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The dilemma
The patient is illustrative. Ms. A., 38, is a Jehovah's Witness admitted with heavy bleeding from uterine fibroids. Her hemoglobin is 6.1 g/dL, and the team recommends a blood transfusion. She refuses, explaining that accepting blood would violate her deepest religious beliefs, and shows the nurse an advance directive card stating that she refuses transfusion of whole blood and its main components. Her sister, who is not a Jehovah's Witness, begs the nurse to "do something."
The nurse feels pulled between respecting Ms. A.'s choice and wanting to prevent harm that a transfusion could avoid.
The principles in tension
Beauchamp and Childress (2019) describe four principles of biomedical ethics:
- Respect for autonomy: respecting the decisions of people who are able to make them.
- Beneficence: acting to benefit the patient.
- Nonmaleficence: avoiding harm.
- Justice: treating people fairly.
Here, autonomy and beneficence point in different directions. Respect for autonomy does not depend on whether the clinicians agree with the decision, so the key question is whether Ms. A. has the capacity to make it.
Assessing capacity
Appelbaum (2007) describes four abilities clinicians assess when judging a patient's capacity to consent to or refuse treatment:
- Communicating a choice: Ms. A. states her decision clearly and consistently.
- Understanding the relevant information: she can explain what anemia means and that refusing blood could lead to organ damage or death.
- Appreciating the situation and its consequences: she acknowledges that this applies to her, saying, "I know I could die."
- Reasoning about the options: she weighs her options in line with her long-held values and asks about alternatives.
Capacity is specific to the decision, and a more serious risk calls for a more careful assessment. Ms. A. meets all four standards, so her refusal is an informed, capable decision.
Resolving the dilemma
Because Ms. A. has capacity, respecting autonomy takes priority. Overriding her refusal would be battery, and it would cause a serious moral harm by violating her religious identity. Beneficence still has a role: the team should do everything possible within the limits she accepts. The nurse can:
- Confirm with the provider that the refusal is documented clearly, along with her understanding of the risks.
- Ask Ms. A. exactly which treatments she would accept, since individual Witnesses decide on some blood fractions and procedures, and record her answers.
- Advocate for alternatives the team can offer, such as treating the source of bleeding, iron and other medications to support red cell production, and minimizing blood draws.
- Offer contact with the hospital's patient liaison or chaplain services, and with her faith community's hospital liaison committee if she wishes.
- Talk privately with her sister, acknowledge her fear, and explain that Ms. A. has the right to decide. With Ms. A.'s permission, invite her sister to a family meeting.
The nurse's own response
Caring for a patient whose choice may lead to her death can cause moral distress. The nurse should talk with colleagues or the ethics service and recognize that honoring a capable patient's decision is part of caring for her, even when it is hard.
References
Appelbaum, P. S. (2007). Assessment of patients' competence to consent to treatment. New England Journal of Medicine, 357(18), 1834–1840. https://doi.org/10.1056/NEJMcp074045
Beauchamp, T. L., & Childress, J. F. (2019). Principles of biomedical ethics (8th ed.). Oxford University Press.
