Legal and Ethical Challenges
The key ethical principles which underpin medical practice are non-maleficence, beneficence, autonomy and justice and their utilisation applies to care of any patient undergoing cardiac surgery, including Witnesses11,12,22,24. This is outlined, along with core legal principles, within existing clinical guidelines, as well as case reports, with one notable example by Papalexopoulou et al .12. This case helps to demonstrate the ethical principles of beneficence and non-maleficence, as it presents a complex case in which the risk-to-benefit of treatment was vital to assess12. It discusses that it can be deemed inappropriate for clinicians to refuse to treat a patient based on such factors as high risk12. A clinicians choice to treat Witness patients is further noted in guidance by RCS England22. Doctors do have a choice about whether to treat patients who refuse blood transfusion, as the clinicians may deem this a conflict to their role as a doctor, especially in life-saving situations. If so, the refusing clinician must refer the patient to a doctor who is prepared to perform treatment with knowledge of the patients views. This must be recorded adequately to prevent claims of misconduct22. Furthermore, the concept of adequate note-taking and record keeping is also considered within guidelines with regards to discussions about treatment options and eventual decision making with patients, allowing for autonomy10,22. Patients with mental capacity have the right to refuse treatment, and this is upheld in both ethical and legal respects, making administration of blood products against the patients will potentially unlawful22. It is imperative that alternative treatments are made available to Witness patients, with a number having been developed over the years.