The Introduction
Healthcare ethics involves making well-researched and considerate decisions about medical treatments, while taking into consideration a patient’s beliefs and wishes regarding all aspects of their health. The healthcare industry, above any other, has a high regard for the issues surrounding the welfare of their patients. This power over a patient’s wellbeing creates a mandatory need for all healthcare organizations to develop an ethics committee. The committee’s goal is to establish a written code of ethics that details policies and procedures that determine proper conduct for all employees.
There are many ethical issues, which may arise in regards to a patient’s healthcare. Treating patients with certain religious beliefs pose important ethical issues in the field of healthcare. Religion is a practical way of expressing a person’s spirituality in the practice of beliefs and rules by following rituals and religious practices. It is important for healthcare workers who must be aware of different beliefs and practices of different religions. In addition, a care worker should be aware that within a religion there may be several separate schools of thought and belief, for example, within Buddhism there are seven different schools of teaching. Within Christianity, there are a number of different churches such as Catholic, Church of England, Pentecostal, and Jehovah Witness.
Religious beliefs can affect a patient’s views on healthcare, how they wish these to be respected and what medical interventions and treatments which they would or would not prefer. Religious factors in relation to diet, prayer and worship routines need to be considered while caring for the whole individual. Healthcare providers must also ensure that individual patients can carry out any rituals or religious practices, including praying, anointing with oils, periods of fasting of self-denial, and special diets among others. As faith is an individual matter, it is important to demonstrate respect for patients’ beliefs. For instance, physicians must understand specific convictions on blood transfusion that guide Jehovah’s Witnesses’ treatment.
This paper will describe an ethical health care issue concerning refusal of care, such as a blood transfusion. It will cover the four ethical principles as they apply to healthcare providers and patients’ rights. In what follows, it is argued that it is important that health care workers should have a rudimentary understanding of Jehovah’s Witnesses philosophy regarding blood transfusion to be proactive in their care management.
The Exposition
In all areas of practice, physicians encounter Jehovah’s Witnesses and their refusal to accept blood transfusion, even when it means saving their lives. Jehovah Witness believes that there is only one True God called Jehovah, the one True God, corresponds only to the father, denying that Jesus is God, and the Holy spirit is a person. They also do not believe in the Trinity, Father, Son and Holy Spirit. They believe that Jesus Christ, the son of God, was God’s first creation and was born as a perfect man. After Jesus’ death, he was raised as a spirit creature that they refer to as Michael, the archangel.
There are many beliefs that cause controversy in this religion. In health care, the major issue is the refusal of blood transfusion. Jehovah’s Witnesses consider blood transfusion as eating blood. Jehovah’s Witnesses refuse blood transfusion believing that accepting blood, from another source, blood that is taken from the body should be poured on the ground as water and disposed of according to God’s laws. Many followers have chosen to die rather than receive blood transfusions, and parents often refuse such treatments for their ill children. The Jehovah’s Witness faith creates some challenges for physicians and nurses caring for its members.
In some instances, physicians have rejected medical interventions for Jehovah’s Witnesses because of their strong, unwavering belief on blood transfusions and use of blood components. Such surgeons feel that they are exposed to potential legal challenges and ethical issues. In addition, they believe that Witnesses’ cases present more challenges to their skills and practices.
Although Witnesses do not express any concerns regarding blood transfusion, physicians have often asserted that this group of patient is somewhat disadvantaged based on blood treatment issues. Hence, the ethical principles of autonomy versus beneficence come into conflict when a physician believes a transfusion is in the best interest of the patient, but the patient refuses. Legal precedence provides a backdrop.
The Assessment
It is imperative for healthcare workers to have a rudimentary understanding of Jehovah’s Witnesses philosophy regarding blood transfusion to be proactive in their care management. In this regard, physicians and nurses should explore other possible interventions to replace blood requirements. While physicians may feel restrained by such unique treatment demands from Jehovah’s Witnesses for fear of subsequent legal repercussions, this perhaps is not a viable reason to decline care for Witnesses. Hence, physicians require appropriate philosophy on ethical issues to protect Witnesses’ rights to reject blood transfusions but still use alternative means of care delivery in a way that deliver safe patient care and quality outcomes.
