Blood and Doctors

Blood: Whose Choice and Whose Conscience?
by J. Lowell Dixon, M.D.
Reprinted by permission of the New York State Journal of Medicine, 1988; 88:463-464, copyright by the Medical Society of the State of New York.
PHYSICIANS are committed to applying their knowledge, skills, and experience in fighting disease and death. Yet, what if a patient refuses a recommended treatment? This will likely occur if the patient is a Jehovah’s Witness and the treatment is whole blood, packed red blood cells, plasma, or platelets.
When it comes to the use of blood, a physician may feel that a patient’s choice of nonblood treatment will tie the hands of dedicated medical personnel. Still, one must not forget that patients other than Jehovah’s Witnesses often choose not to follow their doctor’s recommendations. According to Appelbaum and Roth,1 19% of patients at teaching hospitals refused at least one treatment or procedure, even though 15% of such refusals "were potentially life endangering."
The general view that "the doctor knows best" causes most patients to defer to their doctor’s skill and knowledge. But how subtly dangerous it would be for a physician to proceed as if this phrase were a scientific fact and to treat patients accordingly. True, our medical training, licensing, and experience give us noteworthy privileges in the medical arena. Our patients, though, have rights. And, as we are likely aware, the law (even the Constitution) gives greater weight to rights.
On the walls of most hospitals, one sees displayed the "Patient’s Bill of Rights." One of these rights is informed consent, which might more accurately be called informed choice. After the patient is informed of the potential results of various treatments (or of nontreatment), it is his choice what he will submit to. At Albert Einstein Hospital in the Bronx, New York, a draft policy on blood transfusion and Jehovah’s Witnesses stated: "Any adult patient who is not incapacitated has the right to refuse treatment no matter how detrimental such a refusal may be to his health."2
While physicians may voice concerns about ethics or liability, courts have stressed the supremacy of patient choice.3 The New York Court of Appeals stated that "the patient’s right to determine the course of his own treatment [is] paramount . . . [A] doctor cannot be held to have violated his legal or professional responsibilities when he honors the right of a competent adult patient to decline medical treatment."4 That court has also observed that "the ethical integrity of the medical profession, while important, cannot outweigh the fundamental individual rights here asserted. It is the needs and desires of the individual, not the requirements of the institution, that are paramount."5
When a Witness refuses blood, physicians may feel pangs of conscience at the prospect of doing what seems to be less than the maximum. What the Witness is asking conscientious doctors to do, though, is to provide the best alternative care possible under the circumstances. We often must alter our therapy to accommodate circumstances, such as hypertension, severe allergy to antibiotics, or the unavailability of certain costly equipment. With the Witness patient, physicians are being asked to manage the medical or surgical problem in harmony with the patient’s choice and conscience, his moral/religious decision to abstain from blood.
Numerous reports of major surgery on Witness patients show that many physicians can, in good conscience and with success, accommodate the request not to employ blood. For example, in 1981, Cooley reviewed 1,026 cardiovascular operations, 22% on minors. He determined "that the risk of surgery in patients of the Jehovah’s Witness group has not been substantially higher than for others."6 Kambouris7 reported on major operations on Witnesses, some of whom had been "denied urgently needed surgical treatment because of their refusal to accept blood." He said: "All patients received pretreatment assurances that their religious beliefs would be respected, regardless of the circumstances in the operating room. There were no untoward effects of this policy."
