Transcript POS Religious Issues 2009 - Department of Surgery

Consent in Emergencies:
Religious and Cultural Issues
Martin McKneally
Department of Surgery and
Joint Centre for Bioethics
University of Toronto
Principles of Surgery
December 8, 2009
1
Case Summary
Eleven year old Jennifer Beaulieu has just
been rushed into the trauma room following
a head-on collision in which her father was
killed.
Jennifer is unconscious, cyanotic,
hypotensive, and in severe respiratory
distress. You have inserted an endotracheal
tube, a chest tube, and intravenous lines. A
large amount of blood drains from the chest.
Though Jennifer’s blood pressure has
stabilized, bleeding continues.
2
You are the surgical resident on call.
What should be done, in your judgment,
and what are your reasons?
When are surgical interventions
justified without informed consent?
What is the justification for your
position?
3
Ethics
should
Policy
Law
usually
must
4
Who should make decisions for the
incapable patient?
The patient when capable
Attorney* for personal care
Spouse or partner
Parent or child
Sibling
Any other relative
Concerned friend
Public guardian
5
How should the substitute decision maker
arrive at a decision?
Substitutes should try to determine how the
patient would decide the issue if capable.
1. Written expressed wishes about treatment
2. Spoken wishes
3. Values & beliefs known to be held by the
patient when capable
4. Best interests – what a reasonable person
would consider most helpful & appropriate
6
Jennifer’s mother, Annette Beaulieu,
arrives and informs you that her
daughter and she are Jehovah’s
Witnesses.
She forbids blood transfusions, even if
her daughter will not survive without
them.
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8
Religion
The belief in a superhuman
controlling power, entitled to
obedience and worship.
Canadian Oxford Dictionary
A set of beliefs concerning the
cause, nature, and purpose of the
universe, especially as the creation
of a superhuman agency.
Webster’s Dictionary
9
Religion:
A powerful influence
in the lives of many
patients
people and caregivers
10
Ethics
Policy
Religion
Law
11
Many types of religions
Some view all religions as variations of their own
Different conceptions of God, different rituals
Emerge from different cultures
Very different worldviews
Many ways of being religious
Faith in an ultimate being
Obedience to religious authorities
Community rituals
Individual meditation or prayer
Once a week or all-encompassing
Many types of faith
True believer – shapes conception of reality
Adherents with less conviction
In crisis, moments of doubt, moments of faith
12
How we acquire a religious orientation
Born into it
Conversion – a conscious choice
Conviction of its truth
Desire to join a community
Love of a spouse
Religious and cultural pluralism
Paternalism
Ethical imperialism
Values of the patient vs those of the physician
Religions are moral communities
Authority resides in religious leaders
Family members
Gary Goldsand, Dept of Religious Studies, U of T
13
Science: Belief based on
evidence
Trust:
Belief based on
limited evidence
Faith:
Belief that does not
require evidence
14
Watchtower Blood Policy 1961
15
Watchtower Blood Policy
Allowed
Fractions:
Albumen
AHG
Gamma
globulins
Fibrinogen
Forbidden
Whole blood
Major components:
Plasma
RBC
WBC
Platelets
16
Moral pressure to conform:
Elders
Visitation
Book study groups
Disfellowship
17
18
Moral Reasoning
Emotional, intuitive level
based on feelings, instincts
Rational, prescriptive level
based on laws, policies, precedents
Reflective level
based on values, principles, understanding
sensitive to culture and context
19
Children:
“Parents … are not free to make martyrs
of their children” Justice Holmes,
Prince vs Massachusetts 1944
“Mentally competent baptism”
20
Recommendations
Ask and Advise – privately
Respect – noncategorically
Refusal should be informed
21
Hospital Information Services (Canada)
for Jehovah’s Witnesses, Watch
Tower Society
[email protected]
Associated Jehovah’s Witnesses for
Reform on Blood (AJWRB)
www.ajwrb.org
22
Case 2
Karen, a 13-year-old girl, refused
medical attention for suspected
meningitis. She was supported
by her parents in this refusal on
the grounds of Christian Science
beliefs.
23
First Church of Christ, Scientist
Boston, Massachusetts
24
Mary Baker Eddy
25
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Summary of Religious Issues
Religion is a powerful force
Spectrum of beliefs & practices
Children may not be made martyrs
Refusal should be informed
Indoctrination can go both ways
27
Culture: The socially
inherited characteristics
of a group
Traditions
Beliefs
Practices
28
Culture
Ethics
Policy
Religion
Law
29
Culture
Ethics
Policy
Religion
Law
30
The Culture of Surgery
Values
Beliefs
Traditions
Heuristics
Stories
Tribal Customs
Rituals
Secrets
Myths
Biases
31
Summary
Substitute decision makers
Values, preferences & interests of patient
Role of religious and cultural values
Moral reasoning:
emotional, rational, and reflective levels
32
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What if not capable?
Substitute Decision Maker
Who?
H
i
e
r
a
r
c
h
y
The incapable person’s :
if has authority
1. guardian of the person
to give or refuse
2. attorney for personal care
consent to the
3. representative appointed by
treatment.
the Board under section 33
4. spouse or partner
5. child or parent
(or a children’s aid society or other
person who is lawfully entitled)
6. parent who has only a right of access
7. brother or sister
SDM must be capable
8. any other relative
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Ontario: Health Care Consent Act 1996