotional responses related to grieving and defensive psychological reactions emerge. So it is recommended before any organ request, at first medical team provide conditions for brain death acceptance. Respecting family members experiences and their perceptions about the situation will resolve their internal ambiguities and conflicts. At this situation requesting organ donation seems to be rational.

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The main challenge in organ transplantation is the organ limitation. According to the law of organ donation, it's necessary to obtain family consent for organ donation from a brain-dead patient in addition to patient consent. In this research, we explored Tehran citizens' viewpoints regarding organ donation from beloved ones in case of brain death.
In this cross-sectional study, two interviewers selected 706 study participants by phone interview through random digit dialing during February to November 2010. Calls were made between 6 and 9pm on 5 workdays. Companies and organizations were excluded from the study. Only those over 18 year of age were enrolled in the study.
Of 1379 people who met the inclusion criteria, 706 subjects agreed to have the interview (response rate=51%). Of these, 83.3% (n=688) agreed with organ donation from family member if they had a donor card and suffered brain death. Agreement with organ donation was significantly associated with considering brain death to be real death (P=0.011) and considering it to be irreversible (P=0.028).
In conclusion it is necessary to design public education programs to change their misconceptions about brain death, and provide options to opt for organ donation in case of brain death on common cards such as drivers' license so that family members can make decisions about organ donation more easily when a beloved one suffers brain death.

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Though there are different definitions for the word “mawt” (death), it seems that the most appropriate one would be the loss of power of the soul over the body, and that is when the soul is separated from the body. There are a variety of religious rulings for a human’s death in Islamic moral jurisprudence, and therefore it is necessary for a jurisprudent to have proper knowledge of the subject, reality, and the criterion for death and life. There are two main theories on the criterion for death and life from jurisprudential and moral perspectives. Some hold that everyone dies of cardiac arrest and others argue that man dies of brain death. It is also necessary to view the arguments presented by each group from jurisprudential and moral perspectives. Advocates of the theory of cardiac arrest support their view through the following reasons: authority of established practice in concept analysis, incumbency of guarding the protected soul, principle of caution regarding people’s lives, and principle of istishab. Authors of the present paper have attempted to provide a critical analysis of the above-mentioned arguments in this study. Advocates of the theory of brain death hold their view through the following reasons: the fetal heartbeat before the soul is breathed into it, possibility of cardiac transplantation and impossibility of brain transplantation, similarity between death and sleep, and signs and symptoms of death, among which two have been accepted: a) possibility of cardiac transplantation and impossibility of brain transplantation and b) signs and symptoms of death.

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More than half a century has passed since the onset of successful life-saving and at times astonishing transplantations of organs from brain dead donors, numerous books and articles have been written on the subject, and local, regional and international meetings and conferences have been held. Nevertheless, no consensus has yet been reached among scholars of various fields such as medical sciences, religion, ethics and law on a number of generalities as well as theoretic and practical details of this issue. There have been discussions on topics such as the organ donor’s legal will, gaining consent while the donor is still alive, seeking consent from the brain dead patient’s family, nature of the required organ, observance of religious, cultural and conventional standards, individuals’ dignity and so on. The main challenge to overshadow other factors has so far been the discord among experts, physicians and religious scholars specifically, over determining the time the spirit leaves the body, and a unified definition of death. Some researchers have attempted to minimize religious, ethical and legal challenges and thus facilitate organ donation following brain death by emphasizing the urgency of organ donation and the practices related to certain specialties, and even maintain that brain death is the equivalent of death and a lifeless body. Others have focused on the time of death and the spirit leaving the body based on lexical, religious and medical evidence, regardless of equality of brain death and death, and ensuing rulings. These researchers have thus separated the solution to the problem of those in need of transplants from considering brain death to occur at the same time when the spirit leaves the body, and encourage experts to seek different solutions. Organ donation by brain dead patients is an undeniable social necessity that can be resolved without bringing about fundamental changes in lexical and jurisprudential concepts, and through other alternatives such as propounding “urgency”, declaring a patient “as good as dead” and in general “non-elucidated jurisprudential issues”. Through references to lexical, jurisprudential and medical sources and examination of previous research, the present article will review several definitions of death, spirit, and the time the spirit leaves the body, as these are concepts that are related to brain death for all practical purposes. The article also considers organ donation following brain death to be an undeniable and unavoidable fact of life in human societies, and will examine the necessity of altering lexical and jurisprudential concepts to accommodate current interests and goals.

