Yesterday, I wrote about the overwhelmingly sad case of Dennis Lindberg, the 14-year old Jehovah's Witness who died because of his misguided adherence to the twisted interpretation of a 3,000 year old Biblical text and the court's acquiescence to this lunacy. So did P. Z. Myers. In response to the post on Pharyngula, I saw a comment that disturbed me greatly:
At the hospital where I work we have a procedure in place just for JW's. We have a stack of court orders waiting. When the patient loses consciousness a doctor fills out a form declaring them no longer capable of making their own decisions, someone fills in the name and date on the court order and takes it to the judge (who is not like THAT judge), wakes him up if necessary, he signs, we give the transfusion. If parents are refusing treatment for a minor, we call the police and they are arrested for criminal neglect of a minor. If the patient lives, we drop the charges.
Sometimes, of course, this all takes too long and we lose them. But we try. Our most recent case involved a mother 22 years old who had just given birth to twins. She had bled so much she was in real danger of dying, and she knew it.
We saved her. I don't know if she is glad, but we are.
As much as I can, as a physician, sympathize with this viewpoint, I nonetheless found it appalling.
Although I can pretty much agree with this approach in the case of minors who are Jehovah's Witnesses and would probably have few qualms about implementing it in the case of patients under, say 14 years old (15-18 years old would be a gray area), such a policy is completely misguided and wrong when applied to adults. Indeed, as nearly all bioethicists would certainly agree, such a policy is completely unethical applied to adult Jehovah's Witnesses.
The reason is obvious. In a free society, adults have domain over their own bodies and should be allowed to refuse treatment, regardless of the reason for their refusal, as long as their refusal doesn't endanger others (highly contagious and deadly diseases, for example). It really doesn't matter one whit if the reason for refusing life-saving treatment, be it transfusion, chemotherapy, or whatever, is a careful consideration of the risk/benefit ratio, a desire to pursue quackery instead of evidence-based medicine, or religious delusions based on a tortured interpretation of ancient scripture developed a mere 62 years ago, such as the teachings of the Jehovah's Witnesses about blood transfusion--or whatever. Treating a competent adult against his or her clearly stated wishes is a profound violation of person and intolerable in a free society.
Of course, for children, it's an entirely different matter.
Assuming adults do have complete autonomy, what would you do in the case of an obvious suicide attempt where the patient can be revived? Clearly he or she wants to die. On what grounds could you thwart those wishes?
Is actively trying to take your own life any different from refusing life-saving intervention?
In the USA we have the inalienable right to be idiots, as long as it doesn't hurt someone else.
As much as some might like it to be otherwise, minors are not equipped to make a decision of this magnitude, and so they can't. But then there's the mentally ill person, who believes that invisible spiders from the planet mergon are out to get him. That person is also incapable of refusing treatment, is he not ? If religion is a form of mental delusion, and delusional people can't decide to not be treated, it seems that logically . . . (fill in the blank).
But, there must be some finer point to it than this.
Is it because no one can logically disprove the existence of a deity ? Perhaps it's because religion is widely accepted as a rational belief.
But in the mentioned case, what would have become of the twins?
IMHO, in deciding to have children at all, the mother made a decision for which she is responsible. I don't think she has the right to "let" her babies grow up as orphans when she can help it.
The death of a young person is always tragic, no question about it. You can be sure he would have far rather lived. Yet people routinely put their lives on the line for any number of causes, and they are generally lauded as heroes for it, not deluded nuts. Which are they? Take the one who "gives his life for his country," for example. Only some of that person's own countrymen will think his death noble. Everyone else will conclude he died in vain.
The lad suffered from leukemia. Nobody imagined they could cure him. Instead doctors thought he would likely (70% chance) survive at least for the next 5 years with their regimen which included transfusions. The courageous youngster, Dennis Lindberg, was assessed by a judge who interviewed the parents, his aunt (who had custody), social workers and the boy's doctor. "I don't believe Dennis' decision is the result of any coercion," the judge stated. "He is mature and understands the consequences of his decision."
Being of the same faith and familiar with his mindset, I feel I can identify with his thinking. He would not want to be portrayed as a fanatic nor the victim of fanatics. (The boy's father states "My sister has done a good job of raising him for the past four years," though he feels she imposed her religious beliefs on him. The facts speak otherwise. Dennis had made he beliefs his own.
Don't more youngsters die each year in high school sports than in refusing transfusions? Each year I read a few local examples of the former. I'm not sure I would know any of the latter were it not for news media relaying any such event around the globe. Does anyone think high school sports should be banned or it's coaches judged accessories to "negligent homicide," as some bloggers thought would be appropriate for those who may have contributed to Dennis' mindset?
But one also must address the assumption, never challenged in the media, that rejecting a transfusion is tantamount to suicide. (The judge stated that "I don't think Dennis is trying to commit suicide. This isn't something Dennis just came upon, and he believes with the transfusion he would be unclean and unworthy.") How often does one read the noun "blood transfusion" not proceeded by the adjective "life-saving?" The facts suggest the label is not especially fitting.
For example, Surgeon Bruce Spiess addresses the Australian and New Zealand College of Anesthetists (google it, if you like) a few months ago, and declares blood transfusions have hurt more people than they've helped. Transfusions, he observes, are "almost a religion" because physicians practice them without solid evidence that they help. Several recent studies support his statement.
We all know that blood is a foreign tissue and we all know that the body tries to reject foreign tissue, even when the types match.
Jehovah's Witnesses steadfastly refuse blood transfusions (for religious reasons, not medical) and have created hundreds of Hospital Liaison Committees composed of members who interact with local hospitals and doctors. As a result, some in the medical field have pioneered bloodless techniques. By eliminating the risk of foreign tissue, human error, and blood-borne diseases, these new techniques offer a safety margin that conventional blood transfusions do not. The film Knocking states there are over 140 medical centers in North America that offer some form of bloodless surgical techniques. Might the day come, or is it even here already, when the number of lives saved through such medicine will outnumber those lost by a few members of a relatively tiny religious group that stuck to its principles amidst much opposition?
