The care of a Jehovah’s Witness parturient can pose an ethical dilemma for the anesthesia care team since we are usually the ones who are responsible for transfusion during the perioperative period. On the one hand, we would like to respect the patient’s autonomy but on the other hand as medical doctors we have taken an oath to do no harm. In order to provide the best care to these challenging patients, the healthcare providers should understand the religious background of the Jehovah’s Witnesses, the ethical principles and medicolegal ramifications and the treatments which Jehovah’s Witnesses may be amenable to accept.

Jehovah’s Witnesses is a Christian denomination founded by Charles Taze Russell in Pennsylvania in the 1870s (1). Initially started out as a bible study group, it is now one of the most rapidly growing religious groups in the world with more than 7 million members worldwide and 1.15 million members in the United States, according to its 2009 census (2). The group is officially known as the Watchtower Bible and Tract Society and since 1931 its members are called Jehovah’s Witnesses based on biblical passages (Isaiah 43:10 to 12 and Hebrews 12:1, 2) (3). Jehovah’s Witnesses have a close knitted community and usually meet three times a week in the Kingdom Hall for religious discussion based upon topics from its official publications, The Watchtower and Awake! Jehovah’s Witnesses believe in the literal interpretation of the bible and salvation is dependent on being faithful to the word of Jehovah. Life on earth is a temporary period and death is a period of no conscious existence. All will be judged on Judgment Day and only the faithful and sin-free witnesses will be granted eternal life on paradise earth and the wicked will suffer eternal damnation (2). Jehovah’s Witnesses are known for their house to house ministry, refusal to recognize secular authority and salute flags, pledge allegiance, join service organizations, enlist in the military, vote in public elections, or take any interest in civil government and within the medical community for the refusal for blood transfusion (2,3,4).

In 1945 the Watchtower, the official journal of the Jehovah’s Witnesses, published the first stance against blood transfusion. The article warned its members against taking blood directly into the human body and to respect the sanctity of blood; however, no punitive measure for accepting blood transfusion was mentioned. The source of this belief is based on literal translation of the several passages from the Bible (Genesis 3, 4, Leviticus 17:10 to 16, and Acts 15:28 to 29).

Jehovah’s Witnesses consider receiving blood products intravenously to be the same as “eating blood,” similar to an intravenous feeding of a sugar solution to feed the patient (4,5). The official position of the Watch Tower Bible and Tract Society is that blood is sacred and once blood leaves the body, it must be disposed; therefore, preoperative donated autologous blood and allogeneic whole blood are prohibited. Jehovah’s Witnesses who accepted blood transfusion are at risk for eternal damnation and eternal salvation is forfeited. Since 1961, individuals who “partake” blood can be “disfellowshipped” or excommunicated from the church and other members are required to refrain from spiritually socializing with the disfellowshipped member. This shunning from the community can cause great anguish to the disfellowshipped member (6,7,8). Administration of blood to a Jehovah’s Witness against her wish has been likened by Witnesses to rape (9). If a Jehovah’s Witness received blood against her will, she will not be disfellowshipped but she may have deep and lasting psychological effects (9). In June 2000, The Watchtower magazine published an article which clarified its position on blood transfusion. Blood is divided into four major components: Red blood cells, white blood cells, plasma, and platelets. A Jehovah’s Witness is prohibited from receiving these major components; however, the utilization of minor components of each major component such as hemoglobin-based blood substitute, interferons, interleukins, albumin, globulins, clotting factors, and wound healing factors is left to each member’s conscientious decision (Fig. 43-1) (10,7). This position was reaffirmed in the section “Questions from Readers” in the June 2004 Watchtower.

Jehovah’s Witnesses carry an Advance Medical Directive/Release pocket-sized card which stated that no blood be administered under any circumstances (11,2). This card is renewed every year. The patient can also write in the blood factions and alternative treatments that are personally acceptable.

