Blood transfusion and Jehovahs

Witnesses: the legal and ethical issues

Ally McInroy

Abstract
A critical incident is any event that had an effect, or could have had
an effect, on the welfare of a patient. Patients must be treated with
respect by staff who demonstrate that they are sensitive to individual
needs, values, beliefs and cultural background. This article will examine
the legal and ethical issues relevant to the right of an unconscious
Jehovahs Witness in an intensive care unit (ICU) to refuse a blood
transfusion. The concepts of consent, capacity to consent, necessity
to act, advance directives, decision making, consequences of failing
to obtain consent, ethical principles, human rights and the best interests
of the patient will be explored, in the light of relevant statute and case
law, in order to demonstrate some of the legal and ethical complexities
within acute healthcare delivery.
Key words:  Advance directives  Blood transfusion  Culture
and religion  Ethics  Law  Patients: rights  Unconsciousness

nfortunately, the intensive care unit (ICU)

environment, which is intended to optimize the
prospects of individuals surviving a life-threatening
medical crisis (Beeby, 2000), can lead to the loss of
patient autonomy, the principle of self-determination and the
right to make decisions about ones own health care (Thompson
et al, 1996). For many ICU patients, it is at least problematic and
at most impossible, to voice their needs and wishes as their illness
and dependence can lead to a paternalistic approach to care.This
is defined by Thompson et al (1996) as making decisions for
another person based on personal principles or values and what
is thought to be best or good for that person. Paternalism
overrides the patients autonomy and can lead to the nurse
becoming involved in a legal and ethical debate regarding
treatment which may, or may not, be what the patient, if he/she
could comment, would see as being in his/her best interest.
The ethical treatment of patients involves choices which reflect
the beliefs and feelings about what society fundamentally regards
as good or right. However, decision makers must bear in mind
that such choices, especially those involving the critically ill, will
not always lead to the same decision for all patients. Morality
dictates that in all our dealings with patients we should maximize
good, or beneficence, which involves deciding what is good or
bad for another person (Gillon, 1992) and to minimize harm, or
non-maleficence, which is based on the obligation to do no
Ally McInroy is F Grade Sister with the National Blood Service, Edgware
Clinic, North London. At the time of writing she was a staff nurse
in intensive care, University College Hospitals NHS Trust
Accepted for publication: January 2005

270

harm, while bearing in mind that what is not seen as harmful by

one person may be so for another (Gillon, 1992). It is important
that all health professionals acknowledge that their own values
and beliefs about patient autonomy may influence their view of
an individuals right in the care process and whether he/she
consents to the care offered. This is because for consent to be
valid it must be informed (Department of Health (DoH),
2001a), and to act without consent, or when consent has been
refused, is unethical, unprofessional and illegal (Dimond, 2003).
Obtaining consent in ICU can be an ethical minefield:
conflicting conclusions and clashes between the patients
autonomy and the professional duty of care (Dimond, 2002)
become inevitable in decision making, because each person
brings values, beliefs, perception and experience into the
dilemma. In such instances, outcomes of disputes may be
engineered by the more powerful party (Walsh, 2000). It is
therefore imperative that the nurse acts as a voice for the patient
and respects his/her autonomy rather than try to coerce him/her
into accepting the will of the doctors (Sutherland, 1998).

Jehovahs Witnesses
Jehovahs Witnesses have a cultural and religious objection to
blood donation and transfusion (Figure 1). However, Sanderson
(2002) suggests that nurses need to be aware of the Watchtower
Societys (the governing body of Jehovahs Witnesses) policy on
blood transfusions since many Jehovahs Witnesses are not actually
sure what is acceptable and what is not (http://www.watch
tower.org/) (Table 1). All statements on the subject stress the
individuals right to choose based on his/her own conscience but,
in practice, fear still undermines this basic right. Simpson (2002)
explains that Jehovahs Witnesses and their relatives are taught by
their faith that it is important to keep Jehovahs organization
Genesis 9:4 But you must not eat meat that has its lifeblood
still in it (p.10)
Leviticus 17:13-14 Anywho hunts any animal or bird that
may be eaten must drain out the blood and cover it with earth,
because the life of every creature is its blood. That is
whyyou must not eat the blood of any creature, because the
life of any creature is its blood; anyone who eats it must be cut
off (p.120).
Acts 15:19-20 It is my judgement, therefore, that we should
not make it difficult for the gentiles who are turning to God.
Instead we should write to them, telling them to abstain from
food polluted by idols, from sexual immorality, from the meat
of strangled animals and from blood (p. 1110)
Figure 1. Jehovahs Witnesses believe that blood transfusion is prohibited
by biblical passages;The Holy Bible, New International Version (1989).

