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Ann Thorac Surg 2002;74:1430-1431
© 2002 The Society of Thoracic Surgeons
a Department of Surgery, Toronto General Hospital, University of Toronto Joint Center For Bioethics, Toronto, Ontario, Canada
* Address reprint requests to Dr McKneally, 77 Forest Grove Dr, Toronto, Ontario M2K 1Z4, Canada, USA.
e-mail: martin.mckneally{at}utoronto.ca
Surgery is a warrior culture, whose practitioners are committed to battle heroically and physically against death and disease. Although the law protects caregivers from prosecution when they withhold lifesaving care at a patient’s request, they are not spared the moral anguish they experience when they are required to violate their own personal ethic of care. In this nearly tragic case, the surgeon used every means in his power to rescue his patient from certain death. In the aftermath, his surviving patient feels anger and resentment toward the surgeon, alleging that immoral means were used to save his life. Autonomy, the moral right to choose and follow one’s own plan of life and action, is a deeply embedded and dominant element in western culture, law, ethics, and medicine. Autonomous informed refusal of lifesaving care is an allowable and legitimate choice for mentally competent patients, particularly when they demonstrate a durable and firmly held conviction to refuse treatment and face their death steadfastly.
Religion is a powerful force in the lives of many people; their beliefs can strengthen their resistance to fear and doubt, and also to arguments based on the beliefs and values of scientific medicine. The faithful believer may autonomously delegate decision making to religious authorities and authoritative scriptures. This patient, while conscious, repeatedly affirmed his conviction that he would follow the teachings of his church even if it meant his death; he would not "take the blood of another." Such advance directives are generally prepared when we are well.
An old Spanish proverb, "the aspect of the bull changes when you enter the ring," teaches us an important lesson about perspectives on life, and on brushes with death—death looks different from a distance. The bull of death looks small and its charges look more manageable, less terrifying from this vantage point "in the stands." When the patient became unconscious, his wife, herself a Jehovah’s Witness, became his valid surrogate decision maker. A person who has a thorough understanding of the patient’s deeply held values and beliefs is a better source of guidance for medical decisions than a written advance directive alone, because she can take into consideration new factors and circum-stances unanticipated or underappreciated at the time the directive is written. The patient’s wife, aware of her husband’s durable and repeated attestation that he would choose death over transfusion, can be assumed to be able to understand how he would feel and react through changing circumstances. Circumstances do not define moral values, but may powerfully influence decisions regarding their application. This approach to circumstances is not unprincipled "moral relativism," in which there are no constants or boundaries. It is a concrete and practical assessment of the way in which particular circumstances should influence a value-based decision. In this case, realization dramatically and effectively displaced theorization. The views of the patient about the end of his life, as interpreted by his wife, were clarified as the end came perilously near. Facing the immediate prospect of death, atheists may pray and martyrs may recant. Imagining what her husband would have wanted at this extreme juncture, she gave her consent to transfuse. The wife’s surrogate decision to transfuse was made under duress, but it was ethically sound and legally valid.
Was the surgeon’s action in bringing the patient’s wife to his deathbed coercive, manipulative, or immoral? It certainly was not immoral in my view, although it was powerfully persuasive. The surgeon required her to share the moral anguish of watching a fellow human being to whom she is deeply committed die a preventable death. I suspect that many clinician readers will share my empathy with the surgeon. As pragmatic warriors, most surgeons would look for any means to persuade the patient or his surrogate to accept an available and definitive lifesaving treatment. The impetus to rescue is powerfully reinforced in surgeons because our direct physical intervention is so uniquely and personally linked to the outcome of operative treatment. From an ethical and legal viewpoint, the surgeon followed what is accepted practice in most hospitals when he asked the wife, as next of kin, to make a decision on her husband’s behalf.
When the patient learned about the transfusions from his chart months later, his rage and resentment at being transfused, contrary to his stated wishes, were compounded by the fact that his transfusion was not disclosed to him until he discovered it himself many months later. He made this discovery when he was not facing imminent death, but was safely back in the stands—recovered. The surgeon’s failure to disclose the transfusions was an error, one that might suggest an unethical disrespect of the patient’s rights and person. Nevertheless, I believe that the surgeon did show respect for the patient as well as faithfulness to his own ethic of care because he sought permission to transfuse at the brink of death from the patient’s valid surrogate decision maker.
This article has been cited by other articles:
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  D. T. Ridley Legal consequences of disregarding the wishes of a patient Ann. Thorac. Surg., October 1, 2003; 76(4): 1336 - 1336. [Full Text] [PDF]
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R. M. Sade Legal consequences of disregarding a patient's wishes: Reply Ann. Thorac. Surg., October 1, 2003; 76(4): 1336 - 1337. [Full Text] [PDF]
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