blood so clear you could read the paper through it.

October 26, 2011 12:48 PM

The Academic Ob/Gyn: Taking Care of the Dying Jehovah’s Witness. The comments are good too.
posted by the young rope-rider (83 comments total)

...except for the comments which are typical religious bickering. Those are missing the point by miles and miles.
posted by muddgirl at 1:08 PM on October 26, 2011

I don't want to self-congratulate my religion, Judaism, too much here, but Judiasm is quite clear that its every commandment and prohibition is null in life-or-death situations--yours, or someone else's.

I think it is plausible to call religion a product of human evolution. And some manifestations of evolutionary traits are selected against. This seems like one of those cases.
posted by oneironaut at 1:11 PM on October 26, 2011 [15 favorites]

That's a hard one. I can see where I doctor would feel that his/her hands are being tied during a desperate struggle to save a patient. As some of the comments noted, it gets really difficult if you are talking about the child of a JW parent being the patient.
posted by bitmage at 1:12 PM on October 26, 2011

Very, very hard. I don't know about this statement:

...I am pretty sure that robbing them of their faith and security would do far more harm to their personhood than a few pints of blood could ever heal.

But a few pints of blood, he points out, could save their lives. And they might go on, later in life, to reject all the JW teachings, including the blood thing. So a transfusion could, effectively, save the life of someone who would desperately want a transfusion, were they temporally present to request it.
posted by gurple at 1:16 PM on October 26, 2011 [5 favorites]

People should be free to follow their beliefs (religious or otherwise), even if that, eventually, means their death. Doctors should understand and accept this. I'm sure it's very hard to stand-by and watch someone die from a survivable malady, but if it was their choice, so be it.
posted by Thorzdad at 1:17 PM on October 26, 2011 [10 favorites]

As far as I'm concerned, the right to die when and how you choose is paramount. If Jehovah’s Witnesses don't want transfusions, good on 'em (though I disagree that a doctor who refuses to personally help them in this is necessarily acting on "ego" -- there's a choice there, too, and as long as the doctor sees to it that someone else can help, I don't see what's wrong with making it.)

For me personally, though, it's hard to ignore the role religion plays in keeping me from dying when and where I choose (suicide, assisted or otherwise). There's something very ugly about the way some beliefs are treated as more equal than others.
posted by vorfeed at 1:19 PM on October 26, 2011 [3 favorites]

As some of the comments noted, it gets really difficult if you are talking about the child of a JW parent being the patient.

No. It gets much easier. If that person is a minor they're not able to make that call. They get blood. A parent's wishes cannot result in the death of a minor.
posted by jimmythefish at 1:20 PM on October 26, 2011 [21 favorites]

I think the right to die when and how you choose is paramount, provided that you are 18, or of an age old enough to petition a court for that right.
posted by roomthreeseventeen at 1:21 PM on October 26, 2011 [1 favorite]

Key quote for me:

"While I would love for these people to have good outcomes, I didn’t make them sick. I don’t share their religion, but I am pretty sure that robbing them of their faith and security would do far more harm to their personhood than a few pints of blood could ever heal. Everyone must die eventually, and it seems better for them to go on their own terms than to live on in fear that they have damaged their potential in eternity. I don’t know whether their religion has an accurate view of the long term consequences of taking blood or not. But that doesn’t matter. Making it matter wouldn’t be good doctoring."

posted by ericb at 1:21 PM on October 26, 2011

it gets really difficult if you are talking about the child of a JW parent being the patient.

My heart hurts even thinking about that.
posted by Doleful Creature at 1:22 PM on October 26, 2011 [2 favorites]

What happens when a clearly mentally ill or delusional patient ends up in a similar position and tells the doctor they can't be operated on because space aliens will take their soul?

If I'm a doctor and it's my job to ensure someone's good health, I'm going to take the same position as the person quoted at the beginning of that post. You can't take blood? Find another doctor, then, because if you're willing to die because of some fantastical belief, you're not letting me do my job.

I'm definitely not one to equate religion with mental illness, and most of the time the attitudes of aggressive atheists bother me. But I don't see this as a "right to die" issue at all because the patient is most definitely not making a rational decision.
posted by palidor at 1:24 PM on October 26, 2011 [5 favorites]

bitmage: “As some of the comments noted, it gets really difficult if you are talking about the child of a JW parent being the patient.”

Doleful Creature: “My heart hurts even thinking about that.”

There's not really a reason to have heart-hurt over that case, though, as it's not difficult at all. The doctor treats the child. It is illegal for parents to intervene. If you are a minor, you can get treated, no matter what your parents say.

What is difficult is when a minor of age to make some decisions – 13 or 14, say – decides themselves that they do not want treatment and steadfastly refuse it. Doctors are technically allowed to forcibly treat minors. I don't imagine that makes it any easier to do. There are many doctors who feel that there are 15-year-olds who are mature enough to decide what they want people to do to their own bodies, and I have a feeling I'd have a hard time not feeling that way in certain cases.
posted by koeselitz at 1:27 PM on October 26, 2011 [2 favorites]

No. It gets much easier.

Considering that a quick Google finds multiple court cases, I'd disagree. And to be clear, I have no sympathy for the JW beliefs on this. But I do support the right-to-die movements, and generally the right of a person to make their own medical choices for good or ill. Again, not an easy question from any angle.
posted by bitmage at 1:28 PM on October 26, 2011

The blood prohibition is fascinating, because they take it from a New Testament passage (Acts 15:28, 29). Most prohibitions that Christians follow come from the Old Testament (Leviticus)--wasn't the point of Jesus that he offered a freedom from the old laws?

Judaism has a prohibition against blood, but it is against the consumption of blood, because blood is a ritual substance (as it was in the time of the Temples and the sacrifices) which symbolizes the soul. Man can have the meat, but the blood is reserved for G-d. In no way are transfusions prohibited, although I wonder if Orthodox Jews would accept a pig's heart valve or any xenograft, or if they can use medications made from shellfish, or grown from the cells of a non-kosher animal. As it is not consumption, it may be ok.

But here, the Jehovah's Witnesses are even more Old Testament than the Old Testament religion. Huh.
posted by oneironaut at 1:30 PM on October 26, 2011 [2 favorites]

If they're minors, to hell with the parents' mad ideas: they get the treatment they need. If they're adults, let 'em die if they want to.

One thing these people never seem to care much about is the effect their selfish, preventable death has on those who love them. I know someone who was a Christian Scientist and who basically allowed a perfectly curable form of cancer to slowly kill her. Her non-Christian Scientist family members' frantic and grief-racked attempts at reasoning with her made no impact, and she essentially forced them to watch her slowly fade and die, knowing all the while she could have been saved. I don't respect that, to put it mildly. But if that's the way an adult wants to act, so be it.
posted by Decani at 1:33 PM on October 26, 2011 [1 favorite]

bitmage: “Considering that a quick Google finds multiple court cases, I'd disagree.”

No, seriously – my girlfriend is a family medicine resident. This is how all doctors in the United States are trained, because this is the law: if a child needs medical treatment and the parents refuse for any reason, they call child protective services immediately. This is true in all cases, and sometimes in situations you might be surprised about; for example, if a doctor says "your newborn is at risk, we need to see you tomorrow for an appointment," and the mother doesn't show up, they'll call CPS. And the law is behind them on this. Many religious groups are against it, and that's why there are court cases; but even those religious groups know that this is the law of the land.
posted by koeselitz at 1:33 PM on October 26, 2011

I don't want to self-congratulate my religion, Judaism, too much here, but Judiasm is quite clear that its every commandment and prohibition is null in life-or-death situations--yours, or someone else's.

Except for idolatry, murder, and some forms of sexual immorality.
posted by Jahaza at 1:41 PM on October 26, 2011 [2 favorites]

I have pondered this issue before and always believed that it all boils down to how a doctor weighs the Hippocratic Oath against specific (medically unsound) wishes of their individual patients, but now I’m not so sure any more. Maybe it is a question of how one approaches the principle of nonmaleficence. The author talks about “harm to the patient’s personhood” while his attending seems to define harm only as physical distress. Both interpretations seem justifiable to me.
posted by wachhundfisch at 1:43 PM on October 26, 2011

Well that's a person who is a hell of a lot more patient with other peoples bullshit than I'd be, that's for sure.
posted by Artw at 1:47 PM on October 26, 2011 [3 favorites]

My perspective on this is that I 100% support bodily autonomy, even if it's for the wrong reasons. If a JW doesn't want a blood transfusion, then that is their choice. If I don't want a baby in my womb, then that is my choice. If someone wants to commit suicide, then that is their choice.

It seems to me that many doctors don't really get to consider this - their job is to save lives, autonomy be damned. I have read many troubling stories about doctors violating the autonomy of their patients "for the patients' own good" (and honestly "unwanted blood transfusion" is probably on the more-acceptable end of that scale). I don't know what the solution is to this, except to ask that those who demand medical autonomy for their personal reasons consider the autonomy of others.
posted by muddgirl at 1:56 PM on October 26, 2011 [5 favorites]

I cared for a Jehovah’s witness as she died of post partum hemorrhage (when I was an L&D nurse). I was the only one with her for her last hour. As she continued to bleed and the residents and attendings came to talk to her, it became clear that she would likely die. Being the brazen young pup that I am, I asked her “you realize you will probably die without a transfusion, don’t you?” The look on her face I can remember to this day….she was completely at peace, despite leaving a newborn and 2 other children. She answered quietly “I know that” and gently touched my arm. She believed in the kingdom of heaven and was so happy to be getting to go there.

