Informed consent is the procedure through which a healthcare provider discloses treatment information to the patient. The informed patient is then given the option to choose whether to refuse or accept the physician's intervention (Musmade et al. 134). The roots of this subject can be traced back to the ethical and legal rights of the patient, who has complete control over what happens to their bodies. Furthermore, it is the health worker's moral obligation to completely involve patients in the therapy process. In order for medication to be considered legal, the patient must express informed consent to the health professional. If the patient fails to assent the treatment procedure, then that process is considered an assault or homicide in the event that they die while receiving medication. In summary, for informed consent to be full, it should include a discussion of the following elements:
The overall nature of the decision or procedure
Reasonable possibilities or alternatives provided beside the proposed interventions
All relevant benefits, consequences, and risks, relating to every option
The acceptance or refusal of the available forms of treatment by a patient
The patient’s understanding should be assessed
This paper focuses on various cases of informed consent from an ethical, legal, and political perspective. It also looks at the current trends and status of debates on the subject matter as well as the pros and cons of various ethical arguments. However, the primary emphasis will be on the case of blood transfusion among the Jehovah Witnesses and how their situations have been handled over the years.
Origin of Informed Consent
The idea of informed consent was born from ancient philosophies and conditioned by the moral aspects of religion. It dates back to the medieval period of the Egyptian civilization. As well, there is evidence that is traced back to the Roman and Greek documents showing that patients had first to approve the intervention of a general practitioner. According to Plato law IV, the author had foreseen similar problems which formed the basis for the current informed consent formula (De Monte 99). He suggests that the health provider should create a consensus with the patient that pays attention to his or her social position and quality. Moreover, the ancient philosophy that “In disease, focus on two aims, to improve and not to cause damage,” forms the fundamental medical principle of all ages.
On the other hand, the above statement is perhaps the only guarantee, at that time, that the patient had according to the Hippocratic physician. Besides the ancient general practitioner showing care for a patient’s suffering, he was paying, even more, attention to the outcome of the ill individual (De Monte 101). In doing so, he was avoiding a situation whereby he would be involved in failing to heal the patient leading to death. In other words, the Hippocratic general practitioner did not quite recognize the concept of consensus with his patients. However, he showed awareness of prevention and precautions information when dealing with the patient’s well-being. It is thus clear that these ancient physicians practiced “defensive medicine” especially if the patient had a high social status (De Monte 101). The Hippocratic tradition insisted on a consolidated relationship between the ailing person and their doctor. This agreement required that the physician did what he thought what was best for his patient. On the other hand, the care seeker was expected to accept all the interventions and decisions of the physician wholly. On that note, it was the religious and moral obligation of the health provider to act according to the principle of professional responsibility. From a legal point of view, however, this ideology is relatively weak in spite of being based on regulations and standards set by human beings (De Monte 103).
Similarly, religious interventions failed to change the Hippocratic concept of the consolidated patient-physician relationship. Instead, the religious care providers insisted that God’s power was bestowed on them to heal the patient. All that was required of them was to have strong faith that God would eventually heal them through the general practitioner. Moreover, the patient was considered ignorant, and hence, it was the duty of the enlightened physician to guide them and even make decisions on their behalf. In this regard, the patients could not question his wishes and followed medication to the letter. Thus, the subject of consensus was a non-issue since the sick persons’ opinions were considered useless (De Monte 106).
Over the years, this certainty and conviction that was once entrusted to the physicians has been eroded following numerous cases of legal impunity and misuse of moral authority. They are no longer immune to the law and have since been required to subject and obey the relevant legislation. The concept of informed consent was first legally addressed in the United States on 19th December 1946. It involved a trial of Nazi doctors in Nuremberg. The declaration was that human beings should never be used as instruments for scientific experimentation. Moreover, the 20th century has seen a beehive of a series of legal actions. Such defines the informed consent criteria which emphasizes on respect for personal rights, the importance of objectivity in information, and foresees the patients’ autonomy to decide.
