Jehovah's Witnesses and Blood Transfusions

Does a Patient Have the Right to Refuse Life-Saving Treatment?

Sep 16, 2009 Jeffrey Willett

Bioethics deals with moral issues in medicine, but sometimes doing what is right creates more problems for the physician-patient relationship than doing nothing at all.

Physicians and hospitals work together to save human lives. But what happens if a patient refuses help? Do doctors have an ethical responsibility to override a patient's known wishes and force treatment on someone who does not want it? The following true case explores the ethical problems that arise when a patient's advance wishes conflict with a physician's medical duties..

A Jehovah's Witness Refuses a Blood Transfusion

A middle-aged couple is involved in an automobile accident. The husband dies immediately, but his wife is rushed to a nearby emergency room (ER) for evaluation. The ER doctor notes that she has critical head injuries, numerous bone fractures, and severe blood loss from the mouth and nose. She is in shock and unable to answer questions.

The severe bleeding causes the patient's blood pressure to fall dangerously. In an attempt to increase her blood volume, the doctor orders intravenous solutions of glucose and Ringer's lactate.

Meanwhile, a nurse finds a Medical Alert card in the patient's purse. The card is not dated, but is signed by the patient. The card identifies the woman as a Jehovah's Witness who has religious beliefs that prohibit her from receiving any blood products. The card says she is willing to be treated only with non-blood products such as the ones already given to her.

Can Life-Saving Treatment Be Declined?

The doctor calls an orthopedic surgeon for a second opinion. The surgeon agrees that unless the woman's blood volume is raised, she will die. Unfortunately, her bleeding cannot be controlled by non-blood products. When her blood pressure falls to dangerous levels, the ER doctor decides that the only way to save her life is to administer a blood transfusion.

As the transfusion is prepared, the patient's daughter arrives, who also is a Jehovah's Witness. The daughter objects to the blood transfusion and wants it stopped. The ER doctor refuses, and gives three reasons for his decision:

1. Blood transfusion is standard therapy; without it, the patient will die.
2. The doctor does not know if the Medical Alert card is valid, if the patient is still a practicing Jehovah's Witness, or if the patient would change her mind if conscious.
3. The doctor says he will stop the transfusion only if the patient tells him to stop. As she is unconscious, he is exercising therapeutic privilege (the right of a doctor to give emergency services to an unconscious patient) on her behalf.

Therapeutic Privilege vs. Autonomy

Health care professionals have a legal and moral responsibility to act in the patient's best interests. In this case, her condition is critical, and she is not responding to alternative non-blood treatment. Without a blood transfusion, she will die.

A patient, however, always has the right to make choices; this is the definition of autonomy. Even though the patient is unconscious, her wishes to refuse certain types of medical treatment are known through her daughter and the Medical Alert card. The hospital staff, however, has reservations about what the patient would do if she were conscious.

The ethical problems can be expressed as follows:

• Can an unconscious patient refuse treatment, in advance, even if that refusal results in the patient’s death?
• Does therapeutic privilege override autonomy when a patient is unconscious?

Three Possible Courses of Action

In any ethical debate, options need to be studied and likely consequences assessed before a final decision is made. Here, the doctor has three options:

1. Exercise therapeutic privilege and continue the blood transfusion. As a result, the patient will likely live.
2. Respect the patient’s presumed wishes, as well as the instructions of her daughter, and stop the blood transfusion. As a result, the patient will likely die.
3. Stabilize the patient and transfer her to another hospital. It is uncertain if the patient can survive a transfer, or if a new hospital will respect her wishes.

What Did the Doctor Decide?

The ER doctor continued with the blood transfusion. After the patient's condition had stabilized, she was transferred to another hospital the next morning. No further blood transfusions were needed, and she survived.

After she recovered, the patient sued the ER doctor. She claimed that the doctor had invaded her “bodily integrity” without her consent, so he had committed a battery under civil law. A court ruled in her favor and awarded her $20,000 in damages.

Was the Correct Ethical Decision Made?

Although the lawsuit may appear unjustified, a close examination suggests the ER doctor did act improperly. Of the three possible courses of action, option #2 was the preferred ethical choice.

The patient and her family held religious beliefs that specifically opposed blood transfusions. Those beliefs were clear and not subject to misinterpretation. Even though the patient will die because of that decision, her right to exercise autonomy and reject treatment cannot be ignored.

On the other hand, therapeutic privilege did not apply. Even though the patient was unconscious, her wishes were known. The Medical Alert card did not need to be dated to be valid. Furthermore, the daughter's instructions (as a surrogate decision maker) confirmed her mother's current wishes, which the hospital was required to obey.

The principles behind bioethics are sometimes difficult to accept. The 'right' decision is not always one that results in the happiest ending, but one that respects certain core principles — even if those principles lead to the patient's death.

References

Malette vs. Shulman. Ontario Court of Appeal no. 29-88 (March 30, 1990).

Sneiderman B. 2005. The Shulman case and the right to refuse treatment. Human Medicine. 7(1):15–21.

Willett J. Case Study: No Blood Transfusions! Presented before Erasmus Mundus Master of Bioethics students, Padova, Italy. Spring, 2008.

The copyright of the article Jehovah's Witnesses and Blood Transfusions in Biology is owned by Jeffrey Willett. Permission to republish Jehovah's Witnesses and Blood Transfusions in print or online must be granted by the author in writing.

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