EDITORIALS
Managing Jehovah's Witnesses: Medical, Legal, and Ethical Challenges In 1914, the underlying premise of informed consent was established w h e n N e w York S t a t e S u p r e m e Court Justice Cardozo ruled that "every h u m a n being of adult years and sound mind has the right to determine w h a t shall be done to his own body . . . . -1 Since then, physicians, patients, and legal authorities have struggled with applying a complex doctrine to specific cases and situations. When patients choose to reject recommended diagnostic procedures, necessary treatment, or hosp i t a l i z a t i o n , t h e y create specific medical, legal, and e t h i c a l challenges. For emergency physicians, encountering these problems is not an abstract philosophical consideration, but is an integral aspect of daily practice. 2 When m e m b e r s of the Jehovah's Witness religion require but refuse blood transfusion, they generate unique legal problems with informed consent (ie, informed refusal), create specific medical challenges, and require emergency physicians to make difficult ethical decisions. Understanding the religious rights and beliefs of Witnesses, having a sound knowledge of the ethical and legal ramifications of their care, and being prepared for their opposition to transfusion are essential for an effective response. We have emphasized the importance of preparation in responding to Jehovah's Witnesses in the emergency department and have developed a protocol for their management. 3 We appreciate Mr Rosam's perspective, because, in general, his comments enhance our understanding about Jehovah's Witnesses and improve our ability to provide them w i t h appropriate e m e r g e n c y care. However, Mr Rosam raises a number of important issues that merit further discussion. The administration of blood transfusion has not b e c o m e " s t a n d a r d p r a c t i c e . " Even though the blood supply is safer and in better meta20:10 Octobe r 1991
bolic condition than ever before, e m e r g e n c y physicians are acutely aware of the possibility of infectious disease transmission, as well as the potential for blood incompatibility, allergic reactions, and administration errors. 4-6 In clinical emergency medicine, the decision to transfuse requires clearly defined indications, m u s t be based on objective hemodynamic data and clinical judgment, and mandates thoughtful consideration of the risk/benefit ratio.7, 8 Blood transfusion is not usually required in the initial management of the majority of cases of acute blood loss. Yet, on occasion, hemorrhage can be massive, exsanguination may be imminent, and blood replacement may be truly life-saving. Most experienced e m e r g e n c y physicians have treated p a t i e n t s w i t h u n r e l e n t i n g blood loss who failed to respond to resuscitation w i t h other measures and required blood component therapy for stabilization and, ultimately, for survival. Certainly, some patients have died of exsanguination despite blood transfusion, whereas others, in retrospect, may have survived without receiving blood. However, when confronted by the patient with hemorrhagic shock and given the impossible task of predicting whether urgent blood administration will affect the o u t c o m e for that patient, the emergency physician's response must be directed toward the preservation of life and, when indicated, instituting life-sustaining measures. Decision making in other areas of medicine usually is not subject to the time constraints inherent in the emergency environment. The urgent nature of emergency decisions - particularly those involving resuscitation - usually precludes contacting agencies such as the Jehovah's Witness World Headquarters or Hospital Liaison C o m m i t t e e in order to receive direction on how to best proceed with "alternative therapy." If deemed appropriate, alternative measures may be considered for incorAnnals of Emergency Medicine
poration into the management protocol before the Witness presents to the ED and only with necessary legal safeguards. Court decisions involving Jehovah's Witnesses reflect the complexity of the transfusion issue. Previous court rulings have examined blood refusal on religious grounds by comp e t e n t p a t i e n t s , i n c o m p e t e n t patients, and parents of m i n o r children. 