The cases of Jehovah Witnesses have been in the limelight in the recent past. In a case where a mother, aged 22, died in 2007 following hemorrhage after giving birth to twins. The doctors were prohibited from administering a blood transfusion on her citing religious beliefs (Desborough & Murphy 2013). Often, there have been incidences of individuals refusing to receive critical treatments due to their cultural or religious beliefs but, end up dying. There have been various interventions by the courts to determine the levels of consent.
Descriptions of the problems arising from the history
First, the topic that comes to one’s mind concerning informed consent is the subject of Human Rights (Cohen 143). Traditionally, as illustrated above, the care providers had the absolute authority over a patients’ life. The ability of the patient to either live or die lay in the arms of the physician. One of the challenges arising from this subjection is the vulnerability of patients to the mistakes of the physicians (Corrigan 771). Since they had complete control over a patient’s life and had immunity over the legislation, they started engaging in unethical, morally unacceptable acts. One of the offenses was carrying out experiments on human beings especially with the growth in technology. The case Jehovah Witnesses raises the question of human rights since legally, in the contemporary America, every citizen has the political right to be treated with respect by health providers. Since they believe that the life of an individual is contained in blood, it would be sinful to accept the procedure. Also, the believer argued that blood transfusion goes against their religion, beliefs, cultural background, and individual values.
Secondly, the ability of the patient to make decisions was compromised (Corrigan 776). Traditionally, the care provider was the sole decision-maker since he was considered knowledgeable. Conversely, the patient was regarded as ignorant and, therefore, their opinions could not count. As a result, the ill person was subjected to deadly risks since they were entirely required to obey all the medication instructions given by the general practitioner without objection (Cohen 143). On the other hand, things have since changed in the modern day America. Citizens, and patients for that matter have become more enlightened with improved legal awareness, learning, and technology. Hence, decisions should not be imposed directly on to care seekers. Despite being in the ICU, the Jehovah Witness recognized that their choice counts before undertaking such a critical procedure.
Thirdly, the issue of objectivity in information is yet another item of concern (Corrigan 782). Initially, the patient’s information remained a secret of the general practitioner. He retained such information to himself as a way of exercising defensive medicine to avoid getting involved in the patient died in his hands. Today, care providers are legally required to reveal all the necessary information to patients before undertaking any treatment or procedure to patients. Such details include the risks, benefits, alternative interventions, and the consequences of taking part or refusing to participate in that particular medication. Failure to avail such information could lead to legal action being taken against the caregiver if the patients develop some complications or eventually dies (Patir & Soyer 2016).
Fourthly, the challenge of serving the best interests of the patient arises from the history of informed consent. In addressing the welfare of patients traditionally, the physicians considered both the suffering of the patients and focused more on the outcome of the patients (Corrigan 789). In this case, they mainly paid attention to the survival of the ailing person. This dilemma requires both an ethical and rational approach to be undertaken if a solution is to be found. Such is due to the idea that it pays particular attention to the various personal needs. Determining a person’s best interests could be challenging to define both legally and ethically since it is a Catch-22 situation between one’s decision and the value of losing a life.
Ethical arguments- Pros and Cons
The advantage of respecting the patient’s treatment refusal is that the nurses and other medical staff are challenged to get more innovative and provide alternative treatment methods (Baron 539). Besides finding out ways to come up with the most suitable options, the health providers are also required to equally inform the patients of the benefits and consequences of these procedures otherwise these alternatives will still be regarded as unethical. In the Jehovah Witness instance, the health providers would have considered substituting blood transfusion for procedures such as volume expanders, cell salvage, pharmaceutical options, and antifibrinolytics (Baron 539). They would then have taken the believer through each of the stated alternatives, and probably they would have found one or two options that suit him.
