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Wolvenstar

Giving blood to a child whose parents refuse the transfusion

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Foremost, I would analyze the situation:

 

Is the child capable of competent thought?

Can the child understand the gravity of the situation and how his choice impacts his condition and his life?

Is there any chance of impairment at all?

Does he understand the consequences of refusing treatment?

Next, I would check for true understanding by looking for illogical thoughts or contradicting statements to earlier comments.

 

Second, you should consider other options if there are some.

What are the cost-benefit ratios of going with one line of treatment as opposed to another?

Chances of survival?

Chances of severe impairment?

 

In the case where I cannot assess the child's level of understanding, I would move for assistance from an ethic's committee or a senior resident to see if they had any input that might provide some clarity on the issue.

 

If I am without any resources and forced to make a decision without any of the information from either the child, or colleagues then I would forgo the parents decision and give the child the transfusions to save his life.

 

If it cannot be proved that the child, wholeheartedly chooses to forgo treatment on the basis of religious beliefs, especially if their level of understanding is not sufficient to deal with the task then steps should be taken to save the child's life. It is assumed in situations of dire emergency, that everyone wants to be saved unless documentation can be provided stating otherwise in the form of a legal will or other legal document refusing treatment in such a situation.

 

Simply being the child of a religious parent does not give the parent the ability to endanger a child's life. Such a situation could likened to child abuse, and a legal representative should sought out to make competent decisions in the child's treatment.

 

........ all of this is assuming that the child is not competent and has voiced no competent opinion of his own.

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By defintion, a young child does not have the capacity to make the correct decisions. Therefore, his/her surrogate must make it for them.

 

As a physician, I would listen and understand the wishes of their parents and weigh it accordingly to my final decision.

If the Jehova's witness child receive blood transfusion, the social and religious consequences will be significant.

 

As a physician, therefore, I will provide all the information to the parents. Explaining the consequences of what they are about to do. I will persuade the parents to allow for blood transfusion, making sure no coercion occurs.

 

If the parents still maintains that they want to let the child die, I will honour their wishes.

 

If there are irreconcilable disagreements, this case may be taken to court.

 

What do you think?

 

Andy

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I do realize I might be a few months late, however I agree w/ Dante. Just because we (our civilization/culture/religion/whatever) have grown up with certain norms and beliefs doesn't mean they are widespread throughout the world.

 

Now, I admit that having a patient and not saving them (due to a simple blood transfusion) would be extremely difficult on my morale. But I also beleive that a 5 year old (per example) child does not have the ability to make such a decision. In that case I think the family has to make an important desicion regarding their child's life... and they have to be questioned a lot (why, why and why? they take such a stance) - and as doctors (one day:P), we have have to understand why, not just tell them that we're smarter and know what's better for them. That's being ignorant...

 

I am aware of the supreme courts decisions, but what about the child after that ...I enjoyed the ''satan-child'' idea- haha. What happens after to the childs psychological needs after ?

 

I know many of this has already been said, But I wanted to put my 2 cents in there anyways...

AND, I don't think their is a right or wrong answer, if you can justify it, you'll do ok during interviews anyways :P

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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?

sidenote and correction: honour killings are not apart of islam. Honour killings are a cultural thing, not a religious one

sorry I just had to add that in there.

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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

 

that's the problem, where do we draw the line as to what society deems moral or immoral without impinging on people's rights?

"Letting a child die to appease God is morally reprehensible. " but who determines this and who has the right to determine this?

 

If we let society determine what's right and wrong, then technically shouldn't society ban all forms of religion since they view something other thansociety as the entity that determines how to live life???

i hope that makes sense

:)

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I understand what you mean. Not that I wanted to sound ignorant or anything, but I have actually read that case (or one similar, that has gone to the CSS - might I add I find them boring to read!) Being in that position in real life, I wouldn't just be like ah.. that's too bad, and let the kid die.

But sometimes I do find that people just don't take the time to consider patient's point of view, which I think should be the most valued thing to a doctor. (I guess it doen't apply in this case because it's the child and not the adult, however...)

 

I really do have to add... I enjoyed how passionate your answer was.:D

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I'd like to remind people that "doing no harm" also extends to "taking action when inaction will lead to death."

 

The reason doctors call child services and get court orders to circumvent the parents' authority in this type of case is because the child's life is at stake. It's one thing to respect religious beliefs and another to violate your Hippocratic oath while doing so. You are obliged, as the child's physician, to treat him in this situation. If the medical condition is not life-threatening, then religious beliefs hold more water - but if you let the parents withhold life-saving treatment, you are participating in a form of passive euthanasia.

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This forum is really sweet. I like having the oppurtunity to look at what you folks consider when approaching these questions. I'm interviewing in a few weeks so I'm getting into the prep for it.

 

In my opinion, I have to accept that if the patient is underage, so is not considered compitent to make this decision, and so her parents are the ones who have to legally provide consent. As a physician, I don't think I can just overrule their belief system or values that they used to base their decisions, it just isn't my place. Although the patient is underage, chatting with the patient and finding out what their preferance is would be is a very important step to take, I feel. Perhaps this could be done in the absence of their parents. If the child wanted the treatment, then I would appeal to an ethics board to get involved in making this decision. Even if I was behaving against the parents wishes initially in this matter, I would make sure they knew that the position that I was acting from is not because I don't agree with their belief system. It's backed by the child's choice. If ruled in favour of the parents I would look into the viability of using blood substitutes in the procedure. My understanding is this is an alternative that JW's will accept.

