OK, there really is no such thing. The recent death of a young Jehovah’s Witness has led to some lively discussions about medical ethics. Every ethical conundrum is unique, but all can be analyzed somewhat objectively from a distance.
The details of the JW case have been discussed widely elsewhere. We will explore some of the generalized principles. Some have said that JWs should be transfused against their will as soon as they become unconscious. Others have argued that allowing someone to refuse life-sustaining therapy is morally equivalent to euthanasia. There are flaws in both of these extremes.
Patient Autonomy
One of the principles of medical ethics is patient autonomy, that is, the right of a patient to give or withhold consent for any medical intervention. This often looks like a black-and-white issue, but in clinical practice it is full of greys. Jehovah’s Witnesses hold to a belief that most find irrational—transfusions, even if necessary to sustain life, are immoral. They would rather die than be transfused—but death is not the intent, only the outcome. In most cases, to transfuse a patient with the knowledge that they do not want that intervention is battery.
Then comes the grey. What if the patient is a minor? What if he is an emancipated minor? What if she is a new mother and will leave her children motherless?
Some would argue that the belief against transfusion is so irrational that those who hold it are by definition incompetent. Bullshit—ignorant, yes, incompetent, no.
Nonmaleficence
Another bedrock principle of medical ethics is “nonmaleficence”, or the principle of not intentionally inflicting harm on patients. The grey areas for this principle often appear in the question, “What is harm?” A comment from Respectful Insolence stated the following:
If you honestly believe that a sane adult has the ethical right to refuse life saving treatment that is otherwise medically indicated, for ethical consistency you have to also believe they have the right to actively end their own life. IOW, that if a sane patient made the request, a physician should assist them in committing suicide.
There is no rational basis for asserting that ‘passively’ committing suicide is somehow ethical while ‘actively’ committing suicide is not. Don’t fool yourself: In both cases the person is committing suicide.
Two issues are stuffed into the above. One is suicide, one is euthanasia. As far as suicide is concerned, the physician really isn’t a part of the equation. While it may seem like suicide to refuse life-sustaining treatment, the intent of the patient is not to die, but to refuse a treatment they find abhorrent. Intent is important.
As to euthanasia, “ethical consistency” requires no such thing. Nonmaleficence requires the physician to avoid harm to the patient. In the case of the JW, “harm” is defined as transfusing against their will (violating their autonomy). Actively killing the patient via euthanasia is also “harm”.
In this case, the patient did not ask to be killed, he refused a medical treatment to save his life. He still wished to live. This is not a case of suicide (intent to end ones life), nor euthanasia (physician-assisted suicide by active means). It is a sad case of ignorance leading to death.
December 2, 2007 at 1:42 pm
I appreciate that you are able to break out of the mob mentality going on elsewhere where not only claims of suicide are being thrown around, but also claims that the judge and the aunt “killed” him.
Jehovah’s Witnesses do of course want to receive the best medical treatment possible, just without blood transfusions. As to ignorance, I can tell you that each of us study the topic pretty extensively and even fill out legal forms expressing what treatments we have decided that we will and will not accept long before the issue pops up.
In addition to this, each region has a Hospital Liaison Committee, made up of a group of elders that receive training on the topic, that will go to the local hospitals and speak with doctors and even provide them with the latest information on bloodless medicine. Witness representatives have even set up information booths at medical conferences to help spread information on bloodless alternatives to doctors. So we are quite proactive on the issue.
It is also common to find news articles focusing on some new bloodless surgery being done successfully…on one of Jehovah’s Witnesses. But those rarely receive much attention, even though these types of surgery usually have fewer complications.
More and more doctors are saying that bloodless medicine is the way of the future, and Jehovah’s Witnesses are doing everything we can to help the medical sector make it standard.
Here’s a short preview of a video made available to medical professionals by Jehovah’s Witnesses: http://www.watchtower.org/e/vcnb/article_01.htm
Thanks,
TJ
December 2, 2007 at 4:33 pm
Well-said. This topic is really making the rounds lately. Like any other right-to-refuse or right-to-die scenario, the JW cases have dropped many of us for whom such things are a concern into a real ethical quagmire.
December 3, 2007 at 12:55 am
I appreciate how you stepped back to present the underlying principles of autonomy and nonmaleficence, but not how you conflated the transfusion treatment with the refusal for stem cell transplant. I don’t agree with the theological underpinnings of Witnesses, but do think they are right to be able to make their own decisions. A 14 year old oncology patient can refuse treatment if he isn’t a Witness. So why do we make such a deal of this when religion is involved?
Read more at Hope for Pandora.
December 3, 2007 at 8:17 am
I’m not sure you’re correct about a 14 year old being able to refuse treatment. As a minor, the guardian gets to make those decisions, unless it’s regarding sexual health.
December 3, 2007 at 6:30 pm
Some would argue that the belief against transfusion is so irrational that those who hold it are by definition incompetent.
Bullshit— ignorant, yes, incompetent, no.
Would agree on the basic point, but…
One of my difficulties with ethics and medical ethicists is that their analyses tend to stem from principles which they regard as total absolutes - like autonomy. As you pointed out above, the real world gives you not a lot of black and white, and a lot of shades of grey.
A boring example from research was the one about blood and tissue samples that had been collected for a past study on X, of even just for “research purposes”, later being used for Y. As I remember, some of the ethicists argued for a blanket and absolute prohibition on use of samples for ANYTHING other than what was explicitly consented for in the first place, saying it would violate patient autonomy. This was even if the samples were now decades old and were going to be used anonymously for finding out something important - i.e. they were going to be treated a bit like “routinely collected data” in an epidemiology study.
The law, oddly, sometimes seems to deal with the grey shades of reality better than the ethics folk as it deals with the nuances of individual cases and the “balance of harm”.
I find the recent report of the Jehovah’s Witness mother in the UK who died refusing tranfusion and left the newborn twins motherless a definite grey. The ethicists would presumably say there was nothing in her situation that would/should abrogate her autonomy, and therefore the doctors had to let her die. But in that setting I might have some sympathy for the viewpoint that the decision to leave her two young children motherless strongly suggested she was not capable of a rational decision.
I also wonder whether the decisive factor in such a case could be not having a “dissenting” family member - an “advocate”, in effect - present arguing for not dying. The patient in that case was apparently supported by an extended family of JWs who thus presumably agreed with her decision. I know they have no legal status in the decision, but one wonders about concerted pressure on the patient to keep the faith. What might have happened in an analogous set-up if, say, her partner had been a non-JW and had not wanted her to refuse the transfusion.
Another question is how far the medical people go in their explanations to the patient. Do they actually say “Your children will never know their mother unless we transfuse you NOW”. The doctors’ professional imperative to respect patient autonomy presumably means they can’t be advocates (though oddly doctors doing advocacy is a staple of every medical soap ever filmed).
Anyway, all makes me glad I’m a University Prof and I’ll never have to be in the doctors’ shoes.
December 3, 2007 at 6:52 pm
Actually, I quite strongly advocate for my point of view and try to actively convince patients of the “right” decision. I do not believe this violates autonomy. It’s my job.
December 4, 2007 at 4:20 pm
Good for you, Pal. But don’t tell your medical ethicists! Anyway, I guess we’re back to “grey areas” again there… or, as Mrs Dr Aust says “real life”.
More discussion on this here and in the rapid responses here.
January 6, 2008 at 12:11 pm
[...] Medical musings, health, medical ethics, medicine I have written a bit in the past about medical ethics. The previous case we discussed involved a Jehovah’s Witness, blood transfusion, and [...]