This case presents a moral predicament in which an individual must choose between two options that cannot both be fulfilled (Beauchamp & Walters, 2003). Decisions can have positive and negative consequences. In Juana’s situation, her decision to reject a blood transfusion was based on her religious beliefs but ultimately led to her death. If she had followed the recommendations of the doctors and interdisciplinary team, she might have survived but would have violated her religious principles. The main ethical dilemma was that healthcare professionals confronted the challenge of respecting the patient’s autonomy and religious beliefs while compromising their duty to provide professional care according to established standards (Chua & Tham, 2006). A brief review of recent literature from Nursing Collection II: Lippincott Nursing Journals (from Ovid) and CINAHL databases did not find any evidence supporting the best practice for a pregnant Jehovah’s Witness who has experienced blunt trauma.
Healthcare providers have the power to take legal action in order to force a patient to undergo necessary medical treatment, even if the patient is unwilling. The case of Illinois v. Brown (1996) is an example of this situation, where the Supreme Court of Illinois upheld a mother’s duty to receive blood transfusions for herself and her unborn child despite her refusal. According to the Patient’s Bill of Rights (New York State Department of Health, 2008), healthcare providers are required to provide accurate information and obtain consent from patients before proceeding with any treatment. These principles align with guidelines established by the Federal government that stress healthcare quality and recognize individuals’ responsibility in safeguarding their own well-being (United States Department of Health and Human Services, 1999).
The patient’s right to autonomy, rather than her religious beliefs, governs nursing practice (Levy, 1999). The American Nurses Association (ANA) Code for Nurses with Interpretative Statements (2001) prioritizes respect for human dignity as the first item.
Respecting individuals’ autonomy is dependent on being honest and well-informed. It is essential to provide accurate information, assist in evaluating treatment options, and allow the freedom to choose without pressure. Additionally, offering emotional support is crucial.
It can be challenging to witness death, especially when a person chooses not to receive medical treatment despite having options for sustaining life. The difficulty intensifies further when two lives are involved.
Virtue ethics
The ethical dilemma in question was analyzed by considering both the principles of Western medicine and the religious beliefs of Jehovah’s Witnesses. Three key questions were raised: (a) how would virtue ethics help in understanding Juana’s situation, (b) what were the conflicting ethical principles, and (c) why was it problematic to give Juana a blood transfusion in an emergency.
The clinical dilemma and the questions listed above were addressed using Volbrecht’s framework for ethical analysis. Before the 17th century, virtue ethics was the main theory utilized. This theory focuses on shared familial and cultural histories, as well as religious traditions. It recognizes the community’s capacity to identify, interpret, prioritize, and adapt to moral considerations in a specific context (Volbrecht, 2002). Below is an explanation of this case based on virtue ethics.
Virtue ethics centers on the patient’s autonomy and what is morally correct from their viewpoint. It emphasizes the connection between actions and character, where the ability to act morally depends on one’s moral character and integrity. This ethical approach also considers the context of the situation. The analysis of virtue ethics involves identifying the problem, analyzing context, exploring options, applying the decision process, and implementing the plan while evaluating results.
Identifying the problem
Juana, a 20-year-old Hispanic woman, 32 weeks pregnant, was involved in a car accident resulting in suspected internal bleeding to the thoracic or abdominal cavity. The individuals affected by this situation included Juana, her husband, the fetus, and the interdisciplinary healthcare team. The healthcare team collectively agreed that administering a blood transfusion and performing an emergency cesarean section would be the most appropriate action. However, Juana and her husband declined this option due to religious reasons and provided written documentation expressing their refusal of blood or blood products. Consequently, an ethical dilemma arose regarding whether it was more crucial to prioritize Juana’s physical survival along with her fetus or respect her religious beliefs.
When looking at the surrounding circumstances or background information
The decision-making process in this case can be understood by considering ethical principles such as autonomy, beneficence, nonmaleficence, justice, compassion, and respect. It is important to consider the patient’s religious beliefs and how they influenced her decision (Gardiner 2003). These ethical principles play a significant role in shaping one’s choices. The healthcare team believed that Juana was suffering from internal bleeding and that both she and the fetus were experiencing physical distress. However, Juana’s refusal of the suggested treatment was based on her religious convictions.
