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Giving blood to a child whose parents refuse the transfusion


Wolvenstar

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After one person posted an ethical question he/she was curious about, it has prompted me to ask others about a scenario of my own. One that, yes, is a true story I have heard about. No i do not remember hearing how the situation ended up being resolved.

I will try to generalize this slightly more so it is not the exact circumstances which actually occured.

 

 

Young Patient (gender doesnt matter), is hopsitalized because of a life-threatening condition (whatever you wish to choose, car accident, genetic defect, anything that threatens their life). The patient will die without surgery. The procedure needed requires that the patient be given blood interveinously during the procedure. The patient is underage, and the parents do not wish their child to undergo this procedure because of religious beliefs (they believe that their child will go to hell or some boulderdash like that). Would you as the patient's doctor, go ahead with the surgery (or try to obtain a court order if there is time, again depending on the nature of the condition) even though the parents are would rather their child die? The patient is underage.

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Just a short fyi : unless it's in Quebec, specific age is not what matters. Legally, you have to assess the young patient's ability to understand the decision she has to make & the consequences it may have. You can always just add that it's a 13 yr old in QC to make it work though ;)

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Just a short fyi : unless it's in Quebec, specific age is not what matters. Legally, you have to assess the young patient's ability to understand the decision she has to make & the consequences it may have. You can always just add that it's a 13 yr old in QC to make it work though ;)

 

 

 

Ok everyone adopt this just to make it work... Frankly what I want to see is whether people would/wouldn't respect the religious beliefs over their duty as a doctor, and their reasonings

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let me pose a counterargument that may reflect in most people's eyes what a jehova's witness may see in a medical procedure that involves blood transfusions:

 

let's say there's some hypothetical condition that a young child comes down with which is fatal if not treated, but can be cured completely by having someone have intercourse with the child. I think it is a non issue in any society I have heard of that this would be completely immoral and wrong (sexual acts on children). But the fact remains that it is the only cure. The parents object to the procedure. Would you carry it out and save the child's life? I think most people would not. Using logic, the child's life is saved, why not do it? It is a social taboo that is unanimously decried as reprehensible, but the core issue remains: some procedure that is much less harmful than death will save the patient's life but is rejected on the basis of a cultural belief.

 

The point I'm trying to make is that just because you don't share someone's views doesn't mean they are invalid. Just because most of society thinks it is silly not to accept life saving blood transfusions, doesn't mean that you can get a court order or whatever it is you want to opress these people's beliefs and "save" their children.

 

Just my opinion... sorry for the disturbing analogy (which i really wouldn't reccomend using in an interview :P )

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Guest begaster

Not a fair analogy. Raping a child is going to lead to physical and psychological trauma. That's why people are so hell-bent against it. A blood transfusion isn't going to create any lasting damage. Life is far more important than any otherwise harmless social taboo. I mean, how far do you go?

 

If a kid has treatable cancer and the parents say they don't want you to do it, are you going to be okay with that? Where does the child's right to life come into play? Do parents have full control over life-and-death issues of their children? Should we be allowing, then, Muslim fathers to murder their daughters for taking up Western traditions against the wishes of the family? After all, it's socially unacceptable for the girls to do so, and it's socially acceptable in the ME to perform honour killings. Respect for religion is one thing, but once those beliefs start harming other people, you need to put your foot down and say that these beliefs are absolutely unacceptable. If a JW wants to kill him or herself by refusing a blood transfusion, I'll try to convince them otherwise. If a JW wants to kill his/her child by refusing a blood transfusion, I'll do it anyway and call in child's services. Hell, wasn't there recently a case in BC along the same thinking process?

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i find it unfortunate that the medical profession waits until such cases are in the 'do or die' stage to consider such questions. Has anyone bothered to ask why Jehova's witnesses are against blood transfusions? Has it been attempted to interpret the passages they believe prohibit this act in a way that would allow them religious closure and acceptance of this medical intervention? Why do we wait until the choice is a) let the child die or B) force the procedure upon them, then once all is said and done, we forget about the issue? dialogue now is key to prevent such unfortunate decisions from having to be made under opressive deadlines.