The Watch Tower and Tract Society established a network Hospital Liaison Committee worldwide to provide physicians information on the religious views of a Jehovah’s Witness patient. There are more than 1,600 committees worldwide with some 120 in the United States (11). One can contact the Hospital Liaison Committee at anytime by phone (718-560-4300) or email (his@jw.org) for support (11). Jehovah’s Witnesses have also championed bloodless medicine and surgery programs where blood is avoided and alternative techniques such as optimizing preoperative red blood cell production, oxygenation, and prophylactic angiographic embolization are offered (12). In the United States, many hospitals have developed these bloodless programs not only to treat Jehovah’s Witnesses but also for blood conservation (13,14,15). The Society for the Advancement of Blood Management was founded in 2001 to improve patient outcomes through optimal blood management. Its website (www.sabm.org) provides a list of hospitals with bloodless medicine and surgery programs.

Within the Jehovah’s Witnesses’ community, there is a group who disagree with the Watch Tower Bible and Tract Society’s blood ban policy. The Associated Jehovah’s Witnesses for Reform on Blood seek to change the blood policy which they viewed as misguided policy and biblical misinterpretation of blood by a high-control religious group (6,16). Muramoto noted that “the significance of the reform movement for physicians is awareness of a growing diversity of values and beliefs among individual Jehovah’s Witnesses. Such diversity requires physicians to scrutinize the patient’s premolded medical directive more closely and take a more individualized approach” (16).

In caring for patients, a physician subscribes to the four principles of medical ethics. Each of the principles is equally important and efforts must be made to avoid violation of any one of them (17). Autonomy or “self-rule” is the right to choose or refuse recommended treatment. Beneficence or “doing good” compels the physician to act in a manner that is beneficial to the patient. Non-maleficence is the obligation not to harm or cause injury and Justice is the fair distribution of benefits, risks, and cost. Traditionally, beneficence and non-maleficence played a central role in medical ethics but within the past 30 years, autonomy and justice have become more prominent (18). The principle of autonomy is the foundation of informed consent and a person’s right for self-determination. A person must be competent and have the capacity to give consent. An informed consent must occur prior to any treatment or intervention. The consent is considered informed if it has the following elements (9,18):

Muramoto and Elder have argued that Jehovah’s Witnesses do not have autonomy since there is organized intimidation from the church and members are given insufficient information about blood transfusion (6,19). Malyon and Ridley responded that in caring for Jehovah’s Witnesses, the physician must respect the patient’s autonomy and beliefs and that faith transcends rationality (8,20).

The principle of justice has also come into question when caring for Jehovah’s Witnesses. Savulescu pointed out that in demanding for alternative treatments other than blood transfusion; Jehovah’s Witnesses are receiving more expensive alternative treatments (21). By providing care for a patient, the physician enters into a patient–doctor relationship in which the physician has a moral obligation to always act in the patient’s best interest. The physician’s desire for non-maleficence and beneficence may come into conflict with the patient’s autonomy and society’s justice (22,23,24,25).

When the four principles come into conflict in a difficult clinical situation, the physician may use different perspectives and frameworks to solve the problem. The virtue-based approach relies on qualities of character that dispose health professionals to make choices and decisions that achieve the well-being of patients (26). There is no comprehensive list of virtues but five are applicable to medical practitioner: Trustworthiness, integrity, discernment, compassion, and conscientiousness (27). By using virtue ethics as a framework to a medical dilemma, the physician takes into account the emotions and motivations of the involved parties and arrive at a creative solution. Virtue ethicists recognize that tragic dilemmas can rarely be resolved to the complete satisfaction of all parties and that any conclusion is likely to leave some remainder of pain and regret (27).

The care-based ethics or the ethic of care emphasizes the commitment, empathy, compassion, caring, and love instead of the impartial principles. Good ethical decisions result from personal caring in relationships and the impact of different possible actions on those relationships (26). The communitarian ethics assumes that human beings are social animals and whose lives are lived out within social, political, and cultural institutions and practices (28). The need of the community may supersede personal autonomy. An example of communitarian ethics is the need to balance a patient’s claims of privacy and confidentiality against risks to others (26). The case-based approach to an ethical decision uses previous similar cases as precedent for the current one. Past decisions about moral rights and wrongs in cases serve as a form of authority for decisions in new cases (29). The difficulty in the case-based approach is in determining the similarities and differences among the cases (26).

