Stephen Streat:
Being a Jehovah's Witness with a critical illness earns you "comorbidity" in our database - it is part of that general phenomenon that my colleague Les Galler calls "having a lifestyle incompatible with your disease". We have certainly had such patients "ooze" to death from thrombocytopaenia without platelet infusions even when oxygen carriage and factor mediated coagulation were adequate.
David Crippen:
I have watched this thread with interest. I don't recall having to deal with a life threatening disaster involving a Jehovah's Witness. Several that I have dealt with backed off reluctantly but firmly when eye to eye with the Grim Reaper.
I find the issue of competence interesting. JW has been called a "cult". What is a cult? I have always thought of them as groups that obsess over otherwise obscure and seemingly superfluous biblical passages to the point where potential damage exceeds any benefit from their interpretation (definition mine).
I recall in my youth a family of diabetics who lived near us who knocked off one of their kids after becoming involved in a local cult that pointed out obscure biblical passages regarding purification of the soul curing disease in some sense. They sat around their house for a week or so and purified into fatal ketoacidosis and intravascular depletion. In the papers, the "elder" of the group expressed regret that their faith was not strong enough to see them through".
So, where is the fine line between society allowing competent people to make disastrous decisions on the basis of individual freedom and protecting those who are taken in by charlatans and wackos? Some obscure biblical references are more socially accepted than others. Catholics (used to) eat fish on Friday, forego certain delights over Lent (I gave up lovemaking with Claudia Schiffer.......and I'm not even Catholic) and Jews don't eat pork.
So what's the difference between Jews abstaining from Pork and JW abstaining from exogenous blood? I once had this discussion with Avi Roy-Shapira, one of the brightest people I have ever talked to. He had a very interesting reaction: (paraphrased) "There is nothing wrong with Pork...it is nutritious and tasty. But my Lord and my God has told me I cannot have it, and that ends the discussion". So what's the big deal. Avi has had a discussion with his God and during that discussion, he has had the law layed down. No one else heard that discussion. There is no tape of it so it cannot be proven one way or another. Some would argue that discussion occurred because Avi desires it to. Others would argue that he is simply following imprinted behavior that has been handed down to him from infancy. Others would argue that there is a true deity at the origin.
So what if Avi chooses not to eat pork on the basis of supernatural revelations that he has interpreted. If he lands in an ICU with a hemoglobin of two, he doesn't have to worry about getting intravenous pork. If a wild eyed Southern Baptist held a gun to his head and demanded he eat a pork sausage, he would probably be able to make an advantageous deal with his Lord and God, pleading mitigating circumstances to stay alive. His preference is a safe one. He can pay service to his belief without threatening his life in the process. My partner Hank Rafkin is quite devoutly Jewish, observing kosher dietary restrictions. He must be also be home certain days of the week before sundown with restrictions on socializaton after that time. However, he is allowed some respite from this observation of his faith if the care of critically ill patients demand it.
I think that is the difference between a faith and a cult. A faith allows an out for emergencies. Cults will cheerfully let one of their own die for a religous observation that is otherwise strictly ritualistic.
It could be (and has been) argued that a person who insists on a predictably fatal course on the basis of supernatural guidance could be considered incompetent to make rational decisions. My personal feelings on this matter are simply that I am too old and tired to care much how other adults choose to order their lives. If they choose to die for something so seemingly silly as the radical interpretation of a one sentence biblical passage meant for those living 2000 years ago....hey.....anyone for Chinese?.
But, like I say....I have not really had to deal with it up close and personal. I regret to say that I have been known to do wild and crazy things in the heat of battle. If I were to become intimately involved with a case in which, in my best judgement, imminent death was inevitable specifically on the basis of acute hemorrhagic anemia, and if I didn't think there was any realistic alternative than immediate transfusion, and if the chips were down and I was holding the last card, I cannot guarantee that I would follow the JW party line just because it has gained some social acceptance with bleeding heart liberals. Especially in the case of a minor or someone I felt did not fully understand the consequences.
Condemn a soul to everlasting damnation on the basis of personal arrogance? I don't recall a Randomized Controlled Trial for guidance ;-). My official tack on that matter is that such things should be a matter of individual negotiation between a man (or woman) and his/her God. Matters of faith are personal, between individuals and their deity. Matters of temporal survival include my input, and I am loath to lose arguments on my turf. I am willing to give references and testament to deities on the matter if I presume to intercede. But I like to have God work his side of the street and allow me to work mine.
So if Roy-Shapira lands in my ICU with an acute, life threatening pork deficiency and pleads with me to die rather than get a life saving injection of essence-of-pork.........I'll probably think he's a wacko and I'll move to keep him alive to make future deals with God, claiming extenuating circumstances ;-).
Aviel Roy-Shapira:
I have stayed away from this discussion so far, but I believe we are again confusing value decisions and professional decisions. In a free society, nobody has the right to impose his or her values on someone else. If a patient has a right to accept or refuse treatment offers, he may also do so on grounds that appear silly to me.
I would bet that the Romans who prosecuted the early christian martyrs thought they were stupid to accept death, in lieu of bowing to some statue. The torturers of the Holy Inquisition could not see why their victims would rather die painfully than accept mother church. And we Israelies cannot believe that the suicide bombers really believe that they will each get 70 concubines in paradise, as their religious leaders promise them. Many among us are gladly willing to die for a cause. We salute that will when it is for King and Country (our King and Country, of course) Why should we not accept that someone else is willing to be martyred on his belief?
