There are three witnesses, the Spirit, the water, and the blood, and these three agree.
John 5:8 (RSV)
In the ethics quiz “Of Blood and Truth” in the May issue of Psychiatric Times, readers were asked to assume the role of an ethics consultant called emergently to the bedside of Mr M, a patient in critical need of a blood transfusion. Mr M had accepted several transfusions earlier in the hospitalization but now says he is a Jehovah’s Witness and allowed the transfusions only because he thought he was receiving his own blood. An advance directive cannot be found, nor next of kin. The emergency contact is a girlfriend, S, who told the attending she thought Mr M was “crazy” and advocated strongly for the transfusion.
The attending has concerns the patient lacks the decision-making capacity to refuse and could even be suicidal. The consulting psychiatrist believes the patient is alternating between delirium and lucidity and is not suicidal but frustrated with his medical situation. The attending is anxiously awaiting your arrival to resolve the dilemma.
Before you can begin to offer ethically justifiable recommendations, you must work through the answers to 4 key questions.
1 Ethics consultations often involve a number of different and often conflicting ethical concerns and questions. As the ethics consultant, which of the following do you think is the central ethics issue in this case?
A. If the patient has decision-making capacity, he has the right to refuse a blood transfusion.
B. It is unclear whether the patient has a surrogate who is able and willing to make decisions that respect his wishes and values.
C. Since the attending has the ability to save the patient, she also has the duty to do so since she does not believe he has capacity.
D. The team believes the patient is incapable because he is refusing the clinically indicated medical treatment.
Option A is certainly true. Courts have upheld the right of adult patients with decision-making capacity to refuse a blood transfusion based on religious beliefs.1 (The same is not true for children.) But the psychiatrist is equivocal about the patient’s capacity secondary to his fluctuating mental status.
If this is true, then B—identifying a surrogate—is crucial. But is this really an ethics question? Or is it part of the fact pattern we need to gather in doing the consultation?
The primary team has identified S—a girlfriend whose status as a surrogate would be highly dependent on state law. Often, overworked intensive care and medical teams understandably cast about for anyone to help make urgent medical decisions, and they frequently do not have the knowledge to identify the ethically appropriate decision maker. This is a good place to involve social workers in an attempt to locate an advance directive. If one is not available—which is the situation for about 75% of American patients2—try to contact any family members, who would be the designated surrogates in most state hierarchies of priority.
The attending is morally distressed because of all the uncertainty. Acting on a default ethical and legal position many physicians assume, she believes she has an obligation to save Mr M’s life (option C). The attending considered the implied or presumed consent, often employed in emergencies when there is no time and no voice for the patient.3 Except that the attending recognizes—and herein lies the source of her distress—that if Mr M is capable and this is his real faith position, then she should respect the patient’s beliefs, even if it means he dies.
Option D is true more often than not. Scholarship and experience suggest that clinicians are far more likely to question capacity or determine a patient is incapable when he or she refuses medical and psychiatric treatment or asks to leave the hospital against medical advice.4
1. Barron CH. Blood transfusions, Jehovah’s Witnesses and the American Patients’ Rights Movement. In: Maniatis A, Van der Linden P, Hardy J-F, eds. Alternatives to Transfusion in Transfusion Medicine. 2nd ed. Oxford, UK: Wiley-Blackwell; 2011:531-558.
2. Rao JK, Anderson LA, Lin FC, Laux JP. Completion of advance directives among US consumers. Am J Prev Med. 2014;46:65-70.
3. Veatch RM. Implied, presumed and waived consent: the relative moral wrongs of under- and over-informing. Am J Bioeth. 2007;7:39-41;discussion:33-34.
4. Ganzini L, Volicer L, Nelson WA, et al. Ten myths about decision-making capacity. J Am Med Dir Assoc. 2005;6(suppl 3):S100-S104.
5. Shaner DM, Prema J. Conversation and the Jehovah’s Witness dying from blood loss. Narrat Inq Bioeth. 2014;4:253-261.
6. Dixon JL, Smalley MG. Jehovah’s Witnesses. The surgical/ethical challenge. JAMA. 1981;246:2471-2472.
7. White DB, Curtis JR, Lo B, Luce JM. Decisions to limit life-sustaining treatment for critically ill patients who lack both decision-making capacity and surrogate decision-makers. Crit Care Med. 2006;34:2053-2059.
8. Posluszny JA Jr, Napolitano LM. How do we treat life-threatening anemia in a Jehovah’s Witness patient? Transfusion. 2014;54:3026-3034.