Refusal of potentially life-saving blood transfusions
by Jehovah's Witnesses: should doctors explain that not all JWs
think it's religiously required?
Raanan Gillon, Imperial College School of Medicine, London
University
Journal of Medical Ethics 2000;26:299-301.
In this issue of the journal "Lee Elder",1
a pseudonymous dissident Jehovah's Witness (JW), previously an Elder
of that faith and still a JW, joins the indefatigable Dr Muramoto2
5 (the latter is not a JW) in arguing that even by their own
religious beliefs based on biblical scriptures JWs are not required
to refuse potentially life-saving blood transfusions. Just as the
"official" JW hierarchy has accepted that biblical scriptures
do not forbid the transfusion or injection of blood fractions so
too JW theology logically can and should permit the transfusion
of whole blood when this is medically required.
Few doctors would argue that they should override the adequately
autonomous decisions of Jehovah's Witnesses to refuse blood transfusions
even if they are likely to die as a result of such transfusions.
However, there is a case to be made for doctors asking such patients
to reflect on their potentially fatal refusal of blood and for drawing
to these patients' attention the reasoning of members of their own
faith that justifies acceptance of potentially life-saving blood
transfusions. What is that case? Simply that doctors' primary professional
duty to try to benefit the health of their patients entails trying
to save their patients' lives when and if doing so will benefit
their patients' health. Of course this is not an absolute duty overriding
all other duties; in particular if patients who are adequately autonomous
to do so refuse such lifeprolonging treatment doctors must generally
accept such refusal, however sadly. This editorial endorses that
view in the case of adequately autonomous legally competent JWs.
(In another paper in this issue of the journal Professor Shimon
Glick argues that ethics committees should be empowered—as
they now are in Israel—to override even competent refusals
of life-prolonging treatment where the committee judges that the
treatment would be "clearly beneficial" and predicts that
"if the treatment is imposed the patient will later give his
consent retroactively".6)
But even to argue that doctors should question a patient's religious
beliefs, let alone make suggestions that the patient should consider
a contrary belief, no matter that the contrary belief comes from
within the patient's own religion, is bound to raise hackles. Objections
will be raised that these proposals are no proper part of a doctor's
business; that they are perniciously paternalistic and coercive;
that even when not carried out in an apparently coercive manner
the power imbalance between doctor and patient will ensure that
in practice their effect will often be, or at least be perceived,
to be coercive, and disrespectful of the patient's autonomy. Furthermore,
their implementation would be offensive, and would cause unnecessary
additional distress for patients who already are likely to be exceedingly
distressed at the possibility of having to die in order to meet
their religious obligations. In addition, the proposals may be seen
as both morally and legally unjust by threatening to override the
patient's human and legal rights. Do these counterarguments succeed?
First, is it any business of doctors even to begin to involve themselves
with their patients' religious beliefs? Normally the answer is probably
no. But where such beliefs are likely to impair a patient's health
then it seems reasonable for doctors at least to be concerned with
and about those religious beliefs. As the synoptic argument given
above in favour of such concern indicates, trying to provide benefits
for their patients' health is the primary professional duty of doctors
and all obstructions to such health benefits are of prima facie
concern to doctors.
What about the claim of pernicious paternalism? The rebuttal is
straightforward. Paternalism is only a relevant concept in this
context if, in the absence of an emergency precluding such attempts,
the doctor does not try to discover the autonomous preferences of
an adequately autonomous person, or else overrides or ignores those
preferences, in order to provide a benefit to that person. In other
words paternalism is involved only when the doctor treats the patient
in the way a parent would treat his or her child for the child's
benefit but either without knowing the child's thought-out view
of the matter or else in contravention of that view. So while it
would be paternalistic to give a blood transfusion to a Jehovah's
Witness against his or her decision to reject a blood transfusion,
and while it would be paternalistic not to try to find out if he
or she accepted or rejected a blood transfusion, it would not
be paternalistic to ask such patients their reasons for rejecting
blood transfusions, nor to ask them to consider opposing views.
Would this be coercive or disrespectful of the patient's autonomy?
It would depend on how it was done. There can be little doubt that
questions can be asked and suggestions made in ways that are coercive
and/or legitimately perceived as coercive, and little doubt that
the likelihood of this happening is increased the more relative
power the questioner and suggestion-maker has over his or her interlocutor.