Honestly, reading things like that makes me cry. As far as I'm concerned it's like letting a sick schizophrenic pull out their IVs because they think aliens put them in.

The galling thing for me is what JWs try to say how much they have helped the secular community by spurring the development of bloodless surgery. As one of the docs on the thread said "There is no such thing as ‘bloodless’ surgery as an actual different technique than ordinary surgery. Its just good surgical technique, which will lead to less blood loss. One would hope that a surgeon would practice ‘bloodless’ surgery on every patient, JHW or not."
posted by melissam at 1:58 PM on October 26, 2011 [17 favorites]

Koeselitz: I was disagreeing with jimmythefish saying that it made the situation easier. When you have courts seizing children from their parents, there's nothing easy about it:

In Canada, rulings have held that a 12-year-old girl could refuse treatment, but a 15-year-old boy could not.

A page here notes "In August 2011, the Broward County Florida State Attorney's Office told a reporter that just in the past 3 years that his office had handled a dozen court cases, just in that single county, where Jehovah's Witness Parents had refused to consent to life-saving blood transfusions for their minor children."

I agree with giving the treatment over the parent's wishes, but what a mess.
posted by bitmage at 2:00 PM on October 26, 2011 [1 favorite]

oneironaut, in particular the JW's base this doctrine on the idea that blood is to be poured out on the ground, which would seem to preclude any kind of transfusion.
posted by chrchr at 2:03 PM on October 26, 2011

No, seriously – my girlfriend is a family medicine resident. This is how all doctors in the United States are trained, because this is the law: if a child needs medical treatment and the parents refuse for any reason, they call child protective services immediately. This is true in all cases, and sometimes in situations you might be surprised about; for example, if a doctor says "your newborn is at risk, we need to see you tomorrow for an appointment," and the mother doesn't show up, they'll call CPS. And the law is behind them on this. Many religious groups are against it, and that's why there are court cases; but even those religious groups know that this is the law of the land

No matter what they teach your girlfriend, it's really not that clear cut. This website is from an advocacy group on the other side, but it's a good summary. Most states have laws that allow parents to refuse some kinds of medical treatment for children on religious grounds, but what kinds of medical treatment varies. As a legal question, it is legitimately complicated, so I'm not surprised that they're teaching doctors to always call child protective services, but the parents refusing treatment are not always outside their legal rights.
posted by Bulgaroktonos at 2:05 PM on October 26, 2011

Judaism has a prohibition against blood, but it is against the consumption of blood, because blood is a ritual substance (as it was in the time of the Temples and the sacrifices) which symbolizes the soul. Man can have the meat, but the blood is reserved for G-d. In no way are transfusions prohibited, although I wonder if Orthodox Jews would accept a pig's heart valve or any xenograft, or if they can use medications made from shellfish, or grown from the cells of a non-kosher animal. As it is not consumption, it may be ok.

Beyond that, there's pretty much a catch-all (pikuah nefesh) that allows you to Ignore All Rules (more or less) in order to preserve human life. Orthodox Jews will drive on the Sabbath to evacuate from an impending disaster, eat and drink on fast days if they are unwell, or fight with their military units if in a state of war. Like everything else in Judaism, people interpret this in all sorts of different ways, but the basic point is that you take care of the basic life sustaining needs of the body before worrying about the soul.

The issue of medications with non-kosher ingredients has been discussed quite a bit. See, for example, this article. It's much less clear what observant Jews are supposed to do in non-emergency situations, but if the medication is necessary to preserve life and there's no readily available alternative that is equally effective, you can swallow away. The xenograft issue has also been addressed with similar results.
posted by zachlipton at 2:09 PM on October 26, 2011 [5 favorites]

What happens when a clearly mentally ill or delusional patient ends up in a similar position and tells the doctor they can't be operated on because space aliens will take their soul?

Hey now, you leave Scientology out of this.
posted by joe lisboa at 2:09 PM on October 26, 2011 [5 favorites]

Didn't we just have a FPP about world population hitting 20 bunchillion by lunchtime? Let's not get too weird about people who are willing to take one for the team!
posted by SharkParty at 2:09 PM on October 26, 2011 [1 favorite]

The thing you should understand about devout Jehovah's Witnesses is that to them, this world and this life is very much a temporal thing. A Witness takes to heart 2 Corinthians 4:18 - "So we fix our eyes not on what is seen, but on what is unseen. For what is seen is temporary, but what is unseen is eternal." Witnesses who are faithful believe that God will remember their faith, even in the face of death, and when the world is made anew, they'll be rewarded for their faith. Most Witnesses have a hope of either living through the world's end into a new world, or of being resurrected after Armageddon to live in this new world.

So say you're 14. You've been raised from infancy to understand that the world around you is wicked and that Jehovah will one day make things right. You understand that your friends and family hope to live forever in paradise on earth, and you fervently want to be there too, but to get there, you have to be good. You have to do what God wants you to do, above all else. You've also been raised to understand that one of God's rules is NO BLOOD - he commands that blood is sacred, it contains (represents) the life of a person or creature, and that it should be poured out and not eaten (and by extension, not be used for any other purpose, even to prolong or maintain life).

Now - you're riding your bike in the street and you're hit by a car. You lose a lot of blood. You're rushed to the hospital. Doctors are all around you, and your parents are maybe on the way, but there's one thing you know for certain - whether you live or die, God will remember you and take care of you, as long as you put him first. Now a doctor says to you: "We're going to give you a blood transfusion." He thinks he's going to save your life in this way. But you KNOW that Jehovah would be angry with you, at your presumption to believe you know what's best, at your failure to put your trust in him, in your desperation to save your own life at the expense of defying his command. If you're a devout Witness, blood isn't even an option. You can't do it, and you'll fight tooth and nail against anyone who will try to make you take it, because they won't be saving you - they'll be putting in real danger your hope of eternal life.

At best, a young Witness would consider the forcible administration of blood to be something equivalent to rape. At worst, they'd consider themselves damned. I knew a young man in Indiana who was suicidal afterward - he felt irredeemably lost.

I'm not going to argue that it's the right decision. I'm not saying that Witnesses are better than anyone else or that their faith is in some way superior or more meaningful. (I absolutely don't think that, in fact, for various reasons.) What I am saying though is that it's awfully callous to talk about forcing a decision like this on anyone, adult or child, in the way that so many of you are considering it. You care about saving this life, but they don't care about this life - they care about the next one. Remember that when you think about the decisions they make and why they make them.
posted by Two unicycles and some duct tape at 2:13 PM on October 26, 2011 [19 favorites]

The thing is, I understand their decision completely. But I value the ability for someone to live a healthy life more than I do their feelings.
posted by palidor at 2:17 PM on October 26, 2011

But I value the ability for someone to live a healthy life more than I do their feelings.

And I value your right to determine what is a healthy life for you, over my own opinion of what is a healthy life for you. I expect others to extend to me the same courtesy (although I am continually disappointed in that).
posted by muddgirl at 2:21 PM on October 26, 2011

[full disclosure - I was raised as one of Jehovah's Witnesses and in fact was a pioneer -- roughly equivalent to a missionary -- for about four years. I left many years ago, but I know the faith and the people very well. Like any other group, there are good folks and bad folks there. But whatever your faith or absence thereof, you have to decide whether or not you really support the freedom of people to choose their beliefs and their life's path, and if you do, I think you have to allow them to make decisions that you won't agree with, for reasons that you don't believe or understand, even when it breaks your heart to do so sometimes.]
posted by Two unicycles and some duct tape at 2:21 PM on October 26, 2011 [7 favorites]

I'm a smoker. I'm not proud of this. But if one of my good friends came up to me today and told me he can't go on hanging out with me because it troubles him so much to see me hurting myself and he feels like he's condoning it, I'd understand. I'd be upset, I'd argue with him, but I wouldn't begrudge him for that decision, because I know where it comes from.
posted by palidor at 2:22 PM on October 26, 2011

Well sure, but would you let him rip the cigarettes out of your pocket and install a meter which didn't let you ever purchase cigarettes again, ever?
posted by muddgirl at 2:24 PM on October 26, 2011

Two unicycles and some duct tape, thank you for your perspective. I appreciate it.

If you don't mind, could you tell me whether JWs curtail certain sports/activities because of the risk of injury and blood loss? I personally would feel very nervous going into childbirth, for example.
posted by the young rope-rider at 2:27 PM on October 26, 2011

Let him? No. But I like to think one day I'd thank him.

In any other area I'm content to say than anyone can do whatever they want as long as it doesn't interfere with anyone else. But for whatever reason I've decided that we all only have one life and there are some lines that should be crossed to ensure that someone can live that life in good health.
posted by palidor at 2:28 PM on October 26, 2011

The thing is, being a contemporary religion with an established hierarchy, The Watch Tower Society could change their doctrine. They have changed many of their doctrines quite recently, including ones that prohibited other life-saving medical interventions like vaccination. As far as I know, the doctrine was only put into place in the 1920s. In their publications they lie about the effects of blood transfusions. From what I've seen JW missionaries target populations that are not particularly well educated about science. Their repressive practices, including shunning people who don't follow the party line (of which there are quite a few people who want to stay JW but reform things like this), make it difficult to say that a JW is making an informed decision.
posted by melissam at 2:32 PM on October 26, 2011 [3 favorites]

I think it's unfair to bring the discussions on Judaism into this argument, as if it's in some way inherently better because it encourages saving lives over commandment following. Judaism and JW are two very different religions, with very different faith frameworks - particularly when it comes to life after death. Judaism is a this-world religion, by and large. While there's certainly a notion of some sort of life after death, and some sort of judgement that takes place then, what exactly constitutes that afterlife is sketchy at best - there are too many opinions to count, so the prevailing religious opinion is "we don't know" - which is exactly why you are expected to treat this life as the only one you're going to get.

