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Jehovah’s Witnesses in A&E
  1. J Beezhold1,
  2. B A Foëx2
  1. 1Norfolk Mental Health Partnership Trust, Norwich
  2. 2Manchester Royal Infirmary, Manchester
  1. Correspondence to:
 Julian Beezhold
 County Crisis Resolution Home Treatment Team, Grebe House, Hellesdon Hospital, Drayton High Road, Norwich, NR6 5BE; beezholddoctors.org.uk

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What are the rights of Jehovah’s Witnesses within the emergency department?

Jehovah’s Witnesses of all ages who present to emergency departments requiring blood transfusion continue to pose significant ethical and legal dilemmas for clinicians. This arises from the perceived conflict between the clinician’s professional obligation and the legal rights of the patient.

Sarah Woolley’s paper in this issue presents a lucid, well thought through, and carefully researched discussion of these issues that is relevant for all emergency care clinicians; and includes some more detailed information about the legal position in the United Kingdom.1

The key issues highlighted by Woolley are:

  1. the rights of adult and child Jehovah’s Witnesses requiring urgent transfusion

  2. the duties of the treating clinician

  3. the ethical and legal grey areas raised by the interaction of patient autonomy, consent, capacity, and duty of care in these challenging circumstances.

English courts have clearly stated that, when in doubt in emergencies, the first principle is to act to preserve life.2 This deceptively simple rule immediately runs into the problem of what constitutes doubt, and at what point should clinicians be doubtful.

Woolley makes a case that Jehovah’s Witnesses who refuse a transfusion by means of an advance directive blood transfusion refusal card, are not making this decision autonomously, because of the influence of their Church. She goes on to suggest that sufficient doubt may exist regarding the validity of these cards, so as to justify considering the administration of blood products in life-threatening situations despite the presence of a transfusion refusal card.

On the other hand it may be argued that this view conflicts with the presumption of capacity enshrined in English law; and also the right of patients to refuse medical treatment for reasons which are rational or irrational or for no reason3 and even in circumstances where (she) is certain to die in the absence of treatment.4

This dilemma highlights a grey area in English law. There is reasonable clarity about the information patients should have in order to make an informed decision in favour of an intervention. However, the law is unclear as to what, if any, information should be provided to a patient who a priori merely wishes to refuse a specific intervention.

The different rules for consent to intervention and for refusal of intervention may be illustrated by considering the situation of the Jehovah’s Witness at home, who, despite life-threatening bleeding, refuses to see a doctor. What information, if any, should doctors offer in this situation?

Woolley’s discussion of the autonomy issue has many wider resonances. For example, can consent to any life-saving procedure in an emergency, when the patient is likely to be confused, frightened and in pain, ever be considered truly autonomous? Often it will not, but it may well be good enough, especially as in most cases the “reasonable patient” would give consent anyway.

Doctors will continue to be presented with critical dilemmas without easy answers, and may be held accountable for their actions afterwards. In addition to Woolley’s good advice we would add two points. Firstly, share difficult decisions with colleagues: an approach agreed in this way is easier to defend. Secondly, despite existing law, rulings and guidelines some of these cases will end up in litigation. So, meticulous documentation of discussions and of the reasoning behind key decisions is essential.

What are the rights of Jehovah’s Witnesses within the emergency department?

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