Note please, that I KNOW that JW are reasoning badly. I know that because in the hebrew original, the bible does not say what they think it says. The literal translation into Latin and English simply missed the idiom. Yet, I would not force a transfusion on someone who believes he or she will go to hell if they accept blood transfusion.
So far in our history, this or that religion, has been responsible for more misery and lost lives than anything else we humans were able to invent. The dead JW is just another victim in man's futile chase of immortality, whether here on earth or in some Valhalla (take your pick) Religion, as Marx had said, is indeed opium for the masses (perhaps the only thing he said that stood the test of time) Even so, I will never cease to defend the right of each and every one of us to choose one for his own, to live by, and to die by. (as long, of course, as they let me keep my own secular humanistic views) Is this not a cause worth dying for?
Robert A. Fink:
I have had but one incident involving a Jehovah's Witness and a critical care situation. The patient was a woman with a large subdural hematoma. She was comatose and incompetent. Her husband (along with several elders of the JW church) instructed me to avoid giving blood at any cost (including the death of the patient). Now, it has been ages since I had to transfuse a craniotomy patient, but I didn't want to be in a position where my hands were tied. I told the husband:
I justified my position as follows:
This was satisfactory to the husband (the church elders tried to "talk him out of" it). No blood was necessary and the patient recovered.
Peter Hicks:
From "down under" this has been interesting to follow. In the land where personal rights are taken, we think, to extremes (hand guns are all and Bill Gates won't wear a seltbelt) the patient's can't decide to die because they don't want to be transfused. Can a competent patient refuse chemotherapy for their cancer or an AIDS patient refuse antibiotics for yet another infection without the doctors doing it anyway. We have had several patients refuse blood and die from anaemia following elective surgery or trauma. If we transfused them without consent we would be unlikely to get into trouble legally or ethically but I don't think that is the point.
As the our JW's say; "we dont drink, we dont smoke, we save you guys heaps of money by not getting sick" . Pushing the views on to children is different again and we get legal custody after we transfuse.
Simon Finfer:
No legal opinion required. You have no right to subject a patient to a treatment they do not want whether it be a blood transfusion or a brain transplant. If you can't live with that you shouldn't be a doctor. If your ethics prevent you accepting the patients wishes you should get off the case.
Major Trauma in Two Patients Refusing Blood Transfusion. Simon Finfer, Simon Howell, Jean Miller, Keith Willett, James Wilson MacDonald. BMJ 1994;308:1423-4.
Managing patients who refuse blood transfusions: an ethical dilemma. Authors views. Simon Finfer. BMJ 1994;308:1425-6.
Gordon Doig:
That's a bit strong Simon. You know ethics is culturally based and that standards of care vary from country to country and society to society. Ethics, by nature, is not based on 'facts' or 'laws', but rather principles and ideals, and thus is open to debate and discussion. Especially on such an international list where cultural and geographic distances are covered in microseconds.
In other words, thats a very intersting opinion you put forward, but it is not an accepted fact in many places in the world.
Simon Finfer:
Well, it was meant to be strong! I believe, quite strongly, that a medical degree gives you the priviledge of offering people advice and treatment. It does not give you the right to inflict your ethics/morals on them. Of course we all have different ethics/morals/cultures and we must respect our patients'. If there is conflict between the ethics and morals of doctor and patient the patient's view must prevail. That is part and parcel of the honour, priviledge and responsibility of being a doctor. The ultimate decision whether or not to accept the advice or treatment must rest with the individual patient and we must respect their right to that decision. Personally I have no problem with blood transfusion (although I wouldn't want one until my Hb was 5 or less !) but I respect others right to refuse it.
I had always wondered what I would do if faced with the decision to transfuse some one against their wishes or let them die. In the cases I reported in the BMJ I found out. The two young men involved were able to express their wishes, were sincere in their view, understood the risks and stuck to their guns. One died and his best friend mourned his death but still did not wish a transfusion. Now that is real strength with the blowtorch firmly on the belly. Their families and the church advisors were a delight to deal with and not the aggressive overbearing maniacs we were expecting. I'll do the same next time.
Robert A. Fink:
To carry this further, in the last 15 years or so, California's laws have stated that no one, not even a spouse, can "consent" for another adult (unless the adult is legally incompetent by virtue of a conservatorship); and, in cases of "threat to life or limb", a physician is authorized to treat without any consent.
As to the doctor's conscience, I think that this is important, also. I had one case where the husband (a physician) of a patient who had suffered a cerebral thrombosis (which actually had a good prognosis and which would have left the wife only mildly disabled) instruct me to not administer nutrition or fluids to the patient (she was unconscious but would have awakened, in my opinion). I refused to cooperate and signed off the case. The husband found another physician who would cooperate and it took the poor woman a week to die. She literally died of starvation/dehydration. Not pretty.
Finally, the pork issue. Insulin used to be pork-derived (as we know it is now made from human protein). Orthodox Jews were permitted to take (pork) insulin; I don't know what Islam would say about this. In Judaism, the traditions have usually held that, in order to "preserve life", almost *anything* is permissible. To my recollection, the only thing that a Jew is required to "lay down his life for" is to avoid idolatry or blasphemy.
Wael M. R. Haddara:
This argument was tried in Canada, and it was rejected by the courts (I believe it was the Supreme Court, but I'd have to double check). In this particular case, the husband tacitly consented to the blood transfusion, so there is no problem to start with, but it seems that when it comes to treatment it is the patient's conscience and not the doctor's that counts :-(
Regarding FL's remark that it is unlikely that a patient would have to be given a pork infusion, this is not entirely accurate. There is a multitude of drugs that are pork-derived. For example, every single type of heparin, including low-molecular weight heparins are pork-derived. The gelatin in gelatin capsules is in many cases pork-derived. There are several other examples.
