DIFFICULT MORAL QUESTIONS

Question 72: May a hospital give blood transfusions despite patients’ conscientious refusal?

I am the administrator of a teaching hospital at a major university. We have a problem with the management of Jehovah’s Witnesses as patients. Sometimes these people refuse on religious grounds to consent to blood transfusions, even transfusions that would use their own blood and even those that seem necessary to save their lives. Some staff physicians do not accept these patients, others do. That in itself is no problem for us, but a problem does arise because almost all of our anesthesiologists are unwilling to agree to withhold blood.

A current case was referred to our hospital ethics committee, and they have sent me their recommendation, which I am free to follow or not. The case presentation states the facts as follows. A twenty-three-year-old mother of two wants to deliver her third child at our hospital. Though a caesarean section might be necessary, she is not willing to consent to a blood transfusion, and her obstetrician has agreed to proceed on that basis. He hopes for a vaginal delivery; but if the caesarean becomes necessary, withholding blood would not imperil the baby, and he feels the woman is entitled to run the risk to herself. When he contacted our anesthesiology department to arrange for caudal anesthesia, however, he learned that few obstetrical anesthesiologists are willing to care for the woman on her terms, so that there might not be an anesthesiologist available when needed. Some who refuse explain that withholding an intervention so simple as a blood transfusion would violate their standard of practice and/or that they could not in good conscience agree to stand by while such a patient died, especially when she would leave children motherless.

In discussing the case, members of the ethics committee agreed that people unwilling to accept care in accord with our staff’s conscientious convictions should be asked to go elsewhere. But that will not solve the problem, because we must deal with emergency cases, where neither we nor the patients have a choice about their being here. For such cases, it would be best to have available an anesthesiologist willing to care for these patients on their terms. However, guaranteeing that would require having such a person not only always on duty but always standing by, and that is not feasible. Inevitably, then, we sometimes will have such patients when there is no anesthesiologist available to care for them on their terms. Then, the committee majority argued, whoever does care for them cannot be expected to compromise his or her principles, since a physician’s conscience deserves no less respect than a patient’s. The hospital’s lawyer supported this view, pointing out that almost all lawsuits against hospitals and physicians brought by Jehovah’s Witnesses given blood against their will either have been decided for the defendant or settled by a rather small payment to the patient.

The ethics committee concluded: “When all efforts to find care commensurate with the patient’s wishes have failed, there is no choice but to proceed according to the values of the physicians delivering the care.”

If I endorse that conclusion, we would state our policy very clearly and warn those who might be affected to go elsewhere if they can. Still, I am not comfortable with this approach, because of the problem with emergency patients. We would be making it hospital policy to impose blood transfusions on some of them not only without their consent but despite their express refusal. But what alternative have I, other than trying to coerce members of our staff to act against their consciences?

Analysis:

This question concerns norms for the cooperation of health care providers with patients. Since the relationship between a patient and any care provider should be a free cooperation, neither party should be expected to act against his or her conscience. But, with certain exceptions, care providers may not act on patients without their informed, actual or reasonably presumed consent, and so a care provider can be required to refrain from doing something otherwise required by professional ethics and/or personal moral standards. In emergencies, an anesthe-siologist should do all that can be done consistently with both his or her own standards and the patient’s consent.

The reply could be along the following lines:

In responding, I shall assume that, as in your example, no one else’s life will be at risk; if it were, that would be a different problem.²⁴⁹ I also shall assume that, while Jehovah’s Witnesses are mistaken in thinking that God forbids blood transfusions, their belief is sincere and important to them. Given these assumptions, I do not agree with the ethics committee’s recommendation.

It seems to me the committee’s discussion is flawed in two ways: by presupposing a false view of the relationship between patients and care providers (I use care providers here to refer not only to physicians but to hospital administrators and other health care personnel), and by ignoring a vital distinction between acting and refraining. The relationship between patients and care providers should be a free cooperation. Since the consciences of both physicians and patients deserve the same respect, neither party to this cooperative relationship should be expected to act against his or her conscience. Still, the patient’s unwillingness to proceed can require that a care provider refrain from acting as his or her conscience otherwise would require. I therefore disagree with the statement in the ethics committee’s conclusion: “When all efforts to find care commensurate with the patient’s wishes have failed, there is no choice but to proceed according to the values of the physicians delivering the care.” My analysis of the problem is as follows.