 

and to address my above example, say the child is put to sleep and has no memory of what was done to them ie no psychological trauma... i don't think the physical trauma argument is applicable because most medical interventions (ie surgery) involve great amounts of physical trauma. I'm not saying rape, i'm saying a sexual act has to be performed on them just as any other medical act would be performed. Surgeons don't pull out their drills and scalpels while you're fully awake. and in fact many doctor's visits can be psychologically damaging as well so such arguments that you present simply further accentuate the status of this act as a social taboo (FYI I am in no way advocating such things... just using it as a very extreme example).

 

The father/daughter murder i feel is completely unrelated no medical conditions/interventions are involved. What he did was murder.

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Guest begaster

The honour-killing thing was a bit of a stretch, but it was mainly to respond to this:

 

"The point I'm trying to make is that just because you don't share someone's views doesn't mean they are invalid. Just because most of society thinks it is silly not to accept life saving blood transfusions, doesn't mean that you can get a court order or whatever it is you want to opress these people's beliefs and "save" their children."

 

It's not the correct stance to take. As a society, we have deemed what is morally acceptable and what is morally reprehensible (and you can take it a step further and say these notions are absolute, but I don't want to get into this argument). Letting a child die to appease God is morally reprehensible. Their views are invalid. The view you're endorsing is "let he who is without sin cast the first stone," which is as idealistic as it is unrealistic. The Canadian people have spoken, as have our laws. We won't stand for a parent denying their child the right to live, no matter what religion they adhere to. And you can get a court order. It's happened repeatedly.

 

As for your hypothetical, if the child is put to sleep and has no memory of it, by all means. Lord knows there are plenty of embarrassing treatments and procedures that are done for less. Though, for the record, comparing the psychological damage of a doctor's visit to the trauma of being raped is kind of silly. :P

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The view you're endorsing is "let he who is without sin cast the first stone," which is as idealistic as it is unrealistic. The Canadian people have spoken, as have our laws. We won't stand for a parent denying their child the right to live, no matter what religion they adhere to. And you can get a court order. It's happened repeatedly.

 

what i was trying to do was put the situation in a way that most people can understand/relate to. to me, i admit i have no idea what the reason behind refusing blood transfusions is, and without such knowledge, i think it's a bit of a silly demand. I'm not saying that just because we all have our own quirky beliefs means that we should respect such beliefs of others. I'm saying we should be sympathetic to the beliefs of others and try to have a dialogue whereby each group can understand each other. Through this I hope people can come to terms with (and maybe change) such odd behaviours by understanding the underlying reasons for such behaviour. There was a quote I read once which stated "it is not desireable to cultivate a respect for the law so much as for the right". Laws are proxies for what we believe to be right, but they are not perfect and are always subject to change. Making any argument on the basis of "that's what the law says" may be useful for legal purposes, but not moral ones.

 

Though, for the record, comparing the psychological damage of a doctor's visit to the trauma of being raped is kind of silly. :P

 

hahahaha agreed :P

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Hell, wasn't there recently a case in BC along the same thinking process?

 

Actually that might have been the case that prompted this. Girl (who yes was jehova's witness) needed a surgery to live. I don't remember what the condition was, but I know she needed this surgery or else she would die. The surgery involved blood transfusions. Family said no because she wouldn't go to heaven if she got blood transfusions. Eventually the child (i believe she was in her teens) made her own decision and asked for the surgery. Afterwards her entire family and the jehova community, well i forget the word but they pretty much exiled her, and no one would have anything to do with her.

 

 

 

 

 

 

To Begaster:

 

As far as I know they never discovered the condition till symptoms arose, by that time she needed the surgery. There really was no "feet dragging". So if you were to be put into such a situation as a doctor. The parents said no, but the child needed the surgery (and let us say stayed quiet for whatever reasons, just didn't voice her opinion). If it was down to letting the child die to respect the family's religious beliefs, or save the girl what would you do?