Researchers focused on a case involving a woman who had consented for examination of a fibroid tumor under anesthesia, but withheld consent for removal of the tumor (Panico, Jenq, & Brewster, 2011). While sedated, she underwent resection of the tumor that led to complications. She sued and the judge ruled in her favor, establishing the notion that every human being should have the right to decide what is done with his or her own body. This premise gave any individual the right to refuse treatment if he or she understands the risks and, therefore, a Jehovah’s Witness has the right to refuse a blood transfusion. This ruling set a precedent for informed consent. In 1990, the Canadian case of Malette v Shulman described an emergency department physician who gave a blood transfusion to an unconscious patient who was in hypovolemic shock.
Per report, the patient had a signed wallet card that identified her as a Jehovah’s Witness, although it was undated and not witnessed. The wallet card was considered a legal document, which stated that the patient did not want to receive a blood transfusion under any circumstances (Lantos, Matlock, & Wendler, 2011). Furthermore, when the patient’s daughter arrived and asked that the transfusion be stopped, the physician did not comply. The physician argued that there was no way of knowing if the patient had changed her mind in the minutes before the car accident and, thus, he was duty bound to save her life (Lantos et al., 2011).
The court found the physician guilty of battery. Although it is easy to draw on emotion to argue against the ruling in this case, the verdict has not been overturned. Jehovah’s Witness have been known to refuse transfusions with packed red blood cells to treat their life-threatening diseases. Medical professionals must consider patient has autonomy of thought, intention, and action when making decisions regarding health care procedures.
To comply with patient’s wishes, medical professionals could offer fresh frozen plasma and platelets as an alternative. Physicians must recognize that it is their responsibility to educate patients about different ways to have bloodless transfusions. For instance, one such technique is called cell savage where blood is collected from the body, filtered for cleaning, and returned to the body. Cell savage can also be reversed to limit blood loss and reduce the need for transfusion.
Furthermore, Jehovah’s Witnesses number over one million in the United States and at least six million worldwide. Witnesses believe in strict and literal interpretation of the Bible, which leads them to reject some aspects of modern medical care (Doyle, 2002). Medical professionals have discussed in open forums ethical decisions they are required to make while taking care of a dying patient who refused to accept a blood transfusion. Data suggest they struggled to relate to someone who would take some blood products, but not others, and who are willing to risk death over a red blood cell transfusion.
As previously noted, the strong belief of Witnesses is guided by the Biblical verses, including Genesis, Acts and Leviticus, which prohibit consumption of blood. It is imperative to note that these Biblical passages do not reflect medical terms, but believers consider them as guidelines against blood transfusions. On the contrary, Witnesses are free to use some components of blood such as immune globulins, but personal decision is required. In addition, they are free to accept other forms of treatments, which are non-blood and uninterrupted circulation. Hence, surgeons should consult Witness patients give consent based on their conscience.
The Objection
Justifiably, healthcare workers and physicians who dedicated to caring, improving health and saving lives face critical ethical issues and possible litigation from Jehovah’s Witnesses. Hence, physicians must go out of their well-established, evidenced based standards to use other techniques at their disposal, including ‘creative surgery techniques’. The stand and belief of Jehovah’s Witnesses on blood transfusion is a clear interference with physicians’ work.
Jehovah’s Witnesses still hold archaic medical beliefs, which were discarded after the introduction of modern medicine. Ironically, the Watch Tower Society now permits Jehovah’s Witnesses to undergo organ transplant. Critics argue that there is no major difference between blood transfusion and organ transplant. Hence, objection on medical interventions involving blood transfusion is not consistence with other medical procedures that Jehovah’s Witnesses undergo.
