The Cambridge textbook of bioethics

Ghanem, I. (1984). [Abortion as a necessity.] Al Faisal Med J 9: 61–5.

Golmakani, M. M., Niknam, M. H., and Hedayat, K. M. (2005). Transplantation ethics from the Islamic point of view. Int Med J Exp Clin Res 11: RA105–9.

Goolam, N. M. I. (2002). Human organ transplantation: multicultural ethical perspectives. Med Law 21: 541–8.

Habgood, J., Spagnolo, A. G., Sgreccia, E., and Daar, A. S. (1997). Religious views on organ and tissue donation. In

Organ and Tissue Donation for Transplantation, ed. J. R. Chapman, M. Deirhoi, and C. Wight. London: Arnold, pp. 23–33.

Hamdani, D. H. (1999). Canadian Muslims on the eve of the twenty-first century. J Muslim Minority Affairs 19: 197–209.

Hedayat, K. M. and Pirzadeh, R. (2001). Issues in Islamic biomedical ethics: a primer for the pediatrician.

Pediatrics 108: 965–71.

Islamic Code of Medical Ethics (2003). (www.islamset. com).

Kamali, M. H. (1991). Urf (custom). Principles of Islamic Jurisprudence. Cambridge: Islamic Texts Society, pp. 283–96.

Khalil, K. J. (2002). A sight of relief: invalidating cadaveric corneal donation laws via the free exercise clause.

DePaul J Health Care Law 6: 159–78.

Lundqvist, A., Nilstun, T., and Dykes, A. K. (2003). Neonatal end-of-life care in Sweden: the views of Muslim women. J Perinat Neonatal Nurs 17: 77–86.

Moazam, F. (2001). Reconciling patients’ rights and God’s wisdom: medical decision making in Pakistan. Responsive Community 11: 43–51.

Mohammed, I. (2003). Issues relating to abortions are complicated in Nigeria. BMJ 326: 225.

Moosa, E. (1999). Occasional Paper 35: Languages of Change in Islamic Law: Redefining Death in Modernity. Islamabad: Islamic Research Institute.

Moosa, N. (2002). A descriptive analysis of South African and Islamic abortion legislation and local Muslim community responses. Med Law 21: 257–79.

Muslim World League Conference of Jurists (1990).

Twelfth Session: Regarding Termination of Pregnancy for Congenital Abnormalities, February Mecca.

Ott, B. B., Al-Khadhuri, J., and Al-Junaibi, S. (2003). Preventing ethical dilemmas: understanding Islamic health care practices. Pediatr Nurs 29: 227–30.

Rahman, F. (1979). Legacy and Prospects. Islam. 2nd edn. Chicago, IL: University of Chicago Press, pp. 235–54.

Rashad, A. M., MacVane Phipps, F., and Haith-Cooper, M. (2004). Obtaining informed consent in an Egyptian research study. Nurs Ethics 11: 394–9.

Rassool, G. H. (2000). The crescent and Islam: healing, nursing and the spiritual dimension. Some considerations towards an understanding of the Islamic perspectives on caring. J Adv Nurs 32: 1476–84.

Raz, A. E. and Atar, M. (2003). Nondirectiveness and its lay interpretations: the effect of counseling style, ethnicity and culture on attitudes towards genetic counseling among Jewish and Bedouin respondents in Israel.

J Genet Couns 12: 313–32.

Raz, A. E., Atar, M., Rodnay, M., Shoham-Vardi, I., and Carmi, R. (2003). Between acculturation and ambivalence: knowledge of genetics and attitudes towards genetic testing in a consanguineous bedouin community. Commun Genet 6: 88–95.

Rodrı´guez Del Pozo, P. and Fins, J. J. (2005). Death, dying and informatics: misrepresenting religion on MedLine.

BMC Med Ethics 6: E6.

Sachedina, A. (1995). Islam. In Encyclopedia of Bioethics, revised edn, ed. W. T. Reich. New York: Simon and Schuster/Prentice Hall International, pp. 1289–97.