According to the American Medical Association Code of Medical Ethics, Opinion 8.115, if it is not an emergency situation, the physician may terminate the doctor–patient relationship by transferring the care to another physician who is willing to treat the patient without using blood (30). However, physicians have resorted to the legal system when patients rejected the medical recommendation for blood transfusion.

The First Amendment of the United States Constitution, as extended to the individual States by the Fourteenth Amendment, guarantees the absolute right of every individual to freedom in his religious belief (31). A religious belief is a constitutional guaranteed freedom but religious practice is not an absolute guaranteed legal protection. Courts have upheld a variety of laws on the theory that society has an overriding interest in protecting the lives of its citizens (31). There are no statue laws regarding religious freedom since this is covered by the Constitution; however, there are multiple case laws regarding religious practice. Case laws are the resulting court rulings from individual cases and may be inconsistent due to different jurisdictions and individual states laws. Case laws tend to change over time due to the changing values of society (32).

The case of Schloendorff v New York Hospital (1914) is often cited as the landmark case for patient’s autonomy or the right of a competent adult to accept or refuse care and need of consent for medical procedures. Mary Schloendorff had agreed to have an examination under ether but did not want any surgery done. However, during the examination, the surgeon decided to perform a hysterectomy in order to remove the fibroids. She developed severe postoperative complications with loss of fingers and injuries to her legs. She sued the hospital for surgery performed without her consent and as a result, she was maimed for life (33). Judge Benjamin Cardozo wrote in the court’s opinion that “every human being of adult years and sound mind has a right to determine what shall be done with his own body, and a surgeon who performs an operation without his patient’s consent commits an assault for which he is liable in damages. This is true except in cases of emergency where the patient is unconscious and where it is necessary to operate before consent can be obtained” (34). Unfortunately, Ms. Schloendorff’s claim was rejected because a non-profit hospital could not be held liable for the actions of the doctor who is considered an independent contractor.

The law is clear on a competent adult who knows the nature and consequences of his actions. The competent adult may make a decision about her healthcare that may be contrary to the physician’s recommendations. This right is reiterated in The Patient Self-Determination Act of 1990, which became effective in 1991. The act requires facilities which received Medicare or Medicaid funding to provide in writing to each adult patient describing the person’s legal rights according to the laws of the state in which he or she resides. The patient can accept or refuse medical treatment and has the right to an advance directive (35,36).

Minors have no legal rights and remain under parental jurisdiction until they reach the age of majority but the state has a duty and interest in preserving the health of minors (37). This principle is known as “Parens Patriae” which the state acts as “the father of the people” in order to preserve the basic right of a minor to grow up and become an adult (38). Courts usually intervene in cases involving minors with imminent threat to life or limb by failure to receive blood because of the parent’s religious belief. In 1944, the milestone cases of Prince v Massachusetts which concerned a child distributing Jehovah’s Witness magazine accompanied by an aunt, Justice Rutledge wrote “Parents may be free to become martyrs themselves. But it does not follow they are free, in identical circumstances, to make martyrs of their children before they have reached the age of full and legal discretion when they can make that choice for themselves” (39).

When it comes to a pregnant woman’s rights, the courts have been asked to assert the rights of the woman and that of her unborn child. The Roe v Wade‘s decision in 1973 allows the state to prohibit abortion when the fetus attains the point of viability. However, the state’s interest in protecting the life of the fetus is limited by the mother’s own interests in the preservation of her life and health (40). With the improvement of fetal monitoring, more cesarean deliveries are done to safely deliver the baby. In the 1980s, physicians and hospitals would resort to the court system to compel a pregnant woman to undergo a cesarean delivery when the woman refused the recommended surgery (41). The Supreme Court of Georgia in 1981 ordered a pregnant woman at 39 weeks’ gestation with a diagnosis of placenta previa to undergo a cesarean delivery in Jefferson v. Griffin Spalding County Hospital. Mrs. Jessie Jefferson has refused to consent for a cesarean delivery based upon religious belief and faith in God. This is the first case in which the court ordered a pregnant woman to undergo surgery in order to save a viable fetus and establishes a pregnant woman’s duty to protect the health of a viable fetus and fetal right to such protection and the first time a court asserts jurisdiction over a fetus in order to transfer custody of the fetus to the state (42). The court’s decision in Jefferson was based upon the physician’s opinion that there was a 99% chance that the baby would not survive and a 50% chance that the mother would not survive a vaginal birth and that the Roe analysis allowed the state to protect a viable fetus which derived from the statutes that prohibit abortion (40,42). The court’s conclusion is that the state interest in protecting the potential life of a viable fetus outweighed the mother’s right to refuse medical treatment, to practice her religion, and right to parental autonomy.

