Ethics Q2: Can a minor (Jehovah's) refuse life-saving treatment?

[ofthesun]

Illustrative question: "A minor Jehovah's Witness (11-15 years old) is dying and requires a transfusion but refuses. The patient is lucid and convincing in his religion conviction and understanding of the consequences he desires. Parents are unreachable. "

My understanding is that while lucid and competent adults may refuse treatment under ANY circumstance, minors do not have the autonomy to do the same. Since minors are generally deemed incompetent under the law, any request to abstain from important treatment should be considered, then bypassed. Decisions should be made solely on a generalized definition of best interest.

Preferences may be taken into consideration if there are multiple methods of treatment with equally good outcome (or a patient is terminal and thus has only palliative outcomes), but otherwise, the minor patient's health should come first.

Additionally, I recall a case where a Jehovah's child was incapacitated and parents refused transfusion. The recommendation was that the law protects life-saving treatment of nonconsenting minors against parental wishes.

Can I thus conclude that clear-cut life-saving treatments to minors should thus ALWAYS be provided, irrespective of the minor's or parent's preferences?

Thoughts?

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[flighterdoc]

By definition, non-emancipated minors cannot make informed consent, or refuse medical care.

The parents of the child can refuse, and the courts have pretty universally rejected their arguments, at least in the US.

People can reject what they will on faith, but they cannot refuse for others faith.

 

[Stroganoff]

A twist: What if the parents of the child refuse treatment, but the child wants the treatment [and needs it as deemed by physicians]?

 

[bananaface]

A twist: What if the parents of the child refuse treatment, but the child wants the treatment [and needs it as deemed by physicians]?

Either someone calls CPS and the child is made a ward of the state and treated, or the child gets no treatment.

 

[FoughtFyr]

No question, if the child (being a minor) wants the treatment and the parents refuse, the treatment can, and should, be provided anyway.

But the ethics are a bit stickier, IMHO, if an older child doesn't want the treatment and neither do his/her parents on religious grounds (specifically JWs). The Jehovah's Witnesses, as a long established and well documented religious practice, fully believe that receiving a blood transfusion will prevent them from "rising with Christ" at the second coming - in other words, they will go to he11. This is an absolute, there is no forgiveness and no chance at salvation. If the patient is old enough to cognitively understand this concept, and believes in these tenets, imagine what forcing the treatment does to them...

It boils down to a simple question for them, one you should ask yourself (presuppose you truly believe in the larger concepts for purposes of discussion) "Would you rather die, right now, and be guaranteed a place in heaven, or live some indeterminately longer period on earth but certainly go to he11 when you die?" A bit more complicated than it appears on first glance...

No, I am not a Jehovah's Witness, I've just taken a few courses in comparative religion.

BTW - before you think this JW belief is too far "out of the box", it is derived from the same old testament law that has the religious persons of the Jewish faith attempt to bury all of a persons body (spilled blood and tumors included) at the time of death. We think nothing (in emergency departments) of providing the bloody clothes to the family or of returning surgical waste (to funeral homes, licensed to deal with bodies) in these cases.

At the time of the last Pope's death, there was also a mention of this "whole body" practice in regard to him on television, but as a Catholic I'd never heard that before...

- H

 

[captaindargo]

No question, if the child (being a minor) wants the treatment and the parents refuse, the treatment can, and should, be provided anyway.

But the ethics are a bit stickier, IMHO, if an older child doesn't want the treatment and neither do his/her parents on religious grounds (specifically JWs). The Jehovah's Witnesses, as a long established and well documented religious practice, fully believe that receiving a blood transfusion will prevent them from "rising with Christ" at the second coming - in other words, they will go to he11. This is an absolute, there is no forgiveness and no chance at salvation.

Jehovah's Witnesses do not believe in hell.... yes they do believe that you should not have a blood transfusion because it's in the bible.... but there can be forgiveness if they do decide to have a blood transfusion.

I know this because I know Witnesses and I have studied off and on for most of my life. I don't believe in everything they believe but I respect their religion. The reason I'm not a witness is because I don't believe in everything like children becoming a full blown witness before they are adults because there is a lot responsible in being a Witness.

 

[FoughtFyr]

Jehovah's Witnesses do not believe in hell....

