REVISTA
BRASILEIRA DE
ANESTESIOLOGIA
Publicação Oficial da Sociedade Brasileira de Anestesiologiawww.sba.com.br
SCIENTIFIC ARTICLE
Ethical and legal duty of anesthesiologists regarding
Jehovah’s Witness patient: care protocol
Augusto Key Karazawa Takaschima
a,∗, Thiago Mamôru Sakae
b,c,
Alexandre Karazawa Takaschima
d, Renata dos Santos Teodoro Takaschima
e,
Breno José Santiago Bezerra de Lima
a, Roberto Henrique Benedetti
a,faCETSianestSBA,Florianópolis,SC,Brazil
bUniversidadedoSuldeSantaCatarina(Unisul),Imbituba,SC,Brazil cUniversidadeFederaldeSantaCatarina(UFSC),Florianópolis,SC,Brazil dDireitoEstadual---SantaCatarina,Florianópolis,SC,Brazil
eComplexodeEnsinoSuperiordeSantaCatarina(Cesusc),Florianópolis,SC,Brazil fHospitalFlorianópolis,Florianópolis,SC,Brazil
Received 26 February 2015; accepted 24 March 2015 Available online 12 September 2016
KEYWORDS
Anesthesiology; Bioethics; Rights; Transfusion; Blood products; Blood
Abstract
Background and objectives: Jehovah’s Witnesses patients refuse blood transfusions for reli-gious reasons. Anesthesiologists must master specific legal knowledge to provide care to these patients. Understanding how the Law and the Federal Council of Medicine treat this issue is critical to know how to act in this context. The aim of this paper was to establish a treat-ment protocol for the Jehovah’s Witness patient with emphasis on ethical and legal duty of the anesthesiologist.
Content: The article analyzes the Constitution, Criminal Code, resolutions of the Federal Coun-cil of Medicine, opinions, and jurisprudence to understand the limits of the conflict between the autonomy of will of Jehovah’s Witnesses to refuse transfusion and the physician’s duty to provide the transfusion. Based on this evidence, a care protocol is suggested.
Conclusions: The Federal Council of Medicine resolution 1021/1980, the penal code Article 135, which classifies denial of care as a crime and the Supreme Court decision on the HC 268,459/SP process imposes on the physician the obligation of blood transfusion when life is threatened. The patient’s or guardian’s consent is not necessary, as the autonomy of will manifestation of the Jehovah’s Witness patient refusing blood transfusion for himself and relatives, even in emergencies, is no not forbidden.
© 2016 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license ( http://creativecommons.org/licenses/by-nc-nd/4.0/).
∗Corresponding author.
E-mail:takaschima@uol.com.br(A.K. Takaschima). http://dx.doi.org/10.1016/j.bjane.2015.03.012
PALAVRAS-CHAVE
Anestesiologia; Bioética; Direito; Transfusão; Hemoderivados; Sangue
DeveréticoelegaldoanestesiologistafrenteaopacientetestemunhadeJeová:
protocolodeatendimento
Resumo
Justificativaeobjetivos: OspacientestestemunhasdeJeovárecusamtransfusãosanguíneapor motivosreligiosos.Oanestesiologistadevedominarconhecimentosjurídicosespecíficospara atender essespacientes. Entendercomo odireitoeoConselhoFederal deMedicinatratam essaquestãoéfundamentalparasaberagirdentrodessecontexto.Oobjetivodesteartigofoi estabelecerumprotocolo deatendimentodopaciente testemunhadeJeovácomênfaseno deveréticoelegaldoanestesiologista.
Conteúdo: Oartigo analisa aConstituic¸ão,o Código Penal, resoluc¸ões doConselho Federal deMedicina (CFM), pareceresejurisprudênciapara entenderoslimitesdo conflitoentrea autonomiadevontadedatestemunhadeJeováemrecusartransfusãoeaobrigac¸ãodomédico emtransfundir.Baseadonessasevidênciasumprotocolodeatendimentoésugerido.
