NURS 300: Transition to Professional Nursing
Ethical Issues Paper
Blood transfusions have been used as a life-saving method for hundreds of thousands of patients since its inception. However some patients, In accordance with religious beliefs or due to personal practice standards, are adamant about the refusal of blood transfusions even in life or death situations. The issue of bioethics presents itself with regard to the patient’s right to self-determination and autonomy, management of care of children whose parents have decided to refuse blood transfusions for their children and beneficence for the patient.
A blood transfusion is a procedure where "blood is pumped into a patient's veins via an intravenous (IV) line to boost low blood levels caused by surgery, injury, or disease"(American National Red Cross, 2017). The transfused blood may be from oneself or obtained through donor blood. The blood transfusion process has evolved from the early 1600s to now. In the early 19th century, blood was merely transfused to patients without knowledge of blood types and health risks. Blood is now typed and cross matched in order to assure that the blood being transfused is compatible with the blood type of the patient. Also, blood goes through rigorous screening and testing procedures in order to screen for many common blood-borne pathogens. However, many people choose not to accept blood transfusions in regards to their religious beliefs or personal views on blood transfusions. Certain religions, most notably Jehovah's Witnesses, have developed a strong viewpoint on blood transfusions. They accept certain blood related medical treatments but unanimously refuse transfusion of whole blood. Other religions, like Christian Scientists, refuse all care from doctors and healthcare professionals, believing that God will save their lives and heal them. They refuse all modern healthcare treatments, including blood transfusions. The ethical dilemma that stems from blood transfusions is whether to accept the patient's decision to refuse blood transfusion or whether to override their personal decision, especially in the case of a minor or in life threatening situations.
This ethical issue impacts nurses with differing points of view on this issue. Nurses who seek to help patients to achieve optimal health functioning can see the refusal of the transfusions as a patient choosing to die. Furthermore, it can also impact the nurse's ability to provide unbiased care when the nurse does not accept the decision made by the patient. On the other hand, nurses who accept the patient's right to refuse blood transfusions, or even shares that same belief, can also begin to develop a biased viewpoint of patients who accept blood transfusions. It can even impact of the nurse's ability to deliver care when the nurse may even refuse to administer the blood transfusion. All in all, the ethical principles of autonomy, beneficence and nonmaleficence play an important role in whether one should override the patient's choice or respect the patient’s decision.
Override the Decision
During a bioethics course, a statistical study was carried out by doctors and ethicists from the University of Geneva with caregivers from the University Hospitals of Geneva. The case was presented of a 40 year old female patient who is a Jehovah's Witness undergoing an elective excision of a hemangioma from the latissmus dorsi. The clinicians were polled in regards to who would transfuse the patient in a life threatening situation. Although the majority of clinicians said no, the majority of anesthesiologists present (55%) stated that they would transfuse the patient, overriding the will of the patient. Their rationale is that "they doubted whether he 'really understood what it means to die,' and second, because the OVRs [overriders] refer to their own feelings of compassion in making themselves defenders of the patient’s well-being" (Muzny, 2011, 1685).
Caregivers, especially nurses who spend the majority of their time with their patients, have a strong sense of compassion when it comes to the care of their patients. Therefore, seeing a patient who refuses life-saving treatment could cause them to want to work for what is in the best interest of their patient, regardless of the patient's personal beliefs. An ethical principle that plays a role in this case is nonmalefience, or refrain from doing harm. This is especially true in the case of minor patients whose parents have made the decision as adults to refuse transfusions, whereas, healthcare providers may believe that the minor child is unable to make such a personal decision. Shaw and Busch state that "denying a child treatment is exactly to cause a greater injustice and loss of liberty than infringing upon the parents’ right to freedom of conscience by providing blood" (2012, 385). In such a case, healthcare providers have taken to the use of psychiatric evaluation to determine whether the patient is in full capacity to make such a decision as well as involving Child Protective Services in order to determine what is in the best interest of the patient. Even further, Child Protective Services could intercede in order to determine whether the parent's choice is causing intentional harm to the child. In some cases, the families can attempt to supersede the right of the patient in order to allow blood transfusions. One doctor argues that "transfusing the patient to save [their] life fulfills the value of beneficence while at the same time potentially violating the value of autonomy. However, the decision by the husband and daughter on behalf of the incapacitated patient certainly fulfills the legal definition of appropriate practice and, in my opinion, fulfills the ethical value of autonomy as well"(Naunheim, K., Bridges, C. & Sade, R., 2011, 1561). Overriding the right of the patient allows the family, doctor and nurses to know that they are, in their opinion, giving the best possible care and life-saving treatment.