The patient’s religious beliefs played a significant role in this case as she expressed a preference to be embraced by Jehovah instead of facing eternal condemnation through a blood transfusion. Nurses rely on the code of ethics to understand and empathize with the patient’s perspective while also honoring her wishes. According to the code, nurses should provide services while respecting human dignity and acknowledging the uniqueness of each client, regardless of their social or economic background, personal attributes, or health conditions (ANA, 2001, p.1). To uphold the patient’s dignity and honor her decision, supportive care was administered in an effort to save her life without disregarding her preferences. The ANA Code of Ethics emphasizes healthcare providers’ duty to respect patients’ choices and decisions even if they differ from their own personal beliefs (ANA, 2001).
A framework is being developed for making ethical decisions.
According to virtue ethics, Juana’s autonomy and her right to make decisions based on her beliefs were prioritized by the caregivers. Despite potential consequences, Juana, who is capable and pregnant, made the choice not to have blood transfusions or a caesarean section. The healthcare providers respected Juana’s decision as well as her husband’s decision influenced by their religious values, thus honoring her autonomy. This demonstrates adherence to the principle of beneficence by focusing on promoting spiritual well-being over physical well-being. Additionally, the caregivers upheld the principle of nonmaleficence by avoiding intentional harm to Juana and respecting her wishes in order to uphold deeply held beliefs (Leonard & Plotnikoff, 2000). They also considered the principles of veracity and respect by being honest with Juana and allowing her to make an informed decision (Volbrecht, 2002). Understanding this situation also involved practicing nursing virtues such as compassion, moral courage, and self-reliance.
Evaluating results
At the time this case was presented, there were no specific institution guidelines in place to address the dilemma. However, there are guidelines specifically for Jehovah’s Witnesses regarding the identification and management of gynecological patients. In Australasia, there are guidelines for pregnant women that focus on stabilizing the patient using various treatment modalities to meet their needs, especially for Jehovah’s Witnesses or those who decline blood transfusions (Women’s Hospitals Australasia, 2005). These guidelines for antepartum patients include early identification during prenatal visits, placement on a high-risk protocol, maintenance of high hemoglobin and hematocrit levels, completion of advance directives,and affiliation with other well-equipped hospitals (Women’s Hospitals Australasia, 2005). The Hartford Hospital in Connecticut also provides bloodless procedures for Jehovah’s Witnesses (Miller, 1996).
The ethics committee evaluated Juana’s case and created a risk-management protocol. This protocol mandates that patients who decline blood transfusions must sign a waiver to release the hospital and caregivers from legal responsibility. To support this, the Society for the Advancement of Blood Management maintains a database of hospitals in several countries that provide blood-conserving services (Society for the Advancement of Blood Management, 2008).
In emergency situations, it may not always be possible to transfer the patient to a participating hospital. The Watchtower Bible and Tract Society (2004) recommends having advance directives and legal documents easily accessible in case of an emergency. Healthcare providers should respect the patient’s directives and uphold the principle of virtue ethics (Macklin, 2003). It is important for healthcare providers to show kindness and avoid harm without imposing personal beliefs. Having clearer and more universally applicable guidelines would benefit both patients and providers when faced with similar ethical dilemmas.
Conclusion
Cases of patients refusing blood transfusions or other interventions are becoming more common in nursing practice. To address this issue, it is necessary to integrate content related to ethical issues, such as Juana’s case, into nursing curricula and the clinical arena. By incorporating bioethics into critical thinking during clinical decision making, nursing educators can prepare both novice and experienced nurses to handle complex ethical dilemmas, as discussed in this paper. Teaching approaches that combine lectures with case studies and the use of patient simulators can enhance the learning process and provide opportunities for nurses to intervene in acute patient scenarios in a safe environment, reducing anxiety and promoting learning. Additionally, nurse educators can facilitate learning by offering clinical experiences with diverse patient populations in different settings, followed by discussions on actual clinical experiences, ethical issues, and debriefing (Larew et al., 2006).
