ETHICS IN CARDIOTHORACIC SURGERY

Witnessing Death, Preserving Life: An EthicalDilemma (Hypothetical Case)Robert M. Sade, MDDepartment of Surgery, Institute of Human Values in Health Care, Medical University of South Carolina, Charleston,South Carolina

Harvey Charles, a 51-year-old white man, had severalepisodes of chest pain and was referred to a cardi-

ologist. Before cardiac catheterization, Mr Charles statedthat he was a member of the Jehovah’s Witness faith andthat he would not allow any transfusion of blood or bloodproducts, and would not accept autotransfusion. Hesigned a specific directive for refusal of blood products.Catheterization revealed coronary artery obstructionsthat were not amenable to catheter treatment, and thepatient was referred to John Smith, MD, a respectedcardiac surgeon. The patient told the surgeon of hisJehovah’s Witness faith and his requirement that a bloodtransfusion not be given, signing a document declaringhis refusal of blood transfusions and absolving the sur-geon and hospital of all liability in case lack of transfu-sion led to serious complication or death. Because thepatient and his wife of 30 years had planned a trip longago to visit their grandchildren in another state, andbecause the operation was not urgent, it was scheduledfor 2 months later.

Preoperatively, the patient repeated his desire not tohave blood transfusions, and signed the refusal docu-ment again. Doctor Smith agreed to withhold blood, evenin the face of death. The procedure was uneventful, but 8hours after the patient’s return to the intensive care unit,increased drainage of blood was noted in the chest tubes.Because of unavailability of blood, early reoperation wasadvised, and the patient agreed, restating his refusal ofblood transfusion. Bleeding was moderately well con-trolled by the reoperation, but continued for the next fewhours, slowing considerably by the next morning. Afterthe second operation, Mr Charles failed to awaken fullyfrom anesthesia. Two days after the second operation,the patient had signs of a stroke: semicomatose withright-sided weakness.

At that time, Dr Smith noted that Mr Charles’ hemo-globin was 3.5 g/dL and hematocrit was 11%. He feared

that low oxygen carrying capacity threatened imminentlyto worsen the stroke and perhaps lead to major myocar-dial infarction, with a substantial risk of death. DoctorSmith believed the clinical situation had changed dra-matically since his last conversation with Mr Charles. Heknew that patients sometimes change their minds re-garding treatment refusals when faced with serious con-sequences, so, in keeping with his usual practice, hewanted to offer the patient the option of blood transfu-sion again, now that death seemed imminent. The pa-tient, however, was incapacitated by his stroke, so couldnot make a decision on a final offer of blood.

Rather than simply allow the patient to die withoutmaking a final offer of a transfusion, Dr Smith talked withMr Charles’ devoted wife, who had been fully informedof the events since the operation. She was his legalsurrogate decision maker, and was herself a Jehovah’sWitness. She initially refused the transfusion. The sur-geon suggested she visit with her husband. After sittingfor 30 minutes with the semicomatose patient, however,she asked Dr Smith to transfuse the needed blood,having come to believe that her husband might havechanged his mind. Three units of packed cells weregiven, and the patient’s hemodynamics and clinical con-dition showed immediate improvement. Mr Charles’neurologic deficit gradually cleared during the next fewdays, and he was discharged from the hospital 2 weeksafter the operation.

Six months later, the patient obtained a copy of hishospital record to deal with an insurance dispute, andlearned that he had received blood transfusions. Heexpressed anger at his wife for giving permission for thetransfusions, and was overcome with a wave of what hedescribed as guilt and shame. He had crying episodesintermittently during the next few weeks. During thattime, he was able to forgive his wife for what he consid-ered to be her misjudgment, but continued to feel angerand outrage at Dr Smith for having broken what MrCharles had taken to be his solemn promise not to give ablood transfusion.

Address reprint requests to Dr Sade, Department of Surgery, 96 JonathanLucas St, Suite 409, PO Box 250612, Charleston, SC 29425; e-mail:sader@musc.edu.

© 2002 by The Society of Thoracic Surgeons Ann Thorac Surg 2002;74:1429 • 0003-4975/02/$22.00Published by Elsevier Science Inc PII S0003-4975(02)04100-0