Medical Ethics Friday

Oct 15 2010 Published by under Medical ethics, Medicine

A few readers asked if we could have more frequent ethical discussions.  That seems like a good idea.  Here's a new case.

You are a family physician practicing in a busy urban area where you take care of hundreds of families from diverse backgrounds. You care from them from birth to death, both in the office and in the hospital.  One evening, the emergency department calls you.  Mr. F., a Jehovah's Witness, is in the ED feeling weak and short of breath.  He's a 40 year-old single father of four kids.  You've cared for him since he was a young man,  through his marriage, the birth of his kids (whom you delivered and continue to care for), and the death of his wife.  Lately, he has had terrible back pain from his job at the plant and has been taking a lot of "pain pills".   He has always made it clear to you that his religious beliefs are central to his life, and among these beliefs is an abhorrence of blood transfusions.  He will never accept one, no matter the circumstance.

The ED doctor is frustrated on the phone.  Mr. F.'s blood count is dangerously low.  It looks like he's been bleeding, perhaps from an ulcer.   They are giving him IV fluids, and may consider taking him to the OR, but they are afraid he won't last long.  His kids are in the waiting room with their elderly, infirm grandmother, also your patient.  The ED doc wants to wait until he passes out, then give him an "emergency" transfusion with the patients "presumed" consent.  The ED doc sounds afraid and frustrated and is wondering what you can add to the patient's care.

59 responses so far

  • anonymous says:

    That one is simple. Let him die. I believe that if a person chooses to end their life they should be allowed to do it. I agree that if a person has diminished ability to think clearly ie is mentally disturbed, we have a responsibility to prevent them from hurting themselves, but when a person has a long held belief, or has a rational basis for choosing to end their life, it's their life. Long held religious beliefs aren't rational but they show that the decision isn't simply a matter of disturbed brain chemistry, illness or other factor that should cause us to believe the decision is something that is beyond the person's normal way of thinking. I don't think any child should be allowed to refuse a transfusion, nor should parents be allowed to refuse such a thing for their child but if an adult is stupid enough to choose death over a transfusion then they get to make that choice.

  • beebeeo says:

    I'm not a doc but I'll take a guess. The question is about ethics and not about a different treatment that does not require transfusion. For an atheist like me, the situation would be very difficult. Everyone has the right to their own silly beliefs and to act according to them, as long they don't force their beliefs on society or infringe on the rights of others. In this case one would have to judge whether his decision is of the former (strictly personal) or latter (affecting others rights).

    The only factor that could be judged as affecting others is the fact that he would be leaving his family behind. In particular, as he a single father, his children would probably become orphans if he died (do Witnesses do divorce?). Is it the role of a physician to take that into account? I am not sure but I don't think so. The primary obligation is towards the patient who is sick and the relationship between doctor and patient requires that the patients choices are respected.

    The patient is an adult, not insane and conscious. Any recommendation to go ahead with a transfusion would go against the patients rights. His belief might be irrational, but it is not based on wrong information about the risks of the treatment. His opinion is unlikely to change in future, especially as it hasn't changed now where death might be imminent. It would be unethical to tell the ED to go ahead with a transfusion.

    However, a recommendation that would harm the patient or lower the likelihood of the patient accepting a transfusion would also be unethical. I would probably not discourage the ED from trying to change the patients mind, no matter how difficult. The patient should be confronted and in order to make an informed decision, he should be reminded of all risks: that he might die, that his children might become orphans, that the elderly grandmother might not be able to take care of them etc.

    I guess that is all that one should do.

  • Bing says:

    Oh, the pathos! I smell Lifetime TV movie!

    Man, the really freaking awful decision has basically been made. You can tell the ED to ask the patient again, of course, basically reminding him of the full implications of the decision before he passes out. Or, depending what is on TV, you could hustle over to make that case--that personal connection might help him come to a better medical decision, or at least clarify and confirm whatever decision is made. But I see nothing other than soft persuasion to convince him that could be ethical. (And even then, I'm a little hesitant about that because the man is perhaps especially vulnerable at that moment.) That's it--I'd go over and confirm his wishes.

    No. Wait, tell him to pass out if he wants a transfusion. That'll fix it!

    You're welcome.


  • Philip says:

    You may be missing the fact that the patient's goal is not actually death. It does not seem to be the intent of the patient to die, but rather, to live only under his chosen (debatable, but still...) set of beliefs. I imagine if say, an artificial blood supply could be given that may not violate his religious beliefs, Mr. F might accept such a transfusion. However, my gut reaction in this case is to agree with you: to allow Mr. F to make a personal decision regarding the circumstances under which he will live, or not. Too bad about those kids, though...