9-14 To our knowledge, the Malette decision ]s represents the first ruling that supports the Jehovah's Witness advanced directive (ie, blood refusal document) by awarding damages for the administration of blood products. In fact, the recent Malette ruling conflicts with a 1985 Pennsylvania Superior Court decision in which the value of a medical alert card prohibiting transfusion was discountedJ 6 In that case, the court ordered t r a n s f u s i o n for a c o m a t o s e Jehovah's Witness who required surgery for a subdural hematoma despite previous execution of blood refusal forms. The court ruled that the medical alert card provided some evidence of what the patient would do if competent, but alone could not be substituted for nor represent the patient's judgment or decision making. Nevertheless, the Malette decision appears to strengthen the value of medical alert cards and other adv a n c e d d i r e c t i v e s such as living wills, do-not-resuscitate orders, and durable power of attorney as valid refusals of necessary therapy and is consistent with current medical and legal trends that are shifting toward increased recognition of the patient's previously expressed wishes. Moreover, the possible ramifications of the Malette case for emergency physicians are limitless. What if the Jehovah's Witness with the properly executed refusal document changes his mind during the emergency situation? What if the patient is suicidal with life-threatening hemorrhagic shock from a self-inflicted cardiac stab wound, but has a document pro1148/139
EDITORIALS
hibiting blood administration? What if family members or other surrogate decision-makers express wishes that conflict with the advanced directive? W h a t a b o u t the u n a c c o m p a n i e d minor who requires emergency transfusion, but has a blood refusal form executed and signed by his parents? Clearly there are no easy answers, but there are potential legal conseq u e n c e s of e i t h e r a d m i n i s t e r i n g blood to or withholding blood from a Jehovah's Witness who requires but refuses transfusion. As in the Malette case, the emergency physician who knowingly administers blood to an unconsenting adult Witness may be liable for civil damages. Findley and Redstone 17 reported that the majority of Jehovah's Witnesses they surveyed would consider suing a physician who had forced a blood transfusion on them. Physicians should be aware of the potential for such litigation because physical h a r m is not a prerequisite for a lawsuit based on unauthorized treatment. State statutes addressing this area are lacking, except for Maryland, where, by state law, physicians cannot provide medical treatment to a patient with known religious beliefs t h a t p r o h i b i t s u c h c a r e . 18
On the other hand, despite the assurance that Jehovah's Witnesses "will readily accept responsibility should any problems arise from our decision to refuse blood," it would be imprudent for emergency physicians to assume that legal action resulting from a decision to withhold transfusion would be a "practical impossibility." The likelihood of litigation for w i t h h o l d i n g blood c o m p o n e n t therapy certainly is more than a remote chance, especially if a potentially preventable death is attributable to failure to administer necessary blood c o m p o n e n t therapy. In fact, a wrongful death suit recently was brought against a physician by
140/1149
the family of a Jehovah's Witness who sustained postoperative gastric bleeding and who died after he refused blood transfusion for religious reasons.19 Furthermore, though we are promised that physicians who comply with Witnesses' wishes will find them to be "respectful, cooperative, and understanding," we hesitate to rely on such a stereotype for any group with four to six million members. For these reasons, we advocate that the emergency physician take necessary measures to protect against potential legal actions when Witnesses oppose recommended blood therapy. Contact with hospital legal counsel is essential to ensure t a k i n g the proper steps to comply with or overrule the refusal of transfusion, to obtain informed consent documentation, to clarify liability issues for the physician and hospital, and to facilitate efforts should it become necessary to contact the court for judicial resolution of a transfusion issue, an adjudication of competency, or the appointment of a temporary guardian. In addition, emergency physicians should become knowledgeable of s t a t e l e g i s l a t i o n c o n c e r n i n g Jehovah's Witnesses and advanced directives. Finally, like Jehovah's Witnesses, emergency physicians do not desire confrontation. Rather, emergency physicians strive to make a concerted effort to be reasonable and forthright with their patients, attempt to avoid the manifestations of " a r r o g a n c e and an u n c o o p e r a t i v e spirit," and in general, disdain the use of force, except when absolutely n e c e s s a r y . In d e a l i n g w i t h the Jehovah's Witness who requires but refuses transfusion, emergency physicians may struggle between their c o m m i t m e n t to preserve life and their ethical responsibility to respect the patient's right to refuse treatment, but they should never compro-
Annals of Emergency Medicine
mise their objective clinical judgm e n t s and r e c o m m e n d a t i o n s conc e r n i n g the n e e d for n e c e s s a r y therapy.
