SURGICAL ETHICS CHALLENGESJames W. Jones, MD, PhD, MHA, Section Editor

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Operating one-handed: Emergency treatment ofJehovah’s WitnessesJames W. Jones, MD, PhD, MHA, and Laurence B. McCullough, PhD, Houston, Tex

An elderly woman was brought to the emergency room (ER) hypotensive in a confused mental state from what turned outat exploration to be a ruptured splenic artery aneurysm. You are in the operating room, and the anesthesiologist has justhung the first unit of blood but has not started infusion when the ER calls. The patient and her husband were visitingtheir children and live in another state. Her husband, an elder in a Jehovah’s Witness congregation, arrived and isadamant that she have no transfusions. Her blood pressure is dangerously low. It is being maintained by a high-doseLevophed (leave-um dead) drip and continues to slip. You have avoided operating on Jehovah’s Witness patientsbecause of the added unnecessary risk they pose. Your assistant is of like mind. What is the best ethical course at this time?

A. Transfuse the attached unit and tell the husband it had already been infused.B. Transfuse the attached unit and others as needed.C. Detach the blood per the husband’s wishes and continue the surgery.D. Since you did not agree to perform an emergency procedure without transfusions, you are not ethically bound one way

or the other.E. Page another surgeon who accepts Jehovah’s Witnesses to take control of the case.

1

Our scientific power has outrun our spiritual power. Wehave guided missiles and misguided men.

—Martin Luther King, Jr

Religion provides a codified means of relating to theuniverse and dealing with the prospect of a finite materialexistence. Sociologically, religion unified tribes, then city-states, then nations. Religion consolidated power, sancti-fied war, and assured of meaning during life and afterdeath, except in naturalistic atheism, which by our defini-tion is a religion. Most adherents believe strongly in theprecepts of their religion but find many other religion’sbeliefs unfounded or even trivial. Religious sects continu-ously splinter off from established religious denominationsover angstroms of differences; Christianity and Islam aresuccessful splinterings.

During the last century and half, a number of Christiandenominations that have embraced unconventional inter-pretations of scripture were founded: Christian Science, sub-groups of Pentecostalism, Scientology, and the Jehovah’s

the Center for Medical Ethics and Health Policy, Baylor College ofedicine.or conflict of interest: none.rint requests: James W. Jones, MD, PhD, MHA, 31 La Costa Dr,ontgomery, TX 77356 (e-mail: jwjones@bcm.tmc.edu).editors and reviewers of this article have no relevant financial relationshipsdisclose per the JVS policy that requires reviewers to decline review of anyanuscript for which they may have a conflict of interest.sc Surg 2013;57:573-5-5214/$36.00yright � 2013 by the Society for Vascular Surgery.://dx.doi.org/10.1016/j.jvs.2012.12.002

Witnesses. These offshoots have relied more on faith heal-ing and literal interpretation of the New Testament. Assuch, most discourage medical therapy, and thus, do nothave conditions for therapy. The Jehovah’s Witness faithdoes not rely on faith healing but forbids transfusions.

Charles Taze Russell founded the Jehovah’s Witnessesby disseminating what was then an unfamiliar interpreta-tion of Biblical Scripture. His first converts followed publi-cation of his new magazine, Herald of the Morning, whichsubsequently became Zion’s Watch Tower, then Herald ofChrist’s Presence, and then The Watchtower.2 First knownas “Russellites,” the group developed a strong foundationof believers and able leadership by the time of Russell’sdeath in 1916.

Jehovah’s Witnesses have two essentially contradictoryfoundational principles. Their practices and beliefs area return to those of first-century Christianity.3 Contrarily,they rely on evolution of progressive scriptural interpreta-tion, unalterably. As did the original Christians who uncom-promisingly refused to alter their beliefs when faced withhorrible persecutions by Imperial Rome at its height ofpower, Jehovah’s Witnesses, even when facing death, keeptheir faith and act as it proscribes with respect to bloodand blood products.