  • PalMD says:

    Yeah...those kids who are also your patients.

  • Philip says:

    Regarding the kids: Even though they are my patients too, I still don't think that allows me to violate the rights of their father to serve their interests. Although the precedent of compulsory child support payments makes the interesting point that one's rights (to spend money as one sees fit) may be curtailed in the interests of one's children. Although taking one's money is far different from taking away the right to chose the circumstances under which one choses to live, though they may exist on the same continuum.

    Btw: Love the site PalMD. I have been lurking for a while, and that last post was my first. Guess these discussions bring everyone out of the woodwork.

  • PalMD says:

    I'd say that this puts the physician in a bit of an ethical conflict of interest. She needs to respect the wishes of her adult patient, but also has little patients who will be affected, which may affect her ability to make good decisions.

    • James Sweet says:

      I have to agree with Phillip on this one. The kids being the doc's patients undoubtedly make the situation more uncomfortable, but I don't feel it adds to the ethical conflict. I don't see any situation where the nature of your care for patient A ought to ever be altered by what you think will benefit patient B. (Now, if patient A has an interest in patient B's well-being, it would do well to remind the former of the influence he or she has... but you can't modify your care to help a different patient!)

  • Ewan says:

    Pain pills: presumably aspirin, exacerbating the bleeding? Stop those - or at least identify - perhaps.

    I think that the kids, the grandmother, etc. are - sadly - red herrings: the patient has a right to refuse any given treatment, has done so, and you're done: no blood transfusions. This would be true if the basis for that decision were a sincere belief in blue fuzzy bunnies on Mars controlling his thoughts - although there might then be a question of competency, but it's no more bizarre than any other religion.

    So the ethics bit seems - as suggested by the first commenter - to be simple; seek alternative treatments, urgently and fervently, but if the choice is a blood transfusion or death, you pick - or rather the patient picks - death.

  • PalMD says:

    It may be that the kids are a red herring as far as decisions about the patient are concerned, but they may have a profound effect on the medical staff and their decision-making.

    And yes, the implication is that the patient has an NSAID-induced ulcer. Emergency therapy will include IV fluids, IV proton-pump inhibitors, and emergent endoscopy, depending on the rest of the details.

  • Doughboy says:

    The only ethical solution in keeping with the patient's rights is ask the ED doctor to give the phone to Mr. F (if he is still conscience), and discussion the situation with him. Go in detail on pros and cons of what going to happen with and without the transfusion. Remind what is at stake if he refuses the transfusion, especially the circumstances of his decision also affects his children as well. If artificial blood is available, convince him there no problem with it and to accept the treatment.

    Now if I was a bit unethical (and producer of lifetime channel movie), I tell the ED doctor he is not that religious and wait until he is passed out to give him a transfusion. Then after he is stabilized, have the ED doctor pretend that he made a mistake and go inform the family of what happen and say there was miscommunication with you and ED doctor about his religion practicing to avoid any trouble. If there is artificial blood available, just give it to Mr. F and say it not really blood.

    • Kevin says:

      Last week, Pal made a big point about avoiding dishonesty (in that case in the medical record, but the point is the same). Going through all that subterfuge in one case might make sense, but in the larger scheme of things, I think it helps contribute to that paternalistic ethos people were talking about last week.

      I think I have to agree on the logic - you gotta let the guy die, despite the fact that his beliefs are irrational. Of course, it would clearly be really hard to actually make that call.

  • Vicki says:

    The only other thing I can think of—and this is an issue for later—is to make clear to the relatives that the guy's "pain pills" may have killed him, and that if they share his belief about transfusions, they should avoid aspirin and NSAIDs as much as possible.

    That won't help your current patient—though if the ulcer treatment pulls him through it'll be something to discuss—but it's probably a thing to note if you have JW patients.

  • Pascale says:

    As long as he is conscious, it is his decision- I certainly would have no qualms about reminding him that he could orphan his children!
    Once he passes out, the decision becomes one for the next of kin- is that the grandmother in the lobby? If not, then you have to honor his wishes.

  • Connie Bristol says:

    Like a situation where a patient has a living will, DNR order, he crashes and his family screams at you to save him. He stops breathing and goes asystole...
    You honor the patient's wishes... isn't the patient who is in the situation honored? what if his family were your patients as well?? It's his TIME if you will, his decision, his choice, his right. Let go and let God....