On the one hand, patients are not merely cases on which expert care providers exercise their technical skills in accord with their own professional and moral standards. Competent adults are acting persons responsible for their own life and health, and care providers are potential assistants, to be engaged and cooperated with by mutual consent. Except in certain special cases provided for by law (for example, immunizations to prevent epidemics), no sort of health care ever should be imposed upon competent adults without their actual or reasonably presumed consent. That consent should not be a blank check, licensing care providers to do whatever they consider appropriate, but should be informed and specific, so that the patient can limit the cooperation in accord with morally acceptable interests other than that in health and survival—not least, the interest in obeying what is sincerely believed to be God’s will. Therefore, it seems to me, imposing care on a competent adult against his or her will is doing violence to that person. It follows that anyone who gives a blood transfusion to a Jehovah’s Witness against the patient’s will commits an offense against her or him, and that you, as hospital administrator, should do your best to prevent such an offense. Warning potential patients who do not want blood transfusions to go elsewhere if they can will not adequately safeguard patients’ rights, since, as you say, some people will have no choice about being in your hospital.

On the other hand, care providers are bound not only by the standards of good practice and professional ethics but by their personal moral convictions. In carrying out their professional responsibilities, they never should be required to do anything they believe wrong. Moreover, except when their action is limited by others’ rights, they should not be required to provide professional services under conditions that would prevent them from doing what they consider required by professional standards.

In emergency situations, those available should do what they can (“can” being limited by their conscientious convictions as well as by other limits on their capacity to act) to meet urgent needs, even if they are prevented by a patient’s refusal from doing some things they otherwise would consider obligatory. In dealing with Jehovah’s Witnesses, everything except giving blood can be carried out in full accord with the anesthesiologist’s professional standards. So, if nobody else is available to provide essential service, an on-duty anesthesiologist who considers it wrong to allow a Jehovah’s Witness to die for want of a blood transfusion should do all these other things for the patient while refraining from doing that to which the patient refuses consent. However, when someone willing to cooperate with a Jehovah’s Witness becomes available or the emergency ends, any institution or individual providing service on an emergency basis should be free to avoid further involvement—for example, by discharging the patient from the hospital or withdrawing from the case.

Someone might object that, in caring for any patient, an anesthesiologist would commit a sin of omission by not giving a transfusion he or she judged should be given. But nobody commits a sin of omission except by failing to do something he or she both can and ought to do. To give the transfusion despite the patient’s refusal would not be to cooperate with a competent adult but would be to violate that adult’s rights by unilaterally acting on him or her. So, the anesthesiologist, lacking the patient’s authorization to give the transfusion, cannot rightly do so. Consequently, his or her refraining is not a sin of omission.

Nevertheless, if a court were to order blood transfusions for a patient despite his or her refusal, an anesthesiologist who judged the transfusions appropriate could rightly provide them. In such cases, the blood transfusion presumably is lifesaving and the court presumably acts for some public interest—for example, in forestalling the need to care for orphans. Even if the hospital and/or the anesthesiologist sought the court order, in carrying it out the anesthesiologist would act as an obedient citizen rather than as a physician cooperating with and serving a patient.²⁵⁰

249. The problem regarding children already born, as it confronts a state legislator, is dealt with in q. 197, below. I do not deal with the problem regarding unborn children, which should be handled in the same way as if they were already born. Of course, those who assume that abortion is acceptable will regard it as a quite different, and difficult, problem; see Ruth Macklin, “The Inner Workings of an Ethics Committee: Latest Battle Over Jehovah’s Witnesses,” Hastings Center Report, 18 (Feb.–Mar. 1988): 15–20.

250. However, if a court were to order someone to do an abortion or other act against life or health, that person would be obliged to refuse: “We must obey God rather than any human authority” (Acts 5.29). Many health care providers who do not share the belief of Jehovah’s Witnesses that it is wrong to accept blood transfusions have no problem of conscience in cooperating with these patients within the limits they set. Such people should make known their readiness to care for Jehovah’s Witnesses.