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Reoperación para reemplazo valvular mitral en un niño Testigo de Jehová: realidad de la cirugía cardíaca pediátrica sin sangre

ROBERTO L. DE ROSSI, ERNESTO M. JUANEDA, GUSTAVO J. CAMPOS, HECTOR O. DIAZ, CLAUDIO C. MENESES

Unidad Cardiovascular Pediátrica. Sanatorio Allende. Córdoba. Dirección postal : Roberto De Rossi. Fragueiro 2754. 5001 Córdoba. Argentina. e-mail: robderossi@aol.com

Summary

Un niño, Testigo de Jehová, de 8 años, con antecedente de cirugía correctora de canal auriculoventricular completo fue admitido en nuestro Servicio con diagnóstico de insuficiencia mitral severa. La cirugía, realizada con hemodilución normovolémica, reemplazó la válvula mitral por una prótesis mecánica, sin utilizar sangre o sus derivados. El protocolo utilizado consistió en: tratamiento preoperatorio con eritropoyetina recombinante humana, uso de aprotinina durante la cirugía, cuidadosa hemostasia durante la apertura, disección de las adherencias y cierre del tórax, minimización del circuito extracorpóreo y colocación de un catéter venoso triple lumen a través del cual se extrajeron 450 cc de sangre que quedaron en contacto con el paciente por el lumen utilizado. La evolución postoperatoria fue muy buena y el niño fue dado de alta al sexto día con una hemoglobina de 11 g y anticoagulación oral.
Rev. Fed. Arg. Cardiol. 2005; 34: 407-408

Las personas pertenecientes a la religión Testigos de Jehová no aceptan la transfusión de sangre o sus derivados (Génesis 9; Levítico 17).
En estos pacientes la cirugía cardiovascular con circulación extracorpórea representa un desafío para el equipo médico-quirúrgico que debe tratarlos, especialmente en caso de reoperaciones, ya que hay mayor tendencia al sangrado intra y postoperatorio.

Presentamos una reoperación exitosa, para reemplazo de la válvula mitral sin utilización de sangre en un niño de 8 años, Testigo de Jehová, que a los 8 meses de vida había sido sometido a corrección total de canal auriculoventricular completo.

CASO CLINICO Un niño de 8 años de edad fue remitido a nuestro Servicio con diagnóstico de insuficiencia mitral severa, para considerar su tratamiento quirúrgico. Como antecedente más importante, el niño había sido operado a los 8 meses de edad por presentar canal auriculoventricular completo, quedando sin insuficiencia mitral. La evolución fue muy buena y se mantuvo sin medicación hasta 6 meses antes de nuestra intervención, momento en que se le diagnosticó una insuficiencia mitral que fue progresando e hizo necesario el uso de medicación para controlar la sintomatología.

Los estudios que realizamos mostraron insuficiencia mitral severa con conservación de la contractilidad y moderada elevación de las presiones pulmonares.

Como el paciente pertenecía a la religión Testigos de Jehová, luego de hablar con los padres de las diferentes opciones decidimos colocarlo dentro del protocolo de cirugía cardíaca sin sangre que desarrollamos en el Hospital de Niños de Córdoba.

Con un control inicial de laboratorio de 35% de hematocrito (Hto) y 9g de hemoglobina (Hb), fue tratado durante 3 semanas con eritropoyetina recombinante humana, una dosis de 4.000 unidades subcutáneas semanales, hierro por vía oral a 5 mg/kg/día, ácido fólico y complejo B­ 12.
El día previo a la cirugía el Hto era del 40% y la Hb 13g. El recuento de reticulocitos fue del 1,3% y las plaquetas 295.000.

En cirugía se colocó un catéter triple lumen 7F en la vena yugular interna derecha; por uno de los lúmenes se extrajeron 450 cc de sangre que fueron repuestos con la misma cantidad de hidroxietilalmidón (Voluven, Fresenius-Kabi) y quedaron en contacto con el paciente a través de la tubuladura. Se tomó la precaución de colocar una línea purgada (PT26) entre el acceso venoso central y el oxigenador para mantener la continuidad sanguínea.
Con el inicio de la anestesia se comenzó a infundir aprotinina, una dosis inicial de 240 mg/m2 de superficie corporal y un mantenimiento de 56 mg/m2/hora hasta finalizar la cirugía. La operación se realizó con hemodilución normovolémica e hipotermia a 25°C, se pinzó aorta y se infundió cardioplegia cristaloide, que fue aspirada al exterior.

Se abordó la válvula mitral abriendo el septum interauricular a través de la aurícula derecha; se intentó hacer plástica valvular pero, ante el fracaso de la misma por el mal estado de las valvas que estaban engrosadas y retraídas, se colocó una prótesis mecánica bivalva.

Durante el cierre de las aurículas se recalentó al paciente y, luego de purgar el aire de las cavidades izquierdas, se abrió el clamp de aorta. El corazón retomó ritmo sinusal apoyado con dopamina a bajas dosis (5µg/kg/min) y milrinona a 0,4 µg/kg/min.

El tiempo de circulación extracorpórea fue de 137 minutos y el tiempo de clampeo aórtico fue de 117 minutos, manteniéndose el Hto entre el 23% y el 27%.

No se utilizó hemofiltración porque el flujo urinario del paciente era excelente.

Durante la hemostasia se devolvió la sangre del oxigenador a través de la línea previamente preparada; asimismo se reinfundió la sangre que había sido extraída al comenzar el procedimiento.

En el postoperatorio el Hto fue del 30%, la Hb 9gr, las plaquetas 180.000 y la saturación venosa mixta fue del 72%.

La extubación endotraqueal se produjo a las 6 horas y la sedación se mantuvo durante 24 horas, con dexmedetomidina (Precedex, Abbott) en infusión continua de 0,3 a 0,5µg/kg/hora. El sangrado por tubo de drenaje fue de 0,3cc/kg/h durante las primeras 12 horas.

Al día siguiente de la cirugía el Hto era del 32%, se colocaron 4.000 unidades de eritropoyetina endovenosa, se inició el tratamiento con anticoagulantes por la prótesis y se recomenzó la administración de hierro endovenoso.

Al sexto día del postoperatorio fue dado de alta con 11gr de Hb y 205.000 plaquetas.

COMENTARIO El uso de sangre y sus derivados es un hecho común en la cirugía cardíaca, especialmente en las reoperaciones.
Con el creciente conocimiento del peligro de aparición de enfermedades y reacciones adversas inmediatas y tardías por el uso de sangre también hay en la comunidad médica un deseo de desarrollar técnicas y nuevos productos que en lo posible eviten transfusiones de sangre y sus derivados [1,2]. Al respecto abundan las publicaciones de cirugías en adultos pero es muy poca la bibliografía de cirugía cardíaca sin sangre en edad pediátrica [3-5], especialmente tratándose de reoperaciones. Con esta premisa hace dos años en el Hospital de Niños de Córdoba iniciamos un protocolo para realizar cirugía cardiovascular sin sangre [6] que está en constante revisión para ampliar sus límites.

Los pacientes que pertenecen a la religión Testigos de Jehová son un grupo especial que plantea problemas éticos al grupo médico tratante ya que rehusan totalmente el uso de sangre, incluso la extracción y conservación de sangre propia antes de la operación, aunque sí aceptan procedimientos alternativos como los utilizados en este caso [7].

CONCLUSION Con el uso de drogas específicas, el refinamiento de las técnicas quirúrgicas, de anestesia, perfusión y cuidados postoperatorios, y siguiendo líneas de trabajo ya establecidas, pudimos realizar con éxito una reoperación de cambio de válvula mitral en un niño Testigo de Jehová sin utilizar sangre, solucionando su problema cardíaco y respetando sus creencias religiosas.


SUMMARY HEART SURGERY IN A JEHOVA'S WITNESS CHILD WITHOUT THE USE OF BLOOD OR BLOOD PRODUCTS A Jehovah's Witness child, 8 years old, with a previous correction of a complete atrio ventricular canal at the age of 8 months was admitted in our unit with the diagnosis of severe mitral insufficiency. At the operation, done with normovolemic haemodilution, the mitral valve was replaced with a mechanical prosthesis, without the use of blood or blood products. The protocol used was: pre operative treatment with recombinant erythropoietin, the use of aprotinin during the operation, careful control of the haemostasia, minimization of the extracorporeal circuit, and a triple lumen venous catheter. Using one of the lumens, 450 mL of blood were obtained from the patient, and reserved in a closed circuit in continuity with the child's blood.The post operative course was uneventful, and the child was discharged home the 6 th day with haemoglobin level of 11 mg and oral anticoagulation.


Bibliografía
De Ville A: Blood saving in paediatric anaesthesia. Editorial. Paediatric Anaesthesia 1997; 7: 181-182.
de Castro R: Bloodless surgery: establishment of a program for the special medical needs of the Jehovah's Witness community. The gynaecological surgery experience at a community hospital. Am J Obstet Gynecol 1999; 6: 1491-1498.
Van Son J, Hovaguimian H, Rao I y col: Strategies for repair of congenital heart defects in infants without the use of blood. Ann Thorac Surg 1995; 59: 384-388.
Miyagi K, Hannan R, Ojito J y col: The Ross operation in a Jehovah's Witness: a paradigm for heart surgery in children without transfusion. Ann Thorac Surg 2000; 69: 935-937.
Verger L, Vich A, De Rossi R y col: Uso de eritropoyetina en cirugía cardiovascular pediátrica. Presentación de un caso. Rev Arg Transf 2004; XXX: 283-286.
Verger L, Isler M, Pereyra G y col: Cirugía cardiovascular pediátrica: propuesta de un protocolo transfusional restrictivo. Rev Arg Trans 2004; XXX: 259-263.
Rossengart T, Helm R, Klemperer J y col: Combined aprotinin and erythropoietin use for blood conservation: results with Jehovah's Witnesses. Ann Thorac Surg 1994; 58: 1397-1403.

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Publicación: Noviembre 2005
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bloodless surgery

USC Transfusion-Free Medicine and Surgery Program

The practice of bloodless medicine involves the delivery of medical and surgical care without the transfusion of blood products. This technique has long been applied to Jehovah's Witness patients, but it is now experiencing widespread popularity with other patients due to the lessened risk of infection and immunologic complications.
Drs. Rick Selby and Nicolas Jabbour at the USC University Hospital Center for Liver Disease use a multidisciplinary approach to eliminate the need for the transfusion of blood and blood products. The strategy is to build up the body's own reserve of blood components prior to an operation and perform all surgeries in a fashion that minimizes blood loss. Of critical importance are distinct identification of anatomic planes and rapid control of even minor hemorrhage using surgical ligation and local agents that promote coagulation in the operative field. Drs. Selby and Jabbour have honed this technique during the past 10 years as liver transplant surgeons. Liver transplant surgery is a long and complicated procedure in which all efforts must be made to reduce stresses on the patient. Keeping blood loss to a minimum is of vital importance.
Early on, the two surgeons realized the patient benefits of bloodless surgery in transplantation and began applying the same technique to all abdominal surgical procedures that they performed. Regardless of whether their patients were having surgery for something as simple as a hernia or as complex as major liver or pancreatic surgery, the bloodless surgical technique was used. The results for patients were immediately obvious. The frequency of post-surgical infections was lessened, as was the patient's recuperation time. Bloodless surgical techniques are the standard practice of Drs. Rick Selby and Nicolas Jabbour at the USC University Hospital Center for Liver Disease. If you have any questions about these techniques or the USC Center for Liver Disease, call us at (323) 442-5908 or contact us by e-mail at uscliver@surgery.hsc.usc.edu.

Related links:

USC Transfusion-Free Medicine and Surgery Program
World's first adult-to-adult LDLT without blood transfusion
BLOODLESS SURGERY: Transfusion options can reduce infection risks -- from Health Surfing
Blood Saver -- from USC Health Magazine

A Bloodless Coup

World's First Adult-to-Adult Live Donor Liver Transplant Without a Blood Transfusion

World's First Adult-to-Adult Live Donor Liver Transplant Without Blood Transfusion - June 15, 1999William Jennings, 44, a Jehovah's Witness, has made medical history as the recipient of a living-related liver transplant done without the transfusion of blood or blood products. He received the right liver lobe from his brother, Scott Jennings, 40, and both have recovered well from the surgery. More...

Some said it could not be done. Others simply refused to attempt it. But Bill Jennings needed a liver transplant and he needed the procedure to be performed without the transfusion of blood or blood products. Neither his end-stage liver disease nor his religious beliefs as a Jehovah's Witness would allow for anything less.
Jennings already had a donor lined up: his older brother Scott, who was both able and willing. The problem was finding a doctor who would give Jennings a chance at a normal and healthy life while still respecting his religious convictions.
For Jennings, then 44, the father of two and owner of a computer business in Parker, Arizona, this was yet another bump in a road that had begun 20 years earlier with a diagnosis of primary sclerosing cholangitis or PSC. This rare, debilitating disease is associated with a narrowing and inflammation of the liver's bile ducts, eventually leading to cirrhosis of the liver. No one really knows what causes PSC and its resulting cirrhosis--a lack of understanding that frustrated Jennings, who does not smoke and only drank alcohol in moderation. And the only known cure is liver transplantation.
By the beginning of January, 1999, Jennings' condition had taken a turn for the worse. His disease had progressed and he had developed severe jaundice, his light skin taking on a deeply tanned hue. He could no longer work in his computer shop, and could neither sit nor stand for long periods of time. He then contacted three liver specialists in Northern California, where his mother lived. All declined to perform a bloodless version of the transplant he so desperately needed.
Finally, a family friend from Orange County who was a member of the L.A./Orange County Hospital Liaison Committee for Jehovah's Witnesses pointed Jennings in the direction of Randy B. Henderson, manager of the USC Transfusion-Free Medicine and Surgery Program. Henderson set up an appointment for Jennings to see hepatobiliary specialists Rick Selby, M.D., and Nicolas Jabbour, M.D.
On June 15, 1999, Jennings and the USC team made history by taking part in the first-ever live donor liver transplant without a transfusion of blood or blood products.