  • PalMD says:

    It might be argued that applying some coercion may or may not be warranted. I would probably, as mentioned above, remind him that whether or not he is ready to meet his god, his children may not share his equanimity.

    In fact, despite the paternalistic implications, I may even try to shame him, etc about abandoning his kids.

  • D. C. Sessions says:

    I’d say that this puts the physician in a bit of an ethical conflict of interest. She needs to respect the wishes of her adult patient, but also has little patients who will be affected, which may affect her ability to make good decisions.

    That may be a personal conflict, but I don't see the ethical one. The only real ethical issue I see is that of consent by silence to what certainly looks like an attempt to violate patient autonomy by deceit. Major no-no, that, and our PCP IMHO has an ethical duty to speak to the patient and explain the medical situation and tell him that he has to make his wishes explicitly known.

    On the other hand, I do see a reminder here for physicians whose patients object to the "implied consent" standard: why, oh why, has our PCP not discussed living wills and such before now?

  • Dianne says:

    Don't wait for the patient to pass out. Have a talk with him NOW about whether he is sure that he does not want blood. Explain to him that he will likely die without a transfusion, leaving his elderly mother and children alone. While that is going on, get a gastroenterologist in to stop the bleeding from the probable ulcer. There are EGD techniques that should be doable even in an unstable patient. If they're not available and he refuses the blood that might stabilize him for a transfer, consult a nearby tertiary care center and see if they'd be willing to take him without stabilization on the grounds that stabilizing him is impossible.

    Supposing you can get him stabilized somehow, start IV iron, folate, and as much epogen as you feel comfortable giving him as soon as possible to replace his blood.

  • Connie Bristol says:

    These ethical situations are wonderful. It's always nice to figure out your game plan before things happen. I used to think medicine/nursing was black and white, wish it were, but more and more becoming shades of gray. I feel medicine and nursing as well have lost their autonomy. Insurance companies and law enforcement with multiple divisions, federal and state govts. govern our practice. If only our boards made up of our own respected peers could govern us AND ONLY OUR BOARDS... how silly to be so idealistic that could ever be a reality.
    Sorry I am going off into another direction..nevermind...

  • daedalus2u says:

    My grandmother's sister was a Christian Scientist and had a episode of hemorrhagic bleeding. As my grandmother always told the story, “she had no lips”, there was no color difference between her lips and the rest of her face. This was in the 1940's. My grandmother took her bodily to a hospital, demanded that they treat her, and donated blood herself. Her sister live another 50 years, into her 90's. I don't think any health care professional would do that now.

    This might be a case where the patient's fear that his wishes to not receive blood would not be honored likely delayed his decision to go to the ED. If he had gotten to the ED sooner, stopping the bleeding might have left him with enough blood that he wouldn't need a transfusion. Assuring him that as long as you were his doctor, his wishes to not receive a transfusion would be respected might have gotten him to the ED sooner.

    It is unethical for you to violate his express wishes. Trying to shame him is not unethical, but if he is this adamant, then you still can't, but you can use this as a learning example for the children. They will continue to be your patients, and how you deal with the express wishes of their father will bear on how they trust you in the future.

    You might be able to turn them away from this wacky belief system. You might even tell your patient that. That if he dies, you will work to ensure his children don't adopt his belief system. Maybe his concern over the status of his children's souls will convince him to sacrifice his soul for theirs.

    But if you put nitrite in his IV fluids he will do better. One of the first reactions to hemorrhagic shock is a large increase in NO levels. Some of that NO likely comes from NOS, but a lot of it likely comes from reduction of nitrite to NO. There are many nitrite reductases that are inhibited by O2, and during hypoxia generate NO from nitrite. That NO protects against reperfusion injury by blocking superoxide production by hemes. But if his hemoglobin level is really low, the dose you can use is likely pretty small. He needs to be on a pulse oximeter, and some of them do measure methemoglobin as well as oxy, deoxy and carboxy. Treat him with IV nitrite as for cyanide poisoning, but at a smaller dose (1/5, and titrate to keep his methemoglobin less than 2-5%). You could do almost the same thing with inhaled NO (which is perhaps more conventional and easier to justify but won't work as well). Topical nitrite might even be better. Raise his blood glucose to 3x normal, and consider dialysis with urea containing fluid (to rid him of lactate from all the glycolysis that will be going on to keep his organs functioning without enough O2.

  • skeptifem says:

    What is there to debate about exactly? Patients with DNR bands don't get this trip from people, everyone respects a DNR. This isn't different in any important way.

