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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.

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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. The agreement was recorded though often at an increased risk.3

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Simple methods to decrease the rate of bleeding, such as tourniquets and position- ing the patient with the surgical site elevated, The four levels of good: 3 1. the ultimate good, or the ultimate standard for the patient’s may be used during surgery. Surgeons may life choices. also employ a technology called intraoperative 2. the good of the patient as a person capable of reasoned autotransfusion, since some Witnesses accept decision making. 6 blood that remains in a closed circuit system. 3. the perception of the patient’s own good, or best interests, Moreover, Witnesses do not object to colloid in the patient’s current life situation. or crystalloid replacement fluids, electrocau- 4. the medical good as achieved through medical tery, hypotensive anesthesia, or hypothermia, intervention to treat or manage a disease. as well as newer techniques such as large-dose intravenous iron dextran administration and the ultrasonic scalpel.3-5 Such are some of the options successfully Patient Health care professional employed by surgical teams to decrease blood Identify and rank the four levels of good Identify and rank the four levels of good loss and improve surgical outcomes, but each to determine the overarching good. to determine the overarching good. has associated risks and drawbacks that neces- sitate a detailed informed consent process.3 For instance, acute normovolemic hemodilution, a technique that involves removing whole blood Discuss to determine a plan to minimize any conflict from the patient preoperatively and infusing between the patient’s and the health care professional’s crystalloid or colloid fluids to maintain intra- overarching goods. vascular volume, carries the risk of hypoxia due to excessive hemodilution or hypovolemia as well as risks specific to the resuscitation fluid Figure. The beneficence model applied to clinical decision making. used.10-12 Intravenous iron dextran injections can cause life-threatening anaphylaxis.13 The potential complications of hypotensive anesthe- care.16 An important principle under patient When caring for Jehovah’s Witnesses, ethi- sia include shock, stroke, myocardial infarction, autonomy is informed consent, which must cal challenges arise when there is a conflict be- hepatic failure, and renal insufficiency.14,15 be obtained voluntarily prior to any procedure tween the four levels of a person’s good. There is In addition, preoperative steps should be after patients are fully informed of the risks a propensity for physicians to equate the medi- taken to optimize the patient’s hemoglobin and benefits of the treatment plan, including cal good with the whole of the patient’s good. levels and to normalize bleeding and clotting those of the strategies to reduce blood loss or Through the medical lens, doctors may view times.3 Examples include administering re- those to reduce the medical need to replace the refusal of blood products as not being in combinant erythropoietin and iron to correct blood.5 In order to obtain informed consent, the best interest of a patient’s health, as it may anemia and promote erythropoiesis, and dis- doctors must assess the competency of patients lead to hemorrhagic shock, severe anemia, or in continuing drugs that affect the coagulation to ensure they are fully capable of making their the worst case, death by exsanguination.18 This cascade.3,9 Postoperative care includes nonin- own decisions, even if the decision of refusing seemingly goes against the principle of benefi- vasive techniques, such as close surveillance for care should lead to adverse outcomes such as cence and the fiduciary relationship between bleeding and restricted phlebotomy, and admin- death. For Jehovah’s Witnesses, accepting blood doctor and patient, which demands that doctors istration of pharmacological therapies, such as transfusions is considered a sin so grave that act in the best health-related interests of the hemostatic agents to stop bleeding and eryth- it will result in the loss of any hope for eter- patient, but according to the aforementioned ropoietic agents to promote erythropoiesis.3,9 nal life—which could be viewed as worse than beneficence model, it should account for only death itself.3,5,17 With this reasoning in mind, the medical component of beneficence rather Ethical challenges Jehovah’s Witnesses can be differentiated from than its whole. The principle of patient autonomy provides suicidal patients who are incompetent due to The physician should help the patient un- patients the right to make their own decisions, mental illness.5 It is common for Witnesses to derstand the medical good, then encourage the which must be respected by the health care refuse blood products despite a critical medi- patient to interpret the other levels of good and team. It is paramount for physicians to under- cal need, and the right to make this decision rank them to determine what the overarching stand the decisions made by competent adults, is widely accepted in medical literature and good is [Figure]. In the case of Jehovah’s Wit- even in cases of refusal of medically necessary respected in clinical practice.17 nesses, patients may place the most value on the

