Case Study - Jehovah's Witness

An eighteen year-old female arrives in the emergency room with a profound nose bleed. You are the physician, and you have stopped the bleeding. She is now in a coma from blood loss and will die without a transfusion. A nurse finds a recent signed card from Jehovah's Witnesses Church in the patient's purse refusing blood transfusions under any circumstance. What would you do?

This is the classical ethics question. We’ll go through it using the Doing Right algorithm and provide an example answer.

1. What is the case?

Patient comes into the ER requiring a blood transfusion. However, her prior wishes are to refuse all blood transfusions on religious grounds.

2. What are the ethical dilemmas?

The ethical issues involved primarily revolve around patient autonomy vs. beneficence.

This issue is further

3. What are the alternatives?

There is a single choice to be made:

Give her the blood transfusion or Don’t give her the blood transfusion.

Special consideration must be applied as this case involves an incapable patient with known prior wishes.

Which is part of the larger question of:

Should physicians be allowed to override patient wishes?

4. How do the principles apply?

Beneficence
Beneficence involves the physician’s duty to act on the best interest of the patient. Physicians are trained to prolong life and heal illness, and it runs counterintuitive to forgo a life-saving treatment. It is only natural to want to override someone’s decision to save their life.

Autonomy

Patients have a limited right to choose their therapy but an almost unlimited right to refuse treatment. If the patient is capable, then their autonomy always triumphs over beneficence. However, if the patient is incapable, then her prior wishes must be respected. If her prior wishes are not known, then a next of kin or family member may make a decision for her consistent with her prior beliefs. If a next of kin is not available, then a surrogate decision maker may be appointed to act on the best interest of the patient. In this case, the patient’s prior wishes are known and therefore must be respected even if it means the death of the patient. In certain circumstances, you could override her prior wishes if an argument could be made that she was incapable when she made her prior wishes, but there is no indication of this. Another circumstance is if the signed card was dated 20 years ago and recent indications suggest that she no longer holds this belief, however, this is not the case here.

5. What is the context? Who else is involved?

Canada is celebrated for its acceptance of a diversity of cultures, religious beliefs and social values. Religious beliefs, however idiosyncratic, if it is a deeply held conviction, will always trump autonomy.

6. Propose a resolution

In this situation, because the patient has recently stated her wishes, they must be respected. Do not order a blood transfusion.

7. Critical considerations

Because this is an emergency situation, there is not enough time to properly explore factors surrounding the patient’s refusal of blood transfusions. For example, are the patient’s wishes consistent with her past beliefs and behaviors? Are there any social or cultural pressures that might have influenced her to make a non-autonomous choice at a certain point in the past? Are there any close friends or family that can provide insight into the patient’s refusal of treatment? All these are questions that should be addressed if time allows to properly do right by the patient.

8. Action

Example answer:

“I think this scenario raises numerous questions that are fundamental to the practice of medicine, such as patient autonomy versus the physician’s duty towards patient beneficence. The ethical questions raised in this scenario addresses whether patients should be allowed to refuse a life-saving therapy that will likely result in their death. Should physicians be permitted to override these decisions in emergency situations where the patient is incapable?

In this specific scenario, I can definitely understand both sides of the issue. On one hand, physicians are trained to be healers and provide the best possible medical intervention to prolong life where possible, and the decision to refuse a life-saving therapy may appear to be counterintuitive to the duty to care and treat patients. On the other hand, the decline, and rightly so, of medical paternalism in recent decades has led to a revolution in patient autonomy. Patients are free to choose and refuse therapy if they are capable of understanding and appreciating the situation, and this right must be respected by physicians. This scenario is further complicated by the fact that the patient is currently incapable. For incapable patients, their prior capable wishes regarding treatment should always be followed, even if they may appear irrational to the practitioner. Where prior wishes are unknown, a substitute decision maker should be found if the situation is not an emergency, and failing that, the patient should be treated according to their best interest.

In this case, I would not order a blood transfusion as the patient has prior wishes that such interventions not be performed on her. Patients should be treated as capable unless evidence indicates otherwise. However, one should be especially diligent in cases where serious outcomes may result, and there are certain factors that need to be explored in regards to capacity and the patient. For example, are the patient’s wishes consistent with her past beliefs and behaviors? Are there any social or cultural pressures that might have influenced her to make a non-autonomous choice at a certain point in the past? Are there any close friends or family that can provide insight into the patient’s refusal of treatment? I understand that this is an emergency situation and not all of these factors can be explored in a timely manner. I believe that while physicians will always want to provide the best possible care for their patients, patients have the right to make therapeutic choices, and in the courts have consistently upheld the capable patient’s rights to refuse treatment based on deeply held religious or cultural beliefs. As a physician, I would respect the patient’s wishes and not transfuse.”