In this series of articles, medical students from across the country will discuss a range of topics from medical ethics to the NHS to public health to medical conditions to clinical governance.
Who are Jehova’s Witnesses?
Around 8 million people around the world are Jehova’s Witnesses. Jehovah's Witnesses is a Christian denomination with nontrinitarian beliefs distinct from mainstream Christianity. Jehovah's Witnesses refuse blood transfusions, which they consider a violation of God's law. Jehova’s witnesses have been a topic for discussion in medical ethics for a long time now. What do we as doctors do if our patient has capacity and chooses not to consent to a life-saving procedure? How can we ensure non-maleficence when patients refuse to be ‘saved’? In this situation, what is more important - autonomy or non-maleficence? Let’s explore these ideas from multiple viewpoints in this article.
Adults with capacity:
When an adult with capacity (has the mental ability to make decisions after considering the pros and cons of a treatment) refuses a blood transfusion, doctors and healthcare workers should respect this decision. This is because patients have the right to refuse treatment (autonomy), as long as they understand the cons of making this decision. Here is a scenario from the BMJ -
A 30 yr old M is rushed into the ER with a stab wound. He shows the common signs of bleeding - hypotension, tachycardia, and shock. It is suspected that there is peritoneal bleeding. He is shown to have capacity. The best chance of saving his life is an urgent blood transfusion along with operative intervention to arrest the bleeding. The patient refuses blood since he is a Jehovah’s Witness but asks for treatment instead with the best available non-blood products and surgery, accepting the substantial risk that surgery without blood transfusion is much less likely to save his life than surgery with blood transfusion. As his doctor, you try to urge him to undergo surgery and he adamantly refuses, saying he would rather die. He soon goes into shock and becomes unconscious.
As his doctor, you should respect the patient’s wishes and autonomy. The patient’s own assessment of harms and benefits for himself also leads the patient to conclude that far more harm over benefit would result for him from a life-saving blood transfusion than from death without a blood transfusion; that his rights and legal justice allow him to refuse even life-prolonging treatment.
Adults lacking capacity and children:
However, what if this adult is lacking capacity? Usually, Jehovah’s Witnesses carry ‘advanced directives’ which is a piece of writing that identifies them as Jehovah’s Witnesses and makes it known that they will refuse blood transfusion even in a life or death situation. Alternatively, the doctor could seek consent from family members - known as proxy consent. The situation gets even more complicated when we consider children. Parents and family members cannot force their religious beliefs on their children and children often lack the capacity to make medical decisions. Consider this situation -
A 2 yr old infant has lost a massive amount of blood in a road accident and the best chance of saving the child’s life is an urgent blood transfusion and operative intervention to arrest the bleeding. Both the child’s parents are Jehovah’s Witnesses and refuse to give permission for a blood transfusion, requesting instead that the best available non-blood products are used to restore volume and that surgery is carried out without blood. They understand that this will be a far more dangerous course of action than surgery plus blood transfusion but persist in refusing permission for a blood transfusion for their child.
The surgeon, if he cannot obtain parental consent to save the child’s life, is morally and legally right to override their refusal and administer a blood transfusion on the grounds that the child does not fall within the scope of the principle of respect for autonomy. The parents’ authority to decide on medical treatment for their child morally should not and legally does not extend to imposing severe and probably fatal harm on their child in the pursuit of their own religious beliefs.
The same issue can apply to adults as well - their family cannot and should not impose their religious beliefs on the adult patient in question. In such a case, a discussion about blood transfusion with a competent adult should take place in private. At the same time, if the patient changes his or her mind about their stance on blood transfusion, the physician needs to assess and decide if this change might be a consequence of illness impairing the patient’s capacity to decide.
A Healthcare Worker’s Point of View:
Till now we’ve considered only the patients as stakeholders, however, physicians and other healthcare workers are also important stakeholders to consider.
Consider the case of a 30Y old female who has been diagnosed with leukaemia. The doctors tell her that her best chance of survival is with chemotherapy drugs. These drugs will destroy the cancerous bone marrow cells and therefore, a subsequent blood and marrow transfusion will be required to cure the patient. The patient has capacity and instead of refusing the treatment entirely, she asked for the chemotherapy to be administered with alternatives to blood products, which are more expensive.
This scenario raises a range of questions such as - Is it unethical to give her chemotherapy because in the absence of blood support it was likely to fail, and could even hasten her death? Can a patient demand a partial treatment that the doctor considers futile and could even cause them harm? If the patient's wishes are paramount, is the emotional impact on the nursing staff as important? Should a patient, on religious grounds or otherwise, have the right to more expensive treatment than others?
Summary:
A doctor must always respect a patient’s autonomy, provided they have capacity.
When lacking capacity, proxy consent and advanced directives may be used.
If children have capacity, their autonomy should be respected. When a child lacks capacity, doctors are legally allowed to overrule parents’ wishes in the interest of the child’s life.