Healthcare ethics involves making well researched and considerate decisions about medical treatments, while taking into consideration a patient’s beliefs and wishes regarding all aspects of their health. The healthcare industry, above any other, has a high regard for the issues surrounding the welfare of their patients. This power over a patient’s wellbeing creates a mandatory need for all healthcare organizations to develop an ethics committee. The committee’s goal is to establish a written code of ethics that details the policies and procedures that determine proper conduct for all employees. There are many ethical issues that may arise in regards to a patient’s healthcare.
Treating patients with certain religious beliefs pose important ethical issues in the field of healthcare. This paper will describe an ethical health care issue concerning refusal of care, such as a blood transfusion. It will cover the four ethical principles as they apply to healthcare providers and patients’ rights. It is important that health care workers have a rudimentary understanding of Jehovah’s Witnesses philosophy about blood transfusion so that as professionals we can be proactive in their management.
Ethical Health Care Issue
In all areas of practice, physicians come into contact with Jehovah’s Witnesses and their refusal to accept blood transfusion, even when it means saving their lives. The Jehovah’s Witness faith creates some challenges for physicians caring for its members. The ethical principles of autonomy versus beneficence come into conflict when a physician believes a transfusion is in the best interest of the patient, but the patient refuses. Legal precedence provides a backdrop. In addition, Panico, Jenq, & Brewster (2011) article states, there was a case involving a woman who had consented for examination of a fibroid tumor under anesthesia, but withheld consent for removal of the tumor. While sedated, she underwent resection of the tumor that led to complications. She sued and the judge ruled in her favor, establishing the notion that every human being should have the right to decide what is done with his or her own body. Moreover, this premise gave any individual the right to refuse treatment if he or she understands the risks; a Jehovah’s Witness has the right to refuse a blood transfusion.
This ruling set a precedent for informed consent. In 1990, the Canadian case of Malette v Shulman described an emergency department physician who gave a blood transfusion to an unconscious patient who was in hypovolemic shock. Per report, the patient had a signed wallet card that identified her as a Jehovah’s Witness, although it was undated and unwitnessed. The wallet card, is considered a legal document which, stated that she did not want to receive a blood transfusion under any circumstances (Lantos, Matlock, & Wendler, 2011). Furthermore, when the patient’s daughter arrived and asked that the transfusion be stopped, the physician did not comply. The physician argued that there was no way of knowing if the patient had changed her mind in the minutes before the car accident and thus he was duty bound to save her life (Lantos, Matlock, & Wendler, 2011). The court found the physician guilty of battery.
Although it is easy to draw on emotion to argue against the ruling in this case, the verdict has not been overturned. This case illustrates the current teaching to today’s physicians, who are taught to respect patient’s autonomy and preferences for their own bodies (Lantos, Matlock, & Wendler, 2011). Jehovah’s Witness have been known to refuse transfusions with packed red blood cells to treat their life-threatening diseases. Medical professionals must consider patient has autonomy of thought, intention, and action when making decisions regarding health care procedures. To comply with patient’s wishes medical professionals could offer fresh frozen plasma and platelets as an alternative. Furthermore, Jehovah’s Witnesses number over one million in the United States and at least six million worldwide. Witnesses believe in strict and literal interpretation of the Bible, which leads them to reject some aspects of modern medical care (Doyle, 2002).
Medical professionals have discussed in open forums ethical decisions they are required to make while taking care of a dying patient who refused to accept a blood transfusion. Data suggests they struggled to relate to someone who would take some blood products, but not others, and who are willing to risk death over a red blood cell transfusion. Refusal of blood transfusions became common practice only after a 1945 church decision (Mann, Votto, & Kambe, 1992). Indeed, Jehovah’s Witnesses interpret these sections of the Bible differently and if a member accepts blood into their veins, they are shunned and forfeit their membership in the faith community and eternal life. The society had enforced shunning and social isolation by Witnesses’ own family members, relatives, and friends, ultimately leading to expulsion from the religion (Doyle, 2002).
