Case #1: Informed Consent
Mrs. Wilma Allen, a 42-year-old black woman with no dependents who was employed as a secretary, consulted Dr. Richard Jaeger, an oral and maxillofacial surgeon, about a large swelling in her left cheek. A panoramic radiograph showed that the sinuses were cloudy. Examinations of a biopsy specimen revealed a large amount of dysplastic fibrous tissue, and the lesion was diagnosed as reparative giant cell granuloma. The indicated treatment was surgical removal.
Two complicating factors existed. One was that Mrs. Allen had sickle cell disease; her hematocrit was 15, and her hemoglobin was 5, both quite low.
The other factor was that Mrs. Allen was a Jehovah’s Witness. Although she had no objection to the surgery, under no circumstances would she consent to receive blood products. Her position was absolutely firm.
Dr. Jaeger talked with Mrs. Allen about what would happen if nothing was done—the lesion would grow larger and larger and become even more disfiguring. He always told her that removing the lesion without her authorization for a transfusion, considering her serious involvement with sickle cell disease, could result in grave consequences, even her death. Even so, Mrs. Allen refused to change her mind. Dr. Jaeger discussed the matter with members of her church, and they all agreed with Mrs. Allen.
Mrs. Allen was willing to have the surgery done, but Dr. Jaeger was extremely reluctant to do it. What should Dr. Jaeger do?
Dr. Jaeger is facing an ethical dilemma regarding informed consent and conflicts between autonomy and beneficence. Consider the following courses of action that Dr. Jaeger might follow.
1. Have Mrs. Allen sign the consent form, agreeing with her conditions, and proceed with the surgery, with no blood products available. (The risks, here, are profound, of course. Yes, this option preserves her autonomy, but given her hemoglobin levels, there is increased likelihood that she will need blood products. If she does, could you let her die on the operation table? Also, does this option really preserve her autonomy, given that she doesn’t seem to grasp the gravity of risk that she is undertaking? Nor does she seem to be aware of the risk she would be subjecting you to.)
2. Have Mrs. Allen sign the consent form, telling her that you agree with her conditions, but knowing full well that if necessary, you will provide the needed blood products to save her life. (This option chooses beneficence over autonomy, doing whatever is necessary to preserve her life. Imagine, though, that you proceed in this manner and, indeed, blood products are required. Do you tell her? If you do, you set yourself up for legal liability, though you preserve veracity. This might be at the expense of beneficence, given the stress that such an admission might cause her. If you don’t tell, you sacrifice autonomy and veracity, but preserve beneficence. The patient is healed, and no one is ultimately harmed. Or are they?
3. Tell Mrs. Allen that neither you nor any other responsible surgeon would perform surgery under these conditions, and try your best to persuade her. If she does not finally agree, dismiss her from your practice. (Both autonomy and beneficence toward the patient is sacrificed—her condition isn’t alleviated and she isn’t treated according to her wishes. However, the autonomy of the medical professional is preserved, and you are working in accordance with best practice.)
4. Realize that she isn’t likely to budge on this issue, and dismiss her immediately. (Does this option put the patient’s interest first? In some ways, this might be the easiest option, but is it really the best option?)
5. Other alternative (please describe).