And doctors do have massive relative power over their patients in
many circumstances, especially when the patient is very sick. But
it is perfectly possible to ask questions and make suggestions and
requests, even to very sick patients, let alone to those who are
not very sick, without either being coercive or being perceived
as coercive—just by being ordinarily and sensitively concerned
for one's patient and his or her views as well as about his or her
health.
Would such inquiries and suggestions be offensive and cause harm
and distress to patients who may already be distressed at the prospect
of possibly having to die for their religious beliefs? While again
it would depend in part on how it was done, none the less almost
certainly some JW patients, as well as some of their family members
and co-religionists would be offended and distressed no matter how
tactful and sensitive the doctor was. Others on the other hand might
well be pleased to discuss and explain their own perspective and
to read the dissident JW views on the matter, even if they were
in no measure inclined to change their minds. And when considering
potential harm to patients it is important to consider all
the potential harms and benefits involved—including in these
cases the potential harm of dying unwillingly and unnecessarily
and the potential benefit of realising that not all one's co-religionists
believe that one is religiously obliged to refuse a life-saving
blood transfusion.
Here it may be helpful to recall other potentially offensive or
otherwise upsetting proposals that doctors may none the less feel
professionally obliged to make in the interests of trying to preserve
and or benefit their patients' health. Think for example of offering
to discuss the implications of unpleasant diagnoses with patients;
or of proposing peculiarly upsetting operations such as mastectomies,
colostomies or limb amputations; doctors will know that some patients
are going to reject such proposals and that for those patients the
very suggestions will prove to be excessively unpleasant, upsetting
and sometimes offensive, and with little or no compensating benefit.
Even simple explanations about the unhealthy effects of certain
lifestyles can be offensive and/or upsetting to some patients—none
the less doctors will often consider it their duty to offer such
explanations, (at least once!) in the interests of trying to benefit
their patients' health, despite knowing that they may offend and/or
possibly distress some patients by doing so.
Even if not coercive or offensive will patients' autonomy be somehow
overridden if doctors ask JW patients if they would be prepared
to give their reasons for rejecting life-saving blood transfusions
and to consider dissident JW views that accept blood transfusions?
Surely not, provided of course that such requests are genuine requests—as
distinct from some form of "doctor's orders"—made
in ways that are intended to respect the patient and his or her
autonomy, and that the answer "no" is accepted as such,
however painful it may be for a doctor to accede to such a refusal
and to have to employ alternative techniques that he or she considers
unlikely to save the patient's life. Given such qualifications it
is not disrespectful of such patients' autonomy to ask them if they
would explain the reasons for their refusal and to ask them if they
would read alternative explanations from their co-religionists that
might enable them to save their lives while honouring their religious
commitments. It is also true, as professor Glick points out,6
that respect for autonomy is only one of several potentially relevant
but potentially conflicting moral concerns and that there is no
automatic reason to assume that it must "trump" the others—but
as stated above, this editorial argues that in these cases the competent
JW's refusal of treatment should trump the other moral concerns
and be respected—however tragic the outcome.
Here it might be counterargued that religion is often not based
on reason but on faith, belief and spiritual values and that it
is simply mistaken—as well as damaging and disrespectful to
what might be termed religious autonomy—to attempt to use reason
to undermine them. While this may often be true, it is clear that
the JW belief that blood transfusions are forbidden by God does
purport to be based on reasoning, notably the explicit claim that
Biblical scriptures prohibit it—and both Mr Malyon and Mr Ridley,
on behalf of the main body of JWs, make this clear.7 9
Since such a claim explicitly appeals to reason it is entirely legitimate
to point out, as "Lee Elder" and Dr Muramoto do point
out 1-5 that blood transfusion has nothing to do with
"eating" or "ingestion" of blood (which is what
the relevant scriptures forbid) and that acceptance by the main
body of JWs of medical injection and transfusion of blood fractions
confirms this point. It is also worth pointing out, as Dr Savulsecu
and Professor Momeyer point out,10 that the vast majority
of Christians worldwide reject the antitransfusion interpretation
of biblical scriptures; and that the Christian practice of Holy
Communion is based on biblical scriptures in which, far from forbidding
the eating or ingestion of blood, Christ explicitly tells his disciples
to drink his blood, at least as symbolised in the communion wine
and for those who believe in the doctrine of transubstantiation,
as actualised in the communion wine.