 

 

 

 

 

 

 

 

 

 

Since I haven't actually voiced my own opinion yet, allow me to do so. Religions arose hundreds if not thousands of years ago (depending on the religion) to explain things that could not be explained, to make people that they were not alone, and to make people before more "comfortable" with death (if there is a after-life, then death is not the end). You notice the "make comfortable with the idea of death" This does not mean follow ignorance and forsake the chance at life. People want to believe that "god" is perfect, infallable. They need the bible or whatever they read, to be perfect, exact, and literal: that way they have a "guide to living life the right way"

 

The only problem is that everyone has this need every generation, so everyone is afraid to change the book, because to change it, means it's written by man (which is, but some people believe otherwise...even though its divided into the books of the apostles, and others...you know real living people who weren't god but followed jesus, or listened to god, and tried to do what is best). If it is written by man that means it might not be right and then they dont know if "heaven" is true, or if they are living life properly.

 

This is not healthy, and I doubt any of those who have passages in the bible, or even jesus (if you believe in him) or god, would still want people to be following the bible to the word.

 

I like this saying by a nun in the tv show House: "If I break my leg, I believe God wanted me to break my leg. I also believe god wants me to go to the doctor and put a cast on it."

 

 

I wouldn't hesitate to put a child of any age through surgery to safe their life even if the family didn't want it for religious reasons.

 

I also hope that I haven't offended anyone. Please don't let my opinion stop you from voicing your own. I made this thread to hear what everyone has to say.

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well i still maintain that the attitude of "I'm the doctor, i can save your life, therefore i WILL save your life despite what you or your family want" is not the right kind of attitude. Medicine is more than just physical well being, and I think people need to move beyond the idea that anything>>>>>death. I'm not saying i would throw my hands up in the air and let the child die, but i'm saying it is important to take the family's wishes into consideration. That child might suffer immesurable psychological trauma because her family and community might shun her as a "satan-child" or something because she was saved by a blood transfusion. Have you made her life better?

 

Some cultures burn their dead, others bury them, others still EAT them (no i'm not making this up!). Each culture would be apalled or at least shocked by the other's choices. The underlying principle they all have is that they believe you should honour your dead, but each culture does so very differently. There are many cases where one culture is simply wrong (ie the world is flat vs round), but more often than not, you can find a common understanding between two groups of people. This understanding is ONLY possible if you are open minded and actually LISTEN to what the other group is saying... if there were a simple answer to this question it wouldn't be so hotly debated. But i think it's unfortunate that medicine and religion don't interact more often to try and resolve such issues before they even arise. (I also think there was another case of triplets or quintuplets or something like that born to jehova's witnesses, they needed blood, parents said no, dr's got a court order to do it, but by that time a few had died already).

 

edit: i don't think anyone should be offended by anything said here... it's just a healthy debate :D with many good and important points being raised

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well i still maintain that the attitude of "I'm the doctor, i can save your life, therefore i WILL save your life despite what you or your family want" is not the right kind of attitude. Medicine is more than just physical well being, and I think people need to move beyond the idea that anything>>>>>death. I'm not saying i would throw my hands up in the air and let the child die, but i'm saying it is important to take the family's wishes into consideration. That child might suffer immesurable psychological trauma because her family and community might shun her as a "satan-child" or something because she was saved by a blood transfusion. Have you made her life better?

 

As far as I'm concerned it's more a legal decision then a medical one anyway. Depriving a child of the right to life (or putting them at unnecessary risk) based on a religion that they themselves have not selected (I'm talking about minors too young to consent here) is not legally compatible with how I (and most courts) view the rights of Canadian citizens.

 

An interesting point, a few weeks ago, my class was given a presentation on this topic by the JW hospital liaison committee for our area. One person asked if JW believed children are born innately religious, or if they only gained religion from a personal choice later on. The presenter said they only gained religion later on, then cited the example of the lack of baptism as evidence of the JW belief that children are not born into a religion. The person then followed it up by asking how then, could one justify refusing blood to a child who they just said was not born into the religion, but must make a conscious choice to join it in sound mind. You are essentially forcing he parents views onto a child who has not selected the religion. It was an excellent point, and the presenter really didn't have a satisfying answer for it IMO.

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Guest begaster

Wolvenstar: Yes, I'd put her in surgery right away.

