BCMD2B Using the beneficence model as an ethical approach to surgical decision making: A case report When faced with a request from a Jehovah’s Witness for a bloodless surgery, the surgical team should approach the case with an ethical framework in mind. Sofía Zhang-Jiang, BHSc, Stephen Tredwell, MD, MA, FRCSC ABSTRACT: Ethics-guided decision making in Introduction While the rightness of a decision is not dif- medicine should be approached with a sound Medical ethics ficult to determine in retrospect, evaluating the framework. To explore the efficacy of Pellegrino Ethics describes a moral philosophy that guides right course of action prospectively is no easy and Thomasma’s beneficence model in surgery, we a person’s actions. Health care professionals task for a clinician. Some common ethical di- present the case of a 14-year-old Jehovah’s Witness practise ethical thinking when making decisions lemmas in modern medicine include the abor- with scoliosis requesting a bloodless surgery in about patient management and are generally tion of a fetus and the interplay of end-of-life which the surgeon used the model to achieve a suc- influenced by Aristotle’s decisions and religious cessful outcome. The beneficence model outlines dictum of “first, do no beliefs, both situations four levels of good: the ultimate good, the good While the rightness harm.” The four pillars that prompt debates on of the patient as a person capable of reasoned of a decision is not that lay the foundation the extinguishment of life decision making, the patient’s perception of the for modern ethics are be- difficult to determine in and its associated spiritual patient’s best interests, and the medical good. The neficence, nonmaleficence, retrospect, evaluating consequences. surgeon and the patient each ranked the levels of autonomy, and justice.1 the right course of The ethical dilemma good to determine their respective overarching Current medical ethics that we discuss here cen- goods, and then discussed their perspectives to action prospectively borrows strongly from tres on a pediatric patient’s reach a decision that minimized conflict between is no easy task these concepts. The chal- refusal of blood products their overarching goods. Physicians involved in lenge with medical ethics for a clinician. due to the Jehovah’s Wit- decision making can apply the beneficence model lies in its clinical applica- ness faith, in which at first to examine ethically complex cases from a different tion, when multiple prin- glance the principle of au- perspective, rather than approaching the complex- ciples often appear to conflict, and none of the tonomy seems to conflict with medical benefi- ity simply as a conflict between the medical good four principles can be ranked as primary in ab- cence. We examine this clinical case through and the patient’s autonomy. 2 solute terms. Furthermore, each clinical case can Pellegrino and Thomasma’s beneficence model, be examined through different lenses that vary a medical adaptation of the third major ethi- cal philosophy—the Aristotelian doctrine of Ms Zhang-Jiang is a medical student at in their definition of the right course of action. “the good.” Pellegrino and Thomasma’s view the University of British Columbia (class Two major ethical philosophies that domi- features four components of the patient’s good: of 2022). She holds a Bachelor of Health nate medical ethics today emphasize a respect (1) the ultimate good, which represents the ul- Sciences degree from McMaster University. for persons and, flowing from that, individual timate standard for a person’s life choices; (2) Dr Tredwell is a professor emeritus in autonomy (Kantian) or social utility—specifi- the good of the patient as a person capable of the Department of Orthopaedics at the cally social good over the rights of the individual 2 reasoned decision making (i.e., autonomy); (3) University of British Columbia. (utilitarian). The first theory concerns itself with rights, duties, and obligations; the second the patient’s perception of their own good, or 2 best interests, in their current life situation; and This article has been peer reviewed. values social good and social accountability. 380 BC MEDICAL JOURNAL VOL. 62 NO. 10 | DECEMBER 2020 BCMD2B TABLE. Examples of questions that health care professionals may consider themselves, or ask a patient, to (4) the medical good as achieved through medi- clarify their levels of good. cal intervention to treat or manage a disease.2 The levels of good are listed in the descending Level of good Sample questions order of importance suggested by Pellegrino and “ What holds the highest meaning for you and constitutes the ultimate Thomasma. This view allows a stratification of standard for your life choices?” autonomy, less conflict, and a more thorough The ultimate good “ What is the most important determinant to your happiness; is it living discussion as part of clinical decision making. accordance with God’s will, developing your potential, honor, wealth, social utility, or something else?” The physician