382 BC Medical Journal vol. 62 no. 10 | december 2020 BCMD2B ultimate good of living in accordance with their This discussion may necessitate agreement from is less clear.6,16,17 With evolving legal and ethi- faith—this overarching good trumps the medi- the church elders that the two overarching be- cal standards on autonomy and the rights of cal good; therefore, receiving a blood transfu- liefs need to be respected. Church elders are minors, there is uncertainty in the medical field sion, which results in loss of eternal life, would responsible for congregational governance in about what is appropriate when caring for a not be a beneficent act for this patient even if it their jurisdiction, and they administer disciplin- minor in such cases. Jones and colleagues16 ar- is medically indicated to prevent death. In our ary action against members perceived to have gue that the parental responsibility is a moral case, the surgical team determined through a committed serious sins. In a medical case, the obligation rather than a right and is, therefore, discussion with the patient’s family and church patient’s and family’s anxiety can be reduced secondary to the responsibility of ensuring the elders that the overarching good for the pa- with reassurance that the decision is sanctioned physical safety of the minor. The focus should be tient was the ultimate good of adhering to his by church elders. on the child’s health instead of the right of the Jehovah’s Witness faith, which outweighed parent to decide. There are many documented the medical good of accepting blood products. By examining the cases of court orders granting hospitals the abil- In the family’s view, receiving blood products patient’s and surgeon’s ity to give blood that was absolutely necessary to would equate to a grave sin worse than death. save a minor’s life.16 However, exceptions have There is, however, another variable that may differing overarching been made when the patient was an adolescent need to be introduced into the conversation— goods, conflict is considered to be mature enough to make an the ultimate good as seen by the surgeon. All altered from that of informed decision.6,16 Also worth noting is the participants in the clinical decision have their the medical good potential consequence of a family casting out own interpretations of the levels of good. Par- an adolescent who chooses to receive a blood versus the patient’s ticipants concerned with a patient’s care include transfusion at the loss of their eternal life. the patient, the patient’s family, and the health overarching good. It is important for health care professionals care professionals, and these parties may have to document the decisions made throughout conflicting views. For instance, by operating, these conversations. Discussions often result the surgeon may arrive at a juncture where their The parties involved in this case, including in verbal agreements that are supplemented action creates a situation in which the patient church elders, agreed to minimize blood loss by by clear documentation of the progress in the may die if blood is not given, despite all the optimizing preoperative hemoglobin levels and patient’s medical chart. measures that have been taken to prevent this. perioperative hemostasis through procedures It is recommended that health care pro- From the perspective of the surgeon in our case, such as monopolar cautery and argon gas co- fessionals seek assistance when dealing with not administering blood products in the event agulator. The surgical team respected the fam- cases of conflict with patients and their families of potentially life-threatening loss of blood went ily’s desire for a decreased risk of having to use regarding treatment plans.17 Most health care against his fundamental spiritual beliefs of non- blood products, and the family acknowledged institutions have access to ethics services. The maleficence as a physician and as a member the surgeon’s beliefs of nonmaleficence and his surgeon in this case consulted an ethicist who of his own religion. This is a conflict between decision to terminate the surgery should enough offered valuable feedback regarding the ap- two overarching goods. Acting in accordance blood loss occur to necessitate blood products. proach to the management decision. It is also with their own unwillingness to cause death, In the unlikely event that imminent death be- valuable to involve church elders in the conver- a surgeon may administer blood. The preop- came obvious, all parties agreed to respect the sation on decisions of religious matters to reas- erative discussion should reveal this potential surgeon’s ultimate good. This approach balanced sure