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PRACTICE DILEMMAS
clean and that one of the ways in which they are encouraged so
to do is to inform those in positions of authority about the
indiscretions of others.Therefore, it must not be assumed that all
Jehovahs Witnesses agree with the blood policy and if given
privacy, confidentiality and the exclusion of any third party, some
will agree to blood-based treatments.

Advance directives
An advance directive, or living will, is an advance statement in
which individuals express their wishes about medical care to be
given if they are unable to voice their wishes at a time, in the
future, when decisions have to be made (Haas, 2005).The British
Medical Association (BMA, 1995) states that, as a minimum, the
directive should include the following: name and address of both
the individual and the GP; date of signing; signatures of both
individual and a witness; health professional input if applicable; a
clearly worded statement of his/her wishes; and the name and
address of the nominated decision maker if applicable. Under the
Mental Capacity Bill 2004 this nominated decision maker
would be able to make decisions about life-sustaining treatment
on behalf of the person making the advance directive.
Figure 2. Jehovahs Witness advance medical directive/release: no blood card.

Table 1. Blood products that are

acceptable/unacceptable to Jehovahs
Witnesses
Acceptable

Unacceptable

Haemoglobin
Albumin
Interferons
Interlukins
Clotting factors
Fibrinogen
Immunoglobulins

Whole blood
Red cells
White cells
Platelets
Plasma serum

Source: Watchtower Society (2004)

Incident analysis
This critical incident analysis examines the treatment, and
subsequent death, of John, a 42-year-old man, who was
brought to intensive care following a fall at work which had
resulted in severe head trauma and multiple fractures, including
pelvis, femur, tibia and fibula. He had suffered major blood loss
and his haemoglobin levels were soon reduced to such that a
blood transfusion was needed if he was to have any hope of
surviving. However, it was very likely that Johns devastating
head injury would prove fatal even if all treatment options
were explored and followed.The doctors had been advised by
staff, on admission, that he carried a Jehovahs Witness no
blood card (Figure 2). On their arrival at the hospital, Johns
family confirmed that he held very strong beliefs as to the
inappropriateness of blood transfusion even if by denying one
it would lead to his death. While Johns decision was his to
make, those responsible for his care, understandably, found the
concept of allowing a young man to die very difficult.
However, the fact that, even with a transfusion, death was still
likely did mean that staff were rather less traumatized than they
might otherwise have been.

British Journal of Nursing, 2005,Vol 14, No 5

The fact that John was unconscious and unable to voice his
refusal of treatment meant that the issue of whether to treat or not
had to be considered extremely carefully, in the light of previous
legal and ethical precedents, by those medical staff accountable for
his care. In circumstances such as this the DoH recommends that
doctors consult with a patients family in order to ascertain and/or
confirm values and preferences (DoH, 2001b).To this end, a case
conference, led by one of the ICU consultants, was arranged with
the utmost urgency to examine all the available evidence.The aim
was to draw up a treatment plan which would not be against
Johns will but would ensure that he was treated with all possible
medical alternatives to donor-derived blood transfusion in the
hope that his life could be saved. Examples of systemic clinical
strategies for managing haemorrhage and anaemia include
combinations of drugs, e.g. erythropoietin, equipment and
medical/surgical techniques to reduce or avoid blood loss and to
enhance the patients own blood production (McClelland, 2001).
The basic principle is that if it is known that blood cannot be
given, every opportunity should be taken to save the patients own
blood (McClelland, 2001).
A copy of Johns full advance directive was brought in from
home; the original was kept by church elders and further copies
by his GP and solicitor, and this clearly demonstrated his beliefs
and wishes. It must be borne in mind that John had written his
wishes when fit and well and in the belief, typical of many, that
such a situation would never happen to him. The question is
whether he would really want to die if he could voice his wishes
at that moment or whether he would want to change his
decision now that there was a very real possibility of death.
The consultant came to the conclusion that it was clear in this
case, from discussion with Johns family, the written no blood
card that he carried and the do not transfuse advance directive,
that John would not wish to receive a blood transfusion
regardless of whether it would risk his death to refuse. To go
ahead and administer a blood transfusion would not be in Johns
best interest; indeed, it would be unlawful (Dimond, 2002), and