Phil B Fontanarosa, MD, FACEP Gary T Giorgio, MD Department of Emergency Medicine Northeastern Ohio Universities College of Medicine Akron City Hospital Akron, Ohio
1. Schloendorf v Society of N e w York Hospitals. 211 NY, 125, p 127;105 NE 92 (1914).
2. Adams J, Wolfson AB: Ethical issues in geriatric emergency medicine. Emerg M e d Clin North A m 1990;8:183-192. 3. Pontanarosa PB, Giorgio GT: The role of the emer = gency physician in the management of Jehovah's Wit nesses. Ann Emerg Med 1989;18:1089-i095. 4. Walker R: Special report: Transfusion risks. A m J Clin Pathoi 1987;88:374-378. 5. Myhre BA: To treat the patient or to treat the surgeon (editorial). l A M A 1991;265:97-98. 6. Myhre BA: Fatalities from blood transfusion. JAMA 1980;224:1333-1335. 7. Heyman MR: Blood component therapy, in Cal laham ML (edl: Current Therapy in Emergency Medi cine. Toronto, BC Decker, 1987, p 702 708. 8. Kruskall MS, Mintz PD, Bergin JJ, et al: Transfusion therapy in emergency medicine. A n n Emerg Med 1988;17:327-335. 9. In re Charles P Osborne. DC, 294 A 2d 372, 1972. 10. In re Melideo. 88 Misc 2d 974, 390 NYS 2d 523 (19761.
11. Raleigh Fitkin-Patd Morgan Memorial Hospital etc v Anderson. 42 NJ 421, 201 A 2d 527, 1964. 12. Powell v Columbia Presbyterian Medical Center. 49 Misc 2d 215,216,267 NYS 2d 450,452 {Sup Ct NY County, 1965). 13. Hamilton v MeAuliffe. 277 Md 336, 353 A 2d 634 (1976). 14. John F Kennedy Memorial Hospital v Heston. 58 NJ 576,279 A 2d 647, 1971. 15. Maiette v Shulman. Supreme Court of Ontario, Court of Appeals, No 29/88, Oct 12, 1989. 16. In re Estate of Darrell Dorone. Superior Court of Pennsylvania No. 3200, December, i985. 17. Findley and Redstone: Blood transfusion in adult Jehovah's Witnesses. A r c h Intern M e d 1982;142: 606-607. 18. Rozovosky JD: Consent to Treatment: A Practical Guide. Boston, Little, Brown & Co, 1984, p 236-437. 19. Corlett v Caserta 562 NE 2d 257, Ill App 1 Dist 1990.
20:10 October 1991
Managing Jehovah's Witnesses: Medical, Legal, and Ethical Challenges In 1914, the underlying premise of informed consent was established w h e n N e w York S t a t e S u p r e m e Court Justice Cardozo ruled that "every h u m a n being of adult years and sound mind has the right to determine w h a t shall be done to his own body . . . . -1 Since then, physicians, patients, and legal authorities have struggled with applying a complex doctrine to specific cases and situations. When patients choose to reject recommended diagnostic procedures, necessary treatment, or hosp i t a l i z a t i o n , t h e y create specific medical, legal, and e t h i c a l challenges. For emergency physicians, encountering these problems is not an abstract philosophical consideration, but is an integral aspect of daily practice. 2 When m e m b e r s of the Jehovah's Witness religion require but refuse blood transfusion, they generate unique legal problems with informed consent (ie, informed refusal), create specific medical challenges, and require emergency physicians to make difficult ethical decisions. Understanding the religious rights and beliefs of Witnesses, having a sound knowledge of the ethical and legal ramifications of their care, and being prepared for their opposition to transfusion are essential for an effective response. We have emphasized the importance of preparation in responding to Jehovah's Witnesses in the emergency department and have developed a protocol for their management. 3 We appreciate Mr Rosam's perspective, because, in general, his comments enhance our understanding about Jehovah's Witnesses and improve our ability to provide them w i t h appropriate e m e r g e n c y care. However, Mr Rosam raises a number of important issues that merit further discussion. The administration of blood transfusion has not b e c o m e " s t a n d a r d p r a c t i c e . " Even though the blood supply is safer and in better meta20:10 Octobe r 1991