Finally, what about the claim that it would be against justice for
doctors to ask their JW patients if they would explain why they
rejected blood transfusions and if they would read the opposing
views of some of their (admittedly dissident) co-religionists, on
the grounds that to do so would threaten the human and legal rights
of the JWs concerned? The claim is simply false. There are no human
rights requiring others to desist from asking one for explanations
of one's beliefs or from requesting that one reads views contrary
to one's own—assuming of course that "request" means
request and is not a covert term for coercion of some sort—ie
provided that one is not obliged to meet such requests. Nor, it
is worth explicitly stating, are the proposals in this editorial
based on distributive justice arguments which point out that
the alternative non-blood treatments required by JWs are unjust
because they cost much more than blood and therefore create unnecessary
opportunity costs for others.
Why the anonymity of "Lee Elder"? Despite Mr Malyon's
and Mr Ridley's and other official JW claims to the contrary it
seems to this writer probable that Jehovah's Witnesses who go against
the "official line" forbidding blood transfusions risk
major sanctions from their church, including highly oppressive rejection
by erstwhile friends, coreligionists and worst of all, even by family
members, such rejection apparently sanctioned and sometimes encouraged
by JW authorities. There are simply too many examples cited by Dr
Muramoto and "Lee Elder" and on the web sites cited by
them, as well as in the cases and in the web sites cited by Mr Hart
in his article in The Big Issue,11 for official denials
to be plausible. To help protect "Lee Elder" against such
risks the editor of this journal decided that it was justifiable
to withhold his proper name and instead use the pseudonym.
In summary, this editorial makes the fairly modest proposal that
doctors would at least be professionally justified—and some
might consider that they were professionally obliged—to ask
their Jehovah's Witness patients if they would explain why they
rejected potentially life-saving blood transfusions, and to ask
them if they would read arguments from members of their own religion—of
course currently dissident members—justifying their acceptance
of blood from within the belief system of that religion. The editorial
considers and rejects counterarguments to these modest proposals.
Henceforth the writer intends to act accordingly and to have available
in his medical office photocopies at least of "Lee Elder"'s
paper in this issue1 which he will invite his Jehovah's
Witness patients to read. Other doctors may wish to consider doing
something similar.
One final point, ad homines. Jehovah's Witnesses themselves
should respect the virtues of these proposed actions, which involve
asking people to explain their religious beliefs, asking them to
listen to counterarguments, and asking them to read articles promoting
alternative religious viewpoints. As a group, JWs are among the
most ardent exponents of such an approach, especially on Sunday
mornings when they knock at the doors of perfect strangers and ask
permission to reason with them, and offer them literature, as part
of their endeavour to help these strangers save their immortal souls.
Thus of all people JWs should themselves be the last to find it
offensive or immoral if their doctors risk offending them when they
return the compliment in an effort to save their mortal bodies.
It remains possible for all parties to decline either form of attempted
salvation.
References
1 Elder L. Why some Jehovah's Witnesses accept blood and conscientiously
reject official Watchtower Society blood policy. Journal of Medical
Ethics 2000;26:375-80.
2 Muramoto O. Medical confidentiality and the protection of Jehovah's
Witnesses' autonomous refusal of blood. Journal of Medical Ethics
2000;26:381-6.
3 Muramoto O. Bioethics of the refusal of blood by Jehovah's Witnesses:
part 1. Should bioethical deliberation consider dissidents' views
? Journal of Medical Ethics 1998;24: 223-30.
4 Muramoto O. Bioethics of the refusal of blood by Jehovah's Witnesses:
part 2. A novel approach based on rational non-interventional paternalism.
Journal of Medical Ethics 1998; 24:295-301.
5 Muramoto O. Bioethics of the refusal of blood by Jehovah's Witnesses:
part 3. A proposal for a don't ask-don't-tell policy. Journal
of Medical Ethics 1999;25: 463-8.
6 Glick S. The morality of coercion. Journal of Medical Ethics
2000;26:393-5.
7 Malyon D. Transfusion-free treatment of Jehovah's Witnesses: respecting
the autonomous patient's rights. Journal of Medical Ethics
1998;24:302-7.
8 Malyon D. Transfusion-free treatment of Jehovah's Witnesses: respecting
the autonomous patient's motives. Journal of Medical Ethics
1998;24:376-81.
9 Ridley D. Jehovah's Witnesses refusal of blood: obedience to scripture
and religious conscience. Journal of Medical Ethics 1999;25:469-72.
10 Savulescu J, Momeyer RW. Should informed consent be based on
rational beliefs? Journal of Medical Ethics 1997;23:282-8.
11 Hart S. The end of the world isn't nigh. The Big Issue
2000 Jul 17-23: 21-2 (with thanks to Dr Richard Ashcroft for drawing
this unusually sourced article to the author's attention).
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