- Email: [email protected]
Case conference
CASE CONFERENCE Alan Jay Schwartz, MD, MSEd Frederick A. Hensley, Jr, MD Editors
CASE CONFERENCE 6-1990
Case Presentation* A 70-year-old man was admitted to an outside hospital on June 25, 1989, complaining of the acute onset of abdominal pain. The pain was in the mid and upper abdomen, somewhat to the right side, and radiated through to the back. On evaluation by the physicians at that hospital, a pulsatile abdominal mass was noted and the diagnosis of abdominal aortic aneurysm was entertained. The patient underwent a computed tomography (CT) scan of the abdomen that showed a 7.5-cm abdominal aortic aneurysm. The patient was a Jehovah's Witness (JW) and stated that he would not undergo surgery unless the stipulation could be made that no blood transfusions be given under any circumstances. The physicians at that outside hospital were unwilling to render care to the patient under those circumstances and suggested that he be transferred to the Hershey Medical Center. The surgical chief resident was notified and it was agreed to take the patient in transfer. On arrival in the emergency room he was noted to be a well-appearing 70-year-old man. His past medical history was essentially unremarkable. He was not a smoker and had only mild hypertension that had not required treatment. Physical examination at that time showed stable vital signs with a normal pulse rate and blood pressure. The chest and cardiac examinations were unremarkable. Abdominal examination showed a pulsatile midabdominal mass that was moderately tender to palpation; he also manifested tenderness to palpation in the right upper quadrant with a positive Murphy's sign. Lower extremity examination was unremarkable *Robert G. Atnip, MD
and was characterized by palpable pulses. Laboratory data showed a hematocrit of 42%, and a WBC of 16,000 with a left shift. His CT scans had been sent with him, were reviewed, and confirmed the presence of an abdominal aortic aneurysm. However, we were concerned about this patient's right upper quadrant pain and considered whether or not there might also be cholecystitis present. Therefore, an abdominal ultrasound was done, which showed a distended gallbladder with the presence of one large stone. There was a question of thickening of the gallbladder wall, but there was no perivesical fluid collections or evidence of significant gallbladder wall edema as read by the ultrasonographer. At this point, we were faced with a patient with a large abdominal aortic aneurysm that was tender, the acute onset of abdominal pain, and a physical examination with evidence of possible cholecystitis. There was no sign that the aneurysm had bled, but we were concerned that the aneurysm might be expanding and might be on the verge of rupture. In our minds, this patient had at least one and possibly two indications for emergency abdominal surgery, and it was felt George R. Simms, MD, Department of Family and Community Medicine, and the University Hospital Ethics Committee: Frederick A. Hensley, Jr, MD, Department of Anesthesia: Robert G. Atnip, MD, Department of Surgery, Pennsylvania State University College of Medicine, Hershey,PA. Presented under the title, "Conflicts in the Care of Jehovah's Witnesses," at the Pennsylvania State University College of Medicine. Combined Anesthesia/Surgery Grand Rounds, February 17,1990. Address reprint requests to Frederick A. Hensley, Jr, MD, Department of Anesthesia, Pennsylvania State University College ofMedicine, PO Box 850, Hershey, PA 17033. © 1990 by W.B. Saunders Company. 0888-6296/90/0406-0016$03.00/0
JournalofCardiothoracic Anesthesia, Vol 4. No 6 (December), 1990: pp 751-755
751
752
CASE 6-1990
that he would be a good candidate for surgery. Therefore, we agreed to proceed under his stipulations that no blood transfusions be given. At this point, we contacted our colleagues in the Department of Anesthesia to help us prepare the patient for surgery. Case Presentation [cont'dtt As the anesthesiologist administering the operating room schedule that day, I was the first member of the Department of Anesthesia to be notified of the transfer of this patient. I was notified after the surgery department had accepted transfer and the patient was en route to our Medical Center. Therefore, our department was not consulted prior to Surgery's decision to accept this patient. At 3:00 PM the patient arrived. Because he required additional diagnostic studies, I estimated that the patient would be arriving in the operating room at approximately 7:00 PM. Hence, I proceeded to discuss the case with the anesthesiologist on call. He informed me that he would be willing to care for this patient only if the patient would agree to blood transfusion under life-threatening circumstances. It was apparent after the patient was evaluated by an anesthesiologist that under no circumstances would he accept blood components of any kind. The anesthesiologist on call then refused for personal reasons to be involved in the care of this patient. The back-up staff on call, as well as the cardiac anesthesiologist on call, also declined. It needs to be made clear that the three anesthesiologists who declined to be involved in this case had stressed their prior opposition to being involved in such cases when they occurred on a strictly elective basis. Also, all three anesthesiologists were very willing to do the case if the patient would consent to blood transfusion under dire, life-threatening circumstances. After 45 minutes of discussion with other staff members in the Department of Anesthesia, and rearranging departmental schedules, I found an anesthesiologist who was willing to comply with the patient's desires. The surgery proceeded uneventfully (aneurysm resection and cholecystectomy), no blood was required, and the patient recovered without incident. tFrederick A. Hensley, Jr, MD
