MINOR CHILDREN UNBORN CHILDREN PARENTAL OBLIGATIONS ADULT CHILDREN

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IN RE SHEILA W. was a 2012-13 Wisconsin case. In 2012, a 15 year-old Wisconsin Jehovah's Witness female was diagnosed with aplastic anemia, a life-threatening illness in which a person's immune system attacks the person's bone marrow. She was treated at the University of Wisconsin Hospital, in Madison, where her doctor said she would die without blood transfusions. Sheila and her JW Parents refused to consent to the life-saving blood transfusions. Interestingly, the JW Teen told a Dane County circuit judge that a life-saving blood transfusion would be "devastating to me mentally and physically," and was "the equivalent of a rape", which is the standard WATCHTOWER BS LINE that most JWs state during such court hearings. Dane County filed a petition that led to the appointment of a guardian for the girl, who then approved the needed blood transfusions, which were administered in March 2012. In June 2013, the Supreme Court of Wisconsin declined to rule on the issue declaring this particular lawsuit to be moot due to expiration of the guardian appointment.

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SAN JOAQUIN COUNTY HUMAN SERVICES AGENCY v. MARCUS W., a Minor was a 2010 California appellate court case. See related 2018 Arizona STATE appellate court decision, GLENN HAWKINS AND SONJA HAWKINS v. BANNER CARDON CHILDREN'S MEDICAL CENTER ET AL (GLENN H. v. HOPKINS).

In October 2008, Marcus W., an African-American 16 year old Jehovah's Witness who suffered with sickle cell anemia, was ordered by a California Juvenile Court to undergo periodic blood transfusions for a term of one year to prevent him from suffering a third stroke, and possibly death. Marcus W. and his Jehovah's Witness Parents opposed the transfusions as contrary to his WatchTower beliefs, and appealed the Juvenile Court order. In June 2010, the California Court of Appeals reversed the JC order, despite the fact that it expired in November 2009, explaining:

We conclude the juvenile court lacked jurisdiction to issue the order because the requirements of Welfare and Institutions Code section 369 were not met. (Further section references are to this code unless otherwise specified.) Thus, we need not address the minor's other claims of error.

As we will explain, section 369 provides the juvenile court with jurisdiction to order the performance of necessary medical care for a minor only when (1) the minor has been taken into temporary custody pursuant to section 305, or is a dependent of the court pursuant to section 300, or is named in a petition filed to declare the minor a dependent of the court, (2) a licensed health care professional recommends that the minor needs medical, surgical, dental, or other remedial care, and (3) the minor's parent, guardian, or person standing in loco parentis is unwilling or incapable of authorizing such care.

Here, the minor had not been taken into temporary custody pursuant to section 305, the San Joaquin County Human Services Agency (the Agency) had not filed a section 300 petition to declare the minor a dependent child of the court, and the minor had not already been adjudicated a dependent child of the court. Thus, the juvenile court did not have jurisdiction to order the minor to undergo blood transfusions against his will and over the objection of his parents.

Why did the San Joaquin County Human Services Agency fail to follow proper legal procedure? This court further explained that the Agency and even the local court simply had been kowtowing to the WatchTower Society:

The Agency makes the policy argument that the filing of a section 300, subdivision (b) petition should be excused because such a petition "with its stigma of parental abuse or neglect [has been] found to be offensive to the parents of Jehovah's Witness children and even to the medical professionals seeking the order for the transfusion," and has caused "additional emotional trauma during a time of stress for the family." The Agency states that, in the "early 1990s," the Hospital Liaison Committee for Jehovah's Witnesses in Stockton asked for implementation of a "system by which medical professionals seeking authorization for a court order for blood transfusions could obtain an order without a "300b" petition being filed, but while still providing ... full due process of a hearing before the Judge who would make the order." After "consultation with the Juvenile Court, [such] a system was created" and was later used in this case.

The problem is that, although well intended, the "system" created in San Joaquin County does not comply with the statutory scheme and results in a juvenile court acting without subject matter jurisdiction.

Apparently, this JW Family was encouraged to pursue this belated appeal in order to make yet another attempt to get the California Courts to reconsider their yet-to-date refusal to adopt the "mature minor" doctrine. This appellate court stated:

The minor and his parents filed opposition to the application, requested an evidentiary hearing to determine whether the minor is a "mature minor possessing the competency and the responsibility to make his own medical decisions," and asked the juvenile court to dismiss the application "on the basis that [the minor] is a mature minor with the capacity of giving informed consent."