The Power of Their Convictions

Jehovah's Witnesses are prohibited from the use of blood and blood products because of their acceptance of the Bible as "the inspired word of God," explains Henderson. "Based on several passages in both the Old and New Testament that refer to 'eating' blood and 'abstaining' from blood, they do not accept whole blood or major components-red cells, white cells, platelets or plasma."
But Jehovah's Witnesses are not the only people who are interested in, or even demand, bloodless alternatives. An increasing number of people are rejecting the use of blood for an increasing number of valid reasons. In addition, notes Jabbour, who is both medical director of the Program and associate director of abdominal organ transplantation at USC University Hospital, there are an increasing number of reasons for physicians themselves to consider bloodless alternatives, even if the patient has no objections to the use of blood products. "Blood products are useful but carry their own set of risks," says Jabbour. "Thus, whenever we can avoid using them, we should not only in Jehovah's Witness patients, but in every patient."
Bill Jennings was lucky in that he had the luxury of time. He needed the transplant, of course, and he needed it quickly. But there was time enough to build up his blood levels--in particular, his stores of red blood cells--so that his body could afford to lose some blood during what was sure to be a risky surgery.
Blood has three main cellular components: red cells, white cells and platelets. The percentage of red cells in the blood is measured by hematocrit levels: The normal hematocrit value in an adult man is around 45 percent. Jennings' had dropped to as low as 17. Before they would operate, the USC surgeons wanted to see that boosted to the 45 percent range.
Several things were done to increase his levels. First, blood tests were used sparingly. Second, Jennings was given supplemental iron and folic acid, and a synthetic medication similar to erythropoietin, a hormone-like substance produced by the kidneys that stimulates the bone marrow to produce red blood cells. Those synthetic medications, Epogen or Procrit, are like naturally produced crythropoietin and have the same effects.
The interventional radiologists, led by Michael Katz, M.D., also placed a transjugular intrahepatic portal systemic (TIPS) shunt inside Jennings' liver. Patients with advanced liver disease tend to have dangerous increases in pressure in the veins flowing into the organ; because of the increased pressure, these vessels tend to bleed. A TIPS shunt decreases the pressure in the portal vein, reducing the risk of bleeding both before and during surgery.
Used all together, these techniques were a rousing success. By the day of his surgery, Jennings' hematocrit levels had hit 45 percent. He was ready to go.

Assisting With Anesthesia

Getting Jennings' hematocrit levels up high enough was only the first step in ensuring a successful procedure. The next step was to have a series of reliable and efficient blood management techniques to deal with the inevitable bleeding during the surgery-a task that fell to a USC anesthesiology team of Earl Strum, M.D., Pajesh V. Patel, M.D., and Duraiyah Thangathurai, M.D.
One of these techniques is an approach called acute normovolemic hemodilution, in which the patient's whole blood is collected immediately prior to surgery, and the rest of the blood is diluted with non-blood products such as normal saline or other intravenous solutions. "Consequently," notes Patel, an associate professor of anesthesiology, "if the patient bleeds during surgery, he is bleeding diluted blood." Once the operation is completed, the patient receives the concentrated blood that was collected prior to surgery.
But because Jehovah's Witnesses do not donate or store their own blood, this technique needed to be tweaked in order to be used in the Jennings transplant. To address this, Strum--who serves as interim chair and associate professor in the Department of Anesthesiology, and also holds an appointment with the Department of Orthopaedics--used an innovative device that keeps the collected blood in circuit with the patient. "Since there is still a connection with the body, the collected blood can be transfused back into the patient," Strum notes. "This allows Jehovah's Witness patients to observe their religious beliefs concerning blood products."
A second useful technique involves a device called a "cell saver." A cell saver does precisely that: It collects the patient's blood as it is lost during surgery, cleans it and returns it to the patient. This is acceptable to most Jehovah's Witnesses, says Henderson, because, like the bypass procedure, it "can be viewed as an extension of their circulatory system. The belief is that since the Bible does not specifically comment on these products or equipment, it is left up to each individual to make a conscientious and informed decision."
Finally, doctors working on a bloodless procedure like Jennings’ can give the patient drugs to reduce his blood pressure. This is called hypotensive anesthesia, explains Thangathurai, a professor of anesthesiology who also holds appointments with the departments of surgery and urology. Lowering blood pressure decreases the amount of bleeding that results when blood vessels are cut. "This approach has been especially effective in urology cancer patients," notes Thangathurai.

The Careful Cut

Jennings and his brother, Scott, underwent surgery on Tuesday, June 15th, at 7:30 a.m. The transfusion-free surgical team, under the leadership of Selby, Jabbour and Yuri Genyk, M.D., first removed a segment of Scott's healthy right liver lobe along with the vessels supplying blood to that segment. Jennings' diseased liver was then removed and replaced by the donated healthy segment.
"Bloodless surgery does not require any special instrument or fancy technical changes," Jabbour explains. "All it requires is being meticulous as far as preventing blood loss when we are dissecting the tissue, and knowing how to control the bleeding decisively using sutures and electrocoagulation. Contrary to the image of the 'macho, aggressive, fearless' surgeon, one must be precise and gentle."
"We take our time when performing these major surgeries, including liver transplantation and liver resection," adds Selby. "Through a very careful, calculated approach, we can control the blood flow. Both Scott and Bill Jennings came through their surgeries beautifully. And just eight weeks later, Selby reported, both liver halves, through the organ's natural regenerative ability, had grown to normal size.
"I received excellent care from the surgical team," Jennings said in an interview following the surgery, "and was extremely impressed with their skill and willingness to treat me while respecting my religious convictions."
Related links:
HSC Weekly article, August 13, 1999 - PDF file, 156kb
Live Donor Liver Transplant Home Page
Bloodless Surgery Home Page
USC Liver Transplant Program Faculty & Staff

Elección terapéutica y transfusión sanguínea

Alain Garay*

Abstract

When blood transfussion medicine is debated because of failures in the standard systematic blood screening system, the subject of how to manage the benefit-danger ratio in blood transfussions becomes urgent. Can the patient’s right to select and optional therapeutic method when blood transfussion is not desired. Through the study of Jehovah´s witnesses´calims who turn to science for optional treatments, the essay insists on the implications of such a choice on public and private health policies.

Keywords

Blood transfussion, patient´s rights, Jehovah´s witnesses, alternative techniques.

Reference

GARAY, Alain , Therapeutic choice and blood transfussions, Medicina Legal de Costa Rica, vol. 11, No. 2, 1994; vol. 12, No. 1, 1995, pp. 4-11

Resumen

Cuando la medicina transfusional está en tela de juicio por el fracaso de la rutina sistemática de la sangre, es urgente plantearse la pregunta de ¿cómo gestionar el beneficio-riesgo de la transfusión sanguínea? ¿Puede el libre albedrío del paciente modificar la relación terapéutica? Este artículo explica el papel determinante del derecho del paciente a elegir una terapéutica de sustitución a la transfusión sanguínea. A través del estudio de las exigencias del testigo de Jehová que recurre a la ciencia para elegir un tratamiento selectivo, el artículo insiste en las incidencias del tal elección terapéutica sobre las políticas de salud pública y privada.

Palabras clave

Transfusión sanguínea, derecho del paciente, testigos de Jehová, técnicas alternativas.

Referencia

GARAY, Alain, Elección terapéutica y transfusión sanguínea, Medicina Legal de Costa Rica, vol. 11, No. 2, 1994; vol. 12, No. 1, 1995, pp. 4-11.

Si la transfusión había logrado borrar esa imagen a la vez salvadora y maléfica de la sangre, ahora con el SIDA ha aumentado su imagen de asunto de vida y muerte(1). Los científicos que presidieron los "ritos" tecnológicos se han vuelto "víctimas de las limitaciones de su saber y de su poder". El episodio de las contaminaciones post transfusionales ha modificado profundamente el comportamiento de los donantes así como el de los enfermos, ha hecho ver de cerca una realidad que los especialistas conocían desde que los bancos de sangre existen; ninguna transfusión de sangre está totalmente exenta de riesgos. La seguridad absoluta no existe, "todas las precauciones que se tomen no harán jamás desaparecer totalmente el riesgo transfusional"(2). Esta preocupación mayor de la salud pública recuerda que la sangre, en sí misma, puede ser objeto de incertidumbres, pero también puede tomar un matiz jurídico(3). Tratándose de medidas preventivas, el Código Internacional de Etica elaborado por la Sociedad Internacional de Transfusión Sanguínea subraya que "el objetivo de la transfusión es asegurar una terapia eficaz compatible con el máximo de seguridad". Pero es necesario constatar que en materia de transfusión sanguínea el mundo médico no asegura al enfermo la oportunidad de hacer una selección. Ahora bien, la revisión del reflejo transfusional no puede evitar la reflexión y la renovación de la práctica médica, notablemente, en presencia de pacientes, como los testigos de Jehová, que reivindican el uso de alternativas a los productos sanguíneos.

I. Cuestionar el reflejo transfusional beneficia el libre albedrío del enfermo.

Pese a todos los esfuerzos realizados actualmente para minimizar el riesgo nosocomial transfusional, parece imposible de reducirlo a la nada, tanto más al observar que es muy probable que se cubra bajo los restos de microorganismos misteriosos con un poder patógeno desconocido. ¿En tal contexto, cuáles son las dimensiones del libre arbitrio del enfermo?

A. La medicina transfusional en tela de juicio.

1. En 1994 una observación científica se impone: el fracaso de la rutina transfusional sistemática.

Si bien ya han pasado varias décadas desde que la transfusión sanguínea llegase a ser un proceder generalizado, se han necesitado algunos sobresaltos jurídico-mediáticos para que la comunidad científica sea confrontada con críticas al recurso sistemático en esta técnica. En particular, "la crisis del sistema transfusional francés ha revelado el peso que tienen los establecimientos de colecta y de donantes con perjuicio de los derechos de los receptores"(4). Todavía más extraordinaria es la cristalización del debate francés sobre la contaminación de los hemófiles (5). Por otra parte, la pésima calidad de la selección clínica de donantes de sangre no solo ha ocasionado variedad de contaminación por el virus de inmunodeficiencia (HIV) que sabemos, pero –desde antes de la emergencia del SIDA- una contaminación considerable, quizás todavía proporcionalmente más elevada, por el virus de la hepatitis C (VHC) (6). Como resultado, se puede decir que la ausencia de una cultura de salud pública añadida a una visión técnica de la medicina han obrado en detrimento del os receptores de sangre. El reajuste de la colecta de sangre, este pasaje del "transfusor" al "colector", se hace sin que los principales actores puedan apreciar la considerable distensión de la relación entre el donante y el receptor.
En cuanto a las costumbres de prescripciones médicas, han quedado por demasiado tiempo catalogadas con el sello del laxismo. El profesor Jean-Pierre Soulier, en otro tiempo director general del CNTS (1965-1984) recuerda que "hubo un tiempo donde se transfundía a casi todos los operados, a veces incluso cuando se trataba de operaciones sin importancia (hernia, apendicitis). Los anestesistas-reanimadores seguían las nociones entonces enseñadas; se aconsejaba prevenir el choque operatorio remplazando poco a poco la sangre perdida para obtener consecuencias operatorias simples. Estas transfusiones, de principio sin necesidad vital, deben rechazarse rotundamente, no solo a causa del riesgo residual ínfimo de transmisión del virus HIV, sino también por el riesgo de transmisión del virus de la hepatitis B y, desde 1990, de la hepatitis C (7). Acomodado en sus actitudes, el mundo médico ha reaccionado tarde a una sucesión de accidentes. No es sino recientemente que estas costumbres de prescripción fueron modificadas poco a poco: el número de unidades de productos sanguíneos lábiles ("sangre total" y "concentrados de glóbulos rojos") transfundidos cada año en Francia ha bajado aproximadamente un 19% entre 1986 y 1991 (8).

