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Ann Thorac Surg 2002;74:1432-1433
© 2002 The Society of Thoracic Surgeons
a Department of Surgery, Institute of Human Values in Health Care, Medical University of South Carolina, Charleston, South Carolina, USA
* Address reprint requests to Dr Sade, Department of Surgery, 96 Jonathan Lucas St, Suite 409, PO Box 250612, Charleston, SC 29425, USA.
e-mail: sader{at}musc.edu
If the story of Mr Charles and Dr Smith were a routine case of a follower of the Jehovah’s Witness faith undergoing an operation, the answer to the ethical question of whether the needed transfusions should have been given would be straightforward. The surgeon should not give blood, because the patient directed him not to do it, and he agreed not to do it. But, as is true of many clinical situations that involve conflicting values, the concrete details of the specific case muddy the crystal-clear ethical waters.
There is no question that Mrs Charles is the proper surrogate decision maker for her husband. The central issue in this case is whether the decision to transfuse should be made by the patient (by his repeated advance directives) or by a surrogate decision maker. The answer to this question is not obvious.
As surgeons, we seek definitive answers to the clinical problems we face daily, so it is not surprising that we want the one "right" answer to the question of what Dr Smith should do. When sitting in an easy chair or at a conference room table, considering theoretical possibilities, we can easily justify more than one plausible, reasonable solution to a clinical problem, for example, whether to repair or replace an insufficient mitral valve with complex anatomy. Standing at the bedside or operating table, however, the intellectual luxury of either-or evaporates: a decision is required. The single best choice must be made, but we understand that the best choice may not be the same for different surgeons and for different patients.
In a clinical situation with an ethical component, there may be, similarly, more than one plausible, reasonable answer. Although it may be unsatisfying to us as surgeons, the case of Mr Charles may be such a situation. It may be that Dr Smith could have rightly chosen either of the options open to him.
The law is not helpful in resolving this question. Various jurisdictions have decided similar cases differently, and the legally proper decision cannot be definitively described. A discussion of how the law views informed consent for Jehovah’s Witnesses requires more extensive and detailed discussion than the space allotted for this case permits. Considering the ethics of the situation, however, Drs Guinn and McKneally have given us thoughtful and provocative ethical perspectives to ponder. They do not disagree on the principles that apply to this case: choosing what is best for the patient and respecting the patient’s autonomy. Their differing interpretations of the case provide a good example of the importance of context in ethical analysis: exactly how does one apply the principles? What does "best for the patient" mean, and how does one best respect autonomy under the circumstances? These discussions illustrate that good ethics is often the pursuit of a deliberative, interactive process that may lead to several plausible, reasonable resolutions.
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