Jehovah's Witnesses
and
Blood Transfusions
What obligations and liabilities of a
are the legal
physician when a patient, in anticipation of medi-
cal or treatment, demands that he not be given a
surgical
blood transfusion ? In an elective procedure, where no
emergency exists and the patient is an adult in possession
of his faculties, the patient would have a lawful right to
impose this condition. The physician in turn, in these cir-
cumstances, could elect to accept or refuse the patient for
care and treatment. Should the condition be imposed after
the physician-patient relationship is established, the physi-
cian may lawfully withdraw from the case, providing he
advises the patient of his intention to do so and affords the
patient an opportunity to obtain the services of another
physician.
Emergencies
In anemergency, when the patient or the person legally
responsible for him, demands that no blood be adminis-
tered, a more difficult situation exists. There may be no
time to discuss the medical implications of the demand or
to withdraw from the case without prejudicing the pa
tient's welfare.
In the vast majority of cases in which blood is refused,
a religious belief motivates the patient. Jehovah's Wit
nesses uniformly insist that they not be transfused because
it is contrary to their religious principles.
Courts have been called on rather frequently to interpret
the "freedom of religion" concept of our federal and state
constitutions. In these cases the issue was personal versus
collective rights. In a case decided by the Supreme Court
of the state of Washington, it was contended that the
board of regents of a state college was without authority to
require that all students undergo x-ray examination of the
chest for the purpose of discovering possible tuberculous
infection as a condition precedent to admission. A student,
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a member of the Christian Science church, refused to com
ply. The court quoted the material portion of the First
Amendment to the Constitution of the United States, "Con
gress shall make no law respecting the establishment of a
religion or prohibiting the free exercise thereof." It then
pointed out that religious freedom embraces two concepts,
freedom to believe and freedom to act. The first, according
to the court, is absolute, but not the second. Conduct re
mains subject to regulation for society's protection. This
freedom, said the court, can be restricted to prevent grave
and immediate danger to interests that the state may law
fully protect. Because the public interest threatened was the
health of all students and employees of the university, the
court held that the school requirement was necessary and
valid for the protection of others (State vs Armstrong, 239
P2d 545, Wash, 1952).
Refusal of Blood When Infant Is Involved
This of
matter refusing
blood transfusions for religious
reasons poses intricate
some problems. If an 80-year-old
man refuses a transfusion, one can weigh the matter more
impersonally than if a parent refuses a transfusion for an
8-day-old child. The refusal of a transfusion by a 28-year-
old mother of small children differs from the refusal of a
28-year-old bachelor.
Society has responded where infants are concerned.
Where an infant is involved and a transfusion has been
objected to, courts have seen fit to declare the infant a
ward of the court, appoint a guardian, and authorize him
to consent to the transfusion. Some years ago, an Illinois
district attorney brought an action to determine the fitness
of the parents of an 8-day-old child suffering from erythro-
blastosis fetalis. On proper petition and hearing, the par
ents, Jehovah's Witnesses, who refused to permit medical
treatment, which included transfusions, were declared to be
unfit and the court appointed a guardian for the child. The
guardian authorized treatment. The child was given a trans-
 fusion and, it is reported, responded favorably and lived
{People ex rel Wallace vs Labrenz, 104 NE2d 769, 111,
1952). This procedure, according to reports reaching the
AMA Law Department, has been used in a number of
jurisdictions when the transfusion of infants is medically
necessary.
Refusal of Blood When Adult Is Involved
Recently there has been a spate of cases involving adults.
In one of these cases, a patient was admitted to a hospital
for treatment of a rupturing ulcer. The attending physician
determined that patient would die if she did not receive
transfusions but would have a 50-50 chance of living if she
did. Both patient and her husband were Jehovah's Wit
nesses, and neither would consent to the transfusion be
cause of religious beliefs. The attorney for the hospital
applied for an emergency writ before the US Court of
Appeals for the District of Columbia. One of the circuit
judges, late in the afternoon, spoke to the patient, asking
her if she would oppose the transfusion if he permitted it.
