Module 6 - Religion

Case Studies:

Refusal of Blood Products (i)

The mother of two teenage children, Maria Duran is a Jehovah’s Witness and her beliefs commanded her to abstain from blood products and blood transfusions. She is the only Jehovah’s Witness in her family. When Ms. Duran needed a liver transplant she sought out the University of Pittsburgh Medical Center because she had been told that it had performed liver transplants on Jehovah’s Witnesses without the need for blood transfusions.

Ms. Duran discussed her religious beliefs and her desire to not be given any blood products or transfusions with the medical staff. She even executed a durable power of attorney for medical care. In the document, Ms. Duran specifically stated that she would refuse any blood, no matter what her medical condition. She stated that even if a blood transfusion were the only therapy required to preserve her life or health, she would still refuse. Further, she stated that her family, relatives, or friends may disagree with her beliefs and wishes, but that is legally and ethically irrelevant. In her durable power of attorney, Ms. Duran appointed Larry M. Johnson as her health-care agent.

Before the liver transplant, Ms. Duran left New York, where she had been living, and moved near Pittsburgh with her health-care agent and his wife. Before the transplant, she again discussed her wishes with her husband and family. Maria also provided her Doctors with copies of her durable power of attorney and again told them she would not consent to blood transfusions.

After her transplant, Ms. Duran’s body rejected the liver. Her health-care agent consented to a second transplant, along with kidney dialysis and a biopsy. The second liver was rejected as well, and Ms. Duran’s declining condition left her comatose. Doctors believed she would die within 24 hours if she were not given a transfusion.

Her husband, Lionel, petitioned the court to be appointed her emergency limited guardian for the purpose of consenting to a blood transfusion. Her health-care agent was not given notice of the hearing and the court granted Mr. Duran’s petition. He then consented to the transfusion. She nevertheless died shortly thereafter.

The health care agent appealed and the appellate court held (1) that the appeal was cognizable despite its technical mootness, (2) that Ms. Duran’s self-determination to refuse blood transfusion therapy is protected by common law, (3) that the trial court abrogated Ms. Duran’s right when it appointed the emergency limited guardian, and (4) that the health care agent was entitled to notice of the hearing.

Questions for Discussion
  1. Ms. Duran’s rights of self-determination and religious freedom were, at court, outweighed by the appointment of a guardian with the authority to consent to the transfusion. Did the court do the right thing?

  2. Does the fact that Ms. Duran had two minor children affect whether her rights should have given way to the consent of her husband/emergency guardian?

  3. Ms. Duran specifically selected Mr. Johnson as her health-care agent because he would honor her beliefs and wishes. She believed her husband, as a non-Jehovah’s Witness, would contradict her wishes. Guardians are supposed to use the substituted judgment standard for decision making, when possible. Was it appropriate for her husband to consent to a treatment that he knew she did not want? What justification could be give in acting as he did?

Refusal of Blood Products (ii)

Delores Heston, a 22 year old, unmarried woman, was severely injured in a car accident. Upon entry to the hospital, it was determined that she would not survive without surgery for her ruptured spleen. She also required a blood transfusion.

Ms. Heston and her parents are Jehovah’s Witnesses, a religion which forbids blood transfusions. Ms. Heston later contended that she refused a transfusion, but the hospital’s documentation shows she was in shock when she got there. The attending physicians believed that she was disoriented and incoherent.

Ms. Heston’s mother also opposed the transfusion and signed a release of liability for the hospital and its personnel. Ms. Heston herself was unable to sign the release.

The hospital then made an emergency application to a judge for the appointment of a guardian, with directions to consent to the transfusion, arguing that Ms. Heston’s death was imminent without the transfusion.

The court appointed the guardian with permission to consent to the transfusion.

The appellate court affirmed, holding that the interest of the hospital and its staff, as well as the state's interest in life, warranted transfusion. The court stated:

“The question is whether the State may authorize force to prevent death or may tolerate the use of force by others to that end. Indeed, the issue is not solely between the State and Miss Heston, for the controversy is also between Miss Heston and a hospital and staff who did not seek her out and upon whom the dictates of her faith will fall as a burden.

“Hospitals exist to aid the sick and the injured. The medical and nursing professions are consecrated to preserving life. That is their professional creed. To them, a failure to use a simple, established procedure in the circumstances of this case would be malpractice, however the law may characterize that failure because of the patient's private convictions. A surgeon should not be asked to operate under the strain of knowing that a transfusion may not be administered even though medically required to save his patient. The hospital and its staff should not be required to decide whether the patient is or continues to be competent to make a judgment upon the subject, or whether the release tendered by the patient or a member of his family will protect them from civil responsibility. The hospital could hardly avoid the problem by compelling the removal of a dying patient, and Miss Heston's family made no effort to take her elsewhere.

“When the hospital and staff are thus involuntary hosts and their interests are pitted against the belief of the patient, we think it reasonable to resolve the problem by permitting the hospital and its staff to pursue their functions according to their professional standards. The solution sides with life, the conservation of which is, we think, a matter of State interest. A prior application to a court is appropriate if time permits it, although in the nature of the emergency the only question that can be explored satisfactorily is whether death will probably ensue if medical procedures are not followed. If a court finds, as the trial court did, that death will likely follow unless a transfusion is administered, the hospital and the physician should be permitted to follow that medical procedure."

This decision was, however, subsequently overruled by a later opinion from the same court.

Questions for Discussion
  1. The Court authorized a transfusion to save Ms. Heston’s life, but such a decision directly conflicts with her religious views. Should the Court be allowed to take away her right to refuse to consent here because her religious views will result in her death?

  2. How should health care personnel deal with a person who enters their facility disoriented, incoherent, or in shock, and who refuses to consent to a procedure to save his or her life, a procedure that an ordinary, reasonable person would authorize?

  3. How should the state interest of preserving life be weighed against the individual’s autonomy? Should the state even have an interest in these cases?

  4. How do health care professionals assess the strength of individuals’ religious convictions? Should they do so?