Since Russell’s death, the Watchtower Bible and TractSociety of Pennsylvania (located in Brooklyn) has evolvedthe scriptural dogma of the group. Several hundred maleelders participate in the scriptural clarifications.

Prohibition of transfusions was added in 1945. Thebasis for the doctrine is established by reference to threescriptural sources (Gen 9:3, Lev 17:14, and Acts 15:20

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and 29) forbidding the consumption of sacrificial blood.The blood symbolized the forfeiture of the sacrificialanimal’s life. Genesis specifically prohibits eating sacrificialblood. Leviticus specifically instructs that the blood besprinkled on the temple Mercy Seat. Acts instructs FirstCentury Christians to abstain from meats offered to idols,fornication, and blood. On the basis of their interpretationof these passages, the Watchtower Society (the council’sname in 1945) elders prohibited transfusions.

Compliance is essentially universal among believers. Afteroperating onhundreds of believers, one of us (J.W.J.) remem-bers only one man over the years who confided, “My wife isthe real believer. If I need blood, transfuse but don’t tellher.” He did not require a transfusion.

Witnesses allow cardiopulmonary bypass, use of intrao-perative erythrocyte salvaging devices, and postoperativeretrieval, so long as the infusion tubing remains attachedto their bodies—completing a circuit. Whether albumencan be infused is a matter of individual conscience. In elec-tive cases that allow weeks of postponement, erythropoi-etin can be used to increase red cell mass, provided theyaccept that it is suspended in human albumen.

Accepting patients who refuse to accept transfusion pla-ces a solemn conflict on surgeonswhomay be forced to allowsalvageable patients to die, and occasionally, close calls inflictincreased surgical sphincter spasm. More than three-fourthsof surgeons report having encountered Witnesses needingemergency operations.4,5

The scenario proposed by this case illustrates a seriousconflict between two fundamental principles of medicalethics. The principles of medical ethics include: respect forpatient autonomy; the mandate to benefit, beneficenceand its corollary, the caution not to unjustifiably harm, non-maleficence; and justice—a variation of the general philo-sophic definition, to each according to what is deserved,but in medical care: to each patient according to his or hermedical needs as determined in deliberative, evidence-based clinical judgment.6

The elements of this case interact to generate “theperfect ethical storm.” The ironclad determination ofWitness patients to obey religious beliefs that alter unargu-able medical therapy collide with the surgeon’s professionalresponsibility to manage emergency circumstances on thebasis of deliberative clinical judgment so that each and everypatient’s medical needs are met. To benefit from surgicalrepair of a ruptured splenic artery aneurysm, the patientneeds to survive the surgery, towhich end the administrationof blood may become essential.

First, Jehovah’s Witnesses deserve our utmost respect;they are the only major denomination, since the early Chris-tians, whose members can expect to test their faith with theirlives. And their morals are strongly Christian-conservative,forbidding fornication, gambling, drunkenness, and tobaccouse.2

We crafted the case to generate the greatest conflict.Not only is the transfusion direly indicated, if not used,the blood will be discarded. The degree of conflict doesnot change the overriding principle of respect for patient

autonomy. Unlike much of other human enterprise andcommon sense, being “an authority” in medicine (ie,making deliberative clinical judgments) does not placephysicians “in authority,” being independently able toimplement new treatment decisions. Respect for thepatient’s autonomy requires authorization from the patientor the patient’s surrogate decision maker when the patientis not able to make decisions for herself, as in this case.The “hung” blood must be taken down but may be usedas fertilizer for the surgeon’s roses. Option A must bediscarded.

As described, the deteriorating course will be decidedtoo soon to hand off the case. Your talent maximized isthe best chance for this patient. If the surgeon assistantwas of equal experience and willing to take the case, it wouldbe possible, but he believes as you do. Option E is no escaperoute.

