In the analysis of this ethical dilemma we assess a case of a 20-year-old, pregnant, black Hispanic female presented to the Emergency Department (ED) in critical condition following a car accident. She displayed signs and symptoms of internal bleeding and was advised to have a blood transfusion and emergency surgery in an attempt to save her and the foetus. She refused to accept blood or blood products and rejected the surgery as well.
Her refusal was based on a fear of blood transfusion due to her religious beliefs.
The ethical dilemma presented is whether to respect the patient’s autonomy and compromise standards of care or ignore the patient’s wishes in an attempt to save her life. Her religious values are at stake. The issues concerning her values are the right or wrong of her actions and the acceptance, reputation or embarrassment of her decision in the social world. This case demonstrates dilemmas faced by healthcare professionals caring for patients in critical, life-threatening situations who have divergent views and values contrary to what is offered as a solution to their predicament.
In the analysis of the ethical dilemma surrounding this particular case, we make explorations basing on two principle approaches; utilitarianism and deontology. This is in an endeavour to find the right moral balance and/or stand between the patient’s view and value and that of the healthcare professional seeking to intervene to restore her to health.
Utilitarianism believes that the moral standing of an action, whether right or wrong, is dependent entirely on its consequences. This theory holds that the course of action that is considered proper is one that maximizes utility, maximizing happiness and reducing pain/suffering. In this approach, the worth of an action is only determined by outcome or result, consequent to that action. It therefore is a form of consequentialism (Paul and Elder, 2006). For our purpose and appropriate in this context, Mill (1998) argues that “the morality of the action depends entirely upon the intention – that is, upon what the agent wills to do.” Intention, in it being a foresight of consequences, constitutes the moral position of the act, whether right or wrong.
I acknowledge that what is morally right and best for her in the values that she has expressed, is her religious stand and affiliation in which the medical interventions proposed are denounced. At the same time, however, and under the circumstances, her health risks might lead to miscarriage and there is likelihood that they might also eventually lead her into depression. In the utilitarian view, the young lady in this situation risks losing her own life and that of the foetus she carries if she does not allow the blood transfusion and surgical procedure to bring her to health. The doctors and nurses therefore have to consider her life first. Her circumstance is considered as legally enforceable and specific according to the Bentham’s tradition right (1816), assigning to law the role to define inviolable rights to protect the well-being of the individual (Hart, 1973).
The utilitarian approach is a straight forward way to determine the best possibilities for all involved, balancing pleasure over pain for everyone (Paul and Elder, 2006). According to this principle, it is better to maximize equality between the lady and her foetus, and in view of her severe pain, to go ahead and perform the blood transfusion and emergency surgery. With this approach, I assume that later in a better state of health and recovery and after saving her life, she will console and will reconcile her moral stand with her predicament. The physicians therefore have the moral right to override the young lady’s refusal of the blood transfusion.
Also useful in the argument and supporting the judgment for blood transfusion that the doctor may (or must) seek to override the patient’s refusal are two ethical principles. These are the principle of non-maleficence and the related principle of beneficence. The principle of non-maleficence requires the doctor to avoid harm where possible (Paul and Elder, 2006). So, withholding a proven, beneficial treatment would likely have the effect of producing harm. On the other hand, the principle of beneficence, which is inherent in the maximization of benefits and minimization of harm (Paul and Elder, 2006), could also be useful in support of the argument for the duty to administer the blood transfusion against the patient’s expressed will.
However, this assumption and what society regards as of best interest to the patient should not be determinative of what is ideally her individual best interest. Overriding her wishes and not taking her religious views into account in going ahead with the blood transfusion and intervention might lead to a far worse situation for her. Among the possible eventualities after her treatment is depression, which might result from feeling that she has gone against the rules and expectations of her religion which are very important to her. Her situation might also be worse if she gets eliminated from her church for going against the rules of her religion. She might lose acceptance from her family members and friends. These eventualities might lead to the deterioration of her health, which by taking the contrasted utilitarian approach and our assumptions, we intend to protect. This eventuality will therefore thwart our best intentions.
A more appropriate approach, more suitable to determine what is best for her, is Deontology and especially the philosophical tradition of Immanuel Kant. Unlike utilitarianism which is focused on the outcomes, consequences and eventualities of actions, Deontological ethics often referred to as duty-based ethics, are concerned with what people do, their actions. It is the belief that people have a duty to do the right thing, even it produces more harm (or less good) or a bad result than do the wrong thing (Wood, 1999).
