N 512 Module 3 Assignment Powerpoint Presentation Case Scenario 2 A Jehovah’s Witness Patient On Page 77
N 512 Module 3 Assignment Powerpoint Presentation Case Scenario 2 A Jehovah’s Witness Patient On Page 77
The beliefs of Jehovah’s Witnesses are governed
by their interpretation of scriptural laws and principles.
In 1945, the Watchtower Society, the governing council
of the Jehovah’s Witnesses, prohibited the practice of
blood transfusions, specifically referencing 3 biblical
passages: Genesis 9:3-4, Leviticus 17:10-16, and Acts
15:28-29. These passages detail the sacredness of
blood and the prohibition of blood consumption, which
the Jehovah’s Witnesses interpret as a ban to
intravenous and oral routes. This blood ban includes
allogenic whole blood, red blood cell concentrates,
white blood cells, plasma, and platelets, as well as any
autologous blood that has been separated from the
patient’s body. Of note, many Jehovah’s Witnesses will
accept autologous transfusions if the tubing stays
connected to them, as in the case of cardiopulmonary
bypass or hemodialysis.3,4
However, changes in the blood ban guidelines are
outlined in an article entitled ‘‘Be Guided by the Living
God’’ in a 2004 edition of The Watchtower.
5 This
article details what is unacceptable and what is for the
‘‘Christian to decide.’’ The above treatments are still
banned, but the administration of blood fractionates
from red cells, white cells, platelets, and plasma are
permissible and their use is up to the discretion of the
individual. These fractionates include albumin, recombinant human erythropoietin (rhEPO), immunoglobulins, and factor concentrates.5-7
Treating a Jehovah’s Witness in situations that
potentially require blood transfusion or products poses
a unique medical challenge, involving the need to
provide optimal medical care through alternatives to
the standard of care while also respecting the patient’s
rights, values, and beliefs. It is crucial that physicians
present and explain all options to Jehovah’s Witness
patients.6,7 This paper discusses the ethical and legal
considerations in addition to scientific and technical
challenges for anesthesiologists and surgeons.
The doctrine of informed consent is to respect
persons by fully and accurately providing information
needed to exercise their decision-making rights.
Physicians must engage in the process of informed
consent with patients before undertaking any medical
intervention. Consequently, it is best to discuss with
patients the specifics of their blood transfusion refusal
if possible.9,10 Patients have a moral and legal right to
refuse proposed medical intervention, except when the
patient has diminished decision-making capacity or a
legal intervention mandates treatment.11,12 Informed
consent protects both the patient and the physician
from the consequences of adhering to or refuting the
patient’s wishes. It is legally regarded as battery if
blood products are transfused after the documented
refusal of blood products, despite whether the transfusion ultimately ensured the patient’s survival. Conversely, a physician will likely not be held liable of
malpractice if morbidity or mortality result from not
transfusing in accordance with the Jehovah’s Witness
patient’s wishes.13 However, in cases of emergent lifethreatening situations with no documented advance
medical directive, the physician is obligated to administer blood products if indicated.6,14
The medical ethics are further complicated when
children of Jehovah’s Witnesses are involved. In
pediatrics, parents or guardians have the authority
to give consent by proxy, based on the assumption
that their interests lie in safeguarding the child’s
welfare. However, the physician’s legal and ethical
obligation ultimately lies with the child patient and
not the desires of the parents.15 The American
Academy of Pediatrics recommends that the physician and other healthcare professionals recognize
and respect the importance of religion in personal,
spiritual, and social lives of patients and ‘‘to avoid
unnecessary polarization when conflict over religious practices arises.’’16 However, if religious
convictions interfere with medical care that is likely
to prevent substantial harm and suffering or death,
the physician should initiate legal action to override
parental objections.16
The power of the state to intervene is contained in
the legal concept of parens patriae that allows for the
protection of an individual who is not able to make
decisions in his or her own best interest. The first
court decision regarding the children of Jehovah’s
Witness parents actually involved the sale of religious
literature in violation of state child labor laws, but this
case of Prince v Massachusetts17 has often been cited
in subsequent medical-legal disputes.13 Justice Wiley
Rutledge wrote in the majority opinion, ‘‘Parents may
be free to become martyrs themselves. But it does
not follow they are free, in identical circumstances, to
make martyrs of their children before they have
reached the age of full and legal discretion when they
make that choice for themselves.’’17 In a study of 50
court publications concerning parent-physician disagreements over the care of children, court-mandated
medical care was likely to succeed, especially when
the case called for immediate intervention or when
parental objections were based on religion.18
Mechanisms to resolve ethical conflicts include
additional medical consultations with other involved
physicians, surgeons, and anesthesiologists; shortterm counseling or psychiatric consultation for patient
and family; case management conferences; consultation with individuals trained in clinical ethics or a
hospital-based ethics committee; and the input of
hospital administration.13,19 Furthermore, because of
the variability between individual beliefs, it is common for a Jehovah’s Witness patient to consult the
community elders or minister for help in reaching a
decision regarding accepting any medical treatment
related to blood products.13,20
Although blood components, autologous blood,
and banked blood are generally unacceptable to
Jehovah’s Witnesses, providers should discuss and
document specific acceptances and objections, the
degree of limitation, and changes to the plan for
intraoperative management. It is best to consult each
Jehovah’s Witness patient individually, whenever
possible, to ascertain what treatments he or she will
accept to respect any advance directives.12,20 Documenting all discussions, conferences, objections,
and acceptable interventions crystallizes the patient’s
wishes and provides legal documentation for the
anesthesiologist. Anesthesiologists must be certain
they are capable of fulfilling the patient’s requests;
otherwise, they should not agree to provide anesthesia.12,21 Anesthesiologists have the right to refuse to
anesthetize an individual in an elective situation, and
both anesthesiologist and surgeon should provide
nonemergency care to the patient only if all parties
can agree on the approach to blood management.
Medical, legal, and ethical issues associated with
blood product administration to a Jehovah’s Witness
patient have triggered continued efforts to reduce
blood loss and thus blood transfusions. Numerous
techniques and interventions for the preoperative,
Preanesthetic Assessment of the Jehovah’s Witness Patient
62 The Ochsner Journal
intraoperative, and postoperative stages have been
developed and used over time.
