A Case of Deception?

By Bramstedt, Katrina A.; Macauley, Robert | The Hastings Center Report, November-December 2005 | Go to article overview

A Case of Deception?


Bramstedt, Katrina A., Macauley, Robert, The Hastings Center Report


PB, a middle-aged man, has suffered from Crohn's proctitis, an autoimmune disorder, for most of his life. To treat it, he undergoes a nonemergent colostomy and proctectomy; he had also undergone several bowel resections at other hospitals prior to this with no complications. Before surgery, he meets twice with the surgeon to discuss surgical risks such as heavy bleeding. Preoperatively, his hemoglobin is 10.2 g/dL. However, twenty-four hours after surgery, his hemoglobin drops to 5.1 g/dL, prompting the doctor to recommend transfusion. PB refuses, saying he is a Jehovah's Witness. Jehovah's Witnesses typically refuse blood transfusion based on their interpretation of the Bible verse, "You are to abstain from ... blood" (Acts 15:9). Up until PB's refusal, neither the surgeon nor the anesthesiologist was aware that he was a Jehovah's Witness.

Based on this surprising revelation, the surgeon requests a bioethics consult to find out how to proceed. The bioethicist reviews PB's chart and finds that the hospital admitting clerk had noted his religion as "Jehovah's Witness" on the registration form. The bioethicist then interviews PB and his wife. They provide the bioethicist with a copy of PB's advance directive. This document states that PB will refuse blood transfusions in all situations, but PB did not give it to the surgeon or preoperative staff before surgery.

Did PB have a responsibility to provide information about his religious beliefs that would be relevant to his treatment to all hospital staff and make sure it was understood?

commentary

by Katrina A. Bramstedt

According to the American Medical Association, the practice of medicine is fundamentally a moral activity. Informed consent and therapeutic doctor-patient relationships rely on honesty between both parties. Lack of honesty on behalf of either party can create the potential for devastating consequences, yet often, discourse on this topic focuses on how the doctor communicates with the patient, not the patient with the doctor. In this case, even though the surgeon had multiple conversations with PB before surgery, PB never mentioned that he was a Jehovah's Witness and would refuse transfusion. Knowing these risks, it is somewhat surprising that PB did not choose a "bloodless surgery center" for his operation; however, he may have intentionally deceived the surgeon in order to be sure the surgeon would not decline to operate.

Because the surgeon and anesthesiologist were unaware of PB's faith, they might have given him a blood transfusion during surgery. Was PB gambling with his faith, denying the risk because of the improved quality of life that the surgery would give him? Could his failure to disclose his faith to the surgeon be a way of passively creating an opportunity to receive an intraoperative transfusion that might save his life? Jehovah's Witnesses believe transfusions inadvertently received are not battery, and the patients receiving them are not subject to spiritual retribution. Considering PB's history of multiple surgeries without transfusion, he might have believed his risk of bleeding was low.

The ethical problem with all these scenarios is that the surgeon is removed from the equation. That is, in nonemergency situations (as in this case), the surgeon retains the right to choose which operations he will perform, even if the patient has sought him out. Surgeons and anesthesiologists may elect to withdraw from cases in which a patient's religion constrains their personal practice of medicine. In the case described, the surgeon was shielded from information that was pertinent to PB's health care values and treatment planning. That planning could potentially benefit PB's surgical outcome and quality of life and prevent possibly catastrophic consequences should something go wrong. The preoperative consultations between PB and his surgeon could also have presented an opportunity to discuss "bloodless surgery centers," and for the surgeon to possibly provide referrals.

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