Evaluating Capacity in a Suicidal Jehovah’s Witness Refusing Blood

Evaluating Capacity in a Suicidal Jehovah’s Witness Refusing Blood

Amanda Campbell, BA,a and David Halpern, MDa,*

Evaluation of capacity to refuse life-saving measures for an actively suicidal patient highlights the effects that suicidality has on capacity and the physician’s role in evaluating a patient’s ability to make life-ending decisions. This case presents the ethical considerations of a Jehovah’s Witness who refused treatment for religious reasons following a suicide attempt.

Case Report

In June 2019, a 29-year-old woman with chronic refractory major depressive disorder, prior suicide attempt via overdose, and several inpatient psychiatric hospitalizations presented to the emergency department after jumping in front of a train in an apparent suicide attempt. Ten years ago, the patient had been hospitalized in the intensive care unit for overdosing on an unknown number and type of medication. However, this was the first time the patient had attempted suicide via jumping in front of something. The patient sustained significant blood loss and would require multiple operations. Although she was barely rousable, it was revealed that the patient was a Jehovah’s Witness and was refusing a blood transfusion, prompting a psychiatry evaluation for capacity to refuse medical treatment.

On examination, the patient was inconsistently responsive but repeatedly refused blood products. "No blood," she would mumble. While able to articulate the choice, she was unable to elaborate her reasoning due to her vacillating awareness and did not demonstrate an understanding of the information with which she was presented. She was unable to explain what happened, and when asked if it was a suicide attempt, she shrugged and replied, "Maybe." When asked if she would accept blood, even if refusing it would lead to her death, she stated, "Not at the expense of giving up what I believe." When asked to elaborate or to explain her beliefs, the patient did not respond. Her inconsistency in ability to respond due to her mental status led the psychiatry team to determine the patient lacked capacity to make major medical decisions at that time and that medical decisions should be deferred to her next of kin or power of attorney.

The patient’s family at the bedside confirmed her religion and claimed she carried a signed card detailing her refusal of blood products, which was never located. The family informed us that the patient had not seen a psychiatrist in some time and was not taking the antidepressants prescribed by her primary care physician. The patient’s family also informed us that she had lost her job the morning of her suspected suicide attempt. However, the patient appeared unaware that she had lost her job earlier that day, stating she had no recollection of the event during moments of consciousness. In the absence of an advance directive, the patient’s mother stepped forward to act as her medical decision maker. Although most of the patient’s family members were Jehovah’s Witnesses, the patient’s mother was not. Despite insistence from family, the patient’s mother opted to consent for transfusion given the unique circumstances. The patient’s father (also a Jehovah’s Witness) initially disagreed with his wife’s decision to allow a blood transfusion, but by the next morning before her procedure, he had conceded and agreed to the transfusion, and he always concurred that the patient’s mother was the primary decision maker. The primary team consulted risk management, who advised that in the absence of paperwork demonstrating prior refusal of blood products, she should be transfused only for life-saving measures, and if the family could procure paperwork, she should not be transfused.

The patient’s capacity was reevaluated a few days later. During this evaluation, she was somnolent due to a combination of pain medication, effects of traumatic brain injury, and persistent anemia, resulting in continued lack of capacity to make medical decisions. She received another blood transfusion following that evaluation.

As the patient healed from her traumatic injuries and operations, her mother requested that she not be informed about the events leading up to her hospitalization or her transfusions. However, as the patient recovered and regained medical decision-making capacity, she directly asked and was told about the suicide attempt and her treatment. She appeared upset both at receiving blood products and for having survived the suicide attempt.

Prior to discharge, her family was concerned about her continued depressed mood and suicidal ideation, which the patient denied. Per her father, when asked if she was upset about living through the accident, she stated, "I wish I would’ ve been hit by a faster moving train." The patient was started on duloxetine, and the dose was titrated to 60 mg daily prior to discharge. The patient was eventually transferred to an inpatient psychiatric facility with a plan to continue in a partial program after discharge.