 

Dante: Again, there are two problems with what you're saying:

 

1) You're asking us to let parents make life and death decisions over their children, as if they are property. Their children are not their property. Nobody gets to decide that their child will die because it goes against their own religious beliefs for their child to live. This is why I brought up honor-killings. They are completely legitimate in the ME (as horrific is that is) as the family's honour is worth more than the daughter's life, but does that mean we should accept them here? According to the reasoning you have presented, yes. We should respect all religious beliefs and acts, no matter how monstrous, immoral, and stupid. The family might shun her? Terrible. Not as terrible as dying needlessly. At least she'll get to live a life.

 

2) Not all cultures are equal. Some are simply stupid. Refusing a life-saving treatment due to religious literalism is absolutely idiotic. It always strikes me as funny that if someone were to tell you that God has ordered them to refuse a harmless treatment that would save their life, you would call in a psychiatrist to make sure the person's not psychotic. Yet, if 1000 people tell you the same thing, all of a sudden you have to respect this most foolish of opinions. Sorry, it doesn't work like that. Cultures need to earn their respect. Just because somebody spouts out the R-word (religion) doesn't mean that everyone else needs to be humbled and respectful of it. Some religious practices are worthwhile additions to society while others are detrimental. I will respect those that support life and aiding others, and loathe those that choose death and suffering.

 

So no, as a doctor, it's not about respecting all traditions and beliefs irrespective of what they are. It's about open communication, true, but you don't lose the ability to both have your own opinions and values, and to live by them.

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well i still maintain that the attitude of "I'm the doctor, i can save your life, therefore i WILL save your life despite what you or your family want" is not the right kind of attitude. Medicine is more than just physical well being, and I think people need to move beyond the idea that anything>>>>>death.

 

Hello Dante

 

I'm saying this with the risk of sounding silly.. but some cultures have another name that could be substituted for "doctor" and it is still used quite commonly to refer to doctors which is "wise man". I believe the essence of the doctor's "noble mission" is to save/improve lives and be able to fight simply "idiotic" believes with his/her knowledge of medicine. and if i was a doctor and i wasn't able to prevent this group of ignorant adults from killing a child, then i think i would have failed badly as a doctor.

 

I totally agree with begaster..

We now have an R word that somehow rationalizes things that had they be done without the R word, would have been judged as crazy or immoral.

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That child might suffer immesurable psychological trauma because her family and community might shun her as a "satan-child" or something because she was saved by a blood transfusion. Have you made her life better?

 

Some cultures burn their dead, others bury them, others still EAT them (no i'm not making this up!).

 

 

 

-In my most honest opinion I would have to steal a line from House. Her Parents are idiots.......I can appreaciate people's beliefs and wanting to live by the rules that their faith deems is appropriate. But again I must maintain that too many people follow their 'holy book' right down to the letter. Frankly it doesnt matter whether your jehova, catholic, or muslim. If there is a god and he did let us say play a more active role in the world, he would surely smite anyone dumb enough to follow his holy book to the word.

 

It doesn't matter which religion you are. In all religions life is sacred. Especially offshoots of catholic faith! All christian religions use the same Bible. The only difference is the number of books contained within. Some religions exclude this book or that one, other christian religions exclude other books. That's why a jehova's witness can come to my door and quote me something outta the bible, and I can tell her what book (for those with no religious background think of book as chapter. The bible is divided into books...sorta) it is from.

 

So while her parents might believe they are doing the right thing and saving this child by letting her/him die, they are really ignoring one of the most sacred beliefs: Life is Sacred.

 

Some people in the world are stupid. (I'm sorry I wish it wasnt true, I wish i could change it, but this is the truth, I'm not just being mean) This is why the government must step forward and say "No this isn't right that child needs medical attention."

 

Technically we are a democracy, which means the government represents the people as a whole. So when the government supports Doctors decisions to do this, we can look at it as a group of peers over-riding the decisions of a few people, for the better good.

 

 

Yes some cultures bury their dead, yes some burn them, or eat them. But these people are already dead. We know think it to be right if a group of people throw a child in a coffin and buried her alive because she was dead to them because she got a transfusion. We don't let people cremate a child who is dieing but not yet dead.

 

As for those who eat their dead, I remember hearing about a culture like that. They thought that by eating the brains of their enemies they would gain his strength/cunning or something. They ended up getting some sort of plague or disease that wiped them out. Might not be the culture you were thinking of be I do remember learning about it once.