Perhaps the most thorough critic of Jehovah’s Witnesses’ beliefs on blood is Osamu Muramoto (Muramoto, 1998). According to Muramoto (1998), the obvious inconsistency in practices, involving blood among Jehovah’s Witnesses is a source of concern. For instance, inconsistency is noted on the use of various components of blood such as white blood cells and platelets, which constitute a small percentage relative to the permitted albumin (Muramoto, 1998). Thus, when the Watch Tower considers certain components of the blood as minute, then it is sending mixed signals based on the significant quantity of blood and the allowed quantity.
It further does not make sense when Jehovah’s Witnesses are allowed to die by prohibiting blood transfusion yet they put emphasis on life. Thus, blood, as a symbol, is more important than human life.
From these observations, one can assert that Jehovah’s Witnesses put unnecessary burdens on healthcare professionals and personal inflicted suffering and death by rejecting modern, life-saving blood transfusion. In addition, Jehovah’s Witnesses have also noted that they pose critical medical risk that complicate processes because of their firm belief on blood transfusion. Consequently, they demonstrate extraordinary appreciation for care services they get (Dixon & Smalley, 1981).
The Replies
Refusal of blood transfusions became common practice only after a 1945 church decision (Mann, Votto, Kambe, & McNamee, 1992). Indeed, Jehovah’s Witnesses interpret these sections of the Bible differently. Hence, receiving blood transfusion has severe consequences from the Watch Tower, families and even external life. The society had enforced shunning and social isolation by Witnesses’ own family members, relatives, and friends, ultimately leading to expulsion from the religion (Doyle, 2002). Hence, physicians and nurses require a thorough comprehension of principles of Jehovah’s Witnesses on issues related to blood transfusion, as well as ethical issues surrounding their care provision. As such, physicians and nurses should focus on several alternative therapeutic choices that can result in high quality care.
Physicians should not refuse Jehovah’s Witnesses treatment because of blood transfusion issues based on a blanket policy. Instead, they should not feel that Witnesses deny them opportunities to advance care through evidence-based practices and technologies. Physicians should consider such experiences as learning opportunities that require medical profession to revamp its practices. In addition, physicians should develop effective care standards for Jehovah’s Witness patients to facilitate care delivery. Such care plan should not compromise the quality of care delivered to Jehovah’s Witnesses.
Similarly, research suggests that the health care provider must consider four main areas when evaluating justice. The four areas are fair distribution of scarce resources, competing needs, rights and obligations, and potential conflicts with established legislation (Rao, 2008). In considering many ethical dilemmas associated with Jehovah’s Witnesses and their refusal to accept blood transfusion, medical professionals now focus on ways in which treatments or interventions violate accepted norms of conduct of social science research.
Physicians must be aware of the growing diversity of values and beliefs among Jehovah’s Witnesses. Some of the most intractable ethical problems arise from conflicts among principles and the necessity of trading one off against the other. The balancing of such principles in concrete situations is the ultimate ethical act. Evaluation involves at least four levels of social-political interaction- with government and other agency policymakers who commission evaluation. Evaluation has to operate in this multilayered context of different interests, providing information to inform decisions while remaining independent of the policies and programs themselves.
More importantly, the weight of ethical judgment is thus put on experimental research to justify meeting ethical standards (Panico et al., 2011). Resource allocation is a major issue that physicians are confronted with when dealing with Jehovah’s Witness patients. Beneficence requires that the procedure be provided with the intent of doing goof for the patient involved. As described above, if a patient refuses a blood transfusion and opt for an alternative procedure that costs more, it can prove problematic (Panico et al., 2011). When society thinks of the greater good, this argument poses a challenge to the principles of patient autonomy that everyone also values. In a society in which medical resources are costly, benefits will always be weighed against the potential cost to both the patient and society and, thus, creating ethical challenges.
Finally, the care for a Jehovah’s Witness with life threatening illnesses requires a multidisciplinary and planned approach. These patients suffer from certain conditions, are often anemic, and must be prepared to deal with this issue in both outpatient settings and during an acute crisis. Clinicians must view each patient as an individual who may have varying thoughts about transfusions of the multiple different blood products that are available. Therefore, medical practices today need to continue to open early lines of communication with such patients.