So it is easy to say separate cults and religions on the basis of the extent of perceived disturbance to health provision, but it is not so cut and dried. How far should one go in accomodating the no-pork rule .. Ancrod ?? There is no question that ancrod is associated with greater risks than heparin or LMWH ...
David Crippen:
Simon's stark statements do not seem to take into account the very issue of competency we are discussing. Everyone agrees that children are a separate issue because they cannot make informed decisions. What if adults are making decisions on the basis of faulty reasoning........fruits from the poisoned tree, shall we say. Again, I might proffer the statements I made earlier:
"So, where is the fine line between society allowing competent people to make disastrous decisions on the basis of individual freedom and protecting those who are taken in by charlatans and wackos?"
and
"It could be (and has been) argued that a person who insists on a predictably fatal course on the basis of supernatural guidance could be considered incompetent to make rational decisions."
Let's let Simon defend his statement by examination of a hypothetical case.
A 59 y/o male enters the psych emergency department, brought in by his family after having exhibited gait disturbances at home. He is a frequent visitor the the psychiatric service with a history of depression. His family says has had one suicide attempt in the past but seems to be doing better since attending some kind of "religious services" at a nearby house. He also has a history of chronic atrial fib and his medications include digoxin and coumadin (warfarin). His laboratory numbers are all Harvard as is his Chest X-Ray. His EKG shows stable atrial fib with a well controlled rate. His digoxin level and PTT are both therapeutic.
The Psych ED shifts him over to the medical side because they cannot find any evidence of psychiatric disturbance. He is oriented in all spheres, knows his address, social security number, phone number and area code. He is not in any distress, knows fine details of his environment and family, follows commands accurately. But every time he tries to ambulate he falls down. He also has the barest minimum of weakness in his right leg.
He has a very small abrasion on his forehead just below the hairline. He says he came up too quickly while repairing a pipe under his kitchen sink and bumped his head, following which he had a headache for a while but it got better with some aspirin. His CAT scan shows a vortex subdural hematoma. His PTT is 56. You advise him of these facts and recommend immediate neurosurgical consultation. He refuses and immediately asks the nurse to call his "Life Study Counselor".
He has become a member of a "Life Study Group" that has done wonders for his depression. He feels great. They get together several times a week and think about life in a group fashion. Their group leader directs this study and discussion and frequently reads from a large, leather bound book that serves as a study resource. In big gold letters, it states "The Book of Life" on the cover.
The "Life Counselor" arrives post haste, with several other members of the group, produces the "Book of Life" and points out the following passage: Book 1, Chapter 4, Verse 79:
"For it shall be that the integrity of the body is inviolate and shall remain so without disturbance from the likes of a technology that has set the stage for the doom of society".
The "Life Counselors" interpretation of this passage is simply that the true believer will not submit to any intervention involving entering the body with technologically oriented devices. He then points out another passage, same Chapter, Verse 94:
"For if the true believer's faith shall be of sufficient quality, no infirmity shall claim the body".
The group concludes that his, and all other infirmities, shall be resolvable through faith, and they immediately set out a blanket on the floor of the ED, form a circle, hold hands and begin chanting". After a few minutes, the ED resident does another quick neuro exam on the patient and notes that he can no longer remember his address and social security number and his affect is flattening.
The psych attending, hanging around watching all this, looks with curiosity at the "Life Counselor" and tells you he think's he has seen this guy before. He taps into a nearby computer database and smiles: "Yeah.......Joe Doaks.....he's been here before".
Mr. Doaks has an extensive psychiatric history of bizarre behavior concurrent with a high IQ. He has been admitted for evaluation and carries the diagnosis of "Borderline Personality". He has been in jail several times for mischief related behavior but has never been judged as psychotic. They have not seen him around in a year or so.
The secretary makes a few calls and finds out the Life Study Group is a registered religion and has been granted tax exempt status by the Local and Federal government. The Better Business Bureau has no record of complaints, and the local attorney general's office says they have never had a complaint.
Several minutes later, the patient has a grand mal seizure. The neurosurgeon you called in to see him is pacing back and forth at the bedside cursing. "Look, folks, you are going to have a very dead person here in about two minutes if we don't get the show on the road". The family shrugs......."He has been a member of this group for six months and we have never seen him happier......seems like we ought to respect his wishes. Maybe they have something here with this prayer circle idea". The surgeon and the ED Doc and the family look at you.
How is this religion different than Jehovahs Witnesses or Christian Scientists?
What should you do?
Rolando Berger:
Agree with Simon's view 100%. In my own unit we have strived to made the "rules of the game" very clear:
Robert A. Fink:
At the risk of opening the gunports, I will respond by saying that I would cart him off to the OR (after reversing the anticoagulation) and remove the subdural. I would then notify my malpractice carrier that a suit will most likely be forthcoming (more likely if the patient dies anyway), and would then take my chances with the court system. I would, however, be able to come home after the surgery and get a good night's sleep.
Kelly Randolph:
The discussion regarding Jehovah's Witness, blood transfusions, pork.....etc are fascinating to me for several reasons. First of all, I think that a patients right to refuse is a separate issue from their religious beliefs. I don't think any of us should stand in judgement of anyone solely on their religious beliefs. And I certainly don't think that someone who belongs to a 'fringe' religion is more likely to be incompetent simply because they aren't mainstream.
Many procedures require informed consent. The very process of obtaining informed consent SHOULD produce a patient that is competent to make the decision to accept or reject the proposed procedure. They become informed in the process, and this is the basis of their decision.