 

 

 

 

 

 

An interesting point, a few weeks ago, my class was given a presentation on this topic by the JW hospital liaison committee for our area. One person asked if JW believed children are born innately religious, or if they only gained religion from a personal choice later on. The presenter said they only gained religion later on, then cited the example of the lack of baptism as evidence of the JW belief that children are not born into a religion. The person then followed it up by asking how then, could one justify refusing blood to a child who they just said was not born into the religion, but must make a conscious choice to join it in sound mind. You are essentially forcing he parents views onto a child who has not selected the religion. It was an excellent point, and the presenter really didn't have a satisfying answer for it IMO.

 

 

 

That is really interesting, thanks for sharing I am actually going to write that one down and put it somewhere for safe keeping ;)

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NLengr hit the nail on the head.

 

The debate about whether JWs are valid in their beliefs really isn`t the issue. The issue is that their beliefs in this scenario isn`t necessarily in the best interest of their child. Someone who possibly isn`t able to make an informed consent at this time (hence Talon's question about age...dealing with a 2 year old is alot different than dealing with a 14 or 16 year old). Someone who hasn`t developed their own belief system yet. If this person was able to make their own informed consent then the debate doesn`t exist, since doctors would need to respect the decision made by a competent person.

 

So...if there is time you can get CAS involved and consult with the ethics board of the hospital you work at. If there is absolutely no time and no possible alternative treatment, you could go ahead and treat and deal with the legal matters after. Your actions would be defensible in court.

IF the person you were treating, however, was competent to make the decision not to receive treatment and you went ahead and treated anyway....you would be totally screwed.

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The whole point of these ethical scenarios is to get you thinking on a higher level. You should take a multifaceted approach to analyzing this situation. In this case, ethical principles that emerge are the patient's autonomy, beneficence, and justice.

 

Autonomy. As stated above, because the child cannot give informed consent (assuming he/she is not competent yet), medical decisions are usually made by the parents. On a side note: It is important to respect the patient's autonomy while practicing patient-centered because these individuals will be more satisfied with the care, and more likely to adhere to medical regimen... thus improving medical outcomes.

 

Beneficence. Physicians have a duty to maintain/enhance the wellbeing of their patients.

 

Justice. Physicians have a duty to adhere to morally acceptable laws.

 

In this case, the autonomy of the parents seem to be in conflict with the physician's duty to enhance the wellbeing of the child. However, because the caregivers are making decisions which are in conflict with the best interests of the patient (from a strictly medical perspective), I believe that their right to autonomy should be superseded by the physician's duty to promote health. Ultimately, the family should not have the ability to forgo treatment unless the patient was competent enough to agree with this before they became incompetent (re: Nancy Cruzan). Furthermore, legal precedents seem to back up the need to treat incompetent children in the event that their guardians are not looking out for their best medical interests.

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While the family's autonomy does not have to be accepted in this case, it should still be respected. I think it's important to communicate to the family that you could see where they're coming from, but it is your duty to protect the child's medical interests. By being empathetic to the family's concerns, you show them that you actually CARE. It's important to try to elicit the family's support in a situation like this, even though you're doing something that they don't want you to do. If you're going to give the transfusion anyways, it's important that you still try to incorporate them into other aspects of the child's care, rather than alienating them for their beliefs.

 

Wolvenstar: Yes, I'd put her in surgery right away.

 

Dante: Again, there are two problems with what you're saying:

 

1) You're asking us to let parents make life and death decisions over their children, as if they are property. Their children are not their property. Nobody gets to decide that their child will die because it goes against their own religious beliefs for their child to live. This is why I brought up honor-killings. They are completely legitimate in the ME (as horrific is that is) as the family's honour is worth more than the daughter's life, but does that mean we should accept them here? According to the reasoning you have presented, yes. We should respect all religious beliefs and acts, no matter how monstrous, immoral, and stupid. The family might shun her? Terrible. Not as terrible as dying needlessly. At least she'll get to live a life.