La fragilidad de la cultura de medidas de precaución de los prácticos facultativos ha sacudido la evidencia médica de manera profunda en medicina transfusional (9). La conciencia de los peligros del recurso rutinario de los productos sanguíneos es reciente. Ademas, en Europa, en contraste con América del Norte, la literatura científica no es tan abundante. Salvo las referencias técnicas relativas, por ejemplo a la autotransfusión o la hemodilución, no existen en la bibliografía francesa estudios completos y generales sobre el tema (10). Esta constatación subraya el retraso científico concerniente alas soluciones técnicas aportadas a la crisis del sistema terapéutico transfusional y demuestra que los médicos necesitan sacar provecho de los errores del pasado para gestionar mejor el presente. Según el profesor Castaigne, "yo he prescrito actos para mejorar el confort de vida de ciertos enfermos coronarios(...), eso se lama un error médico; lo hacemos a menudo, y no todos tienen consecuencias jurídicas, pero no tenemos el derecho de negar su existencia porque hacerlo es arriesgarse a repetirlo. En 1970 la sangre era un producto mágico, salvador; en 1980 se ha convertido en un asesino; a finales de 1991 sabemos con certeza que la transfusióm sin riesgos no existe".. ¿Sin embargo, el juramento de Hipócrates y la deontología médica reglamentada, no imponen a la comunidad médica esta obligación de medios, grabada como una moneda, por la jurispruedencia del Tribunal Supremo en 1936 (12)? Mientras que el derecho parece exigir que el abastecimiento de sangre destinada a las transfusiones sea un producto limpio (13), es sin embargo paradójico el hecho de que ninguna decisión de salud pública, ni programa de investigación nacional, ni recomendación deontológica alguna apoyen los esfuerzos en favor de la instauración de protocolos científicos de sustitución máxima a la transfusión de sangre el profesor Castaigne concluyó así su preocupación en cuanto a este asunto: "Esperábamos que las autoridades administrativas nos informasen, que tomasen las decisiones para la modificación de nuestra práctica y que nos incitasen a considerar la sangre como un medicamento que solamente ha de utilizarse con la preocupación permanente de la relación beneficio-riesgo"(14).

2. La urgencia de una gestión beneficio-riesgo en medicina transfusional.

La medicina transfusional, como las otras, conoce dos límites: el respeto de la regla de la razón proporcionada y la prohibición de la aplicación de tratamientos imprudentes. Se constituye un requisito previo: el equilibrio que debe encontrar la intención terapéutica en materia transfusional en la balanza de la relación beneficio-riesgo. La Sra. Dorsner-Dolivert precisa que es "indispensable que el propósito buscado resulte positivo; el beneficio que se espera en el tratamiento o en la operación debe ser superior a los riesgos". Conscientes de este paso, los poderes públicos han decidido, por vía de la circular del 28 de agosto de 1987 de la Dirección General de Salud, velar por "limitar a lo estrictamente necesario el número de transfusiones de sangre"(15). Esta preocupación aparece en filigrana en una recomendación sacada del a circular del 15 de enero de 1992 de esta misma dirección que subraya: "los médicos deben prescribir a los enfermos los productos mejor adaptados, evitando todas las indicaciones que no son estrictamente justificadas reservando únicamente los productos y las técnicas más seguras (...) Además, cada médico debe, informar al paciente de la transfusión y efectuar un control de seguimiento (16). En derecho médico, la regla de la razón proporcionada impone la constatación de una proporcionalidad entre los riesgos de la abstención selectiva y las ventajas de la acción transfusional con referencias ala gravedad del diagnóstico (17). El riesgo terapéutico autorizado puede medirse en términos de mortalidad de accidentes infecciosos con respecto a un tratamiento que ha resultado ineficaz. La jurisprudencia considera que es una falta el hacer correr al paciente peligros terapéuticos injustificados (18) y que es correcto el rehusar los riesgos mal evaluados (19). Esos principios del derecho médico se aplican al momento de elegir entre varias terapias posibles, la que es menos perjudicial para el paciente, que presente la mejor proporción riesgos/beneficio previsibles (20). En medicina transfusional. Algunos estudios han insistido en la conveniencia de la gestión beneficio-riesgo. En particular, en un famoso editorial del The American Journal of Medicine, titulado; ´Are transfusions overrated? Surgical outcome of Jehovah’s witnesses?, el profesor Craig S. Kitchens ha comparado el 20% de casos de complicación post transfusional, que podían resultar en un cierto número de muertes, con cifras situadas entre 0.,5 et 1,5% de los casos de testigos de Jehová operados sin transfusión y fallecidos posteriormente a consecuencia de una anemia muy severa. Concluye, subrayando que "this risk of not tansfusing patients must be weighed against the cost, morbisity and mortlaity thar would be expected to accrue had these patients been transfused. These concepts should be employed whenever one is formulating a risk-beneficit ratio for the patients for whom transfusion is contemplated" (21). Según un estudio depediatras americanos, "the lack of benefit from red blood cell transfusion in the moderately anemia critically ill patient questions the risk-beneficit ratio of this therapy for not only severaly ill but for the nonsurgical and surgical patient as well"(22).
En relación con la exigencia científica de la relación beneficio-riesgo, el libre albedrío del paciente debe ser, en la medida de lo posible respetado, mientras que el tratamiento transfusional presente peligros potenciales.

B. Lo que está en juego: El libre albedrío del enfermo.

1. Las garantías del poder de decisión del paciente.

Informado de las graves consecuencias derivadas de la transfusión de sangre, el práctico facultativo tiene la obligación de prevenir al paciente y de informarle sobre los riesgos (23). En medicina transfusional, el enfermo debe poder gozar de oportunidades de elección entre varias soluciones médicas. En efecto, los principios de la autodeterminación informada y de la inviolabilidad de la persona progresivamente se han alimentado de garantías consagradas por los textos internacionales protectores de los derechos humanos. La cuestión del rechazo selectivo de tratamiento médico ha sido una ocasión para modificar el papel desempeñado por el enfermo en las decisiones que le conciernen (24). De hecho, la actual medicina transfusional involucra la revisión de la noción epistemológica de resultado en la asistencia médica. Este debate debe instaurarse sobre un cuestionario fundado en un conflicto de valores prioritarios en cada caso y a optimizar según un consenso de aceptación de las referencias médicas, morales y humanas. En efecto, el mero interés por la salud no justifica los atentados a la personalidad del paciente, aunque estuvieran en conformidad con los adelantos actuales de la ciencia. Pero, una pregunta queda en suspenso ¿cuál es el interés del enfermo? Para los profesionales de la transfusión lo que verdaderamente está en juego en la enfermedad, constituye el elemento determinante, mientras que el paciente queda, él mismo, marcado por el contexto sociocultural y por una historia personal y familiar mucho más notable. El diálogo médico-enfermo, calificado en teoría del encuentro de una confianza y de una conciencia, permanece colocado bajo la garantía recíproca del pluralismo ético de los asociados al acta médica interesados por el interés y la voluntad del enfermo (25). Pero es necesario constatar que el paternalismo médico ha mantenido por demasiado tiempo al paciente en una relación dominado-dominante. Antaño, eminentes autores denunciaban "el imperialismo médico en el terreno del derecho"(26). El mito del "maestrazo del derecho divino" de los médicos, estancado en la imaginación colectiva, provocó derivas hacia el cientificismo. En el nombre de los postulados metodológicos de la ciencia médica los prácticos facultativos continuaron sanando el cuerpo contra la conciencia del paciente (27). Sin embargo, parece que la problemática de la oportunidad del acto médico está subordinada a dos nociones principales, la primera es la libertad del individuo, designada por los juristas "derecho a la autodeterminación". La segunda corresponde al compromiso profesional y moral del médico a tratar de concurrir ala curación deseada. Entre estas dos exigencias bilaterales, un conflicto puede surgir; se asimila a un antagonismo entre la libertad personal del paciente y el recurso subjetivo a la noción del interés o el bien del paciente. Entonces, la urgencia está en instaurar condiciones de negociación entre los dos asociados, fundadas en "un intercambio de informaciones y en la toma de decisión de cada una de las partes interesadas"(28). Está claro que las relaciones médico-paciente deben inscribirse en una auténtica diligencia bilateral, donde cada uno de los dos actores principales deben poder afirmar sus pretensiones y poderes. Esta actitud está garantizada por el principio constitucional y universal de libertades individuales (29). La negación selectiva de la terapia sanguínea por un paciente está protegida por la Declaración de los Derechos Humanos y del Ciudadano, la Declaración Universal de los Derechos Humanos y la Convención Europea de los Derechos humanos (30). El ejercicio de la libre elección de rechazar un consentimiento a la transfusión de sangre no es oponerse al orden público, donde la noción es, por esencia, evolutiva (31). Y no vemos en qué el ejercicio de una selección médica individualizada en materia de transfusión pudiera comprometer la moralidad o la salud pública, el orden sanitario y social...

¿Considerando que el médico tiene una obligación de medios, es simplemente un prestatario de servicios? En efecto, consultar un facultativo no significa automáticamente la adhesión absoluta y permanente a las proposiciones terapéuticas. El técnico propone, el hombre que sufre debe disponer.

2. La primacía de una selección informada de la terapéutica al enfermo.

Si el enfermo tiene un poder de decisión, esto significa que puede libremente aceptar o rehusar los cuidados, pero también ejercer una selección con todo el conocimiento de causa. Esta libertad de opción existen o solamente en la selección primera sino, además en el transcurso de la terapia. Ella supone una información máxima sobre las causas y consecuencias médicas de la dolencia (32). Si son posibles diferentes tratamientos, el médico deberá revelarlos al enfermo indicando las ventajas e inconvenientes respectivos. El médico debe entregarse a una verdadera prueba de evaluación cuando considera recurrir a la administración de una transfusión de sangre. Desde ese punto de vista, es inaceptable el recurso clandestino de transfundir en secreto, denunciado por el doctor Louis René (33).

Progresivamente, el paciente deja el papel de receptor de informaciones cuando manifiesta su voluntad y ejerce su selección informada, actitud que sobrepasa la del consentimiento (34). Desde este momento, el respeto por la elección del paciente prohibe al médico hacer caso omiso de la voluntad expresada del paciente (35). Desde 1958 el Tibunal de apelaciones de Rouen decidió que "la integridad corporal, derecho inherente a la persona humana que deja al enfermo la facultad de elegir entre la operación que se le presenta como necesaria para su salud y los riesgos que le acarrearían el rechazo de someterse a la misma, no se podría deducir la ausencia de prejuicios por el hecho de que una operación realizada sin el consentimiento del enfermo tuvo un resultado favorable"(36). Si el enfermo rechaza la transfusión de sangre, la jurisprudencia no considera la abstención del médico como un delito. Un comunicado de la Sala de lo Criminal del Tribunal Supremo, con fecha del 3 de enero de 1973, atestigua que el delito de no ayudar a persona en peligro, no se mantendría contra el médico una vez constatado que "la terapia adecuada ordenada por él no ha sido aplicada por causa del rechazo obstinado y hasta agresivo de la Sra. G. De someterse a los cuidados prescritos"(37). Esta posición jurisprudencial concuerda con el punto de vista de la doctrina dominante en Francia (38).

La exigencia reivindicatoria de los testigos de Jehová en medicina transfusional interpela a la comunidad científica que descubre progresivamente el error consistente a concebir de manera benéfica el recurso a priori salvador de la transfusión de sangre (39).

II. La postura ineludible de la selección informada del enfermo en medicina transfusiona: el caso clásico de los testigos de Jehová.

Mientras que los testigos de Jehová no dudan en presentarse como "pioneros de la cirugía sin transfusión de sangre"(40), el esfuerzo de lucidez que pide el dar este paso típico-ideal, evita a los científicos, sociólogos y juristas perder el dominio de sus instrumentos y asimilar de esta manera sus juicios de valor a las experiencias científicas.

A. El tipo ideal de la comunidad de los testigos de Jehová.

1. Dimensión religiosa y médica del rechazo selectivo de transfusión de sangre.

Una abundante literatura norteamericana y francesa ha tratado las implicaciones médicas y jurídicas del rechazo selectivo de transfuisón de sangre de estos cristianos (41). Uno de los primeros estudios franceses documentados titulado: "El rechazo de sangre por respeto a Jehová o temor al SIDA" fue redactado por médicos (42) que recuerdan la base bíblica y religiosa de la posición científica y ética de este grupo. Generalmente, los autores tratan de desmitificar las explicaciones religiosas insistiendo en la conducta terapéutica y deontológica a sostener frente a esta categoría de personas. Charles Baron sitúa la acción de los testigos de Jehová en la prolongación del movimiento de enfermos (43). Cita dos estudios norteamericanos que explican en particular que "en la gran mayoría de los casos que les conciernen, el riesgo operatorio en la ausencia de transfusión de sangre no es más importante que en los enfermos que han sido transfundidos". (Dixon, Smalley, Jehovah’s Witness: the surgical/ethical challenge, JAMA, 1991, 2471). El autor concluye diciendo que "la entera sociedad americana se ha beneficiado de esta acción. No solo los testigos de Jehová sino el conjunto de enfermos que probablemente recibirán menos transfusiones sanguíneas inútiles que en el pasado, a causa de los comités de enlace con los hospitales de los testigos de Jehová".

Entre religión y ciencia, la experiencia de esta comunidad que reivindica unos 4,7 millones de adeptos en el mundo revela una paradoja: en otros tiempos fueron completamente denigrados (44), hoy representan un interés científico (45). Para J.M. Thomas, "recent developments have convinced me that it is time physicians met the surgical and ethical challenge presented by Jehova’s witnesses and that we end the unfortunate hostility that prevails in some areas"(46). Pero, a pesar de los resultados prometedores de las alternativas a la transfusión de sangre, un cierto número de prácticos facultativos persisten en administrar este producto a espaldas y contra la voluntad del paciente (47). Un estudio recientemente realizado entre 242 médicos miembros de EUROPEAN SOCIET OF INTENSIVE CARE MEDICINE revela que el 63% de ellos practicarían, a pesar de un rechazo escrito, una transfusión sanguínea en un testigo de Jehová. En estas circunstancias 26% de los prácticos interrogados no informarían al paciente de este acto clandestino (48). Estos resultados invitan ala comunidad científica a medir mejor las implicaciones terapéuticas, éticas y jurídicas de los medios utilizados para respetar la conciencia de esta población en particular.

