The pregnant Jehovah’s Witness came to a Sydney hospital with leukemia and a directive against blood transfusions, a decision stemming from her religious beliefs.
The hospital’s staff was faced with an extremely difficult situation: How to treat the 28-year-old woman and her fetus while respecting that her religious beliefs prohibited them from administering potentially life-saving treatments.
The case ended tragically with the fetus dying in utero, followed by the mother, who suffered from organ failure. “Staff were distressed, grappling with what was perceived as two ‘avoidable’ deaths,” doctors at the Prince of Wales Hospital in Australia wrote in a letter published this month in the Internal Medicine Journal.
One of those doctors, Giselle Kidson-Gerber, told the Sydney Morning Herald that her own Christian faith and experience treating cancer patients helped her understanding of the case. But, as she and co-author Amber Biscoe write in the letter, laying out the case could help other health professionals who find themselves in similar situations.
“There is little published information to assist physicians to manage their own anxieties, doubts and potential moral disagreement with the patient, and to help them maintain respect for a patient and continue to deliver good medical care,” the authors write.
The pregnant woman suffered from acute promyelocytic leukemia (APL), a treatable condition: The American Cancer Society says that “more than 90% of patients with APL go into remission with standard induction treatment.” The authors of the letter also note that pregnant women with the cancer have reported an 83 percent remission rate, with a good outlook for their babies when the women are diagnosed in their second or third trimesters.
In this case, the patient repeatedly declined blood products — including red cell, white cell, platelets or plasma transfusions — while knowing that such a decision could have drastic consequences, including death, the letter says. Physicians began treating her but deemed chemotherapy to be unsafe. They also decided against having her give birth via Cesarean section.
“She would have had to have a classical Cesarean, and she most likely would have bled to death,” Kidson-Gerber told the Sydney Morning Herald. “The obstetricians weren’t comfortable with that when there was a chance we could have got her through.”
The baby died while still in the womb, and the woman then delivered it vaginally, and with little blood loss. But she eventually developed a stroke, suffered multi-organ failure and died after 13 days of treatment. The Australian authors write that not giving the woman any blood products “undoubtedly contributed” to the deaths of the woman and her fetus. They didn’t give her any blood transfusions because “maternal autonomy was respected.”
“Refusal of a lifesaving intervention by an informed patient is generally well respected, but the rights of a mother to refuse such interventions on behalf of her fetus [sic] is more controversial,” the authors write. “A doctor indeed has moral obligations to both the pregnant woman, and perhaps with differing priority to the unborn fetus [sic].”
Cases involving pregnant women’s decisions and the impacts they have on their fetuses raise complex ethical and legal issues. A recent U.S. case that resulted in a precedent-setting “feticide” conviction has prompted a debate over the actions of pregnant women.
When it comes to decisions about their own treatment, pregnant women and patients at most U.S. health facilities are supposed to be informed of their rights within state law. The 1991 Patient Self-Determination Act also requires health institutions to disclose their own policies about advance medical wishes.
In Australia, as long as patients aren’t suffering from a condition that interferes with their ability to make decisions, doctors can’t force medical treatments upon them, Australian Medical Association vice president Steve Parnis told News.com.au.
“What you do have is an obligation to give the patient all the information so they know about all possible outcomes,” Parnis said. “When we talk about care of an unborn child, the best option is to give the mother the best possible care. We have to recognize her autonomy.”
The Australian doctors writing about the case in Internal Medicine Journal recommended regularly keeping a patient informed of her options as well as “developing a clear understanding of your own attitudes and beliefs, open communication between staff, identifying alternative practitioners where time permits, and accessing staff counselling.”
Laws that could impact pregnant Jehovah’s Witnesses who refuse blood transfusions vary across the United States, according to Columbia University Medical Center’s Cynthia Gyamfi, an associate professor of obstetrics and gynecology. In a 2010 review, Gyamfi recommended that clinicians check their institutions’ policies and with relevant courts when they take on such women as patients.
Some hospitals around the world have clear guidelines on how to treat such patients. For instance, the U.K.’s Nottingham University Hospitals published guidelines that delineate the types of therapies Jehovah’s Witnesses do, do not and may accept, underscoring that some adherents may be willing to accept certain therapies while others may not. In practice, people differ in how they approach the issue.
Jehovah’s Witnesses don’t accept blood transfusions due to their religious beliefs, the official Web site of the Jehovah’s Witnesses explains. “Also, God views blood as representing life,” the site states, citing the Bible verse Leviticus 17:14. “So we avoid taking blood not only in obedience to God but also out of respect for him as the Giver of life.”
A 2004 study published in Obstet Gynecol reviewed the charts of 61 self-identified pregnant Jehovah’s Witnesses in New York state and found that the majority of them noted they were willing to accept some sort of blood product. The authors write that their findings refute the notion that all Jehovah’s Witnesses refuse any blood product.
Aside from the legality of such decisions, there’s “another ethical principle that comes into play in the management of a Jehovah’s Witness is nonmaleficence, or ‘do no harm,'” Gyamfi writes. “Although a provider may believe that allowing a bleeding patient to die by not transfusing her with blood is clearly causing harm, a devout Jehovah’s Witness may perceive far more harm in the belief that eternal damnation will ensue from such a transfusion.”