The role of nursing faculty is to guarantee that nurses possess the necessary skills to recognize and solve ethical challenges in their work. This involves supporting ongoing education aimed at enhancing nurses’ understanding of ethical principles. It is imperative to prioritize culturally sensitive care and respect for patient autonomy in clinical practice, educational settings, and research. Equally emphasizing ethics is essential for delivering comprehensive high-quality care. Failing to fulfill this responsibility would be unjust both to the nursing profession and our patients.
REFERENCES
The Code of Ethics for Nurses with Interpretive Statements was published by the American Nurses Association in 2001. It is located in Washington, D.C.
The 6th edition of the book “Contemporary Issues in Bioethics” was published in 2003. It was written by T. Beauchamp and L. Walters and published by Wadsworth in Belmont, CA.The website of the Society for the Advancement of Blood Management can be accessed at http://www.sabm.org/hospitals/. (Society for the Advancement of Blood Management, 2008)In the 2006 Singapore Medical Journal, Chua and Tham authored an article titled “Will ‘no blood’ kill Jehovah Witnesses?” (vol. 47, pp. 994-1001).The citation for the article “A virtue ethics approach to moral dilemmas in medicine” by Gardiner, P. (2003) can be found in the Journal of Medical Ethics, volume 29, pages 297-302.The case of Illinois v. Brown (In Re to Fetus Brown) No. 96-JA-03312, which took place in 1996, can be found at the following link: http://lw.bna.com/lw/19980120/962316.htm. This information was accessed on June 19, 2008.The New York State Department of Health provides the Patient’s Bill of Rights on their website at http://www.health.state.ny.us/nysdoh/hospital/english2.htm#patients. The information was accessed on June 19, 2008.The article titled “Innovations in clinical simulation: Application of Benner’s theory in an interactive patient care simulation” by Larew, C., Lessans, S., Spunt, D., and Covington, B. (2006) is published in the Nursing Education Perspectives journal. The article can be found on pages 16-21 of volume 27, issue 1.
Leonard, B., & Plotnikoff, G. A. (2000). “Awareness: The heart of cultural competence.” American Association in Critical Care, 11(1), 51-59.
The article titled “Jehovah’s Witnesses, pregnancy, and blood transfusion: A paradigm for the autonomy rights of all pregnant women” by Levy (1999) is published in The Journal of Law, Medicine, and Ethics. It can be found in volume 27(2), pages 171-189.The source journal article “Applying the four principles” by Macklin, R. (2003) is cited as Journal of Medical Ethics, volume 29, pages 275-280.
Patients are gaining more influence in surgical decisions, according to an article in the New York Times (Miller, J., 1996). The article can be retrieved from http://query.nytimes.com/gst/fullpage.html?res=9804E3D91330F936A1575BC0A960958260 and was accessed on June 18, 2008.
The text is a citation for the book “Nursing ethics: Communities in dialogue” by R. Volbrecht. It was published in 2002 and can be found in Upper Saddle, NJ at Prentice Hall.
United States Department of Health and Human Services. (1999). The Patients’ Bill of Rights in Medicaid and Medicare [Fact sheet]. Retrieved June 19, 2008, from http://www.hhs.gov/news/press/1999pres 990412.html
Watchtower Bible and Tract Society. (2004). Rightly value your gift of life. Watchtower, 15, 14-16.
Women’s Hospitals Australasia (2005) provides clinical practice guidelines on refusing to accept blood and blood products. The guidelines can be downloaded from their website at http://www.wcha.asn.au/index.cfm/spid/1_47.cfm?paction=doc.download&document_id=129&category_id=5∈_browser=0.
Alsacia L. Pacsi, MS, RN, FNP, CEN, CCRN
Alsacia L. Pacsi is a nursing lecturer at Lehman College, City University of New York in Bronx, NY. Her expertise lies in emergency and critical care nursing. She is also currently pursuing a doctoral degree in nursing science at the City University of New York Graduate Center. This article was written as a course assignment by Vidette Todaro-Franceschi, PhD, RN.
No part of this article may be reproduced without the explicit written permission of the copyright holder. Copyright 2008 Gale, Cengage Learning. All rights reserved.
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