Well, insane people usually get a guardian for their own good when they're clearly not able anymore to make sane decisions.
Sometimes they even get locked up in a mental institution if they are too crazy or a danger to other people or themselves.
Refusing a life saving blood transfusion (which hasn't even any side effects) is clearly insane if the refusal is just because of the blood transfusion itself. After all we also stop people who want to kill themselves more actively (if they're healthy, an argument can be made for suicide if someone is terminally ill).
If they want to kill themselves after they've left the hospital, well, too bad. Not much can be done against that. (Besides the above mentioned locking and drugging up in an institution. But that isn't really feasible anyway.)
But when they're in a hospital, well, then society is under obligation to try to save their life, even if they're too crazy to want it. If they can't agree with that, well, they just don't need to go to a hospital anymore.
DLC, I understand what you're saying. First of all, there are psychological and psychiatric techniques for determining if somebody is mentally ill. It's not just a decision the attending physician can make up on the fly. Heck, there are people who believe that God's existence is so obvious that the atheists are the delusional ones. Like you said, there is a nontrivial distinction between unfalsifiable beliefs and beliefs that contradict what lies under your nose. I guess you could argue that creationists are deluded, or you could argue that the evidence for evolution isn't "obvious" enough to people without a scientific background. But anyway...
I'm not up to date on my law. If someone in Dennis' position is mentally healthy, but wants to die for moral (but not religious) reasons, must his wishes be honored? For example, say he wants to collect on life insurance to save his impoverished family, or he's a repentant convict who wants to die to ease the family of the victim. I don't know, those are the only two things that come to mind. I'm just wondering if there really is a religious exemption in this kind of situation.
Either way, I agree with Orac that children are different. In this particular case, something definitely went wrong in the legal system.
Interested in David Marjanovic's comment. The last time this issue came up I posed a similar question - if a mother of a newborn child apparently wants to die, rather than live, doesn't that argue per se that she is not rational and thus not capable of taking the decision to not accept a transfusion (and almost certainly die) rationally?
Let's make sure we include the whole picture here. On one side, we have the lives saved by avoiding blood transfusions. On the other side, we have the lives lost by people who refuse blood transfusions. But don't forget the lives lost to diseases that could have been treated if doctors didn't have to waste time researching "bloodless" techniques for catering to a small religious group.
If these "bloodless" techniques really did save that many lives, then they would be justified on their own merit, without any patient-martyrs. And let's not forget the discontinuity of reasoning here. The reason they refuse transfusions has nothing to do with medical research. If research were to show that transfusions really are unhelpful, that does not justify the original reasoning. "Their principles" is that the bible is right, and not "medical science shows ...".
Re: sports vs. blood transfusions:
How on EARTH is that a rational analogy? You DO know more people play sports than get blood transfusions, right?
The studies that I've seen that make a such a strong claim that blood transfusions increase the risk of death and complications almost always textbook examples of the fallacy of confusing correlation with causation. Why? Because you have to think about why patients are transfused and who is transfused. It's the patients with more severe anemia, greater blood loss, and/or a worse coagulopathy. In other words, it's the patients who have lost more blood during surgery. Since it's dubious ethics to do a randomized study (it's incredibly hard to design such a study where you wouldn't either have to give transfusions to patients who don't need them or withhold them from patients who do need them order), it takes a highly sophisticated study to answer the question. Decent studies that look at this issue acknowledge that correlation doesn't necessarily equal causation and point out that the correlation may well be due to a lot of confounding patient-specific factors. Decent studies also look more at where our triggers for transfusion should be (are they set too high?) rather than making such over-reaching blanket claims.
In any event, you're bringing up a red herring anyway. As you point out, Jehovah's Witnesses do not refuse blood transfusion because they think that accepting a transfusion is riskier than not accepting it. They refuse them because of their bizarre (and only 62-year-old) interpretation of a 3,000+ year old passage in a book written by members of a pre-scientific society. It would be utterly irrelevant to JWs if transfusions were completely risk-free and never caused any adverse reactions. They'd still refuse them, even at the cost of their own lives, as Dennis did. It would have been life-saving, too. Your harping on a "five-year survival" misses the point that, in leukemia, if a patient makes it to five years without a recurrence chances are very, very good that the cancer's gone for good and very small that it will come back. Why do you think oncologists usually look at five year survival rates for this disease?
As for the "risk-benefit" ratio, in saying that transfusions have hurt more people than they've helped (assuming that's an accurate quote not taken out of context, something I would remain skeptical of until I can see the primary source) Dr. Spiess has come perilously close to crank-dom. (Whenever I see a scientist or physician calling something a "religion," my skeptical antennae start twitching rapidly.) Saying that we transfuse too often and that 25% of transfusions are not medically necessary (which he has said) is one thing. Most physicians would probably agree that more transfusions are done than necessary. But going on to say that transfusions harm more people than they help and that they've "never been tested" for safety and efficacy (yes, I've heard of Spiess before, and I've seen at least one interview with him where he's said that) is going beyond the pale.
Moreover, it's hilarious to see JWs taking credit for bloodless surgery and drugs like Epogen. Physicians didn't develop these drugs and techniques because of pressure from JWs; they developed them because (1) blood and blood products are limited resources of which there are frequent shortages, sometimes severe (indeed, there's almost always a blood shortage in the summer), and (2) because there are known risks of infection (very low) and of transfusion reactions (relatively low but common enough to be a significant concern). These developments would have occurred even if there were no such thing as Jehovah's Witnesses, and whether or not these developments find their way into widespread use will have nothing to do with JWs. If the science supports their efficacy physicians will ultimately adopt them; if the science doesn't, they won't.
If you honestly believe that a sane adult has the ethical right to refuse life saving treatment that is otherwise medically indicated, for ethical consistency you have to also believe they have the right to actively end their own life. IOW, that if a sane patient made the request, a physician should assist them in committing suicide.
There is no rational basis for asserting that 'passively' committing suicide is somehow ethical while 'actively' committing suicide is not. Don't fool yourself: In both cases the person is committing suicide.