    • Dianne says:

      Resuscitation is rarely successful and people with DNR orders generally have ultimately fatal conditions such that they would not be likely to live long or well even if successfully resuscitated. This patient very likely has an entirely reversible problem and might live to 100 if he accepted standard medical care.

      • skeptifem says:

        How is it different ethically though? I don't see how the chances of it working changes the issue at all. To me it is a conflict of violating a mentally competent adults decision about their own care. PERIOD. It doesn't have to make sense to you personally because it doesn't affect you personally.

    • PalMD says:

      I think it's important because caregivers don't always make dispassionate decisions. Nor, it might be argued, should they.

  • Dianne says:

    Treatment of JW is a difficult problem in general in medicine. Unlike, for example, Christian scientists, they are willing and eager to accept medical care-with the exception of blood and blood products. So you can have a JW simultaneously demanding the most aggressive possible care and making that impossible by refusing blood.

    If Pal will excuse me, I am reminded of another difficult case. I didn't see this case personally and in any case am altering the details but the central dilemma is intact: A young woman of 18 or 19 who is a JW presents to the ER accompanied by her parents with a complaint of severe fatigue and easy bruising. Her CBC shows a WBC of 95.4 (nl 4-10), essentially 100% blasts (immature cells which are not normally seen in the peripheral blood), Hgb 4.3 (nl 11-13) and platelets of 3 (nl 150-450). She is quickly diagnosed with AML. She and her parents both state that they want aggressive care for the AML but refuse transfusion. She expresses a high level of fear about the diagnosis and the possibility of dying and is in severe respiratory distress due to the anemia. What do you do?

    Notes for the non-specialists: AML has an 80+% complete response rate with aggressive care and probably about a 50% cure rate with best care. Less aggressive treatment has an essentially 0% complete response rate. It is impossible to treat aggressively without inducing a period of bone marrow aplasia during which the person will die of infection, bleeding, or anemia if not properly supported ie given blood and platelet transfusions. There are no commercially available substitutes for blood and platelets and, as far as I know, no products ready for clinical trials.

    • Scote says: what degree do you need to separate the young, but legally adult, patient from her parents to make sure her decision is **really** her decision?

      • Dianne says:

        That, to me, is the critical question. If this is truly her desire and belief, there's not much to do. But she has to be asked with the parents out of the room. A teenager is still very much influenced by her parents.

        I believe in the event she maintained her view, refused transfusion, and eventually died of, essentially, suffocation. The person who told me this story still vividly remembered the events and was emotionally distressed by them 10 years later.

  • What a selfish jerk this guy is. I was wondering if the ethical considerations would differ if he had attempted suicide and needed blood products to save him. I suppose in that case he is not of sound mind and therefore doctors could give him a transfusion?

    I may not remember this correctly, but I recall reading an anecdote a few years ago about a JW woman who hemorrhaged at childbirth. The husband, who had power of attorney, refused a transfusion on her behalf. The hospital staff begged him to reconsider. Her newborn twins lost their mother and the husband sued because he said he didn't know that she would actually die without blood.

  • daedalus2u says:

    I think you have to go to his bedside and talk to him in person and tell him, that if he dies or becomes incapacitated because he refuses treatment for something you could treat because of his JW beliefs, that your responsibility to his children as his children's physician will require you, in any custody, guardianship, adoption or other procedures regarding who is to be the guardian of his children and in what manner, to work as hard as you can to ensure that what killed their father will not kill his children.

    That you will work as hard as you can to ensure they are not adopted or fostered into a JW family and as long as they are minors are kept away from JW teachings.

    As the physician who treated the family for many years, that testimony would have significant weight.

    Not a threat, a solemn promise.

  • PalMD says:

    Like many of these scenarios, there are few good answers.

    While the children are also your patients, your immediate responsibility is to the sick patient you're caring for now. To violate his autonomy by intentionally transfusing him would be wrong. I would argue that a dose of paternalism in trying to convince him to accept the transfusion is also your responsibility. The harm of the small violation of his autonomy to achieve a greater good is justified (IMO). The greater violation of transfusing him is not justified.

    It is important not to underestimate the complexity of the situation and the effect on the caregivers, for which the patient also bears some ethical responsibility. While doctors are trained to deal with life/death situations, it may still traumatize the care team to watch him die "needlessly" and to have to watch his children deal with their loss.

    While it may seem easy enough ("let me die"= let him die), things rarely go this smoothly in real life.

  • daedalus2u says:

    I wouldn't characterize the scenario I laid out, where you tell him that if he dies you would work to have his children fostered in a non JW household as being “paternalistic”. When he dies, your obligations to him go to zero. Your obligations to his minor children (as your patients) remain intact.

