How To Approach Ethical Scenarios in the Medical School Interview and in the MMI
In an MMI, you might be asked to respond to an ethical 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?
Answers to these types of 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 scenarios. If you would prefer to listen, please see our podcast episode on approaching a patient who is refusing a blood transfusion.
A Common Scenario: Treatment of the Jehovah’s Witness with a 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 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 determining their wishes, and if a delay may place the patient in serious harm
Even in an emergent situation, you should involve other team members in your decision- making. You should also consider consulting with the hospital's administration and legal team.
Remember to involve other team members in this challenging decision
What if you cannot consult with the hospital administration before proceeding with treatment?
In an emergency situation, you may not be able to consult with others before making a decision regarding blood transfusion. If you feel that you have no other option but to proceed, given the patient’s medical condition, it's extremely important to document what happened and why you did what you did.
Once the patient is stabilized, you need to discuss the situation with your hospital's team because there are potential legal ramifications to your actions.
In general, when asked to respond to any questions that involve ethical principles, it’s always important to demonstrate to interviewers that you would confer with others whenever possible.
The Framework for a Response to an Ethical Scenario
It’s very helpful to have a general framework for your response. It’s also helpful to have a few introductions that are ready to go.
One other important point: if you have any personal experience with such a situation, that can be helpful to add in.
Here’s an Example of an Outline that You Can Use to Develop Your Full Response
I know that physicians are sometimes faced with these types of challenging scenarios. When I was volunteering in the emergency room, I noticed that the ER nurses would ask every patient about their wishes regarding potential blood transfusions.
Verbalize the underlying issue or question
In this case, the most important thing would be the emergent care of the patient. Can I stop the bleeding and stabilize the patient without having to use a blood transfusion? If a blood transfusion is deemed medically necessary, can I administer that blood transfusion in a patient whose faith speaks against the use of blood transfusions?
Response (notice the use of words that help structure your response)
To begin with, I would try to determine the patient's own wishes. Patient autonomy is such an important ethical principle, and I would do everything in my power to try to understand the patient’s wishes. Hopefully, they are conscious and coherent and are able to tell me in their own words.
If they were not able to convey their wishes, I would then do everything possible to see if there was any other indication of their wishes. I especially would not want to jump to any conclusions about a patient’s wishes. I know that among practitioners of different religious faiths, there are variations in how closely individuals adhere to the tenets of their faith, and therefore I would try to understand everything I could about the patient’s own wishes.
I would look through the chart to see if there was any information there. I would check to see if there were any advanced directives about blood transfusions. If this information wasn’t available, I would check with their family members or loved ones to try to understand their wishes.
If I could not locate any information in a timely fashion, I know the most important thing in an emergent situation is to treat the patient, and therefore I would proceed with blood transfusion if it were medically necessary. If I had enough time, I would definitely try to speak with the hospital administration and legal team. If we didn’t have enough time, I would make sure to document thoroughly, because there may be legal ramifications. After the patient was medically stabilized, I would then make sure to speak with the hospital administration more thoroughly.
This is a tricky scenario, and it really highlights the importance for patients of trying to prepare advanced directives to make sure that their wishes are known in a medical emergency. It also highlights how important it is for physicians providing routine care to help their patients understand the need for advance directives, and especially how important these become in a medical emergency.
Dr. Rajani Katta is the creator of Medical School Interviewing 101, the course that teaches students how to ace their interviews. She is also the author of the best-selling book The Medical School Interview: Winning Strategies from Admissions Faculty, and served as Professor of Dermatology at the Baylor College of Medicine for over 17 years.
Dr. Samir Desai is the author of The Medical School Interview and Multiple Mini Interview: Winning Strategies from Admissions Faculty. He has served on the medical school admissions and residency selection committees at the Baylor College of Medicine and Northwestern University Feinberg School of Medicine.