2. El recurso sistemático al desarrollo científico.

Enormes medios técnicos e institucionales se han puesto en práctica bajo el impulso de esta comunidad religiosa. Buscando la cooperación y no la confrontación, los testigos de Jehová han instaurado un vasto servicio de información que tiene como propósito el facilitar el intercambio de medios y de técnicas entre equipos médicos, además de desarrollar la información médica sobre la cirugía sin transfusión de sangre y las soluciones sustitutivas. Una estructura internacional, centralizada en Nueva York con 90 delegaciones repartidas por todo el mundo, supervisa la intervención de unos 1.000 comités de enlace con hospitales que disponen así de las referencias de 45.000 prácticos facultativos que han aceptado tratar sin transfusión sanguínea (49). Hasta el día de hoy, 38 programas de cuidados sin transfusión han sido organizados en los establecimientos hospitalarios suscritos a un contrato a través de la compañía de asistencia y traslado sanitario AYUDA MUNDIAL. Con esta armada de medios institucionales muchos facultativos levantan el desafío técnico, notablemente entre los pioneros y los médicos más experimentados (50). Entonces, si la decisión de transfundir es equivalente a la de operar, las dos significan riesgos y ventajas comparables en términos de análisis de decisión. El facultativo que comprende la lógica del análisis está motivado a emitir una proposición transfusional que se inscribe en un contexto económico y político dado.

B. Las incidencias sobre la política de salud.

1. Importancia de los factores económicos y político-sociales.

Hoy los escritos especializados permanecen casi mudos sobre el estudio del costo social y económico del rechazo selectivo de la transfusión de sangre. Muy perentoriamente, algunos expresan "que si evocan una economía de productos sanguíneos, nadie ha estimado el costo de las técnicas complejas de anestesia (...) Este costo suplementado sufragado por la sociedad sobrepasa por mucho las economías realizadas a veces en productos sanguíneos"(51). Uno de los raros estudios sobre el balance de costo-ventaja de la transfusión homóloga da a conocer, en los Estados Unidos, la cara escondida del sistema (52). Este estudio toma en cuenta los gastos inducidos y directos y pone en evidencia las cifras siguientes. El costo global de la transfusión homóloga es de 1.322 dólares por unidad, mientras que el costo de la transfusión autóloga se evalúa en 350 dólares. La conciencia de factores tales como el costo administrativo de las medidas públicas de seguimiento transfusional y d hemovigilancia, del total de las indemnizaciones de reembolso, del perjuicio causado por las víctimas de la contaminación o de accidentes post transfusionales, así como los efectos financieros relacionados con las complicaciones médicas y las bajas en el trabajo, permitirían medir mejor las incidencias económicas. Queda por emprender un estudio de la perspectiva económica y social, sobre todo en el marco de la política de la salud pública. Sin embargo, hasta el día de hoy no se dispone de estudios documentados sobre esta cuestión de primera importancia, sino solamente de aproximaciones parciales (53). Esta situación interesa notablemente a los responsables de la salud pública que en los Estados Unidos intentaron evaluar la cantidad superior a 13 millones de unidades de sangre transfundida anualmente y cuyo gasto por paciente sería de 400 dólares por unidad; esto asegurará al mercado de productos de sustitución sanguínea un beneficio de 5.720 millones de dólares (54).

Por otra parte, la carencia de una formación inicial y continua de los cirujanos y los anestesistas reanimadores sobre los métodos de la economía sanguínea y las técnicas de sustitución frenan el desarrollo de esta nueva disciplina. Además, en presencia de tal carencia, el cuerpo médico continúa pretendiendo complacientemente que la transfusión de sangre constituye la aproximación correcta frente a ciertas situaciones clínicas. Esta visión idealizada de una práctica médica completa, sustituyéndose al consentimiento del enfermo, la hace una práctica profesional estándar. Por ejemplo, las reglas médicas sobre el momento de transfundir, y el nivel de hematocritos, continuan siendo solo aproximaciones, aunque muy utilizadas (55). Este déficit pedagójico no podrá ser eliminado sin que los principales responsables públicos tomen antes la iniciativa de sensibilizar el conjunto médico a este cambio terapéutico. Desde este punto de vista, el desarrollo de jornadas de estudio profesional sobre la economía y las alternativas de la transfusión de sangre, pudieran dar resultados prácticos, incluyendo además, reflexiones éticas y jurídicas sobre estas cuestiones (56). En esta situación, es únicamente bajo la acción de los pacientes que se organiza el desarrollo de soluciones científicas en un "silencio institucional ensordecedor."

2. El papel vital de las reivindicaciones individuales del paciente.

La insistencia de los pacientes ha sido aquí un factor de progreso científico. Esta reivindicación fundada ante todo por motivos religiosos ha permitido al colectivo médico efectuar operaciones quirúrgicas en otro tiempo rechazadas. Mientras que el riesgo, históricamente, se ha confundido con la voluntad de sanar en situaciones desesperadas, la medicina transfusional ha evolucionado en estos últimos años, quizá por el hecho de que movimientos de enfermos tales como los hemofílicos contaminados y los testigos de Jehová se han manifestado (57). Identificada, evaluada, anunciada y consentida ésta, el aceptar el riesgo puede ser un medio de progresar (58). Individualizado, el proceder del paciente se ha articulado en torno ala firma de un documento de rechazo selectivo de transfusión dado al médico y conservado en el expediente clínico en el caso de cirugía regulada (59). Los testigos de Jehová además poseen un documento explicando su posición permanente e incondicional en caso de urgencia y/o inconsciencia. Esta medida de protección jurídica se analiza como la expresión de la voluntad permanente del paciente de recibir cuidados con excepción de una transfusión de sangre (60). Esta precaución, a la vez respetuosa de la convicción del paciente y de la seguridad del facultativo, ha sido recomendada pro los representantes del consejo Nacional del Colegio de Médicos. El doctor Louis René aconseja a los facultativos "hacer constatar para que ulteriormente no pueda ser discutido el rechazo obstinado del paciente y de su entorno. En el caso particular de fallecimiento, tal atestación podrá añadirse a una descarga de la parte del paciente o su entorno a fin de demostrar a posteriori a los jueces la ausencia de culpa del médico en la pérdida sufrida"(61).
Este trámite participativo del paciente consagra el respeto de las libertades individuales del enfermo (62). Se inscribe en el marco de recomendación del Comité de Ministros del Consejo de Europa, del 30 de abril de 1980, en los siguientes términos. "la relación establecida entre enfermos y profesionales debe transformarse en una relación conjunta basada en una confianza recíproca (...) Convendría señalar la adopción de una concepción dinámica de la participación del público a la protección de la salud y del enfermo a su propio tratamiento"(63). El acuerdo sobre estos fundamentos necesita no solo largas confrontaciones sino también un verdadero acercamiento bilateral de la relación terapéutica. Aquí, el paso ético fundamental consiste, según el filósofo K. Apel, "en un reconocimiento de las personas como sujetos de la argumentación y de sus diferencias. Esto implica necesariamente representaciones de la enfermedad más allá del campo de la terapéutica, en un terreno donde los valores éticos y religiosos ocupan una función más determinante que los hechos biológicos. ¿La elección terapéutica, expresión de la singularidad insustituible del individuo y del pluralismo ético, no será la traducción de una ética de la responsabilidad y de la dignidad inalienable de la persona humana?

Referencias

1. Transfusión sanguínea en Europa: un libro en blanco, P.J. Hagen, Les éditions du Conseil de l’Europe, 1993, p. 7.

2. "La lista de riesgos potenciales –inmediatos o secundarios- es larga. Entre las reacciones agudas podemos citar el shock hemolítico y el no hemolítico, el shock anafiláctico hipotensivo las septicemias. Otras patologías –aloinmunización, hepatitis virales, paludismo, SIDA, por ejemplo-, se manifiestan más tarde (...) Globalmente, la transfusión sanguínea en Europa induce a efectos negativos inmediatos o secundarios en un 10 a un 15% de ñps receptores". Transfusión de sangre en Europa, precitado, pp. 16-17. Sobre los efectos incontrolados del fenómeno de la "ventana serológica", las posiciones científicas continúan siendo aleatorias: Walker R.H., Transfusion risks, am. J. Clin. Pathol 1987: 88: 374-8; B. Lasalle y otros, Accidents hémolytiques transfusionnels par incompatibilité ABO RH-responsabilité médicale, La Presse Médicale, el 3 de abril 1992, 22, No. 12, pp. 565-568.

3. J.-P. Baud, La naturalez jurídica de la sangre; J. Bouineau, Sang, droit et histoire, Revue trimestrielle de la Cour d’appel de Versailles, octubre-diciembre 1993, No. 30, pp. 17-34.

4. J. Sourdille, c. Uriet, La crisis del sistema transfusional francés –rapport de la Commission d’énquete du Sénat, Económica, 1992.

5. "Cómo explicar que en Francia, se presenta de manera muy sensible la situación de la contaminación de los hemófilos, a la vez que se intenta ignorar la otra cara de la moneda. La contaminación post tansfusional": A. Morelle, L’ institution médicale en question –retour sur l’affaire du sang contaminé, Esprit, oct. 1993 p. 6.

6. La conclusión Micoud, hecha pública por el ministro de salud B. Louchner, el 8 de enero de 1993, estima que entre 500.000 y 2.000.000 de personas son portadoras de HIV en Francia; entre ellas, de 100.000 a 400.000 habrán sido contaminadas por una transfusión (Le Monde, 9 de enero de 1993); B. Habibi, Sécurité et morbidité transfusionnelles en France, Le concours médical, 1992, 114, pp. 271-281.

7. Transfusión y SIDA-El derecho a la verdad, Ed. Frison-Roche, 1992, p. 107.

8. Fuente: Servicio de Estadísticas, de Estudios y de Sistemas de Información (SESI) del Ministerio de Asuntos Sociales, de Salud y de Ciudad.

9. A. Garay, Voluntad del enfermo y evidencia médica: de la búsqueda de la lógica a la del sentido, 1º Congreso Mundial de Medicina y Filosofia, París, 30 de mayo de 1994, resúmenes a publicarse ed. John Libbery-Eurtext (París) y Kluwer (Dordrecht).

10. Economizar una sangre cada vez menos peligrosa; La medicina transfusional en mutación, JAMA, vol. 17, No. 251, del 15 de octubre de 1992; Tratamiento dela hemorragia aguda: la búsqueda de un riesgo transfusional cero, Euromédecine 1993, 10-13 de noviembre de 1993; ¿La cirugía sinuitlizaicón de sangre, es posible?, Coloquio AMS, el 1 de noviembre de 1985; Ateliers d’épargne sanguine, París del 27 de enero de 1994; Soigner les Témoins de Jéhovah: une entrve ou un défil?, coloquio AMS, el 8 de noviembre de 1986.

11. Sida Transfusional – un centro de cuidados y seguimiento es indispensable, Le concours médical, el 11 de enero de 1992, p. 73.

12. Cass. Civ. El 20 de mayo de 1936, D.P. 1936, 1, 88, concl. Matter, rapport Josserand.

13. A. Dorsner-Dlivet, Abastecimiento de sangre: la obligación de resultados, La Presse Médicale, el 23 de abril de 1994, p. 728.

14. Ya citado, nota 11,

15. Circular DGS 3B/763, DH/9 B.

16. Circular DH/DGS/3B/47 del 15 de enero de 1992 relativa al seguimiento de la seguridad transfusional. ¿Esta medida de seguimiento individual del enfermo transfusado pro el médico prescriptor, no es en sí misma una preocupación del peligro potencial de una reacción incontrolada o de un efecto negativo de la transfusión de sangre? ¿Cómo evaluar y con qué instrumentos metodológicos?

17. "Esta búsqueda de la coherencia de la selección, tomando en cuenta el equilibrio de los intereses en cuestión y la gravedad de los daños que amenazan, constituye para el que se libra a una práctica dudosa un conflicto, y tanto más que nadie está al abrigo de una subvalorización arbitraria de un interés al perjuicio de otro". Hennau-Hublet, La actividad médica y los delitos de amenaza a la vida, la integridad física y la salud e las personas, tesis Universidad Católica de Lovaina, 1985, LGDJ; "La elección de una prescripción médica depende de los beneficios que se pueden espera, teniendo en cuenta los inconvenientes eventuales que pueden resultar de tal tratamiento", Les prescriptions médicales, Bull, Ordre des Médecins, diciembre 1992, no. 12, p. 254.

18. Cass. Civ. 1ª, el 5 de marzo de 1974, D 1974 IR 127; Gaz. Pal 1974, 1, sumario 124. Ver igualmente, el 20 de febrero de 1979, JCP 1979, IV, 145: "El metiodal podía causa lesiones a veces irreversibles y debía ser administrado únicamente si las terapias aplicadas y los medios de investigación empleados se revelaban ineficaces".