DISCUSSION:!:
The Chairman of the Department of Anesthesia has asked if I would assist him in exploring some of the legal and ethical ramifications of the treatment of JWs. It has become apparent that there is a difference of opinion between some members of the Department of Anesthesia and the Department of Surgery in how to approach the critically ill JW patient. Therefore, rather than a traditional grand rounds presentation we have decided to create an open forum. The case presentation will serve as a prelude for an overview of the current legal and ethical issues of blood transfusion in the JW patient. We will then open the floor for a discussion of this particular case as well as other pertinent legal and ethical issues. More than 500,000 people in this country, and more than 2 million people worldwide, share a conviction that accepting blood in any form places them in grave spiritual danger and they would rather die than risk that consequence. Jehovah's Witnesses, unlike some religious sects, do not eschew medical care. In fact, they recognize the importance of good health, want good medical care, and appreciate all efforts made by the medical profession on their behalf. Their problem lies specifically in the firmly held injunction against accepting blood in any form and under any circumstances, their deep commitment to their interpretation of the passages in the books of Genesis and Leviticus of the Bible, and the dire consequences they must face in adopting such a position. The problem for many in the medical profession, especially surgeons and anesthesiologists who are most directly faced with the issue of blood transfusion, is that they, too, want to do their best for these patients. The conflict appears to lie in the definition of "best interests." For the JW patient, it is just as much a matter of life-and-death as it is for the physician. However, for them the issue is spiritual death, whereas for us the issue is physical death. It is quite clear which is more important to them so that we are often confronted with the difficult tasks of trying to decide, in the context of the unique medical
:j:George R. Simms, MD
753
CASE 6-1990
situation, what issues are truly at stake, how the patient can best be served, and who is to decide.
Legal Issues Forcing a treatment modality on a patient has legal as well as ethical ramifications. To force a competent adult to undergo a treatment that he/she has clearly stated is not wanted, regardless of how medically necessary the treatment may be or how irrational this refusal may appear to the treating physician, is to violate the constitutionally guaranteed rights of the individual. Clear legal precedence prohibits giving blood to a JW patient if that person, after explanation of the medical implications, still refuses to receive blood on the grounds of his/her religious belief. To override that restraint is to risk being sued for assault and battery, to say nothing of doing great personal harm to the individual involved. Unfortunately not all JW patients are adult, alert, and competent when they arrive in the Emergency Room and the physician is faced with a medically indicated need to order a blood transfusion. Difficult situations include: 1. The minor patient. Courts have rejected, and continue to reject, parents' claim for sole authority in the decisionmaking process for children. If the physician is convinced of the life-saving need for blood, courts have generally upheld that decision against strong parental bias, even though there is a strong history in this country that favors parental authority in all decisions having to do with how children should be raised and cared for. 2. The maternal/fetal patient. The courts currently favor the fetus in late gestation. Several recent decisions have upheld the justification for maternal transfusion in the mid-to-late second trimester of pregnancy. Transfusion in early gestation is as yet unaddressed. 3. The incompetent adult patient. There appears to be some inconsistency in court decisions in this area. It is increasingly clear that if a JW patient carries some form of identification stating that she/he is a JW and that under no circumstances is blood to be given, and then a transfusion is given, the physician is libel for assault and battery
regardless of the medical indications. On the other hand, when such identification is not available or when the identification comes from a second party (ie, spouse, member of the family, friend, neighbor, colleague, etc) then the physician is placed in the very difficult position of having to accept second-hand evidence in a lifethreatening situation. Many would go ahead and transfuse and defend their case in court on the lack of substantive evidence. All physicians must be aware of the growing danger of a lawsuit if they transfuse a JW patient, regardless of the medical indication, without explicit permission of the patient or the courts.