bolic condition than ever before, e m e r g e n c y physicians are acutely aware of the possibility of infectious disease transmission, as well as the potential for blood incompatibility, allergic reactions, and administration errors. 4-6 In clinical emergency medicine, the decision to transfuse requires clearly defined indications, m u s t be based on objective hemodynamic data and clinical judgment, and mandates thoughtful consideration of the risk/benefit ratio.7, 8 Blood transfusion is not usually required in the initial management of the majority of cases of acute blood loss. Yet, on occasion, hemorrhage can be massive, exsanguination may be imminent, and blood replacement may be truly life-saving. Most experienced e m e r g e n c y physicians have treated p a t i e n t s w i t h u n r e l e n t i n g blood loss who failed to respond to resuscitation w i t h other measures and required blood component therapy for stabilization and, ultimately, for survival. Certainly, some patients have died of exsanguination despite blood transfusion, whereas others, in retrospect, may have survived without receiving blood. However, when confronted by the patient with hemorrhagic shock and given the impossible task of predicting whether urgent blood administration will affect the o u t c o m e for that patient, the emergency physician's response must be directed toward the preservation of life and, when indicated, instituting life-sustaining measures. Decision making in other areas of medicine usually is not subject to the time constraints inherent in the emergency environment. The urgent nature of emergency decisions - particularly those involving resuscitation - usually precludes contacting agencies such as the Jehovah's Witness World Headquarters or Hospital Liaison C o m m i t t e e in order to receive direction on how to best proceed with "alternative therapy." If deemed appropriate, alternative measures may be considered for incorAnnals of Emergency Medicine
poration into the management protocol before the Witness presents to the ED and only with necessary legal safeguards. Court decisions involving Jehovah's Witnesses reflect the complexity of the transfusion issue. Previous court rulings have examined blood refusal on religious grounds by comp e t e n t p a t i e n t s , i n c o m p e t e n t patients, and parents of m i n o r children. 9-14 To our knowledge, the Malette decision ]s represents the first ruling that supports the Jehovah's Witness advanced directive (ie, blood refusal document) by awarding damages for the administration of blood products. In fact, the recent Malette ruling conflicts with a 1985 Pennsylvania Superior Court decision in which the value of a medical alert card prohibiting transfusion was discountedJ 6 In that case, the court ordered t r a n s f u s i o n for a c o m a t o s e Jehovah's Witness who required surgery for a subdural hematoma despite previous execution of blood refusal forms. The court ruled that the medical alert card provided some evidence of what the patient would do if competent, but alone could not be substituted for nor represent the patient's judgment or decision making. Nevertheless, the Malette decision appears to strengthen the value of medical alert cards and other adv a n c e d d i r e c t i v e s such as living wills, do-not-resuscitate orders, and durable power of attorney as valid refusals of necessary therapy and is consistent with current medical and legal trends that are shifting toward increased recognition of the patient's previously expressed wishes. Moreover, the possible ramifications of the Malette case for emergency physicians are limitless. What if the Jehovah's Witness with the properly executed refusal document changes his mind during the emergency situation? What if the patient is suicidal with life-threatening hemorrhagic shock from a self-inflicted cardiac stab wound, but has a document pro1148/139
EDITORIALS
hibiting blood administration? What if family members or other surrogate decision-makers express wishes that conflict with the advanced directive? W h a t a b o u t the u n a c c o m p a n i e d minor who requires emergency transfusion, but has a blood refusal form executed and signed by his parents? Clearly there are no easy answers, but there are potential legal conseq u e n c e s of e i t h e r a d m i n i s t e r i n g blood to or withholding blood from a Jehovah's Witness who requires but refuses transfusion. As in the Malette case, the emergency physician who knowingly administers blood to an unconsenting adult Witness may be liable for civil damages. Findley and Redstone 17 reported that the majority of Jehovah's Witnesses they surveyed would consider suing a physician who had forced a blood transfusion on them. Physicians should be aware of the potential for such litigation because physical h a r m is not a prerequisite for a lawsuit based on unauthorized treatment. State statutes addressing this area are lacking, except for Maryland, where, by state law, physicians cannot provide medical treatment to a patient with known religious beliefs t h a t p r o h i b i t s u c h c a r e . 18