Schenker, J. G. (2000). Women’s reproductive health: monotheistic religious perspectives. Int J Gynaecol Obstet 70: 77–86.

Schenker, J. G. (2002). Gender selection: cultural and religious perspectives. J Assist Reprod Genet 19: 400–10.

Schenker, J. G. (2005). Assisted reproductive practice: religious perspectives. Reprod Biomed 10: 310–19.

Serour, G. I. (ed.) (1992). Islamic views. In Proceedings of the First International Conference on Bioethics in Human Reproduction Research in the Muslim World, December 1991, Cairo. Cairo: International Islamic Center for Population Studies and Research, Al Azhar University, pp. 234–42.

Serour, G. I. and Dickens, B. M. (2001). Assisted reproduction developments in the Islamic world. Int J Gynecol Obstet 74: 187–93.

Shad, A. R. (1981). The Rights of Allah and Human Rights. Lahore: Kazi.

Shaheen, F. A. M. and Ramprasad, K. S. (1996). Current status of organ transplantation in Saudi Arabia. Transpl Proc 28: 1200–1.

Shaheen, F. A. M., Al-Jondeby, M., Kurpad, R., and Al-Khader, A. A. (2004). Social and cultural issues in organ transplantation in Islamic countries. Ann Transpl 9: 11–3.

Sher, C., Romano-Zelekha, O., Green, M. S., and Shohat, T. (2004). Utilization of prenatal genetic testing by Israeli Moslem women: a national survey. Clin Genet 65: 278–83.

Todorova, B. and Kolev, V. (2004). Theological and moral aspects of cadaverous donation-heart transplantation from the point of view of Islam. Formos J Med Human 5: 29–36.

Tsianakas, V. and Liamputtong, P. (2002). Prenatal testing: the perceptions and experiences of Muslim women in Australia. J Reprod Infant Psychol 20: 7–24.

Walters, L. (2004). Human embryonic stem cell research: an intercultural perspective. Kennedy Inst Ethics J 14: 3–38.

Wong, M. L., Chia, K. S., Wee, S., et al. (2004). Concerns over participation in genetic research among MalayMuslims, Chinese and Indians in Singapore: a focus group study. Community Genet 7: 44–54.

Yaseen, M. N. (1995). The rulings for the donation of human organs in the light of Shar’i rules and medical facts. In Health Policy, Ethics and Human Values: Islamic Perspective, ed. A. R. El-Gindy. Kuwait: Islamic Organization of Medical Sciences, pp. 303–67.

Related websites

BBC World Service guide to Islam: www.bbc.co.uk/ worldservice/people/features/world_religions/ islam.shtml

Canadian Council of Muslim Women: http:// www.ccmw.com/

Islamic studies: www.arches.uga.edu/~godlas Islam Top Sites: www.islamtopsites.com

A 65-year-old Jehovah’s Witness (JW) elder was admitted for a three-day history of dizziness, weakness, shortness of breath, and hematochezia. His hemoglobin level on admission was 70 g/l. He was mentally competent and fully committed to the religion. He refused any blood products under any circumstances. Colonic diverticular bleeding was diagnosed. Despite maximum conservative treatment, the bleeding continued. A decision was made to perform a subtotal colectomy without blood products.

A 17-year-old JW female was brought to an emergency department after a suicide attempt by self-inflicting multiple cuts to her left medial elbow. The wound reached the main artery. By the time she was found in her bed, she had lost a large amount of blood and was hypotensive and lethargic. The first words the JW parents gave to the emergency personnel were that she must not receive blood transfusion. When confronted with the emergency physician who advised them that blood transfusion was inevitable, the parents threatened lawsuit against him and the hospital if he gave her blood. They called in a congregation elder, who handed out the list of ‘‘no-blood alternatives’’ published by their organization and insisted on using them, but not blood. She did not carry an advance directive. Despite a large volume fluid resuscitation, hemorrhagic shock ensued.

What is Jehovah’s Witness bioethics?

What is Jehovah’s Witnesses?