Are you consistent? Or are you doing the "good ethics are whatever does't make me uncomfortable" dance?
Nonsequitur. Even in the case that it were to be conceded that a sane adult has the right to actively end his or her own life, it does not follow from that concession that a physician is obligated to assist that patient in doing so.
That person is also incapable of refusing treatment, is he not ?
No, if that person is not institutionalised, that person is totally capable of refusing any given treatment, up to and including the pills that will make those nasty spiders go away.
Damn, the first sentence in that is a quote.
Yet you believe it is your ethical obligation to take a negative 'action' to end their life because of their their express wishes.
You are inconsistent.
To make my point clearer, you are in essence arguing that killing someone with your left hand is ethical while killing them with your right hand is not.
The problem is that it is the killing, not the hand, that is the key ethically.
Misinterpreting the Old Testament prohibition against eating animal blood as a routine food item, in 1945, the WatchTower Society began teaching that receiving a blood transfusion was "eating human blood". Jehovah's Witnesses believe that receiving an infusion of human blood into their body's circulatory system is scientifically the exact same thing as eating or ingesting blood into their body's digestive system:
"A patient in the hospital maybe fed through the mouth, through the nose, or through the veins. When sugar solutions are given intravenously it is called intravenous feeding. So the hospital's own terminology recognizes as feeding the process of putting nutrition into one's system via the veins. Hence the attendant administering the transfusion is feeding the patient through the veins, and the patient receiving it is eating through his veins." -- The WATCHTOWER magazine, July 1, 1951.
Jehovah's Witnesses refuse to acknowledge that when human blood is transfused into their body's circulatory system that the transfused human blood remains to be human blood and continues to function as human blood. Jehovah's Witnesses refuse to acknowledge that if blood is eaten, then the ingested blood enters the body's digestive system, where the blood would be treated by the body exactly the same as it would treat a hotdog, a potato chip, or any other food item. Ingested blood would be completely digested and broken down into proteins, carbohydrates, fats, and waste; which are then either assimilated or excreted by the body.
The WatchTower Society uses scriptures which speak about the blood of slaughtered animals to teach Jehovah's Witnesses that blood is "sacred" because blood is the "symbol of life". Then, the WatchTower Society turns around and requires Jehovah's Witnesses to sacrifice their own "life" to maintain the alleged "sacredness" of a "symbol" of the very thing they are sacrificing -- their life. Jehovah's Witnesses refuse to acknowledge that the WatchTower doctrine on blood moronically places a higher value on the SYMBOL than it does on the THING SYMBOLIZED
In fact, the Old Testament scriptures permitted the eating of unbled animal meat, which the Bible treats exactly the same as eating animal blood itself. In isolated occasions, when humans needed to eat unbled meat in order to sustain their own human life, the Mosaic Law permitted such, but then required the eaters to fulfill the requirements of being "unclean" for a few days. Thus, the Bible recognized that the sustaining of human life was more "sacred" than maintaining the sacredness of animal blood. To do otherwise would be doing exactly what the moronic WatchTower Society does. It would make the SYMBOL more SACRED than the THING SYMBOLIZED.
In fact, the WatchTower Society is leading Jehovah's Witnesses to disobey GOD and violate the Holy Scriptures in one of the most serious ways possible. Because humans were created in GOD's image, GOD considers human life sacred. A Jehovah's Witness who sacrifices their SACRED LIFE in order to maintain the sacredness of a SYMBOL of that SACRED LIFE varies little from those who profane life by committing suicide. Those Jehovah's Witness Elders who teach and police this moronic doctrine vary little from common accessories to murder. The Bible is fairly clear in how GOD views murder, and how He deals with Murderers.
This moronic twisting of scripture would be laughable if not for the fact that it has lead to the pointless deaths of numerous Jehovah's Witnesses in the past, and it will continue to lead to the pointless deaths of many more Jehovah's Witnesses in the future.
The following website summarizes over 315 U.S. court cases and lawsuits affecting children of Jehovah's Witness Parents, including 200+ cases where the JW Parents refused to consent to life-saving blood transfusions for their dying children:
DIVORCE, BLOOD TRANSFUSIONS, AND OTHER LEGAL ISSUES AFFECTING CHILDREN OF JEHOVAH'S WITNESSES
http://jwdivorces.bravehost.com
Orac: But what if, say, a Jew or a Catholic or an Atheist (i.e., not a JH) happened to be mentally incompetent and made a decision that would cause his or her own death. Medical personnel with a court order could override that decision. Why is this crazy religion not a form of mental incompetence?
I'm just saying....
Orac - I agree with you and I respect your views and how you present them. The extension of that position is also to respect (indeed, to provide) euthanasia. After all, if I can choose not to have a transfusion for reasons of faith, it's not a long step to giving me a shot of blue juice for reasons of despair.
The funny thing is that the religious can't see it both ways. Terry Schaivo, anyone?
Benjamin: It's ridiculous to argue that taking a "negative" action (i.e., not doing anything, as in the case of a physician who does not force blood transfusions on patients who refuse them) is morally the same as taking a "positive" action (i.e., giving a suicidal patient drugs with which to kill himself). I mean, at the moment, there are starving children in third-world countries who will eventually die of malnutrition, and I'm not doing anything to stop it. Am I as culpable in their deaths as I would be if I shot them in the head myself? (Hint: the answer is "no.")
We have to remember that hospitals have liability issues. What it the admitted JW is the lone convert in a family? If the medical staff withhold treatment, they open themselves to a lawsuit.
I think the only ethical option for doctors is to give the treatment to an unconscious or underage patient, regardless of their faith. If the patient can make a full informed decision, and can absolve the hospital from legal ramifications, then treatment can be withheld. But not until then.
Refusal of treatment cannot be used as a demonstration that the patient is incompetent, because that completely negates patients' ability to choose and replaces it with whatever the physicians in question judge to be appropriate.
Orac is right: this is a profound violation of medical ethics.
Kassiane:
"Re: sports vs. blood transfusions:
How on EARTH is that a rational analogy? You DO know more people play sports than get blood transfusions, right?"
