You Have the Right to Choose

A current medical approach (called risk/benefit analysis) is making it easier for doctors and patients to cooperate in avoiding blood therapy. Doctors weigh factors such as the risks of a certain drug or surgery and the probable benefits. Patients too can share in such an analysis.

Let us use one example that people in many places can relate to—chronic tonsillitis. If you had this problem, likely you would go to a doctor. In fact, you might consult two, since health experts often recommend getting a second opinion. One might recommend surgery. He outlines what that means: length of hospital stay, amount of pain, and cost. As to risks, he says that severe bleeding is not common and death from such an operation is very rare. But  the doctor giving a second opinion urges you to try antibiotic therapy. He explains the type of drug, likelihood of success, and expense. As to risk, he says that very few patients have life-threatening reactions to the drug.

Each competent physician likely considered risks and benefits, but now you have to weigh the risks and possible benefits, as well as other factors that you best know. (You are in the best position to consider such aspects as your emotional or spiritual strength, family finances, effect on the family, and your own ethics.) Then you make a choice. Possibly you give informed consent for one therapy but decline the other.

This would also be so if it was your child that had the chronic tonsillitis. The risks, benefits, and therapies would be outlined for you, the loving parents who are most directly affected and who will be responsible to cope with the results. After considering all aspects, you can make an informed choice on this matter involving your child’s health and even his or her life. Perhaps you consent to the surgery, with its risks. Other parents might choose the antibiotics, with their risks. As physicians differ in their advice, so patients or parents differ as to what they feel is best. Such is an understood feature of making informed (risk/benefit) choices.

What about use of blood? No one who objectively examines the facts can deny that blood transfusions involve great risk. Dr. Charles Huggins, who is the director of transfusion service at the large Massachusetts General Hospital, made this very clear: “Blood has never been safer. But it must be considered unavoidably non-safe. It is the most dangerous substance we use in medicine.”—The Boston Globe Magazine, February 4, 1990.

With good reason, medical personnel have been advised: “It is necessary to reevaluate as well the risk part of the benefit/risk relationship for blood transfusion and to seek alternatives.” (Italics ours.)—Perioperative Red Cell Transfusion, National Institutes of Health conference, June 27-29, 1988.

Physicians may disagree as to the benefits or risks in using blood. One may give many transfusions and be convinced that they are worth the risk. Another may feel the risks are unjustified, for he has had good results with nonblood management. Ultimately, however, you, the patient or the parent, must decide. Why you? Because your (or your child’s) body, life, ethics, and profoundly important relationship with God are involved.

YOUR RIGHT IS RECOGNIZED

In many places today, the patient has an inviolable right to decide what treatment he will accept. “The law of informed consent has been based on two premises: first, that a patient has the right to receive sufficient information to make an informed choice about the treatment recommended; and second, that the patient may choose to accept or to decline the physician’s recommendation. . . . Unless patients are viewed as having the right to say no, as well as yes, and even yes with conditions, much of the  rationale for informed consent evaporates.”—Informed Consent—Legal Theory and Clinical Practice, 1987. *

Some patients have encountered resistance when they have tried to exercise their right. It might have been from a friend having strong feelings about a tonsillectomy or about antibiotics. Or a physician might have been convinced of the rightness of his advice. A hospital official might even have disagreed, based on legal or financial interests.

“Many orthopaedists elect not to operate on [Witness] patients,” says Dr. Carl L. Nelson. “It is our belief that the patient has the right to refuse any type of medical therapy. If it is technically possible to provide surgery safely while excluding a particular treatment, such as transfusion, then it should exist as an option.”—The Journal of Bone and Joint Surgery, March 1986.

A considerate patient will not pressure a physician to use a therapy at which the doctor is unskilled. As Dr. Nelson noted, though, many dedicated physicians can accommodate the patient’s beliefs. A German official advised: “The doctor cannot refuse to render aid . . . reasoning that with a Jehovah’s Witness not all medical alternatives are at his disposal. He still has a duty to render assistance even when the avenues open to him are reduced.” (Der Frauenarzt, May-June 1983) Similarly, hospitals exist not merely to make money but to serve all people without discrimination. Catholic theologian Richard J. Devine states: “Although the hospital must make every other medical effort to preserve the patient’s life and health, it must ensure that medical care does not violate [his] conscience. Moreover, it must avoid all forms of coercion, from cajoling the patient to obtaining a court order to force a blood transfusion.”—Health Progress, June 1989.