Jehovah’s Witnesses (JW) is a bible-based religion founded in the late nineteenth century in Pennsylvania, USA (Penton, 1998). Although the

new religion then had a strong influence from the Second Adventist movement, the current JWs do not consider themselves as a Christian denomination. There are fundamental differences in theology from traditional Christian faiths. The central organization of JWs is the Watchtower Bible and Tract Society (WTS), which grew out of a small religious sect in the USA in the early and mid twentieth century to a worldwide publishing giant producing their religious magazines and books today. It has an extensive network of branches, printing factories, and congregations in 235 lands with total 6.5 million baptized followers (WTS, 2006). The religious life of JWs is centered around five religious meetings every week and door-to- door preaching. Important religious activities include weekly studies and discussion of the magazines, books, and the Bible published by the WTS. Preaching or ‘‘field service’’ is another important activity, and each JW is required to report monthly the time spent for preaching activity and the amount of literature distributed. Many unique religious rules govern their personal lives. The following are strictly prohibited: participation in politics and the military, association with other religions, celebration of holidays and birthday, pledging allegiance to a national flag, singing a national anthem, smoking, and medical use of certain blood products. JWs also must shun excommunicated (‘‘disfellowshipped’’) members including those who willfully accepted forbidden blood products, and opposing former members (‘‘apostates’’).

The JWs believe the Bible as the ultimate source of their religious doctrines, which are often based on strict literal interpretations that are not shared by Christian denominations. The blood doctrine is the best example. One of the most important doctrines of JWs is that this world is currently in the ‘‘Last Days,’’ awaiting imminent Armageddon or cataclysmic destruction of the present system. According to their doctrine, the Last Days started in 1914, and the WTS has predicted different years as the starting year of Armageddon, including 1918, 1920, 1925, and 1975. In 1995, they finally abandoned the previous practice of predicting specific years. Nonetheless, the WTS maintains that Armageddon is still imminent in the near future, a literal destruction of this system is inevitable, and only the faithful JWs will survive and live forever in paradise on earth. This sense of urgency, constant preparation for Armageddon, and repeated postponements of paradise, are very important in understanding JWs’ psychology and worldview.

Views on life

The JW’s views on life are key to understanding their unique attitudes toward medical care. Unlike most other Bible-based religions, JWs do not believe in immortal souls. Instead, their future hope is their physical survival of Armageddon (or if they die before Armageddon arrives, resurrection in fresh bodies) to enter paradise on earth. Their current life in this world is only a temporary period of preparation for Armageddon and life in paradise. Since their entry into paradise depends on their conduct in this world, the most important concern in JWs’ lives is to work hard to fulfill Jehovah’s requirements, which include strict adherence to teachings of the WTS and dedication to preaching activity. Violations of the religious rules are one of the worst offences, which disqualify JWs from survival in paradise. Their eventual goals are not in this present system of the world, but in the future paradise. Many JWs even postpone childbearing until after Armageddon (WTS, 1988).

Views on health and disease

JWs believe in the literal presence of Satan, who is ruling in the Last Days and is the ultimate cause of all social injustice, disasters, epidemics, and death that increasingly plague this system (WTS, 1988). Diseases and suffering are the results of the original sin that has been inherited through the genetic system. Since Satan will not be destroyed until after Armageddon, they believe that no cure is available to human diseases and suffering in this system. They have no expectation or trust in human efforts to solve these evils (WTS, 2001). This is the main reason that JWs are not interested in social improvement or charitable contribution through traditional means, as are other religions.

JW’s eventual ‘‘health’’ lies in survival or resurrection in paradise on earth. While they seek the best medical care in ordinary circumstances, when the decision comes to the point where they have to choose between a violation of the Jehovah’s law and their own health and preservation of life in this system, they would readily forgo their own health.