19. Cass. Civ. 1ª, del 22 de mayo de 1964, Bull, civ. 1, 204; del 8 de neero de 1975, Bull. Civ. 1, 9.

20. Para G. Mémeteau, "el rechazo tradicional del juez de inmiscuirse en los casos puramente médicos, no le impiden de apreciar la prudencia de una elección y declarar la responsabilidad del que ha optado en favor del tratamiento más inútilmente peligroso", nota sobre el principio de proporcionabilidad en derecho médico, Medicina y Derecho, No. 5, marzo-abril de 1994, pp. 40-41.

21. The American Journal of medecine february 1993, vol. 94, pp. 117-119; ver "Bien inspirés Témoins de Jéhovah, La Gazette médicale, tome 100, No. 19, p.8.

22. K.A. Dietrich y otros, Cardiovascular and metabolic response to red blood cell transfusion in critically ill volume resuscitated nonsurgical patients, Critical: care Médicine, vol. 18, No. 9, 1990, pp. 940-944.

23. Cass. Civ. 1ª, el 4 de mayo de 1979, D. 1970, sumario 227. En ningún caso está justificado elt ransfundir clandestinamente, contra la voluntad del enfermo.

24. Cf. La recomendación R (80) adoptada por el Comité de Ministros del Consejo de Europa, el 30 de abril de 1980, concerniente ala participación activa del enfermo a su propio tratamiento. Ver también, C. Byk, Recherche médicale et droits de l’homme-une approche européenne, JCP 1993, p. 484-488. Del mismo autor, Les progres de la médicine et de la biologie au regard de la Convention européenne des droits de l’homme, Conseil de l’Europe, rapport H92-5, en marzo de 1992.

25. H. Anrys, L’éthique médicale et les droits de l’homme, in Médecine et droits del’homme-Normes et reperes de la juridiction internationale de l’éthique, des morales catholiques, protestantes, juives, musulmanes, bouddhistes et agnostiques, Conseil de l’Europe, el 16 de julio de 1992, DECS/MED DH (91) 2.

26. R. Savatier, D 1952, chro 157.

27. G. Gremy, Entre le scientisme et l’humanisme . le déficulturel, La Presse Medicale, el 10 de abril de 1993, 22; D.J. Roy, Practique médicale et recherche – Perspectives nord – americaines sur le consentement, Méd. Et Hyg., 1986, 44, pp. 2014-2017.
28. J.L. Baudoin, m.H. Parizeau, Réfelxions juridiques et éthiques sur le consentement au traitement médical, Médecine-Sciences, 1987; B,. Hoerni, M. Benezech, L’information en médecine –Evolution sociales, juridique, éthique, Masson,} 1993. Para un estudio exhaustivo de la cuestión del consentimiento aclarado, Sra. Sommerville, Le consentement al’acte médical, Comm. Réf., Dr. Du Canada, serie "Protección de la vida", 1980.

29. "Rechazando la transfusión por motivos religiosos, la víctima ha ejercido una elección derivada de una libertad esencial", Cass. Crim. El 30 de junio de 1987, aff. Tetiarahi, inédit. Ver también M. Heraudeau, Le malade, personne libre face au médeci, teis Poitiers, 1955.

30. La aplicación del artículo 3 de la Convención Europea que trata de la prohibición de "maltrato inhumano o degradante" pudiera extenderse hasta el derecho delos enfermos, cf. F. Sudre, La notion de peines et traitements inhumains ou dégradants dans la jurisprudene de la Commission et de la Cour euroéenne des droits de l’homme, R.G.D.I.P. 1984, p. 852, Y. Madiot, La protectioninternaitonale de la personne, La personne humaine-sujet de Droit, PUF 1994, pp. 173-206.

31. El conjunto convencional de los derechos del hombre toma en cuenta estas evoluciones. "Así, los factores de le evolución son (...) el progreso científico y la tolerancia de la comunidad, y el sentido de la evolución está claramente indicado: hacia una más grande comprensión de los problemas de los pacientes. Para ser evolutivas, las nociones inscritas en una convención que protege los derechos del hombre deben al menos obedecer al adinámica de desarrollo de esos derechos", M. Delmas-marty, Pour un droit commun, Seuil, 1994, p. 76.

32. Concluyendo que "faltando a su obligación de explicar al enfermo sobre las eventuales consecuencias de su elección de aceptar la operación que le proponen, ese médico quizá en una decisión más juiciosa, únicamente ha privado al enfermo de una posibilidad de escapar a un riesgo que finalmente se realizó", Cass. Civ. 1º, del 7 de febrero de 1990, JCP 1990, IV. P. 133. "El derecho individual a la calidad de vida, primero pasa por ser informado". Una disponibilidad efectiva de la vida de cada individuo supone la posibilidad de hacer elecciones aclaradas", M. Borysewicz, La qualité de la vie; une finalité nouvelle de la regle de droit, Mélanges Jauffret, Fac. Aix-Marseille, 1974, p. 145.

33. El antiguo presidente del Consejo Nacional del Colegio de médicos, igualmente ha denunciado esta actitud considerada como una "mentira piadosa", Transfusión sanguine et interdits religieux, La vie médicale, 1975, 35, pp. 2961-2962.

34. B. Rajbaut, El papel de la voluntad del enfermo en materia médica, tesis París XII, 1982.

35. Cons. de Estado, del 27 de enero de 1982, D. 1982, IR 275, note Penneau: "La voluntad del paciente disponiendo de su integridad intelectual debe constituir un límite que no se pueda violar; el paciente está libre, hipotéticamente, de aceptar, si lo decide así, el destino que se le presenta. Ver igualmente, Cons. de Estado, del 29 de enero de 1988, M. Labidi, JCP 1989, II, 21222, note G. Mémeteau; Cons. de Estado, del 6 de marzo de 1981, Dr. Pech, Revue Dr. San,, et Social, 1981, 407, note Dubois et 413, note Labetoulle.

36. Rouen, el 10 de diciembre de 1958, D. 1959, IR p. 60.

37. D. 1973, p. 220; Le refus de transfusions sanguine – aspects juridiques, AMS, 1990, 152 p.; J. Bouton, Lóbligation de se soigner?, tesis Strasbourg II, 1990, pp. 34-40.

38. Ver J.M. Auvy, Le droit de la santé, PUF, Themies, p. 222; . Mémeteau, Le droit Médical, LITEC, p. 372; J. Penneau, La responsabilité du médecin, Dalloz 1992, p. 20-21; M. Véron, la responsaiblité pénale du médecin, Droit médical et hospitalier, LITEC, Fasc. 21, p. 25; M. Troper, Volonté du patien et acquis de la science – le point de vue du juriste, La revue du praticien, tomo 7, el 18 de octubre de 1993, p. 42; G. Levasseur,note sous Cass. Crim. El 3 de enero de 1973, Rev. Sc. Crim. 1973, pp. 696-694.

39. Dicha constatación, concede, al control y al estudio del análisis médico una posición preponderante. En efecto, "las reglas de la medicina deben distinguirse de la práctica (práctica utilizada rutinariamente, pero que no es necesariamente actual); y comprendemos mejor la jurisprudencia que decide el hecho de seguir una práctica que puede ser una falta, mientras que el hecho de seguir unas pautas de medicina está excluido de toda falta profeisonal". J. Penneau, La prescription, Actes du colloque 19-20 de junio de 1992, PUM 1993; J. Lowell Dixon, Le sang: a qui le choix? "Pour quelle conséquence?, New-York State journal of medicine, septiembre de 1988, vol. 88, No. 9.

40. Cf. Despertad, del 22 de noviembre de 1991, pp. 8-11.

41. British Medical Journal, Managing patients who refuse blood transfusions: an ethical dilemna, No. 6941, vol. 308, pp. 1423-1426; E.B. Goldman, H.A. Oberman, Legal aspects of transfusion of Jehovah’s witnesses, W.Nielsen, The biblical laws against transfusions reexamined, Transfusion medicine reviews, No. 4 de octubre de 1991; G. Bagou, M.C. Laplace,L’anesthesiste-réanimateur et le Témoin de Jéhovah, Ann. Fr. Anesth. Réanim. 1991, 10, 354-361; B. Habibi, Transfusion et Témoin de Jéhovah, Rev. Fr. Transfus. Hémobiol, 1992, 35, 13-23; A. Najand, jJ. Canova, Le patient Témoin de Héhovah et les nouvelles techniques médico-chirurgicales, Colloque Bordeaux, el 5-7 de octubre de 1992; Rouge et al, Le refus de transfusion sanguine – l’exemple des Témoins de Jéhovah, Le concours médical, el 6 de noviembre de 1993, pp. 3107-3110.

42. J. Gynecol. Obstet. Biol. Reprod. 1988, 17, 965-980. De los mismos autores, ver también Le praticien face au refus de transfusion sanguine, Le concours médical, el 31 de marzo de 1990, pp. 1138-1140.

43. Sang, pécheé et mort, Les Térmoins de Jéhovah et le mouvement desdroits des malades, Revue trim. Tribunal de apelaciones de Versailles, octubre y noviembre de 1993, No. 30, pp. 93-115.

44. "Los testigos de Jehová pensan que solo la oración sana, y excluyen toda intervención médica", P.J. Doll (presidente del Tribunal de apelaciones de París), nota en el Cass. Crim., del 30 de octubre de 1974, Tolle, Gazette du Palais, del 27 de mayo de 1975.

45. J. R. Zaorski y otros, Open heart surgery for acquired heart disease in Jehovah witnesses-a report of 42 operations, The American Journal of Cardiology, 1972, vol. 29, pp. 186-189; Ott. Cooley, Cardiovascular surgery in Jehovah’ s witnesses-report of 542 operations without blood transfusion, JAMA, septiembre 19, 1977, vol. 328, pp. 1256-1258; J. Seguin, Chirurgie cariaque chez les adultes Témoins de Jéhovah, La Presse Médicale, el 26 d eoctubre de 1991, No. 34, p. 1644.

46. Meeting the surgical and ethical challenger presented by Jehovah’s eitnesses, Canadian Medical Association Journal, vol. 128, del 15 de mayo de 1983, p. 1153.

47. L. Rozovsky, F. Rozovsky, Treating the Jehovah’s witnesses patient, Canadian Doctor, 1982,

48, pp. 81-84.

48. J.L. Vincent, Transfuison in the exsanguinating Jehovah’s witness patient-the attitude of intensive-care doctors, European Journal of Anaesthesiology, 1991, 8, pp. 297-300.

49. D. Delmas, a. Garay, La oficina de información de hospitales de los testigos de Jhová, La Gazette de la transfusion, julio de 1983, 88, pp. 36-38.

50. M. E. Boyd, El obstetra, el ginecólogo y los testigos de Jehová, Journal soc. Des Obs. et Gyn. du Canada, julio y agosto de 1992, pp. 13-16; B. Eiseman, Transfusion sanguine péri- opératoire, Surgical rounds, noviembre de 1988, pp. 31-35.
51. Bagou, Laplace, citado, p. 359.

52. E. Munoz, The hidden costs of homologous blood, Ortho biotech, Toltzis communication, 1991.

53. D. Clair Lambert, el gasto mundial del SIDA-1980/2000, CNRS ediciones, 1992; Alternativas económicas del SIDA, mayo de 1993, pp. 25-31; Chossegro sy otros, Gasto en Francia delashepatits A agudas del paciente adulto, La Presse Médicale, el 26 de marzo de 1994, 23, pp. 561-564.

54. Blood sustitutes: application potential and safety concerns, Lab-medica internaitonal, enero y febrero de 1994, p. 4.

55. Sobre la regla dicha de 10/30 en materia de nivel de hematocritos, un autor califica esta referencia de mito, cuyo origen "se toma de una traducción oscura y no se apoya en ninguna prueba clínica o experimental": Zauder, How did we get a "magic number" for presperative hemtocrit/ hemoglobin level,in Perioperative real cell transfusion-program and abstracts, Bethesda, MD; National institutes of health, 27-29 de junio de 1988, p. 29.

56. Cf. las jornadas de estudio del grupo de Anestesia, reanimación, tecnología, evaluación del Hospital Broussais (París), sobre la economía de sangre, la eritropoyectine, la expansión del volumen y los testigos de Jehová (dirigido por el doctor Jean Francois Baron), Innovationen transfusion sanguine, Institut National de Transfusion Sanguine, formation continue, 1993. Sur les limites de l’enseignement médical face aux nouveautés scientifiques, ver F. Carasso, L’enseignement et les soins: deux professions impossibles? Esprit, octubre de 1993, pp. 52-66.
57. A.Morelle, citado, pp. 50-51.

58. B. Glorion, La prise de risque, facteur de progres en medicine, in colloque Risque therapeutique et responsabilité médicale, Paris, el 4 de diciembre de 1992.

59. A. Garay, P. Goni, La valeur juridique de l’attestation de refus de transfusion sanguine, Les Petites Affiches, el 13 de agosto de 1993, pp. 14-18; D. Ritley, Comment s’adapter au choix des Témoins de Jéhovah de ne pas accepter de sang?; Perspectives inhealtheare risk management, winter 1990, pp. 17-21.

60. El tribunal de apelaciones de Ontario, de manera expresa, ha consagrado el valor de este documento reteniendo la responsaiblidad de un médico que había transfundido un paciente, teniendo conocimiento de tal documento; Malette v./Shulman, No. 29-88, physician’s management manual, mayo de 1990, pp. 68-69.