Ethical Issues If we start with the basic premise that our moral obligation as physicians is to act in the best interests of the patient, then a number of important questions arise: 1. Am I morally bound to honor every sincere request of a patient? The answer is "No." I am not morally bound to grant every patient request simply because I am in a fiduciary relationship with a patient. Many patients want us to do frivolous and sometimes dangerous things and we don't take them seriously, because we sense that their requests, although sincere, lack a convincing rationale and are not grounded in a process that is existentially meaningful and persuasive. On the other hand, there is the occasional request, whether we agree with it or not, that gives evidence of being grounded in a clearly thought-out belief system. It may seem bizarre within our own existential framework, but it is not frivolous and carries a certain weight of inner conviction. I submit that we are morally obligated to honor this latter request, because it touches on the vital core of another human being's deepest self-concept. Blood transfusion to the JW is one such example. What is in question is not whether the physicians understand or even agree with the value system expressed, but rather whether that request represents a deeply held personal conviction and has been well
CASE 6-1990
754
thought out. If so, every attempt must be made to honor it. 2. Once the doctor-patient relationship has been established (eg, accepting the transfer, starting to work on the patient, etc) and we have now entered a fiduciary relationship with that person who espouses a belief system such as the JW, are we not under a moral obligation to work as effectively as we can under those constraints? That is, once we know and accept the patient, have we also accepted his/her constraints as our own? 3. Is there a distinction to be made morally between my obligations to such a patient under emergency conditions (eg, bleeding to death in the emergency room) and nonemergency conditions in which the physician has time to talk with the patient to ascertain with assurance what his/her wishes are? 4. Is it morally permissible for a physician to enter a doctor-patient contract wherein the patient will bind the hands of the doctor from doing what she/he thinks is medically in the best interests of the patient? Put another way, is it ever permissible to stand aside and let another person die when you have the means to preserve their life (eg, a blood transfusion)? Most physicians are very uncomfortable with that stance, and many simply cannot abide it. 5. Does one party have the right to override the moral convictions of the other? For example, does the anesthesiologist have to be forced into doing the case? Does the surgeon (either out in the community hospital or at the Medical Center) have to be forced into doing the case? Was the transfer a moral cop-out or should the outside surgeon simply have done the case because the patient was there and needed the surgery? Another all-too-common example is the decision to give blood intraoperatively after the surgeon has promised the JW patient she/he would not use blood under any circumstances. You can say nothing and hope he doesn't notice the charge for the transfusions or doesn't get hepatitis 3 months later; you can lie and risk a crisis of confidence in the relationship; or you can
tell the truth and plead the case for having saved his life. "Well, at least I saved your life and acted in your best interests, didn't I?" The problem is, saving his life at that price may not really be acting in the best interests of the patient. COMMENTS
K. T. (Anesthesiologist): From a legal standpoint, could an anesthesiologist who refused to be involved in an urgent case like the one presented be accused of abandonment? That is, a situation somewhat different than this case, in which a patient would ultimately die because of the anesthesiologists' noninvolvement? R.A. (Surgeon): I would argue that in an urgent situation as described in this transfer, the anesthesiologist is not in a fiduciary relationship with the patient and, therefore, there are no moral and legal obligations incurred. On the other hand, once a physician-patient relationship is established, then moral and legal obligations are incurred. F.B. (Anesthesiologist): If I were in a situation where a true emergency existed (ie, a JW with a ruptured abdominal aortic aneurysm arriving in the operating room) and no other anesthesiologist was immediately available who would be willing to care for this patient upholding their religious beliefs, I would render care to this patient. However, if I was informed that this patient carried a card stating that he/she was a JW, I would override the patient's belief system and administer blood, but only if absolutely necessary. My own value system would require me to act in his/her best interest in a way that would be congruent with saving his/her life. If I walked away from this patient, and no other anesthesiologist stepped in, I would certainly consider that abandonment. However, in this forced situation, it then becomes a matter of the patient's belief system versus mine. An elective case or urgent case like the one presented is relatively easy because it is usually possible to locate a suitable anesthesiologist to care for the patient. I would not be involved in such nonemergency cases. J.G. (Surgeon): That would be battery and thus a felony. It is not my job to tell the patient what he/she should or should not believe. If the patient believes he/she would be denied salvation