The parallel items to compare are not high school students to JW's in transfusion circumstances. They are high school students to JW youngsters.
Mat - case law on the subject goes both ways, and depends largely on the intrusiveness of the treatment and the legal perception of whether or not the patient is a danger to himself or others.(not to mention the personal biases of the judge involved) The right to refuse treatment has big, fuzzy grey limits to it. However, I maintain that the youth in this case should not have been told "yes, you can refuse treatment."
i don't see why it should, nor do i see why the child should change the hypothetical. if an adult woman apparently wants to die, that alone is not prima facie evidence of any lack of reason, after all.
No. It 'feels' different. But it isn't different at all. "Not doing anything" is not free of ethical onus. It is still an action.
The classic 'trolley problem' is on point. I recommend you read it and think hard before you conclude 'doing nothing' is not an action.
if an adult woman apparently wants to die, that alone is not prima facie evidence of any lack of reason, after all.
Maybe not -- depends how you define "reason," I guess. But even if it's rational to want to (in effect) kill yourself, I think it's pretty deeply unethical to kill yourself right after giving birth to a child (or, in this instance, twins).
When the options available to a doctor consist of either saving someone against their will, or leaving two babies without a mother, I can certainly see the value in the hospital's opting for a utilitarian rather than rights-based approach.
I know that JWs insist that autologous blood transfusion is just as shun-inducing as homologous blood, and that they've had angels-dancing-on-heads-of-pins discussions about cellsavers, crystalloids-backed dilution and reinfusion, etc.
Seriously. Crystalloids aren't OK? Your own blood isn't OK? The cellsaver isn't OK?
(the easily offended should start scrolling now)
My Un-PC opinion is let 'em die. It keeps them out of the breeding pool. If you are that willing to let dogma created by fallible humans triumph science (note that I do *not* speak of the literal word of scripture - just manufactured product), you seriously should not be allowed to participate in furthering the race.
E
No, the right to refuse treatment is quite well-delineated. It's the application of that right that's ambiguous.
If they reject autologous transfusions, then by logic, they should drain out their own blood because by leaving it in their body they are in effect "eating" it.
Actually, it is only red blood cells that are confined to the vasculature. Plasma perfuses everywhere, and is not fully drained when meat is butchered. Any kind of meat almost has to have albumin in it, which is the main protein in plasma.
I don't know. Can religion cripple someone's decision making capacities? I think so.
HJ
Just to reiterate, almost every physician in North America recognizes the right of a competent adult to refuse any therapy. To fail to do so can result in battery charges. It is the definition of "competent" and "therapy" that sometimes come into question.
And there is a clear distinction between allowing someone the autonomy to refuse care and actively aiding their suicide. There have been debates on this issue on the pages of JAMA, and in other medical sources, and of course, in the Catholic Church, but it is generally agreed upon at this point, at least in the States.
Exactly.
Benjamin seems to act as though the issue of the ethical and moral distinction between "active" and "passive" euthanasia is an issue that ethicists hadn't considered much or deeply before. If he sees no distinction between abiding by a patient's refusal of care and actively helping that patient to kill himself, I'm not sure I can explain it to him, although if I try I wouldn't waste the effort it would take in the comments of a post. Writing something like that would take enough effort that it would be a shame to waste it in the comments here, where few would read it. I'd make a full blog post out of it. Hell, one could make a serious of blog posts out of it. Hell, one could write a book on it. Certainly there are situations where the distinction might become a bit muddy, but those situations do not invalidate the distinction.
Be that as it may, Benjamin's just plain wrong when he claims it is "morally inconsistent" or "ethically inconsistent" to accept a competent patient's right to refuse care and to believe that physicians should not actively euthanize their patients or help them to commit suicide. It is not.
Benjamin Franz -
No. It 'feels' different. But it isn't different at all. "Not doing anything" is not free of ethical onus. It is still an action.
Bullshit. I have a living will. Under certain circumstances, I have a do not resuscitate order. Under others I am to be removed from life support. A doctor is ethically and legally obligated to follow my wishes, under those circumstances. In effect, it is little different than exactly what we are talking about here. The only difference being what I am unwilling to accept and they are. I have no problems whatsoever, getting a transfusion. I do have serious issues with my body surviving my brain.
I actually believe very strongly in proactive euthanasia as well. Under circumstances that would require I be removed from life support, I think it would be preferable to receive a fatal dose of sodium morphate, than be allowed to drown in my own fluids, starve to death or what have you. I do not expect that any doctor should be compelled to follow those wishes though. There is a vast difference between allowing me to die from lack or removal of interventions keeping my body alive and actively pushing the plunger that would speed nature along. Legally, it's the difference between following the wishes of the patient and a murder charge.
There is salient point here which has not been addressed: The believer's "right" to choose his own death does not create a moral obligation in the non-believer to honor that "right". Life itself is the greatest good, and for the physician it must trump the patient's deluded expectation of an afterlife -- unless of course the physician shares the delusion. For myself, if I found myself in the presence of such a patient, whose life I could easily save, and it was clear to me that his death would serve no purpose beyond the observance of his religious beliefs, I would feel no moral compulsion to let him die. He could, of course, make whatever corrections he thought best at a later time, when he is beyond the influence of secular physicians.
I'm well aware that it has been considered by ethicists. Orac, however, misrepresents the status of physician assisted suicide if he is attempting to imply that it is considered unethical by the majority of ethicists, physicians or the general public. In each case, his position is in the clear minority.
jponder:
So... you're pro-life, then?
I know of no moral philosopher, whether theist or non-theist, who would agree with that premise. (Most, at least, would argue that it's ill-posed.)
There are a lot of very smart people who have put a lot of thought to issues such as these, applying reason and proper methodology to these questions. By saying that you would not support a competent adult's wishes in refusing treatment, you dismiss the best thought on this issue out of hand. At the very least, you should hear them out before making up your mind.
This is an interesting debate :)
How about an example where both actions are `passive' i.e. someone who has slashed their wrists/taken an overdose and wants to die. This is much more similar to the JW case than the actively assisting a suicide example.
