In 1979, the nation of Iran underwent an intellectual-cultural-religious-political revolution integrating Islamic law/principles into Iranian healthcare legislation and healthcare delivery. In this chapter, we investigate the domain of patient autonomy in Islamic law and scrutinise Iranian statute law and by-laws, including the Patient Rights Charter (2009). We conclude that advance directives in Iran, at most, function to advise the patient’s legal surrogate decision maker provided they are in keeping with the law. Despite this, advance directives are significantly underutilised in Iranian healthcare. This may be influenced by a lack of legislation clarifying the status of physician liability for respecting advance directives to refuse life-sustaining treatment, controversy in Islamic legal circles over personal autonomy, pressure from relatives to continue futile care, cultural beliefs around divine fate/suffering and a lack of palliative care services. In order to utilise the potential for advance directives to improve the delivery of appropriate healthcare in end-of-life patients, a clear fatwa is required on the matter, followed by clear legislation clarifying patient rights to refuse treatment and physician liability. Hospital and community healthcare services must also be empowered to implement advance directives and improve delivery of palliative care where indicated.

Making sense of advance directives, and the regulatory frameworks governing healthcare more generally, in Saudi Arabia requires a careful understanding of the traditional Islamic religious legal framework of Shari’ah. There is much uncertainty about how to interpret Islamic legal principles in making use of advance directives and in providing end-of-life care in Saudi Arabia. In this chapter, we aim to offer clarity on how well-established principles, and Islamic statements of permissible and impermissible behaviour, should be reasoned through to provide an underpinning governance framework for healthcare practices at the end of life. We also review published evidence on the practical application of advance directives in Saudi Arabia and examine the social and cultural factors that may explain the limited uptake of advance directives, We conclude with two suggestions for establishing an appropriate role for advance directives in future – one concerning the need for legal clarity and the other concerning how to bring about improvements in professional knowledge and understanding.