Ethics: Jehovas witness and parent/child issues

[neuronix]

So, I've read some conflicting things about whether the parents of an infant can refuse blood transfusion for religious reasons...

 

One source says that they CAN refuse treatment, since the patient does not have the capacity and cognition to understand the situation - sort of a parent knows best - which means that the patient will die.

 

Another source says that the physician is obliged to try and save the life even though the parents are not allowing the transfusion...

 

Does anyone have any insight?

[TheFonz]

"In the case of children who are incapable of making their own health care decisions, parents or legal guardians generally have the legal authority to act as surrogate decision-makers. The surrogate decision-maker is obliged to make treatment decisions in the best interest of the child. Health care providers who believe that a surrogate’s decisions are not in the child’s best interest can appeal to provincial child welfare authorities. The courts have the authority to assume a parens patriae role in treatment decisions if the child is deemed to be in need of protection. This issue has arisen most commonly with respect to Jehovah’s Witnesses who refuse blood transfusions for their children on religious grounds, and courts have authorized treatment in recognition of the state’s interest in protecting the health and well-being of children."

 

Taken from: Harrison C., et al., (1997). Bioethics for clinicians: 9. Involving children in medical decisions. CMAJ, 156(6), 825-828.

 

Specific case: R.B. v. Children's Aid Society of Metropolitan Toronto, [1995] 1 SCR 315 (SCC)

 

I will say, however, that the article is 13 years old, and the law may have changed since then. Also, according to the article, there are slight variations from province to province.

[bloh]

Parents have to act in the interest of the child. A child is incapable and therefore cannot value religion above his/her well-being. Thus parents are not in the right to assume that the child will have the same religious beliefs and would be willing to forfeit their life in the name of religion.

 

short answer: go through the courts to get permission to give treatment.

[nemesis]

"In the case of children who are incapable of making their own health care decisions, parents or legal guardians generally have the legal authority to act as surrogate decision-makers. The surrogate decision-maker is obliged to make treatment decisions in the best interest of the child. Health care providers who believe that a surrogate’s decisions are not in the child’s best interest can appeal to provincial child welfare authorities. The courts have the authority to assume a parens patriae role in treatment decisions if the child is deemed to be in need of protection. This issue has arisen most commonly with respect to Jehovah’s Witnesses who refuse blood transfusions for their children on religious grounds, and courts have authorized treatment in recognition of the state’s interest in protecting the health and well-being of children."

 

Taken from: Harrison C., et al., (1997). Bioethics for clinicians: 9. Involving children in medical decisions. CMAJ, 156(6), 825-828.

 

Specific case: R.B. v. Children's Aid Society of Metropolitan Toronto, [1995] 1 SCR 315 (SCC)

 

I will say, however, that the article is 13 years old, and the law may have changed since then. Also, according to the article, there are slight variations from province to province.

 

+1

 

Couldn't have answered it any better.

[neuronix]

thanks guys, that clears it up.

[NewfieMike]

ok, here's a curveball (which I realize will probably not be asked in an interview):

 

Emergency situation (life/death) - patient needs blood (let's say female, 25) - but she is conscious and doesn't want a transfusion due to religious reasons.

 

What's the protocol here?

 

if she is conscious and appears in capacity to make an informed decision, and refuses the transfusion, this should be a no brainer--inform her of the consequences of refusing, but respect her wishes and do not intervene.

[TheFonz]

ok, here's a curveball (which I realize will probably not be asked in an interview):

 

Emergency situation (life/death) - patient needs blood (let's say female, 25) - but she is conscious and doesn't want a transfusion due to religious reasons.

 

What's the protocol here?

 

If she is conscious and capable (mentally; i.e. in the right state of mind), she has the right to refuse treatment. If there is sufficient reason to believe that she is not capable of making the proper decision (i.e. due to mental disorder), then a surrogate can be used. Once again though, the same rules regarding "patient's best interest" still applies, as it would with a child.