755
CASE 6-1990
or access to heaven, then it is my job to accept that decision and recalculate the risk-benefit ratio of treatment based on these new facts. L.M. (Surgeon): When I was in medical school, I was told that becoming a surgeon did not give me the right to make moral decisions for others. I still think that is a correct position to hold. B. T. (Surgeon): Wide surgical experience in this country has shown that one can do almost all vascular procedures today without the absolute necessity of blood transfusions. This being the case, I would honor their belief and their request. J.G. (Anesthesiologist): I was one of the two anesthesiologists doing this particular case and I can tell you that I felt completely comfortable operating without blood. I would feel completely comfortable if the patient had died. I think one of the basic tenets of this country is the freedom of religion, and this is not a frivolous part of their religion. There was excellent communication with the patient, his desires were clearly understood, he was intelligent and well informed, and went into the operation knowing what the implications were. If the patient had died for lack of blood, I could have lived with myself. J.B. (Anesthesiologist): Some of the most exciting advances in anesthesiology today have come from the challenge of the JW. Another unrelated, similar example was when Dr Lavar at the Massachusetts General Hospital in the mid-1960s began to operate on intracranial aneurysms by placing the patient on cardiopulmonary bypass. That was in part the origin of the hemodilution technique we use today. Thus, challenges such as these often advance medical science. T.S. (Anesthesiologist): If you do enough of these cases, someone is going to die. I think it is important for both the surgeon and the anesthesiologist to be prepared for the eventual death that will result from this calculated risk. Not that it
shouldn't be taken, but rather to know that there will be a disaster one day, and to be emotionally prepared for it. I'm also concerned that there are JW patients who will accept blood even though they say they won't. Often there is enormous pressure from the elders of their church to hold firm to the doctrine when, deep down inside, they really don't want to die and would be willing to accept a blood transfusion. K.D.C. (Ethicist): It is true that some JWs will accept some form of blood substitute. However, it is generally accepted teaching that once the blood leaves the body it cannot come back into the body. However, volume expanders using Ringer's lactate and dextran are perfectly acceptable. A lot of people have traded on the indefiniteness of the JWs about what they really want. Some surgeons and anesthesiologists believe that if they don't consent and you force it on them, then it is OK. So the surgeon will say: "Just leave it in my hands and I'll do what is best. You haven't consented to anything." That plays well in some circles, but is really against the interpretation of the elders of the church and is doing a disservice. M.L. (Anesthesiologist): I think physicians certainly have the right and should have the moral obligation to respect a patient's wishes in the area of significant religious belief. However, I also think that what caused grave consternation to the Department of Anesthesia with this particular case was the failure to realize that there were two physicians caring for the patient simultaneously. One was the surgeon and one was the anesthesiologist. The surgeon should not place himself under the moral obligations of the patient to agree not to give blood without prior consultation with the anesthesiologist to be sure that the anesthesiologist agrees to that position. I don't think any surgeon has the right to morally obligate an anesthesiologist to enter into a contract with a patient unilaterally, simply because they are our patients as well as theirs.
SUGGESTED READINGS Benson KT: The Jehovah's Witness patient: Considerations for the anesthesiologist. Anesth Analg 69:647-656, 1989 Blood Transfusion-Why not for Jehovah's Witnesses? Statement to members of the medical profession. Brooklyn, NY, Watch Tower Society.