Discussion

Capacity is a clinical and ethical judgment made regarding a patient’s ability to make a specific decision at a specific point in time. It is possible for a patient to lack capacity to make one decision and have capacity to make another.1,2 When approaching capacity assessments, clinicians must set aside their own personal morals and beliefs,3 while considering the patient’s medical needs and respect for their values and autonomy.4,5 According to Appelbaum,6evaluation of capacity requires consistency in 4 domains: (1) the ability to communicate a choice; (2) the ability to understand, synthesize, and repeat relevant information; (3) the ability to understand risk-benefits of the decision; and (4) the ability to explain themselves rationally. Some believe that there is a fifth component, in that a patient’s choice should be in line with his/her prior decisions.5

In the present case, we were faced with the dilemma of considering our patient’s collaterally confirmed but formally undocumented religious values as a Jehovah’s Witness in the setting of her acute suicidality and critical condition with need for blood transfusion. Jehovah’s Witnesses believe the Bible prohibits them from receiving blood, and a majority of these individuals carry cards documenting their refusal of blood products. Case law states that these cards are legally binding equivalents to advance directives, leaving little room for argument of medical management.2 However, in the setting of a suicide attempt there is room for legal interpretation to invalidate a patient’s advance directive, as these documents were designed to aid in decision making in the event of incapacitation due to natural illness or accidental injury.7,8 In our patient, it is possible to interpret her refusal of life-saving blood as suicidal behavior in and of itself. One could argue that the patient selected this particular method of suicide knowing she would not receive blood products if her attempt was unsuccessful and would likely die from blood loss. This possibility further complicates the question of her medical decision-making capacity.

Acute suicidality calls into question the global decision-making capacity of a patient, as a suicide attempt in an otherwise physically healthy individual can be seen as reflecting an irrational mental state.7-9 Involuntary intervention is justified by the assumption that a suicide is inherently nonautonomous, meaning that those suffering from depression are "coerced" by their illness to commit suicide.9 Although some conceptions of suicide allow for a more libertarian defense of patient autonomy,10 the commonly accepted medical position is to treat a patient with the principle of beneficence and withhold the principle of autonomy while determining the effect of acute mental illness.7,8 As more information is learned about the patient’s established values, morals, and past medical decisions, evidence for continuity of beliefs can be demonstrated. In this way, although patients may lack the capacity to end their own life, they do not necessarily lack capacity to make informed decisions regarding their treatment course. A patient may reasonably refuse or elect for certain treatment based on previously held beliefs or values unrelated to their acute suicidality.7,10

The assumption that all suicide attempts are nonautonomous is challenged by the libertarian perspective of suicide: that not all suicidal actions mean that a patient has a mental illness and is incapacitated to make a choice regarding his/her own body.7,9-11 In this view, a person can voluntarily choose suicide after a careful analysis of the risks and benefits,10 introducing the principle of "rational suicide." For suicide to be rational, clinicians must accept that people with mental illnesses are not inherently irrational, that treatment is not always effective or tolerable, and the goal of ending psychological or physical suffering is, in itself, a worthy reason for suicide.9,10 If we were to consider chronic refractory depression a terminal illness, refusal of care in a chronically suicidal patient could be equivalent to cessation of treatment in a patient with terminal cancer. In patients who have trialed numerous treatments, have had years of unrelenting symptoms, and wish to end their life by suicide, is it always unethical for a physician to allow them to end their suffering through death? The consideration that even some suicide attempts may be rational allows for the discussion that not all acutely suicidal patients are inherently nonautonomous in their decision-making abilities, implying capacity to make medical decisions following the event.

Although our patient’s suicide attempt was not considered rational, if given the chance to explain her longstanding beliefs while not in a delirious state, she may have clearly communicated that receiving blood products went against her core beliefs. If her motive for refusing blood was unrelated to her suicidality, her refusal of blood may have been autonomous. Further, she possibly may have been accepting of other alternatives to blood in an effort to preserve her life, demonstrating sound judgment not impacted by her suicidality. The impact of her delirium on her capacity assessment could have been decreased by more frequent capacity evaluations, with purposeful timing to avoid administration of sedating medications, and correction of metabolic abnormalities. The patient was determined twice to be incapacitated due to transient delirium, resulting in blood transfusions the patient may have otherwise had the capacity to refuse.

Ultimately, the assessment of patient capacity is a delicate balance of respecting patient autonomy to refuse life-saving treatment, while simultaneously considering the principle of beneficence and a clinician’s moral obligation to preserve life. These evaluations must be done on a case-by-case basis, considering the patient’s present wishes, established values and beliefs, and decisions detailed in advance directives or those expressed by surrogate medical decision makers. Although it is commonly assumed that a suicidal patient lacks the capacity to refuse any treatment, clinicians must discerningly examine the context of the situation and carefully consider the patient’s motives and reasoning.

Published online: November 19, 2020.

Potential conflicts of interest: None.

Funding/support: None.

Patient consent: Consent was received from the patient to publish the case report, and information has been de-identified to protect anonymity.

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