 

This is even the case if the patient is unconscious, but is carrying written documentation with explicit orders that were created when the patient was capable. I believe there was even a case of a physician who was tried in court for treating an unconscious patient with a blood transfusion, even though the patient was carrying a card in his/her wallet/purse claiming to be a Jehovah's Witness and refusing any blood transfusions (the doctor didn't see the card). The physician was deemed guilty in this case, as the court ruled that the physician should have investigated this possibility before delivering the transfusion. I also think this is a totally plausible scenario for an interview question.

 

Anyone feel free to correct me if any of the above is wrong. My ethics notes are too far away for me to double-check lol.

[NewfieMike]

If she is conscious and capable (mentally; i.e. in the right state of mind), she has the right to refuse treatment. If there is sufficient reason to believe that she is not capable of making the proper decision (i.e. due to mental disorder), then a surrogate can be used. Once again though, the same rules regarding "patient's best interest" still applies, as it would with a child.

 

This is even the case if the patient is unconscious, but is carrying written documentation with explicit orders that were created when the patient was capable. I believe there was even a case of a physician who was tried in court for treating an unconscious patient with a blood transfusion, even though the patient was carrying a card in his/her wallet/purse claiming to be a Jehovah's Witness and refusing any blood transfusions (the doctor didn't see the card). The physician was deemed guilty in this case, as the court ruled that the physician should have investigated this possibility before delivering the transfusion. I also think this is a totally plausible scenario for an interview question.

 

Anyone feel free to correct me if any of the above is wrong. My ethics notes are too far away for me to double-check lol.

 

I'm familiar with that case, as well. I think what you said was a good summary

[nemesis]

If she is conscious and capable (mentally; i.e. in the right state of mind), she has the right to refuse treatment. If there is sufficient reason to believe that she is not capable of making the proper decision (i.e. due to mental disorder), then a surrogate can be used. Once again though, the same rules regarding "patient's best interest" still applies, as it would with a child.

 

This is even the case if the patient is unconscious, but is carrying written documentation with explicit orders that were created when the patient was capable. I believe there was even a case of a physician who was tried in court for treating an unconscious patient with a blood transfusion, even though the patient was carrying a card in his/her wallet/purse claiming to be a Jehovah's Witness and refusing any blood transfusions (the doctor didn't see the card). The physician was deemed guilty in this case, as the court ruled that the physician should have investigated this possibility before delivering the transfusion. I also think this is a totally plausible scenario for an interview question.

 

Anyone feel free to correct me if any of the above is wrong. My ethics notes are too far away for me to double-check lol.

 

The case you are referring to is Malette v. Shulman and as you mentioned, it set an important legal precedent.

[Noodle]

If she is conscious and capable (mentally; i.e. in the right state of mind), she has the right to refuse treatment. If there is sufficient reason to believe that she is not capable of making the proper decision (i.e. due to mental disorder), then a surrogate can be used. Once again though, the same rules regarding "patient's best interest" still applies, as it would with a child.

 

Definitely one should respect patient autonomy. But if the patient is in an emergency situation they are most likely not thinking clearly anyway, regardless of whether that patient has a mental disorder or not.

 

If someone (or written documentation) can vouch for the fact that this decision by the patient (i.e. no treatment) is in accordance with their values, then the treatment shouldn't happen.

 

But, since time is at a premium if an emergency situation is taking place, and if these items or persons cannot be found, I think that a doctor should assume that the patient would want to live and would do what they could to save them by doing a blood transfusion.

 

Just some thoughts.

[Noodle]

I am terrible at quoting

[nemesis]

I am terrible at quoting

 

See the end quote HTML markings at the top of your quoted post?

 

Instead of "QUOTE]", change it to "".

 

Then you can delete the message I quoted by choosing the EDIT feature, once you sign in.

[Noodle]

thanks nemesis!

[TheFonz]

The case you are referring to is Malette v. Shulman and as you mentioned, it set an important legal precedent.

 

That's right. Thank you, kind sir.

[BigM]

If she is conscious and capable (mentally; i.e. in the right state of mind), she has the right to refuse treatment. If there is sufficient reason to believe that she is not capable of making the proper decision (i.e. due to mental disorder), then a surrogate can be used. Once again though, the same rules regarding "patient's best interest" still applies, as it would with a child.