Correct, that was as an example. They believe that "As Jesus promised, "the hour is coming in which all those in the memorial tombs will hear [Jesus'] voice and come out." (John 5:28, 29) Although no longer presently existing in any form, millions of dead ones who are in Jehovah God's memory will be resurrected, or brought back to life, in a restored earthly paradise.—Luke 23:43; Acts 24:15.". So those not in a "state of grace" stay dead while the saved live forever in an earthly paradise.

yes they do believe that you should not have a blood transfusion because it's in the bible....

Well, that is how they interpret the bible, the actual scriptures speak mainly to the ingestion of animal blood: "The Law repeatedly stated the Creator's ban on taking in blood to sustain life. "You must not eat the blood; pour it out on the ground like water. Do not eat it, so that it may go well with you and your children after you, because you will be doing what is right."—Deuteronomy 12:23-25, NIV; 15:23; Leviticus 7:26, 27; Ezekiel 33:25.".

They go on to note, of relevance to this discussion:

"Contrary to how some today reason, God's law on blood was not to be ignored just because an emergency arose. During a wartime crisis, some Israelite soldiers killed animals and "fell to eating along with the blood." In view of the emergency, was it permissible for them to sustain their lives with blood? No. Their commander pointed out that their course was still a grave wrong. (1 Samuel 14:31-35) Hence, precious as life is, our Life-Giver never said that his standards could be ignored in an emergency."​

but there can be forgiveness if they do decide to have a blood transfusion.

Not to pick a fight, but most of what I've read in The Watchtower doesn't seem to fit this. King David was another godly man with a weakness. On one occasion he gave in to passion and had sexual relations with another man's wife. He then attempted a cover-up by having her husband killed. (2 Samuel 11:2-27) Afterward, he deeply regretted his crimes, and God forgave him. But David had destroyed a family, and Jehovah did not shield him from the devastating calamities that followed. David's baby boy got very sick, and Jehovah did not intervene, despite David's prayers in behalf of his child. The boy died, and thence followed a string of tragedies in David's household. (2 Samuel 12:13-18; 18:33) David paid a very high price for yielding to moral weakness.

These examples show that God holds humans responsible for their conduct." {emphasis added}

The article goes on to say:

"Because God does not allow imperfection to be a constant excuse for bad conduct. (Jude 4) Jehovah wants humans to clean up, to get their lives in good moral order. The Bible says: "Abhor what is wicked." (Romans 12:9) Why does God take such a strong stand?

One reason is that yielding to weakness is harmful. "Whatever a man is sowing, this he will also reap," says the Bible at Galatians 6:7. Those giving in to addictions, greed, and promiscuity often reap a terrible harvest in their lives. But there is a more important reason.

Sin offends God. It causes "division" between us and Jehovah. (Isaiah 59:2) Since those practicing sin cannot gain his favor, he exhorts such ones: "Wash yourselves; make yourselves clean; . . . cease to do bad."—Isaiah 1:16.​

It seems from these readings that one who sins and allows the consumption of blood, even if they later atone, is at risk of not being "called from the tomb". Think about the ramifications that would have in the mind of a teenager who believes... Pope John Paul II has observed that forcing someone to violate his conscience "is the most painful blow inflicted to human dignity. In a certain sense, it is worse than inflicting physical death, or killing." from: http://www.watchtower.org/library/hb/article_07.htm

I know this because I know Witnesses and I have studied off and on for most of my life. I don't believe in everything they believe but I respect their religion. The reason I'm not a witness is because I don't believe in everything like children becoming a full blown witness before they are adults because there is a lot responsible in being a Witness.

O.k., that is your belief. I'm asking you to consider the implications of forcing a 14 or 15 year old to go against their conscience and the effects that might have on the course of their life. How does a teenager who believes they are "beyond salvation" act?

- H

 

[t33sg1rl]

So, at the time, my friend was 15 and diagnosed with cancer. Blood transfusions were a standard part of the chemotherapy regimen. He was a Witness, his mother was a Witness, and his father was not.
The father wanted to give him the standard transfusions. The mother wasn't sure-she was a Witness, sure, but when you think about your child dying, principles fall. The boy was firm about not wanting any blood transfusions.
The family finally agreed not to give blood during chemo, even though it meant he'd be sicker and would be more likely to die from the chemo. They did decide, though, that if his life were at stake, that he would get transfused against his wishes. But, after they let him refuse the weekly transfusions, he didn't mind the possibility of life-saving transfusions so much.
Anyway, he's now 10 years cancer-free, and never had a single transfusion.
Happy endings all around!