For any religion that believes this life is only a stepping stone to the next, better life that comes afterwards, that opinion makes no sense at all. Why doom yourself to an eternity of suffering just to buy yourself a few more mortal years?

As a rationalist (or an atheist), the idea that you must preserve human life because living is better than dying makes perfect sense. But religion isn't generally rational. For people who truly believe in an afterlife in which you can be punished for disobeying the will of G-d while alive, it makes perfect sense to let yourself die and get to heaven sooner.

As far as I know, no one has ever died and come back and can report factually what happens next. For many, that's proof that there is nothing next. But not for everyone. If it turns out there is something else, and the Jehovah's Witnesses (let's say) are right about this, then it's the rationalists here who will be the ones looking silly. There's simply no way to know.

So you can step in on behalf of those - like children and the mentally incapacitated - who can't make a decision of this magnitude with the best of their ability. Or you can impose your own beliefs on everyone and insist that no one is allowed to encourage their own death. But I think that personal autonomy over your own body is a much bigger issue than simply 'religion is good' or 'religion is evil' - and particularly bigger than 'this religion is more evil than others'. Either our bodies are our own to control, or they're not. Which leads to issues like suicide and euthanasia and abortion, and naturally makes people uncomfortable - but are still conversations worth having. Who decided that life is better than (nonviolent) death? Based on what criteria? just because we assume it to be so, doesn't mean that it is.
posted by Mchelly at 2:40 PM on October 26, 2011 [1 favorite]

Having some Witnesses in the family, I can say that Two unicycles is spot on. They'll give you the shirt off of their back because the Bible tells them to do that is well, so there is some amazing good mixing in with some catastrophic bad, from my perspective. I was on my way to being baptized until I read the bible without guidance.

One of the most peculiar things about literalism is the firm belief that a person can correctly interpret God's intent for them from ancient holy books, despite all the differences in language, culture, and general knowledge between the society that the books were (allegedly) written for, and the one we have now. To imagine that God has no new advice for us in the last few thousand years of human history is a spectacular curiosity.
posted by deanklear at 2:43 PM on October 26, 2011 [4 favorites]

Who decided that life is better than (nonviolent) death? Based on what criteria? just because we assume it to be so, doesn't mean that it is.

This discussion is so focused on personal choice. What about the loved ones of the persons who choose to die? What about the children of the mother I read about in the comments who died from post partum hemorrhaging because she wouldn't accept blood?

To me this is just where I draw the line and say that I choose to live in a rational society, and that some things are more important than personal choice. It's not an easy decision to make for me, and I haven't really thought about anything this much in a while. But I feel we've come far enough with modern science and medicine to be able to make that decision.
posted by palidor at 2:57 PM on October 26, 2011 [1 favorite]

At best, a young Witness would consider the forcible administration of blood to be something equivalent to rape. At worst, they'd consider themselves damned. I knew a young man in Indiana who was suicidal afterward - he felt irredeemably lost.

I get this. I think most of us do. But again, people feel this way about all sorts of things, and only some of them get to have their cake and eat it, too. This is pretty similar to how I feel about the likelihood of dying a slow, meaningless straw-death in some hospital somewhere, but see if anyone cares enough to kill me when I ask them to... and again, you care about saving this life, but they don't care about this life - they care about the next one is exactly what's responsible for that.

As much as I'd love for this to be a simple, one-dimensional question of personal autonomy, it isn't, because we don't have a single, coherent doctrine of personal autonomy. We have a weird, self-contradictory quilt sewn out of a hundred different scraps of denial, pain, science, and Cartesian dualism, which is why cases like this make our collective heads explode.
posted by vorfeed at 3:01 PM on October 26, 2011 [3 favorites]

But whatever your faith or absence thereof, you have to decide whether or not you really support the freedom of people to choose their beliefs and their life's path, and if you do, I think you have to allow them to make decisions that you won't agree with, for reasons that you don't believe or understand, even when it breaks your heart to do so sometimes.

I suppose my whole point is that I don't feel like it's that black and white. That, if I support someone's right to do as they choose, that must include their right to what is essentially suicide. Irrational suicide. Something that's almost a sick joke because of its sheer misguidedness.

No, I respect an individual's autonomy, but I also respect science, and rationality.
posted by palidor at 3:10 PM on October 26, 2011 [1 favorite]

ahhh...another great example of why pride is a deadly sin...because IT CAN KILL YOU.
posted by sexyrobot at 3:12 PM on October 26, 2011 [1 favorite]

To be frank, the idea that someone would refuse life-saving medical treatment because of their religious beliefs disgusts me.

The idea of someone being forced to accept medical treatment against their will horrifies me.

I honestly don't know which is worse.
posted by Zozo at 3:16 PM on October 26, 2011 [1 favorite]

If you don't mind, could you tell me whether JWs curtail certain sports/activities because of the risk of injury and blood loss? I personally would feel very nervous going into childbirth, for example.

I can't say whether concerns about blood loss in childbirth were significant; it wasn't something that came up much in discussion, and (as an unmarried Witness guy) I never had reason to consider it personally or with a wife. Most congregations I visited were full of young couples and babies, though, so obviously it wasn't slowing most folks down. I expect there were likely some early conversations with ob/gyns in cases where couples were concerned (history of difficult births, that kind of thing) and I wouldn't be surprised to hear that some couples thought long and hard about having kids for that reason. There were definitely childless couples, and some who were actually waiting for the end of this world and the start of the next before having families.

I don't think there was ever really much concern about avoiding sports or activities due to risk of injury or blood loss, but mostly because two other doctrines (well, general Witness philosophies at least) would probably get in the way before the blood issue would ever come up. One is a general respect for the sanctity of life, which would tend to steer folks away from dangerous activities. Skydiving, bungee jumping, those sorts of things were looked on very disapprovingly in the (admittedly conservative) congregations where I grew up. The other point to remember is that Witnesses are supposed to be "no part of the world", which often means that young JWs avoid participation in extracurricular activities at school or in their neighborhoods to avoid associating unnecessarily with non-believers. For example I would have loved to play football in high school, and the coach was *furious* that I couldn't (I've got the build for it, and he desperately needed good players), but neither my conscience nor my parents would allow it. Nothing to do with potential injury; everything to do with "bad associations" and failing to focus on what's important.
posted by Two unicycles and some duct tape at 3:18 PM on October 26, 2011

I suppose my whole point is that I don't feel like it's that black and white.

With respect, palidor, I suggest that the shades of gray you're seeing here would also prevent you from being a very good Witness. If Jehovah's Witnesses didn't see this and similar tests of faith as black-and-white issues, they likely wouldn't remain Witnesses for long.
posted by Two unicycles and some duct tape at 3:23 PM on October 26, 2011 [1 favorite]

Exactly! I'm not going to try to debate the merits of religious value systems because I don't want this thread to go to hell (ha ha puns!), but I do appreciate the perspective of someone with such familiarity with the religion in question.

In terms of my values, I've actually been thinking on and off over the last few years if there's anything I can really, truly believe in as a foundation for social and political views. Something I could argue with conviction, the way someone religious might argue their own views. And all I've been able to settle on is that life itself is valuable. I try to include "quality of life" in the equation as well, because with issues like abortion and assisted suicide, things get more complicated. So apparently I even need some shades of gray in my black-and-white foundational belief, I suppose.

But I have no doubt whatsoever there is no afterlife. We are biological machines, and the only soul I acknowledge is the kind that inhabits good music. So I feel it's a betrayal of this belief to just say "it's their decision" if someone chooses to die rather than accept treatment available to them because of their misguided belief in an afterlife. They deserve to live more than they deserve to make a decision based on a delusion.

Anyway, I'm kind of threadsitting at this point, but it's probably because this issue resonates with my own little personal quest for values.
posted by palidor at 3:43 PM on October 26, 2011

I've sometimes withheld life-prolonging treatment or interventions or pain relief because someone requested it. Or switched a patient to "comfort care" - which is basically a food/fluid refusal modality that enables many bodies to tire and die with a minimum of fuss. Or started someone on a medication that may kill them sooner. When I do that, I try to be sure that the person's request to refuse (or to accept) has "capacity": it is culturally appropriate, and their cognition is not grossly affected by delirium, psychosis or depression. As with many things like this, there is a wide latitude for decisions that can indicate dominant religious or cultural beliefs to justify them. But if a person cannot speak for themselves, I've found it unwise to let someone's background or family dictate their treatment - there have been too many times where I made assumptions about an unresponsive person's future decisions based on their religion or their family and then found later that they had come to quite different accommodations with the beliefs of their religion or their family. But in these situations, there's also the issue of emergency and context. It's one thing to write a refusal for anaesthesia or blood in advance, but another to become suddenly emergent with no clear wishes. In that situation, unless it's medically futile, I'm probably going to intervene *unless* the patient earlier stated such wishes clearly to me, or has a clear advance directive or appropriately delegated durable power of attorney available. It's a strange and uncomfortable sensation to stand by when you know you could be doing something, but this is where we are today with personal autonomy.

