How To Approach Ethical Dilemma Scenarios in the Medical School Interview and in the MMI
Updated: Jan 10
In an MMI, you might be asked to respond to an ethical dilemma scenario. Such questions are less common in traditional interviews, but may still be asked.
One such common scenario is related to the treatment of a Jehovah’s Witness. Specifically, how would you respond to a scenario in which you were treating a patient who might require a blood transfusion and was known to be a Jehovah's Witness?
Before and After Sample Response:
How to Approach Blood Transfusions in Jehova's Witnesses
Answers to these types of ethical dilemma scenarios and questions are not about cognitive knowledge or medical reasoning, but rather your overall approach to challenging situations that pose ethical dilemmas. How do you approach a patient like this, and how does that reflect upon your compassion, your values, and your understanding of medical ethics? In this post, we outline our approach to handling these types of challenging ethical dilemma scenarios.
The post begins with important background to help you understand why Jehovah's Witnesses may refuse blood transfusion.
Then we provide a sample response to how to respond to this ethical dilemma scenario.
If you'd prefer, you can skip to the end of the post to see our sample response.
If you would prefer to listen, please see our podcast episode on approaching a patient who is refusing a blood transfusion.
A Common Ethical Dilemma Scenario in the MMI:
Jehovah’s Witnesses Blood Transfusion
If you were treating a patient who was a Jehovah's Witness, and he or she was bleeding out on the table, what would you do if you have only minutes to decide?
This is a common ethical dilemma scenario, and it's one that physicians have faced many times in the past. It's also a common question among interviewers.
The management of the Jehovah's Witness patient with serious bleeding is very challenging. There are multiple ethical, legal, and medical concerns for the practitioner.
Don't Jump to Conclusions When It Comes to Blood Transfusions in a Jehovah's Witness Patient
This is a challenging situation. Many applicants know that among practitioners of this faith, blood transfusions are typically rejected. Therefore, in responding to this question, many students jump to the conclusion that the physician should not administer a blood transfusion.
However, the situation is more nuanced than that. The best response to this question involves:
First, an understanding that practitioners of religious faiths may vary in how they observe their faith.
Second, an understanding of the major ethical principles underlying the practice of medicine.
In this post, we'll show you how to come up with a powerful response to this question.
Why do Jehovah's Witnesses refuse blood transfusions? Important Background
Before we discuss how to handle this challenging situation, let's take a step back and review some important information about Jehovah's Witnesses and their faith.
There are over 1 million Jehovah's Witnesses in the United States. The Jehovah's Witness society is a Christian denomination. It traces its origins back to 1872.
In charge of the society is a governing body known as the Watchtower Society. Witnesses believe in a very strict and literal interpretation of the Bible. It is this interpretation which leads practitioners of the faith to refuse some types of medical care.
For example, one passage from Genesis reads "but you must not eat blood that has its lifeblood still in it." This passage has been taken to mean that blood cannot be eaten as a form of nourishment.
In medicine, we can "nourish" our patients in different ways. One form of nutrition is delivered through the IV or intravenous route. Since blood transfusions are also given intravenously, the Watchtower Society views blood transfusion as a form of nourishment, or eating of blood.
This view led to a 1945 church decision, and that decision prohibited Jehovah's Witnesses from receiving blood transfusions. Many Jehovah's Witnesses believe that by accepting blood, they will give up their right to be a member of their faith and lose any hope of eternal life. In the past, the Watchtower Society has supported the shunning and social isolation of members who violate this doctrine.
In 2000, the Watchtower Society loosened its stance a bit, backing off on the excommunication of members who violate the doctrine. They wrote, and I quote, "If a baptized member of the faith willfully and without regret, accepts blood transfusions, he indicates by his own actions, that he no longer wishes to be one of Jehovah's Witnesses. The individual revokes his own membership by his own actions."
It's important to have this context and background about Jehovah's Witnesses, because we hear so much about how we shouldn't give blood transfusions to practitioners of the faith.
Although you may have heard of this belief, we find that many medical school applicants aren't familiar with the reasons why this belief is held. It's very important that we take the time to understand where patients are coming from and their perspectives.
Do all Jehovah’s Witnesses refuse blood transfusion?
Not all practitioners of this faith refuse blood transfusion in all cases.
Especially in an emergent situation, it's important to ensure that the patient understands the consequences of refusing blood transfusion. It’s not unheard of for a patient to go against this tenet of their faith when faced with a medical threat to their life. The bottom line is that the patient gets to decide, and it’s important to understand what the patient’s wishes are.
It’s Important to Understand Autonomy as One of the Foundational Principles of Medical Ethics
There are four major ethical principles that underlie the practice of medicine. These include:
In order to be prepared for ethical questions, you need to understand these four major principles. For a quick explanation of these principles, you can listen to two of my podcast episodes on this topic. These are episodes that were recorded for the Step 2 Success Podcast, which is used to help medical students prepare for the USMLE step 2 exam.
In this episode, I review the principles and present a few representative cases
In this episode, I delve deeper into the principle of autonomy
What does autonomy mean in medical ethics?
Essentially, autonomy means that a patient gets to decide what happens to his or her body.
Specifically, an adult patient with capacity gets to decide what medical care they receive or don’t receive.
How does this relate to our Jehovah’s Witness patient? The first thing to do in this situation is to ask the patient. In the case of a patient who is awake and coherent, they can obviously tell you their wishes. You would proceed or not proceed with a blood transfusion depending on the patient’s wishes.
As a healthcare provider you must involve the patient in their care plan
Decision-Making in the Patient’s Best Interest: The Importance of Beneficence
Beneficence states that we provide medical care that is in the patient’s best interest. If the patient is unconscious, and you have no information about their wishes, you are obliged to act in the patient’s best interest. In the case of a bleeding patient, you would focus on stopping the bleeding. If blood transfusion is necessary, the situation becomes more complex.
In general, autonomy takes precedence over beneficence. In other words, a patient can decline medical care, even if it’s in their best interest. In this case, the patient is unconscious and you don’t know what they would choose to do. This is when you need to turn to collateral sources of information.
Collateral Sources of Information:
The Importance of Looking for Advanced Directives or Seeking Information from Family Members or other Loved Ones
If a patient is unconscious, you may need to turn to collateral sources of information.
You can look through the hospital record or chart, and see if there’s any notation or documentation of the patient’s wishes. Have they made a specific request not to be transfused in the past?
Some Jehovah’s Witness patients carry advanced directive cards with them, on their person, indicating their wishes regarding blood transfusions. Always look for any advanced directives.
If such information is not available, you can contact a relative or other loved ones. They can inform you what the patient would have wanted.
What if you have no information about what the patient would have wanted, and you are dealing with an emergency situation?
If you do not have any information about the patient’s wishes, and this is an emergency situation, then you need to act in the patient’s best interest. If there is no other alternative but to give blood, then you may choose to do so.
This action is in agreement with the Health Care Consent act, which states that medical treatment may be given without consent in an emergency.
This specifically holds true if, in the opinion of the physician, there is no means of communicating with the patient or det