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therefore it should not proceed. In these circumstances, namely

an advance directive to refuse a particular medical intervention
and the best interests of the patient, it is lawful to withhold lifesustaining treatment without which Johns life would
undoubtedly be shortened (Dimond, 2002). A decision was
made not to escalate treatment further. Nursing care to maintain
Johns comfort and dignity was provided (BMA,1995) and he
died peacefully 2 days later.

The legal and ethical issues

Under common law everyone has a right to self-determination
and to have his/her autonomy respected. This fundamental
principle is echoed in Article 8 of The Human Rights Act 1998
(Figure 3). Furthermore, Lord Donaldson, in the case of Re T (an
adult) (refusal of medical treatment) [1992] states that this right
to choose is not limited to decisions others might regard as
sensible, it exists notwithstanding that the reasons for making the
choice are rational, irrational, unknown, or even non-existent.
The Human Rights Act 1998 incorporates the rights and freedoms set out in the
European Convention on Human Rights into UK law. It is intended to improve upon
and supplement existing legal provision to safeguard human rights in UK law,
not to replace them. Individuals who believe that their Convention rights have been
infringed by a public authority may either bring proceedings against that public authority,
or rely on their Convention rights in proceedings brought by others (p.910).
Two articles of the Act, 8 and 9, are particularly applicable in a case such as Johns:
Article 8 regarding privacy and related matters
It provides that everyone has the right to respect for his private and family life
and there shall be no interference by a public authority with the exercise of this right
except such as is in accordance with the law (p. 125).
Article 9 regarding religion and belief
It provides that everyone has the right to freedom of thought, conscience
and religionand in public or private, to manifest his religion or belief, in worship,
teaching, practice and observance and a freedom to manifest ones religion or beliefs
which shall be subject only to such limitations as are prescribed by law. Protection
under article 9 does extend to Jehovahs Witnesses, since Kokkinakis v. Greece (1994)

Figure 3. Human
Rights Act 1998.

272

Consent refers to the legal right of an individual to determine

what shall be done with (his) own body (Schloendorff v. Society
of New York Hospital [1914]). It can only be given by a
competent person an independent adult in full possession of
his/her senses and must be informed and freely given (DoH,
2001a). As acknowledged in the Re T (an adult) (refusal of
treatment) [1992] case: The patient has the right both to consent
and to refuse medical treatment. Consent, or refusal to consent,
can be written,implied or verbal and does not need to be formally
witnessed. However, if the patient is incompetent not able to
perform a particular task or make a deliberate choice the health
professionals may act out of necessity in the best interests of the
patient. This principle was established in the case of Re F (F v.
West Berkshire Health Authority [1989]) which concerned the
sterilization of a mentally incapacitated woman.
Stauch et al (2002) state that for consent to be valid it must
fulfil three criteria: the patient must be competent to give the
consent; there must be no duress or undue influence upon the
patient to give the consent; and the patient must be suitably
informed about the nature of the proposed intervention. The
doctors, therefore, had to be sure that it was John who did not
want a transfusion, not his family or his church elders.

