When medicine and religion collide

Few medical conflicts are as morally vexing-or as legally risky-as when a patient's religious beliefs limit a physician's treatment options. Some fundamentalist Christian patients, for instance, may decide to forgo treatment, preferring to rely on prayer instead. Patients in some sects refuse vaccination; others would refuse an appendectomy, because the body must enter the afterlife with all its organs. Even the decision to undergo pre-natal testing may be colored by religious beliefs.

In such situations, a doctor is forced to choose between two fundamental principles: respect for patient autonomy, and the duty to provide optimal care. In most cases, the most a physician can do is reason with the patient. But there are instances when the physician might be in a position to override a patient's expressed wishes. In those situations, the physician's decision could leave him as a defendant in a malpractice suit or charged with battery.

While the AMA ethics code offers no specific rules for doctors caught in such conflicts, a number of court decisions provide useful guidance. Most such cases involve Jehovah's Witnesses, whose roughly 1 million US members generally oppose blood transfusions on religious grounds; typically they request "bloodless" alternatives instead.

For physician defendants in these cases-surgeons as well as primary care doctors who refer Witness patients to them-battery claims can pose a much greater financial risk than malpractice claims because battery is an intentional tort, not an act of negligence or malpractice. So a battery claim might not be limited by caps on noneconomic damages (depending on state law); and it might qualify for punitive damages, which are rarely awarded in malpractice cases. Worst of all, since battery is not considered negligence, it's generally not covered by malpractice insurance policies-meaning the doctor-defendant could be personally liable for a judgment against him.

An unconscious patient needs a transfusion

Consider the case of Charles Harvey, who was diagnosed with blockage in his carotid artery and referred to Glen Strickland, a general surgeon in West Columbia, SC. Harvey, then 50, explained that as a Jehovah's Witness, he wouldn't accept blood transfusions. Strickland agreed to remove the blockage, and told Harvey it could be done without a transfusion. (Strickland had replied to a survey from the Jehovah's Witnesses indicating that he was "willing in principle" to offer medical treatment without the use of blood.)

Harvey then signed two forms, "Refusal of Treatment/Release from Liability" and "Consent to Operation," in which he expressly refused the transfusion of blood or blood products, even in emergency situations, and relieved Strickland from any resulting legal claims. On those documents, he indicated that he fully understood the attendant risks of his decision, and that "in all probability, my refusal for such treatment, medical intervention, and/or procedure" could "seriously imperil my health or life."

Strickland performed a carotid endarterectomy, which initially appeared to have gone well. But in the recovery room, Harvey developed more blood clots and had a stroke. Strickland then performed a second procedure to remove the clots. Afterward, when the ICU nurse discovered that Harvey was having trouble breathing, he was intubated by an on-call ED doctor. The next day, he began to bleed from the surgical site. By then, he had lost about 30 percent of his blood volume, and his heart rate was extremely high.