Conclusões:Aresoluc¸ãodoCFM1021/1980,oCódigoPenalnoartigo135,queclassificacomo crimeaomissãodesocorro,eadecisãodoSupremoTribunaldeJustic¸asobreoprocessoHC 268.459/SPimpõemaomédicoaobrigac¸ãodetransfusãoquandohouverriscodevida.Nãoé necessárioconcordânciadopacienteoudeseuresponsável,poisnãoéproibidaamanifestac¸ão devontadedopacientetestemunhadeJeováaorecusartransfusãosanguíneaparasieseus dependentes,mesmoememergências.
©2016SociedadeBrasileiradeAnestesiologia.PublicadoporElsevierEditoraLtda.Este ´eum artigoOpen Accesssobumalicenc¸aCCBY-NC-ND( http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Jehovah’s Witnesses patients refuse blood transfusion.1 They claimreligious impediment based ona literal inter-pretation of the Bible. Inclined to spread their beliefs, this American movement grows significantly. Thus, the medical care of members of this denomination is grow-ingincreasingly in hospitals,2 some in need ofemergency bloodtransfusions.BasedondecisionsmadebytheBrazilian JudiciaryintheConstitution,PenalCode,CodeofMedical Ethics,andresolutionsofthe Federal Councilof Medicine (CFM),weelaboratedananestheticcareprotocolof Jeho-vah’sWitnesseswhoneedtransfusion.
Initially, we will address concepts of bioethics impor-tantforunderstandingthesubject.Thenwewillreviewthe jurisprudenceandfinallypresentaprotocolsuggestionfor thissituation.
Freedom
of
choice
and
manifestation
of
will
InitsArticle 5, theConstitution3 guarantees full freedom to the Brazilian citizens. This constitutional guarantee is reflectedin theprinciple of freedomof choice. Clinically speaking,manifestationofwillisunderstoodasthepatient’s choicefor aformof treatmentor evenof notreatment.4 Examplesofpatient’swillarethedecisiontocontinue smok-ingdespitefacingalungproblemortheoptionofapatient toget pregnant even withcoexisting illnesses that imply life-threateningduringpregnancyorchildbirth.5
The manifestation of will makes the decision of the patientpublic.Inthissense,Article22oftheCodeof Medi-calEthics6states:‘‘Thephysicianshall:notfailtoobtainthe patient’sorhis/herlegalguardianconsentafterinforming
himabouttheproceduretobeperformed,exceptincasesof imminentriskofdeath’’.Asstated,consentisarequirement forelective medicalpractice.4Usually,thepatientsignsa termdeclaringtobeawareofthe medicalprocedure and itscorrespondingrisksandtakesthemwillingly.Thisisthe manifestation ofwill mostusedroutinely.Anotherway of manifestation ofwillistheJehovah’sWitnessesrefusalto receivebloodtransfusions.
Judicialdoctrinestatesasvalidrequirementsofthe man-ifestationofthewill:capableagent,objectnotprohibited by the law,and in a manner prescribedby law.7 Fulfilled these criteria, the Jehovah’s Witness patient manifesta-tionofrefusing blood transfusionis absolute.This right is basedon theBrazilian Constitution3(Article 5, SectionII) thatguarantees: ‘‘Nooneisobliged todoor refrainfrom doingsomethingexceptbyvirtueof thelaw’’.Asthereis nolegalprovisioninthelawrequiringsomeonetoconsent toanytreatment,noneedtoagreetobesubmittedtoblood transfusion.7
Legal
regulation
of
blood
transfusion
‘‘Incaseofrefusaltoallowbloodtransfusion,the physi-cian,accordingtohisCodeofMedicalEthics,shouldobserve thefollowingconduct:
1. Ifthereisnoimminentdangertolife,thephysicianshall respect the will of the patient or the patient’s legal guardians.
2. If thereis imminent danger to life, the physician will perform blood transfusion, regardless of the patient’s consentorofhis/herlegalguardians.’’
The RegionalCouncilofMedicineoftheStateofRiode Janeiro(CREMERJ),inlinewiththeCFMissuedthe Resolu-tionNo.136/9911toregulatethesubject,ofwhichwecite thefollowingarticles:
Article1--- Thephysician,formallyawareofthepatient’s refusal to receive blood transfusionand/or blood compo-nents,shouldusealloftheoptionalmethodsoftreatment available.