Brahams D: Jehovah's Witness transfused without consent: A Canadian case. Lancet 2:1407-1408,1989 Dixon JL, Smalley MG: Jehovah's Witnesses-The surgical ethical challenge. JAMA 246:2471-2472,1981 Oh DA, Cooley DA: Cardiovascular surgery in Jehovah's Witnesses. JAMA 238:1256-1258,1977
CASE CONFERENCE 6-1990
Case Presentation* A 70-year-old man was admitted to an outside hospital on June 25, 1989, complaining of the acute onset of abdominal pain. The pain was in the mid and upper abdomen, somewhat to the right side, and radiated through to the back. On evaluation by the physicians at that hospital, a pulsatile abdominal mass was noted and the diagnosis of abdominal aortic aneurysm was entertained. The patient underwent a computed tomography (CT) scan of the abdomen that showed a 7.5-cm abdominal aortic aneurysm. The patient was a Jehovah's Witness (JW) and stated that he would not undergo surgery unless the stipulation could be made that no blood transfusions be given under any circumstances. The physicians at that outside hospital were unwilling to render care to the patient under those circumstances and suggested that he be transferred to the Hershey Medical Center. The surgical chief resident was notified and it was agreed to take the patient in transfer. On arrival in the emergency room he was noted to be a well-appearing 70-year-old man. His past medical history was essentially unremarkable. He was not a smoker and had only mild hypertension that had not required treatment. Physical examination at that time showed stable vital signs with a normal pulse rate and blood pressure. The chest and cardiac examinations were unremarkable. Abdominal examination showed a pulsatile midabdominal mass that was moderately tender to palpation; he also manifested tenderness to palpation in the right upper quadrant with a positive Murphy's sign. Lower extremity examination was unremarkable *Robert G. Atnip, MD
and was characterized by palpable pulses. Laboratory data showed a hematocrit of 42%, and a WBC of 16,000 with a left shift. His CT scans had been sent with him, were reviewed, and confirmed the presence of an abdominal aortic aneurysm. However, we were concerned about this patient's right upper quadrant pain and considered whether or not there might also be cholecystitis present. Therefore, an abdominal ultrasound was done, which showed a distended gallbladder with the presence of one large stone. There was a question of thickening of the gallbladder wall, but there was no perivesical fluid collections or evidence of significant gallbladder wall edema as read by the ultrasonographer. At this point, we were faced with a patient with a large abdominal aortic aneurysm that was tender, the acute onset of abdominal pain, and a physical examination with evidence of possible cholecystitis. There was no sign that the aneurysm had bled, but we were concerned that the aneurysm might be expanding and might be on the verge of rupture. In our minds, this patient had at least one and possibly two indications for emergency abdominal surgery, and it was felt George R. Simms, MD, Department of Family and Community Medicine, and the University Hospital Ethics Committee: Frederick A. Hensley, Jr, MD, Department of Anesthesia: Robert G. Atnip, MD, Department of Surgery, Pennsylvania State University College of Medicine, Hershey,PA. Presented under the title, "Conflicts in the Care of Jehovah's Witnesses," at the Pennsylvania State University College of Medicine. Combined Anesthesia/Surgery Grand Rounds, February 17,1990. Address reprint requests to Frederick A. Hensley, Jr, MD, Department of Anesthesia, Pennsylvania State University College ofMedicine, PO Box 850, Hershey, PA 17033. © 1990 by W.B. Saunders Company. 0888-6296/90/0406-0016$03.00/0
JournalofCardiothoracic Anesthesia, Vol 4. No 6 (December), 1990: pp 751-755
751
752
CASE 6-1990
that he would be a good candidate for surgery. Therefore, we agreed to proceed under his stipulations that no blood transfusions be given. At this point, we contacted our colleagues in the Department of Anesthesia to help us prepare the patient for surgery. Case Presentation [cont'dtt As the anesthesiologist administering the operating room schedule that day, I was the first member of the Department of Anesthesia to be notified of the transfer of this patient. I was notified after the surgery department had accepted transfer and the patient was en route to our Medical Center. Therefore, our department was not consulted prior to Surgery's decision to accept this patient. At 3:00 PM the patient arrived. Because he required additional diagnostic studies, I estimated that the patient would be arriving in the operating room at approximately 7:00 PM. Hence, I proceeded to discuss the case with the anesthesiologist on call. He informed me that he would be willing to care for this patient only if the patient would agree to blood transfusion under life-threatening circumstances. It was apparent after the patient was evaluated by an anesthesiologist that under no circumstances would he accept blood components of any kind. The anesthesiologist on call then refused for personal reasons to be involved in the care of this patient. The back-up staff on call, as well as the cardiac anesthesiologist on call, also declined. It needs to be made clear that the three anesthesiologists who declined to be involved in this case had stressed their prior opposition to being involved in such cases when they occurred on a strictly elective basis. Also, all three anesthesiologists were very willing to do the case if the patient would consent to blood transfusion under dire, life-threatening circumstances. After 45 minutes of discussion with other staff members in the Department of Anesthesia, and rearranging departmental schedules, I found an anesthesiologist who was willing to comply with the patient's desires. The surgery proceeded uneventfully (aneurysm resection and cholecystectomy), no blood was required, and the patient recovered without incident. tFrederick A. Hensley, Jr, MD