English law recognizes the general principle that a competent

patient is entitled to refuse treatment, even if it is required to
sustain life. Reiterating this, Judge LJ (St Georges Healthcare
NHS Trust v. S [1999] said even when his/her own life depends
on receiving medical treatment, an adult of sound mind is
entitled to refuse it and the ethos of this judgment is supported
by Article 8 of the Human Rights Act 1998 (see Figure 3).
If John was deemed to be competent when he drew up his
advanced directive his right to refuse treatment must be
respected. The Court of Appeal case has emphasized that
provided the patient has the necessary mental capacity, which is
assessed in relation to the decision to be made, then he/she can
refuse to give consent for a good reason, a bad reason, or no
reason at all (Tingle and Cribb, 2002; Dimond, 2003). This
reflects the autonomy of each individual, the right of selfdetermination and that the will of the patient is to be respected.
These rights were supported by Dame Elizabeth Butler-Sloss
in the case of Re B (adult: refusal of medical treatment) [2002].
B had been mechanically ventilated in an ICU since a ruptured
blood vessel in her neck had left her paralysed from the neck
down. B was of sound mind and knew that there was no cure and
applied to the court for a declaration that the ventilator could be
switched off. Dame Butler-Sloss held that B was mentally
competent and could refuse the treatment being given. This
reaffirmed that all patients have the right, whatever their reasons,
to decide whether to accept the treatment offered or not. Equally,
it is possible for a patient to make an advance directive to ensure
that life-sustaining treatment, such as artificial nutrition and
hydration, will not be withdrawn solely owing to the progression
of a known disease (Burke v. General Medical Council [2004]).
A patients right to argue that the decision to refuse treatment
is his/hers to make is a fundamental human right which is now
protected in the Human Rights Act 1998. In the case of John,
who was refusing (through an advance directive) a blood
transfusion on the grounds that he was a practising Jehovahs
Witness, Article 8 would support his right to respect for privacy
without interference from public authority, and Article 9, his
freedom to follow a chosen religion (Tingle and Cribb, 2002).
In the Schloendorff case in New York, which was the first
important ruling on informed consent (Schloendorff v. Society
of New York Hospital [1914]), Judge Cardozo stated: Every
human being of adult years and sound mind has a right to
determine what shall be done with his own body; and a
[doctor] who [provides treatment] without his patients
consent commits an assault.
The consequences of failing to obtain consent are that a
practitioner may face disciplinary action for: negligence, because
he/she did not act in accordance with practice considered proper
by his/her peers (Bolam v. Friern Barnet HMC [1957]); or the
preferred legal action of trespass to the person which, when made
more specific, is either battery, where the person is actually
touched, or assault, where he/she feels that he/she will be touched
(Rodgers, 2000; Dimond, 2002;Tingle and Cribb, 2002).
It is presumed under common law that John, an adult, has legal
capacity unless it is shown otherwise and this would have been
established when the advance directive was made.The legal test
for capacity was established in the case of C, a paranoid
schizophrenic held in Broadmoor Hospital, who refused to
consent to having his foot amputated when he developed