 

This is even the case if the patient is unconscious, but is carrying written documentation with explicit orders that were created when the patient was capable. I believe there was even a case of a physician who was tried in court for treating an unconscious patient with a blood transfusion, even though the patient was carrying a card in his/her wallet/purse claiming to be a Jehovah's Witness and refusing any blood transfusions (the doctor didn't see the card). The physician was deemed guilty in this case, as the court ruled that the physician should have investigated this possibility before delivering the transfusion. I also think this is a totally plausible scenario for an interview question.

 

Anyone feel free to correct me if any of the above is wrong. My ethics notes are too far away for me to double-check lol.

 

Interesting addition to that particular event. The lady had signed her card but had neglected to get someone to sign as a witness. The physician was put in a position where if he left the woman die, a family member could have sued him for basing a decision on a card which was not legally complete. In this case the court decided that it was unreasonable to ignore the card based on the fact that it wasn't witnessed. I agree with the the decision the court made, but the point is sometimes in medicine you get screwed between what is legally the right thing to do and what is reasonably the right thing to do.

[TheFonz]

Definitely one should respect patient autonomy. But if the patient is in an emergency situation they are most likely not thinking clearly anyway, regardless of whether that patient has a mental disorder or not.

 

If someone (or written documentation) can vouch for the fact that this decision by the patient (i.e. no treatment) is in accordance with their values, then the treatment shouldn't happen.

 

But, since time is at a premium if an emergency situation is taking place, and if these items or persons cannot be found, I think that a doctor should assume that the patient would want to live and would do what they could to save them by doing a blood transfusion.

 

Just some thoughts.

 

I mostly agree. I was just using mental illness as an example of when a physician might question a patient's capacity to make medical decisions.

 

Regardless, it is under the physician's discretion as to whether the patient is capable or not. You're right, some people become hysterical in emergency situations. But I think in most cases, if a patient is momentarily hysterical (and given no alternatives, such as explicit written documentation), but demonstrates understanding of the consequences of avoiding treatment, then it is pretty much a given that the physician must respect those wishes. I think actively treating a patient against his/her wishes, when the patient is a competent adult (and in the absence of mental illness) will almost always result in the physician being legally reprimanded. Now if the patient is unconscious, and no alternative directions exist, then I fully agree with you that the physician should assume that the patient wants to live.

 

Now if the patient is hysterical and asking for inappropriate treatment (pretty much the complete opposite of refusing treatment), then the physician does have the right to refuse that. But again, a proper evaluation of the situation must take place before a decision is rendered.

[BigM]

I agree with TheFonz, when a patient is not able to decide for themselves (i.e. unconscious or incompetent) then you need to pick the treatment that a reasonable people would want under those circumstances. Most reasonable people want to have their life preserved if they was a near-fatal accident so the bottom line is to perserve life unless you have been given reason not to. This is the rule for emergency situations when there isn't time to find an alternative decision maker.

 

Even when you have a patient who is chronically ill and their long-term outcome looks bleak. Unless you have discussed with the patient or family pallative care or end-of-life care that prevents you from treating, your job is to perserve their life. In some situations this can lead to horrific outcomes, i.e. a family wanting you to revive someone who is terminal and in intense pain. In these situations you are going to need to thread carefully. Talk to the family and educate them on the possible outcomes and consequences. If the family still insists that this individual's suffering be dragged out, even when they are fully educated on the situation, then it is time to call in the hospital's legal team.

[fandanstan]

I don't want this to turn into a religion bashing thread, but what kind of religion would allow someone to die because of something as trivial as blood transfusions?

[nemesis]

I don't want this to turn into a religion bashing thread, but what kind of religion would allow someone to die because of something as trivial as blood transfusions?

 

A simple Google search can provide the rationale:

 

"Jehovah's Witnesses believe that the Bible prohibits ingesting blood, and that this includes the storage and transfusion of blood, including in cases of medical emergency."

 

http://en.wikipedia.org/wiki/Jehovah's_Witnesses_and_blood_transfusions

[nemesis]

The docs teaching us ethics actually said that you can get sued either way no matter what decision you make in this situation.

 

Probably, but in a similar situation, I'd fall back on established legal precedent. This doesn't mean that it is appropriate to always accept the law unconditionally; however, generally laws are in place for the common (greater?) good.