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With the progress of science, organ transplantation emerged as one of the modern innovations of the medical science. Like other innovations, organ transplantation brings individuals in the society some disadvantages alongside numerous advantages. Legislators have therefore adopted rules and regulations for the mutual support of society members and their rights.In this article the researchers will examine the current regulations on organ transplantation in Iran. Legal sources in Iran, especially the constitution, Islamic criminal law, health and sanitary regulations, moral codes and so on will be referred to in this respect.In the constitution (as epigraph of all laws and regulations within the country), articles 14, 29, 43, 167 will be examined, and in Islamic criminal law articles 159, 372, 495, 497 and 724 will be discussed as the most significant existing articles on organ transplantation. In relation to the moral codes and medical and sanitary regulations we studied the following: Organ transplantation act of April 5, 2000 about the deceased or patients whose brain death has been confirmed the protocol on confirmation of brain death, established 2000 executive regulations for transplant from the deceased or patients whose brain death has been confirmed, adopted May 15, 2002 act of renal transplantation and donation from living donors passed on October 20, 2008 executive regulation 13101 approved on April 29, 2006 about living donors (with the exception of transplantation from a living donor to a foreign citizen) and the charter of patient’s rights ratified in 2009. Lastly, it should be mentioned that transplantation laws and regulations that presently exist in Iran appear to be inadequate for the purpose of resolving the current challenges and problems.

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In the past decades, the need for organ donation has increased while consent rate continues to remain inadequate. One of the most important limiting factors in organ donation is families’ refusal to grant consent, and therefore it is important to determine the circumstances influencing the phenomenon. The aim of this study was to investigate the factors affecting consent to organ donation in families of brain death patients in hospitals affiliated with Shahrekord University of Medical Sciences. For this purpose, a self-made questionnaire was distributed among 54 family members of brain death patients admitted in hospitals affiliated with Shahrekord University of Medical Sciences between 2003 and 2013. The data were reported as mean, frequency and percentage using the SPSS16 software. The average age of the deceased was 31.38 ± 13.72 years, and car accidents were the most frequent cause of brain death (59.3%) in this study. In addition, 72.2% of the deceased were male and 90.7% of them lived in or around the city of Shahrekord. About 37% of the families consented to organ donation. The average age of the family members who participated in the study was 42.15 ± 8.9 years. The most frequent reasons affecting families’ consent to organ donation were religious rewards (100%), confidence in the medical team and staff (100%), and confidence in physician diagnosis (100%).The findings of the study show that religion, faith and family ties affect the willingness for organ donation, and therefore specific attention should be given to these factors in educational programs. In the present study, religious beliefs and confidence in the performance of health care workers were highlighted as the most effective factors in consent to organ donation in brain dead patients' families. Consequently, in order to increase organ donation rate, special attention to these factors and proper planning is necessary.

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According to the principle of respect for autonomy, which is one of the essential precepts of medical ethics, patients are entitled to the right of self-determination for a hypothetical future when they may lose the decision-making capacity. Thus, when still adequately competent to make decisions, a person can prepare a document and predict their therapeutic options and state their wishes for the possible time of lack of decision making capacity, or assign a surrogate who will make the best decision considering the attitudes and interests of the patient. This document, called advance directive, has advantages and disadvantages, and has been investigated from different perspectives. The present study addresses this new issue through non-systematic internet and library review of resources, and aims to investigate some aspects of this subject and examine the possibility of its naturalization from certain viewpoints, particularly from the Islamic perspective. In Islam, life is highly respected and physicians are obliged to do their best to protect human life. In cases where patients refuse the suggested treatments, even when it harms them fundamentally, the physician is obliged to respect their wishes for several reasons. Nevertheless, physicians should avoid any direct measure that may end up in the patient’s death. As regards advance directives, the patient no longer has the capacity to make decisions and has done so formerly, which may be in conflict with the physician’s responsibility to save the patient’s life under present circumstances. In such cases, despite a preliminary injunction, there is no reason to extend the patient's right to the time of their consciousness. Therefore, based on the religious principles observed in Iran, acting on the patient's previous decisions can only be valid as long as they do not conflict with the physician’s responsibilities. Furthermore, advance directives currently do not have a place in our legal system and the recognition of such documents is contingent upon further studies, including legal and cultural reviews.