 

2) Not all cultures are equal. Some are simply stupid. Refusing a life-saving treatment due to religious literalism is absolutely idiotic. It always strikes me as funny that if someone were to tell you that God has ordered them to refuse a harmless treatment that would save their life, you would call in a psychiatrist to make sure the person's not psychotic. Yet, if 1000 people tell you the same thing, all of a sudden you have to respect this most foolish of opinions. Sorry, it doesn't work like that. Cultures need to earn their respect. Just because somebody spouts out the R-word (religion) doesn't mean that everyone else needs to be humbled and respectful of it. Some religious practices are worthwhile additions to society while others are detrimental. I will respect those that support life and aiding others, and loathe those that choose death and suffering.

 

So no, as a doctor, it's not about respecting all traditions and beliefs irrespective of what they are. It's about open communication, true, but you don't lose the ability to both have your own opinions and values, and to live by them.

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This is why I brought up honor-killings. They are completely legitimate in the ME (as horrific is that is)

 

Where exactly in the middle east are you referring to? Be more careful in delineating regional differences and don't get carried away in diffuse misconceptions. Sometimes honor killing happens and sometimes, for whatever reason, it goes unpunished by local authorities. That doesn't make it socially or culturally legitimate.

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Guest begaster

Obviously you should not be trying to war with the parents. If you can convince them, all the better. If not, the facade of mutual respect is always beneficial to any situation. Attacking their religion is not going to do anything worthwhile for the patient.

 

As for honour killings, until very recently, they were completely legal under Jordanian law. Currently, they're in the realm of semi-legality in multiple Muslim countries, including Pakistan, Syria, Iraq and Palestine. Semi-legality in that they're generally hidden by the family, the government doesn't take proper notice of them, and the punishment for these crimes are a tap on the wrist. Outside of the ME, you also have Sub-Saharan Africa participating in these practices. Basically, any place that treats women like subhuman commodities has a nasty history of condoning it. By sweeping it under the carpet and pretending it doesn't exist, you trivialize the practice in such a way that nobody can hope to stop it. Here's a fairly good site on the subject, if you're interested - http://www.stophonourkillings.com/

 

But, really, this is another discussion for another time.

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As for honour killings, until very recently, they were completely legal under Jordanian law. Currently, they're in the realm of semi-legality in multiple Muslim countries, including Pakistan, Syria, Iraq and Palestine. Semi-legality in that they're generally hidden by the family, the government doesn't take proper notice of them, and the punishment for these crimes are a tap on the wrist. http://www.stophonourkillings.com/

 

But, really, this is another discussion for another time.

 

I don't want to spark a debate or anything, but I just wanted to indicate that this isn't the norm in Iraq. Murder was always a serious offence, but now that the country has no government... you can guess...

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In this case, the autonomy of the parents seem to be in conflict with the physician's duty to enhance the wellbeing of the child. However, because the caregivers are making decisions which are in conflict with the best interests of the patient (from a strictly medical perspective), I believe that their right to autonomy should be superseded by the physician's duty to promote health. Ultimately, the family should not have the ability to forgo treatment unless the patient was competent enough to agree with this before they became incompetent (re: Nancy Cruzan). Furthermore, legal precedents seem to back up the need to treat incompetent children in the event that their guardians are not looking out for their best medical interests.

 

While the family's autonomy does not have to be accepted in this case, it should still be respected. I think it's important to communicate to the family that you could see where they're coming from, but it is your duty to protect the child's medical interests. By being empathetic to the family's concerns, you show them that you actually CARE. It's important to try to elicit the family's support in a situation like this, even though you're doing something that they don't want you to do. If you're going to give the transfusion anyways, it's important that you still try to incorporate them into other aspects of the child's care, rather than alienating them for their beliefs.

 

Couldn't have said it better myself. On my peds rotation, I was involved in the care of a patient who was almost in the exact same situation.

Assuming that the child is deemed incompetent and cannot make the decision him/herself, in this case, you would go ahead and remove the parents' legal rights to make the decision, and give the transfusion.

And this might actually be a GOOD thing for the parents! Think about it, the parents are in a difficult position themselves, torn between the physical wellbeing of their child vs the religious consequences. By having the medical team make the decision, you are taking away that burden from the parents.

But like thecoolest said, you still have to try and involve them, and really make an effort to accomodate them. For example, using EPO, minimizing bloodwork and etc to avoid repeated transfusions.

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