Similarly, research suggest that the health care provider must consider four main areas when evaluating justice and the four areas are fair distribution of scarce resources, competing needs, rights and obligations, and potential conflicts with established legislation (Gillon, 1994). In considering the many ethical dilemmas associated with Jehovah’s Witnesses and their refusal to accept blood transfusion have medical professionals focusing on the ways in which treatments or interventions violates accepted norms of conduct of social science research. Physicians must be aware of the growing diversity of values and beliefs among Jehovah’s Witnesses. Some of the most intractable ethical problems arise from conflicts among principles and the necessity of trading one off against the other. The balancing of such principles in concrete situations is the ultimate ethical act (House, 1993, p. 168).
Evaluation involves at least four levels of social-political interaction- with government and other agency policy makers who commission evaluation. Evaluation has to operate in this multilayered context of different interests, providing information to inform decisions while remaining independent of the policies and programs themselves (House, 1993, p. 170). More importantly, the weight of ethical judgment is thus put on experimental research to justify meeting ethical standards (Panico, Jenq, & Brewster, 2011). Resource allocation is a major issue that physicians are confronted with when dealing with Jehovah’s Witness allocation. Beneficence requires that the procedure be provided with the intent of doing good for the patient involved. As described above if a patient refuses a blood transfusion and opt for an alternative procedure that costs more it can prove problematic (Panico, Jenq, & Brewster, 2011).
When society thinks of the greater good, this argument poses a challenge to the principles of patient autonomy that we also value. In a society in which medical resources are costly, benefits will always need to be weighed against the potential cost to both the patient and society thus creating ethical challenges. Finally, the care of a Jehovah’s Witness with life threatening illnesses requires a multidisciplinary and planned approach. These patients suffer with certain diseases and are often anemic and must be prepared to deal with this issue in both outpatient settings and during an acute crisis. Clinicians must view each patient as an individual who may have varying thoughts about transfusions of the multiple different blood products that are available. Therefore, medical practices today need to continue to open early lines of communication with these patients.
Providing adequate information and educating the patient about realities and obtaining informed consent before subjecting a patient to any test, procedure, or surgery is very essential. It is vital to the optimal care of a Jehovah’s Witness patient. It is necessary that dialysis unit nurses and social workers have conversations with patients about their beliefs on blood products. Discussing a patient’s wishes, understanding their basis for these decisions, and discussing risks, benefits, and alternatives that can be used in both emergent and non-emergent situations is crucial to preparing for more urgent situations, when these conversations often are not possible.
To many Jehovah’s Witnesses, the consequences of accepting a blood transfusion can be worse than death itself. Not every Jehovah’s Witness patient abides by the same beliefs regarding the acceptance of blood products. These patients can be managed through careful planning and open lines of communication between physicians and patients. Understanding the premise behind the beliefs of patients who are Jehovah’s Witnesses is critical to beginning conversations and truly understanding the patient. Ultimately, when a patient establishes what they will accept, as clinicians, ethically we must optimize the care we provide within their wishes about blood products. Frequent and open dialogue is essential for enhancing care for a Jehovah’s Witness.
As an alternative to violating a patient’s autonomy some physicians and some hospitals are more comfortable with bloodless procedures and patients can be referred to these centers if necessary for specialty care. Overall, health care professionals should be able to provide ethical health care to patients who are Jehovah’s Witnesses at any hospital or community office, but must continue to be educated and aware of their beliefs and respect their wishes and the impact these may have on organizing and providing their care. If these considerations are neglected one can surely expect ethical breaches or dilemmas as inevitable.
Doyle D. Blood transfusions and the Jehovah’s Witness patient. Am J Ther. 2002;9(5):417–424. Gillon, R. (1994). Informed consent: an ethical obligation or legal compulsion. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2840885/ House, R. (1993). Ethics in evaluation. Retrieved from http://www.uk.sagepub.com/gray3e/study/chapter12/Book%20chapters/Ethics_in_Evaluation.pdf:168-170. Lantos J, Matlock A, Wendler D. Clinician integrity and limits to patient autonomy. JAMA.2011;305(5):495–499. (Lantos, Matlock, & Wendler, 2011). Mann M, Votto J, Kambe J, McNamee M. Management of the severely anemic patient who refuses transfusion: lessons learned during the care of the Jehovah’s Witness. Ann Intern Med. 1992;117(12):1042–1048. Panico, M. L., Jenq, G. Y., & Brewster, U. C. (2011). When a patient refuses life-saving care. American Journal of Kidney Diseases, 58(4), 647-653.