Article3---Thephysician,whenanalyzingthepresenceof riskofdeathforapatientinanysituation,shouldmakeuse ofallmeansathisdisposaltoensurethepatient’shealth, includingbloodtransfusionand/orbloodcomponent admin-istrationand,ifnecessary,reporttothecompetentpolice authorityhisdecision,iftheresourcesusedarecontraryto thewishofthepatientorhis/herrelatives.
Itisclearthatbothresolutionsimposeonthedoctorthe dutyofprovidingbloodtransfusionwhenthepatient’slife is at risk. Regarding the coercive power of these resolu-tions,theAttorneyGeneralofRiodeJaneiro,inanopinion involving the Pedro Ernesto University Hospital in Rio de Janeiro and the Jehovah’s Witnesspatient who refused a bloodtransfusion,stated:‘‘...certain isthatitwillnotbe tranquil,fromthedisciplinarystandpoint,thesituationof physicianswho,fromthesameperspective,donotcomply withtheResolution No.136/99 ofthe RegionalCouncilof Medicine oftheStateofRio deJaneiro(CREMERJ),which specifically deals withthe refusal to receive blood trans-fusionandblood components.This actstatesthatdoctors havethe tendencytoavoidtheneed fortransfusions,but predictsitsforcedfulfillmentincaseofimminentdangerto life(emphasisofthearbiter).Hence,thejudgmentofdirect action of unconstitutionality before the Federal Supreme Courtissuggested.’’12Theopinionpositioningistorespect thewillofthepatient.However,itrecognizesthatthe CRE-MERJResolution136/99imposesonthephysicianthedutyto performtransfusions.Fordisagreeingwithitscontent, the prosecutionsuggeststhedirectactionofunconstitutionality judgmentofthisresolution,acknowledgestheobligationof unconstitutionalityofthisresolution,andacceptstheduty obligation that is imposedon doctorswhen suggesting its cancelation.
Disrespecttoacouncilresolutionissubjectto adminis-trativesanction.Thephysicianwhodoesnotperformblood transfusion when needed bears this risk. However,this is nottheonlypunishmenttowhichadoctormaybesubject.8 Thereisthepossibilityofexperiencingcivil(actionfor dam-ages and/or governmental regressiveactions if the State iscondemnedbythedoctor’somission)andadministrative consequencesbeforethegovernmentaldisciplinary commit-teestowhichheis linked,in theeventofpublicservants
doctors,and, of concern, criminal proceedings, ifdenied assistanceisunderstood(Article135oftheCriminalCode).13
Boundaries
Theboundarybetween theautonomyof thepatient’swill andthedoctor’sdutytoactistheriskofdeath.The Crimi-nalCode13Article146establishesasacrimeagainstpersonal freedom: ‘‘Embarrassing someone, either by violence or seriousthreat,orafterhavingreduced,byanyothermeans, his/herresilienceabilitytonottodowhatthelawallows, ortodowhatitdoesnotrequire’’.Theexceptiondirectly related to medical action is in Paragraph 3 of the same Article: ‘‘It is not included in the provision of this arti-cle:themedicalorsurgicalinterventionperformedwithout the consent of the patient or his/her legal guardians, if justifiedbyimminentthreattolife’’.Thus,ifblood trans-fusionisnecessarytosavethepatient’slifeitmaynotbe considereda violationof theJehovah’sWitness autonomy ofwill.
Insomemedicalconditions,whenthepossibilityof seri-ousbleedingisexpectedbeforeamajorsurgery,thedoctor requestsjudicialauthorizationforprophylacticblood com-ponents administration in Jehovah’s Witnesses patients. Somejudges denythisrequest.8Others clarifythat isnot thejudiciaryresponsibilitytoauthorizeorprescribe medi-caltreatment,confirmtheauthorityofthemedicalactand underlinethe necessary independence thatan emergency situationrequires,statingthatthedoctorhasanobligation totakethenecessarymeasurestotreatpatients.Any clini-calpicturethatrequiresbloodtransfusionshouldbetreated withoutjudicialmediation.
Jurisprudence
There area large number of lawsuits involving Jehovah’s Witnessesand doctors.8 Noteworthily, the Supreme Court ofJustice (STJ) decisionin the lawsuit(HC 268,459/SP)14 pendingincourtforover20yearsreferringtoa13-year-old daughterofaJehovah’sWitnesses.