A patients religious beliefs are one thing, and their ability to comprehend medical procedures and explanations are another. To override someone's wishes simply because their judegments are guided by a somewhat different 'set of rules' is intolerance. Are we not pressuring them to play by 'our rules', which may be considered more mainstream?
IMHO, this issue has ties back to our US Constitution on which our forefathers founded this country. Religious freedom was an aspect considered in the formation of this country. It is one of the reasons cited for the Pilgrim's long boatride :) We also enjoy a (withering) separation between church & state in the USA. I don't think we really want the gov't to monitor religions and decide who has 'acceptable' beliefs and who does not. This has been done before.
I cared for a JW that needed a transfusion, badly. He and his family refused. The surgeon exploded over this. He wanted a nurse to go to court with him to get a court order for a transfusion. I refused. He found another nurse, went and got a court order. He transfused the patient without delay. The patient died a month later from other complications.
To this day I feel I did the right thing. I respected his right to decide, and I respected his religious beliefs as well.
Simon Finfer:
OK. Never one to refuse a challenge but this is grossly unfair!! In less than forty eight hours I have to debate Don Chalfin and Ernest Benjamin and chair another session in between. I haven't got the slides in the carousel yet! Don't you guys have any work to do!!
Lets stick to our principles. This guy has acute organic brain disease and so is currently incompetent in the legal sense. Therefore we can crack his head unless we have reliable information that when of sound mind he had formed a strong religious view that meant he did not wish us to. Against this are the inconsistencies in your story:
Clearly many would consider his religious advisors to be nutters. Nevertheless, if he did not have organic brain disease and the psychiatrists said he was OK you would have to respect his wishes. The presence of acute organic brain disease may make his family the arbiters and they will go for surgery.
What would my view be? If I could not establish to my satisfaction that his pre-morbid wish when mentally competent was to be left to die I would personally push him round to the OR. Conversely if I could establish the reverse I would restrain the neurosurgeon! This scenario is very different from knowing the patients wishes but deciding that you as a doctor had the right to override them to satisfy your own moral/ethical agenda.
Imagine the converse. The neurosurgeon joins the "Life Study Group" ! He advises all future patients with life treatening ASDH that it is etically wrong to do surgery, but the patient wants surgery. Whose view do we respect? Always the (competent) patient's.
I rest my case.
Errington C. Thompson:
I don't think that it matters if the patient's reasoning is faulty if the patient is competent to make a decision. One of the great misconceptions in the Southern urban populations is if you operate on a person with cancer and the air hits the cancer then the cancer will spread. You can understand the reasoning. The patients see a "healthy" person go into the hospital and a dying patient emerge weeks later. I have explained to many patients that this myth is not true. Some patients believed me and others did not. I can not operate on those patients who are convinced that cancer spreads once the air hits it.
Louis Brusco:
There have been more than a few court cases where the courts have upheld the family's right to make the determination that their incompetent JW relative would not have wanted blood even if it meant their death. You were lucky in this case that the family did not fight it, but they can, they have, and they have won. Most often, a case as you describe happens with a patient who is JW but a family member who is not. They will usually say that they will refuse blood until you bring up the "unto death" part, when they many times will relent.
Dick Burrows:
The issue of transfusion for the Witness is one of eternal damnation - if he is transfused that's where he goes. The volume of blood doesn't matter. The hypocrisy that surrounds the issue doesn't matter. The science surrounding the issue doesn't matter.
It is the individuals belief that matters and this is regarded as sacred. It is his autonomous wish that matters and this has been laid down for many years and Nuremburg emphasised the issue. It is different if his autonomy interfers with another's right - if he insists on an ICU bed to the exclusion of others while he acts out his religion.
We all have to live by the decisions we make and the Jehovah's Witness is no different . He has made a decision which affects his life and he has a right to die by his decision. Whether he is truly autonomous or whether anybody is for that matter is a different issue. You may feel that your conscience and clinical responsibilty is impugned by the Jehovah's Witness but then you should hand over to somebody else. Ethical and moral principles are fine things to live by but when taken to the extreme they are sticks with which to beat each other into submission. They must be tempered with tolerance.
Someone has to give way and compromise otherwise the only way is the way of the dictator. I can't save everybody's life - it is simply not written that way. I have no moral conscience that is better than anyone else's. I do a job - I try to help people - when I feel that they are making the wrong decision I try to explain to them the consequences of their decision and allow me to help them but if they are solid then my job is still to help them and if I cannot do that well then I'll get somebody else who can.
"One cannot cry for the whole world. It is beyond human strength, one must choose." (Jean Anouille)
David Crippen:
You guys seem to be saying that you make absolutely no prospective analysis of the thinking process validity of people standing on the brink of death! I think you are trivializing this issue of competency by treating it in such an inflexible manner. I also don't think any of you guys have ever stared the Grim Reaper in the eye and felt it's hoary breath on your nose. It gives you a much different perspective on death, and what you'll do to stay alive.
Death is a very intimidating phenomenon, and a very final one. It irrevocably changes the lives of all who come in contact with it. This is an otherwise salvageable person, who should go on to get something out of the rest of his life. Everyone reading this knows in their heart of hearts that the patient's reasoning for accepting death so meekly is faulty. If anyone's 19 year old daughter wrote a note announcing they had joined the Life Study Group en-residence and had been selected to help soothe the Life Leader's administrative frustrations on occasion with ten other similar specimens, you know damn well you'd wade in there and drag her out of there by the hair.