Views on blood and blood transfusion

The most well-known and frequently encountered bioethical issue involving JWs is their refusal of blood products. The doctrine had not existed until 1945, when the WTS decided that the prohibition of eating blood in the Bible also prohibited blood transfusions. In 1951, the doctrine was firmly established based on three biblical passages, Genesis 9:4, Leviticus 17:12, and Acts 15:28,39 (WTS, 1951). For many years, they prohibited all the constituents of blood, including serum, and vaccination until 1952. Various medical and surgical procedures that take out blood and return it to circulation, such as heart–lung machine and hemodilution were also prohibited. In the 1960s and 1970s, owing to increasing demand and availability of blood component treatments and new technologies, the WTS gradually introduced exceptions to the rules, allowing use of serum and hemophiliac clotting factors. In 1981, a WTS physician wrote to the

418O. Muramoto

Journal of the American Medical Association on the blood policy, which became a standard for the treatment of JWs in 1980s and 1990s (Dixon and Smalley, 1981). This 1981 article established that autologous blood could not be used, and hemodilution was objectionable, whereas hemodialysis, heart–lung machine, and intraoperative salvage were acceptable. All plasma fractions were now permitted as a result of this article.

The most recent policy change involves the use of hemoglobin. In 2000, as hemoglobin-based blood substitutes were being tested in clinical use, the WTS announced that hemoglobin products were now permissible (WTS, 2000a), retracting their long-standing prohibition against the medical use of human or animal hemoglobin, a policy that had been restated as recently as 1998 (Bailey and Ariga, 1998). Another change involves transfusion of autologous blood. Prior to 2000, the WTS prohibited transfusion of autologous blood that had been removed from a JW’s circulatory system. As of 2000, the WTS permits JWs to accept autologous transfusions of blood so long as the collection and re-infusion is part of what its policy calls ‘‘current therapy’’ (WTS, 2000b). In practical terms, this policy change permits hemodilution, blood cell tagging, and blood patch, which all require removal of own blood, temporary storage outside the patient’s circulatory system, and infusion. However, the WTS still prohibits preoperative autologous blood donation (WTS, 2000b). The only difference between now permitted hemodilution and still prohibited autologous transfusion is whether the infused blood is collected intraoperatively or preoperatively.

As of this writing, the WTS seems to try to streamline the blood policy that has become so technical and incomprehensible to medically uneducated JWs. The way to understand the current policy is to prohibit the whole blood and ‘‘primary’’ components (red blood cells [RBCs], white blood cells, platelets, and plasma), whereas ‘‘fractions’’ derived from the primary components are now all acceptable (WTS, 2004). However, such a distinction between ‘‘primary’’ component and ‘‘fraction’’

is not universally defined, and the usage of such vague terms does not help in the comprehension of the rationale behind such a distinction. For example, RBCs, a fraction of the whole blood, are still prohibited, but hemoglobin, a primary component (98% of dry weight) of the RBC, is now permitted. Another example of a lack of rationale is that the removal and return of own blood for ‘‘current therapy’’ is permitted, but the same procedure for future therapy is prohibited, as mentioned above. JWs are unable to articulate why one is acceptable and the other unacceptable, other than saying ‘‘the Society (WTS) said so.’’ As one JW elder wrote to the WTS (2000) such distinctions are beyond what JWs can explain based on their scriptural reasoning, or are simply beyond their common sense reasoning.

Originated in 1945 as a simple doctrine of refusal of whole blood transfusion, the current policy has become an extremely complicated technological protocol. The WTS first prohibited every component of blood, but then later progressively permitted various parts of blood and certain selected technologies. The most difficult predicament of the bioethics of JWs is found in this very fact that the religious doctrine has become intricately woven into the most advanced technological specifications in medicine, which is constantly changing through rapid technological advancement. When a life and death decision relies on the religious doctrine that is published by the medically untrained religious authority in religious publications, yet involves highly technical and evolving details of medical, rather than religious, information, neither the patient nor the clinicians can have a solid foundation of their informed decisions.