In this case, I guess a doctor would immediately classify the attempted suicide as mentally unfit and patch them up anyway, then get them some counselling.
Personally (and perhaps in a slightly snarky way), I'd classify the suicide response as more rational on occasion - hell, people's life can someone get so bad that dying may seem a release. Refusing to live when your life is OK over some ridiculous belief, though: that's crazy.
In my dealings with Jehovah's Witnesses, I have found them to be rational and ethical.
While I found some of their beliefs to be a bit . . . unusual . . ., I chose to study with them, rather than to dismiss them as "morons", as some have done.
Getting to know the basis of some of their beliefs went a long way to helping me understand their reasoning and to expand my own thinking, overcoming my own mind set, so to say.
They are, by and large, a group of people who have chosen a path that causes them to live in ways that the larger society finds threatening and attacks at every opportunity.
That is quite understandable, as to view them in any other way would require the attackers to change their lives in ways that are "inconvenient".
When I disagreed with some interpretations, I never found a Jehovah's Witness to be hostile or disparaging. On the contrary, I often found them to be quite happy to discuss matters.
While they do, in my opinion, interpret some things "wrongly", that does not reduce my respect for their efforts to "know the truth" and it does not make them "morons" that I happen to disagree.
Quite the contrary, my respect for them has increased, over the years, for their Bible knowledge, intelligence, ethics and effort, even while I continue on my own path, such as it may be.
Joe,
I appreciate your experiences with Jehovah's Witnesses as positive, but reading the Bible or shopping with someone is much different than making life and death decisions.
I have seen many JW's in my medical practice mainly because other physicians in town are less than enamored with caring for them. I would agree that all are pleasant and deserve respect, but I have come to the conclusion that anyone who could hold such a tangential view of an ancient scripture most likely has other failures of rationale as well.
The questions I ask myself, and them, repeatedly:
1. Do they really really understand the diagnosis?
2. Do they really really understand the treatment recommendations?
3. Do they really really understand all the possible outcomes?
I had one patient who was pregnant and was seen for a routine prenatal exam. On her intake questionnaire she identified herself as JW and wanting no blood transfusions. (This makes obs very nervous.) On further questioning, she said "Well, if my life is in danger, well then, yea, of course I would want blood-- but not otherwise." Duh!
To put it bluntly, I always have to wonder that if they have one screw loose that I know about, then how many other nuts and bolts are loose as well?
To conclude, JW patients are a challenge-- and many physicians feel this is a challenge not worth taking on. Practicing medicine is hard enough...
(BTW, Orac and this blog have covered this issue superbly.)
Grodge writes:
I always have to wonder that if they have one screw loose that I know about, then how many other nuts and bolts are loose as well?
That's a wonderful way of putting it!!
There's a fair amount of misinterpretation of ethical ideas in this discussion, giving rise to any number of red herrings and non sequiturs.
Even if both "active" and "passive" roles are equally causally implicated in bringing about the death of a patient, that doesn't erase the difference between acting in accord with vs contrary to a competent patient's rejection of proffered medical procedures. In most situations, if a competent patient says "No!", healthcare providers are ethically bound to respect the patient's right to make that choice, whether or not they agree with it.
Of course, that patients can refuse treatment shouldn't be taken to imply that they can compel it. Healthcare providers are also assumed to be competent, autonomous agents who can sometimes refuse to provide treatment they think is morally or medically inappropriate.
I do agree that patients deserve the right to commit medical suicide, but doesn't that also mean that they have the right to commit suicide period? I agree it is unethical to require a medical professional to participate in suicide directly. What if a person decides to commit suicide on their own and attempts to but fails? Wouldn't the most ethical action be to let them die of the injuries they intended anyways?
To "Joe" above, who found offensive my characterization of the WatchTower Society's teachings on blood transfusions as "moronic", and who proceeds to defend the JWs, because he has "studied" with the JWs.
Well, Joe, I was a JW -- for my first 40 years.
Well, Joe, I was a 4th generation JW.
Well, Joe, in the 1990s, I REFUSED a blood transfusion. Fortunately, I survived. Thousands of JWs have not been so fortunate.
DIVORCE, BLOOD TRANSFUSIONS, AND OTHER LEGAL ISSUES AFFECTING CHILDREN OF JEHOVAH'S WITNESSES
http://jwdivorces.bravehost.com
Joe, You may have found JWs to be "rational", "ethical", "non-hostile", "non-disparaging", "intelligent", etc. However, if you check out the above website, plus this next one, there are 100s of officially documented cases of JWs NOT rational, ethical, intelligent, etc, including documented cases where JWs are hostile and disparaging. I guess such "trumps" your undocumented assertions.
EMPLOYMENT ISSUES UNIQUE TO JEHOVAH'S WITNESSES EMPLOYEES
http://jwemployees.bravehost.com
Blood issue at a glance: The Watchtower leadership of the Jehovah's Witnesses say NO blood, BUT they actually DO ALLOW some blood "fractions".
Problem is this variance is so esoteric complicated that by the time special elders appear in the ER with the rule book, the JW patient is at the point of no return,bleeding to death.
NOW,they blame the hospital staff for not having a "cell saver" machine instead of the Watchtower leaders who are responsible for making the rules.
I was born a 3rd generation Jehovah's Witness in 1957 and endured the Watchtower's no blood commandment with longstanding bleeding Crohn's disease.The Watchtower leadership expects followers to die for their dogma and many have.The medical staff get blamed and are 'damned if they do damned if they don't'.
In 20 years there will be artificial blood for anyone who chooses it,putting an end to this drama.
--
Danny Haszard
Orac,
"Your harping on a "five-year survival" misses the point that, in leukemia, if a patient makes it to five years without a recurrence chances are very, very good that the cancer's gone for good and very small that it will come back. Why do you think oncologists usually look at five year survival rates for this disease?"
I have a very young friend who had rectal cancer, and I remember talking about the 3 and 5 year survival rates. If I remember correctly, I understood that they never provided any risks past 5 years. I understood that to be the case because they didn't have any numbers. Is that true?