should approach the case with The good of the patient as a the four components of the patient’s good in “ What is your choice as a human being capable of reasoning and with person capable of reasoned freedom to express?” mind and ascertain the patient’s opinion on decision making each of them [Table]. When one or more levels “ What course of action is in line with your best interests given your current The perception of the of good conflict, a hierarchy should be deter- circumstances? patient’s own good in their mined among them to identify the overarching “ What quality of life is worthwhile or consistent with your life goals, aims, current life situation good. If, following the discussion, the medical and plans?” good is in direct conflict with a patient’s over- The medical good “ What is medically indicated for this disease or illness?” arching good, rethinking is needed. Jehovah’s Witnesses’ beliefs The Jehovah Witness Christian movement was for corrective surgery at age 12. His case was in the patient’s chart and was discussed with founded in the United States by Charles Rus- complicated by an additional diagnosis of se- the anesthesia team. sell in 1872 and has grown to over 6 million vere factor IX deficiency. As a result of factor Preoperative and perioperative procedures members worldwide.3 Members of this religion IX desensitization protocol, his scoliosis surgery implemented to maximize hemoglobin and hold a fundamental belief that “consumption” was delayed until age 14. Scoliosis surgery can minimize blood loss included erythropoietin, of blood is forbidden, as indicated by Biblical be associated with significant intraoperative oral iron supplement, recombinant factor IX passages such as: “Only flesh with its soul— blood loss of up to 4.5 L, and higher Cobb concentrate, and tranexamic acid. Surgical its blood—you must not eat” (Genesis 9:3-4); angles (severity of the curvature) are associated time for posterior fusion of spinal levels T2– 7,8 “[You must] pour its blood out and cover it with increased blood loss. It has been report- L1 was 4 hours. The use of monopolar cautery, with dust” (Leviticus 17:13-14); and “Abstain ed that Cobb angles greater than 50 degrees a local anesthetic solution of epinephrine, and from . fornication and from what is strangled increase the risk of massive blood loss 2.47 an argon gas coagulator optimized surgical 8 and from blood” (Acts 15:19-21).4,5 Jehovah’s times. This patient’s Cobb angle had increased hemostasis. Total intravenous fluid adminis- Witnesses interpret these verses as indicating to 65 to 70 degrees by age 14. The medical as- tered was 2700 mL and intraoperative blood prohibition of the transfusion of whole blood pects of this case have been described in more loss was estimated at 350 mL, with no blood 9 or its primary components (including packed detail in a previous case report. products given. No adverse events were noted red blood cells, white blood cells, plasma, and Prior to surgery, the surgeon consulted with in the patient’s postoperative care and the platelet administration) under any circumstance. the patient’s family and church elders together patient was discharged in stable condition Some Witnesses may accept secondary compo- using Pellegrino and Thomasma’s beneficence on day 11. nents such as albumin, immunoglobulins, and model as a framework. All parties agreed to hemophiliac preparations, as their use is not minimize the conflict between the patient’s Discussion absolutely prohibited.4-6 Furthermore, many and the surgeon’s overarching goods (see Ethi- Surgical outcomes Witnesses believe that blood that has been cal challenges below). The family refused the The ethical concern regarding Jehovah’s Wit- removed from the body should be disposed use of blood products during surgery due to ness patients’ refusal of blood products is not of; thus, techniques to remove and store the their religious beliefs. Strategies to maximize an uncommon issue in surgery. Although some patient’s own blood are often unacceptable.3,4 preoperative hemoglobin concentration and surgeons and anesthesiologists prefer to decline These patients pose a unique challenge to an- minimize perioperative blood loss were imple- surgeries on Witnesses, viewing the inability esthetic and surgical teams in cases in which mented, and the surgeon agreed to terminate to use blood products as tying their hands, a blood-free surgery is desired and the risk of the surgery should sufficient blood loss oc- there is an increasing number who are ready 3,4 significant blood loss is high. cur to require blood products. Blood transfu- to take on such cases. Advances in medical sions would be considered only in the case of a care have enabled more elective surgeries and Case report life-threatening intraoperative hemorrhage, and trauma cases to be performed without blood The patient was diagnosed with juvenile onset the family was not required to sign a transfu- transfusions, as requested by Witnesses, al- idiopathic scoliosis at age 10 and was scheduled sion consent form.