DISCUSSION:!:
The Chairman of the Department of Anesthesia has asked if I would assist him in exploring some of the legal and ethical ramifications of the treatment of JWs. It has become apparent that there is a difference of opinion between some members of the Department of Anesthesia and the Department of Surgery in how to approach the critically ill JW patient. Therefore, rather than a traditional grand rounds presentation we have decided to create an open forum. The case presentation will serve as a prelude for an overview of the current legal and ethical issues of blood transfusion in the JW patient. We will then open the floor for a discussion of this particular case as well as other pertinent legal and ethical issues. More than 500,000 people in this country, and more than 2 million people worldwide, share a conviction that accepting blood in any form places them in grave spiritual danger and they would rather die than risk that consequence. Jehovah's Witnesses, unlike some religious sects, do not eschew medical care. In fact, they recognize the importance of good health, want good medical care, and appreciate all efforts made by the medical profession on their behalf. Their problem lies specifically in the firmly held injunction against accepting blood in any form and under any circumstances, their deep commitment to their interpretation of the passages in the books of Genesis and Leviticus of the Bible, and the dire consequences they must face in adopting such a position. The problem for many in the medical profession, especially surgeons and anesthesiologists who are most directly faced with the issue of blood transfusion, is that they, too, want to do their best for these patients. The conflict appears to lie in the definition of "best interests." For the JW patient, it is just as much a matter of life-and-death as it is for the physician. However, for them the issue is spiritual death, whereas for us the issue is physical death. It is quite clear which is more important to them so that we are often confronted with the difficult tasks of trying to decide, in the context of the unique medical
:j:George R. Simms, MD
753
CASE 6-1990
situation, what issues are truly at stake, how the patient can best be served, and who is to decide.
Legal Issues Forcing a treatment modality on a patient has legal as well as ethical ramifications. To force a competent adult to undergo a treatment that he/she has clearly stated is not wanted, regardless of how medically necessary the treatment may be or how irrational this refusal may appear to the treating physician, is to violate the constitutionally guaranteed rights of the individual. Clear legal precedence prohibits giving blood to a JW patient if that person, after explanation of the medical implications, still refuses to receive blood on the grounds of his/her religious belief. To override that restraint is to risk being sued for assault and battery, to say nothing of doing great personal harm to the individual involved. Unfortunately not all JW patients are adult, alert, and competent when they arrive in the Emergency Room and the physician is faced with a medically indicated need to order a blood transfusion. Difficult situations include: 1. The minor patient. Courts have rejected, and continue to reject, parents' claim for sole authority in the decisionmaking process for children. If the physician is convinced of the life-saving need for blood, courts have generally upheld that decision against strong parental bias, even though there is a strong history in this country that favors parental authority in all decisions having to do with how children should be raised and cared for. 2. The maternal/fetal patient. The courts currently favor the fetus in late gestation. Several recent decisions have upheld the justification for maternal transfusion in the mid-to-late second trimester of pregnancy. Transfusion in early gestation is as yet unaddressed. 3. The incompetent adult patient. There appears to be some inconsistency in court decisions in this area. It is increasingly clear that if a JW patient carries some form of identification stating that she/he is a JW and that under no circumstances is blood to be given, and then a transfusion is given, the physician is libel for assault and battery
regardless of the medical indications. On the other hand, when such identification is not available or when the identification comes from a second party (ie, spouse, member of the family, friend, neighbor, colleague, etc) then the physician is placed in the very difficult position of having to accept second-hand evidence in a lifethreatening situation. Many would go ahead and transfuse and defend their case in court on the lack of substantive evidence. All physicians must be aware of the growing danger of a lawsuit if they transfuse a JW patient, regardless of the medical indication, without explicit permission of the patient or the courts.