Planning ahead is everything - some docs tend to be quite cursory about the "DNR/DNI" question, but during any hospital admission, if I am interviewing you then you *will* be asked, quite explicitly and in some detail, what should be done if your heart stops beating? And is that in every context, or are there different rules if it stops because of something *we* did? Also what to do if you stop breathing, do you want to be bagged, or do you want a machine to breath for you? I agree with the original blog article, I have professional sympathy but do not extend empathy: I may think that your decision is silly, but it's your decision.

All this, of course, gets much trickier when you are dealing with children for whom adults are claiming decision-making capacity.

palidor: "What happens when a clearly mentally ill or delusional patient ends up in a similar position and tells the doctor they can't be operated on because space aliens will take their soul?"

I've actually had this pretty much this *exact* situation more than once. I can only speak to California. I can get a judicial hearing to request to treat you psychiatrically irrespective of your stated wishes. There are two components to this: involuntary detention and involuntary treatment. Involuntary detention only enables me to hold you within a facility for a stated period of time, and I may not treat or medicate you against your wishes. But I can also ask for involuntary treatment. Now, treatment may take a while, and winning a Riese in any case will not enable me to treat you medically against your stated wishes (Cali has unusually strict distinctions between "medical" and "mental health" treatment). In that case, if it was emergent, I could assess whether you lacked capacity to refuse, and my threshold for intervention could be much lower. If it was not emergent, I could apply for a medical conservatorship hearing. If I won, the court would appoint a temporary decision-maker for you whose sole authority extended to making medical decisions for you unless and until you later found to be competent. None of these are fast processes, but I've been surprised to see how even people in the most advanced stages of schizophrenic decompensation are capable of making rational medical decisions after only a few days of reconstitution. Even when they still state that, yes, the influencing machines are in control, they will still consent to something like heart valve or open fracture surgery.
posted by meehawl at 3:44 PM on October 26, 2011 [12 favorites]

That's really fascinating, thanks for the in-depth answer (to something that was at least 50% a rhetorical question lololol (but seriously thanks)).

I suppose I'm also really interested in these issues because I'm studying biology, and before long I'm going to have to decide if that means going into medicine, in a hands-on way, or something else.

I don't know that, being the person I am now, I could avoid the empathy part. I see in the original post and mentioned in one of the comments, by the physician who witnessed the post partum hemorrhaging, that they started out taking the hard line (the latter even refusing to see any JW patients for 10 years), but later on came to see "it's not about me." But is there really a logical removal of yourself from the equation there, or is it just that, over time as a physician, you just get more cold, because practicing medicine with full empathy would result in insanity? And does that end up bleeding (more puns!) into other areas of life? If I become a doctor am I going to become a cold, emotionless robot in all of my relationships? HELP!

Joking... mostly
posted by palidor at 4:19 PM on October 26, 2011

A professor in my department--who is pretty well famous--wrote an interesting book about Canadian law, Jehovah's Witnesses, and underage cancer patients. It's called "Defining Harm," and it's by Lori (G.) Beaman. (I won't link to it as I'm a grad student in her department and I feel that would be unseemly, on this website).

It very heavily Foucauldian in its analysis (meaning: if you don't like Foucault, don't bother), but if you're interested in hearing a former lawyer turned religious studies prof discuss these issues and how the discourses of law and medicine interact with religious discourse, it's an interesting read. I think it's her first book, or one of her very early works, so it's not as excellent as her later stuff, but still. Consider giving it a glance.
posted by flibbertigibbet at 4:38 PM on October 26, 2011 [3 favorites]

I'm in favor of medical practitioners respecting religious beliefs.
posted by Renoroc at 4:47 PM on October 26, 2011

To me this is just where I draw the line and say that I choose to live in a rational society, and that some things are more important than personal choice.

It's not irrational to understand that preserving individual autonomy benefits the society as a whole, regardless of whether it allows some people to make irrational or destructive decisions.

Without institutional protection for consent and respect, a belief in the primacy of reason (at least, as some person or group of persons conceives of it)becomes just another club to beat someone with.
posted by emjaybee at 5:19 PM on October 26, 2011

Sprawling comment touching on several things:

1. "I can get a judicial hearing to request to treat you ... If I won, the court would appoint a temporary decision-maker for you whose sole authority extended to making medical decisions for you unless and until you later found to be competent. None of these are fast processes"

My husband did these cases for a local hospital for a while (in a different state) and around here it's done within hours. If he had a call at 9 a.m. they'd be done in court by noon. In bigger cities, where they have night court, it can even be done in the middle of the night. So it can be faster or slower, depending on the state and local laws and systems.

2. I actually find these questions of bodily integrity w/r/t religion (and various non-religious philosophies) super-interesting. For instance, neither Jews nor Muslims may ingest pork, but Jews can receive immunizations (and insulin?) with pig cells and Muslims cannot. (At least U.S. Jews and Muslims, who are conservatively observant, speaking generally. I'm sure it varies and that individuals make different choices -- also pig-derived gelatin in medical products is okay for Muslims, I believe.) Most ancient scriptures have at least some preoccupation with bodily integrity and boundary crossing (food, sex, cutting, bleeding, menstruation, male masturbation, skin rashes and lesions (including leprosy), speaking, hearing -- anything that goes inside->outside the body or outside->inside the body, including words). The prevalence of needle phobias suggests it's a very natural human fear, so it makes sense it would show up in most scriptures. The Jehovah's Witness preoccupation with blood may strike us as extreme because of our cultural norms, but preoccupation with bodily integrity and bodily boundaries is so, so human and it's all over the place in religion, philosophy, law, literature -- everywhere we're busy being human. There's even a really good Babylon 5 episode about it.

3. When I was 15 or so I babysat for a Christian Scientist family who rejected all medical treatment (which I understand is not required by Christian Scientists and other families make a different decision). They were lovely people, with great kids whom I really liked, but after I sat for them twice I had to tell them I couldn't do it again, because I would lie awake in fear the whole night the night before about what I would do if one of the kids, say, got a bloody scalp wound that needed stitches. The parents specifically prohibited me from calling 911, and I found the thought of even a minor injury to the kids, when I couldn't help how I knew to help or get the kind of help I knew to get, absolutely paralyzing and absolutely terrifying. The parents were nice about it when I said I couldn't sit for them anymore. I'm not sure I would be other-than-paralyzed if faced with a similar situation as an adult, so I'm glad I don't have to face what this doctor does.
posted by Eyebrows McGee at 5:20 PM on October 26, 2011 [3 favorites]

Question for Two unicycles or any other JWs in this thread. What happens to JWs who choose to receive blood?
I work in a medical lab and occasionally I get blood ready for patients. About once a year we see a JW patient that needs a transfusion to save their life. I have been doing this for over 15 years and like a third of the of the JW patients I have come across, when it comes down to get a transfusion or you will be dead tomorrow, they consent to the transfusion (or more likely their families consent- by then the patient is in no condition to do anything). Do they get excommunicated (or whatever you call it), are they looked down on by other JWs? I've always wondered what happens to these people and their religious beliefs when they leave the hospital.
posted by get off of my cloud at 6:25 PM on October 26, 2011

Boy, reading those comments really riled me up. It's pretty easy to play armchair doctor. You or I might think we're pretty certain of our beliefs, but lemme tell you something: we may not be. I've seen the most devout tremble and question their beliefs, be they religious or atheist.

There's a lot of discussion to be had specifically with Jehovah's Witnesses. There are a lot of alternatives to transfusion of whole blood products. Many of these will not fix the medical issue at hand. Some of these are ridiculously expensive. None of this should matter. (We can debate about the larger, financial aspects of health care some other time.)

I think back to my attending that had the hard line, and think perhaps he had a little too much of his own ego involved.

The point is, there should be no ego involved. Absolutely none. Confidence? Yes, of course, but confidence in your abilities as well as the knowledge of your own limitations. Partly because there's no room for guesswork if there are answers (and sometimes there aren't any-- what I mean is failure to consult a subspecialist, or, you know, look something up in a fucking book or something), but partly, too, because it's not your life that's in jeopardy.

People in medicine always talk about allowing patients to make their own, informed and educated decisions, and that it's our job to do our best to explain to them what their options are, along with associated risks/benefits, so they can do as such. Now, I'll be the first person to say that sometimes my first thought is that that some people are stupid. I'll also be the first to say that some physicians fall far short of doing their best to teach, or explain things in a way that any particular person can understand.

But we, as physicians, have to remember that we're here to serve, and that doesn't necessarily mean make someone live longer. We talk about quantity vs quality of life, palliative and hospice care, and feel pretty comfortable with comfort measures when we feel like it's time to give up: when there is no cure, or when things are clearly terminal. Patient X is 95 years old and has metastatic lung cancer. Yeah, ok, comfort measures seems the way to go. In fact, some physicians push for it, because hey the patient is 95 years old and has metastatic lung cancer.

Fine. What about patient Y who's 65 years old and has severe sepsis, is on the vent, has multiple drugs running to keep their blood pressure up, and is not responding to antibiotics?

