In transfusion, patient's wishes are sacred

THE CASE: Charlotte has been in a serious road traffic accident and immediately needs major surgery to save her life. She will also need blood transfusion as part of this treatment, but as she is unconscious her consent cannot be sought or obtained. A nurse discovers that as Charlotte is a devout Jehovah’s Witness she carries a refusal of blood card.

Without the transfusion she will die from injuries which the doctors believe to be treatable. The doctors decide to proceed with the surgery, believing that Charlotte will be glad to be alive when she recovers.

THE DISCUSSION: As we have seen in previous weeks, the first aim of medicine is to restore health and save life. For healthcare professionals it is anathema to lose lives which could be saved. At a personal level, therefore, the doctors’ decision is intelligible. Had the card not been there, or not discovered, the doctors would have had the authority to proceed without Charlotte’s consent.

That authority is derived from the legal doctrine of necessity, which permits treatment not consented to where it is necessary to save life or prevent deterioration of the patient’s condition.

The doctrine does not permit just anything to be done to the patient, however. In one case, for example, a doctor unilaterally decided to sterilise a patient in the course of other surgery, believing in good faith that a further pregnancy could be life-threatening.

This was not covered by the necessity doctrine as it was not necessary to save life or prevent deterioration; the patient’s consent should have been sought.

However, ethically, the decision in Charlotte’s case is debatable for two reasons.

First, it is impermissible to second-guess what appears to be the competent decision of a patient, even if she is not capable, at the time, of repeating it. The authority of advance directives or statements, which are specific and apply to the circumstances - as is clearly the case here - is now settled in law. Given that there was no reason to believe that Charlotte had changed her mind, her previously expressed wishes should be followed.

Second, freedom of religion should be generally respected, and is in fact a specific right contained in the European Convention on Human Rights which was incorporated into UK law by the Human Rights Act 1998.

The rights to both hold to a particular faith and to express the tenets of that faith in one’s personal life choices are clearly outlined by the Human Rights Act. Thus, however irrational the decision may seem to others who do not share those religious views, there is no doubt that it should be respected.

Doubt arises, though, when patients refuse life-sustaining transfusions and there is reason to doubt the voluntariness of those decisions.

In one case, for example, a young woman who had been brought up as a Jehovah’s Witness but no longer regarded herself as such, refused transfusion after a conversation with her mother, who remained a committed Jehovah’s Witness.

In this case the court was unwilling to respect her choice, deeming her decision to have been made under undue pressure from her mother. It could not, therefore, be categorised as a true exercise of the patient’s autonomy. The court was then obliged to make a decision in her best interests.

This is clearly a different situation from the case described at the beginning, where the patient’s intention is clear and unequivocal. It seems correct to reject the patient’s decision in the latter case, but not so in the former.

Doctors who refuse to respect a competent decision, such as the one made by Charlotte, run considerable legal risk.