To Lie or Not To Lie About Patient Care?

I was in practice about five years and was about to do a radical nephrectomy on a patient. I met with the patient and his son in my office and the son informed me that he and his father were Jehovah's Witnesses and that he didn't want his father to receive any blood or blood products before, during, or after surgery. I asked the father if that was his wish and he sheepishly agreed that it was his decision as well. I had him sign a consent form, with the appropriate documentation, that would absolve me of any negligence if he should require a blood transfusion and didn't receive it.

The night before surgery, I met with the patient alone in his room. He confided in me that he was not as "religious" as his son - if he needed blood, he wanted to receive it. However, he requested that I shouldn't tell him or his son if he received a transfusion.

I thought that was a prudent plan of action, and I documented our discussion in the patient's chart. I then made calls to the laboratory and the blood bank, to type and hold several units of packed cells.

The surgery was a little more difficult than I anticipated and the patient lost several units of blood - he had signs of hypovolemia in the immediate post-operative period. At the end of the procedure I ordered that the blood be given to the patient in the recovery room. I told the nurses not to allow any family members into the recovery room while the transfusions were being given. I also had the nurses change the IV tubing after the transfusions were given so that there would be no tell-tale signs of blood in the IV tubing that could be seen by the family. I thought I had covered all of my bases.

I then walked out to meet with the family in the family lounge. The son asked me about the surgery and I told him about the difficulty of the operation but that his father was stable and doing well in the recovery room. The son then asked me, "Did my father receive any transfusions or any blood products?" Pow! I know I had the look of a deer stunned by the headlights. There were so many thoughts that raced through my mind in the interval between his questions and my response.

I responded, "Why do you ask?" as I was hoping to have just a few more seconds to gather my thoughts. The son said that someone from the blood bank had come into the family lounge during the surgery and asked if anyone in the family would consider donating blood, as their father was going to receive blood. I thought I had taken care of everything but I didn't give the blood bank a heads up on my agreement with the patient. I thought, do I tell the truth and risk rupturing rapport between the father and the son and/or between the patient and myself? To give an adult patient blood against their will or wishes could be considered an assault with battery. I was truly scared about the legal ramifications the truth would subject me to. Or do I lie and protect the patient? I decided that my responsibility was to the patient and that the patient deserved that I protect his wishes and preserve his relationship with his son.

I said, "There must have been a mistake as your father did not receive any blood." The son gave a sigh of relief and I know that inside I, too, was also relieved that the rapport was not blown between the patient and me, or between the patient and his son.

I ask, if you were the doctor in this situation, what would you have done? Would you be perfectly honest and tell the son about your discussion with the father the night before? Or would you do as I did, and lie to the son in order to protect your patient, his father?

We have all taken the Hippocratic Oath, which admonishes us "To do no harm." I believe this dictum refers to more than just clinical harm to the patient, but also to psychological harm. I believe that had I been forthright about the transfusions, I would have harmed the patient - the lie protected the patient.

A certain moral goodness is expected in physicians, and if goodness is not present, education probably will not create it. Superior moral reasoning can enhance moral behavior, and we only have to look at the lessons of the great physicians who preceded us for the answers and the advice that can guide us in the practice of our profession.

This was one of the scariest days in my professional life and I believe, to this day, that I behaved in the best interest of my patient.

Addendum: I have researched this issue and the legal implications associated with blood transfusions in Jehovah's Witness patients. The advice is that "medical providers should take care that each patient presenting as one of Jehovah's Witnesses has ample opportunity to express their personal preferences of treatment outside the presence of any other member of the faith, including close family members." And that is exactly what I did.

Dr. Neil Baumis a practicing urologist in New Orleans, Louisiana and the author of "Marketing Your Clinical Practice: Ethically, Effectively, and Economically," (4th edition) Jones and Bartlett, 2009.