Schwartz,
Survival stats are kept for longer periods of time than 5 yrs for most diseases and cancers, but survival stats are designed to evaluate initial treatment protocols. A few things to consider:
1. For most cancers, survival at 5 years tends to be equated with cure because recurrence after 5 yrs is not as common. Breast cancer is a notable exception. Leukemias are usually "cured" quickly, or the patient dies. Ref: http://www.meds.com/leukemia/trends/mon_pt1.html
2. After 60 months or so, patients will begin to die from other things, so statistics are not as clean. Prostate cancer is the shining example. Traditional question asked of medical students: What do most men with prostate cancer die from? Answer: heart disease, just like the general population.
3. A "young person with rectal cancer", in the example you have given, would not fit most categories since the vast majority of rectal cancers are in older folks, so the survival stats may not be as accurate. Younger patients may do better since they are likely to be healthier otherwise, have fewer co-morbidities, survive surgery better, survive noxious chemotherapy better, etc. Patient care must, in the end, be individualized. Things like nodal involvement, stage at diagnosis, cell type, genetic markers, etc, also affect survival.
4. "Second primary" cancers do occur and are often difficult to differentiate from a recurrence of the initial primary tumor, especially after several years. A patient with risk factors for rectal cancer will still have those same risk factors (ie, family history, gene defect, etc) 5 and 10 yrs later. So, is the "recurrence" really a second primary tumor and how should that be figured when evaluating the treatment that was given 10 yrs ago?
I'm sure there are other issues, too, but you get the idea.
'So... you're pro-life, then?'
by which you mean, strictly opposed to all abortion? Of course not. If you mean, do I consider the life of my patients more important than their religious beliefs, the answer is yes, just as I have said. I know full well that this runs counter to the position of most medical ethicists, wherein self-determination is placed above being alive. Is it not true, however, that self-determination is meaningless if you are well-and-truly dead? If the physician does not share his patient's belief that he will somehow be not-really-dead, is that not relevant?
Avoiding side issues (such as abortion), I am asking for clarification of this particular scenario:
An individual who previously was fully alive has sustained a potentially mortal defect that can be readily corrected;
That individual has presently lost the capacity to act on his own behalf;
It is known that this individual previously held a belief that if he behaved in a certain way, he would not really die, but live on to enjoy the rewards of his correct behavior;
A life-saving treatment is one of the behaviors proscribed by this individual's previously stated beliefs;
The physician knows that the individual will die without the treatment, and does not share the belief that there is another life awaiting the deceased in which to reap the rewards of having avoided the treatment.
My question is this: Is not the secular physician entitled to assume that the patient values life above all else, notwithstanding and even because of his previously expressed belief that certain behavior will ensure an everlasting life?
jponder asks, "Is not the secular physician entitled to assume that the patient values life above all else, notwithstanding and even because of his previously expressed belief that certain behavior will ensure an everlasting life?"
In a word, no. First, you're playing on an ambiguity in the term 'life,' since the sort of life the patient values (i.e., eternal, blissful, whatever...) isn't the same thing as the life the physician might be able to save (i.e., functional integrity of a human organism). But more to the point, _assumptions_ about the values held by another don't "withstand" direct evidence to the contrary.
Yes. In practice, it would often be difficult to distinguish between true suicides, accidents, and homicide attempts, so it's reasonable to permit medical professionals to treat when there is genuine uncertainty as to the motives of the patient.
There are no ethical grounds for preventing people from killing themselves. People who wished to prevent suicide have previously manufactured such grounds, even going as far to declare that the desire to kill yourself was inherently 'disordered', but this is sophistry.
jponder -
I am sincerely grateful you are not my physician. I honestly could give a damn what you believe or feel about the situation. Whether I am conscious and capable of expressing myself or not, my wishes are my own. If a physician treating me is aware of them, they should damn well follow them, regardless of their feelings about my wishes.
What the hell gives you the right to make that decision, contrary to my (the patient) feelings on the matter? How dare you? Seriously.
Benjamin Franz,
By your statement:
"No. It 'feels' different. But it isn't different at all. "Not doing anything" is not free of ethical onus. It is still an action."
are you throwing out intent, situation, and moral priority? If so, then you are guily of the deaths of millions who you have failed to help. Don't oversimplify moral philosophy.
Also, you seem to imply that life should be held higher than self-determination, which leads to some rather undesirable conclusions.
jponder,
You have said that life-saving treatments trump self-determination. What about high risk activities, like military jobs? What about low risk activities, like walking (might fall and break your neck)? Where would you draw the line?
My take on the matter is that ultimately anyone who subscribes to the no-blood doctrine has been brainwashed, and is not fit to make decisions for themselves on this basis.
My take on the matter is that ultimately anyone who subscribes to the no-blood doctrine has been brainwashed, and is not fit to make decisions for themselves on this basis.
Well that's great Justin. What other decisions do you believe it's your right to usurp, due to the obvious inability for an adult to make their own decision? Suppose a doctor finds it irrational for me to not want to be cared for if there is a significant risk of substantial loss of function. Suppose they think I have been brainwashed to believe this is the best choice for me. Guess what, they do not have a right to contradict my choice. The same is true of religious nuts who believe that transfusions are evile. I think they're making a really bad decisions, but that is their decision to make.
Shiritai,
Risk-taking behavior is not the same as claiming you would actually rather be dead, and the specific situation to which I have alluded is one in which the patient has lost the capacity to act, but the physician has not.
DuWayne,
Yes, you understand, my question is precisely whether the physician's beliefs are relevant. You hold that they are not, that I am not entitled to act as a moral agent myself, and that my commitment to the preservation of life must be abrogated if it is in conflict with a religious belief. I am not so sure, and I don't consider it arrogant to ask the question.
bob koepp,
Let me clarify my dilemma;
I am assuming that in the scenario I have described, there is a reasonable probability that intervention will return the patient fully to his previous quality of life, which is perhaps more than you intend by 'functional integrity of a human organism';
I also assume that the patient's expressed expectation of some kind of afterlife is more than just a metaphor, that it means that he really wants to go on living;
So, given that his life can be saved, in the here and now, and that I don't share the expectation of his somehow surviving his death, what are my moral obligations? Is there an absolute requirement that I be constrained by his previous religious beliefs, or even signature on legal documents, which are revocable, when confronted by his very real and irrevocable impending death?
