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Ann Thorac Surg 2003;76:1336-1337
© 2003 The Society of Thoracic Surgeons
a Department of Surgery, Institute of Human Values in Health Care, Medical University of South Carolina, 96 Jonathan Lucas St, Suite 409, Charleston, SC 29425, USA,
e-mail: sader{at}musc.edu
To the Editor:
I am grateful for the comments of Donald Ridley, legal counsel for the Christian Congregation of Jehovah’s Witnesses, and respect his organization’s point of view. His discussion of the law surrounding informed consent was interesting; however, Dr McKneally [1] and I [2] deliberately avoided any mention of legal action to focus on the ethics of the case. Had we wished to discuss the legal aspects of decision making in cases of complications after operations on Jehovah’s Witnesses, we would have framed the case report differently. Although surgeons must be mindful of both law and ethics, the law affecting their decision making is that of the jurisdictions in which they practice, and state laws (statutes and case law) are not uniform.
Mr Ridley’s implication that a consent form is an advance directive on a par with wills, insurance policies, and other contracts is highly misleading. A signed consent form carries considerable weight in determining what may be done for the patient because it represents evidence of the patient’s wishes. It is not, however, a contract and is not as weighty as a properly witnessed and notarized advance directive such as a living will.
A living will rigidly controls decision making at the end of life. However, it is precisely its rigidity that has been cited as an important weakness because it rules out the possibility of flexible responses that might otherwise more accurately express the desires of the patient [3, 4]. Informed consent ends at the successful conclusion of an operation; this is why each new procedure during a hospitalization requires that a new disclosure and consent process be undertaken. The flexibility resulting from fresh consent for each new situation allows accurate and focused decision making in evolving clinical circumstances. Mr Ridley’s argument would have been stronger if he had explained why a new consent was not needed in the case we presented, especially as a new consent had been obtained at each preceding decision point.
Mr Ridley wrongly assumes that I agree with Dr McKneally. In my editorial, I did not make clear that my advice to the surgeon, had he asked me, would have been to accept the patient’s repeated refusals of blood transfusions and not recruit a surrogate decision maker. For me, the persistence of the patient’s refusals over time provided strong evidence that this course would have been ethically more consistent with his right to self-determination. On ethical grounds, however, the surgeon’s belief that he needed to have a new consent in the face of a dramatically altered clinical situation is not unreasonable.
References
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