Views on mental health

JWs traditionally have unique views on mental health. Instead of recognizing mental disorders as diseases, they often attribute these conditions to ‘‘spiritual weakness.’’ The WTS also interpreted the nature of certain mental illnesses as a possession of Satan, who dominates this system in the

‘‘Last Days.’’ This is consistent with their literal interpretation of the Bible concerning human illnesses (e.g., James 5:13–16). The advice given by the WTS to congregations has been to treat mentally ill members with spiritual advice of elders, rather than to take them to psychiatrists (WTS, 1963). The JWs have mistrusted psychiatrists and psychologists for many years because their advice is not consistent with the teaching of the Bible (WTS, 1975). In recent years, the WTS does not prohibit members from seeking advice from these professionals, but many JWs still follow the traditional advice to treat mental illnesses within the religious context (Bergman, 1992). It is noteworthy that JWs’ religious doctrines, such as imminent cataclysmic disaster with a ‘‘narrow gate’’ to survive in paradise on earth, repeated postponements of paradise for almost one century since the foundation of the religion, many strict rules of conducts, and shunning of former members including their own family, have provided fertile soil for mental disorders. Yet the issue of JWs’ mental health has been mostly unnoticed in medical literature (Spencer, 1975; Weishaupt and Stensland, 1997).

Views on other health and medical issues

There are several other medical and health issues which are unique to JWs, and clinicians should be aware of. Their lifestyle is generally healthy: they strictly avoid smoking and illicit drugs, though use of alcohol is permitted. JWs also prohibit potentially risky behaviors such as sexual promiscuity, martial arts, and contact sports. Regarding reproductive ethics, they strictly prohibit abortion and oppose to the use of intrauterine devices and morning-after pills because they are considered ‘‘abortive’’ (WTS, 1979), but they permit sterilization and birth control pills. Although the WTS has prohibited vaccination for the same reasons as they currently prohibit blood transfusions, and also prohibit organ transplantation as ‘‘cannibalism’’ (WTS, 1967), they now accept both vaccination and transplantation, including bone marrow

transplantations (Ballen et al., 2000). Apparently, the WTS is not concerned about the fact that bone marrow transplants contain numerous immature as well as some mature blood cells. Rather, they justify bone marrow transplants based on a biblical passage that ancient Israelites ate bone marrow (Isaiah 25:6; WTS, 1984).

Why is Jehovah’s Witness bioethics important?

There are several important points that are unique to JWs bioethics. Firstly, JW’s refusal of blood products is one of the most frequent and universal cases of refusal of treatment, affecting more than 16 million people worldwide (including sympathizers and former members who attend the annual Memorial), which leads to life or death situations that could be easily reversed but which the clinician is constrained from doing so. It has often been considered a ‘‘paradigm case’’ of bioethics for refusal of treatment in relation to autonomy, informed consent, and advance directives. Historically, JW cases have contributed to the development of the concept and practice of informed consent and advance directives for healthcare.

Secondly, the ethical issues involving JWs have become increasingly complicated today because of the technical complexity and the wavering of the blood policy. Most JWs simply cannot comprehend it sufficiently enough to make a truly informed consent. Moreover, the internal information promulgated to the general membership tends to delay, overestimate the danger of blood transfusions, and underestimate the risk of alternative treatments. Such a misrepresentation on the part of the WTS might be morally disturbing (LouderbackWood, 2005).

Thirdly, there is an increasing diversity among JWs toward the blood policy. Some JWs, particularly those who are well educated, can see obvious contradictions and inconsistencies inside the technical web of the blood policy. Since the late

1990s, an increasing number of dissident JWs who have different views on the blood policy have become vocal (Muramoto, 1998a; Elder, 2000). This has raised an important moral issue of personal identity of the members of a religious organization. Clinicians tend to treat JWs uniformly according to the policy of the WTS. While such a treatment may be respecting their uniform religious identity, their diverse personal identity may be ignored. Such a ‘‘standard’’ treatment is also problematic when a refusal of blood is made by non-JWs; their wishes may not be respected as much as those of JWs because they lack a religious identity.

How should I approach Jehovah’s Witness bioethics in practice?

