Justice and Respect for Autonomy: Jehovah's Witnesses and Kidney Transplant

Abstract

That Jehovah's Witnesses may refuse lifesaving blood transfusions is a morally accepted feature of contemporary medical practice. The principle of respect for autonomy supports this, and there is seldom reason to interfere with this choice because it rarely harms another individual. Advances in surgical technique have made it possible for transplant surgeons to perform bloodless organ transplant, enabling Jehovah's Witnesses to benefit from this treatment. When the transplant organ is a directed donation from a family member or friend, no ethical dilemma arises. However, when a Jehovah's Witness cannot identify a living donor and wishes to be listed for organ transplant, the transplant team may face an ethical dilemma. On the one hand, it wishes to provide care to the patient that is compatible with her or his preferences. On the other hand, the team may wonder if it is fair to other patients who need an organ and will accept blood transfusion to include the Jehovah's Witness patient on a waiting list for a donated organ. If the Jehovah's Witness patient is listed and receives an organ, then a patient who also needs an organ, and who is willing to accept all care to optimize the success of the transplant, may be denied an organ. To frame the ethical dilemma outlined above we present an anonymized case of a Jehovah's Witness woman in urgent need of a kidney, who was referred to one of the authors' institution's transplant center. We review the evolution of the Jehovah's Witness position on blood transfusion and the medical community's efforts to provide care that accommodates this religious commitment. If Witnesses are to be denied transplant in the name of justice, there must be an ethically sound reason. We identify two rationales in the literature: (1) this allocation is unacceptable because it will cost lives; (2) resources should be allocated to patients who comply with the standard of care. We argue that neither apply to this dilemma. We also emphasize the importance of examining the data on outcomes of transplant with and without transfusion. Our interpretation of the published data on transplant without transfusion is that the outcomes are similar. We conclude that, in the absence of data that resources are risked, it is not ethical to refuse to include a Jehovah's Witness patient on a waiting list for an organ. Finally, we reflect on the heterogeneity in transplant institutes' polices for accepting Jehovah's Witness patients.