For those who have said that the value of life trumps religious opinion on this matter, and those who feel that religion should be considered an indicator of mental illness (at least in a situation where the religion is demanding that the patient refuse a life-saving therapy) . . . .
What, fundamentally, is the difference between a religious opinion and a secular opinion? Belief in God? Why should this make us treat a religious opinion any differently? Adult patients can refuse blood transfusion if they are JWs, they can refuse chemo if their hairdresser convinced them to try homeopathy, they can refuse a ventilator if they feel it is undignified . . . . The only caveat is that they have to be mentally competent and they have to understand the risks they are taking by refusing the treatment. And if they are not mentally competent, that doesn't give the doctors carte blanche -- their legal guardian then assumes that role.
This is good, not bad. You want to be able to refuse a therapy when you disagree with your physician, do you not?
Besides, "life is good" is not a simple statement. It is good, but interventions to prolong life are horrific if they do nothing more than prolong agony. My husband's grandmother passed away a couple of weeks ago, having decided of her own free will to have the ventilator disconnected. There was no longer any chance that she'd get better, and her quality of life had dropped to zero. She was in constant pain, could no longer see well enough to watch TV or read her romance novels, and was rendered mute by the tracheotomy. The doctors could have kept her alive for years. Was it unethical for them to grant her wish and stop intervening? Of course not.
We need the freedom to say no in a medical setting. This does mean that sometimes people will say no foolishly -- and sometimes will say no for reasons which may or may not be clearly foolish or sensible.
By definition, if you are basing your decisions on the WatchTower you cannot be rational. Unlike Orac, I found the comment in the thread a pragmatic response to deal with irrationality. Too much had-wringing over ethics - hooray for affirmative action.
And it shouldn't be too hard to distinguish between decisions for treatments that are (1) effective, (2) very low risk, and (3) maintain quality of life and those that don't. If people refuse treatments that don't meet those criteria (as a starting point) I can respect that.
I don't respect letting someone bleed to death or inflict self-harm because of their magical beliefs.
jponder:
You said you would attempt to save the life of the patient above all other concerns. That sounds like "pro-life" to me.
Let's make this simpler: Would you or would you not honour a "do no resuscitate" order?
I thought Orac did a good job identifying that the linchpin of this case was not the religious influence, but the patient's age.
There are several perspectives and particular facts most readers may not have yet encountered. I compiled some of them here.
we should respect their believes
http://www.spymac.com/details/?2311958
I have read only two (besides my own) non-condemnatory posts on this subject, perhaps from the two most qualified to speak, since they spoke to or knew people involved. Everyone else gave knee-jerk responses based on the newspaper account. (And a couple of writers who invariably contribute anti-Witness comments to any post) I listed the two sources in my own post.
One of the blogs (by a friend of Dennis) says this:
"A related side note: I have read twenty years of the New England Journal of Medicine's articles on what he had. In the list of treatments recomended, Blood transfusion was not mentioned. The only reason they recommended it was to try to buy more time for the blood thickening drugs to bring the levels up so he could accept the continuation of chemotherapy. Also, they got to it too late. He'd already had leukemia for a long time and nothing could save him; the only thing a transfusion could do was extend his misery a couple years at most."
The other (by a med student who spoke to some involved) says this:
"The treatment denied by the judge was not the stem cell transplant. It was a blood transfusion. Why is this distinction important? Stem cell transplants are the single most expensive procedure in medicine (hundreds of thousands of dollars just to do the procedure). We do them (and many health insurers cover them) because they work, but not all patients facing leukemia choose to be transplanted. Some cannot afford it. Some do not want to go through the pain of the procedure. Others (like this patient) have different reasons. If after providing all of the information, the patient does not consent to a procedure, the medical establishment usually respects this decision. Keep in mind that the legal decision here was related to the blood transfusion which could keep the patient alive for several days, not the stem cell transplant, which has 70% survival at 5 years as reported in the media. It's not as simple as a 750 word article would have you believe. (Although the Seattle PI wrote a good story overall.)"
Is the blog author a medical person? If so, would you comment on these two posts. I don't have any specialized background.
Unfortunately, both statements appear to be so unsophisticated as to be meaningless. That being said, I certainly don't know the particulars of the case, and there are certainly situations in which a transfusion could be seen as futile care.
jponder -
and that my commitment to the preservation of life must be abrogated if it is in conflict with a religious belief.
Your commitment to the preservation of the life of any patient of consenting age, is abrogated when it is conflict with their wishes, religious or otherwise. I have no religious objections to any medical treatments. I do however, have a number of objections to having my body outlive my brain. I also have objections to surviving a significant loss of certain functions. I honestly don't believe that your desire to preserve life, trumps my desires in the least. Your not the one who has to be me when the preserving part is done.
The fact that some objections are religious in nature, does not make any real difference. I don't care how irrational you think those beliefs are. Just as I don't care how irrational you might find my position. That choice is not yours to make. If you actually believe it is, if you actually believe that your beliefs and desire to act on them, trump the beliefs and desires of your patients, then with all due respect, you're in the wrong profession.
It blows my mind that you actually think your beliefs and desires should actually trump those of your patients, blows my mind. It puts me in mind of people who become pharmacists, then refuse to do their job if it requires they dispense birth control pills. If your beliefs put you at odds with following the wishes of your patients, then you shouldn't be a doctor. Your not god. Some decisions are not yours to make. If you can't set aside your beliefs, to respect those of your patients, your nothing but a monster. Certainly you are no better than the ridiculous fundies who take jobs as pharmacists, yet refuse to fill certain scripts.
DuWayne - I'm on board with you regarding the rights of patients to refuse treatment. In your final paragraph, however, you seem to be arguing that healthcare workers do not have a symmetrical right to refuse to provide treatments requested by clients. So, do you think it's part of the job description of physicians, pharmacists and other healthcare workers to give up their own autonomy to take directions from their clients?