The fundamental moral principle I propose when clinicians approach JW patients is to respect autonomous wishes of the individual person, but not necessarily her religion (Muramoto, 2001). Put in other words, respect the patient as a person, but not necessarily as a member of her religious organization. If the doctrines and policies of her religion are identical with her autonomous wishes at any given time and in any particular situation, then these two are inseparable. However, such is almost impossible, given ever-changing human cognition and individuality of each medical and surgical condition. Moreover, as discussed above, there are very few JWs who actually understand the entirety of the technical details of the policy. Chances are that your JW patient has never seriously thought about such technical details until the issue becomes her own. It is likely that the commitment to the blood policy of your next JW patient is quite different from your last JW patient. It is critical to maintain an open-minded attitude and discuss the patient’s personal conviction regarding blood first, rather than obediently following the guidelines published by the WTS. Misinformation and biased information circulated inside the JW community are quite common (Muramoto, 1998a; Louderback-wood, 2005). It is critical to discuss

such misinformation in order to ensure a chance for the JW patient to be fully informed (Muramoto, 1998b). If possible, such an inquiry should be done with strict confidentiality to relieve the peer pressure from her family and religious friends (Muramoto, 1999, 2000).

Faced with the need for blood products, JW patients have shown many different reactions depending on individual personality, social environment, educational level, and the degree of commitment to the religion. One reaction is to decline every possible treatment that has anything to do with blood, even if some of them are recently permitted by the WTS. Their reaction might be based on misinformation but could be uniquely personal. Another reaction is to leave their decisions to the congregational officials. Many JW patients call in special elders of their congregation or ‘‘the hospital liaison committee,’’ who have special training to deal with the blood issue. Many JW patients delegate their decisions to those officials who function as a judge to decide which treatment is acceptable or unacceptable according to the then current WTS policy. Other JW patients are willing to accept some of the prohibited blood products based on their own interpretation. For example, some educated JWs may know that platelets are, in fact, a very small fraction, much smaller than the permitted albumin, and may conscientiously accept it. Others may have been skeptical about the blood policy all along but have not had a chance to seriously consider the issue. Such JWs might be willing to accept prohibited products under strict confidentiality. In any of those cases of deviation from the official policy, it is critical to maintain the strict confidentiality of the clinician–patient communications, and the specifics of the treatment (Muramoto, 1999, 2000).

When the patient expresses unequivocal conviction that she refuses any treatment that the WTS teaches as unacceptable, the clinician should accede to her request to the extent his own moral conviction can accommodate. Whenever alternative treatments are available without a substantial increase in risk, such treatments should be

provided, and the refusal of objectionable blood products should be honored. When the clinician feels that it is impossible or uncomfortable to accede to the patient’s demand, he should refer the patient promptly to a willing clinician after stabilization.

In an emergency when there is no current advance directive available and the patient cannot express her own wishes, it is legally defensible to use whatever is necessary to stabilize the patient’s life-threatening condition first based on implicit consent (American College of Emergency Physicians, 2001). While the Canadian court ruled that the ‘‘no-blood card’’ carried by an exsanguinating and unconscious JW could not be overridden even in emergency (Malette v. Shulman, 1990), this ruling has been criticized because the card was signed but not dated nor witnessed (Noble, 1991). The emergency physician had no way of knowing her contemporaneous wishes or her status of being adequately informed of the risks (Migden and Braen, 1998). In recent years, the WTS is using more formal advance directive forms compliant with each jurisdiction, which the WTS requires each JW to execute and carry, in addition to the ‘‘no-blood card.’’ If a valid and adequately executed advance directive is made available, it is legally indefensible to override it even in an emergency.

In any case, the best legal defense in cases of refusal of treatment is based on thorough communication with the patient, complete documentation of the patient’s directives, and strict protection of medical confidentiality.

Finally, minors of JW parents should be treated separately from the parent’s religion. Courts have repeatedly ruled that minors cannot become a martyr of the parent’s religious beliefs in healthcare. Beauchamp (2003) argued that it is morally required, not merely permitted, to overrule the parental refusal of treatment. Decisions regarding ‘‘mature minors’’ or adolescent children are more problematic. The maturity of each child is different, and so is the child’s understanding and commitment to the blood policy. If there is any unsolved

ethical or legal issue regarding JW minors, it is most appropriate to obtain a court order after necessary stabilization. (For more information on this topic, see Ch. 17.)