RATHER THAN THE COURTS

Many people agree that a court is no place for personal medical issues. How would you feel if you chose antibiotic therapy but someone went to court to force a tonsillectomy on you? A doctor may want to provide what he thinks is the best care, but he has no duty to seek legal justification to trample on your basic rights. And since the Bible puts abstaining from blood on the same moral level as avoiding fornication, to force blood on a Christian would be the equivalent of forcible sex—rape.—Acts 15:28, 29.

Yet, Informed Consent for Blood Transfusion (1989) reports that some courts are so distressed when a patient is willing to accept a certain risk because of his religious rights “that they make up some legal exceptions—legal fictions, if you will—to allow a transfusion to occur.” They might try to excuse it by saying that a pregnancy is involved  or that there are children to be supported. “Those are legal fictions,” the book says. “Competent adults are entitled to refuse treatment.”

Some who insist on transfusing blood ignore the fact that Witnesses do not decline all therapies. They reject just one therapy, which even experts say is fraught with danger. Usually a medical problem can be managed in a variety of ways. One has this risk, another that risk. Can a court or a doctor paternalistically know which risk is “in your best interests”? You are the one to judge that. Jehovah’s Witnesses are firm that they do not want someone else to decide for them; it is their personal responsibility before God.

If a court forced an abhorrent treatment on you, how might this affect your conscience and the vital element of your will to live? Dr. Konrad Drebinger wrote: “It would certainly be a misguided form of medical ambition that would lead one to force a patient to accept a given therapy, overruling his conscience, so as to treat him physically but dealing his psyche a mortal blow.”—Der Praktische Arzt, July 1978.

LOVING CARE FOR CHILDREN

Court cases regarding blood mainly involve children. On occasion, when loving parents have respectfully asked that nonblood management be used, some medical personnel have sought court backing to give blood. Of course, Christians agree with laws or court action to prevent child abuse or neglect. Perhaps you have read of cases in which some parent brutalized a child or denied it all medical care. How tragic! Clearly, the State can and should step in to protect a neglected child. Still, it is easy to see how very different it is when a caring parent requests high-quality nonblood medical therapy.

These court cases usually focus on a child in a hospital. How did the youngster get there, and why? Almost always the concerned parents brought their child to get quality care. Even as Jesus was interested in children, Christian parents care for their children. The Bible speaks of ‘a nursing mother cherishing her own children.’ Jehovah’s Witnesses have such deep love for their children.—1 Thessalonians 2:7; Matthew 7:11; 19:13-15.

Naturally, all parents make decisions affecting their children’s safety and life: Will the family use gas or oil to heat the home? Will they take a child on a long-distance drive? May he go swimming? Such matters involve risks, even life-and-death ones. But society recognizes parental discretion, so parents are granted the major voice in nearly all decisions affecting their children.

In 1979 the U.S. Supreme Court stated clearly: “The law’s concept of the family rests on a presumption that parents possess what a child lacks in maturity, experience, and capacity for judgment required for making life’s difficult decisions. . . . Simply because the decision of a parent [on a medical matter] involves risks does not automatically transfer the power to make that decision from the parents to some agency or officer of the state.”—Parham v. J.R.

 That same year the New York Court of Appeals ruled: “The most significant factor in determining whether a child is being deprived of adequate medical care . . . is whether the parents have provided an acceptable course of medical treatment for their child in light of all the surrounding circumstances. This inquiry cannot be posed in terms of whether the parent has made a ‘right’ or a ‘wrong’ decision, for the present state of the practice of medicine, despite its vast advances, very seldom permits such definitive conclusions. Nor can a court assume the role of a surrogate parent.”—In re Hofbauer.

Recall the example of parents choosing between surgery and antibiotics. Each therapy would have its own risks. Loving parents are responsible to weigh risks, benefits, and other factors and then to make a choice. In this connection, Dr. Jon Samuels (Anesthesiology News, October 1989) suggested a review of Guides to the Judge in Medical Orders Affecting Children, which took this position:

“Medical knowledge is not sufficiently advanced to enable a physician to predict with reasonable certainty that his patient will live or die . . . If there is a choice of procedures—if, for example, the doctor recommends a procedure which has an 80 per cent chance of success but which the parents disapprove, and the parents have no objection to a procedure which has only a 40 per cent chance of success—the doctor must take the medically riskier but parentally unobjectionable course.”

In view of the many lethal hazards in medical use of blood that have surfaced and because there are effective alternative ways of management, might not avoiding blood even carry the lower risk?

Naturally, Christians weigh many factors if their child needs surgery. Every operation, with or without the use of blood, has risks. What surgeon gives guarantees? The parents may know that skilled physicians have had fine success with bloodless surgery on Witness children. So even if a physician or a hospital official has another preference, rather than cause a stressful and time-consuming legal battle, is it not reasonable for them to work with the loving parents? Or parents may transfer their child to another hospital where the staff is experienced in handling such cases and willing to do so. In fact, nonblood management will more likely be quality care, for it can help the family “to achieve legitimate medical and nonmedical goals,” as we noted earlier.

