Should this Jehovah’s Witness be transfused?

Autonomy is a bedrock ethical principle in medicine that has supplanted medical paternalism.  Patients have a right to make their own medical decisions and are entitled to know the advantages and drawbacks of all reasonable options.  Clearly, informed consent cannot be given if the patient is only partially informed or has been given a slanted presentation by the physician.

When a patient does not have the capacity to provide consent, then a surrogate is used.  This individual is charged to make the decision that the patient would have made if the patient were capable of doing so.  Some argue that the surrogate should decide on what he feels is in the patient’s best interest, which may be different than what the patient would have preferred.

Can Christian Scientist parents deny lifesaving treatment to their children? The courts have properly ruled for the children in many of these cases.   These decisions may be traumatic for loving parents who feel that conventional medical treatment may cause an irrevocable spiritual catastrophe.  Is the situation more complex if the child is 15 or 16 years old and does not want surgery or chemotherapy?  What about a 17-year-old?

I was asked to see a patient recently who was profoundly anemic, having lost about 2/3 of her blood.  Ordering blood transfusions would have been a reflex for any physician.  The patient was a Jehovah’s Witness.  Practicing Witnesses will refuse blood transfusions even at the risk of their lives.  I have treated many of these individuals over the years and respect their right to make informed medical decisions.  This patient, however, was mentally retarded and her sister was making decisions on her behalf.

At the sister’s request, no blood transfusions were administered and the patient survived.  I wondered if this case was ethically problematic as the sister was denying care that may have been lifesaving to a patient who could not express an opinion on the issue.  Perhaps, she would not have wanted to die or might not have been a practicing Witness at all.  Should the sister, despite noble intentions, have been entrusted with this decision?

I think that had we decided to ask a court to rule on this issue, that blood may have started to flow.

Michael Kirsch is a gastroenterologist who blogs at MD Whistleblower

Comments are moderated before they are published. Please read the comment policy.

  • ninguem

    You have to make an important ethical decision on short notice.

    All too often, I find the hospital “ethics committee” to be fairly useless, at the very moment when they are most needed. They’ll have a couple of meetings, pontificate for a while, and let you know their opinion, about two weeks after the patient’s funeral.

    I’ve had those Jehovah Witness cases. I’ve found the person saying “no blood” may not be the official power of attorney or legal decision-maker.

    One time I had an emergent case, a child being brought in, the person bringing in the child, saying “no transfusion” to anyone in earshot, was the kid’s daycare provider. Fortunately, transfusion was not an issue anyway, and real parents were found soon after anyway, to continue the emergent treatment.

    So, of course you have to make sure the person saying “no transfusion” is even authorized to say such a thing.

    So, I’d have placed the call to risk management and/or ethics, and documented same.

    They usually get back to me after the patient is discharged, and they second-guess my decision.

    One of the many reasons that I dropped hospital work.

  • maggiebea

    It’s worth noting that the patient survived. Which looks like prima facie evidence that the lack of transfusion was not fatal.

    Whether the patient is a practicing Witness or not is well beyond the doctor’s power to know, as it would be with a cognitively typical patient who is a member of any religion. Many people with cognitive limitations have well-established ways of communicating within their families.

    From my perspective (as a member of a different minority religion with no doctrinal view about blood or blood products) it looks to me like it would have been an important invasion of privacy if the hospital had found a way to compel transfusion.

    • ninguem

      http://www.law.cornell.edu/supremecourt/text/321/158

      Prince v. Massachusetts (No. 98)
      Argued: December 14, 1943
      Decided: January 31, 1944

      It involved a Jehovah’s Witness.

      “Parents may be free to become martyrs themselves. But it does not follow they are free, in identical circumstances, to make martyrs of their children before they have reached the age of full and legal discretion when they can make that choice for themselves.”

      I’ve had competent adult Jehovah’s Witnesses refuse transfusion, children all grown, for reinforcement, I bring in the spouse, both agree, no transfusion, I say fine. We’ll do the best we can without blood.

      As soon as a minor child is involved, or a legally incompetent adult (assuming that’s the case here), than all bets are off. I’d say the law has been pretty clear on this for some time, but lot a lawyer mind you.