Respecting the Decision
In modern medicine, the patients are respected with the ethical principle of autonomy, or the right to self-determination. In such cases, patients are allowed the choice to refuse lifesaving measures such as blood transfusions. This involves asking the patient what decisions they would like to make in regards to their care. This principle is true because of the varied decisions made by patients, including those made by various Jehovah's Witnesses. "One study has shown that close to 10% of Jehovah’s Witnesses would agree to a red blood cell transfusion for themselves if needed. One could argue that patients should be informed that varied opinions exist within the Jehovah’s Witness community and, further, that each patient should be assessed individually without assuming that his or her views on transfusions are based on religious affiliation" (Kitney, L., Kanani, R. & De Souza, C., 2012, 1058). Therefore it is important for healthcare professionals to determine whether the patient chooses to accept treatment or not. "The ethical basis of the obligation to ask for the patient's acceptance is grounded in the recognition of the personal dignity of the individual, together with the 'principle of autonomy', according to which a competent patient must be given - within the deontological limits represented by physical life and quality of life as 'goods' -the right to free, informed choices" (Sacchini, D., Liumbruno, G., Bruno, G., Liumbruno, C., Rafanelli, D., Minacori, R., Refolo, P. & Spagnolo, A., 2013, 17). Providing an informed consent, where in the patient understands both the risks and implications of their decision, allows the patient to make an informed decision about their care and treatment and also allows the healthcare professional to understand that they have provided all the information necessary for the patient to make their decision, regardless of what that decision may be.
Many medical professionals may not understand the decision that the patient has made and their compassion may choose to move them to want to ask the patient to alter their decision. "The medical professional may feel compassion for the patient in question because he himself may suffer upon seeing the patient subjected to the merciless consequences of his beliefs. But he forgets at the same time that these feelings of compassion are based on the values held by the individual and that these are not necessarily shared by others" (Munzy, 2011, 1687). Respect for the autonomy of the patient can foster a stronger provider patient relationship with the patient sees that the healthcare provider has taken the time to understand their beliefs in regards to their care. It allows healthcare providers, most notably nurses, to display empathy for their patients regardless of the circumstances.
In nursing there are situations that can challenge one's established morals or preconceived notions about life, death and health. The issue of blood transfusions is a situation where there is no clear-cut correct answer. Overriding the patients decision can serve as a means of saving one's life. However, one finds that the psychological impacts of forcing one to except something can affect both the patient and the staff. Respecting the patient's wishes help protect the patients’ right to self-determination, however, it can mean that the patient can die. These issues force one to examine oneself in order to see whether providing the appropriate care outweighs assuaging one's conscience. Ethical dilemmas serve as an opportunity for one to grow as a professional by dealing with varying situations without a clear correct answer. However, the nurse's ultimate goal is to understand their patient, themselves and the care that they seek to give in order to provide care that always serves in the best interest of the patient.
American National Red Cross. (2017). History of Blood Transfusions. New York: USA.
Kitney, L., Kanani, R. & De Souza, C. (2012). "A Jehovah’s Witness adolescent with pancytopenia." Canadian Medical Association Journal. 184 (9), 1055-1059. http://content.ebscohost.com.remote.baruch.cuny.edu/ContentServer.asp?T=P&P=AN&K=22586337&S=R&D=mdc&EbscoContent=dGJyMMTo50SeprU4v%2BbwOLCmr0%2Bep7NSsKm4TLaWxWXS&ContentCustomer=dGJyMPGqtkiwr65MuePfgeyx44Dt6fIA
Munzy, P. (2011). "Respecting the Will of the Patient: Between Illusions and Realities." Pain Medicine. 12 (11), 1684-1688. http://content.ebscohost.com.remote.baruch.cuny.edu/ContentServer.asp?T=P&P=AN&K=67322968&S=R&D=a9h&EbscoContent=dGJyMMTo50SeprU4v%2BbwOLCmr0%2Bep7NSsKq4TbKWxWXS&ContentCustomer=dGJyMPGqtkiwr65MuePfgeyx44Dt6fIA
Naunheim, K., Bridges, C. & Sade, R. (2011). "Should a Jehovah's Witness Patient Who Faces Imminent Exsanguination Be Transfused?" The Annals of Thoracic Surgery, 92(5), 1559-1564.
Sacchini, D., Liumbruno, G., Bruno, G., Liumbruno, C., Rafanelli, D., Minacori, R., Refolo, P. & Spagnolo, A. (2013). "Ethical and deontological issues in Transfusion medicine." Trasfusione del sangue, 11(1), 14-25. http://content.ebscohost.com.remote.baruch.cuny.edu/ContentServer.asp?T=P&P=AN&K=23058865&S=R&D=mdc&EbscoContent=dGJyMMTo50SeprU4v%2BbwOLCmr0%2Bep7NSsq64SbOWxWXS&ContentCustomer=dGJyMPGqtkiwr65MuePfgeyx44Dt6fIA
Shaw, D. & Busch, J. (2012). "Rawls and Religious Paternalism." Journal of Medicine and Philosophy, 37(4), 373-386. http://content.ebscohost.com.remote.baruch.cuny.edu/ContentServer.asp?T=P&P=AN&K=22914539&S=R&D=mdc&EbscoContent=dGJyMMTo50SeprU4v%2BbwOLCmr0%2BeqK5SsKu4SbOWxWXS&ContentCustomer=dGJyMPGqtkiwr65MuePfgeyx44Dt6fIA