On the other hand, despite the assurance that Jehovah's Witnesses "will readily accept responsibility should any problems arise from our decision to refuse blood," it would be imprudent for emergency physicians to assume that legal action resulting from a decision to withhold transfusion would be a "practical impossibility." The likelihood of litigation for w i t h h o l d i n g blood c o m p o n e n t therapy certainly is more than a remote chance, especially if a potentially preventable death is attributable to failure to administer necessary blood c o m p o n e n t therapy. In fact, a wrongful death suit recently was brought against a physician by
140/1149
the family of a Jehovah's Witness who sustained postoperative gastric bleeding and who died after he refused blood transfusion for religious reasons.19 Furthermore, though we are promised that physicians who comply with Witnesses' wishes will find them to be "respectful, cooperative, and understanding," we hesitate to rely on such a stereotype for any group with four to six million members. For these reasons, we advocate that the emergency physician take necessary measures to protect against potential legal actions when Witnesses oppose recommended blood therapy. Contact with hospital legal counsel is essential to ensure t a k i n g the proper steps to comply with or overrule the refusal of transfusion, to obtain informed consent documentation, to clarify liability issues for the physician and hospital, and to facilitate efforts should it become necessary to contact the court for judicial resolution of a transfusion issue, an adjudication of competency, or the appointment of a temporary guardian. In addition, emergency physicians should become knowledgeable of s t a t e l e g i s l a t i o n c o n c e r n i n g Jehovah's Witnesses and advanced directives. Finally, like Jehovah's Witnesses, emergency physicians do not desire confrontation. Rather, emergency physicians strive to make a concerted effort to be reasonable and forthright with their patients, attempt to avoid the manifestations of " a r r o g a n c e and an u n c o o p e r a t i v e spirit," and in general, disdain the use of force, except when absolutely n e c e s s a r y . In d e a l i n g w i t h the Jehovah's Witness who requires but refuses transfusion, emergency physicians may struggle between their c o m m i t m e n t to preserve life and their ethical responsibility to respect the patient's right to refuse treatment, but they should never compro-
Annals of Emergency Medicine
mise their objective clinical judgm e n t s and r e c o m m e n d a t i o n s conc e r n i n g the n e e d for n e c e s s a r y therapy.
Phil B Fontanarosa, MD, FACEP Gary T Giorgio, MD Department of Emergency Medicine Northeastern Ohio Universities College of Medicine Akron City Hospital Akron, Ohio
1. Schloendorf v Society of N e w York Hospitals. 211 NY, 125, p 127;105 NE 92 (1914).
2. Adams J, Wolfson AB: Ethical issues in geriatric emergency medicine. Emerg M e d Clin North A m 1990;8:183-192. 3. Pontanarosa PB, Giorgio GT: The role of the emer = gency physician in the management of Jehovah's Wit nesses. Ann Emerg Med 1989;18:1089-i095. 4. Walker R: Special report: Transfusion risks. A m J Clin Pathoi 1987;88:374-378. 5. Myhre BA: To treat the patient or to treat the surgeon (editorial). l A M A 1991;265:97-98. 6. Myhre BA: Fatalities from blood transfusion. JAMA 1980;224:1333-1335. 7. Heyman MR: Blood component therapy, in Cal laham ML (edl: Current Therapy in Emergency Medi cine. Toronto, BC Decker, 1987, p 702 708. 8. Kruskall MS, Mintz PD, Bergin JJ, et al: Transfusion therapy in emergency medicine. A n n Emerg Med 1988;17:327-335. 9. In re Charles P Osborne. DC, 294 A 2d 372, 1972. 10. In re Melideo. 88 Misc 2d 974, 390 NYS 2d 523 (19761.
11. Raleigh Fitkin-Patd Morgan Memorial Hospital etc v Anderson. 42 NJ 421, 201 A 2d 527, 1964. 12. Powell v Columbia Presbyterian Medical Center. 49 Misc 2d 215,216,267 NYS 2d 450,452 {Sup Ct NY County, 1965). 13. Hamilton v MeAuliffe. 277 Md 336, 353 A 2d 634 (1976). 14. John F Kennedy Memorial Hospital v Heston. 58 NJ 576,279 A 2d 647, 1971. 15. Maiette v Shulman. Supreme Court of Ontario, Court of Appeals, No 29/88, Oct 12, 1989. 16. In re Estate of Darrell Dorone. Superior Court of Pennsylvania No. 3200, December, i985. 17. Findley and Redstone: Blood transfusion in adult Jehovah's Witnesses. A r c h Intern M e d 1982;142: 606-607. 18. Rozovosky JD: Consent to Treatment: A Practical Guide. Boston, Little, Brown & Co, 1984, p 236-437. 19. Corlett v Caserta 562 NE 2d 257, Ill App 1 Dist 1990.
20:10 October 1991
