Medical Ethics: Gillon

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 Muramoto^{2 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).