Death screws up peoples entire weekends and their families remember it for a long time. If this guy dies, he won't have a chance to think better of his decision making processes on later reflection. Like it or not, YOU are put in a position of DIRECTLY altering history here, and YOU see the situation very clearly. You have chosen a contact sport and this is the contact. If all the cards are on the table and YOU are holding the last one, you have two choices only....you can play'em or you can fold 'em. There aren't any other options.
If you choose to fold 'em, that means you refuse to make any determination at all as to the validity of the patient's thinking process as he accepts certain death. That means if the patient says he refuses to be saved because the voices told him not to; that reasoning is perfectly acceptable to you. ANY extenuating or mitigating factors to this decision process are above your responsibility to intercede. He's a big boy, he doesn't want to live, so what's the problem. (Odor of vinegar) "I was my hands." Similarly, I see no reason why you should make any decision at all concerning any medical care issue. Simply give them what they want. They, are, after all, autonomous aren't they.
If you choose to play 'em, that means that you must make SOME kind of determination as to validity of the patient's thinking process and you must use some analytical criteria to do so. The stakes are high here. That means that you must make a determination that the patient is REALLY authoritative in his thinking process and understands the consequences his actions. But, ALL supernatural orders of authority claiming to intercede in earthly matters rely on unproveable and undemonstrable processes of relaying those commands to individuals. So what are the objective criteria for these determinations?
I ask, what is the practical difference between an alleged psychotic obeying the voices ordering him to kill his mother-in-law by communications through the fillings in his teeth, and interpretation of biblical passages that directly result in death and mayhem? What is the difference in the patient who refuses lifesaving surgery because an interpretational difference of an isolated stanza in a Book of Life you never heard of and the interpretation of a stanza prohibiting the infusion of blood from another volume no one knows the authority of?
The only practical difference is that some of these issues are more socially sanctioned than others, and so they take on a legal mantle of acceptance. But the reality is that none can be proven one way or the other. Therefore, the reality is in the eye of the beholder on a case by case basis. And THIS is the case in question and YOU have the power to DO THE RIGHT THING! If you aren't qualified and invested to determine the right thing, who the hell is? If it is not your responsibility to do the right thing, then whose responsibility is it? How far are you prepared to go to do the right thing thing even if it's unpopular? If you choose to do nothing, what are you prepared to doing any emergency? Check to regulations to see what the current fashion is?
You guys with the sense of "not getting involved" in patently stupid and lethal decisions made by others when the chips are all down and you're holding the last card need to look down the bore of an AK-47 at point blank range in a pouring monsoon on a long range patrol at night once or twice. Gives you perspective on what death means and how it affects people and what you can do about it and what you can't do about it. You are a physician and physicians are supposed to make decisions on analytical criteria that directly affect the death process. You can't stand out of the game and let others make unpopular decisions. You're it. If you didn't want the job, you should have been a radiologist. Moral imperatives are interpretational. Were it not so, there would be only one religion....or no religion.
As a physician holding the last card in a high stakes game, I have an obligation to interpret moral imperative as best I can because it counts. If I choose to abdicate the simple task of recognizing the right thing to do and doing it, I mock moral justice. This guy is on his way to the OR and these lunatics chanting on the blanket are outta here. Let the chips fall where they may.
Errington C. Thompson:
Hold on one minute. You have turned your amp up too high one too many times and jarred some neuro connections. We, physicians, nurses and health care workers, have to practice in the society in which we live. If you are practicing in Africa among the Bushmen, you must alter your practice to their beliefs. In western society we MUST practice within our societies set of rules. Our rule is that religious beliefs will be respected. Period.
Who's to say what the "right thing is"? Are you? Certainly not. Because religion is a belief WE can not say that saving a person's life is the right thing for that patient. As you know, we, the medical profession, have done horrendous acts trying to do the right thing. What is "right" for me or you may not be right for this patient. We need to honor his wishes no matter how crazy they might sound to us.
Harald Mertes:
I totally agree with you in the cases of conscious patients. The situation remains unclear in cases of unconscious patients. It is normal in Germany to give a blood without any knowledge about the religion of the patient. But I you know the unconscious patient and if you know that he is a Jehovah Witness and would refuse any transfusion, you must not transfuse. But the most common case is unclear: The unconscious patientm has a signed document of the Jehovah Wtnesses, that he refuse blood transfusion in emrgencies. Our courts generally discriminate weather the patient has decided freely or he was influenced (e.g. by the community of Jehovah witnesses). How can you select these cases? Case 1 no transfusion alowed, Case 2 transfusion necessary. There are no decisions and every argumentation seems to be possible. Comments?
Rolando Berger:
Herald Mertes makes a good valid point about the actual difficulty of making a decision for an unconscious patient who is (allegedly) a practicing JW, and who needs a blood transfusion. Nobody said it was always easy and clear-cut! That is where rule #2 from my previous posting comes into play: you don't have to follow third-party instructions if, in your best judgment (imperfect as it may be), you do NOT believe that the alleged advanced-instructions truly reflect the patient's free preference. Of course you may be wrong in that judgment (either way), but that's life: you do the best you can with what you have where you are when you have to.
So, in our unit we would talk to the family, friends, church people, or whomever happens to be around, and then decide in good conscience whether we accept the instructions as reflecting the true free will of the patient. In this regard, my dealings with JWs so far have been very gratifying: reasonable, articulate people, far from the stereotypical image of overzealous fanatics foaming at the mouth and preaching eternal damnation to the infidels. Quite to the contrary, they were all uniformly polite, not abusive, not demanding, and definitely non-threatening (the issue of lawyers, suits, etc., was NEVER brought up, not even obliquely, in any of the three cases in which I've been involved so far, including one many years ago in which I did not go along with their wishes). I am sure others in the list may have had a different experience, but that is probably true of any group (including doctors): there is always the potential for running into a jackass among the many.