61. Citado, p. 2962; Ver también La responsabilté médicale-données actuelles, ed. Lacassagne, Lyon, 1992, p. 68: "En todos los casos, es importante de conservar pruebas del comportamiento recalcitrante (...); nada mejor que una prueba escrita, que evita toda discusión sobre el valor del testimomio; el documento puede mencionar elt ratamiento propuesto y, debajo la negativa del enfermo escrito y firmado de su propia mano"; J. H. Soutoul, F. Pierre, Le praticien face au refus des transfusion sanguine, Le concours médical, el 31 de marzo de 1990, p. 1140; De manera general, el Colegio Nacional de médicos, en lo que concierne a las prescripciones médicas recomienda la redacción escrita de las informaciones médicas destinadas al paciente, citado, nota 17.

62. J.M. Clément , Les pouvoirs a l’hopital, Le cahier hospitaliers-Berger Levrault, 1990, pp. 126-137.

63. Recomendación No. 12 (80) 4, concerniente a la participación activa del enfermo a su propio tratamiento.
*128, rue Thiers, 92100 Boulogne-Billancourt, FRANCIA

don`t you understand

"we don`t want blood"

Malette v. Shulman et al. Indexed as: Malette v. Shulman (Ont. C.A.) 72 O.R. (2d) 417 [1990] O.J. No. 450 Action No. 29/88 ONTARIO Court of Appeal Robins, Catzman and Carthy JJ.A. March 30, 1990.
Professions — Physicians and surgeons — Consent to treatment — Unconscious patient carrying card declaring her to be Jehovah's Witness and refusing consent to blood tranfusions — Physician administering blood liable for damages for battery.
Damages — Assault and battery — Consent to treatment — Unconscious patient carrying card declaring her to be Jehovah's Witness and refusing consent to blood transfusions — Physician administering blood transfusion — $20,000 awarded for mental distress.
Torts — Assault and battery — Consent — Unconscious patient carrying card declaring her to be Jehovah's Witness and refusing consent to blood transfusions — Physician administering blood — Saving patient's life — Action nevertheless constituting battery.
The plaintiff was severely injured in an automobile accident and was taken unconscious to the defendant hospital where she was examined by the defendant physician in the emergency department. He concluded that a blood transfusion was indicated but a nurse discovered a card in the plaintiff's purse identifying her as a Jehovah's Witness and requesting on the basis of her religious convictions that she be given no blood transfusion under any circumstances. Having formed the opinion that the plaintiff's condition made a blood transfusion necessary to preserve her life and health, the defendant physician personally administered transfusions to her and later refused to follow the instructions of the plaintiff's daughter who sought to terminate the transfusions. The physician believed that it was his professional responsibility to give his patient a transfusion and he was not satisfied that the card expressed her current view. The plaintiff recovered and brought an action against the physician, the hospital, its executive director and four nurses, alleging that the administration of blood constituted negligence and assault and battery. The trial judge awarded the plaintiff $20,000 by way of damages for battery. The defendants appealed to the Court of Appeal.
Held, the appeal should be dismissed.
The plaintiff had a right to control her own body. The tort of battery protects the interest in bodily security from unwanted physical interference. Any non-consensual touching which is harmful or offensive to a person's reasonable sense of dignity is actionable. A competent adult is generally entitled to reject a specific treatment or all treatment or to select an alternate form of treatment even if the decision may entail risks as serious as death and may appear mistaken in the eyes of the medical profession or of the community. Regardless of the doctor's opinion it is the patient who has the final say on whether to undergo the treatment. While in an emergency the doctrine of necessity may protect the physician who acts without consent, the doctor is not free to disregard a patient's advance instructions. The plaintiff had conveyed her wishes in the only way possible.
While the interest of the state in protecting and preserving the lives and health of its citizens may override the individual's right to self-determination in order to eliminate a health threat to the community, it does not prevent a competent adult from refusing life-preserving medical treatment.
The fact that the physician had no opportunity to offer medical advice could not nullify instructions intended to cover any circumstances where advice was not possible. Any doubts about the validity of the card were not rationally founded on the evidence.
The cross-appeal against dismissal of the action against the hospital and the order with respect to costs should be dismissed.
Cases referred to
Schloendoff v. Society of New York Hospital, 211 N.Y. 125 (1914); Videto v. Kennedy (1981), 33 O.R. (2d) 497, 125 D.L.R. (3d) 127, 17 C.C.L.T. 307; Reibl v. Hughes (1980), 114 D.L.R. (3d) 1, [1980] 2 S.C.R. 880, 14 C.C.L.T. 1, 33 N.R. 361; Marshall v. Curry, [1933] 3 D.L.R. 260, 60 C.C.C. 136; Parmley v. Parmley, [1945] 4 D.L.R. 81, [1945] S.C.R. 635; Mulloy v. Hop Sang, [1935] 1 W.W.R. 714; In re Estate of Brooks, 205 N.E. 2d 435 (1965); Randolph v. City of New York, Sup. Ct. N.Y., July 12, 1984, Index No. 17598/75 (unreported); revd 501 N.Y.S. 2d 837 (1986); vard 514 N.Y.S. 705 (1987)
Statutes referred to
Public Hospitals Act, R.S.O. 1980, c. 410
Rules and regulations referred to
O. Reg. 518/88 (Public Hospitals Act,) s. 25
APPEAL by defendant physician and CROSS-APPEAL by plaintiff from a judgment of Donelly J., 63 O.R. (2d) 243, 47 D.L.R. (4th) 18, 43 C.C.L.T. 62, awarding the plaintiff damages against the physician for battery and dismissing the action against the hospital.
Michael E. Royce and Harry C.G. Underwood, for appellant.
W. Glen How, Q.C., and John M. Burns, for respondent.
The judgment of the court was delivered by
ROBINS J.A.:— The question to be decided in this appeal is whether a doctor is liable in law for administering blood transfusions to an unconscious patient in a potentially life-threatening situation when the patient is carrying a card stating that she is a Jehovah's Witness and, as a matter of religious belief, rejects blood transfusions under any circumstances.
I
In the early afternoon of June 30, 1979, Mrs. Georgette Malette, then age 57, was rushed, unconscious, by ambulance to the Kirkland and District Hospital in Kirkland Lake, Ontario. She had been in an accident. The car in which she was a passenger, driven by her husband, had collided head-on with a truck. Her husband had been killed. She suffered serious injuries.
On arrival at the hospital, she was attended by Dr. David L. Shulman, a family physician practising in Kirkland Lake who served two or three shifts a week in the emergency department of the hospital and who was on duty at the time. Dr. Shulman's initial examination of Mrs. Malette showed, among other things, that she had severe head and face injuries and was bleeding profusely. The doctor concluded that she was suffering from incipient shock by reason of blood loss, and ordered that she be given intravenous glucose followed immediately by Ringer's Lactate. The administration of a volume expander, such as Ringer's Lactate, is standard medical procedure in cases of this nature. If the patient does not respond with significantly increased blood pressure, transfusions of blood are then administered to carry essential oxygen to tissues and to remove waste products and prevent damage to vital organs.
At about this time, a nurse discovered a card in Mrs. Malette's purse which identified her as a Jehovah's Witness and in which she requested, on the basis of her religious convictions, that she be given no blood transfusions under any circumstances. The card, which was not dated or witnessed, was printed in French and signed by Mrs. Malette. Translated into English, it read:
NO BLOOD TRANSFUSION!