BTW, depending on the specifics of the employment contract, it might be "part of the job" of an employee pharmacist to dispense whatever is prescribed, period. But an independent operator writes his/her own job description. Also, I know of at least one pharmacist whose stated reason for refusing to fill a prescription for Plan B was that it wasn't medically indicated; and noted that he had no qualms about filling such a prescription if pregnancy was contraindicated. Of course, he was interpreting 'contraindicated' in a strictly medical sense. Is there something morally wrong with his stance?
Personally, I do not think it is ethical to force anyone to accept a treatment (unless they are a child or mentally incompetent, and their legal guardian agrees to the treatment) -- and I do not think it is ethical to force anyone to *provide* a treatment.
That said, there is a responsibility for medical boards and other regulatory bodies to ensure that a minimum standard of care is met. If, for instance, a patient needs a transfusion, desires the transfusion, and suitable blood is available, a doctor who refuses to perform the transfusion could be liable for malpractice. There have also been cases where a physician determined that the patient was "unworthy" of treatment and declined to provide treatment. This is obviously unacceptable. The line between malpractice and refusing to do something the practitioner considers morally abhorrent is not as clear-cut as "if the patient says no, you don't do it". The patient has no obligation to say no sensibly, but the physician *does* have an obligation to have a good reason, and that does complicate things.
It is easy enough to understand a pro-life pharmacist refusing to dispense mifepristone, for instance, especially if he believes he'll go to hell if he does. But what about a nurse refusing to administer the HPV vaccine to a teenaged girl on the basis that it encourages promiscuity? There are cases which seem easy and cases which are obvious, but probably most of the cases are not so simple.
bob koepp -
Sorry, I think you were misunderstanding my point. It was not a perfect comparison, in that I don't think that doctors should be required to provide treatments that go against their ethics (my belief in proactive euthanasia being a perfect example). The comparison was more in the notion of entering a profession that might require that one set their personal beliefs to the side in the light of the needs of those they serve.
That said there is a gray area that can put a doctor's ethics in providing treatment, or more to the point, information to their patients. My partner and I are expecting our second child (actually a matter of days now). Early on we had a scare when a nurse called to tell us that we needed to come in to discuss further testing and the potential that the fetus was going to have down syndrome (turns out it was a less than three percent chance, but the nurse failed to mention that, throwing us into a significant panic). I posted about it when it happened and got a horror story sent in my email. The writer claimed that the fact that their fetus was down syndrome, was known fairly early on in the pregnancy. Apparently her doctor decided not to mention this to them, because he was afraid they would have an abortion (which was in fact the case, they had two children already). While they love their boy dearly, they really wish they had had the option to abort. It has been a huge drain on their ability to care for the other two kids.
As far as I am concerned, their doctor had absolutely no right not to inform them of the situation. I don't believe that he should have been required to perform the abortion, if that is what they decided to do, but he had a responsibility to inform them of his findings. In situations such as this, like following patients wishes to forgo life saving measures, the doctor should put aside their own beliefs and attitudes.
I would note that I do not know the person who emailed me with that story and cannot verify that it actually happened. However, it does not seem like something that someone would just make up.
Grodge,
Thanks for the info. My friend's case was indeed listed as a strange occurrence (he was only 34 at the time of diagnosis).
I was impressed by the team of doctors that were put together to work on his case and his treatment was very personalized as you indicated. It is interesting that team did not object to complimentary CAM therapy (to help with the Chemo and radiation side effects) with the one qualification that they didn't use herbs that might counteract the Chemo drugs (and they listed them I believe).
He is still cancer free (and healthy) today, and the stoma is a small price to pay for such a serious cancer.
LOOK none of the red-herring arguments about tainted blood supply can apply to banking saving your OWN blood for elective surgery.If you take 'whole-blood' or autologous (use your own stored blood) you will be shunned by your family and friends.The Watchtower organization is in control of your life. I don't want someone else's blood in me anymore that I would want their other body parts heart,kidney,liver unless I needed a lifesaving transplant so goes the same with EMERGENCY blood transfusions.
"My Un-PC opinion is let 'em die..."
I would probably agree with this in the case of a non mentally ill adult, but not for the case of children. While an adult has the rights to refuse treatment, a child should not be able to decide this for themselves. Hence why they are still legally under the care of someone else.
As for Benjamin:
"There is no rational basis for asserting that 'passively' committing suicide is somehow ethical while 'actively' committing suicide is not. Don't fool yourself: In both cases the person is committing suicide."
It is not the fact that the person is committing suicide that should be the issue, it is "who has their hand on the knife slashing their wrists" for lack of a better analogy. If someone wants to kill themselves, that is their prerogative. I may not agree with it, but it is not me doing the killing. Now, if someone wants ME to kill them...well, that is another story, wouldn't you say? We are not talking about the ethics of the person who wants to die, but the ethics of the person asked to kill them. In this case I WOULD say that doing nothing is different than assisting them in their death, because one is "assisting in the death of someone" and the other is "not".
And, for the record, I am NOT dancing around uncomfortably about my ethics.
Jehovah's Witnesses beliefs:
A) They are at your door to recruit you for enslavement to their watchtower corporation,they will say that "we are just here to share a message from the Bible" this is deception right off.
B) Their 'message' is a false Gospel that Jesus had his second coming in 1914.The problem with this is it's not just a cute fairy tale,Jesus warned of the false prophets who would claim "..look he is here in the wilderness,or see here he is at the temple..."
C) Their anti-blood transfusion ban has killed hundreds if not thousands
D) once they recruit you they will "love bomb" you in cult fashion to also recruit your family & friends or cut them off. There are many more dangers,Jehovah's Witnesses got a bad rap for good and valid reasons.
99% of the world has rejected the teachings of the Watchtower Jehovah's Witnesses, the darker truth is they are a destructive and oppressive organization.
--
Danny Haszard Jehovah's Witness X 33 years http://www.freeminds.org