Fine. Now start lowering the patient's age and severity of illness. Things start to get a little nebulous at some point. Now we might stop pressing for comfort measures or hospice. Now we might start pushing for more aggressive therapies. We might think: we can save this person.

But where are our own, personal markers that sway us in either direction? The answer is rooted in the guesswork of medicine: the percentages of outcomes based on medical literature, which we should communicate. And yes, sometimes people with a high chance of dying pull through and recover, just as sometimes people with a low chance of dying die despite our best efforts. This, too, we might communicate. But what it comes down to is this: we don't always know.

So how best are we to serve? Well, it's quite a bit easier when a patient has advanced medical directives. It also helps if they're able to discuss the issues at hand, you know, they're awake and oriented and able to make their own decisions. It helps to be able to communicate with them, and/or their family/MPOA in a way such that you're able to come to a mutual agreement regarding a plan of care.

But sometimes they can't answer for themselves. Sometimes there's little or no time. And sometimes you really, really don't agree with their decisions. So you do your best for them, whatever their beliefs are. They're human. You've got to be humane.

And not just humane toward them, but yourself as well. If you find that you cannot do your best for them, you must find someone who can. This does not mean that you should necessarily excuse yourself from their care, for if you're the only option, you still might be the best option.

It's a lot of grey, to be sure. I've got my own set of beliefs, just as I'm sure as everyone else does. In medicine, everyone is a unique and special snowflake, though many such snowflakes are similar enough such that treatments are standardized and protocol-driven. Where any one person's circles of beliefs intersect with yours can be pretty damn hazy, and we should think about the theoretical and practical. But, except in very rare and specific circumstances, you don't get to draw the lines for anybody. They do. It's not your life: it's theirs. You can talk about your differences later, when they're comfortably recovering or comfortably dying. Even then, apart from the services you're providing or able to provide, you don't get to dictate the conversation. They do. And if they wanna talk about Popeye's chicken instead of cancer, so be it.


People with egos in medicine, I think, feel like they have something to gain and something to lose. This is wrong. It's not about any doctor's "winning." That's not to say you can't revel and be happy with a patient who has recovered from illness, or that you can't be sad when they're suffering or die. But that feeling of gaining or losing something should be directed away from oneself and toward the patient and, many times, their family.

You've got to be kind to them as well as yourself. Sometimes some people can't handle the incongruities of beliefs or the emotional gravity associated with not doing what you might think is best. But again, it's not about what's in your best interest. Sometimes in order to do your best for someone you've got to turn their care over to someone else who can.

But you've got to do your best, because doing anything less would mean prolonging suffering or, perhaps, actively harming someone. That's not what medicine's about. And doing your best means caring for someone as a human being.

That sounds so simple and stupid, and I guess it is. I can rail all day against any particular group's system of beliefs or politics, but I hold onto my faith in the goodness of everyone. Yeah, sometimes it feels like it's really, really hard to find or so deep inside of an individual's personality it's under five thousand layers of shit, but I've got to believe it. I have to. Cause the moment I stop feeling any sort of sympathy for the crack addict with cardiomyopathy who's coming in for the 20th time in the past year is the moment I'll do less then my best and possibly deliver substandard care. And that's the day I should quit.

One last thing: I've often heard the claim that so-and-so went into medicine because it was their calling. Well, it's not a fucking call from Ed McMahon to let them know they've won the sweepstakes. It's a call to serve.

tl;dr: There's a big difference between thinking about what you'd do if someone were dying before you and actually having someone dying right in front of you. Don't be a dick. Especially in medicine. Care. Even crack addicts deserve a warm blanket when they're cold.
posted by herrdoktor at 6:35 PM on October 26, 2011 [8 favorites]

Without institutional protection for consent and respect, a belief in the primacy of reason (at least, as some person or group of persons conceives of it)becomes just another club to beat someone with.

The point I'm trying to make, though, is that it doesn't have to be a slippery slope. This is an issue, maybe the only issue, where I feel like rationality should be able to trump someone's personal beliefs. If the foundational directive is that life is valuable, and maybe that's only me, then life should come first. Beliefs change, attitudes change, maybe even from day to day. Someone who's a JW now may not be next year. But a person only has one life.

Of course herrdoktor's wonderful post points out that things aren't always so clear, and I agree. But in cases where someone is in a condition where a simple blood transfusion will save their life?

We should be able to debate where the line is, because otherwise it does become easy to beat someone over the head with the cause of "reason." I'm just asserting that there is a line.
posted by palidor at 6:55 PM on October 26, 2011 [2 favorites]

Of course herrdoktor's wonderful post points out that things aren't always so clear, and I agree. But in cases where someone is in a condition where a simple blood transfusion will save their life?

I agree. If we restrict assisted suicide and have institutions in place to prevent other forms of suicide, it doesn't make sense to also allow people to chose to die because of a religion either. People who try to jump off of bridges are just as firm in their beliefs as JWs are.
posted by melissam at 7:02 PM on October 26, 2011

palidor, you might be mostly joking, but you ask good and important questions that I think a lot of people don't think much about before they choose to go into medicine.

First off, as an aside: I strongly, strongly encourage studying something other than the sciences if you're considering medical school. Mostly because I think the humanities and, well, just about any life experience outside of science can inform one's practice of medicine beneficially, partly because it'll probably help you get into med school, and partly because shit, it's the last opportunity you're gonna have to study anything you enjoy. Take ceramics. Make some bowls.

But is there really a logical removal of yourself from the equation there, or is it just that, over time as a physician, you just get more cold, because practicing medicine with full empathy would result in insanity?

Yeah, you've got to separate yourself from the equation a bit, because it can drive you nuts-- we're talking heavy burdens, emotional and psychological. More importantly, you must acknowledge a patient's autonomy. This, along with beneficence and non-maleficence, are the foundations of medical ethics, and will be engrained into you from day one of med school.

Yes, you might just get totally numbed out. People get fried out and crispy, burnt out from practicing medicine, sometimes to the detriment of the physician, who people will refer to as "asshole" rather than "doctor."

Instead, one can acknowledge and be open to the emotional and psychological aspects of patient care and let these experiences inform their practice of medicine. By this I suppose one could say: by seeing enough suffering, one might know what it's like to suffer (yeah, yeah, qualia). It's also important to realize that everyone's still growing up and will continue to go through different life experiences, such as friends or family dying, and such events may also shape one's character and medical practice.


And does that end up bleeding (more puns!) into other areas of life?

I think it does, just as much as anyone's job or experiences would color their character or beliefs. It's one of the reasons for arguing for separation of work and non-work life. Anyone might become a crotchety ass because they hate their job, have a jerk of a boss, or whatever. The opposite is true, too: anyone might be an ass at work because their home/non-work life is shit.

But so, too, might one become a better person from their work life, just as a physician might become a better doctor because of their non-work experiences. It goes both (four?) ways.

If I become a doctor am I going to become a cold, emotionless robot in all of my relationships?

Yes. No. Maybe. I've been called an emotional robot (I think she meant "having the emotional capacity of a robot," and not a robot who cries or throws records in anger, but whatever), but I think that had more to do with my cultural upbringing than anything else. Still, I catch myself from time to time thinking about how work has affected my personal relationships, and still find positive and negative aspects. Mostly the latter. I still struggle with the work/non-work life balance.

It is a strange, strange economy.
posted by herrdoktor at 7:13 PM on October 26, 2011 [3 favorites]

get off of my cloud: What happens to JWs who choose to receive blood?

Knowing and willful acceptance of blood transfusions in this way would generally end with the Witness being "disfellowshipped" (the Witness version of shunning or excommunication as a disciplinary action). That's the official stance, anyway.

As to the opinions of other JWs, it's an interesting thing. You have to remember that in some congregations, especially those with older Witnesses, practically everyone knows someone who's been in this exact situation. Our heroes growing up were those Biblical personalities who stood fast and kept their faith even in the face of certain death (Daniel in the lion's den, the three Hebrew youths in the fiery furnace, and of course Christ himself), and we regularly read in our publications about modern-day heroes who faced similar trials and perservered to the end. If you refused a blood transfusion, you'd be a hero to your friends and family, and if you died as a result, you'd be both grieved and revered. That's about as close to sainthood as you'll find among Witnesses.

Conversely, if it became known that you chose to extend your life with blood transfusions, even if you weren't disfellowshipped for it, you'd likely be unofficially shunned by those who heard of it. To use a not-entirely-appropriate analogy, it would be as if Jesus said "Whoa, wait a minute, crucifixion? Seriously? Look, I was just kidding, I'll knock it off." Not that we don't have Biblical examples of some who have done exactly this and still gone on to redeem themselves (Peter's three denials of Jesus, for example) but those cases are very much the exception and a Witness would have to work extremely hard to win back the acceptance of his congregation.
posted by Two unicycles and some duct tape at 7:20 PM on October 26, 2011 [2 favorites]

I agree. If we restrict assisted suicide and have institutions in place to prevent other forms of suicide, it doesn't make sense to also allow people to chose to die because of a religion either. People who try to jump off of bridges are just as firm in their beliefs as JWs are.

You're failing to make an important distinction here. People who jump off of bridges usually want to die. Jehovah's Witnesses who refuse blood transfusions usually want to live. Again, it's a question of belief in a higher power and in another life beyond this one. The fact that you don't share it does not automatically invalidate their belief.