[Footnotes]

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RELIEVING LEGAL CONCERNS

You may wonder, ‘Why are some doctors and hospitals quick to get a court order to give blood?’ In some places a common reason is fear of liability.

There is no basis for such concern when Jehovah’s Witnesses choose nonblood management. A doctor at Albert Einstein College of Medicine (U.S.A.) writes: “Most [Witnesses] readily sign the American Medical Association form relieving physicians and hospitals of liability, and many carry a Medical Alert [card]. A properly signed and dated ‘Refusal to Accept Blood Products’ form is a contractual agreement and is legally binding.”—Anesthesiology News, October 1989.

Yes, Jehovah’s Witnesses cooperatively offer legal assurance that a physician or hospital will not incur liability in providing requested nonblood therapy. As recommended by medical experts, each Witness carries a Medical Document card. This is renewed annually and is signed by the person and by witnesses, often his next of kin.

In March 1990, the Supreme Court of Ontario, Canada, upheld a decision that commented approvingly on such a document: “The card is a written declaration of a valid position which the card carrier may legitimately take in imposing a written restriction on [the] contract with the doctor.” In Medicinsk Etik (1985), Professor Daniel Andersen wrote: “If there is an unambiguous written statement from the patient saying that he is one of Jehovah’s Witnesses and does not want blood under any circumstances, respect for the patient’s autonomy requires that this wish be respected, just as if it had been expressed orally.”

Witnesses will also sign hospital consent forms. One used at a hospital in Freiburg, Germany, has space where the physician can describe the information he gave the patient about the treatment. Then, above the signatures of the physician and the patient, this form adds: “As a member of the religious body of Jehovah’s Witnesses, I categorically refuse the use of foreign blood or blood components during my surgery. I am aware that the planned and needed procedure thus has a higher risk due to bleeding complications. After receiving thorough explanation particularly about that, I request that the needed surgery be performed without using foreign blood or blood components.”—Herz Kreislauf, August 1987.

Actually, nonblood management may have a lower risk. But the point here is that Witness patients happily relieve any needless concerns so that medical personnel can move forward in doing what they are committed to do, helping people get well. This cooperation benefits all, as Dr. Angelos A. Kambouris showed in “Major Abdominal Operations on Jehovah’s Witnesses”:

“Preoperative agreement should be viewed as binding by the surgeon and should be adhered to regardless of events developing during and after operation. [This] orients the patients positively toward their surgical treatment, and diverts the surgeon’s attention from the legal and philosophical considerations to the surgical and technical ones, thus, allowing him to perform optimally and serve his patient’s best interests.”—The American Surgeon, June 1987.

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“Overuse of medical technology is a major factor in the increase of current health care expenditures. . . . Blood transfusion is of particular importance because of its cost and high risk potential. Accordingly, blood transfusion was classified by the American Joint Commission on Accreditation of Hospitals as ‘high volume, high risk and error prone.’”—“Transfusion,” July-August 1989.

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United States: “Underlying the necessity for patient consent is the ethical concept of individual autonomy, that decisions about one’s own fate should be made by the person involved. The legal ground for requiring consent is that a medical act performed without the patient’s consent constitutes battery.”—“Informed Consent for Blood Transfusion,” 1989.

Germany: “The patient’s right of self-determination overrides the principle of rendering assistance and preservation of life. As a result: no blood transfusion against the will of the patient.”—“Herz Kreislauf,” August 1987.

Japan: “There is no ‘absolute’ in the medical world. Doctors believe that the course of modern medicine is the best and follow its course, but they should not force every detail of it as an ‘absolute’ on patients. Patients too must have freedom of choice.”—“Minami Nihon Shimbun,” June 28, 1985.

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“I have found the families [of Jehovah’s Witnesses] to be close knit and loving,” reports Dr. Lawrence S. Frankel. “The children are educated, caring, and respectful. . . . There even appears to possibly be stronger compliance to medical dictates, which might represent an effort to demonstrate acceptance of medical intervention to the extent that their beliefs permit.”—Department of Pediatrics, M. D. Anderson Hospital and Tumor Institute, Houston, U.S.A., 1985.

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“I fear it is not uncommon,” comments Dr. James L. Fletcher, Jr., “for professional arrogance to supplant sound medical judgment. Treatments that are regarded as ‘the best today’ are modified or discarded tomorrow. Which is more dangerous, a ‘religious parent’ or an arrogant physician who is convinced that his or her treatment is absolutely vital?”—“Pediatrics,” October 1988.