Jehovah's Witness and Blood Transfusion

[tophat118]

Quick question here that I hope to not oversimplify.

If a Jehovah's witness, who was injured and is bleeding profusely, enters your ER or wherever and requests to be operated on without a blood transfusion, do you have to honor their request. In this situation the patient will almost certainly die without a blood transfusion, and will very likely live if given one.

I know you can wait for them to enter shock and then transfuse them anyways, but that is not my question. I want to know if a doctor has the right to say essentially "No, I will not perform a procedure on you which transfusions have been deemed medically necessary for survival while you are refusing them. I should not have to be responsible for you dying on my operating table because of your religious beliefs. I am sorry but I will not do that. Do you still not want a transfusion?"

It just seems wrong to force a doctor to perform a procedure, which without a blood transfusion, will almost certainly result in death. Almost being the key word, can the doctor still be at fault for the person who refuses the transfusion death, simply because there is an astronomically small chance for survival. By not operating you would honor their request by not transfusing them once they enter shock, and the doctor would not have to be faced with a situation where their operating basically speeds killing the patient, right?

Thanks,

An entering first year thinking on an ethics question

---

Members don't see this ad.

 

[loveoforganic2]

My understanding, if I'm wrong, I'm sure I'll be corrected. All answers are assuming the patient is an ADULT, peds patients ALWAYS receive lifesaving treatment (leave it at that, I'm not talking about giving a 3rd round of chemo to a kid with ALL that's crumping; standard of care stuff)

Quick question here that I hope to not oversimplify.

If a Jehovah's witness, who was injured and is bleeding profusely, enters your ER or wherever and requests to be operated on without a blood transfusion, do you have to honor their request.

Yes

In this situation the patient will almost certainly die without a blood transfusion, and will very likely live if given one.

Doesn't matter, patient autonomy dictates their right to accept death as a possibility of their choices (assuming competence, and there's no given reason to question it here)

I know you can wait for them to enter shock and then transfuse them anyways, but that is not my question.

If you do so after they've clearly expressed their desire not to receive a transfusion, you're looking at losing a lawsuit if they choose to pursue one (even if they live)

I want to know if a doctor has the right to say essentially "No, I will not perform a procedure on you which transfusions have been deemed medically necessary for survival while you are refusing them. I should not have to be responsible for you dying on my operating table because of your religious beliefs. I am sorry but I will not do that. Do you still not want a transfusion?"

Not in an emergent situation with EMTALA

It just seems wrong to force a doctor to perform a procedure, which without a blood transfusion, will almost certainly result in death. Almost being the key word, can the doctor still be at fault for the person who refuses the transfusion death, simply because there is an astronomically small chance for survival. By not operating you would honor their request by not transfusing them once they enter shock, and the doctor would not have to be faced with a situation where their operating basically speeds killing the patient, right?

You're operating to give the patient the small chance they have to live. They made the informed decision to not allow an aspect of care

Thanks,

An entering first year thinking on an ethics question

That said, you should make an effort to ask the patient the question in isolation from any family, friends, etc.

 

[tophat118]

My understanding, if I'm wrong, I'm sure I'll be corrected. All answers are assuming the patient is an ADULT, peds patients ALWAYS receive lifesaving treatment (leave it at that, I'm not talking about giving a 3rd round of chemo to a kid with ALL that's crumping; standard of care stuff)



That said, you should make an effort to ask the patient the question in isolation from any family, friends, etc.

Yes, the patient would be an adult in this case. I realize I am looking at this from a pure ethics point of view but it just seems wrong to force a doctor to operate in a situation where refusing a blood transfusion basically equates to death.

I was hoping that the answer might have been that the doctor could refuse in that type of situation. This would be honoring the patients autonomy by not transfusing when they are under and also doesnt put the doctor in the aforementioned type of situation. I guess I'll be interested to see what more people have to say on this.

Last thing, sort of an aside. It just seems weird to me that a person can dictate how a doctor must treat them. When a person enters a hospital they are being seen to recieve an opinion from a person who has years of medical training. Then, they can hear what the doctor has to say on what he thinks is the best course of medical action and basically subsequently dictate the procedure as it is convenient for them?

I hope I am making sense, its getting late over here.