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PRACTICE DILEMMAS
gangrene which the court upheld (C (re) (an adult) (refusal of
treatment) [1994]). The test has three components: the patient
must be able to comprehend and retain information, believe the
information, and be able to weigh it in the balance so as to arrive
at a choice (DoH, 2001a; Stauch et al, 2002). Since John was
unconscious he would currently not meet the test for capacity
and therefore is unable to give legally effective consent. However,
his prewritten advance directive was binding upon all.
If an adult lacks the legal capacity to make treatment decisions
and cannot give valid consent, no-one, regardless of how they
may be related to the patient, can either give, or refuse to give,
consent to a medical treatment (Re T (an adult) (refusal of
medical treatment) [1992]). In the case of a patient being unable
to give consent because of being unconscious, the decision as to
the path of treatment is the responsibility of medical staff unless
there is a valid advance directive. However, medical staff should
still approach relatives in order to ascertain, if possible, what they
feel the patient would have wanted to happen if he/she was able
to comment (DoH, 2001b; Tingle and Cribb, 2002). However,
one must be acutely aware that what a relative tells us may, in fact,
not be the truth. There are many anecdotal incidents of family
feuds and disagreements where the relatives may give their own
opinion as to the proposed course of action rather than their
view of what the patient would have wanted in the circumstances
if he/she was able to speak for him/herself. However, in the case
of John, there was a valid advanced refusal of treatment which
clearly informed the doctors of his wishes.
The Law Commission for England and Wales (1995) states
that an unconscious person is deemed to be without capacity
at the material time (the time the decision is needed) since it
is not possible for him/her to communicate a decision.
Therefore, doctors must arrive at a decision that they are sure
is in the patients best interest and not a paternalistic, save life
at all cost decision (Jones et al, 1998). Best interests are not
confined to best medical interests since case law has established
that other factors need to be taken into account, including the
patients values and preferences when competent, his/her
psychological health, wellbeing, quality of life, family
relationships, spiritual and religious beliefs and his/her own
fundamental interests (Cornock, 2002). In addition, if the
doctors have knowledge that patients have drawn up a living
will they must treat it as seriously as a refusal made at the time
treatment is offered; it cannot be ignored (BMA, 1995).
The Enduring Power of Attorney Act 1985 enables people to
create powers for someone to act in their interest if they cease to
have capacity. However, this does not extend to the delegation of
power to decide on treatment and relatives sometimes feel that it
does not matter what their loved one may have wanted because,
since they cannot speak for themselves, all decision making lies
with the doctors. However, this has been addressed by the
Mental Capacity Bill 2004 which supports advance directives and
allows for individuals to nominate a named individual as their
decision maker should such a situation arise where they are
unable to voice their own wishes.
Indeed, the Mental Capacity Bill 2004 will allow decisions by a
nominated person or persons to be made on behalf of mentally
incapacitated adults (Dimond, 2002) and, as this becomes accepted
practice, staff will need to be even more acutely aware of the
implications and possible ramifications of any action taken. The

British Journal of Nursing, 2005,Vol 14, No 5

Mental Capacity Bill 2004 will provide legislation for advance

directives.There were many recommendations on changes to the
draft Bill, three significant changes were that: if life-sustaining
measures are to be refused this must be stated clearly; that the
actual treatment to be refused must be specified; and a living will
must be in writing and be witnessed.
It has also been suggested that individuals should not be able
to refuse measures that are essential to maintain comfort, e.g.
basic care and pain relief (BMA, 1995; The Law Commission
for England and Wales, 1995; General Medical Council
(GMC), 2001); however, they can refuse, in advance of
becoming too ill to give consent or refusal, to specific
treatments which they feel would be inappropriate for them as
an individual, e.g. a Jehovahs Witness not wanting to receive
blood, which is what John had done.
In a similar vein to that of Stauch et al (2002) who discussed
capacity to consent, Kennedy and Grubb (2000) state that four
criteria must be met if a medical directive is to be upheld at
law. At the time of the refusal the patient must be competent,
their decision must have been theirs alone, they must have
been sufficiently informed of the nature and effect of the
treatment which is being refused (or consented to) and the
refusal must cover the actual situation in question.
If a Jehovahs Witness were to be given a blood transfusion
when it was known that they had stated that they did not want
one they may wake up and sue. Advance refusals of specific
treatment, as illustrated by the Malette v. Shulman case in
Canada, where an unconscious patient was given a life-saving
blood transfusion in spite of the fact that she was carrying a card
refusing such treatment (Malette v. Shulman [1991]), are binding
on the doctor provided that the patient was competent when
making the decision, had sufficient information to make a
considered choice, did so freely and there is no good reason to
believe that the patient would have changed his/her mind in the
interim (Dimond, 2002). In the Malette v. Shulman case the
patient won 20 000 Canadian dollars as the doctor had ignored
her written request and this constituted a trespass to the person.
The Jehovahs Witnesses give advice for their followers which
provides direction as to how to complete the advance directive
and explains fully the reasons for their refusal of treatment by
blood transfusion (http://www.watchtower.org/).
Legally, consent must be obtained for any treatment unless,
in an emergency, the practitioner acts from necessity (Dimond,
2002; Montgomery, 2003). However, the fact that John carried
a no blood card on his person negated the doctors duty to act.
Doctors and nurses in their duty of care for the patient may
take life-saving action on the basis of their common law
powers (recognized in F v. West Berkshire Health Authority
[1989]) to act out of necessity in the best interests of a mentally
incapacitated adult; however, if a valid advance directive is
known about, such action would be inappropriate.
According to Lord Goff (F v.West Berkshire Health Authority
[1989]) there are two requirements for the best interest proviso to
operate: there must be a necessity to act in a situation where
medical staff cannot communicate with the patient and the action
must be what a reasonable person would do in the best interest of
the patient. While the law supports medical treatment without
consent provided that treatment is in accordance with the
appropriate professional standard and is in the best interests of the