Kelly Randolph:
Dr. Crippen, what responsibility, if any, do you feel for the JW, living a life full of guilt, because they received a transfusion against their will?
David Crippen:
I have three answers to that:
Errington C. Thompson:
In western society we MUST practice within our societies set of rules. Our rule is that religious beliefs will be respected. Period.
David Crippen:
I think that is a myth. Rules change vaporously according to who is empowered to make and interpret them. Society has had a snootfull of religions and quasi-religions making tons of money, hiding it all from taxation and practicing political coercion and influence peddling. It is no longer a knee-jerk reflex that "religions must be respected simply because that's the way they bill themselves. The potential for abuse exceeds the potential for benefit. A religion that readily allows righteous people to expire on the basis of VERY obscure scriptural interpretation is incongruous with the stated aims of religiosity. I reserve the right to subject them to the sniff test.
Negotiations with death is part of my turf. I have an intimate relationship with death, and in the past, I have sat down to discuss terms on an intimate basis. Death is a tough and savvy negotiator and he gives no quarter. Small errors in bargaining quickly put amateurs out of the game. Like Amarillo Slim*, when you sit down to a game you better damn well know how to play poker or you have no business being there. If they land on my turf, I am obligated to play to win. The right thing is what I say it is in order to gain a bargaining advantage.
* (FYI, the World Champ poker player, never really been beaten).
Dick Burrows:
I can't remember who the judge (American) was but he said that there is a very real difference between a belief and the acting out of that belief. A society may well state and even write into the constitution that individuals have the right to practice their religion. It is a right commonly, and mistakenly, elevated to the absulute but which depends on tolerance to allow it.
A belief is different to a practice - you may believe that Satan is the true god and that's no problem - until you decide to indulge yourself in the practice of pederasty and human sacrifice as an act of worship. You will very quickly find the difference between a belief and the acting out of that belief. The same thing may be said about other religions, cults, whatever to a greater or lesser extent as they proselytize to all and sundry.
Ken Mattox:
I have stayed out of this fray for about as long as I can stand it. The psychodynamics of each of us as shamen, the clergy, and a musican are virtually identical. Religious zealots and religious conservatives differ very little from those of us who are likewise extremely opinionated. In truth, much of the foundation of our bias as physicians has religious underpinnings. We respect varying medical opinion (be it surgical vs internal medicine, emergency medicine vs critical care, pediatrician vs psychiatrist,etc), often with tremendous dicotomized and polarized views. We still treat the patients professionally in a way we would wish to be treated should our roles be reversed, as they will some day.
At that time, we each will want our physician to respect our opinions relating to pain control, leg stockings, antibiotics, and views regarding futility care. We now in turn must respect the "religious" views of our patients who have reached majority. We have no right to impose our particular religious faith on a patient, nor do we have the right not to respect their views, as long as they are an adult. If minor children are involved the courts have clear definitions as to who and when a third and even a fourth party can address the interest of the child.
David Crippen:
This is hairy ape talk for "We are the world....We are the Children......" in the key of A minor featuring Michael Jackson on the high notes and Cyndi Lauper rattling beads. I don't give a diddly what the citizens of the world do in their spare time. When they endeavor to kill people on my turf under the guise of religous benevolence, I have to look at that askance. Let `em kill people on Mattox's turf if he's willing to look the other way.
Dick Burrows:
I don't dispute Ken Mattox's thoughts at all. the only time I feel it necessary to intercede and go contrary to the individual's right to practise his religious belief is when he is acting contrary to the interests of another person (not mine) If the JW insists on a bed for several weeksin ICU on ventilators inotropes and the like while I have to turn away patients with reasonable chances of survival then I think he is interfering with other's rights to survive. We all have to live by the decisions we make and the Jehovah's Witness is no different simply because he has decided to forgo blood on religious grounds.
I see no reason to load my conscience or religious belief onto the patient at all. I simply do a job and try to bring a reasonably equitable service to all my patients subject to the excigencies of the service.
The problem lies with the Jehovah's Witnesses themselves. They have a responsibility to realise that their religion has led them to a situation where, one day, the chickens may well come home to roost and at that time, as I see it, my responsibility is simply to determine whether or not they are sincere in their belief and then try to do my best by them without transfusion but at the same time warning them of the issues wherein others, not involved in their dogma, might also have reasonable expectations of treatment. It's their choice.
As regards children there is no doubt that there is one bit of indisputable logic and that is that an alive child has more chance of growing up normal than a dead child. However I have known of Jehovah's Witness parents to disown and cast out the child - why an innocent child should suffer in the eyes of God because of the sin of another is quite beyond me but I cn't force them to love their child - so the child becomes a ward of the state. Interestingly the issue is not cut and dried here. We had a minor some years ago who was injured and had a haemoglobin of 5 - he was 14 years of age - we went to court to get a court order and were refused on he grounds that the child had issued the refusal and also understood the issues which, in fairness, he seemed to understand. In fact he survived.
It boils down to the argument of the judge who said that "Everybody has the right to go to hell in what so ever way he chooses".
M. Macvey:
Why is it, if the patient agrees with you and consents to the treatment, he is obviously competent to make *that* decision, but incompetent if he disagrees with you? Sound like a catch -22 situation to me.
David Crippen:
Because the stakes for each decision are different.