The cases

The first case is a straightforward case of competent and fully committed adult JW who unequivocally refuses any blood products. As an elder, he is also well informed of the blood policy, even though it is still unclear how biased his internal information was. There was no morally justifiable reason to override his autonomous and informed decision. Postoperatively, his hemoglobin level fell to 39 g/l, requiring neuromuscular blockade and full ventilatory support. His recovery was protracted, with several complications including pneumonia and cardiac failure secondary to severe anemia, requiring a total of 21 days of stay in intensive care and several weeks of hospital admission with incomplete recovery. If there was any ethical issue involved in this case, it is the excessive cost of care that would probably have been avoided if preand postoperative blood transfusions had been given. The issue is distributive justice of finite resources (Wooding, 1999).

The second case is more complicated. The patient was admitted to the intensive care unit where she received four units of packed red blood cells to stabilize her life-threatening condition. Her wound was repaired and then she was transferred to a psychiatric unit. Subsequent interviews by a psychiatrist revealed that she was born and raised in a JW family, but she was recently ‘‘disfellowshipped’’ because of a forbidden sexual activity and smoking. She still lived with her JW family, but the stress of guilt and being treated as the ‘‘spiritually weak’’ made her depression worse. Apparently she had not been committed to the religion for several months, though her parents were hopeful that she would return to the religion soon. She had a chance of being reinstated to the congregation if she repented her previous sins and

422O. Muramoto

led a ‘‘godly’’ life by adhering to all the standards set forth by the WTS. For her parents, it was critical that their daughter be in good standing from JW standards. Naturally, their concern was primarily her ‘‘spiritual health,’’ which was to be defiled by consenting to blood transfusion, rather than her impending physical death.

She was not resentful nor did she feel defiled by receiving blood, yet she was fearful of the consequences, including the repercussions from her family and friends, and punishment from Jehovah, which is a painful death at the upcoming Armageddon. A week later, she was released under the custody of her parents. Antidepressants were prescribed, and a follow-up visit to the psychiatrist was arranged. However, the family never brought her back to the psychiatrist. Six weeks later, she committed suicide by hanging herself.

This case highlights several difficult issues involving JWs’ healthcare. Firstly, the patient was 17 years old and legally a minor. Secondly, the patient was suicidal and most likely mentally ill, and her autonomy and competency could be compromised. Thirdly, at the moment of life-threatening emergency, it was highly unlikely that any of the ‘‘noblood alternatives’’ the JW congregation elder offered would work. Fourthly, although she was presented as a JW by her family, she was in fact disfellowshipped and at that time she was in probationary status, which became known to the clinician only after the life-saving treatment. The judgement and decision by the team of clinicians were extremely difficult, but they were fully justified morally and legally based on the overriding emergency, her minor status, and mental illness.

Finally the other important point this case highlights is the mistrust of mental health services by JWs. While her mental disorder was deeply rooted in her religion, the ‘‘spiritual’’ treatment by the parents and the congregation officials eventually failed. Culturally sensitive psychiatric care of JWs is badly needed to gain trust from the JW community in order to provide better mental health services to this vulnerable population.

REFERENCES

American College of Emergency Physicians (2001). Code of Ethics for Emergency Physicians. [Policy 400188, 1997; reaffirmed October 2001.] Dallas, TX: American College of Emergency Physicians (http://www.acep.org/webportal/PracticeResources/PolicyStatements/ethics/ codeethics.htm) accessed 14 August 2006.

Bailey, R. and Ariga, T. (1998). The view of Jehovah’s Witnesses on blood substitutes. Artif Cells Blood Substit Immobil Biotechnol 26: 571–6.

Ballen, K. K., Ford, P. A., Waitkus, H., et al. (2000). Successful autologous bone marrow transplant without the use of blood product support. Bone Marrow Transpl 26: 227–9.