Likewise, failure by a patient to consent helps increase the confidence of the patients and in the long run, supports the possibility of malpractices by physicians. First, modern patients have become more educated concerning their rights and hence handling them is even more complicated (Baron 543). Unlike in the past when they would submit to the medication and instructions given by the care provider, they currently question almost every aspect of their treatment. When a patient refuses to undertake a particular therapy that they are unsure about, they probably want to know more about their diagnosis, the side effects for drugs, and if there are other possible ways of curing the disease or condition. In doing so, they can clear the air concerning any suspicions they might have. Moreover, if the nurse, for instance, had intended to administer a blood transfusion to a patient wrongly and they refuse, the intervention of a general practitioner might prove that the procedure was unnecessary. In such a case where medication is wrongfully prescribed and ends up harming the patient, they could sue the nurse for malpractice.
One of the disadvantages of informed consent is that it could lead to loss of life (Manson 2013). The Jehovah Witness insisted that their refusal of blood transfusion had to be ethically respected but unfortunately, ended up dying. Morally, a nurse or other health providers cannot proceed to administer the process, or else they stand being accused of conducting a criminal act. Furthermore, the Witness is an adult who is above 18 years of age and is deemed mature enough to make rational decisions. They have also been ardently informed of the possible consequences if they fail to take the treatment procedure but remain adamant. The health providers, therefore, have ethically performed their professional duty to respect the patient’s interests, but eventually allow them to die knowing very well that a particular procedure or treatment would have saved a life. From a legal perspective, one could argue that he took his life and that his decision was unjustified (Fullbrook 1306). On the other hand, the medical practitioners who refused to administer any form of treatment to the Jehovah Witness are ethically justified in fulfilling the wishes of the patient.
Currents state of the debate
The recent controversy around whether it is ethically or legally right to administer a blood transfusion procedure especially on patients whose life is at great risk has remained heated in the media. Most cases concentrate on whether the patient is well informed about the treatment procedures and possible outcomes (Smith 2016). Further, the million-dollar question has always been, what are the limits of a patient’s informed consent? In the resent times, as illustrated in the cases below, there have been contradicting verdicts in the federal courts of law. These rulings either favor the Jehovah’s Witness refusal to consent or justifying the actions of health providers who forced treatment of the patient to save a life. In some instances, political amendments have to be made in order to accommodate specific court rulings. Studies has shown that most cases that were resolved earlier than 2010 such as the McAuley Josh case was handled differently from those of 2011 to date. Josh, a Jehovah Witness believer, refused to take a blood transfusion after a fatal car-crash and eventually died (Roberts, 2010). The 15-year-old boy was undergoing treatment at Selly Oak hospital, Birmingham but succumbed to fatal injuries after that.
In September 2017, a Superior Quebec Court ruling was passed authorizing McGill University Health Centre medical practitioners to administer a blood transfusion to a girl aged 14. The teenager, who is also a cancer patient, had refused to take up the procedure citing her Jehovah’s Witness religious beliefs. Justice Granosik Lukasz argued that it is lawfully right to protect a child’s life. Though this might be against the teenager’s wishes, it would serve her best interests because such a decision could either be fatal or alter her life permanently. “The need for a blood transfusion should be considered to save the life of girl X or avoid irreversible damage to her physical integrity,” He stated (Remiorz 2017). Having been diagnosed in June 2017, the teen had been receiving chemotherapy treatment. Her doctor was worried that X might need a blood transfusion if she was to be cured. However, both X and her mother had refused to take the transfusion because it was against their religious belief. Dr. Sabapathy, the teenager’s general practitioner, therefore requested the court to grant her permission to go ahead with the treatment saying “I am concerned that X and her family continue to make changes in her treatment plan which are not medically sound and put her chance of cure at risk” (Remiorz 2017).
Further, a previous case in November 2016 prompted amendments in the Civil Code of Quebec following the death of Dupuis Eloise, a Jehovah Witness. The lady, aged 26, died six days after giving birth. The care providers had reported that she had lost a lot of blood days after delivering her first child but had refused to pursue a blood transfusion alluding to her religion (Smith 2016). Every Jehovah Witness member is obliged to sign a refusal card whenever they are required to seek a blood transfusion. Soon afterwards, Dupuis’s aunt, Boyer Manon, called for policy changes allowing the hospital’s staff to provide life-saving treatment in emergency situations. While addressing BBC, Manon said “This has to stop. There cannot be another Dupuis, and more children left motherless.” She added that “I will not stop until the legislation is amended” (Smith 2016).