When a patient is a Jehovah’s Witness, beyond the matter of choice, conscience comes into the picture. One cannot think only of the physician’s conscience. What of the patient’s? Jehovah’s Witnesses view life as God’s gift represented by blood. They believe the Bible’s command that Christians must "abstain from blood" (Acts 15:28, 29).8 Hence, if a physician paternalistically violated such patients’ deep and long-held religious convictions, the result could be tragic. 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."9
While Jehovah’s Witnesses refuse blood for religious reasons, more and more non-Witness patients are choosing to avoid blood because of risks such as AIDS, non-A non-B hepatitis, and immunologic reactions. We may present to them our views as to whether such risks seem minor compared to the benefits. But, as the American Medical Association points out, the patient is "the final arbiter as to whether he will take his chances with the treatment or operation recommended by the doctor or risk living without it. Such is the natural right of the individual, which the law recognizes."10
Related to this, Macklin11 brought up the risk/benefit issue regarding a Witness "who risked bleeding to death without a transfusion." A medical student said: "His thought processes were intact. What do you do when religious beliefs are against the only source of treatment?" Macklin reasoned: "We may believe very strongly this man is making a mistake. But Jehovah’s Witnesses believe that to be transfused . . . [may] result in eternal damnation. We are trained to do risk-benefit analyses in medicine but if you weigh eternal damnation against remaining life on earth, the analysis assumes a different angle."11
Vercillo and Duprey12 in this issue of the Journal refer to In re Osborne to highlight the interest in ensuring the security of dependents, but how was that case resolved? It concerned a severely injured father of two minor children. The court determined that if he died, relatives would materially and spiritually care for his children. So, as in other recent cases,13 the court found no compelling state interest to justify overriding the patient’s choice of treatment; judicial intervention to authorize treatment deeply objectionable to him was unwarranted.14 With alternative treatment the patient recovered and continued to care for his family.
Is it not true that the vast majority of cases physicians have confronted, or likely will, can be managed without blood? What we studied and know best has to do with medical problems, yet patients are human beings whose individual values and goals cannot be ignored. They know best about their own priorities, their own morals and conscience, which give life meaning for them.
Respecting the religious consciences of Witness patients may challenge our skills. But as we meet this challenge, we underscore valuable liberties that all of us cherish. As John Stuart Mill aptly wrote: "No society in which these liberties are not, on the whole, respected, is free, whatever may be its form of government . . . Each is the proper guardian of his own health, whether bodily, or mental and spiritual. Mankind are greater gainers by suffering each other to live as seems good to themselves, than by compelling each to live as seems good to the rest."15
[REFERENCES]
1. Appelbaum PS, Roth LH: Patients who refuse treatment in medical hospitals. JAMA 1983; 250:1296-1301.
2. Macklin R: The inner workings of an ethics committee: Latest battle over Jehovah’s Witnesses. Hastings Cent Rep 1988; 18(1):15-20.
3. Bouvia v Superior Court, 179 Cal App 3d 1127, 225 Cal Rptr 297 (1986); In re Brown, 478 So 2d 1033 (Miss 1985).
4. In re Storar, 438 NYS 2d 266, 273, 420 NE 2d 64, 71 (NY 1981).
5. Rivers v Katz, 504 NYS 2d 74, 80 n 6, 495 NE 2d 337, 343 n 6 (NY 1986).
6. Dixon JL, Smalley MG: Jehovah’s Witnesses. The surgical/ethical challenge. JAMA 1981; 246:2471-2472.
7. Kambouris AA: Major abdominal operations on Jehovah’s Witnesses. Am Surg 1987; 53:350-356.
8. Jehovah’s Witnesses and the Question of Blood. Brooklyn, NY, Watchtower Bible and Tract Society, 1977, pp 1-64.
9. Pope denounces Polish crackdown. NY Times, January 11, 1982, p A9.
10. Office of the General Counsel: Medicolegal Forms with Legal Analysis. Chicago, American Medical Association, 1973, p 24.
11. Kleiman D: Hospital philosopher confronts decisions of life. NY Times, January 23, 1984, pp B1, B3.
12. Vercillo AP, Duprey SV: Jehovah’s Witnesses and the transfusion of blood products. NY State J Med 1988; 88:493-494.
13. Wons v Public Health Trust, 500 So 2d 679 (Fla Dist Ct App) (1987); Randolph v City of New York, 117 AD 2d 44, 501 NYS 2d 837 (1986); Taft v Taft, 383 Mass 331, 446 NE 2d 395 (1983).
14. In re Osborne, 294 A 2d 372 (DC Ct App 1972).
15. Mill JS: On liberty, in Adler MJ (ed): Great Books of the Western World. Chicago, Encyclopaedia Britannica, Inc, 1952, vol 43, p 273.