If you really believe we need to take these folks in hand and make them see things your way, what you're essentially saying is: "I don't believe in a higher power or another life beyond this one, and I believe that human life as we know it must be valued and protected above all else, and these two beliefs of mine override any beliefs you may have about this life and its value."

You can either allow people to follow their hearts and live and die as they see fit, or you can force them to follow your heart and live and die as you see fit. You really can't have it both ways.
posted by Two unicycles and some duct tape at 7:47 PM on October 26, 2011

I wouldn't expect a psychiatrist to let a patient commit suicide in the office after they come in for treatment. And if you were to ask beforehand, I'm sure they would tell you that explicitly. When you come to a physician for medical treatment the motto is do no harm, and I don't think it's unreasonable to expect them to save your life even over your objections. If you're such a committed JHW, find a doctor explicitly willing to respect your belief or don't come to me for treatment.

I'm non-religious, although I'm sure Judeo-Christian ideas have influenced me, but to me the greatest sin I can think of is to either kill another person or to let them die when I could prevent their death. Why should I (as a hypothetical doctor) be required to damn myself (albeit, according to my beliefs, only for my lifetime) to prevent the patient from damning their self (for eternity).

Also, I wonder if that writer is just trying to justifiy why she isn't bothered by letting Jehova's Witnesses die from treatable injury/illness. Putting the empathy/sympathy discussion aside, it also takes the pressure off the doctor. Instead of being required to provide the best treatment with the best outcome which I know is not always clear, death is almost a certainty and you can easily reason that it's not your decision or your fault. Your a good doctor and you absolutely did the best you could. In the weekly/monthly Morbidity and Mortality meeting it isn't likely anyone is going to find fault with your decision, at least medically. Another added perk is your almost certainly off the hook for malpractice claims as well unless you outright smothered them with a pillow.

WooHoo! My first post! I love you Metafilter, I love your links, and even your crazy commentators! wOOhoo!
posted by PJLandis at 8:09 PM on October 26, 2011

I had a lot of JW classmates in high school.
One thing I noticed is most of them had NO ACNE!
One of them had awful acne and she also did not buy most of the teachings.
I bet she left home and quit. These kids were not that aloof from other kids, but church stuff really cut into homework time.
posted by Katjusa Roquette at 8:15 PM on October 26, 2011

Two unicycles and some duct tape: You care about saving this life, but they don't care about this life - they care about the next one.

Doesn't that depend on whether they're lucky enough to be in the 144,000?
posted by dr_dank at 8:24 PM on October 26, 2011

"You can either allow people to follow their hearts and live and die as they see fit, or you can force them to follow your heart and live and die as you see fit. You really can't have it both ways."

But if you strongly object to letting people who come to you as a doctor die from easily preventable causes as a religous conviction or close as possible within your belief system, then aren't you being forced to live as that person sees fit?

If you want to bleed to death, stay home, and if you want to kill yourself don't do it where everyone else is trying to drive.
posted by PJLandis at 8:25 PM on October 26, 2011

"If the foundational directive is that life is valuable, and maybe that's only me, then life should come first. Beliefs change, attitudes change, maybe even from day to day. "

But (and I'm not necessarily defending this particular practice -- as I noted above, I found a similar hypothetical situation paralyzing) most of us in western society, or in US/Canadian society, would agree that there are certain situations in which it's admissible or even admirable to value other things over life. Off the top of my head, since 1940 or so -- defense of one's self, family, or homeland; defeating fascism, communism, or terrorism; fighting for freedom, civil rights, the First Amendment; refusing to recant something one knows is true (a scientific truth, a claim of innocence) even in the face of death; reporting truth from a war zone or in the face of a hostile power; I'm sure there are more. We would not all agree with all of them, but most of us would agree that there are at least SOME situations where a particular ethical belief or social value is more important than life itself.

So if you want to remove religious beliefs from the set of beliefs that people are "allowed" to place more importance on than their lives, I think you'll have to make a very compelling argument as to why religion is different than and separate from all of the above. I do agree there's probably a line, but I'm not sure why this is where one would choose to draw it.

(I would consider children a separate -- and in many ways more difficult -- discussion.)

"But is there really a logical removal of yourself from the equation there, or is it just that, over time as a physician, you just get more cold, because practicing medicine with full empathy would result in insanity? And does that end up bleeding (more puns!) into other areas of life?"

I'm not a doctor, but lawyers are trained in something similar, to remove their emotions from the situation so they can focus on the necessary complex and logical thinking required to deal with tough cases. If you read a criminal law textbook, they're usually full of cases that shock the conscience so that you want to say "STRING THAT ASSHOLE UP!" instead of remembering that everyone gets constitutional rights and a presumption of innocence and so on. So, having gone through THAT training, I think it is quite possible to hold two thoughts in your head at once -- "omg I hate this asshole" and "this guy deserves a robust defense." Or "this patient is making a terrible life choice" and "this patient has a right to make those choices." I think if you're able to hold those two thoughts at once, in tension, you don't have to lose your humanity to, I don't know what you'd call it, maintain professional distance? I think, in my observation of doctors and lawyers both, it's the people who have trouble thinking both thoughts at once who are more likely to "become assholes" because they have to shut down one half of the contradictory thoughts.

But I think you also have to have a certain level of comfort with complexity and non-answers to be able to have both thoughts at once.

But possibly I am talking out of my ass. :)
posted by Eyebrows McGee at 8:32 PM on October 26, 2011

You can either allow people to follow their hearts and live and die as they see fit, or you can force them to follow your heart and live and die as you see fit. You really can't have it both ways.

Unfortunately, I guess, I feel that this really comes down to a science vs. religion battle. At least in this case though it's a matter of practicality and not an abstract debate.

I do want to say that I think this has been a wonderful thread. I'm of course an atheist, but I have a pretty big distaste for Richard Dawkins and the kind of "militant atheism" stuff. I'm glad this thread isn't just a bunch of religion-bashing.

But all I can say is that I believe our society's values can only be based on what is provable. An afterlife is not provable. A blood transfusion condemning someone to eternal suffering is not provable. It's not about having it both ways, it's about wanting to live in a rational society that values life. Do whatever you want, but when it comes down to a simple procedure that can save your life, an otherwise healthy life free of suffering, with people who love you, I can't just say "that's your decision" if you choose to die.

So if you want to remove religious beliefs from the set of beliefs that people are "allowed" to place more importance on than their lives, I think you'll have to make a very compelling argument as to why religion is different than and separate from all of the above. I do agree there's probably a line, but I'm not sure why this is where one would choose to draw it.

My whole point is, if the context is a simple blood transfusion, that's where I can draw the line. I'm not even going beyond that. I understand the need to pull back and say "well what about this, or this?" And it's a wonderful discussion to have. But I'm focusing on the cases presented in the original post, and some of the comments there. I feel like we don't have to deal with this in absolutes, and I hope that as a society we can come down against personal agency in certain select cases without it being some kind of omen representing fascism.
posted by palidor at 8:41 PM on October 26, 2011

dr_dank: Not really. I mean, I agree that Witnesses believe in two destinies, a small handful with a heavenly destiny and a vast majority with an earthly one, but that doesn't really change the overall mentality. Neither group believes that the end of this life is anything more than a temporary inconvenience.
posted by Two unicycles and some duct tape at 8:42 PM on October 26, 2011

If someone wants to commit suicide, then that is their choice.

50mg of citalopram and I literally lose the ability to contemplate suicide except as a pure abstract concept that does not apply to me. This is a treatable medical condition caused by something being out of whack in my serotonin. There's a lot more going on in these sort of situations than "choice", whatever the hell that means.
posted by Phalene at 9:01 PM on October 26, 2011 [3 favorites]

Also, herrdoktor, thanks for that great response to my really-only-barely-joking question. I've actually wondered sometimes if I might be a good candidate to go into medicine, or some field that requires a certain amount of emotional distance because I guess I see myself as someone who is comfortable disconnecting myself or compartmentalizing things or whatever. But on the other hand I also feel like I've been quite lucky (or perhaps unlucky depending on your worldview) to have not had to deal with much personal tragedy in my life, so I wonder if I may just not be too battle-tested, so to speak. I've known a few people who got their feet wet only to find themselves unable to handle things emotionally, so they went into other fields. I even know someone who went into a field of research that involved some kind of animal testing and very quickly abandoned it, though that's a different ethical issue.

But I suppose I'm only able to think about these things so much because I'm on the "10-Year Bachelor's Degree Plan"! Actually, I really do want to take more non-science courses, but I've pretty much entirely covered all my liberal arts requirements for my degree, and I'm not sure I can afford to take classes that are then elective in every sense of the word. Here's hoping I'm wrong, though!
posted by palidor at 9:02 PM on October 26, 2011

palidor: Well, we'll have to agree to disagree. As soon as we start talking about society overruling personal agency in matters as intimately personal as how and when we die, you've left me behind.

Part of being human is being free to look up at the stars and scratch your head and consider why you're here and what it all means. Another part of being human is to take whatever conclusions you've come to in all that head-scratching and use them to map out a way of living for yourself, some way to add meaning and structure to our lives. We've already agreed as a society that -- to the extent that we can all do so without destroying each other -- having the freedom to believe as we wish and to pursue our own ways of honoring that belief is an inviolable human right.