Counsel for the Agency responded that, while some states have recognized a mature minor doctrine, allowing sufficiently mature minors to make their own medical decisions, such a doctrine "has not been recognized in California." Indeed, argued county counsel, the fact the Legislature has enacted specific statutes allowing certain minors to make their own medical decisions' e.g., emancipated minors (see Fam. Code 7050, subd. (e)) and minors seeking medical care related to sexually transmitted diseases, treatment of drug or alcohol abuse, and mental health care (see Fam. Code, 6926) indicates "the failure to enact a broad `mature minor' statute is not an oversight, but rather an intentional limit on the rights of minors to make their own health care decisions." Accordingly, county counsel asserted, "until such time as [the minor] reaches the age of full and legal discretion, the court [should] exercise its interest as parens patriae, to [e]nsure that [he] gets appropriate treatment."

At the hearing on the application, the minor's attorney conceded "California does not have a mature minor doctrine," but disagreed with county counsel's assessment that the specific statutes allowing certain minors to make their own medical decisions in certain situations indicated the Legislature intended to preclude the courts from straying outside the confines of these provisions in recognition of a broader mature minor doctrine. In the alternative, the minor's attorney argued that the juvenile court should hear from the minor, "as [a] due process measure," to allow him to express his feelings concerning the blood transfusions.

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WASHINGTON STATE'S CONSPIRACY OF DEATH

In the opinion of the medical personnel, this created an imminent and serious risk to her life or health. Her doctors wished to give her a blood transfusion, but both she and her Jehovah's Witness Parents refused to consent to the receipt of any blood or blood products on religious grounds. The hospital contacted the Director of Child and Family Services, and the director apprehended April as a child being in need of protection.

An application was filed with the court requesting that the time for notice be abridged subject to an undertaking that written documentation would be filed within 24 hours of the hearing, that the application be heard, and that the director be granted an order authorizing qualified medical personnel to administer blood transfusions to April Cadoreth, as deemed necessary by the attending physician, without the consent of her parents.

The hearing began with the applications judge hearing the matter in the courtroom with a clerk. Counsel for the director was in the courtroom. Counsel for the Winnipeg Regional Health Authority attended by way of telephone conference call. WRHA counsel and April's doctor were in a boardroom of the hospital, along with April's father. Due to time constraints, the WatchTower Society coordinated the hiring of a local attorney, who participated in the hearing, first by way of cellular telephone in his car, and then, once he had arrived at the hospital, by way of telephone, along with April's father and counsel for the Winnipeg Regional Health Authority, in the conference room of the hospital.

The social worker, April's doctor and April's father all gave evidence. The child protection social worker testified that she had placed April under apprehension in the early hours of Sunday morning after speaking to April's Jehovah's Witness Parents, who had refused their consent to any treatment involving blood transfusions or blood products.

April's doctor testified that he felt blood transfusions were indicated because April's hemoglobin level was very low and there was a risk her vital organs were not receiving sufficient oxygenation. As well, hospital personnel were giving her intravenous fluid to maintain adequate blood pressure, which had the effect of further diluting the amount of hemoglobin that was actually circulating in her body. Until her low hemoglobin level was dealt with, the doctors could not take any procedures to investigate further and determine whether the bleeding was continuing. While the non-blood product that was presently being administered (factor seven) might assist in stopping further bleeding, it had its own risks. In any case, it would not affect her present low hemoglobin count. Even if there was no further bleeding, it might take a week or two for April's hemoglobin to rebuild naturally.

The doctor explained that the risk to April was "significant". The concern was that even if they assumed that the internal bleeding had stopped, if they waited for the hemoglobin to rebuild naturally, there would be ongoing damage to April's bone marrow and her kidneys. If April's body went without oxygen long enough, as a result of her blood loss and consequent diminished hemoglobin, April "will suffer some serious damage to her organs." While the doctor was unable to predict the timing involved in the situation, he did testify:

"The longer she goes without, the more the risk is of her having serious oxygen deprivation to the point where [if] for argument sake she's not getting enough oxygen to her kidneys, they will shut down and cause essential poisoning of her system. If she does not get enough oxygen to her brain she can conceivably have seizures and other manifestations of the brain that will contribute to a faster demise or death." 

Counsel for the Jehovah's Witness Parents cross-examined the social worker and the doctor. April's father testified that he and his daughter had a religious objection to the use of blood products.

Based on the evidence, the applications judge was satisfied that there was "immediate danger as the minutes go by, if not death, then certainly serious damage." The judge assumed for the purposes of the hearing that April had "capacity" and that her wishes were to refuse the blood transfusion. In addition to the evidence of her father and the hospital personnel as to April's wishes, the judge also took into account the "Advance Medical Directive" executed by April earlier that year.

Nonetheless, the Judge granted the treatment order, concluding that the blood transfusions would be in April's "best interests". He held that the "best interests" test governed this decision even for minors with capacity, if they were under 16 years of age. April was then given three units of blood. 