The patient had sickle cell anemia. In a severe vaso-occlusivecrisis,theparentstookherdaughtertoahospital emergencydepartmentinSãoPaulo.Theconditionwas seri-ous.Clinicalexaminationandlaboratorytestshadindicated theneedfortransfusionofpackedredbloodcellstotreat thepatient.Her parentsdidnotauthorize theprocedure. Theybroughtadoctoroftheirtrust,alsoaJehovah’s Wit-ness,whothreatenedtosuethemedicalassistantsifthegirl weretransfused.Transfusionwasnotperformedandthegirl diedhoursafteradmissiontothehospital.
beaccusedofmurder.The applicationwasdismissed. The defense appealed to the Supreme Court withan applica-tionforhabeascorpuswiththesamethesis.Thecase was triedbythe6thChamberoftheSTJ.Therapporteur,inher reportandvote,assertedthattheparentscouldnotbeheld responsibleforthedeathoftheirdaughter.Inheropinion, the parents’ refusal could not be a reason for not trans-fusingthe teenager.Theblame wouldfallondoctorswho shouldhavetransfusedthepatient,evenagainstthewillof thoseresponsible.Therewouldbenocrimeinrefusingblood transfusionfor oneselfor his/herdependents, asreligious freedom and the manifestation of the will are constitu-tionalrights.Itis statedinher reporttheCFMResolution 1021/1980.
It should be notedthat the vote of the rapporteur, in agreeingto the defense arguments, wasaccepted by the STJ. The parents would be innocent because the mani-festation of will is free and absolute, it is not a crime. Therewould benoneed toagreetothe transfusion.The doctor has a duty obligation that the patient or legal guardianhasnot.Transfusionshouldbeperformed regard-lessofthepatient’sorguardianmanifestationofwillbeing contrary.
This decision is considered critical because, as it fol-lowedthecriminal andnotcivil proceedings,itdelimited theStatetutelageontheissue.Whentransfusionis neces-sary,thephysicianhasanobligationtoact,givepriorityto life-savingoverfreedom.TheState,whilemaintaining com-plete freedom of action regarding religion, shall conduct theprotection of fundamental rights, determine to those responsibleforpublicandprivatehealthallprocedures nec-essaryforthepreservationoflife.15
Protocol
service
Based on the study on the subject, we have developed thefollowing anestheticprotocol for Jehovah’sWitnesses patients:
(1) Identification of emergency situation and transfusion requirements.
Faithfullydocumenttheclinicalcondition,vitalsigns, andadditionaltests.Theneedfortransfusionshouldbe evident.
(2) Do notattempttochange thewillor manifestationof willofthepatientorrelatives.
Patientsortheirrelativesaregoingthroughdifficult situation.Atatimewhenfaithandreligionserveas sup-port;confirming thecommitmentofnon-transfusionis very important for Jehovah’s Witness. It is not advis-abletodiscussoraskpermissionforthetransfusion.It isunnecessary.Thesocialworker,psychologist,oreven nursemaytalktorelativesandsaythattheemergency teamunderstandsandfullysupportsthedecisiontonot carryouttransfusion,butthattransfusionwillbedone to save the patient’s life. This position is evenmore importantwithchildrenandadolescents.
(3) Incaseofphysicalresistancefromrelativesorpatients. If there is physical resistance from patients or guardianstopreventtransfusion,requestthepresence ofapoliceauthorityifnecessary.
(4) Transfusion.
In case of life-threatening, transfusion is a medi-cal duty. Prior commitment to the patient ensuring that blood components will not be administered dur-ingsurgery,aswellasadocumentsignedbythepatient orguardiandonotexemptanesthesiologistsfromtheir responsibilities.
Conclusion
The CFM Resolution 1021/1980, the Criminal Code Article 135, whichclassifies failuretoprovidemedicaltreatment asacrime,andthedecisionoftheSupremeCourtontheHC 268,459/SPprocessimposeonthephysiciantheobligation of blood transfusionwhenlife is threatened.The consent of thepatient or guardianis not necessary,asthe auton-omyofwillmanifestationoftheJehovah’sWitnesspatient refusingbloodtransfusionforhimselfandrelatives,evenin emergencies,isnotforbidden.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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