I was caring for a 20 year old patient suffering a cardiac arrest after drowning in a swimming pool. He was in a critical condition for several days. After three days, the parents inform me that their son is a Jehovah’s witness, like them. They were worried that the condition of anaemia would develop further even though at present, this was not an immediate concern. I told them that if it goes on, we’d have to resort to a blood transfusion. They told me “that’s not an option”. How to handle such a situation?
1. Identities of the actors in the situation
Narrator: Medical doctor, non-practicing catholic, male, 44 years old, at the moment of the incident not in a hierarchical position yet.
Patient: 20 years old, Jehovah’s witness.
Parents of the patient: 47-48 year old, father working in a factory in mid-size French town.
2. Context of the situation
Several encounters took place between the parents and the narrator in the hospital, in the reanimation ward, specifically in the young man’s room standing by his bed. The patient himself was still unconscious.
At that time (early 90’s) it was not customary in French hospitals to have a separate space for encounters with family members. There were time periods, quite restricted (about two hours per day) when families could visit. It was an informal practice of the narrator (not a general practice of all doctors) to walk around in the corridors in these family visiting hours as a way to make himself available for family members.
Representation of Jehova’s witnesses in France:
There are more than 100,000 Jehovah’s Witnessesin France today, but their general representation is somewhat ambiguous. This is partly due to their perception as a sect rather than a religion, partly to some practices (such as social isolation, refusal to take part in celebration, refusal of social media etc.). Finally, in France laicité (sometimes translated as secularity or laicism – a separation between state and religion) is a core concept in the constitution and a highly adhered value, accordingly any religion whose doctrines, rules require interference in public domains can be problematic.
3. Emotional reaction
“My reaction was quite arrogant, thinking, why are these people coming in to interfere in my domain? I have a sacred mission, which is to save their son, and they keep putting a stick in the wheel… we have a common objective I guess: that their son leaves this place in the best condition possible, but they didn’t let me do my job. I was thinking and saying to myself, I’m the one who knows how to proceed but at the same time I did not let them see any of this “arrogant thinking”. I also had a sensation of great serenity and certainty.
The situation reminded me of a situation I had experienced a long time ago when I was a young resident and I saw a head doctor assume his role in a delicate situation, telling a patient “Madam, I am the one taking the decision” I knew this had to happen to me once.
4. Representations, values, norms, ideas, prejudice: The frame of references of the person who experienced the shock.
1) The role of religion in medical practice –in accordance with the principle of laicité, religion should not have a role in the medical practice, in a public hospital that is a rule.
2) Mission and responsibility of the medical doctor: to safeguard life in this world, is considered as a sacred mission. The aim is to make the person leave the hospital in the best possible condition using all the tools of the medical science, and to do this it is the doctor who should make the necessary decisions and take the necessary steps. Life and death decisions should be made based on professional knowledge and not on the belief system.
3) Representation of blood transfusion: it used to be considered a harmless everyday act until the appearance of blood contaminated with HIV which led to killing people instead of giving their life back. A generation of doctors was marked by these events. The ambiguity of the issue is well illustrated by the fact that only recently the ban on gay men giving blood has been lifted. And what remains is a general idea to proceed with extreme care, while measuring the possible advantages and disadvantages of blood transfusion and other products deriving from human blood.
4) Representation of Jehovah’s Witnesses as an institution: it seems to the narrator more like a sect than a religion, the difference being that one adheres to a religion and can leave it when one desires. Sect is about intellectual manipulation of the members, who cannot leave it. Sect is also connected to proselytism, a desire of active recruitment, conversion of new members.
5) Freedom of choice is an important concern for the narrator, as the 20 year old unconscious boy is a Jehovah’s witness according to the parents, but whether he chose to become a Jehovah’s witness or it was imposed on him by the parents is a question. For the narrator, religion or membership in a sect should not be an automatic consequence of the parents’ religion but a deliberate choice.
6) Action plan taking into account the legal framework: had it come to a critical situation, the narrator had a concrete action plan to overcome the situation: on the one hand signaling to the district attorney the fact that the parents put the life of the child in danger, on the other hand telling the parents that the decision ultimately is his, in straightforward language.
5. What image emerges from the analysis of point 4 for the other group (neutral slightly negative, very negative, "stigmatized", positive, very positive, real, unreal) etc?
Very negative –
The narrator insists on the fact that even if the image he had about the parent was very negative he wasn’t judgmental towards their beliefs and he didn’t express this negative feeling while communicating with the patient’s family.
6. Representations, values, norms, prejudice: The frame of references of the person or group that is causing the shock / that caused the shock in the narrator.
1) Religion is everywhere, in private or public sphere and has an effect in all domains of life, ie. also in the medical.
2) Important doctrines of the religion are non-negotiable, even in the case of health issues, even in the case of danger. The transcendental is prior to the material survival of the body. Transgressing important doctrines such as the prohibition of blood transfusion comes with exclusion from the group, which is seen as worse than physical death.
3) Blood transfusions are not refused by Jehovah’s witnesses because blood is impure. To the contrary, in their reading of the Bible “God views blood as representing life”, blood is sacred.
In their reading of Genesis 9:4, Leviticus 17:14, Acts 15:20, God explicitly asks not to eat the blood. For Jehovah’s witnesses this interdiction translates to transfusions, and so they have to “avoid taking blood not only in obedience to God but also out of respect for him as the Giver of life”.
7. Does the situation highlight any problem concerning the professional practice, or in general about the respect of cultural differences in intercultural situations?
In this case the narrator made it a priority to follow a negotiated strategy, taking into account as much as possible, the identity of the patient / parents.
Despite the fact that he has doubts concerning this religion (about whether it should be considered religion or sect, about certain doctrines etc.) in the communication with the parents this was not shown at all. In fact, the parents perceived him as the only doctor who they can trust and who could reassure them.
However, the narrator also fixed a limit of tolerance: he knew, that if the situation came to a real life-threatening stage, he would not hesitate to perform blood transfusion. Such limits / thresholds play an important role in intercultural situations, where protagonists tend go beyond what may seem their usual practice, but there is often a threshold beyond which they are unwilling to step, as it represents a core value – culturally or professionally – or possibly part of a national legislation. For this reason it is a useful exercise to become aware of our own limits.
Alternative negotiation strategies have appeared as a variety of bloodless surgical techniques have been developed lately, which can also accommodate Jehovah’s witness patients. Furthermore, there are permitted procedures and products that can avoid the need for a blood transfusion (that itis four primary components—red cells, white cells, platelets and plasma).