As one of Jehovah's Witnesses with firm religious convictions, I request that no blood or blood products be administered to me under any circumstances. I fully realize the implications of this position, but I have resolutely decided to obey the Bible command: "Keep abstaining ... from blood." (Acts 15:28, 29). However, I have no religious objection to use the nonblood alternatives, such as Dextran, Haemaccel, PVP, Ringer's Lactate or saline solution.
Dr. Shulman was promptly advised of the existence of this card and its contents.
Mrs. Malette was next examined by a surgeon on duty in the hospital. He concluded, as had Dr. Shulman, that, to avoid irreversible shock, it was vital to maintain her blood volume. He had Mrs. Malette transferred to the X-ray department for X-rays of her skull, pelvis and chest. However, before the X-rays could be satisfactorily completed, Mrs. Malette's condition deteriorated. Her blood pressure dropped markedly, her respiration became increasingly distressed, and her level of consciousness dropped. She continued to bleed profusely and could be said to be critically ill.
At this stage, Dr. Shulman decided that Mrs. Malette's condition had deteriorated to the point that transfusions were necessary to replace her lost blood and to preserve her life and health. Having made that decision, he personally administered transfusions to her, in spite of the Jehovah's Witness card, while she was in the X-ray department and after she was transferred to the intensive care unit. Dr. Shulman was clearly aware of the religious objection to blood manifested in the card carried by Mrs. Malette and the instruction that "NO BLOOD TRANSFUSION!" be given under any circumstances. He accepted full responsibility then, as he does now, for the decision to administer the transfusions.
Some three hours after the transfusions were commenced, Mrs. Malette's daughter, Celine Bisson, who had driven to Kirkland Lake from Timmins, arrived at the hospital accompanied by her husband and a local church elder. She strongly objected to her mother being given blood. She informed Dr. Shulman and some of the other defendants that both she and her mother were Jehovah's Witnesses, that a tenet of their faith forbids blood transfusions, and that she knew her mother would not want blood transfusions. Notwithstanding Dr. Shulman's opinion as to the medical necessity of the transfusions, Mrs. Bisson remained adamantly opposed to them. She signed a document specifically prohibiting blood transfusions and a release of liability. Dr. Shulman refused to follow her instructions. Since the blood transfusions were, in his judgment, medically necessary in this potentially life-threatening situation, he believed it his professional responsibility as the doctor in charge to ensure that his patient received the transfusions. Furthermore, he was not satisfied that the card signed by Mrs. Malette expressed her current instructions because, on the information he then had, he did not know whether she might have changed her religious beliefs before the accident; whether the card may have been signed because of family or peer pressure; whether at the time she signed the card she was fully informed of the risks of refusal of blood transfusions; or whether, if conscious, she might have changed her mind in the face of medical advice as to her perhaps imminent but avoidable death.
As matters developed, by about midnight Mrs. Malette's condition had stabilized sufficiently to permit her to be transferred early the next morning by air ambulance to Toronto General Hospital where she received no further blood transfusions. She was discharged on August 11, 1979. Happily, she made a very good recovery from her injuries.
II
In June, 1980, Mrs. Malette brought this action against Dr. Shulman, the hospital, its executive director and four nurses, alleging, in the main, that the administration of blood transfusions in the circumstances of her case constituted negligence and assault and battery and subjected her to religious discrimination. The trial came on before Donnelly J. who, in reasons now reported at 63 O.R. (2d) 243, 47 D.L.R. (4th) 18, 43 C.C.L.T. 62, dismissed the action against all defendants save Dr. Shulman. With respect to Dr. Shulman, the learned judge concluded that the Jehovah's Witness card validly restricted his right to treat the patient, and there was no rationally founded basis upon which the doctor could ignore that restriction. Hence, his administration of blood transfusions constituted a battery on the plaintiff. The judge awarded her damages of $20,000 but declined to make any award of costs.
Dr. Shulman now appeals to this court from that judgment. Mrs. Malette cross-appeals the judge's dismissal of the action against the hospital and his order with respect to costs.
In his reasons for judgment, Donnelly J. fully and carefully set out the facts of this case as he found them. I see no need to restate those facts in any greater detail than I already have. Nor do I see any need to repeat the arguments that were advanced in both the appeal and the cross-appeal by which the parties seek to impugn the judge's findings in certain particulars. I think it sufficient to say that I am of the opinion that the judge's factual conclusions are unassailable. His findings were properly made within his province as the trier of fact and are supported by the evidence. It is not this court's function to weigh conflicting evidence or to determine the relative effect of contradictory medical opinions with respect either to bloodless medicine or to the benefits and risks of blood transfusions. The legal issues to be determined in this appeal must be dealt with on the basis of the findings made at trial.
I should perhaps underscore the fact that Dr. Shulman was not found liable for any negligence in his treatment of Mrs. Malette. The judge held that he had acted "promptly, professionally and was well-motivated throughout" and that his management of the case had been "carried out in a competent, careful and conscientious manner" in accordance with the requisite standard of care. His decision to administer blood in the circumstances confronting him was found to be an honest exercise of his professional judgment which did not delay Mrs. Malette's recovery, endanger her life or cause her any bodily harm. Indeed, the judge concluded that the doctor's treatment of Mrs. Malette "may well have been responsible for saving her life".
Liability was imposed in this case on the basis that the doctor tortiously violated his patient's rights over her own body by acting contrary to the Jehovah's Witness card and administering blood transfusions that were not authorized. His honest and even justifiable belief that the treatment was medically essential did not serve to relieve him from liability for the battery resulting from his intentional and unpermitted conduct. As Donnelly J. put it at p. 268 O.R., p. 43 D.L.R.:
The card itself presents a clear, concise statement, essentially stating, "As a Jehovah's Witness, I refuse blood". That message is unqualified. It does not exempt life threatening perils. On the face of the card, its message is seen to be rooted in religious conviction. Its obvious purpose as a card is as protection to speak in circumstances where the card carrier cannot (presumably because of illness or injury). There is no basis in evidence to indicate that the card may not represent the current intention and instruction of the card holder.
I, therefore, find that the card is a written declaration of a valid position which the card carrier may legitimately take in imposing a written restriction on her contract with the doctor. Dr. Shulman's doubt about the validity of the card, although honest, was not rationally founded on the evidence before him. Accordingly, but for the issue of informed refusal, there was no rationally founded basis for the doctor to ignore that restriction.
On the issue of informed refusal, Donnelly J. said at pp. 272-3 O.R., pp. 47-8 D.L.R.:
The right to refuse treatment is an inherent component of the supremacy of the patient's right over his own body. That right to refuse treatment is not premised on an understanding of the risks of refusal.
However sacred life may be, fair social comment admits that certain aspects of life are properly held to be more important than life itself. Such proud and honourable motivations are long entrenched in society, whether it be for patriotism in war, duty by law enforcement officers, protection of the life of a spouse, son or daughter, death before dishonour, death before loss of liberty, or religious martyrdom. Refusal of medical treatment on religious grounds is such a value.
. . . . .
If objection to treatment is on a religious basis, this does not permit the scrutiny of "reasonableness" which is a transitory standard dependent on the norms of the day. If the objection has its basis in religion, it is more apt to crystallize in life threatening situations.
The doctrine of informed consent does not extend to informed refusal. The written direction contained in the card was not properly disregarded on the basis that circumstances prohibited verification of that decision as an informed choice. The card constituted a valid restriction of Dr. Shulman's right to treat the patient and the administration of blood by Dr. Shulman did constitute battery.
III
What then is the legal effect, if any, of the Jehovah's Witness card carried by Mrs. Malette? Was the doctor bound to honour the instructions of his unconscious patient or, given the emergency and his inability to obtain conscious instructions from his patient, was he entitled to disregard the card and act according to his best medical judgment?
To answer these questions and determine the effect to be given to the Jehovah's Witness card, it is first necessary to ascertain what rights a competent patient has to accept or reject medical treatment and to appreciate the nature and extent of those rights.
The right of a person to control his or her own body is a concept that has long been recognized at common law. The tort of battery has traditionally protected the interest in bodily security from unwanted physical interference. Basically, any intentional nonconsensual touching which is harmful or offensive to a person's reasonable sense of dignity is actionable. Of course, a person may choose to waive this protection and consent to the intentional invasion of this interest, in which case an action for battery will not be maintainable. No special exceptions are made for medical care, other than in emergency situations, and the general rules governing actions for battery are applicable to the doctor-patient relationship. Thus, as a matter of common law, a medical intervention in which a doctor touches the body of a patient would constitute a battery if the patient did not consent to the intervention. Patients have the decisive role in the medical decision-making process. Their right of self-determination is recognized and protected by the law. As Justice Cardozo proclaimed in his classic statement: "Every human being of adult years and sound mind has a right to determine what shall be done with his own body; and a surgeon who performs an operation without his patient's consent commits an assault, for which he is liable in damages": Schloendoff v. Society of New York Hospital, 211 N.Y. 125 (1914). See also, Videto v. Kennedy (1981), 33 O.R. (2d) 497, 125 D.L.R. (3d) 127, 17 C.C.L.T. 307 (C.A.); Linden, Canadian Tort Law, 4th ed. (1988), at pp. 40-3 and p. 59 et seq.; Prosser & Keeton, The Law of Torts, 5th ed. (1984), at pp. 39-42; and Fleming, The Law of Torts, 7th ed. (1987), at pp. 23-4.
The doctrine of informed consent has developed in the law as the primary means of protecting a patient's right to control his or her medical treatment. Under the doctrine, no medical procedure may be undertaken without the patient's consent obtained after the patient has been provided with sufficient information to evaluate the risks and benefits of the proposed treatment and other available options. The doctrine presupposes the patient's capacity to make a subjective treatment decision based on her understanding of the necessary medical facts provided by the doctor and on her assessment of her own personal circumstances. A doctor who performs a medical procedure without having first furnished the patient with the information needed to obtain an informed consent will have infringed the patient's right to control the course of her medical care, and will be liable in battery even though the procedure was performed with a high degree of skill and actually benefitted the patient.
The right of self-determination which underlies the doctrine of informed consent also obviously encompasses the right to refuse medical treatment. A competent adult is generally entitled to reject a specific treatment or all treatment, or to select an alternate form of treatment, even if the decision may entail risks as serious as death and may appear mistaken in the eyes of the medical profession or of the community. Regardless of the doctor's opinion, it is the patient who has the final say on whether to undergo the treatment. The patient is free to decide, for instance, not to be operated on or not to undergo therapy or, by the same token, not to have a blood transfusion. If a doctor were to proceed in the face of a decision to reject the treatment, he would be civilly liable for his unauthorized conduct notwithstanding his justifiable belief that what he did was necessary to preserve the patient's life or health. The doctrine of informed consent is plainly intended to ensure the freedom of individuals to make choices concerning their medical care. For this freedom to be meaningful, people must have the right to make choices that accord with their own values regardless of how unwise or foolish those choices may appear to others: see generally, Prosser & Keeton, op.cit., p. 112 et seq.; Harper, James & Gray, The Law of Torts, 2nd ed. (1986), c. III; Linden, op.cit., p. 64 et seq.; and Reibl v. Hughes (1980), 114 D.L.R. (3d) 1, [1980] 2 S.C.R. 880, 14 C.C.L.T. 1.
IV
The emergency situation is an exception to the general rule requiring a patient's prior consent. When immediate medical treatment is necessary to save the life or preserve the health of a person who, by reason of unconsciousness or extreme illness, is incapable of either giving or withholding consent, the doctor may proceed without the patient's consent. The delivery of medical services is rendered lawful in such circumstances either on the rationale that the doctor has implied consent from the patient to give emergency aid or, more accurately in my view, on the rationale that the doctor is privileged by reason of necessity in giving the aid and is not to be held liable for so doing. On either basis, in an emergency the law sets aside the requirement of consent on the assumption that the patient, as a reasonable person, would want emergency aid to be rendered if she were capable of giving instructions. As Prosser & Keeton, op.cit., at pp. 117-18 state:
The touching of another that would ordinarily be a battery in the absence of the consent of either the person touched or his legal agent can sometimes be justified in an emergency. Thus, it has often been asserted that a physician or other provider of health care has implied consent to deliver medical services, including surgical procedures, to a patient in an emergency. But such lawful action is more satisfactorily explained as a privilege. There are several requirements: (a) the patient must be unconscious or without capacity to make a decision, while no one legally authorized to act as agent for the patient is available; (b) time must be of the essence, in the sense that it must reasonably appear that delay until such time as an effective consent could be obtained would subject the patient to a risk of a serious bodily injury or death which prompt action would avoid; and (3) under the circumstances, a reasonable person would consent, and the probabilities are that the patient, would consent.
See also Marshall v. Curry, [1933] 3 D.L.R. 260, 60 C.C.C. 136 (N.S.S.C.); Parmley v. Parmley, [1945] 4 D.L.R. 81, [1945] S.C.R. 635; Mulloy v. Hop Sang, [1935] 1 W.W.R. 714 (Alta. C.A.); Picard, Legal Liability of Doctors and Hospitals in Canada, 2nd ed. (1985), at p. 45; Restatement of the Law of Torts, Second, s. 892 D (1979); and s. 25 of O. Reg. 518/88 under the Public Hospitals Act, R.S.O. 1980, c. 410.
On the facts of the present case, Dr. Shulman was clearly faced with an emergency. He had an unconscious, critically ill patient on his hands who, in his opinion, needed blood transfusions to save her life or preserve her health. If there were no Jehovah's Witness card he undoubtedly would have been entitled to administer blood transfusions as part of the emergency treatment and could not have been held liable for so doing. In those circumstances he would have had no indication that the transfusions would have been refused had the patient then been able to make her wishes known and, accordingly, no reason to expect that, as a reasonable person, she would not consent to the transfusions.
However, to change the facts, if Mrs. Malette, before passing into unconsciousness, had expressly instructed Dr. Shulman, in terms comparable to those set forth on the card, that her religious convictions as a Jehovah's Witness were such that she was not to be given a blood transfusion under any circumstances and that she fully realized the implications of this position, the doctor would have been confronted with an obviously different situation. Here, the patient, anticipating an emergency in which she might be unable to make decisions about her health care contemporaneous with the emergency, has given explicit instructions that blood transfusions constitute an unacceptable medical intervention and are not to be administered to her. Once the emergency arises, is the doctor none the less entitled to administer transfusions on the basis of his honest belief that they are needed to save his patient's life?
The answer, in my opinion, is clearly no. A doctor is not free to disregard a patient's advance instructions any more than he would be free to disregard instructions given at the time of the emergency. The law does not prohibit a patient from withholding consent to emergency medical treatment, nor does the law prohibit a doctor from following his patient's instructions. While the law may disregard the absence of consent in limited emergency circumstances, it otherwise supports the right of competent adults to make decisions concerning their own health care by imposing civil liability on those who perform medical treatment without consent.
The patient's decision to refuse blood in the situation I have posed was made prior to and in anticipation of the emergency. While the doctor would have had the opportunity to dissuade her on the basis of his medical advice, her refusal to accept his advice or her unwillingness to discuss or consider the subject would not relieve him of his obligation to follow her instructions. The principles of self-determination and individual autonomy compel the conclusion that the patient may reject blood transfusions even if harmful consequences may result and even if the decision is generally regarded as foolhardy. Her decision in this instance would be operative after she lapsed into unconsciousness, and the doctor's conduct would be unauthorized. To transfuse a Jehovah's Witness in the face of her explicit instructions to the contrary would, in my opinion, violate her right to control her own body and show disrespect for the religious values by which she has chosen to live her life: see In re Estate of Brooks, 205 N.E. 2d 435 (1965, Ill.); and Randolph v. City of New York an unreported judgment of the Supreme Court of New York released July 12, 1984, Index No. 17598/75; reversed 501 N.Y.S. 2d 837 (1986); varied 514 N.Y.S. 2d 705 (1987).
V
The distinguishing feature of the present case -- and the one that makes this a case of first impression -- is, of course, the Jehovah's Witness card on the person of the unconscious patient. What then is the effect of the Jehovah's Witness card?
In the appellant's submission, the card is of no effect and, as a consequence, can play no role in determining the doctor's duty toward his patient in the emergency situation existing in this case. The trial judge, the appellant argues, erred in holding both that the Jehovah's Witness card validly restricted the doctor's right to administer the blood transfusions, and that there was no rationally founded basis for ignoring the card. The argument proceeds on the basis, first, that, as a matter of principle, a card of this nature could not operate in these circumstances to prohibit the doctor from providing emergency health care and, second, that in any event, as a matter of evidence, there was good reason to doubt the card's validity.