Kant gives a ‘categorical imperative’ to act morally at all times. One was that it was wrong to act in a way that treats others as mere means, rather than end in themselves.
According to Kant, persons are made special by a distinctive set of principally psychological capacities which includes self-consciousness and rationality, a distinct capacity for personhood (Wood, 1999). This view is founded on two basic principles; first, a person has the distinctive ability to think and to act rationally, best expressed when they behave morally or as a moral community. Secondly, people have dignity and are valuable in a distinctive way, a unique, intrinsic value that has no exchange value. This is in contrast to things which have an exchange value such as a coat whose value is equivalent to the money paid for it (Wood, 1999).
According to Deontology, it will be wrong to undermine her autonomy and flout her dignity – treat her as a mere means. It is better, therefore, to respect her religious belief and respect her decision not wanting to have the blood transfusion. Respect for the patient’s principles and her status as a competent adult mandates that doctors should comply with her expressed wishes even if the predicted outcomes are unfavourable or may result in death. It is her choice as a self-conscious, rational adult with intrinsic capacity to evaluate and know what is morally right and acceptable for herself.
Morality versus religion
For many religious people, and especially those in monotheistic religions, morality and religion are the same – they are inseparable. For them, it is either that religion is their morality or that morality is part of their religion (Childress, et al., 1986). Religions have frameworks of values through which adherents are guided in determining right and wrong. The monotheistic religions derive ideas of right and wrong by the rules and laws set in their respective holy books and by their religious leaders (Childress, et al., 1986).
For adherents like our patient, the rules set out and as interpreted by religious leaders are absolute and there are dire consequences for flouting such rules. For most monotheistic religions, flouting rules and values is considered ‘sin’, a failure that leads to punishment in the after-life. The patient in this instance expresses a fear of blood transfusion due to her religious beliefs, possibly a fear of dire consequence such as future punishment. This absolutism and the derivation of values from deity and holy books can hardly be challenged by rational criticism and explanations that seek to give some worth to disallowed practices and procedures such as blood transfusion in this particular case.
My personal view
There can be different opinions and points of view about what should be done with the patient in the analysis of this ethical dilemma. There can be different possibilities and we may never reach clear and generally agreeable conclusions with regard to what is morally right in this case, with our conclusions and inferences dependent on our varied ideas and beliefs over morality based on varied religious, societal and cultural backgrounds, among other influences.
With the well-being of the individual protected as an inviolable right in the utilitarian approach, and since under the circumstance, the patient risks losing her life, risks miscarriage and possible depression as consequences of her refusal of intervention, the doctors and nurses have to consider her life first as legally enforceable and specific. The related principles of non-maleficence and beneficence provide useful support for the argument requiring that the doctor, with the knowledge of the necessity of the intervention, avoids harm by not withholding such beneficial treatment. This makes the assumption that it is for the patient’s individual good that she receives treatment even if her expressed will has to be overridden.
Although the patient’s autonomy should be respected as it is her life and at her age she is a competent adult, in this case, she will have to deal with the consequences of the blood transfusion in the future, when in a position of health and when her death has been avoided. This decision is justified based on my opinion to maximize the patient’s high quality of well-being on J. S Mill’s Principles of Utility (1806-1873). Mill (1998) states that the principle of utility does not mean that any given pleasure or exemption from pain (such as health) is to be looked upon as a means to happiness, and so to be desired. They are desired and desirable in and for themselves; besides being a means, they are a part of the end, a part of the happiness.
An acknowledgement of the importance of her religion to her is, however, essential and is considered to be an important part of the argument put forth. Her religious stand and affiliation makes her wary of blood transfusion and represents the morally right position for her. I consider that under the principle of utility applied to this context, blood transfusion, if performed against her expressed will, would cause the patient unhappiness and pain in the future. However, considerations of future stigma and loss of acceptance, or depression resulting from her reaction to these consequences are only possible if she manages to survive her current predicament. It is therefore a priority and a greater good, that she receives such an intervention and manages to survive and that her unborn child also survives.
I feel that she has a right to be accepted by the church and her family despite the decisions she makes, with the realization in all rationality that the blood transfusion, though considered a ‘mistake’ or ‘sin’, serves to get her to health and possibly to save her life after the accident. It is not an intended procedure that she willingly sought, but is necessitated by her medical predicament after the accident. She wouldn’t have to have the procedure in a state of adequate health and well-being. I would in this case, therefore, appeal for such rational consideration among the people in her social circle, with the acknowledgement of her predicament and respect for her autonomy and individual capacity and competence.