Ethical Issues If we start with the basic premise that our moral obligation as physicians is to act in the best interests of the patient, then a number of important questions arise: 1. Am I morally bound to honor every sincere request of a patient? The answer is "No." I am not morally bound to grant every patient request simply because I am in a fiduciary relationship with a patient. Many patients want us to do frivolous and sometimes dangerous things and we don't take them seriously, because we sense that their requests, although sincere, lack a convincing rationale and are not grounded in a process that is existentially meaningful and persuasive. On the other hand, there is the occasional request, whether we agree with it or not, that gives evidence of being grounded in a clearly thought-out belief system. It may seem bizarre within our own existential framework, but it is not frivolous and carries a certain weight of inner conviction. I submit that we are morally obligated to honor this latter request, because it touches on the vital core of another human being's deepest self-concept. Blood transfusion to the JW is one such example. What is in question is not whether the physicians understand or even agree with the value system expressed, but rather whether that request represents a deeply held personal conviction and has been well
CASE 6-1990
754
thought out. If so, every attempt must be made to honor it. 2. Once the doctor-patient relationship has been established (eg, accepting the transfer, starting to work on the patient, etc) and we have now entered a fiduciary relationship with that person who espouses a belief system such as the JW, are we not under a moral obligation to work as effectively as we can under those constraints? That is, once we know and accept the patient, have we also accepted his/her constraints as our own? 3. Is there a distinction to be made morally between my obligations to such a patient under emergency conditions (eg, bleeding to death in the emergency room) and nonemergency conditions in which the physician has time to talk with the patient to ascertain with assurance what his/her wishes are? 4. Is it morally permissible for a physician to enter a doctor-patient contract wherein the patient will bind the hands of the doctor from doing what she/he thinks is medically in the best interests of the patient? Put another way, is it ever permissible to stand aside and let another person die when you have the means to preserve their life (eg, a blood transfusion)? Most physicians are very uncomfortable with that stance, and many simply cannot abide it. 5. Does one party have the right to override the moral convictions of the other? For example, does the anesthesiologist have to be forced into doing the case? Does the surgeon (either out in the community hospital or at the Medical Center) have to be forced into doing the case? Was the transfer a moral cop-out or should the outside surgeon simply have done the case because the patient was there and needed the surgery? Another all-too-common example is the decision to give blood intraoperatively after the surgeon has promised the JW patient she/he would not use blood under any circumstances. You can say nothing and hope he doesn't notice the charge for the transfusions or doesn't get hepatitis 3 months later; you can lie and risk a crisis of confidence in the relationship; or you can
tell the truth and plead the case for having saved his life. "Well, at least I saved your life and acted in your best interests, didn't I?" The problem is, saving his life at that price may not really be acting in the best interests of the patient. COMMENTS
K. T. (Anesthesiologist): From a legal standpoint, could an anesthesiologist who refused to be involved in an urgent case like the one presented be accused of abandonment? That is, a situation somewhat different than this case, in which a patient would ultimately die because of the anesthesiologists' noninvolvement? R.A. (Surgeon): I would argue that in an urgent situation as described in this transfer, the anesthesiologist is not in a fiduciary relationship with the patient and, therefore, there are no moral and legal obligations incurred. On the other hand, once a physician-patient relationship is established, then moral and legal obligations are incurred. F.B. (Anesthesiologist): If I were in a situation where a true emergency existed (ie, a JW with a ruptured abdominal aortic aneurysm arriving in the operating room) and no other anesthesiologist was immediately available who would be willing to care for this patient upholding their religious beliefs, I would render care to this patient. However, if I was informed that this patient carried a card stating that he/she was a JW, I would override the patient's belief system and administer blood, but only if absolutely necessary. My own value system would require me to act in his/her best interest in a way that would be congruent with saving his/her life. If I walked away from this patient, and no other anesthesiologist stepped in, I would certainly consider that abandonment. However, in this forced situation, it then becomes a matter of the patient's belief system versus mine. An elective case or urgent case like the one presented is relatively easy because it is usually possible to locate a suitable anesthesiologist to care for the patient. I would not be involved in such nonemergency cases. J.G. (Surgeon): That would be battery and thus a felony. It is not my job to tell the patient what he/she should or should not believe. If the patient believes he/she would be denied salvation