 

[docB]

So, at the time, my friend was 15 and diagnosed with cancer. Blood transfusions were a standard part of the chemotherapy regimen. He was a Witness, his mother was a Witness, and his father was not.
The father wanted to give him the standard transfusions. The mother wasn't sure-she was a Witness, sure, but when you think about your child dying, principles fall. The boy was firm about not wanting any blood transfusions.
The family finally agreed not to give blood during chemo, even though it meant he'd be sicker and would be more likely to die from the chemo. They did decide, though, that if his life were at stake, that he would get transfused against his wishes. But, after they let him refuse the weekly transfusions, he didn't mind the possibility of life-saving transfusions so much.
Anyway, he's now 10 years cancer-free, and never had a single transfusion.
Happy endings all around!

The problem with this scenario is that while it sounds reasonable it's really not. By refusing the standard treatment it becomes more likely that he will become gravely ill. Once he becomes gravely ill he is more likely to have a bad outcome regardless of if he then decides to accept transfusion. It would be analagous to saying "I don't want to have my inflammed appendix out but if I get really sick when it perfs I want CPR." People in this country want to pick and choose what they get but they frequently pick and choose things in in silly groupings.

 

[QuikClot]

It seems to me that many posters are treating this as if it were a legal question, rather than an ethical one. Legally, one may be compelled to treat a minor against their wishes. Ethically, the concept of a "minor" is meaningless.

Let's leave aside the question of whether there is an ethical imperative to follow the law; anyone can correct my impression, but I don't think that's the thrust of the question.

The patient is postulated to be mature, coherent, articulate and reasonable. The law cares whether their 18th birthday was yesterday or is tomorrow, but an ethicist should not. So the question is really: is it ethical to force lifesaving treatment on a competent patient (minor or not) against their clearly expressed wishes.

The answer is no. It is the patient's decision. We serve the patients, according to our own conscience, to the extent they will allow it. We do not have the moral right -- though we may have the legal obligation -- to force treatment on a competant individual who does not want it.

 

[fab4fan]

Thank you to the individual who clarified that JW do not believe in hell. They don't believe in a "rapture," either, as a previous post seemed to suggest.

I've been a member of this faith all mylife so this is always a topic of interest as well as frustration.

I would recommend checking out www.noblood.org; it's a site with excellent information on this and related topics. Most of the moderators there are medical professionals affiliated with hospitals that have bloodless medicine programs. While there are some forums for lay people, there are also forums for medical professionals to discuss treatments and situations such as you describe.

FYI: Someone else mentioned that for a JW to accept a trasfusion would= being beyond forgiveness/redemption. That's not true. It would be far too difficult for me to try to explain this in a post, and in any case, the subject is really should a physician force someone, even a minor to accept a treatment that the patient feels violates his beliefs. I agree with QuikClot.

 

[FoughtFyr]

FYI: Someone else mentioned that for a JW to accept a trasfusion would= being beyond forgiveness/redemption. That's not true. It would be far too difficult for me to try to explain this in a post,

I apologize, this is what I had been led to believe by more than one JW specifically speaking to medical professionals on this issue.

and in any case, the subject is really should a physician force someone, even a minor to accept a treatment that the patient feels violates his beliefs. I agree with QuikClot.

See, if the above is true (that is, there exists a mechanism for forgiveness) than I think the ethics change with concern to minors. Medical professionals have to observe some "line in the sand" where it is socially accepted that an individual is presumed capable of understanding the implications of their healthcare choices and below which it is presumed they do not. Our society, by the process of law, has decided that line is at 18 years of age. If freed from the burden of such a decision having "permanent and eternal" implications within a faith, I would far more comfortably give the blood. It is difficult to insure that the minor will continue to believe as they grow into adulthood. If my failure to act prevents them from reaching adulthood, well, then the choice is easy - assuming my decision does not permanently bar them to aspects of that faith during the adulthood I've now enabled them to reach.

- H

 

[FoughtFyr]

It seems to me that many posters are treating this as if it were a legal question, rather than an ethical one. Legally, one may be compelled to treat a minor against their wishes. Ethically, the concept of a "minor" is meaningless.

