The question: You are a doctor and your patient, a 25yo male who is a Jehovah’s witness, has declined to have a blood transfusion which he requires in order to survive. What do you do? Background: The mass use of this ethical predicament has been deconstructed by mainstream media for years due to it’s unique situation. Generally a Jehovah’s witness will refuse blood transfusion and site religious reasons for doing so. Pre-Understanding: Medical ethics work off the four pillars of medicine; autonomy, justice, non-maleficence and beneficence. It is crucial to understand each of these concepts before engaging and answering medico-ethical questions. Along with these concepts there must also be an understanding of a doctors requirements under law (both state and national) in Australia refer to section 39 (Good medical practice) and then relevant state legislation which may be relevant. If the scenario is changed and the patient is a minor, or pregnant – there may also be other relevant authorities, laws and ethics which should be considered. Structuring your response: 1) Before considering patient AUTONOMY we must first assess whether the patient has the ability to make a decision. This is important in all cases – we assess their CAPACITY; their ability to understand a procedure, weigh up options and then make an informed decision. In this specific case we may question the patient’s ability to have capacity because they may have been losing blood (hence requiring the transfusion) or they may be in shock etc. So the first thing we do is assess their capacity and we may need to bring in a psych team or a third party to help in doing so. Also the patient may have a congenital/genetic syndrome/disease which may make it difficult to ascertain whether they have the proper capacity to make a decision like this. E.g. Patients with intellectual disabilities or heart/respiratory issues that affect oxygen/blood perfusion to their brain. 2) Autonomy – it is now time to consider patient Autonomy since we have assessed capacity. This may be words from the patient, or it could be from a legal parent/guardian if there are appropriate forms giving medical authority to them. If we can not find someone who has authority, and the patient does not have CAPACITY we might involve lawyers at the hospital and even the Guardianship Tribunal in order to seek permission to act in the patient’s best interest. 3) Beneficence & non-maleficence – here we assess the pro’s and con’s of giving treatment. What are the adverse effects of receiving blood; in Australia we have fantastic screening for infectious diseases and there should be ample time to type the blood and ensure the patient does not experience adverse effects to receiving the treatment. By not giving the patient blood we also make an argument that we are not ‘doing good’ and are possibly ‘doing bad’ by the patient. 4) Justice – this doesn’t play much of a role in this scenario but you could explore the fact that by choosing one treatment to give or withholding treatment we set a precedence for other people to do so and cite other religious or cultural beliefs. 5) Other considerations – Is there another treatment available that makes the doctors happy and the patient happy? Can we put the patient on a ventilator and dialysis machine and wait for him to naturally produce more red blood cells and give them IV fluids in the meantime to stabilise them? 6) Ideal response – It would be ideal to note that if the patient had capacity then we would respect their decision to decline medical treatment. It is also worth adding that you would be required to explain the outcome (possibly death) and they would need to understand and accept that. All other treatment options should be explored, sometimes there is something that could be done (if there is minimal blood loss perhaps IV fluids and close monitoring will give the patient enough time to recover by growing their own red blood cells). Thanks for reading! If you would like to suggest a type of question to be deconstructed in the future post here!