Conclusion and Recommendations
The concept of informed consent was fast-tracked by an age which puts more emphasis on social and personal values other than the economic aspect. What followed was the rapid growth in biotechnological advancement and their increased use in offering numerous forms of treatment to patients. In a bid to counter these new healthcare interventions, there was a need to have some standards that control these evolving technology. Therefore, the legal field came in as the regulating body that determines the lawfulness of healthcare support offered to patients. The governments hence sought to protect the individuals seeking surgical or medical interventions from direct decisions made by health providers on behalf of the patients. Thus, the care seeker has the absolute mandate to choose the kind of treatment that they want. In the recent past, there have been attempts to legally challenge the degree of informed consent among Jehovah Witnesses and rejection of blood transfusion. The idea of informed consent has since gained ground in the medical field and influences almost every routine aspect of the health providers. My personal opinions and recommendations on the subject are:
First, from a legal perspective, health providers should not pursue a blood transfusion upon refusal by the patient. This could be deemed unlawful leading to leading to a criminal accusation especially if the treatment procedure is unjustifiable.
In a case where a teenager rejects a blood transfusion procedure, the doctor should move to court to challenge the decision especially in cases of Jehovah Witnesses. Despite their parent’s wishes, saving the life of a teenage is considered justifiable ethically and in a court of law. If anything, consent should be obtained from individuals responsible for the parenting of the child.
Political amendments should be made to provide for un-consented treatment in the event of emergencies. It should be noted that a care provider has the ethical obligation to administer a blood transfusion in case of accidents or hemorrhage to save lives irrespective of the patients’ wishes. This is because doctors, in such instances, usually do not have adequate time to file a petition.
Informed consent should only apply to adult patients whose refusal to undertake a blood transfusion procedure, for instance, does not compromise the life of say a newborn child in the case of hemorrhage after birth. Further, the patient must have been fully aware of the consequences and benefits of their decision.
References:
Baron, C. H. (2010). Blood Transfusions, Jehovah's Witnesses, and the American Patients' Rights Movement. Alternatives to Blood Transfusion in Transfusion Medicine, 531-555. doi:10.1002/9781444319583.ch44
Cohen, S. (2011). The Gettier Problem in informed consent. Journal of Medical Ethics, 37(11), 642-645. doi:10.1136/jme.2010.041939
Corrigan, O. (2003). Empty ethics: the problem with informed consent. Sociology of Health and Illness, 25(7), 768-792. doi:10.1046/j.1467-9566.2003.00369.x
De Monte, A. (2004). Informed Consent: Origin, Controversies, Contradictions and Sociological Aspects. Perioperative and Critical Care Medicine, 99-111. doi:10.1007/978-88-470-2135-8_10
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Patir, P., & Soyer, N. (2016). Beta-thalassemia Major and Non-Hodgkin Lymphoma. Journal of Blood Disorders & Transfusion, 7(3). doi:10.4172/2155-9864.1000352
Remiorz, R. (2017). Jehovas’s Witness, 14, ordered to receive blood transfusion despite beliefs. Canadian Press. Extracted from: http://www.cbc.ca/news/canada/montreal/jehovahs-witness-blood-transfusion-1.4299992
Roberts, L. (2010). Teenage Jehovah’s Witness refuses blood transfusion and dies. The telegraph. Extracted from: http://www.telegraph.co.uk/news/health/news/7734480/Teenage-Jehovahs-Witness-refuses-blood-transfusion-and-dies.html
Smith, S. (2016). Calls to amend Quebec Civil Code mount in wake of Jehovah’s Witness death. British Journal of Nursing. Extracted from: http://www.cbc.ca/news/canada/montreal/jehovahs-witness-death-quebec-civil-code-1.3868610