    If it was a minor child of a JW who was in this situation, you would (I presume) get legal services involved to remove medical decision making from the JW parents (who may also be your patients) so the child could be transfused.

    It is my understanding that removing medical decision making from parents of an otherwise healthy minor child when those parents are refusing standard of care life saving medical care for that minor child is the only ethical course of action that any health care professional can adopt. Telling your dying JW patient this is not unethical, even if it might be very disturbing to him in his present condition.

    Even if he tries to fire you as his children's physician on his death bed because of this, that firing is done in an attempt to deny his children life saving medical care, and so is not within the scope of what he is allowed to do as a parent. If he lives, and wants to fire you, he can, but your obligation is then to make very clear in the medical records what the firing was for, and to perhaps involve children's services for the potential of medical neglect. Putting words to that effect in the children's medical records leaves a paper trail that puts the next physician on warning and perhaps at greater jeopardy if the next physician does not follow the standard of care.

    • PalMD says:

      Whoa! I'm not responsible for the raising of the kids. If the kids are injured and need a transfusion, the courts would likely support that. But it's not my obligation, and in fact would be wrong, if I were to interfere with the religious upbringing of the kids.

      • daedalus2u says:

        I agree with you, that you shouldn't interfere with the children's religious upbringing unless is poses significant medical risks to them. But to the extent it does pose significant medical risks to them, you do have a responsibility to inform those involved with their medical care about those risks and to seek to mitigate those risks consistent with your duties and responsibilities as a health care provider.

        Suppose the patient was instead a snake handler, and had been bitten by one of the poisonous snakes he had been handling and was refusing antivenin. Suppose the religious group he was doing snake handling with was planning a snake handling event, where the patient's minor children would be given poisonous snakes to handle, and this event was supposed to “cure” the patient who was now refusing antivenin.

        I think you would have an obligation to report this to children's protective services as suspected child abuse, even though it is a religious event.

      • daedalus2u says:

        Let me rephrase what I am trying to convey.

        While the children have a legal guardian, you as their non-guardian have no right or obligation to interfere with their religious upbringing.

        Once the children do not have a guardian, then no one has the authority to specify their religious upbringing, and no one does until they do have a legal guardian.

        The process by which a legal guardian is specified is a legal process which requires input from multiple sources and is (should be) based on what is in the child's “best interests”.

        When a child has a legal guardian, that guardian can exert considerable discretion in what “best interests” means. Once the child has no guardian, then the state becomes the guardian and the definition of “best interests” defaults to a “reasonable person” standard.

        I can conceive of no way that JW or snake handling can be endorsed as practices that are in a child's “best interests” under a “reasonable person” standard.

  • Connie Bristol says:

    For no blood and snakehandlers..
    God wants religious fruits not religious nuts

    Galatians 5:22-23
    But the fruit of the Spirit is love, joy, peace, longsuffering, gentleness, goodness, faith, meekness, temperance: against such there is no law.

    As to the man refusing blood transfusion

    When I was in Haiti on medical mission, 14 month old child, minutes away from dying in acute respiratory distress, with NO ELECTRICITY, NO CRASH CART, NO VENTS, NO ET TUBES, on a mountain with a clinic an hour away only by crossing a river driving dirt roads... you get the picture.
    I called for the elders of the church in Haiti and my church, they and I prayed over him and HE WAS HEALED INSTANTLY.

    I wasn't too cool to have faith, I wasn't too proud of my secular medical knowledge, wisdom, and training. because IT WOULD NOT HAVE SAVED THAT BOY! No man could save that boy...

    Miracles do happen I've witnessed them.

    What am I saying.

  • PalMD says:

    While the story is thrilling, it has absolutely nothing to do with the supernatural.

  • I watched a local boy linger for a month in the ICU and then die even though more than 14,000 people were praying for him.

  • Connie Bristol says:

    Thank you for being polite.

  • G.D. says:

    I am not a medical doctor, and maybe I shouldn't be one. As far as I can see, I am the only one in the thread thus far who would go through with the ED's plan. Wait until he passes out and then do the transfusion. If there were no possible legal issues involved (abstracting away from the possibility of court cases) I would not afterwards lie about the situation. I was perfectly aware that I went against his explicit wishes. My reasoning is (put a little bluntly) as follows: If a person stands on the roof of a skyscraper prepared to jump because he believes he can fly, I wouldn't let him jump. He cannot fly, and despite his rights to have whatever stupid and delusional beliefs he wants, it is clearly not in his best self-interest to jump off the building. We simply don't find it OK to let people act on such severe delusions. And I do not see any relevant different in the case described, apart from the fact that we seem to think that there is something special about certain insane delusions when they are filed under the category "religious beliefs".