I also consider the people she is associated with and her unborn child and the possible impact her unhappiness would bring them in future. I am aware that this conduct of blood transfusion could upset her family and church and cause some conflict within their relationship, but the main subject to consider is the patient. Respect for her autonomy and competence in the decision would make her feel worthy, valued, respected and dignified. Depression could result from either of the choices, if the blood transfusion is conducted or not. This could in turn cause harm to her unborn baby, to herself, and to those she associates with in her social world, who have to live with the consequences of such ill health. This means that whether or not the blood transfusion is conducted, there will possibly be consequences and we have then to weigh the relative impact of either option over the other to acquire a morally right position.
However, our assumptions of the best interest for the patient and her good cannot be determinative of her ideal best interests. The consequences from proceeding with the blood transfusion against her expressed will, which we consider less harmful than the consequences of withholding of treatment, might well turn out to be worse for her. Depression and deterioration of health exacerbated by her loss of acceptance in her church and social circle could be terrible for her, worse in her case than the consequences of death or ill health consequent from withholding treatment which we consider to have more harm.
Will we, by overriding her will, therefore be undermining her autonomy and treating her as a mere meansAcknowledging that she is a self-conscious and rational individual having distinct capacity and competence, we would and it would clearly be wrong to undermine her autonomy and flout her dignity. She can rationally evaluate the predicted outcomes, however unfavourable, and make appropriate decisions on what is acceptable for herself and morally right. The doctors therefore should comply with her expressed wishes, however unfavourable the outcome.
From these arguments put forward in this case, I deduce that there would be more negatives than positives if the blood transfusion is conducted, even with her death and the loss of her unborn child as possible eventualities of withholding treatment.
The overall and ultimate questions are who is or what is it that determines what is right and what is wrongDo we do what is morally right according to the patient and respect their autonomy or do we go against her wishes and act based on what we as a society feel is morally right according to usGiven that our conclusions are dependent upon individual ideas and beliefs about what is moral and what is immoral basing on our religious, societal, cultural backgrounds, etc., what should we do in line with our work ethics, beliefs, codes of conduct, etc.?
In assessing the case of the 20-year-old patient and the ethical dilemma resulting from her refusal of blood transfusion citing contravention to her religious beliefs, I have made explorations of this particular case using two major approaches; the utilitarian and deontological principles, together with the ethical principles of non-maleficence and beneficence to support the various arguments.
The utilitarian approach seeks to protect the well-being of the patient as a legally enforceable right as under these circumstances, justifying the override of her wishes to conduct the blood transfusion. This approach is supported by ethical principles of non-maleficence and beneficence, that the doctor avoids harming the patient by not withholding necessary intervention and beneficial treatment. On the other hand, Kantianism/the deontological approach seeks to protect the autonomy and psychological independence of the patient in the evaluation of her predicament and the making of choices appropriate and acceptable to her in her moral standing.
This latter approach is more appealing, considering that we cannot assume to be able to accurately quantify the greater of harms consequent from any of the choices of the ethical dilemma. There is a tendency for us to determine that death as an eventuality is a significant harm, and therefore to consider it a greater good to try and prevent such an eventuality whatever the arguments against it. This is especially so with an assumption that she can reconcile her predicament later after she manages to survive and is in better health.
For the young patient, however, our assumptions of her best interest cannot be determinate of her ideal good and the consequences may turn out to be a greater harm to her, worse than the withholding of treatment. Her unhappiness from the override of her expressed will in conducting the blood transfusion and possible depression may lead to a deterioration of her health, with suffering and death as possible eventualities as well. With this consideration, I deem it morally right that the doctors respect her expressed will not to conduct the blood transfusion however unfavourable the consequences.
Childress, (ed.), James, F., Macquarrie, (ed.) John, 1986. The Westminster Dictionary of Christian Ethics. Philadelphia: The Westminster Press. p. 400.
Hart, H., 1973. “Bentham on Legal Rights.” In: Oxford Essays in Jurisprudence. Oxford: The Clarendon Press.
Paul, R., and L., Elder, 2006. The Miniature Guide to Understanding the Foundations of Ethical Reasoning. United States: Foundation for Critical Thinking Free Press.
Mill, J., 1998. Crisp, R., ed. Utilitarianism. Oxford University Press. pp. 65.
Wood, A., 1999. Kant’s Ethical Thought. New York: Cambridge University Press.