There is a lack of U.S. Supreme Court opinion on maternal rights versus fetal rights. However, there are inconsistent state case laws regarding the right of a pregnant woman to refuse medical treatments. Because of the different state laws, maternal–fetal rights remain a highly emotional charged issue.

The state of Illinois is a strong maternal right state (43). In 1988, the Illinois Supreme Court determined in the case of Stallman v. Youngquist that the mother is not liable to her child for accidental prenatal injury. The father sued the mother on behalf of his child who had suffered injury due to an automobile accident which occurred when the mother was driving when she was 5 months pregnant. The court held that the child does not have the right to recover against its mother and that “judicial scrutiny into the day-to-day lives of pregnant women would involve an unprecedented intrusion into the privacy and autonomy of the citizens of this State” (43). The landmark decision of the Stallman case is that the Illinois Supreme Court determined that fetal rights are not superior to maternal rights.

In 1994, the Illinois Court of Appeals upheld with the lower court’s decision to refuse to order a cesarean delivery In re Baby Boy Doe. The case involved a pregnant woman at 37 weeks’ gestation who had refused to undergo a cesarean delivery upon the recommendation of her doctor because of placenta insufficiency, citing religious reasons. The court’s opinion was based upon the previous Illinois cases including Stallman and stated that “a woman’s right to refuse invasive medical treatment, derived from her rights to privacy, bodily integrity, and religious liberty, is not diminished during pregnancy. The woman retains the same right to refuse invasive treatment, even of lifesaving or other beneficial nature that she can exercise when she is not pregnant. The potential impact upon the fetus is not legally relevant; to the contrary, the Stallman court explicitly rejected the view that the woman’s rights can be subordinated to fetal rights” (40,43). The patient delivered vaginally a healthy baby boy 3 weeks after the court’s petition.

In re Fetus Brown, a court order was obtained to forcefully transfuse Darlene Brown after a surgery to remove a
urethral mass at 34 and 3/7 weeks pregnant. She had refused blood transfusion during surgery because of her Jehovah’s Witness’ belief and no blood was given; but after surgery her hemoglobin level was 4.4 g/dL and continued to drop to 3.4 g/dL on postoperative day 2. Her doctor, who feared that without a blood transfusion Darlene Brown and her fetus would not survive, asked the hospital to request a court intervention so that a blood transfusion can be given to save the patient’s and her viable fetus’ lives since blood transfusion was considered minimally invasive to Mrs. Brown. The Illinois circuit court citing the state’s interest in a viable fetus appointed the hospital administrator as a temporary custodian for Fetus Brown who then consented to blood transfusion based on the physician’s recommendation. Darlene Brown had to be sedated and restrained during the transfusion. She delivered a healthy infant a few days later. Brown appealed to the Illinois Court of Appeals contending that as a competent adult under federal and Illinois law, she has an absolute right to refuse medical advice and treatment and to overturn the trial court’s order appointing a temporary custodian to blood transfusion for the benefit of her fetus (44). The Illinois Court of Appeal agreed to hear the case even though the issues had become moot since Brown had delivered and the hospital custody was terminated. The court considered the case since the issue may come up again in the future and the issue is “a public one requiring authoritative determination for the future guidance of public officials, especially given the emergency and expedited nature of such proceedings” (44). In examining the case, the court had to determine the right of a competent adult to refuse medical treatment to the state’s four interests in refusal of treatment cases:

In the first interest, the court found that the state had an interest in preserving the life of both mother and fetus. However, the court held that “the State may not override a pregnant woman’s competent treatment decision, including refusal of recommended invasive medical procedures, to potentially save the life of the viable fetus” (43,44). The court also found that “blood transfusion is an invasive procedure that interrupts a competent adult’s bodily integrity.”