I currently have a JW in the ICU that refuses cardiac surgery because of the blood issue. He plans to go home and die, I guess. I have not interfered in this decision at all, not do I care much about it because he has had plenty of time to think it over, his decision has had time to mature and he has plenty of time to change his mind when the discomfort starts. However, the patient I have described in the case is going to die before any maturing of his decision making process. If he agrees with me, he gets a longer cooling off period between the onset of the problem and death. He gets a better option to think better ofhis decision and recant (repent?). If he dsagrees with me, he dies in several minutes, seizing and never has the option to re-think this disastrous decision that he has made in only a very short period of time.
Fernando & Margarida:
I tend to think that someone who chooses to die because of what is allegedly written on the bible - or any other religious book - is probably nuts. But, many thousands of man and women have done so through the centuries, if you think about it, and not only by refusing transfusions. Who am I, or any of us doctors, to be the ones to know what 'the right thing' is? In my years as a doctor I've come to the conclusion that one of the reasons why people choose to be doctors is the power involved in the exercise of the profession; and intensive care is certainly one of the fields in medicine where one can really enjoy this feeling. And we're talking about the power of powers here: the one who separates life from death. Aren't we?
John T Herbert:
If the patient were truly a Jehovah's witness, with appropriate notice and warnings on the chart, your carrier in NY State might inform you that you are not covered since this is now assault, a criminal act. I wonder if you would still get a good nights sleep!
Robert Fink:
As I also posted, here in California, the law states clearly that no person (other than the parent of a minor or the holder of a legal Conservatorship) can give consent for another. In cases of "threat to life or limb", a physician may proceed with treatment in the absence of consent. Thus, one's liability insurance would not consider this "assault".
David Crippen:
If they were a card-carrying JW, and there was proper prior notice, and if there were warnings in the chart, and if this was a well thought out plan with family support and the like, I would not intervene.
However, if, as I have described in my case, there was no prior notice of religious concerns, I didn't know the patient, the validity of the religious prohibitions was shaky and I didn't feel there was enough time to consider options to inevitable quick death, I think this is an extenuating circumstance I would be willing to explain to a jury and an insurance carrier. Assault implies malicious intent, and I don't think it would stick in this case. Like the CCM-L mouthpiece says, it's harder to collect for pain and suffering of a live patient than damages for wrongful death.
Steven M. Schwartz:
At what point does this become battery? I was always taught that a competent adult patient has the right to refuse any treatment, from an antibiotic for pneumonia to a blood transfusion for critical anemia. We have taken the position that we will honor the request of a JW to refuse blood in open heart surgery. One patient has died due to anemia, many others have survived. Perhaps a legal opinion for one of our legal-lurkers?
Angela Foehl, JD:
Sometimes the choice of how to proceed in cases where there is a question of whether 1) there is a directed refusal of treatment by the patient and 2) the directed refusal of treatment is an informed decision by a mentally competent patient comes down to which decision is most likely to incur liability for the physician and hospital.
If a physician withholds potentially lifesaving treatment on the basis that a person would have refused treatment (if conscious) or automatically can be imputed to have refused treatment due to their purported religious affiliations, then the patient dies, a lawsuit by survivors is always a strong possibility.
One cannot automatically assume that being in a group like JWs or Christian Scientists will make a patient refuse treatment when their life is at stake. The issues of mental competence and intent to refuse treatment are always intertwined. Is it even possible that a person has true mental competency to make a life & death decision about treatment under the severe duress of a life-threatening episode? Contract provisions have been struck void for lack of competence for less aggregious circumstances.
If there is any doubt in the physician's mind whatsoever, providing the care is a lot less risky than not doing so. If a patient survives, the worst they can do is to sue for some type of emotional damages, I suppose. How many judges or juries are going to say, well, what a shame you are now alive--you certainly deserve thousands in damages for still being alive, even though your beliefs were compromised.
On the other hand, imagine having to explain to the jury why the patient is dead--the survivors who sue for thousands for wrongful death can be the very people who encouraged the doctor to withhold treatment on the basis of religious (or other) belief.
While I think physicians do owe it to patients to follow advance directives, to the extent they were made by competent persons & are drafted well enough to be useful in decisions, I can well understand and appreciate Robert Fink's approach to excercising treatment, saving the patient and letting the chips fall--how many people truly will sue a doctor for saving their life?
Dick Burrows:
The schizophrenia of the American system of law as it is applied never ceases to amaze me. On the one hand you want the individual to be given the absolute right to determine his own destiny in respect of an autonomous right to refuse treatment and beware the doctor who is inconsiderate enough to trample on the patient's right to go to hell in the way he chooses. But then on the other hand - ZZZap! you screw the doctor for being so inconsiderate as to allow him to die becuase even if he declared such he might not have meant it.
You want a system wherin the individual is both responsible and not responsible at one and the same time. Then you rend your garments because you want it legislated to infinity to account for everybody's actions in every concievable situation. Egad!
Everybody must expect that sometime he will have to live by the decisions that he makes. If somebody refuses treatment then it is his indaba. If he robs the bank he should have thought of the consequences first. He can change his mind and that is fine too because it is an uncertain world and people change but the issue is one of caveat emptor - buyer beware. You cannot make a decision that will profoundly affect your life and not expect severe repercussions sometime - that is as clear in any walk of life and it is so unto death.
If you win the sweepstakes and do your boss in the eye you shouldn't expect too much sympathy when you are on the bones of your arse because you have lost it all on the nose of a nag with three legs and a limp! It is fine to ask the individual if he is sincere in his belief and if he says no then treat him. But if he has declared his belief and lands up unconscious and his belief is known then he must expect the consequences. That's life.