    One should not forget, either, that by allowing himself to die because of his religious beliefs the father is blatantly violating his own moral duties towards his own family. Allowing him to make the choice is in fact not incomparable to the following scenario: A person you know is severely anti-gay for religious reasons and thinks it is his religious duty to beat up gays. You can stop him from doing so in some manner that involves tricking him. Is it wrong for you to stop him because it violates his trust in you and fails to let him act out his religious beliefs? Clearly not. The situation is the same in this respect: you don't allow someone to cause harm to others (for deeply held religious reasons) even if stopping him is, to some extent, a violation of his autonomy and exercise of free will. And this is of course the situation for the father described above as much as for the violent anti-gay bigot.

    Of course, that standpoint is based, as mentioned, on abstracting away from any possible legal issues. I am aware that the decision would imply a violation of the patient's trust, and possibly entail that he and his family would stop having me as their general practitioner as well, and I would possibly feel that I am betraying someone's trust. All these things would of course go into a real-life decision making process, but are not obviously relevant to the purely moral aspects of the situation.

  • PalMD says:

    @GD, your reasoning is satisfying, but not sound. In our society, we place an extraordinary value on personal freedoms, and we number religious thinking among these, even when it is pretty effed up. Jumping from a skyscraper is, for whatever reason, not viewed in the same way as harmful religious beliefs by our society.

    I agree that we should remind the father that he has a moral obligation to his family, but he would probably believe that his moral obligation to his god is superior, as crazy as it would seem to us, and it is not our job make him follow our moral beliefs: our job is to deliver medical care in a way that benefits the patient, fails to cause harm, and respects the autonomy of the individual. These ethics sometimes come into conflict, as in this case, but the conflict depends very much on where you stand. From the patient's perspective (the one that matters most), he is behaving in the most ethical fashion.

    There are also intangibles in situations like this. When you substitute your own judgement for someone else's, there is a potential to cause unforeseen harms. The children might develop a life-long distrust of medicine that adversely affect them, for example, or the family may be shunned by their community in a time of need, and have no backup community for support.

  • PalMD says:

    @Connie, I'm sorry if I was short. I apologize.

    I'm just pointing out that what you view as a miracle is not seen that way by everyone. Many of us see such things in a more mundane way.

  • Connie Bristol says:

    No you weren't. I should have sent a smiley sign to let you know really, thank you for being polite. 🙂

  • daedalus2u says:

    GD, your actions also open you up to criminal prosecution. By transfusing him against his will you are committing assault and battery. If he lives, he could seek to have you prosecuted and you likely would be convicted. Maybe the extenuating circumstances of wanting to save his life would convince a jury, but maybe not.

    It is pretty clear cut malpractice.

  • G.D. says:

    GD, your actions also open you up to criminal prosecution. By transfusing him against his will you are committing assault and battery. If he lives, he could seek to have you prosecuted and you likely would be convicted. Maybe the extenuating circumstances of wanting to save his life would convince a jury, but maybe not.

    I agree. That's why I wanted to abstract away from legal considerations. I do think it is worthwhile to look at the purely moral factors pertaining to the situation as well, independently of the legal issues.

    I agree that we should remind the father that he has a moral obligation to his family, but he would probably believe that his moral obligation to his god is superior

    This raises some thorny issues. I am aware that the father thinks he has a moral obligation to his god and that this trumps his duties to his family. But unless you go completely relativistic about morality, his beliefs about his duties does no more entail that he is right about his duties than someone's beliefs that the earth is flat entails that the earth is, in fact, flat. The father might think this, but he is simply mistaken.

    And I think we can safely dismiss total moral relativism. None of us are total relativists anyway. We would not say to anyone who though homosexuality was immoral that he was right because he believed it. We would say that his moral beliefs were mistaken. Homosexuality just isn't immoral, regardless of what anyone believes about the matter.