No, it isn't. There has to be some point where an individual is capable of not only making a decision but also understanding the implications of that decision. Certainly you would suggest that we allow a 4 year old type I diabetic refuse insulin that both his/her parents wish them to receive because they don't like getting an injection?

At some point, individuals are capable of making these decisions. And our society as a whole has agreed, under law, that point is 18 years of age.

The ethical dilemma of this case, in my opinion, are created in the dissonance between that definition of "capable" and the definitions within the faith. The actions of the physicians are presumed to be in the interest of survival. If that survival will be significantly "altered" by the actions of the physician (e.g., the patient will be ostracized from their community or faith) then there is a problem. If, as fab4fan suggests, there is not a alteration of faith based on the actions of the physician, then in my opinion the ethical dilemma disappears.

The patient is postulated to be mature, coherent, articulate and reasonable. The law cares whether their 18th birthday was yesterday or is tomorrow, but an ethicist should not. So the question is really: is it ethical to force lifesaving treatment on a competent patient (minor or not) against their clearly expressed wishes.

We can't make that postulation. You are right, in the ethical sense the question is, at base, "is it ethical to force lifesaving treatment on a competent patient against their clearly expressed wishes?" But the answer to that is easy and well known. No, it is not ethical. That is why, as a society, we have decided that 18 year olds are presumed competent and those below 18 years of age are not. That creates a necessary standard. The dilemma is, in my opinion, created when the societal definition varies largely from the definition in the community (religious or cultural) in which the patient lives.

- H

 

[QuikClot]

No, it isn't. There has to be some point where an individual is capable of not only making a decision but also understanding the implications of that decision.

Yes . . . there is such a point, but it is not necessarily the day we turn 18. As an ethical question, we ask, "is the patient capable of not only making a decision but also understanding the implications of that decision"? Not "Is the patient a minor?"

This patient seems to be able to.

At some point, individuals are capable of making these decisions. And our society as a whole has agreed, under law, that point is 18 years of age.

"Our society" has not agreed. Our lawmakers have agreed to treat 18-year-olds as capable -- whether they are or not. That does not necessarily imply that lawmarkers think they are capable -- only that they have drawn the line there. You are trying to treat a legal decision as if it binds the ethicist -- as if the law creates reality. It doesn't.

The actions of the physicians are presumed to be in the interest of survival.

Is survival against the wishes of a competant patient a positive value? If so, DNRs are unethical, because they bind the physician to abjure treatment that can prolong life.

If that survival will be significantly "altered" by the actions of the physician (e.g., the patient will be ostracized from their community or faith) then there is a problem. If, as fab4fan suggests, there is not a alteration of faith based on the actions of the physician, then in my opinion the ethical dilemma disappears.

You are ignoring the issue of patient autonomy, here. You think no one under 18 has any rights over their person. Legally, this may sometimes be true -- but not always. Ethically, it is not true; a competant decision maker has the right to refuse treatment based upon any subjective idea of the good.

We can't make that postulation. You are right, in the ethical sense the question is, at base, "is it ethical to force lifesaving treatment on a competent patient against their clearly expressed wishes?" But the answer to that is easy and well known. No, it is not ethical. That is why, as a society, we have decided that 18 year olds are presumed competent and those below 18 years of age are not. That creates a necessary standard.

This is the crux of our disagreement. Legal decisions do not create ethical standards. There may be an ethical imperative to follow the law, but I delibrately excluded that from my discussion. But legal standards are not binding ethical realities. Take, for example, the Dred Scott decision. According to the law, Negroes were property. As property, they had no legal right to contest their treatment. The ethical imperative of respecting a man's property rights became the basis for affirming slavery.

The decision is ethically indefensible, because just because the law does not recognise a man, it does not mean he isn't there. Similiarly, just because the law does not reguard our patient as competent, he does not lose his ethical right to refuse treatment if in fact he does understand the consequences of his actions.