If my belief system leads me to a place where I choose to allow events to proceed without your intervention, understanding that my life may end, and yet I *choose* that path with open eyes as the right decision and the right way to honor the meaning and structure I've chosen to live by -- that should always, absolutely, be my choice to make. Any society that claims otherwise is not a society I'd want to live in.

I do want to say that I think this has been a wonderful thread.

Agreed. This has been a thoughtful and interesting discussion and I'm glad I happened to be passing by Metafilter at the right time today to be a part of it. And thanks to the young rope-rider for sharing such a thought-provoking piece.
posted by Two unicycles and some duct tape at 9:09 PM on October 26, 2011 [1 favorite]

But all I can say is that I believe our society's values can only be based on what is provable. An afterlife is not provable. A blood transfusion condemning someone to eternal suffering is not provable. It's not about having it both ways, it's about wanting to live in a rational society that values life.

"Valuing life" is not provable, either. This is nothing more than a subjective value judgment -- there is no proof that "life" is inherently more valuable than quality of life, achievement, happiness, a good death, or any number of other possible values. And as Eyebrows McGee pointed out above, it's tough to claim that our society operates on this principle to begin with. Our prison system, our wars, and our health-care system don't strike me as "valuing life".

I'm about as anti-religious as it gets, but I think your appeal to "rationalism" is iffy at best. There's nothing "rational" about claiming that your own personal value judgments apply to everyone.
posted by vorfeed at 9:15 PM on October 26, 2011 [1 favorite]

This all makes me wish the Anonymous or South Park would take on the Watchtower Society. Say what you want about religion, while almost all religions have some abhorrent beliefs and a dark history, a great many of them are on the whole a net positive for promoting human welfare in the modern world. Christian Science and Jehovah's Witnesses are great examples of religions that cause unnecessary harm and death to their followers. I notice very few people seem to have trouble criticizing the health problems the Catholic church has caused with its stance on condoms. The JW stance on blood transfusions is much worse.

If you really believe we need to take these folks in hand and make them see things your way, what you're essentially saying is: "I don't believe in a higher power or another life beyond this one, and I believe that human life as we know it must be valued and protected above all else, and these two beliefs of mine override any beliefs you may have about this life and its value."

That's the funny this- I'm not an atheist. Maybe it's because I do believe in a higher power that I believe that religions that cause harm to people are just someone's personal choice, but active forces for bad in this world.
posted by melissam at 9:23 PM on October 26, 2011 [2 favorites]

palidor, I'm glad to see your involvement in this thread, if only to make me thing about things again (I get settled in my practices and beliefs, and it's good to shake up a bit).

The point I'm trying to make, though, is that it doesn't have to be a slippery slope. This is an issue, maybe the only issue, where I feel like rationality should be able to trump someone's personal beliefs. If the foundational directive is that life is valuable, and maybe that's only me, then life should come first. Beliefs change, attitudes change, maybe even from day to day. Someone who's a JW now may not be next year. But a person only has one life.

Whose rationality should trump whose beliefs? Whose beliefs are "right?" Are your reasoned beliefs more correct? It may help to remember that there's a lot we don't know and still get wrong in medicine. Of course, when it comes to the specific instance in question, it's clear: get blood, or die.

Then we must think about life's value. Value to whom? Who assesses this? Is life indeed inherently valuable? To most people it is. But say, again, there's a 95 year old patient with metastatic lung cancer who's dying of a bleeding stomach ulcer. She tells you she's lived a full and good life, and she's comfortable with dying. She says she has had a wonderful 70 years with her husband, who passed away last year. She knows she's dying, and requests that we not stick her with needles for any more labs or IV line insertions, which are difficult, because she's go no blood keeping her veins nice and open. She does not want a blood transfusion. She's not a Jehovah's Witness. What are your thought processes in this case?

Again, try lowering the age bit by bit, the severity of the acute medical issues, and the number of comorbid conditions. Where would you "draw the line" or begin to feel discomfiture at their refusal to accept transfusion or treatment? Some people say they're ready to die, for whatever reason.


In the particular case where it's "get a transfusion, or you're going to die," you're trying to trump reason with belief, and claim that life is held in greater value than belief. You're essentially claiming that your beliefs outweigh, are more correct than, or are superior to the other person's, and that you know what's better for them than they do themselves. But this is impossible to know without fully realizing and acknowledging their worldview. Which is something we in medicine try to do by learning more about their culture or beliefs while we try to inform them about our beliefs in medicine. We hope to bridge gaps and come to a mutual agreement, and sometimes we succeed: they may accept alternatives to whole blood products, which can help depending on what acute medical process is going on. Or you might come to a better understanding of them as a person, which may, for some reason and almost as if by magic, make you really feel like and believe that their decision is ok-- that the whole concept of autonomy comes into focus in this very specific setting.

It doesn't always happen like this. But I can tell you that when I've had differing viewpoints with patients and their desires for plan of care, and have talked to them about it, sometimes something just clicks and I feel like "ah, I understand." And that usually is rooted in the ideas of beneficence and non-maleficence. "Do no harm" extends to the physical, emotional and psychological.

The conversations I have with patients and families many times have to deal with quality of life and quantity of life. That my job as a physician is to serve the patient. That there's a balance between quantity of life and trying to cure disease, and quality of life and preventing and easing suffering. Sometimes the scales balance somewhere in the middle, and sometimes they're tipped greatly to one side.

Life is comprised of many elements, all of which, too, must be balanced. Is it worth living a longer life when one is wracked with intractable physical pain? Or terrible emotional and psychological suffering because they can't walk, can't talk, can't breathe on their own, see their families suffer, too? When they know they can't get better, but can be sustained indefinitely in a physical capacity, what value is their life? To them? To you?

And so, we, not being Jehovah's Witness, or not subscribing to any particular patient's set of beliefs, not suffering from the same illness or medical problems, can only imagine what they must be going through. Who can we possibly be to gauge that?

I don't write this to be argumentative or inciteful, palidor. We may be at a point where we must acknowledge our viewpoints differ enough for me to excuse myself from the thread. I just don't believe that life is an ultimate goal for everyone, in every instance, or that as a physician my personal beliefs are more impotant than and outweigh the beliefs and choices of my patients.
posted by herrdoktor at 9:27 PM on October 26, 2011 [4 favorites]

Or you might come to a better understanding of them as a person, which may, for some reason and almost as if by magic, make you really feel like and believe that their decision is ok-- that the whole concept of autonomy comes into focus in this very specific setting.

That's the thing- I've been part of a religion that required you to put religious customs before health (though not in a life or death manner). I understand where these people are coming from and it's not a place of autonomy. It's a place of intense coercion, in which they will be shunned and cast out from the people they know and love, usually their family, if they chose to live. Autonomy is an illusion. You aren't fighting reason vs. religion. There are religions that do not involve coercion.

I can only hope the same thing happens to the mainline Watchtower JW church that has happened to Christian Science- people start abandoning the religion because it destroys lives and the leaders have to reform in order to not die out.
posted by melissam at 9:38 PM on October 26, 2011 [1 favorite]

Excuse me. I have to return some videotapes.
posted by herrdoktor at 9:43 PM on October 26, 2011

Well at least now we know where herrdokotor stands on the value of life as compared to business card designs!!

It's not argumentative or inciteful at all, and in fact, I appreciate having to write further and think about the issue more if only because I feel like I've done a pretty terrible job explaining myself. One of those days where the words don't really come out like you want them to, you know? I did however word this a very specific way:

Do whatever you want, but when it comes down to a simple procedure that can save your life, an otherwise healthy life free of suffering, with people who love you, I can't just say "that's your decision" if you choose to die.

In the case of the 90 year old woman, my thought process is entirely different. She's suffering, she's lived a long life and whether she's ill or not it's nearing its natural end. I don't have any trouble saying "that's your decision" in that case, as you might assume.

And yes, it does get more difficult if you bring that down in age. I appreciate how complicated it is. That's why I've tried to emphasize I'm only speaking of the one specific context. I'd say that once you reach a certain number of difficult questions regarding a specific patient's agency in choosing their own death via denying treatment, you very likely don't have any standing if you try to assert that a belief in the value of life trumps everything else.

See, I'm just repeating myself and not really making the connections I want to be making! Grrr. I'm going to watch last Friday's Daily Show (I'm slow) and hopefully I'll get all my eloquence back soon and make a decent point? Actually melissam is probably making it for me, at least when it comes to the issue of coercion. I may have gone too broad talking about science vs. religion.
posted by palidor at 10:02 PM on October 26, 2011

Also my apologies herrdoktor for implying you might be a Star Wars RPG.
posted by palidor at 10:05 PM on October 26, 2011

melissam, I understand what you're saying and I agree that some JWs have come to their present stance through coercion. I'd ask you to understand though that there are JWs, just as there are people in many other faiths, who have come to their present stance through careful consideration. You seem like someone with a strong opinion of how you'd like to live your life, so I'd also ask you to consider how you'd feel if the situation was reversed.

At the end of the day I'm not arguing that Witnesses are doing the right or noble thing here, though I do have a great deal of respect for JWs and others who take principled stands based on their faith. What I am arguing is that anyone - believer or non-believer, Witness or Catholic or Protestant or atheist - anyone should have the right to determine for themselves what is going to happen to their body and how they will choose to face death.