      What’s worse, and there have been cases like this, where the doctors act as though they will support the decision, things go badly, they panic and transfuse…..too late.

      The patient is not only dead, but in the eyes of the religion, their eternal soul is now doomed. If you’re going to do it, or not do it, at least be consistent.

      • Teresa Brown

        niguem, you are incorrect about your statement that the patient’s “eternal soul being doomed.” For one thing, JW do not believe in souls that survive the physical body. For another, if the blood is given due to interference by legal authorities, the child and parents are considered blameless. If the parents did everything in their power to explain their stance to the physician(s) and the courts, there’s nothing more they could have done.

        Full disclosure: I was raised as a JW and have been baptized for nearly 40 years. I’m also a registered nurse and have worked in areas where transfusions were commonplace (emergency; oncology). I respected the rights of my patients who were prescribed blood and transfused them when it was ordered. I appreciated my oncologist’s respect for my beliefs when my treatment dropped my hgb to 6,6 and white count ~1.0. Any other doc would have insisted I get blood, since I was symptomatic. My doc let me make my own decision. A few weeks later, I bounced back up to a level that allowed me to complete treatment.

        The Witnesses have what’s known as a “Hospital Liason Committee” which is comprised of elders in the local congregations who has specialized training in the advances of bloodless medicine, and are excellent go-betweens if there is a conflict with patient’s and staff. I know one of the local ones in my area, and his knowledge is mindboggling. They can be a valuable resource for staff as well as a support for the patient and family.

        At the risk of sounding like I am proselytizing, you can get more information about JW and blood at their website, http://www.jw.org, and then search “blood” or “blood transfusions.” You may find information that can help you understand the Witnesses’ POV. You don’t have to agree, but understanding goes a long way.

    • ninguem

      “……It’s worth noting that the patient survived. Which looks like prima facie evidence that the lack of transfusion was not fatal……”

      If you chamber one bullet in a six-shooter, spin the cylinder, point the gun to your head and pull the trigger, five times out of six, nothing happens.

      That does not mean that Russian Roulette is a safe activity.

      The lack of transfusion was not fatal, but it was still dangerous. That the patient survived does not mean it was good practice not to transfuse, but for the religious objection that it.

      The highway turn had a 35-mph speed limit. I took it at 50 and I’m still alive with the car intact. Does that mean it was OK to speed the turn?

      Lots of Monday morning quarterbacks around medical decisions, by the people who are never required to make them.

  • NewMexicoRam

    I think most ethics committees would agree with this:
    If it is a competant adult who has expressed their views not to have the transfusion (or whatever treatment is involved), then don’t give it and don’t try to get a court order.
    If they are not compentant, or are a minor, get the court order first. From others who have gone through this, they relate that the families involved are actually relieved the decision was taken out of their hands.

  • MKirschMD

    Excellent comments. I do not think that a child who is not of sufficient maturity to comprehend the depth of the issue should be forced by parents or anyone to forego a treatment that is highly likely to save his life. In my view, the state’s right to preserve life of one who cannot competently provide informed refusal trumps the parents’ right of religious freedom. I invoke this principle when the stakes are high, not for routine medical matters.

    • ninguem

      Given your line of work, I assume a GI bleed was the issue?

      Intriguing thought. Has a patient with a GI bleed “eaten blood” in violation of Jehovah Witness theology? Involuntary of course.

      Again as far as I know, the principle applies to the person’s own blood as well as the blood of another. I’ve seen the objection discussed with respect to autotransfusion and epidural blood patches.

      Not that I claim any expertise on the matter.

      • Teresa Brown

        No, that would not be considered he same thing.

  • John C. Key MD

    To borrow a term from the inestimable Al Gore, I thought the idea of blood transfusions in Witnesses was “settled science”. You talk to patient, family, or others with legal responsibility; they refuse, you don’t transfuse. This was a pretty standard approach in the surgical communities of which I’ve been a member. No need to involve legal authorities or the totally worthless “ethics committee”. Patient autonomy rules, medical paternalism is dead.