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patient concerned (Tingle and Cribb, 2002), it also supports the

withholding of treatment on the basis of the presence of a valid
advance directive (Dimond, 2004).

The nurses role

Nursing practice can be seen to contain elements of philosophy.
Deontology places an emphasis on moral obligation or
commitment (Thompson et al, 1996) whereby nurses are
obliged to serve their patients in a moral and non-judgmental
way. Consequentialism is where an action is deemed to be right
if it produces the best possible outcome (Singleton and
McLaren, 1995). Nurses are obliged by the Code of Professional
Conduct (Nursing and Midwifery Council, 2002) to respect the
patient as an individual, obtain consent before any treatment
and be trustworthy. In determining patients best interests the
nurse must consider that quality of life is subjective and the
values of patients, relatives, and healthcare staff, may differ.The
overall responsibility for decisions made lies with the consultant
in charge of the case who will determine best interests, with
recourse to court for a declaration on the validity of the
advance directive as necessary (Dimond, 2004).
The responsibility of the nurse, as Johns advocate, is to promote
and protect his interests while he is unable to make decisions for
himself. If he were conscious John would be made categorically
aware that to not have a blood transfusion would inevitably lead
to death; however, since he was unable to confirm his wishes or
change his mind this placed added burden on the nurse. If nursing
is to be truly holistic it, necessarily, should be about compromise,
partnership and power sharing (Ford and Walsh, 1994) between
nurse and patient. While this may be difficult within an ICU
environment, it is not impossible, and through such advocacy the
nurse encourages fair, non-judgmental decisions and conforms to
the professional element of nursing. If a patient, such as John,
cannot make his feelings known the nurse must be prepared to
involve family and friends and ensure that they are fully appraised
of the plan of care and rationale for treatment in the light of the
advance directive made by the individual involved.

Conclusion
Analysis of this incident has highlighted the complex legal, ethical
and professional issues surrounding the inability of the
unconscious patient to consent to treatment.Thorne (1999) states
that being valued and understood as a unique person is often as
important, or more important, than being cured. By respecting
Johns human right, as a Jehovahs Witness, to refuse treatment
with blood products the staff involved acted in his best interests.
In times of ethical dilemma nurses are often a human bridge
between doctors, technology and the individualized care of the
patient and his/her family. Being prepared to speak up in their role
as an advocate, while caring in a holistic and compassionate
manner, is a challenge that delivers much reward for nurses. BJN
The author would like to acknowledge Rachel OConnell, University of Hertfordshire,
for her advice and guidance, and Karen Wilson, her partner, for her unstinting support.
Beeby JP (2000) Intensive care nurses experiences of caring. Intensive Crit Care
Nurs 16: 7683
BMA (1995) Advance Statements About Medical Treatment. BMA Publishing Group,
London
Bolam v. Friern Barnet HMC [1957] 2 All ER 118
Burke v. General Medical Council [2004] EWHC 1879 (Admin)
C (re) (an adult) (refusal of treatment) [1994] 1 All ER 819