EDIT: good point on asking the person in private, I understand family can place a large amount of pressure on a person. I also do not want to give the impression that I am heartless, I'm just curious on this topic.

 

[loveoforganic2]

Yes, the patient would be an adult in this case. I realize I am looking at this from a pure ethics point of view but it just seems wrong to force a doctor to operate in a situation where refusing a blood transfusion basically equates to death.

I was hoping that the answer might have been that the doctor could refuse in that type of situation. This would be honoring the patients autonomy by not transfusing when they are under and also doesnt put the doctor in the aforementioned type of situation. I guess I'll be interested to see what more people have to say on this.

You don't get to pick your patients in life threatening trauma. You don't operate and that patient dies, I'm pretty confident the hospital is going to lose several million $, and you're going to be out a job (possibly your license)

Last thing, sort of an aside. It just seems weird to me that a person can dictate how a doctor must treat them. When a person enters a hospital they are being seen to recieve an opinion from a person who has years of medical training. Then, they can hear what the doctor has to say on what he thinks is the best course of medical action and basically subsequently dictate the procedure as it is convenient for them?

No, patients do not dictate how a physician must treat them - you're expanding the explanation to conditions it doesn't apply. If a patient goes to the GP and requests fentanyl, they're not going to get it. However, if the physician recommends a beta blocker (lets say it's the best choice for the patient's arrhythmia), but the patient places high value on sexual function (which can be impaired by beta blockers), they very reasonably decline that medication and ask a different recommendation from the physician. A more extreme situation that's more analogous to the one initially proposed would be a complicated pregnancy in which childbirth poses a significant chance of costing the mother her life, but she accepts the risk of attempting to birth the child - would you anesthetize her and abort the baby against her consent?

I hope I am making sense, its getting late over here.

Edit:

EDIT: good point on asking the person in private, I understand family can place a large amount of pressure on a person. I also do not want to give the impression that I am heartless, I'm just curious on this topic

It doesn't come across as heartless, I'm just pretty confident it isn't in line with accepted medical ethics. I have a feeling you'll almost certainly discuss this exact topic during your 1st two years

 

[Kevin Baker]

Yes, the patient would be an adult in this case. I realize I am looking at this from a pure ethics point of view but it just seems wrong to force a doctor to operate in a situation where refusing a blood transfusion basically equates to death.

I was hoping that the answer might have been that the doctor could refuse in that type of situation. This would be honoring the patients autonomy by not transfusing when they are under and also doesnt put the doctor in the aforementioned type of situation. I guess I'll be interested to see what more people have to say on this.

Last thing, sort of an aside. It just seems weird to me that a person can dictate how a doctor must treat them. When a person enters a hospital they are being seen to recieve an opinion from a person who has years of medical training. Then, they can hear what the doctor has to say on what he thinks is the best course of medical action and basically subsequently dictate the procedure as it is convenient for them?

I hope I am making sense, its getting late over here.

EDIT: good point on asking the person in private, I understand family can place a large amount of pressure on a person. I also do not want to give the impression that I am heartless, I'm just curious on this topic.

Doctors can refuse to treat when it conflicts with their own morality/personal/religious beliefs, and when it's a non-emergent circumstance, or if you deem the alternative treatment to not be worth the risks. Most people argue some sort of referral is necessary for the patient in these circumstances. So if that were the case here, nothing wrong with that. But one isn't allowed to refuse to treat due to pettiness or because a patient disagrees with a treatment plan, which is what this scenario sounds like. I'm sure it happens though, but I wouldn't call it ethical. In a scenario like this you'd weigh the costs and benefits of different treatment plans and rule them in/out until you're left with supportive care, which might be all one can do in this scenario.

 

[kavorca]

I doubt most surgeons would operate if he would probably die with or without surgery. They get dinged if they have a death within 30 days of the surgery. I have seen some surgeons refusing palliative surgeries for this reason, eg colon cancers causing complete obstruction. If you are going to handcuff them with no blood transfusions before or after surgery, they probably won't do it.

 

[Instatewaiter]

If a Jehovah's witness, who was injured and is bleeding profusely, enters your ER or wherever and requests to be operated on without a blood transfusion, do you have to honor their request. In this situation the patient will almost certainly die without a blood transfusion, and will very likely live if given one.