He said the patient indicated "it would not then be her
responsibility." The judge determined that the patient was
not in a mental condition to make a decision and signed
the order. In an opinion explaining his action, the judge
pointed out that the patient, 24 years old, was the mother
of a 7-month-old child. He said that the state will not
allow the patient (parent) to abandon her child, so it will
not allow this ultimate of voluntary abandonment. The
patient, according to the judge, had a responsibility to the
community to care for her infant. A forceful dissenting
opinion was filed in which another judge asked where an
assumption of jurisdiction over matters such as this could
lead us (Application of President and Directors of George
town College, 331 F2d 1000, 1964).
In a New Jersey case, the patient was a 29-year-old
woman in the 32nd week of pregnancy. Delivery was com
plicated by placenta previa. The court authorized the ad
ministration of a blood transfusion if it became necessary
to save life. The court felt that the welfare of the unborn
child and the patient were so intertwined and inseparable
that it was impracticable to distinguish between them
{Raleigh-PitkinPaul Morgan Memorial Hospital et al vs
Anderson, 201 A2d 537, NJ, 1964).
The Supreme Court of Illinois adopted a different view.
A married woman, hospitalized, suffering from a peptic
ulcer, refused a transfusion. She with her husband signed
a release absolving the hospital and physician from any
civil or criminal liability that might result from failure to
administer blood. An order of a trial court was obtained,
nonetheless, appointing a conservator and authorizing him
to consent to the transfusion. The Supreme Court held this
order of the trial court interfered with a basic constitu
tional right and must be reversed. The Illinois court said
the First Amendment, as extended to the states by the
14th Amendment, protects every individual's absolute right
to freedom of religious belief and the exercise thereof
except that the exercise thereof may be limited by govern
mental action if it constitutes a clear and present danger to
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the public health, welfare, or morals. What was done here
by the trial court was a judicial attempt to decide what
course of action was best for the
patient despite her con
trary views based on religious convictions, and this is
clearly unconstitutional, said the Supreme Court (In re
Brooks Estate, 205 NE2d 435, 111, 1965).
Personal, lawful action based on religious belief, which
does not affect the health or welfare of society and does
not disrupt society's machinery of government, is a right of
citizenship. It may be reasonably concluded that an indi
vidual may lawfully forego therapy that is contrary to his
religious principles as long as he does not thereby endan
ger the health and welfare of others by his actions.
In case of emergency, or where the physician cannot be
certain that the patient is in full possession of his faculties
or where the physician is uncertain that another has author
ity to act for the patient, he should proceed with caution
from both the medical and legal points of view. Consulta
tion as time permits should be sought. Complete records
should be maintained. The refusal of the patient should be
reduced to writing and witnessed if at all possible. If this
is impossible, a witness should be obtained who may ob
serve and, if necessary, describe the facts as they existed.
The burden is on the physician to insure that evidence of
the patieat's condition and the circumstances under which
the demand not to give a blood transfusion was imposed
are carefully made and preserved.
In an elective procedure when the patient is a minor,
in the eyes of the law, the physician may consider seeking
the assistance of the state's attorney or a child welfare
agency who might apply to the appropriate court for a
proper review of the case. Review by the courts might also
b sought when an adult is involved if the facts are similar
to those in the Georgetown and Raleigh-Pitkin Hospital
cases.
In an emergency or where it is impossible for the phy
sician to withdraw from the case or seek judicial interven
tion without danger to the patient, it would seem that the
physician is obligated to respect the demands of the adult
patient and the demands of the parents of a minor to the
greatest extent possible. If during the procedure the ad
ministration of blood becomes necessary to save life, the
physician is faced with a decision of his own, according to
his judgment and conscience. If he does give the trans
fusion, contrary to the demands of patient or parent, it is
conceivable that on recovery gratitude will be expressed.
It is, however, just as possible that he may be sued for
assault. If this charge was sustained, the damages allegedly
incurred would have to be predicated on saving life! It
may be doubted that any more than nominal damages
would be awarded for such an assault. If the patient died
as a result of the administration of blood, the usual rules
of law relating to malpractice would govern.
Forms of use to physicians, including a "Refusal to Per
mit Blood Transfusion," may be found in Mediclegal
Forms With Legal Analysis, prepared by the AMA Law
Department. Copies of this booklet are available to mem-
bers on request. Edwin J. Holman