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In my opinion, I have to accept that if the patient is underage, so is not considered compitent to make this decision, and so her parents are the ones who have to legally provide consent. As a physician, I don't think I can just overrule their belief system or values that they used to base their decisions, it just isn't my place. Although the patient is underage, chatting with the patient and finding out what their preferance is would be is a very important step to take, I feel. Perhaps this could be done in the absence of their parents. If the child wanted the treatment, then I would appeal to an ethics board to get involved in making this decision. Even if I was behaving against the parents wishes initially in this matter, I would make sure they knew that the position that I was acting from is not because I don't agree with their belief system. It's backed by the child's choice. If ruled in favour of the parents I would look into the viability of using blood substitutes in the procedure. My understanding is this is an alternative that JW's will accept.

 

 

If I was on the interview panel and you gave me this answer I would be a little confused about your stance to be honest.

 

You have said that you would not overule the parents' decision as it wasn`t your role. But then you say you could appeal to an ethics committee despite it being against their wishes.

 

Also, I am not sure it is clear that you grasp the idea of informed consent. You talk about the child being underage and so not able to consent but then later talk about how you would discuss the issue with the child and use the child's decision to back up your appeal to the ethics committee.

 

This just posted and deleted half of what I wrote! So I will summarize the remainder....

 

So you are aware not everywhere has a minimum age of consent....in Ontario for example there is no minimum age. (there is a minimum age to be able to refuse treatment though)

 

In your answer, it is not clear that you are being an advocate for your patient. Your patient is the child and you seem to be much more concerned with the parents.

 

You do present some important points about important aspects of communication with the parents....yes, your pt technically is the child, but that doesn`t mean you can just ignore the parents and not involve them. And bringing up blood substitutes is a nice idea

 

You have some good ideas, but maybe consider reformulating your answer so your ideas are more clear. Just my thoughts.

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We were talking about this in an ethics seminar a while ago, and one interesting perspective shared by a physician who has dealt with these issues is that parents may be very relieved when the courts give surrogate decision making status to the hospital to allow the child to get a transfusion. There is enormous social pressure not to accept transfusions within the JW community, and a parent who chooses to allow their child to get a transfusion may be choosing to be ostracized from their faith community. By having that decision taken away from them, their child's life is saved and they also save face at the same time.

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Thanks for the feedback Satsuma, if I confused you with my answer, I may very well have confused the interview panel. To clarify, the patient may not give consent as they are underage, but their opinion still matters. If the pt wants the treatment, parents are still legally in a position to overrule the pt, as the child is not considered old enough (competant) to make the decision themselves. I would use this predicament as the reason for pursueing outside council on the situation. To clarify about the going against the parents, what I would try to do in this situation, is to express to the parents that we're on the same team, both looking out for the best interests of the child. The parents feel their child risks being ostrasized from the community or forbidden from heaven, while I feel that the child themselves wants to take the transfusion, which is in his/her best interests, medically.

 

I think another cause for confusion is the question itself, it really isn't a, have a surgery or don't have a surgery situation, it's more specifically a, have a blood transfusion or not situation. JW's are against blood transfusions not surgery. This is because of their literal following of the bible which they feel is the word of God.

 

I don't feel your paraphrase captures what I wrote down really. Perhaps it does, but it feels a little like selective reading. By overruling the parents, I was referring to their value system. A physician can't say that their value system is superior to that of others, they need to have a balanced stance. They need to engage the situation for what it is, and encourage a healthy environment where dialogue can occur. I can't see that happening by having a view vs view approach. Appealing to an ethics committee isn't necessarily against their wishes, the parents just want what is best for their child.

 

If I was on the interview panel and you gave me this answer I would be a little confused about your stance to be honest.

 

You have said that you would not overule the parents' decision as it wasn`t your role. But then you say you could appeal to an ethics committee despite it being against their wishes.

 

Also, I am not sure it is clear that you grasp the idea of informed consent. You talk about the child being underage and so not able to consent but then later talk about how you would discuss the issue with the child and use the child's decision to back up your appeal to the ethics committee.

 

This just posted and deleted half of what I wrote! So I will summarize the remainder....

 

So you are aware not everywhere has a minimum age of consent....in Ontario for example there is no minimum age. (there is a minimum age to be able to refuse treatment though)

 

In your answer, it is not clear that you are being an advocate for your patient. Your patient is the child and you seem to be much more concerned with the parents.

 

You do present some important points about important aspects of communication with the parents....yes, your pt technically is the child, but that doesn`t mean you can just ignore the parents and not involve them. And bringing up blood substitutes is a nice idea

 

You have some good ideas, but maybe consider reformulating your answer so your ideas are more clear. Just my thoughts.

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Have a stance but make sure you see all sides of the argument.

Generally they're not judging your actual answer but rather your ability to reason and your support for the decision.

 

Acknowledge you understand/or would attempt to understand why the parents would have such a wish, whether you agree with them or not.

 

Explain how you feel but realize in the big picture that your morals on the matter aren't the end-all.

 

I'd acknowledge that there are many external factors that could play a role, ie: hospital policy, recent legal precedent, geographic location....

 

In the end I would go to the ethic's board, because while I realize respect for autonomy is enormously important to medicine, precedent in our health and legal system have shown the a parent's wishes for their child aren't always the bottom line. I would also provide my personal reason for believing in such a decision as I grew up in a very religious family who are still religious however I am not. Atheism is the fastest growing religious belief in the World today (Just for informations sake: while not being a believer of organized religion I'm not an atheist either) and there's a strong possibility the child may not have made the same decision as their parents when competent to make such a decision. So with respect to not only my wishes, but the families wishes, and the foundations on which our health care system operates, I would seek what I believe to be the most impartial and hopefully fair method to resolving the decision in the Child's best interest.

 

I would add a few more things and articulate much better (hopefully) but this is the gist of it. I believe while it's important to have opinions backed with good reasons it's even more important to realize there's another side of the story in any discrepancy that needs to be reasonably evaluated.

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