I know you can wait for them to enter shock and then transfuse them anyways, but that is not my question.

You CANNOT transfuse them if they have said they don't want a transfusion and have expressed understanding they could die without it. That is assault and people have been sued in the past for this very complaint.

I want to know if a doctor has the right to say essentially "No, I will not perform a procedure on you which transfusions have been deemed medically necessary for survival while you are refusing them. I should not have to be responsible for you dying on my operating table because of your religious beliefs. I am sorry but I will not do that. Do you still not want a transfusion?"

A doctor does have that right. You do not have to do anything that is medically futile

 

[numberwunn]

I know you can wait for them to enter shock and then transfuse them anyways, but that is not my question.

It is disappointing to see how little you respect the autonomy of your patient. They have made a choice; and you don't care. I hope that it is more because you have not thought the problem out (and are acting out of what you believe to be benevolence). If the patient refuses the blood transfusion out of their religious convictions, and you give it to them anyways, you are basically saying that you know best, and their silly little convictions don't matter. How would you feel if others took your theological/philosophical convictions so lightly?

I'm not defending JW theology. Just their right to follow their theological convictions.

I want to know if a doctor has the right to say essentially "No, I will not perform a procedure on you which transfusions have been deemed medically necessary for survival while you are refusing them. I should not have to be responsible for you dying on my operating table because of your religious beliefs. I am sorry but I will not do that. Do you still not want a transfusion?"

Legally, you may have the right (will leave answer to those who know better). But do you have the moral right? How many other patients would you tell, "I'll treat you, but only if you abandon your religion and adopt mine." I find this to be morally appalling - how is this any different from what the Nazis did? Why not treat the patient on their terms? Do the best you can to save their life - and if they die because they refused a blood transfusion, then so be it?

I apologize for the tongue-lashing, but it raises the hair on the back of my neck when people disrespect their fellow man. Try to think from the patient's perspective, and respect their autonomy. I hope you'll reflect on this some more and mature your thinking.

 

[Bamfu]

Legally, you may have the right (will leave answer to those who know better). But do you have the moral right? How many other patients would you tell, "I'll treat you, but only if you abandon your religion and adopt mine." I find this to be morally appalling - how is this any different from what the Nazis did? Why not treat the patient on their terms? Do the best you can to save their life - and if they die because they refused a blood transfusion, then so be it?

I apologize for the tongue-lashing, but it raises the hair on the back of my neck when people disrespect their fellow man. Try to think from the patient's perspective, and respect their autonomy. I hope you'll reflect on this some more and mature your thinking.

What happens when you raise your own hair? The OP has a controversial issue that he is seeking advice/other opinions on to broaden his own point of view. The tone of your post suggests that he is doing the opposite, and it shows your own disrespect for him. Your post is an oversimplification and a terrible attempt to link two very different cases. To equate a confused soon-to-be physician seeking answers for a better understanding with the Holocaust?.. I hope you are trolling.

Anyways, as for my own opinion on the matter:
As long as it is legal, I feel like a physician not only has the moral right but also the moral obligation to say whatever they need (again, within the boundaries of the law) to get a patient to accept live-saving treatment. There are plenty of ways to go about it without intimidating, insulting, or coercing a patient. In fact, it seems that simply announcing the severity of the consequences (in this case, death) would be enough to convince most. Sometimes you just have to be creative with your delivery. However, if nothing gets through to the patient, I'm pretty sure Instatewaiter is correct - a doctor does not have to administer medically futile treatments. That being said, if I were the physician, I would make 100% sure that the treatment would be medically futile without a transfusion (in this case). If there was even a small chance of survival and the patient insisted, I feel like you would have to do it or refer to another doctor as was mentioned earlier.

 

[Rendar5]

To the OP:

Actually, the surgeon does not have the right to refuse to treat the patient in this case because it's an emergent situation and they are legally bound to treat the patient within the confines given them, at least in the US. As has been said, if they refuse a transfusion and make it known that they are refusing, then you cannot give them a blood transfusion, regardless of what happens. What right do you have to condemn their eternal soul to hell just for a few more years on earth just so your numbers look good? That's essentially what you'd be doing in their minds by providing a blood xfusion. (not that I share that opinion, but it's not my religion). At this point they're an adult and have the capacity to make medical decisions, and these beliefs are no longer forced on them as they are in a child.