The appellant acknowledges that a conscious rational patient is entitled to refuse any medical treatment and that a doctor must comply with that refusal no matter how ill-advised he may believe it to be. He contends, however, to quote from his factum, that "a patient refusing treatment regarded by a doctor as being medically necessary has a right to be advised by the doctor, and the doctor has a concomitant duty to advise the patient of the risks associated with that refusal". Here, because of the patient's unconsciousness, the doctor had no opportunity to advise her of the specific risks involved in refusing the blood transfusions that he regarded as medically necessary. In those circumstances, the appellant argues, it was not possible for the doctor to obtain, or for the patient to give, an "informed refusal". In the absence of such a refusal, the argument proceeds, Dr. Shulman was under a legal and ethical duty to treat this patient as he would any other emergency case and provide the treatment that, in his medical judgment, was needed to preserve her health and life. In short, the argument concludes, Mrs. Malette's religiously motivated instructions, prepared in contemplation of an emergency, directing that she not be given blood transfusions in any circumstances, were of no force or effect and could be ignored with impunity.
In challenging the trial judge's finding that there was no rationally founded evidentiary basis for doubting the validity of the card and ignoring the restriction contained in it, the appellant puts forth a number of questions which he claims compel the conclusion that he was under no duty to comply with these instructions. He argues that it could properly be doubted whether the card constituted a valid statement of Mrs. Malette's wishes in this emergency because it was unknown, for instance, whether she knew the card was still in her purse; whether she was still a Jehovah's Witness or how devout a Jehovah's Witness she was; what information she had about the risks associated with the refusal of blood transfusion when she signed the card; or whether, if she were conscious, she would refuse blood transfusions after the doctor had an opportunity to advise her of the risks associated with the refusal.
With deference to Mr. Royce's exceedingly able argument on behalf of the appellant, I am unable to accept the conclusions advocated by him. I do not agree, as his argument would have it, that the Jehovah's Witness card can be no more than a meaningless piece of paper. I share the trial judge's view that, in the circumstances of this case, the instructions in the Jehovah's Witness card imposed a valid restriction on the emergency treatment that could be provided to Mrs. Malette and precluded blood transfusions.
I should emphasize that in deciding this case the court is not called upon to consider the law that may be applicable to the many situations in which objection may be taken to the use or continued use of medical treatment to save or prolong a patient's life. The court's role, especially in a matter as sensitive as this, is limited to resolving the issues raised by the facts presented in this particular case. On these facts, we are not concerned with a patient who has been diagnosed as terminally or incurably ill who seeks by way of advance directive or "living will" to reject medical treatment so that she may die with dignity; neither are we concerned with a patient in an irreversible vegetative state whose family seeks to withdraw medical treatment in order to end her life; nor is this a case in which an otherwise healthy patient wishes for some reason or other to terminate her life. There is no element of suicide or euthanasia in this case.
Our concern here is with a patient who has chosen in the only way possible to notify doctors and other providers of health care, should she be unconscious or otherwise unable to convey her wishes, that she does not consent to blood transfusions. Her written statement is plainly intended to express her wishes when she is unable to speak for herself. There is no suggestion that she wished to die. Her rejection of blood transfusions is based on the firm belief held by Jehovah's Witnesses, founded on their interpretation of the Scriptures, that the acceptance of blood will result in a forfeiture of their opportunity for resurrection and eternal salvation. The card evidences that "as one of Jehovah's Witnesses with firm religious convictions" Mrs. Malette is not to be administered blood transfusions "under any circumstances"; that, while she "fully realize[s] the implications of this position", she has "resolutely decided to obey the Bible command"; and that she has no religious objection to "nonblood alternatives". In signing and carrying this card Mrs. Malette has made manifest her determination to abide by this fundamental tenet of her faith and refuse blood regardless of the consequences. If her refusal involves a risk of death, then, according to her belief, her death would be necessary to ensure her spiritual life.
Accepting for the moment that there is no reason to doubt that the card validly expressed Mrs. Malette's desire to withhold consent to blood transfusions, why should her wishes not be respected? Why should she be transfused against her will? The appellant's answer, in essence, is that the card cannot be effective when the doctor is unable to provide the patient with the information she would need before making a decision to withhold consent in this specific emergency situation. In the absence of an informed refusal, the appellant submits that Mrs. Malette's right to protection against unwanted infringements of her bodily integrity must give way to countervailing societal interests which limit a person's right to refuse medical treatment. The appellant identifies two such interests as applicable to the unconscious patient in the present situation: first, the interest of the state in preserving life and, second, the interest of the state in safeguarding the integrity of the medical profession.
VI
The state undoubtedly has a strong interest in protecting and preserving the lives and health of its citizens. There clearly are circumstances where this interest may override the individual's right to self-determination. For example, the state may in certain cases require that citizens submit to medical procedures in order to eliminate a health threat to the community or it may prohibit citizens from engaging in activities which are inherently dangerous to their lives. But this interest does not prevent a competent adult from refusing life-preserving medical treatment in general or blood transfusions in particular.
The state's interest in preserving the life or health of a competent patient must generally give way to the patient's stronger interest in directing the course of her own life. As indicated earlier, there is no law prohibiting a patient from declining necessary treatment or prohibiting a doctor from honouring the patient's decision. To the extent that the law reflects the state's interest, it supports the right of individuals to make their own decisions. By imposing civil liability on those who perform medical treatment without consent even though the treatment may be beneficial, the law serves to maximize individual freedom of choice. Recognition of the right to reject medical treatment cannot, in my opinion, be said to depreciate the interest of the state in life or in the sanctity of life. Individual free choice and self-determination are themselves fundamental constituents of life. To deny individuals freedom of choice with respect to their health care can only lessen, and not enhance, the value of life. This state interest, in my opinion, cannot properly be invoked to prohibit Mrs. Malette from choosing for herself whether or not to undergo blood transfusions.
Safeguarding the integrity of the medical profession is patently a legitimate state interest worthy of protection. However, I do not agree that this interest can serve to limit a patient's right to refuse blood transfusions. I recognize, of course, that the choice between violating a patient's private convictions and accepting her decision is hardly an easy one for members of a profession dedicated to aiding the injured and preserving life. The patient's right to determine her own medical treatment is, however, paramount to what might otherwise be the doctor's obligation to provide needed medical care. The doctor is bound in law by the patient's choice even though that choice may be contrary to the mandates of his own conscience and professional judgment. If patient choice were subservient to conscientious medical judgment, the right of the patient to determine her own treatment, and the doctrine of informed consent, would be rendered meaningless. Recognition of a Jehovah's Witness' right to refuse blood transfusions cannot, in my opinion, be seen as threatening the integrity of the medical profession or the state's interest in protecting the same.
In sum, it is my view that the principal interest asserted by Mrs. Malette in this case -- the interest in the freedom to reject, or refuse to consent to, intrusions of her bodily integrity -- outweighs the interest of the state in the preservation of life and health and the protection of the integrity of the medical profession. While the right to decline medical treatment is not absolute or unqualified, those state interests are not in themselves sufficiently compelling to justify forcing a patient to submit to nonconsensual invasions of her person. The interest of the state in protecting innocent third parties and preventing suicide are, I might note, not applicable to the present circumstances.
VII
The unique considerations in this case arise by virtue of Mrs. Malette's aim to articulate through her Jehovah's Witness card her wish not to be given blood transfusions in any circumstances. In considering the effect to be given the card, it must, of course, be borne in mind that no previous doctor-patient relationship existed between Dr. Shulman and Mrs. Malette. The doctor was acting here in an emergency in which he clearly did not have, nor could he obtain, her consent to his intervention. His intervention can be supported only by resort to the emergency doctrine which I outlined in Part IV of these reasons.
Under that doctrine, the doctor could administer blood transfusions without incurring liability, even though the patient had not consented, if he had no reason to believe that the patient, if she had the opportunity to consent, would decline. In those circumstances, it could be assumed that the patient, as a reasonable person, would consent to aid being rendered if she were able to give instructions. The doctor's authority to make decisions for his patient is necessarily a limited authority. If he knows that the patient has refused to consent to the proposed procedure, he is not empowered to overrule the patient's decision by substituting his decision for hers even though he, and most others, may think hers a foolish or unreasonable decision. In these circumstances the assumption upon which consent is set aside in an emergency could no longer be made. The doctor has no authority to intervene in the face of a patient's declared wishes to the contrary. Should he none the less proceed, he would be liable in battery for tortiously invading the patient's bodily integrity notwithstanding that what he did may be considered beneficial to the patient.
In this case, the patient, in effect, issued standing orders that she was to be given "NO BLOOD TRANSFUSION!" in any circumstances. She gave notice to the doctor and the hospital, in the only practical way open to her, of her firm religious convictions as a Jehovah's Witness and her resolve to abstain from blood. Her instructions plainly contemplated the situation in which she found herself as a result of her unfortunate accident. In light of those instructions, assuming their validity, she cannot be said to have consented to blood transfusions in this emergency. Nor can the doctor be said to have proceeded on the reasonable belief that the patient would have consented had she been in a condition to do so. Given his awareness of her instructions and his understanding that blood transfusions were anathema to her on religious grounds, by what authority could he administer the transfusions? Put another way, if the card evidences the patient's intent to withhold consent, can the doctor none the less ignore the card and subject the patient to a procedure that is manifestly contrary to her express wishes and unacceptable to her religious beliefs?
At issue here is the freedom of the patient as an individual to exercise her right to refuse treatment and accept the consequences of her own decision. Competent adults, as I have sought to demonstrate, are generally at liberty to refuse medical treatment even at the risk of death. The right to determine what shall be done with one's own body is a fundamental right in our society. The concepts inherent in this right are the bedrock upon which the principles of self-determination and individual autonomy are based. Free individual choice in matters affecting this right should, in my opinion, be accorded very high priority. I view the issues in this case from that perspective.
VIII
The appellant's basic position, reduced to its essentials, is that unless the doctor can obtain the patient's informed refusal of blood transfusions he need not follow the instructions provided in the Jehovah's Witness card. Nothing short of a conscious, contemporaneous decision by the patient to refuse blood transfusions -- a decision made after the patient has been fully informed by the doctor of the risks of refusing blood in the specific circumstances facing her -- will suffice, the appellant contends, to eliminate the doctor's authority to administer emergency treatment or, by the same token, to relieve the doctor of his obligation to treat this emergency patient as he would any other.
In my opinion, it is unnecessary to determine in this case whether there is a doctrine of informed refusal as distinct from the doctrine of informed consent. In the particular doctor-patient relationship which arose in these emergency circumstances it is apparent that the doctor could not inform the patient of the risks involved in her prior decision to refuse consent to blood transfusions in any circumstances. It is apparent also that her decision did not emerge out of a doctor-patient relationship. Whatever the doctor's obligation to provide the information needed to make an informed choice may be in other doctor-patient relationships, he cannot be in breach of any such duty in the circumstances of this relationship. The patient manifestly made the decision on the basis of her religious convictions. It is not for the doctor to second-guess the reasonableness of the decision or to pass judgment on the religious principles which motivated it. The fact that he had no opportunity to offer medical advice cannot nullify instructions plainly intended to govern in circumstances where such advice is not possible. Unless the doctor had reason to believe that the instructions in the Jehovah's Witness card were not valid instructions in the sense that they did not truly represent the patient's wishes, in my opinion he was obliged to honour them. He has no authorization under the emergency doctrine to override the patient's wishes. In my opinion, she was entitled to reject in advance of an emergency a medical procedure inimical to her religious values.
The remaining question is whether the doctor factually had reason to believe the instructions were not valid. On this question, the trial judge held that the doctor's "doubt about the validity of the card ... was not rationally founded on the evidence before him". I agree with that conclusion. On my reading of the record, there was no reason not to regard this card as a valid advance directive. Its instructions were clear, precise and unequivocal, and manifested a calculated decision to reject a procedure offensive to the patient's religious convictions. The instructions excluded from potential emergency treatment a single medical procedure well known to the lay public and within its comprehension. The religious belief of Jehovah's Witnesses with respect to blood transfusions was known to the doctor and, indeed, is a matter of common knowledge to providers of health care. The card undoubtedly belonged to and was signed by Mrs. Malette; its authenticity was not questioned by anyone at the hospital and, realistically, could not have been questioned. The trial judge found, "[t]here [was] no basis in evidence to indicate that the card [did] not represent the current intention and instruction of the card holder" [p. 268 O.R., p. 43 D.L.R.]. There was nothing to give credence to or provide support for the speculative inferences implicit in questions as to the current strength of Mrs. Malette's religious beliefs or as to the circumstances under which the card was signed or her state of mind at the time. The fact that a card of this nature was carried by her can itself be taken as verification of her continuing and current resolve to reject blood "fully realiz[ing] the implications of this position".
In short, the card on its face set forth unqualified instructions applicable to the circumstances presented by this emergency. In the absence of any evidence to the contrary, those instructions should be taken as validly representing the patient's wish not to be transfused. If, of course, there were evidence to the contrary -- evidence which cast doubt on whether the card was a true expression of the patient's wishes -- the doctor, in my opinion, would be entitled to proceed as he would in the usual emergency case. In this case, however, there was no such contradictory evidence. Accordingly, I am of the view that the card had the effect of validly restricting the treatment that could be provided to Mrs. Malette and constituted the doctor's administration of the transfusions a battery.
With respect to Mrs. Malette's daughter, I would treat her role in this matter as no more than confirmatory of her mother's wishes. The decision in this case does not turn on whether the doctor failed to follow the daughter's instructions. Therefore, it is unnecessary, and in my view would be inadvisable, to consider what effect, if any, should be given to a substitute decision, purportedly made by a relative on behalf of the patient, to reject medical treatment in these circumstances.
One further point should be mentioned. The appellant argues that to uphold the trial decision places a doctor on the horns of a dilemma, in that, on the one hand, if the doctor administers blood in this situation and saves the patient's life, the patient may hold him liable in battery while, on the other hand, if the doctor follows the patient's instructions and, as a consequence, the patient dies, the doctor may face an action by dependants alleging that, notwithstanding the card, the deceased would, if conscious, have accepted blood in the face of imminent death and the doctor was negligent in failing to administer the transfusions. In my view, that result cannot conceivably follow. The doctor cannot be held to have violated either his legal duty or professional responsibility towards the patient or the patient's dependants when he honours the Jehovah's Witness card and respects the patient's right to control her own body in accordance with the dictates of her conscience. The onus is clearly on the patient. When members of the Jehovah's Witness faith choose to carry cards intended to notify doctors and other providers of health care that they reject blood transfusions in an emergency, they must accept the consequences of their decision. Neither they nor their dependants can later be heard to say that the card did not reflect their true wishes. If harmful consequences ensue, the responsibility for those consequences is entirely theirs and not the doctor's.
Finally, the appellant appeals the quantum of damages awarded by the trial judge. In his submission, given the findings as to the competence of the treatment, the favourable results, the doctor's overall exemplary conduct and his good faith in the matter, the battery was technical and the general damages should be no more than nominal. While the submission is not without force, damages of $20,000 cannot be said to be beyond the range of damages appropriate to a tortious interference of this nature. The trial judge found that Mrs. Malette suffered mentally and emotionally by reason of the battery. His assessment of general damages was clearly not affected by any palpable or overriding error and there is therefore no basis upon which an appellate court may interfere with the award.
IX
The cross-appeal against the hospital can be dealt with very shortly. The findings made by the trial judge applicable to this claim, which I have not reproduced but which I have indicated are not subject to attack, provide no basis for holding the hospital liable for the acts of the doctor. This ground of appeal is accordingly without merit.
The cross-appeal with respect to costs must also be dismissed. This is a matter within the discretion of the trial judge. In denying costs to the successful party for the reasons given by him, the trial judge made no error in law or in principle. There is therefore no warrant for this court's intervention in this matter.
X
In the result, for these reasons I would dismiss the appeal and the cross-appeal, both with costs.
Appeal and cross-appeal dismissed.