Discovering that the goalpost has been moved does notinvalidate the patient’s right to define the rules. Option D,suddenly imposing limits to standard practice, unacceptablein business transactions, is completely valid in medicalethics. Once treatment is underway, patients and familiesstill, within reason, retain the right to alter what is doneto their bodies, and surrogate decision makers have theethical and legal right to exercise this right for the patient.

The justification of option B vs option C is a functionof the validity of the surrogate decision of the patient’shusband and whether there is time to engage him to obtaina valid surrogate decision. The latter is the case here;a member of the surgical team that will not compromisecare should be sent to speak to the patient’s husband.

Valid surrogate decisions meet one of two ethical andlegal standards, in priority order. The first is the substitutedjudgment standard, according to which the surrogateshould represent the patient’s wishes as these can be reli-ably determined. The second is the best interests standard,which applies when the patient’s wishes cannot be reliablydetermined and is essentially beneficence-based.

The patient’s husband should be asked whether hiswife is a Jehovah’s Witness and whether she accepts theteaching of her faith community on the administration ofblood. If her husband reports that she is and can supportthis claim, such as by providing a brief history of her lifein this faith community, and if he reports that she acceptsthe teaching of this faith community on the administrationof blood, then the substituted judgment standard has beensatisfied. In that case, the patient’s husband should beinformed that blood will not be administered and shouldbe informed that implementing this decision will increasehis wife’s risk of death and, if she survives the procedure,increase his wife’s risk of brain or organ damage. Thisdisclosure should be documented in detail in the patient’srecord. This disclosure and its detailed documentationsatisfy the requirement of informed refusal. Option Cbecomes the ethically justified management of the ethicalchallenges in this case.

Surgery should proceed without administration ofblood. Should the patient die or should she survive with

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organ damage attributable to nonadministration of blood,the surgeon and team should not be penalized in qualityreview for mortality and morbidity, because both were ex-pected outcomes authorized in a valid surrogate decision.

If the patient’s husband cannot establish his wife’s statusin the Jehovah’s Witness faith community or if the discus-sion cannot be concluded before the administration of bloodis indicated in deliberative clinical judgment, then thesubstituted judgment standard has not been satisfied andthe best interests standard should be applied by the surgeon.Blood should be administered based on deliberative clinicaljudgment for its need, satisfying the requirements of benef-icence and justice. Option B becomes the ethically justifiedmanagement of the ethical challenges in this case.

Preventive ethics calls for preparation for scenarios likethis one. By providing the basis for such preparation, preven-tive ethics complements master technical status withapproaches to manage unexpected—but not unforesee-able—ethical challenges.

Surgeons who say they have not faced serious unforeseencircumstances have not performed major procedures. Master

technical status is attained when a routine is developed forvirtually every major intraoperative complication and theexclamation “there” rather than “oops” is heard.

REFERENCES

1. Jones JW, McCullough LB, Richman BW. Painted into a corner:unexpected complications in treating a Jehovah’s Witness. J Vasc Surg2006;44:425-8.

2. Wikipedia. Jehovah’s Witnesses. Available at: http://en.wikipedia.org/wiki/Jehovah’s_Witnesses#Ethics_and_morality. Accessed December1, 2012.

3. Jehovah’s Witnesses—Who are they? What do they believe? WatchTower Bible and Tract Society of Pennsylvania, 2006. Accessed: Apr 12,2006.

4. Gouezec H, Ballay JL, Le Couls H, Malledant Y. [Transfusion andJehovah’s witnesses. A review of medicosurgical attitudes in a Universityhospital in 1995]. Ann Fr Anesth Reanim 1996;15:1121-3.

5. Weinberger M, Tierney WM, Greene JY, Studdard PA. The develop-ment of physician norms in the United States. The treatment of Jeho-vah’s Witness patients. Soc Sci Med 1982;16:1719-23.

6. McCullough L, Jones J, Brody B. Principles and practice of surgicalethics. In: McCullough L, Jones J, Brody B, editors. Surgical ethics.New York: Oxford University Press; 1998.