If it were not emergent, then the surgeon has full rights to not treat.

In addition, if it's futile, than there is no role for surgery regardless, but someone who can make their wishes known rarely has a futile condition.

BTW, Bamfu, wait til you really get into medicine and see what patients will refuse knowing full well the consequences of their actions.

 

[Bamfu]

In addition, if it's futile, than there is no role for surgery regardless, but someone who can make their wishes known rarely has a futile condition.

BTW, Bamfu, wait til you really get into medicine and see what patients will refuse knowing full well the consequences of their actions.

I was hoping someone with experience would jump in. Rendar, is it considered futile if there is an overwhelming (~100% chance) that blood will be required during the surgery and the patient refuses blood? I can't think of an example, but you might be able to.

I'm sure you're right about the refusal. I've actually seen a little bit of (what I would consider silly) refusal with dire consequences. It's really frustrating and one of the things I am looking forward to least in this career 🙁 However, the prospect of immediate death is enough to get through the conviction of a lot of, if not most, people.

 

[Rendar5]

I was hoping someone with experience would jump in. Rendar, is it considered futile if there is an overwhelming (~100% chance) that blood will be required during the surgery and the patient refuses blood? I can't think of an example, but you might be able to.

I'm sure you're right about the refusal. I've actually seen a little bit of (what I would consider silly) refusal with dire consequences. It's really frustrating and one of the things I am looking forward to least in this career 🙁 However, the prospect of immediate death is enough to get through the conviction of a lot of, if not most, people.

I can say there are plenty of situations in trauma where there is 100% chance that the patient will be recommended blood, but I doubt there are really clear-cut situations where the surgery would be considered completely futile only if the patient were to refuse blood. Riskier, sure, futile? eh... It's a question best left up to a trauma surgeon or a cardiothoracic surgery or vascular surgeon (Emergent aortic surgeries have a tendency to use lots of blood)

EDIT: To answer your original question a bit better, futile would mean 99+% mortality if undergoing surgery. In some cases, non-surgical treatment may be attempted in place of surgical treatment, but it's all a risk:benefit.

 

[Smurfette]

My partner just had this happen last month (Jehovah with life threatening condition with emergent problem requiring blood). He operated on the patient after having a thorough discussion (well documented) about how not getting transfused meant chances of dying was nearly 100%. Patient and family chose to proceed with surgery. Post op hemoglobin was 2.6. Everyone was shocked when the patient actually lived, albeit with ARF and other complications. Currently is recovering at home.

However, if as a surgeon, I think surgery is futile or not in the patient's best interest, I CAN refuse to operate. EMTALA does not mandate I operate, just that the patient is evaluated and treated. I can't refuse to treat a patient in the ER based on insurance status, belief system, physical condition, etc. If a patient is 90 yrs old with a laundry list of severe medical problems develops free air, septicemia and looks as though death is imminent, I can tell the family that surgery is not a reasonable option, and give the patient supportive treatment only based on my judgment.

 

[FutureInternist]

It is disappointing to see how little you respect the autonomy of your patient. They have made a choice; and you don't care. I hope that it is more because you have not thought the problem out (and are acting out of what you believe to be benevolence). If the patient refuses the blood transfusion out of their religious convictions, and you give it to them anyways, you are basically saying that you know best, and their silly little convictions don't matter. How would you feel if others took your theological/philosophical convictions so lightly?

I'm not defending JW theology. Just their right to follow their theological convictions.



Legally, you may have the right (will leave answer to those who know better). But do you have the moral right? How many other patients would you tell, "I'll treat you, but only if you abandon your religion and adopt mine." I find this to be morally appalling - how is this any different from what the Nazis did? Why not treat the patient on their terms? Do the best you can to save their life - and if they die because they refused a blood transfusion, then so be it?

I apologize for the tongue-lashing, but it raises the hair on the back of my neck when people disrespect their fellow man. Try to think from the patient's perspective, and respect their autonomy. I hope you'll reflect on this some more and mature your thinking.

Only 6 posts in
That's the fastest one I've seen

http://en.wikipedia.org/wiki/Godwin's_law