    Thus, I simply disagree with this claim:

    From the patient’s perspective (the one that matters most),

    The patient's perspective just isn't the most relevant factor. His duties to his family, regardless of whether he recognizes them or not, matters more.

    we place an extraordinary value on personal freedoms, and we number religious thinking among these

    Again, I agree. But the question isn't really about what our current practices are, but what they should be. We all agree, I think, that infringing upon someone's autonomy is ok in cases where acting on one's beliefs or goals interfere with the autonomy of others. For instance, we do think it is OK to lock up someone who is about to go on a killing spree, even if it infringes upon his autonomy. And I do think the case at hand is of the same kind in relevant respects. Insofar as the father's choices harms the welfare of his family, and severely so (presumably, given how the case is described), I do think this is reason enough to restrict his autonomy in this case. The fact that a large number of Americans disagree because of the value they put on religion is kinda beside the point unless you think moral questions are determined by polling (which you probably don't think, for instance in the case of the purported immorality of gay marriage). I am not even sure acting against his explicit wishes is, in fact, infringing upon his autonomy - his crazy beliefs are what is infringing upon his autonomy as a rational agent able to exercise his free will (some Kantspeak in here, sorry).

    When you substitute your own judgement for someone else’s, there is a potential to cause unforeseen harms. The children might develop a life-long distrust of medicine that adversely affect them, for example, or the family may be shunned by their community in a time of need, and have no backup community for support.

    This I fully agree with, however, and are certainly things that complicate my position here. It certainly exemplifies how harmful irrational religious beliefs and ignorance can be. Makes one wonder whether, given its harmful effects on society, having religious beliefs at all might, in certain cases, be immoral.

  • ecologist says:

    An interesting case and lots of questions. I'm curious about the relation to DNR orders. These lead to the same dilemma (someone in a situation where an intervention would save their life, but who has said in advance that they do not want that intervention), but they do not seem to bring up some of the same emotional responses as refusals of intervention for religious reasons.

    The fact that the patient with the DNR may also have a short life expectancy due to some condition isn't relevant (I think). A doctor will work hard to save the patients life, even if it will be a short one, and in the absence of a DNR, will include resuscitation in that attempt.

    Do doctors and other medical professionals feel the same degree of ethical conflict over DNR orders? If not, what helps them to differentiate it from the situation in this case?


  • PalMD says:

    That's a great questionthat might eventually need a post of its own.

    In the sense of honoring a patients autonomy, I would agree that there is little difference between forgoing attempts at resuscitation and forgoing a life-saving transfusion. There are the same.

    However, in general DNR orders pertain to end-of-life care and are often relevant in situations where attempts at resuscitation are unlikely to benefit the patient substantially. They are essentially a failsafe, a protection against overly-aggressive futile care.

    As a reminder, a "DNR order" is an order written in a chart by a physician. It is an advanced directive, such as a living will, that allows the patient to express their wishes when they can't otherwise communicate.

  • Jim Kornell says:

    The scenario describes the children as minors -- he's 40, the kids are young. His wife is dead; there's no family in appropriate shape to take the children in. So -- someone has to pay, both costs and time/energy. My religious beliefs don't entitle me to demand that you pay for my children. From this perspective, discussions of the patient's autonomy that don't consider the degree to which his decisions will have unavoidable effects on the autonomy of others seem incomplete. This leads me to two inferences, one of which makes me really uncomfortable. First, were the children adults, the situation would seem entirely different to me. (That's easy.) Second, were the patient rich--he would leave behind adequate resources to bring his children to adulthood and self-sufficiency without imposing on others (without their consent) -- then again, it seems different. (This one really sticks in my craw.) I can't think about this, though, without autonomy seen as a point in an ecology, where its extent is not autonomous.

  • PalMD says:

    Not all societies share the same medical ethics. Of course, not all Americans share all beliefs. This is one of the many reasons transparency in decision-making and ethical discussions is so important.

    There are, as you all are aware, certain ethno-religious communities (and among various families and individuals) in which "life" is sacred, and in practice, either explicitly or implicitly, dying bodies must be kept "alive" at all costs.

    This means torturous, expensive futile care is delivered. As a society, we've chosen to support this, often for good reason, but it would be insane not to recognize explicitly what we are doing.

  • Connie Bristol says:

    DNR and living wills can sometimes cross over to the area of euthanasia. Like families agreeing to extubate and watch their family member die especially if he is incoherent, unresponsive, terminal.

    Where is a hospice specialist to take a STAB at this? no pun intended

    And as stated, the financial burdens, should we keep certain people alive with certain medical conditions..

    I personally have a conflict with euthanasia, if I am the one pulling the plug.
    If a patient has stated his wishes, beliefs, the very best is to find out beforehand so you do not go down the road of possible MURDER as I see it later.

    However, watching my father die an agonizing death of cancer, I asked for ,morphine pca for his comfort knowing what would happen..
    I pushed the button any time I remotely thought he was in pain.

    he wanted to be DNR DNI, i honored his wishes.