I have had to work through a great deal of bitterness about my time with the Witness organization. There were so many things I missed out on because of it (not least of which, a proper education). Now, I'm estranged from my family. There have been times I've literally resorted to Googling the names of family members to find out if they've died, since I often won't hear about it any other way. I do owe the Witnesses a few debts as well, and there are some genuinely good people in the organization, but in the final accounting there's an awful lot of red, and even now it sometimes makes me angry if I let myself dwell on it.

And yet I'm not sure any of this matters to the key point at issue right now, which is that of personal agency and an individual's right to choose the nature and extent of their medical care. Regardless of how you feel about the Witnesses or any other group, there are basic human rights at issue here.

I've said enough in the thread already and so I'll step back (need to get some sleep anyway), but all I'd ask is that you try to consider this specific question of personal agency at a human level and not at a Witness level or at the level of any one religion or belief system. Consider that it may be you someday fighting for control of your body and your right to choose the terms by which you'll live and die. Are you really prepared to relinquish that right to someone else just because they assume they're in a better position than you to decide what to do with your life?
posted by Two unicycles and some duct tape at 10:35 PM on October 26, 2011 [1 favorite]

Which is something we in medicine try to do by learning more about their culture or beliefs while we try to inform them about our beliefs in medicine. We hope to bridge gaps and come to a mutual agreement, and sometimes we succeed: they may accept alternatives to whole blood products, which can help depending on what acute medical process is going on.

Wow thank you for this comment herrdoktor (and all of them really), it really clarifies some things for me. When I was in college I had some difficulty with classes on counseling and human services ethics because I could not figure out what we were supposed to do with the knowledge on different cultures. I understood learning about different cultures but could not for the life of me grasp how to apply that knowledge. I have always wanted to work as a helping professional but it's easy to forget that this is a collaborative effort and hard to refrain from paternalism, and because of that tendency I have been reluctant. Being able to use what you learn about others can help one to sympathize and collaborate to find a unique solution. Even if that solution does not solve the problem of how to save a life it may solve other problems, such as how to cope with the medical consequences of the preferred treatment.

As a Jehovah's Witness I would say my relationship to death and dying is somewhat complex, not moreso than anyone else's, mind you, but in a different way. True, I do not believe that this life is all there is, but we can have life again. Dying is a part of (this) life, and it is the second death (destruction, no chance at living forever) that we wish to avoid. Therefore, the plea "it could save your life" would not only not really appeal to me, it might even solidify my faith because it is a reminder of what I was really living for in the first place. For many of us I think we might have a tendency to stop there and not think further, especially those of us who have thankfully not had to face the prospect of dying due to no blood transfusion. I have certainly been turned down for care due to the risk of treating me, and the funny thing is I might not mind so much dying on the operating table but I really do mind living without care at all. Or, more accurately, I would say I mind living with what I perceive as reduced quality of life because no one I have access to is willing to try. But that is an issue that extends far beyond blood transfusions.

At the same time, I also believe death is ultimately a bad thing, "the last enemy" as Paul put it. It's not something abstract to me and I hate that we have to die. To read of health professionals crying in the waiting room as a young mother dies and leaves her children behind strikes me to the heart and helps me to have a lot more empathy for doctors, nurses and others faced with this situation, including some of those who have turned me away. The anguish over "needless" death makes sense to me, especially as ultimately I think all death should be needless. Death is a part of life except when it's not.

Then of course there are many health practitioners who decline to treat us, not simply because of the anguish over watching us die, but over the frustration of having their hands tied by the patient's religion with regard to treatment options. This is similar to my own difficulties with counseling those whose cultural or philosophical beliefs prevent them from following the advice I think would really change their lives for the better. This is why I am appreciative of your perspective on this as someone who has had to work through this because it broadens my own.
posted by Danila at 11:56 PM on October 26, 2011 [2 favorites]

Thanks for the comments Danila, though I have to ask--

What are the moral principles behind refusing blood? How does it enrich you or your community in this life, and how is it connected to the afterlife? Like, in what manner does accepting blood corrupt someone compared to other sins or "wrong" actions?

I hope you understand that from my perspective, there's just this huge impression of arbitrary cruelness to the thing. A man or group of men decided on something in the past and the result is countless lives cut short, with even countless more people suffering due to those preventable deaths. And from what I've been told, and experienced with some religious people in my life, a surely vast amount of wonderful individuals who refused to share themselves with others, who were unable to enrich or be enriched by people because they considered those people outsiders.

Why does the afterlife require this sad, zero-sum game?

In my religion of one, the only rule is that you do your best to live a long, healthy life full of loving and being loved.

That's about all I can say, I'm not going to try to argue what I believe should be the law or anything, but I do hope that we've reached a point as a society where we might know when it is right to override someone's personal agency in the interest of saving their life.
posted by palidor at 2:01 AM on October 27, 2011

You seem like someone with a strong opinion of how you'd like to live your life, so I'd also ask you to consider how you'd feel if the situation was reversed.

I understand what it's like to be reversed. I (and probably most of my friends) have certain beliefs about health that are restricted by the government. And guess what? I understand why, because they are potentially harmful to my life and the lives of others. As I've matured, I've become less libertarian in my beliefs and more focused on solutions so that things like raw milk cheese can be made safe through HACCP plans and other technology.

I can imagine the JW reform movement, which has slowly pushed through some minor reforms that allow JW to at least take some fractions of blood, is coming from a similar place. That's how "cults" and "fringe movements" end up mainstream. Look at Mormonism- they reformed their religion under pressure and now they are major political players instead of a persecuted "cult." Their religion flourishes. Pressure to reform and exposure of the lies behind harmful doctrines DOES work, particularly when a religion is threatened and has a centralized hierarchy.

The truth is, while I'm sure JWs have a wonderful faith, the blood transfusion doctrine was invented in the 1940s. Christians and Jews were following the verses it was interpreted from for thousands of years without coming out with such a doctrine. The Watchtower society has spread lies about the history of the verse and about blood transfusions. It is wildly inconsistant as well, allowing albumin for example, but not platelets. This is from the Dutch Watch Tower Society who opposed the doctrine when it was first standardized:

When we lose our life because we refuse inoculations, that does not bear witness as a justification of Jehovah's name. God never issued regulations which prohibit the use of drugs, inoculations or blood transfusions. It is an invention of people, who, like the Pharisees, leave Jehovah's mercy and love aside.

Osamu Muramoto is also worth reading on the subject.

We are talking about a state of autonomy and non-paternalism that is an ideal, an ideal our own government and culture do not follow. And for some very good reasons. Imagine if the government had not pushed smallpox vaccination because of cultural relativism? There were people back then (and there still are) that firmly believe their children's bodies would be contaminated by vaccine.
posted by melissam at 8:02 AM on October 27, 2011 [1 favorite]

Vaccination directly affects everyone through herd immunity; infants, immune-suppressed persons, or elderly people can become infected, suffer, and even die because others choose not to be vaccinated, and major outbreaks have recently put thousands at risk, including vaccinated children. Thus, it makes some sense to override people's choices with regards to vaccination (or, as the Supreme Court put it in Jacobson v. Massachusetts, "a community has the right to protect itself against an epidemic of disease which threatens the safety of its members.") Same with the "transfusions vs condoms" example: discouraging condom use spreads disease, and spreading disease harms everyone.

People who choose when and how to die do not affect everyone; allowing individuals to choose death over treatment cannot be said to "protect [society] against an epidemic [...] which threatens the safety of its members". The justification for overriding choice here amounts to little more than legislating moral values which many citizens do not share, and it even causes suffering in and of itself, far more so than forced vaccination would. And it's worth noting that we do not actually force people to vaccinate -- the actual history of smallpox vaccination is chock-full of scofflaws, and virtually all US states' school-immunization laws allow for religious exemption, with many allowing philosophical exemption.

As for "pressure to reform and exposure of the lies behind harmful doctrines", "religions that cause harm to people are not just someone's personal choice, but active forces for bad in this world", etc -- I believe that all organized religion is harmful, particularly the sort which claims the same rights it simultaneously denies to others. I despise the Witnesses' religion, but I see no evidence of laws which force hundreds of millions of others to abide by their disgusting tenets... unlike those religions you claim have been "a net positive for promoting human welfare in the modern world".

Would that all religions were so "harmful"!
posted by vorfeed at 12:08 PM on October 27, 2011

I despise the Witnesses' religion, but I see no evidence of laws which force hundreds of millions of others to abide by their disgusting tenets... unlike those religions you claim have been "a net positive for promoting human welfare in the modern world".

You do realize that JWs have roughly the same conservative tenets as much Evangelical Christians follow. It's telling that they criticize more modernized Christianity's stance on things like homosexuality. And I didn't claim that things like Christianity "have been" a net positive- Christianity has a pretty mixed record in the past, but I strongly believe most modern Christians are now interested in making the world a better place and that anti-humanist tendencies are decreasing.
posted by melissam at 1:22 PM on October 27, 2011

There's little point in playing the which-religion-is-less-harmful game with you, especially since I made it clear that I believe they're all harmful. My point was that your personal dislike of this particular religion is no different from my personal dislike of all religion -- you say potato and I say poTAHto, but neither justifies stripping people of their rights simply because we think starchy root vegetables are "active forces for bad in this world".

Be careful what you label "harmful" "lies", because I can guarantee you that others will see the same in any religion you care to name, including yours.
posted by vorfeed at 2:31 PM on October 27, 2011