755
CASE 6-1990
or access to heaven, then it is my job to accept that decision and recalculate the risk-benefit ratio of treatment based on these new facts. L.M. (Surgeon): When I was in medical school, I was told that becoming a surgeon did not give me the right to make moral decisions for others. I still think that is a correct position to hold. B. T. (Surgeon): Wide surgical experience in this country has shown that one can do almost all vascular procedures today without the absolute necessity of blood transfusions. This being the case, I would honor their belief and their request. J.G. (Anesthesiologist): I was one of the two anesthesiologists doing this particular case and I can tell you that I felt completely comfortable operating without blood. I would feel completely comfortable if the patient had died. I think one of the basic tenets of this country is the freedom of religion, and this is not a frivolous part of their religion. There was excellent communication with the patient, his desires were clearly understood, he was intelligent and well informed, and went into the operation knowing what the implications were. If the patient had died for lack of blood, I could have lived with myself. J.B. (Anesthesiologist): Some of the most exciting advances in anesthesiology today have come from the challenge of the JW. Another unrelated, similar example was when Dr Lavar at the Massachusetts General Hospital in the mid-1960s began to operate on intracranial aneurysms by placing the patient on cardiopulmonary bypass. That was in part the origin of the hemodilution technique we use today. Thus, challenges such as these often advance medical science. T.S. (Anesthesiologist): If you do enough of these cases, someone is going to die. I think it is important for both the surgeon and the anesthesiologist to be prepared for the eventual death that will result from this calculated risk. Not that it
shouldn't be taken, but rather to know that there will be a disaster one day, and to be emotionally prepared for it. I'm also concerned that there are JW patients who will accept blood even though they say they won't. Often there is enormous pressure from the elders of their church to hold firm to the doctrine when, deep down inside, they really don't want to die and would be willing to accept a blood transfusion. K.D.C. (Ethicist): It is true that some JWs will accept some form of blood substitute. However, it is generally accepted teaching that once the blood leaves the body it cannot come back into the body. However, volume expanders using Ringer's lactate and dextran are perfectly acceptable. A lot of people have traded on the indefiniteness of the JWs about what they really want. Some surgeons and anesthesiologists believe that if they don't consent and you force it on them, then it is OK. So the surgeon will say: "Just leave it in my hands and I'll do what is best. You haven't consented to anything." That plays well in some circles, but is really against the interpretation of the elders of the church and is doing a disservice. M.L. (Anesthesiologist): I think physicians certainly have the right and should have the moral obligation to respect a patient's wishes in the area of significant religious belief. However, I also think that what caused grave consternation to the Department of Anesthesia with this particular case was the failure to realize that there were two physicians caring for the patient simultaneously. One was the surgeon and one was the anesthesiologist. The surgeon should not place himself under the moral obligations of the patient to agree not to give blood without prior consultation with the anesthesiologist to be sure that the anesthesiologist agrees to that position. I don't think any surgeon has the right to morally obligate an anesthesiologist to enter into a contract with a patient unilaterally, simply because they are our patients as well as theirs.
SUGGESTED READINGS Benson KT: The Jehovah's Witness patient: Considerations for the anesthesiologist. Anesth Analg 69:647-656, 1989 Blood Transfusion-Why not for Jehovah's Witnesses? Statement to members of the medical profession. Brooklyn, NY, Watch Tower Society.
Brahams D: Jehovah's Witness transfused without consent: A Canadian case. Lancet 2:1407-1408,1989 Dixon JL, Smalley MG: Jehovah's Witnesses-The surgical ethical challenge. JAMA 246:2471-2472,1981 Oh DA, Cooley DA: Cardiovascular surgery in Jehovah's Witnesses. JAMA 238:1256-1258,1977