    Did I murder him? No, the cancer mets with aspiration pneumonia did.
    You're right Doc Pal, this deserves another blog as I am going off into another rabbit trail.
    It is hard not to deviate from the "straight and narrow path.

  • Daniel J. Andrews says:

    I wonder if he'd be open to a bit of a Bible Study? The injunction against blood transfusions stems from the Old Testament dietary law about not eating/drinking blood. These were dietary laws regarding certain animals and animal products, which in their time could be dangerous (transmission of disease, parasites, spoilage in the desert heat, etc). Show the context. Don't eat blood products = don't have blood transfusion.

    JW's do not follow those other dietary laws so ask him why he ignores those laws that are in the same context but refuses to drink blood products which are banned by those same laws he's ignoring anyway.

    Then jump to the New Testament and Peter's vision where God tells him not to call anything he has created "unclean"--in other words, the message was "eat what you will". So he could now eat blood products, so by the same logic as above = he could now take a blood transfusion.

    Not that I expect highlighting inconsistencies in his beliefs will be very effective, but some people in some circumstances are just looking for a face-saving (conscience-saving?) reason to not be sticklers about a particular belief they've been told is there but which their own scriptures do not support.

  • Connie Bristol says:

    Great idea Brother Andrews. I still like prayer, provided, the person has been called to intercession, obedient, have faith, belief, already been in prayer, perhaps fasting, and of course the main, relationship. It's not a religion, it's a relationship. If he were that RELIGIOUS, I hate that word, wouldn't matter, but if he had an unbroken fellowship with God, he could simply ask the Lord and he would tell him, perhaps exactly what you have said.

  • daedalus2u says:

    The case I am remembering was a Jewish family where a 13 year old had brain death but because the definitionn of "life" they were using was a beating heart, so long as his heart was beating the hospital was to do anything and everything to keep his heart beating. This went on for a couple of months. The parents never visited, they knew he was brain dead and was gone, they just wanted to keep his heart beating as long as possible because of their religious beliefs. I think he was on a respirator, and required round-the-clock care just to keep his heart beating. As I remember the article, it was very hard on the staff to have to keep doing this, knowing how much it cost, knowing what the outcome was going to be, knowing that there were living people who needed these resources more.

    • Dianne says:

      Also note that keeping the body of this poor boy alive did potential harm to people in several other ways:
      It prevented his organs from being donated at an appropriate time, which might have saved a number of lives.
      People on respirators, brain function or no, are at very high risk of acquiring severe, often resistant infections-and passing these infections on to other patients if ANY person in the care team: doctors, nurses, technicians, volunteers, etc is even slightly careless about infection prevention procedures.

  • James Sweet says:

    Clearly the patient's wishes must be respected -- the ED doctor should not given the transfusion while the patient is unconscious.

    That said, this is one of many reasons why I could never be a doctor. What a fucking stupid reason to die. If I were the ED doc, I'd lose patience pretty fast and pretty much be yelling in his face. Not that I think that's the right thing to do; of course I don't! But I don't think I could have patience with such pointless pigheadedness.

    It's not even that I am incensed by people doing foolish things that jeopardize their health. It's just that, you know, you ought to have fun while you're doing it. Best not to be a heroin junkie, but it doesn't really infuriate me the way this does, because hey, at least the junkie is getting high for his troubles. This guy is getting... what? Guilt? False promises? What a rip-off for him.

  • Moderation says:

    As an ER MD, I find this question fairly straight forward ... I would respect this man's religious beliefs, including not trying to get around them by waiting for him to pass out. I would however use every tool in the chest to get him to change his mind ... including reminding him of his children's needs, perhaps even having him see them. I would even contact his religious leader or other family members to see if they were as committted to this course as the patient. In my work I deal mostly with minors so the picture can be clearer and at the same time cloudier. Clearer when it comes to young minors, but cloudier when it comes to older minors (especially in less emergent cases).

  • Side says:

    So, half of you would let him die out of spite because you think the man is stupid, and the other half would let him die because you think his beliefs are sacrosanct. That is saddening. Tell the ED doctor to prep him for surgery, get an anesthesiologist down there to knock him out before he bleeds any further, and, once he's out, hook up IV blood and preform the surgery. The ED doctor is legally covered, and you can claim that you were only consulted after the fact. Then you lecture him on how he needs to call you if he ever feels faint and not wait until he needs an EMT.

    "Oh no, my living patient might get mad at me, I better let him die!" Pathetic.