Beauchamp, T. L. (2003). Methods and principles in biomedical ethics. J Med Ethics 29: 269–74.

Bergman, J. R. (1992). Jehovah’s Witnesses and the Problem of Mental Illness. Clayton, CA: Witness.

Dixon, J. L. and Smalley, M. G. (1981). Jehovah’s Witnesses. The surgical/ethical challenge. JAMA 246: 2471–2.

Elder, L. (2000). Why some Jehovah’s Witnesses accept blood and conscientiously reject official Watchtower Society blood policy. J Med Ethics 26: 375–80.

JW elder (2000). Blood and upholding righteous standards. [A personal letter addressed to the Watchtower Bible and Tract Society by a Jehovah’s Witness elder] (http:// ajwrb.org/watchtower/2000.03.01Jensen.pdf) accessed 14 August 2006.

Louderback-Wood, K. (2005). Jehovah’s Witnesses, blood transfusions, and the tort of misrepresentation. J Church State 47: 783–822.

Malette v. Shulman (1990) 72 O.R. (2d) 417 (Ontario Court of Appeal).

Migden, D. R. and Braen, G. R. (1998). The Jehovah’s Witness blood refusal card: ethical and medicolegal considerations for emergency physicians. Acad Emerg Med 5: 815–24.

Muramoto, O. (1998a). Bioethics of the refusal of blood by Jehovah’s Witnesses: part 1. Should bioethical deliberation consider dissidents’ views? J Med Ethics 24: 223–30.

Muramoto, O. (1998b). Bioethics of the refusal of blood by Jehovah’s Witnesses: part 2. A novel approach based on rational non-interventional paternalism. J Med Ethics 24: 295–301.

Muramoto, O. (1999). Bioethics of the refusal of blood by Jehovah’s Witnesses: part 3. A proposal for a don’t- ask-don’t-tell policy. J Med Ethics 25: 463–8.

Muramoto, O. (2000). Medical confidentiality and the protection of Jehovah’s Witnesses’ autonomous refusal of blood. J Med Ethics 26: 381–6.

Muramoto, O. (2001). Bioethical aspects of the recent changes in the policy of refusal of blood by Jehovah’s Witnesses. BMJ 322: 37–9.

Noble, W. H. (1991). CMPA and Jehovah’s Witness. Can J Anesthesiol 38: 262–3.

Penton, M. J. (1998). Apocalypse Delayed: The Story of Jehovah’s Witnesses, 2nd edn. Toronto: University of Toronto Press.

Spencer, J. (1975). The mental health of Jehovah’s Witnesses.

Br J Psychiat 126: 556–9.

Weishaupt, K. J. and Stensland, M. D. (1997). Wifely subjection: mental health issues in Jehovah’s Witness women. Cultic Studies J 14: 106–44.

Wooding, N. (1999). Costs incurred by one severely ill Jehovah’s Witness could run one unit in Africa for one year. BMJ 318: 873.

WTS (1951). Question from readers. The Watchtower, 1 July, 414–16.

WTS (1963). Where to turn for counsel. The Watchtower, 15 January, 37–9.

WTS (1967). Question from readers. The Watchtower, 15 November, 702–4.

WTS (1975). Question from readers. The Watchtower, 15 April, 255–6.

WTS (1979). Questions from readers. The Watchtower, 15 May, 30–1.

WTS (1983). Disease: sign of the last days? The Watchtower, 1 May, 3–4.

WTS (1984). Questions from readers. The Watchtower, 15 May, 30.

WTS (1988). Childbearing among God’s people. The Watchtower, 1 March, 18–22.

WTS (2000a). Questions from readers. The Watchtower, 15 June, 29–31.

WTS (2000b). Questions from readers. The Watchtower, 15 October, 30–1.

WTS (2001). God’s permission of suffering nears its end.

The Watchtower, 15 May, 4–8.

WTS (2004). Be guided by the living God. The Watchtower, 15 June, 19–24.

WTS (2006). 2005 service year report of Jehovah’s Witnesses worldwide. The Watchtower, 1 February, 27–30.