Providing adequate information, educating the patient about realities, and obtaining informed consent before subjecting a patient to any test, procedure, or surgery is extremely essential. It is vital to the optimal care of a Jehovah’s Witness patient. It is necessary that dialysis unit nurses and social workers have conversations with patients about their beliefs on blood products. Discussing a patient’s wishes, understanding their basis for these decisions, and discussing risks, benefits, and alternatives that can be used in both emergent and non-emergent situations is crucial to preparing for more urgent situations, when these conversations often are not possible.
It is also important to recognize that Jehovah’s Witnesses have often expressed their willingness to desist from blood transfusion by providing consent to relieve surgeons and care facilities of liability. Moreover, many Witnesses have their medical identification cards. Physicians should recognize that such cards are considered as medical documents, and they are legally binding and, therefore, failure to acknowledge them would be regarded as a violation of patients’ rights.
Hence, the need to protect such rights should be guided by relevant narratives, including legal opinions. For children, Jehovah’s Witnesses have often stressed that physicians should consider the family’s religious practices and blood transfusion issues. Moreover, Witnesses prefer the use of interventions, including therapies that do not go against religious beliefs. Hence, physicians must understand how to care for the whole person by avoiding invasive techniques that could cause psychological torture and spiritual pain.
It is necessary to recognized that Jehovah’s Witnesses have deeper conviction and strong will to stay alive. Hence, Witnesses willingly cooperate with care providers to ensure that they overcome these challenges together and are often grateful for services rendered.
The Conclusion
To many Jehovah’s Witnesses, the consequences of accepting a blood transfusion can be worse than death itself. Not every Jehovah’s Witness patient abides by the same beliefs regarding the acceptance of blood products. These patients can be managed through careful planning and open lines of communication between physicians and patients. Understanding the premise behind the beliefs of patients who are Jehovah’s Witnesses is critical to beginning conversations and truly understanding the patient.
Ultimately, when a patient establishes what they will accept, clinicians ethically must optimize the care provided within their wishes about blood products. Frequent and open dialogue is essential for enhancing care for a Jehovah’s Witness. As an alternative to violating a patient’s autonomy, some physicians and some hospitals are more comfortable with bloodless procedures and patients can be referred to these centers if necessary for specialty care. Overall, health care professionals should be able to provide ethical health care to patients who are Jehovah’s Witnesses at any hospital or community office, but must continue to be educated and aware of their beliefs and respect their wishes and the impact these may have on organizing and providing their care. If these considerations are neglected, one can surely expect ethical breaches or dilemmas.
References
Dixon, J. L., & Smalley, M. G. (1981). Jehovah’s Witnesses: The surgical/ethical challenge. Journal of the American Medical Association, 246(21), 2471-2. Web.
Doyle, D. J. (2002). Blood Transfusions and the Jehovah’s Witnesses Patient. American Journal of Therapeutics 9, 417.
Lantos, J., Matlock, A. M., & Wendler, D. (2011). Clinician Integrity and Limits to Patient Autonomy. JAMA, 305(5), 495-9. doi: 10.1001/jama.2011.32.
Mann, M. C., Votto, J., Kambe, J., & McNamee, M. J. (1992). Management of the severely anemic patient who refuses transfusion: lessons learned during the care of a Jehovah’s Witness. Annals of Internal Medicine, 117(12), 1042-8.
Muramoto, O. (1998). Bioethics of the refusal of blood by Jehovah’s Witnesses, part 1. Journal of Medical Ethics, 24(4), 223-230.
Panico, M. L., Jenq, G. Y., & Brewster, U. C. (2011). When a patient refuses life-saving care: issues raised when treating a Jehovah’s Witness. American Journal of Kidney Diseases, 58(4), 647-53. Web.
Rao, K. H. (2008). Informed Consent: An Ethical Obligation or Legal Compulsion? Journal of Cutaneous and Aesthetic Surgery, 1(1), 33–35. Web.