274

Cornock M (2002) Legal basis of decision making in critical care. Nurs Crit Care
7(5): 23540
Dimond B (2002) Legal Aspects of Nursing. 3rd edn. Longman, Harlow
Dimond B (2003) Medicinal products and consent by mentally capacitated
patients. Br J Nurs 12(18): 11067
Dimond B (2004) The refusal of treatment: living wills and the current law in the
UK. Br J Nurs 13(18): 11046
DoH (2001a) Consent What You Have a Right to Expect.The Stationery Office,
London
DoH (2001b) Good Practice in Consent Implementation Guide. The Stationery
Office, London
F v.West Berkshire Health Authority [1989] 2 All ER 545
Ford P,Walsh M (1994) New Rituals for Old Nursing Through the Looking Glass.
Butterworth-Heinemann, Oxford
Gillon R (1992) Philosphical Medical Ethics. Wiley, Chichester
GMC (2001) Withholding and Withdrawing Life-Prolonging Treatments: Good Practice in
Decision Making. Draft guidance from the Standards Committee. GMC, London
Haas F (2005) Understanding the legal implications of living wills. Nurs Times
101(3): 346
Jones S, McWilliam D, Coakley J (1998) The Really Useful Book on Intensive Care.
Martin Lister Publishing, Carnforth
Kennedy I, Grubb A (2000) Medical Law. Oxford University Press, Oxford
Kokkinakis v. Greece (1994) 17 EHRR 397
McClelland DBL, ed (2001) Handbook of Transfusion Medicine. The Stationery
Office, London
Malette v. Shulman [1991] 2 Med LR 162
Montgomery J (2003) Health Care Law. 2nd edn. Oxford University Press, Oxford
Nursing and Midwifery Council (2002) Code of Professional Conduct. NMC, London
Re B (adult: refusal of medical treatment) [2002] EWHC 429 (Fam) [2002] 2 All
ER 449
Re T (an adult) (refusal of medical treatment) [1992] 4 All ER 649
Rodgers M (2000) The child patient and consent to treatment: legal overview. Br
J Community Nurs 5(10): 4948
Sanderson A (2002) Blood pressure. Nurs Times 98(2): 26
Schloendorff v. Society of New York Hospital [1914] 211 New York Reports 125
Simpson J (2002) Nursing with dignity. Part 9: Jehovahs Witnesses. Nurs Times
98(17): 367
Singleton J, McLaren S (1995) Ethical Foundations of Health Care: Responsibilities in
Decision Making. CV Mosby, London
St Georges Healthcare NHS Trust v. S [1999] Fam 26. (1998) 2 All ER 673, CA
Stauch M, Wheat K, Tingle K (2002) Sourcebook on Medical Law. 2nd edn.
Cavendish, London
Sutherland P (1998) Ethical issues. In: Bassett C, Makin L, eds. Caring for the
Seriously Ill Patient.Arnold, London
The Holy Bible, New International Version (1989) 15th impression. Hodder and
Stoughton, London.
The Law Commission for England and Wales (1995) Mental Incapacity: Law
Commission Report 231.The Stationery Office, London
Thompson IE,Melia KM,Boyd KM (1996) Nursing Ethics. 3rd edn.Churchill,London
Thorne S (1999) Communication in cancer care: what science can and cannot
teach us. Cancer Nurs 22(5): 3709
Tingle J, Cribb A, eds (2002) Nursing Law and Ethics. 2nd edn. Blackwell
Publishing, Oxford
Walsh M (2000) Nursing Frontiers: Accountability and the Boundaries of Care.
Butterworth-Heinemann, Oxford
Watchtower Society (2004) Quality Alternatives to Transfusion.Watchtower Society
(http://www.watchtower.org/library/hb/index.htm) (last accessed 23
February 2005)

KEY POINTS
The intensive care unit (ICU) environment can lead
to the loss of patient autonomy and the principle
of self-determination.
Obtaining consent in ICU can be an ethical minefield.
English law recognizes that a competent patient is entitled
to refuse treatment even if it is to sustain life.
Unconscious patients do not meet the test for capacity
and are therefore unable to give, or refuse to give, legally
effective consent but if there is a valid advance directive
then this is legally binding.
Doctors should attempt to ascertain what the patient
would have wanted to happen in the circumstances
if he/she could speak for him/herself.
The Human Rights Act 1998 supports the right of a
Jehovahs Witness to refuse a blood transfusion and to make
such a decision known in advance of needing to make it.

British Journal of Nursing, 2005,Vol 14, No 5

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