Old Enough
- Old Enough
Joy is a thirteen year old from a Jehovah's Witness family who developed knee pain without obvious trauma two weeks ago. Several days later she was admitted to the hospital with fever and an infected knee joint caused by Staphylococcus aureus. Doctors started her on antibiotics, but the infection spread to her blood, her bones, and her lungs, where it developed into pneumonia.
Joy's multiple infections improved with further antibiotic treatment, but her chest cavity still has a lot of thick pus and scar tissue in it. Doctors propose surgically removing the pus and tissue. Her blood count, normal when she was admitted, has dropped to a very anemic level from the infections. She has been given erythropoietin, an injectable enzyme to stimulate her bone marrow, for several days now. (Erythropoietin, although derived from human blood, is one of several blood components considered "matters of conscience" by Jehovah's Witnesses—some accept it, and others decline it.)
Joy is the oldest of three in a family with a long and strong Jehovah's Witness tradition. Her parents became Witnesses as adolescents; her maternal grandfather and paternal uncle are elders in Jehovah's Witness congregations. Following instruction by her family, she was accepted as a full member of the Jehovah's Witness community five months ago after examination by the elders found her to have sufficient understanding of pertinent matters of faith. She is also an excellent student, and her teacher told her nurse that Joy is one of the most mature eighth graders she has ever encountered in many years of teaching.
In the presence of her parents, uncle, and grandfather, Joy clearly articulates the Jehovah's Witness position on refusing blood products in response to doctors' inquiries. She quotes scripture and explains her understanding of Jehovah's prohibition, then says she does not "want it on [her] conscience" to accept blood. She asks that blood not be used during surgery, "if possible." When gently challenged on this last point, she clearly—but tearfully—states that she does not want to receive any of the forbidden blood products, even if it means that she might die as a result. She repeats this when doctors speak to her without her family present.
Her pediatrician and infectious disease consultant believe they must proceed with surgical intervention. The consulting pediatric surgeon reports that surgery is likely to involve significant blood loss. Using the Cell Saver (a device to suction and filter surgical blood loss and return it to the patient's circulation) will not be possible because the blood in the surgical field would be contaminated with Staphylococcus. Joy's degree of anemia makes surgery risky, and the surgeon is not willing to operate without first giving her blood. He requests that the pediatrician seek a court order for this.
Should the pediatrician do so, or should this adolescent's refusal of potentially lifesaving treatment be accepted?
- Commentary
All adult Jehovah's Witnesses refuse whole blood, packed red blood cells, white cells, platelets, and plasma. There is strong ethical precedent for honoring voluntary refusals from adequately informed adults with decision-making capacity, even if withholding blood will lead to death. Treating children of Jehovah's Witness parents is a different matter. Then the legal precedent is to obtain a court order allowing doctors to transfuse children of Jehovah's Witnesses over their parents' objections if withholding blood is likely to lead to death or disability. Statutory law suggests doctors follow this precedent until the child reaches majority, which in most states is eighteen years of age. However, legislators recognize the arbitrary nature of this line. Many states accept treatment decisions from an emancipated minor, and some also recognize the mature minor—a child under eighteen who demonstrates adult decision-making capabilities. Most states also list situations in which a child may consent to treatment without parental involvement, often designating an age limit below the age of majority.
Following this line of reasoning, more and more ethicists believe that the morally relevant feature for such critical decisions is the child's level of understanding, not her age. Many would honor the refusal of a mature minor...