 

[QuikClot]

As I've said above, I don't think the legal status of the minor is relevant to the ethics of refusal -- but it is interesting, and in my meanderings I hit a couple of interesting pages:

To obtain consent, the patient must be clinically and legally competent. In most states, the legal age of consent for medical treatment is 18 years. Parents or legal guardians normally are required to consent for the medical treatment of minors, although a few exceptions exist as follows:


The Emergency Medical Treatment and Active Labor Act (EMTALA) requires hospitals to provide an adequate medical screening examination to anyone (including minors) who presents to the ED, even if appropriate consent cannot be obtained. If no immediately life-threatening condition is identified, institute procedures to obtain consent for treatment.

In many states, marriage or pregnancy often confers an emancipated status to minors, who then can consent to procedures and treatments.

In the interest of a greater societal good, various conditions exist (depending upon the state) for which minors can consent to treatment. These conditions include treatment for (1) sexually transmitted diseases, (2) alcohol or drug abuse, (3) domestic or sexual abuse, and (4) mental health issues.

Minor parents of children also can consent to treatment for their children and themselves.

Additionally, mature minors (ie, close to age of maturity) can consent, at times, to less invasive or less risky procedures if the physician feels the patient understands the concepts of consent.

http://www.emedicine.com/emerg/topic740.htm

Laws vary from state to state (and from country to country.) In Alabama, for example:

As is true in some other states, Alabama has a statute that deals directly with the issue ofwhether minors may consent on their own to receive health care. Section 22-8-4 states asfollows: Any minor who is 14 years of age or older, or has graduated from high school, or is married, or having been married is divorced or is pregnant may give effectiveconsent to any legally authorized medical, dental, health or mental health servicesfor himself or herself, and the consent of no other person shall be necessary.

Weird, huh? But it's a legal question we're all going to have to deal with. Legally, we're going to have to ask our 11-15-year-old "Are you from Utah? OK. Are you married? Divorced?" and use the answer to guide our treatment . . . an absurdity that illustrates why the ethical question is different from the legal one.

 

[fab4fan]

FoughtFyr: What I meant was, if a JW accepts a transfusion, there may indeed be consequences, but it does not necessarily mean that person is forever "condemned," for lack of a better word. It also doesn't mean that a JW can accept the transfusion, then say, "Whoops, I'm sorry," and that makes things right.

Like I said, it's a complex issue, and cases are looked at individually. Ultimately, we believe it's God who decides what was in the person's heart. Witnesses have been disfellowshipped for accepting transfusions. It's considered a very serious matter.

Maybe some are OK with forcing a treatment on an individual if it means saving that person's life. But there is more to life than just the physical. How good is a life if you break someone's spirit? One account I read of a teen who'd had blood forced on her stated she felt like she'd been raped.

If a situation arises where a JW patient needs a transfusion and refuses, there are other resources. There are other doctors out there who are willing to respect that choice, even when it's a minor involved. If you feel like you can't in good faith honor that request, then refer the patient to someone who can. Witnesses don't want doctors to do something that violates their conscience, either.

I think it's important to also be aware that the field of bloodless medicine has greatly advanced. How many are aware of what's even going on in this specialty?

 

[flighterdoc]

As I've said above, I don't think the legal status of the minor is relevant to the ethics of refusal -- but it is interesting, and in my meanderings I hit a couple of interesting pages:



http://www.emedicine.com/emerg/topic740.htm

Laws vary from state to state (and from country to country.) In Alabama, for example:



Weird, huh? But it's a legal question we're all going to have to deal with. Legally, we're going to have to ask our 11-15-year-old "Are you from Utah? OK. Are you married? Divorced?" and use the answer to guide our treatment . . . an absurdity that illustrates why the ethical question is different from the legal one.

They don't have to BE from anywhere. In your Alabama example, the only pertinent issue is WHERE is the treatment being offered? If it's in Alabama, then Alabama law prevails. If it's in Utah (or wherever) those laws prevail.

Also, society determines different ages for different consents: In Alabama, a 15 year old can decide their own medical treatment just like an adult. However, they cannot vote, they cannot drive an automobile, they cannot buy alcoholic beverages (err, I hope!).

 

[QuikClot]

They don't have to BE from anywhere. In your Alabama example, the only pertinent issue is WHERE is the treatment being offered? If it's in Alabama, then Alabama law prevails. If it's in Utah (or wherever) those laws prevail.

You misunderstand. The question goes to the likeihood that someone would be married at a very young age . . . clearly a tongue-in-cheek question.