both the health care professional and the conflict and elucidate all possible strategies to the parties’ conflicting overarching goods. patient that the chosen pathway is philosophi- avoid this clash of overarching goods, up to and At our clinic, we have had only one inci- cally acceptable. The goal is to reach a collab- including stopping the surgery and returning dence where this kind of agreement has not orative consensus that avoids or minimizes the another day if possible under the circumstances. been reached. This illustrates the strength of the clash between participants’ overarching goods. It is then necessary to evaluate the risk of this concept of beneficence-in-trust; the surgeon is clash occurring. trusted to expend all efforts available in a real- Summary In such a case, by examining the patient’s istic attempt to adhere to the patient’s wishes When faced with a request from a Jehovah’s and surgeon’s differing overarching goods, con- with a frank and honest expectation of success. Witness for a bloodless surgery, the surgical flict is altered from that of the medical good The ethical dilemma becomes more complex team should approach the case with an ethical versus the patient’s overarching good. If the risk in pediatrics. A child’s definition of their own framework in mind. While, on the surface, the of requiring a transfusion to prevent death is levels of good may be distinct from those of conflict appears to be one between the medical sufficiently remote, an understanding or agree- the parents. Whether minors are competent good and the patient’s autonomy, Pellegrino and ment to respect the surgeon’s unwillingness to to make the decision to refuse blood products, Thomasma’s beneficence model is a different cause death may allow the surgery to proceed. which may result in serious adverse outcomes, Continued on page 385

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Continued from page 383 fluids. Anaesthesiol Intensive Ther 2017;49:303-308. before trying the saline gargle again or using 13. Walters BAJ, Wyck DB Van. Benchmarking iron dextran an NP swab as the alternative. lens through which to examine such cases. sensitivity: Reactions requiring resuscitative medica- Through a careful discussion with the patient, tion in incident and prevalent patients. Nephrol Dial Lessons learned the physician should ascertain the patient’s Transpl 2005;20:1438-1442. Testing continues to be key to addressing the views on each component of good in order 14. Ahlering TE, Henderson JB, Skinner DG. Controlled hypotensive anesthesia to reduce blood loss in COVID-19 pandemic, and saline gargle im- to rank them and determine what the over- radical cystectomy for bladder cancer. J Urol 1983; proves testing accessibility. This popular col- arching good is for the patient. The physician 129:953-954. lection method, with high user acceptance, should also reflect on their own definition 15. Sollevi A. Hypotensive anesthesia and blood loss. addresses an important aspect of the pandemic of the overarching good and determine the Acta Anaesthesiol Scand Suppl 1988;89:39-43. 16. Jones JW, McCullough LB, Richman BW. A surgeon’s response as reluctance toward the NP swab is extent to which they are willing to fulfill the obligations to a Jehovah’s Witness child. Surgery a barrier to testing. patient’s request. If the patient’s interpreta- 2003;133:110 -111. The ability to increase testing among tions of the overarching good conflict with 17. Brezina PR, Moskop JC. Urgent medical decision mak- school-aged children and youth helped less- the surgeon’s, the parties should pursue op- ing regarding a Jehovah’s Witness minor: A case re- port and discussion. N C Med J 2007;68:312-316. en the chance of a school-based outbreak in tions that minimize the clash of beliefs and 18. Naunheim KS, Bridges CR, Sade RM. Should a Je- the first month after school started. While determine a course that is acceptable to all. By hovah’s Witness patient who faces imminent ex- COVID-19 continues to circulate in the com- approaching the decision-making process with sanguination be transfused? Ann Thorac Surg 2011; munity and school-based outbreaks will oc- empathy, clear communication, and meticu- 92:1559-1564. cur, expanding saline gargle and increasing lous planning, and using surgical techniques laboratory capacity will help BC manage the to decrease bleeding, it is possible to achieve pandemic. a successful surgical outcome. n Multiple jurisdictions, in Canada and abroad, have taken the work performed in Competing interests BC to facilitate the adoption of the saline None declared. gargle method in their region. n —Meghan McLennan, BSc, MLT References BC Medical Journal 1. Beauchamp TL, Childress JF. Principles of biomedi- Project Manager, Provincial Laboratory @BCMedicalJrnl Medicine Services cal ethics. 5th ed. New York: Oxford University Press; 2001. —David Goldfarb, MD, FRCPC 2. Pellegrino ED, Thomasma DC. For the patient’s good: Follow Medical Microbiologist and Pediatric The restoration of beneficence in health care. 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