To do otherwise is to suppose that everybody will invariably change his mind when the chip are down and that is also an assumption which may well be far from correct. What's it they say "live by the sword..........."
Kelly Randolph:
Now FL, this is dangerous ground. As to whether or not their beliefs are a scam or sociopathic delusions are nothing more than speculation on your part. In fact your opinions are probably as unscientifically based and distasteful to them as their religious beliefs are to you.
David Crippen:
I agree totally with your statement. This is, indeed, dangerous ground, and I am not taking it lightly. This is why I have taken the time and energy to flesh out a seemingly alternative opinion from the rest of the group. In order to get perspective on any dificult issue, you gotta hear all the angles. Only then can you make an educated decision on what your actions will be when this show comes to your town.
I am being obtuse and difficult here because the issue of bad things happening to good people is not cut and dried. Societies' viewpoint on how much autonomy "religions" should be allowed to exert over otherwise righteous people is simply fashion and superstition, not well thought out. If I can get you to at least think about the rationale for the alternatives in this issue, it will be a good thing.
Thomas J. McGuire:
By: Samuel Maull 06/06/97
NEW YORK (AP) -- An appeals court has set aside a jury's $9.6 million award to a Jehovah's Witness who rejected surgery after an auto accident because her religion forbids blood transfusions. The State Supreme Court's Appellate Division, voted Thursday in an apparently unprecedented ruling on the consequences of religious belief, to overturn the 1995 award to Gwendolyn Robbins. The court ordered a new trial on how much money the 57-year-old woman should get.
No one may interfere with another's religious belief, the court said, "but the question is whether the consequences of that belief must be fully paid for here on earth by someone other than the injured believer." The appeals court said it threw out the award because the trial judge, Justice Edward Greenfield, failed to tell the jury to decide whether Robbins' refusal to accept the transfusions was a reasonably held religious belief.
Robbins, of Manhattan, was badly injured in 1991 when the leased car in which she and other family members were returning to New York City from Plattsburgh veered off the highway and crashed. Robbins sued the car leasing company and the insurance carrier because she was travelling in their car.
The court said circumstantial evidence showed that her 70-year-old father, the driver, fell asleep while going about 65 mph. Both Robbins' parents died in the accident and her niece's husband was left paraplegic. Robbins suffered a damaged right hip and left knee. Her own medical expert agreed with other physicians that appropriate surgery and other treatment would have enhanced her chances for a good recovery.
But Robbins refused surgery because it would have required blood transfusions. The court said her religion does not exempt her from the legal obligation of any injured person to seek treatment before seeking damages. The damages are to be paid by the car leasing company and its insurance carrier, the appeal majority's 15-page decision said.
Robbins' lawyer, Richard Frank, blasted the decision and said he plans to appeal. "She is entitled to the full measure of her damages," he said. Frank said the ruling calls for unprecedented interference with one's religious beliefs. The First Amendment of the U.S. Constitution bars the state from requiring one to violate one's religious principles, he said.
Angela Foehl, JD:
That trial court decision is a really interesting take on expression of religious freedom,as it conflicts with the tort-law principle of "mitigation of damages" that requires a person suing in tort "to exercise reasonable diligence and ordinary care to avoid aggravating the injury or increasing the damages."
Interestingly, the appellate court did not really have to deal with balancing these potentially at-odds principles, since it reversed the trial court due to the error in failing to deal properly with the issue of whether refusal of medical treatment was a reasonably held religious belief--an essential finding of fact for the jury. However, the appellate court did provide dicta about the balancing of interests problem, which gave a strong message about its position on this issue.
Personally, I hold the appellate court's view, which is consistent with our legal principles as a whole. I don't see why another person should have to pay for someone's increased disability over and above what they would have had if they had received medical treatment for injuries. This goes to the "reasonable person" concept.
Given Darwinian principles and general social consensus, a reasonable person seeks medical care to mitigate the results of their injuries. You could say that a person who does not do so for religious or other reasons (or purportedly religious reasons) either is unreasonable, as the term is generally meant, or that the person is reasonable.
If the person is "unreasonable" in their actions, they do not deserve damages under tort law, which in itself does not look to constitutionally-derived rights for a determination. If the person is "reasonable," then this concept has to be re-defined. Maybe the court did not even go into this vexing problem, but just dealt with religious freedom, period.
The balance of individual rights of one vs. another is always tenuous and difficult to define, hence the Scales of Justice." My interpretation of the essence of our system is that a person should, unquestionably, have the right to excercise their version of religion, as per the Constitution. However, that same person should not expect another person or society at large to pay them damages arising from their exercise of that religion, per the balancing of interests under all forms of law.
Religion involves personal choices (though some would argue otherwise who believe in divine motivations, I suppose) and to that extent, incurs personal gains or losses that come with that religion. I agree with the appellate court & believe this trial court's decision was wrong in its essence, if reported accurately. It could have resulted in a precedent that makes everyone else responsible for paying the ante for religious decisions, as the appellate court noted.
Given the rather broad definition of religion in our country, I fear for the upcoming cases that make people pay out for all sorts of "religious" beliefs. How about having to pay for death of a motorcyclist with the crushed skull, whose "religious" beliefs included not wearing a helmet so as to be one with the wind? How about paying full disability to someone whose "religion" prohibits them from working a paying job if they are injured?
Attorneys will, undoubtedly, use this argument in various cases. As it is nearly impossible to define what should be considered a "legitimate" religious belief, we all may be in trouble with this one.