Case Studies

Case Studies

Case No. 1: Refusal of Treatment

Identify the ethical issues which arise in this case.

The ethical issue that is in consideration here is Refusal of treatment by patient. The family of Mr. George wants him to get treated whereas; Mr. George himself does not want to get treated. It appears that all conscientious objections to blood transfusions made in the US are based on religious scruples and made by members of the Jehovah's Witnesses. There is apparently no other organized group in the US, religious or secular, that prohibits receiving blood and blood products when required for legitimate healthcare reasons. The theological basis for the prohibition against blood transfusions is said to be contained in the Bible, Genesis 9:4 and Leviticus 17:14. It is curious that the Jehovah's Witnesses interprets these passages as a prohibition against their members receiving blood transfusions, while the Jewish religion uses these passages from the bible to require that blood be removed from animal flesh before it is cooked and eaten. It might be one of the reasons why Mr. George was refusing to the blood transfused (Dean, 1992).

Peer pressure, including the prospect of ostracism and expulsion, also encourages members of the Jehovah's Witnesses to refuse blood transfusions. Therefore it is essential that a hospital should enforce strict confidentiality if a Jehovah's Witness is offered a primary blood component. If the patient refuses a transfusion the decision must be respected provided the patient is fully informed and executes an informed consent.

In the Cooper University Hospital bloodless care program methods of treatment had to be developed so as to meet the required standard of care. The first step was a thorough evaluation of the best alternatives to transfusion for each individual patient. Treatment focused on aggressive prevention and reduction of bleeding, including use of less invasive surgical techniques. Phlebotomy samples are kept as small and as few as possible, coupled with the use of pharmaceutical agents such as epoetin alfa for the replenishment of the patient's blood supply. Advanced technology such as “cell savers” are used to collect blood lost during surgery for immediate re-use on the patient. Other sophisticated devices are harmonic scalpels that cut and cauterize simultaneously, and electrocautery and lasers to minimize blood loss (Perry & Edwards, 1990).

There are organized programs in the US established to save lives while accommodating refusals to receive blood transfusions, even when such refusals can be fatal. One is the “Bloodless Care Program” which offers viable alternatives to blood transfusions, see Units Potentially Involved, below (Illich, 1976). Another reason given for refusing blood, which does not seem quite logical, is a shortage in the supply of blood. In accommodating objections to blood transfusions, informed consent procedures must be scrupulously observed and documented, including the patient's condition, treatment options, benefits (if any), and risks (Dean, 1993).

How do you think the doctor should proceed in this case? Give reasons for your decision.

The Bloodless Care Program at Cooper University Hospital, Camden NJ, was established in 1997 to provide the best ...