Your patient’s husband and adult daughter consent to life-saving blood transfusion despite the patient’s religious refusal of treatment before losing consciousness.

Mrs. Genericson is a 46-year-old woman who presented to the emergency department following a serious motor vehicle accident. She sustained severe traumatic injuries, including internal organ damage, significant blood loss, and major head trauma. She was transferred immediately to the trauma surgery team in critical condition.

Despite the severity of her injuries, Mrs. Genericson was initially able to communicate with paramedics and the medical team. While the trauma team was preparing her for surgery, she looked at the trauma surgeon, Dr. Roberts, and stated, “I’m a Jehovah’s Witness, and I refuse any blood transfusions.”

Dr. Roberts explained that he would likely be unable to perform the surgery successfully without a transfusion and that refusing blood products would likely result in her death. Mrs. Genericson stated that she understood and was comfortable with that decision. She further explained that she would rather die than receive a blood transfusion.

Before Dr. Roberts could ask additional questions or further assess her understanding and decision-making capacity, Mrs. Genericson lost consciousness and was no longer able to communicate.

Shortly afterward, Mrs. Genericson’s family — her husband, Mr. Genericson, and their adult daughter, Sam — arrived at the hospital. Because the surgery would likely be unsuccessful without transfusion, and Mrs. Genericson could no longer speak for herself, Dr. Roberts quickly discussed the situation with them.

Both Mr. Genericson and Sam urged Dr. Roberts to proceed with surgery, including the use of blood transfusions if necessary. They explained that Mrs. Genericson had recently experienced a crisis of faith. Although she was raised Baptist, she had begun exploring other religions in recent years and had only relatively recently become involved with the Jehovah’s Witness faith. According to her family, she had expressed uncertainty about remaining in the religion and had recently discussed possibly leaving the church altogether.

They believe that her statement refusing blood products was influenced by fear, emotional distress, and the effects of her traumatic head injury rather than a deeply held or stable religious conviction. They argue that honoring her refusal would not truly respect her autonomy and insist that she would not genuinely want to die over this decision. Both strongly consent to the surgery and transfusion on her behalf.

Dr. Roberts requests an urgent ethics consultation.

 Take a moment to consider your own answer before reading further.

Should Dr. Roberts honor Mrs. Genericson’s clearly expressed refusal of blood transfusions, despite concerns about possible impaired decision-making capacity and the likelihood that she will die without treatment? Or should he proceed with surgery and transfusion based on the recommendations of her family, who believe her refusal does not reflect her authentic and enduring wishes?

On its face, this case seems straightforward: an adult patient who is a Jehovah’s Witness is refusing a blood transfusion. Medical students are routinely taught that adult patients with decision-making capacity can refuse treatment for any reason, even life-sustaining treatment. This ethical precept is enshrined in the AMA Code of Medical Ethics: “a patient who has decision-making capacity appropriate to the decision at hand has the right to decline any medical intervention or ask that an intervention be stopped, even when that decision is expected to lead to their death and regardless of whether or not the individual is terminally ill.”

Here we have an adult patient who has sustained severe traumatic injuries because of a motor vehicle accident. The facts indicate that Dr. Roberts was not able to fully assess decision-making capacity before Mrs. Genericson lost consciousness (although the conversation indicated that “she understood” refusing blood products would lead to her death). The first question for us to ask then is whether Mrs. Genericson truly had decision-making capacity to refuse treatment. Her family claims that her decision-making capacity was influenced “by fear, emotional distress, and the effects of her traumatic head injury.”

Decision-making capacity is not necessarily a binary or static concept. We often view it on a spectrum and as something that can wax and wane. In this case, the patient seems to exhibit some features of decision-making capacity. Yet did she possess full decision-making capacity to make such a momentous decision regarding refusal of potentially life-sustaining treatment? If so, both law and ethics would find that her decision must be honored and that even if her capacity wanes, a surrogate decision maker cannot override her firmly held religious conviction. If, however, her decision-making capacity was not fully assessed, and she has no advance directive that explicitly documents her wishes, then a surrogate decision maker must be identified. In this case, Mrs. Genericson’s husband is the likely surrogate, and if he were to be unable or unwilling to make healthcare decisions, then her adult daughter would be the next likely surrogate.

When making decisions for a patient who once had but now lacks capacity, surrogate decision-makers should make decisions based on substituted judgment. Applying substituted judgment means that the surrogate makes decisions based on what the patient would have wanted if they had decision-making capacity. In this case, Mrs. Genericson’s husband and daughter provide some insight into Mrs. Genericson’s recent crisis of faith during which she became involved with the Jehovah’s Witness faith tradition. They indicate that she had actually been considering leaving the church altogether. This additional information strongly suggests that this may not have been a firmly held religious conviction. This, combined with the concern that Mrs. Genericson’s decision-making may have been impaired due to the inability to fully assess capacity prior to her losing consciousness, suggests that proceeding with the surgery and a blood transfusion (if necessary), would be ethically appropriate.

This case highlights the ethical tension between respecting patient autonomy and the obligations of beneficence and nonmaleficence. The clinical team must decide whether to honor the patient’s verbal refusal of blood transfusions, expressed immediately prior to loss of consciousness, or to proceed with life-saving surgery and transfusion based on surrogate (family) consent. A central concern is whether the patient’s refusal, which conflicts with recommended care, reflects an authentic and stable preference or was influenced by fear, emotional distress, or potential head trauma.

Respect for autonomy is a foundational ethical principle, supporting a patient’s right to refuse treatment, even when such refusal may result in death. Honoring such a decision requires confidence in the patient’s decision-making capacity (DMC), including understanding, appreciation of consequences, reasoning, and stability of choice. In this
case, Mrs. Genericson clearly refused blood transfusions, citing her Jehovah’s Witness (JW) faith, and acknowledgment that this decision could result in her death shows an appreciation for the consequences of her decision. This suggests both understanding and appreciation, providing ethical relevance to her refusal.

However, several factors raise questions about the reliability of her decision. Acute head trauma, the urgency of the situation, and the possibility of emotional distress may have affected her DMC. Additionally, family members report that her affiliation with the JW faith was recent and marked by uncertainty as evidenced by her consideration for leaving the church, suggesting her expressed refusal may not reflect deeply held or enduring values.

They describe a recent crisis of faith and assert she would genuinely prefer surgical intervention and transfusion over death. Input from a JW liaison could help clarify the extent and sincerity of her religious convictions.

Unfortunately, the team was unable to obtain further information directly from Mrs. Genericson to better assess her understanding or the stability of her decision. While these uncertainties weaken confidence in a full capacity assessment, they do not automatically invalidate her stated refusal.

When DMC is unclear, clinicians typically rely on substituted judgment, asking surrogates to speak on the patient’s behalf by inferring what they believe to be decisions the patient would make for themselves if capacitated. However, the family’s perspective may also be influenced by fear, emotional distress, and the urgency of the situation, potentially limiting the reliability of their claims. As such, their input, while important, must be weighed cautiously.

Given the high stakes and the absence of definitive evidence of incapacity, the patient’s clearly expressed refusal carries significant ethical weight. In this context, it is ethically permissible to respect her decision to decline blood transfusions while still considering surgical intervention. The surgical team should explore bloodless techniques or acceptable alternatives (e.g., blood fractions) consistent with JW beliefs, where feasible.