Also, society determines different ages for different consents: In Alabama, a 15 year old can decide their own medical treatment just like an adult. However, they cannot vote, they cannot drive an automobile, they cannot buy alcoholic beverages (err, I hope!).

Again, this "society determines" stuff is nonsense. The law is the law is the law; your equvalence fails in three ways:

* It is the government, not "society" that makes the law. "Society" (whatever that is) may have input on the law, but does not control it directly.

* The law "determines" what is legal, it does not "determine" what reality is, or even what will happen in a given situation . . . not all laws are (or should) be obeyed.

* The law for consent is variable; a 13-year-old is considered able to decide if they are married. An 11-year-old can decide if they've graduated from high school. And so on.

 

[QuikClot]

They don't have to BE from anywhere. In your Alabama example, the only pertinent issue is WHERE is the treatment being offered? If it's in Alabama, then Alabama law prevails. If it's in Utah (or wherever) those laws prevail.

You misunderstand. The question goes to the likeihood that someone would be married at a very young age . . . clearly a tongue-in-cheek question.

Also, society determines different ages for different consents: In Alabama, a 15 year old can decide their own medical treatment just like an adult. However, they cannot vote, they cannot drive an automobile, they cannot buy alcoholic beverages (err, I hope!).

Uh . . . the fact that the age of consent can differ is implied by my sources. So here you are basically repeating what I said to you as if it were news. Why?

Again, this "society determines" stuff is nonsense. The law is the law is the law; your equvalence fails in three ways:

* It is the government, not "society" that makes the law. "Society" (whatever that is) may have input on the law, but does not control it directly.

* The law "determines" what is legal, it does not "determine" what reality is, or even what will happen in a given situation . . . not all laws are (or should) be obeyed.

* The law for consent is variable; a 13-year-old is considered able to decide if they are married. An 11-year-old can decide if they've graduated from high school. And so on.

 

[shane679]

To begin, if this is the child of a Jehovah’s Witness, he probably has an advance directive that states the objection to blood and it is signed by his parent(s)/guardian(s). Therefore, even if the parents cannot be reached, that treatment option is eliminated as if it they were in the room.

Parents do have the right to choose which medical treatments their child will receive, just as any other patient would. The DCS cannot remove a child from a parent simply because a physician thinks they should have a blood transfusion. This is not abuse. It does not fit the description of emotional abuse, sexual abuse, physical abuse, or neglect. It is somewhat absurd to think that a child that does not possess the ability give an informed refusal is capable of giving informed consent. So if you do not respect the wishes of the patient when it is contrary to what you believe is best, then you cannot respect those wishes because they comply with your reasoning.

Let’s suppose that blood was the miraculous healer. People have the right to die and the freedom to worship and serve their God as they please, as long as it does not violate the laws. So, even if blood were the ultimate healer, if obeying God as ruler rather than man means death, then so be it.

Are there not alternatives to blood? You should hurry and answer YES 😉 . Jehovah’s Witnesses have found great success in both the judicial and medical arena in upholding their faith in Bible principles. If the physician is not comfortable with treating patients without the use of blood, then the Witness finds one that is competent to do so. If your mechanic is not comfortable with Fords, you simply go to one that was.

Jehovah’s Witnesses do not refuse healthcare or just want to die. They refuse treatment options involving blood, based on the Bible teachings. If they were not interested in caring for the needs of the child (and theirs, if in the same position), would they have come to a physician in the first place? Would this even be a question? So obviously, they want the same things other patients desire, the best possible care, except without blood.

On a side note, I am sure that they do not have the illusion of “rising with Christ at the second coming” or an unhealthy fear that “they will go to hell.”

In the future, before deciding something is “silly” you might want to gather the proper information and then make an informed decision founded on knowledge.

In conclusion, resources are available to any physician (or person) that is legitimately searching for an answer to this question. Issues are addressed with the legal, medical, and ethical implications involved in the decision. NO BLOOD. Medicine Meets the Challenge, TRANSFUSION ALTERNATIVE HEALTH CARE. Meeting Patient Needs and Rights are among the multiple resources available to those who want to learn more. For those that are genuinely interested in the answer to any question regarding the faith of Jehovah’s Witnesses (specifically in matters that are important to them), I say stop by a Kingdom Hall of Jehovah’s Witnesses and ask the people that can best answer the question.

Hope that everyone has a good day. Take care.

csh 🙂