On April 21, 2006, the director filed a petition and notice of hearing . When it became apparent that the treatments were successful, and the child was recovering, the director sought to withdraw its application for an order declaring April Cadoreth to be a child in need of protection. The petition was withdrawn May 1, 2006.

According to the WatchTower Cult book, GOD'S KINGDOM RULES!, page 163, "April later likened the experience to rape."

"Refusal of Blood transfusion for a minor. As the parent/guardian of a minor child I understand that the doctor(s) treating my child will make every effort to respect my beliefs regarding the transfusion of blood products as indicated above. However I also recognize that my child's physicians have a legal obligation not to withhold therapy they think is necessary to keep my child alive or to keep him/her from serious harm or permanent injury or disability. I understand therefore that, if the treating physician believes transfusion, after evaluating alternative non-blood medical management, is necessary to save my child's life, or to prevent serious irreversible harm, my child may be transfused although every effort will be made to avoid this."

Below that crossed out paragraph, father hand-wrote the following statement:

"Berkley Ross Conner Jr. is a mature minor. Will not condone blood transfusion but will accept [blood fractions and blood alternatives]. Berkley, at 4 months shy of 18 yrs is able to make his own decisions. This statement by parent /s/ Berkley Conner."

Eight days later, on November 22, 2005, Conner's treating physician, along with other concurring physicians at OHSU, prepared a handwritten letter to the local court requesting an ex parte order authorizing them "to be able to transfuse [Conner] with blood products if necessary, in the future, to prevent death or serious irreversible harm." The court granted that order.

The following day, Conner's parents requested and were afforded a hearing. Present at that hearing were Conner's mother, father, and attorney. Conner testified by speaker phone. During the hearing, Conner's attorney explained that "the only real issue here is [Conner's] capacity to make [health care] decisions under the law." Conner's attorney submitted to the court several cases from other jurisdictions that had applied the common-law "mature minor" doctrine in cases similar to Conner's. He also stated, almost parenthetically and with no supporting argument, that "the matter of due process, equal protection, and fundamental fairness would demand that a child that's that close to being 18 should have an opportunity to be heard." The court heard testimony from Conner's father, mother, and from Conner himself, primarily regarding his capacity to make health care decisions concerning blood transfusions and the sincerity of his faith. Specifically, Conner and his parents testified that he was a senior in high school; he had a 3.5 grade point average; he was interested in chemistry and physics; he has spoken at length to the doctors regarding his diagnosis; and he fully understood the nature of his disease and the consequences of refusing a blood transfusion. They further explained that Conner refused the blood products explicitly on religious grounds that he has held since age 10, and that he himself had chosen to be baptized in the church the previous summer.

The juvenile court declined to create and apply an Oregon version of the "mature minor doctrine", noting that its own "obligation is to enforce the laws of this state, and the law in this state is that somebody under the age of 18 is a minor and therefore does not have the legal capacity to make this kind of a medical decision." The court then issued an order stating: "This Court's 11/22/05 order authorizing transfusions if deemed necessary by the attending physicians to prevent death or serious irreversible harm is hereby continued."

"... petitioner makes a variety of legal arguments supporting his contention that a mature minor exception should be applied in the present case. He explains that the legislature has long afforded minors the ability to make health care decisions on certain issues, such as treatment of venereal disease, ... sterilization, ... and abortion... . He points out that other jurisdictions have allowed mature minors to make health care decisions, including refusal of treatment. See In re E.G.,... (1989) (17-year-old Jehovah's Witness with leukemia allowed to make decision regarding refusal of blood transfusion as a mature minor even though the age of majority in Illinois is 18); In re Swan, ... (1990) (minor's stated desire not to remain on life support adhered to); In re Rena,... (1999) ("It is appropriate for a judge to consider the maturity of the child to make an informed choice.").

 

"Petitioner argues that the federal and state constitutions provide protections not only for adults, but also for minors, ensuring them free exercise of religion and substantive due process. He notes in particular that the Supreme Court has deemed unconstitutional a flat ban on abortions for minors, requiring instead individualized hearings. See Planned Parenthood of Missouri v. Danforth, ... (1976) ...

"Although petitioner raises complex and interesting issues, we do not have occasion to consider them in the present case. ...

 

"... The court's order authorizing emergency medical care ceased to have any legal effect on petitioner's eighteenth birthday. The present appeal is therefore moot. Appeal dismissed."

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The following is an excerpt from the article, Who decides: You or your patient?", from MEDICAL ECONOMICS, December 2004:

If the patient isn't a consenting adult, however, all bets are off. In the case of a minor, most states require you to notify child protection services if a parent refuses vital therapy on a child's behalf. "Most parents base these decisions on religious beliefs," [Dr. Eric E.] Shore says. "I had that situation once with a teenager who had lost a great deal of blood due to trauma. The parents were Jehovah's Witnesses and, since the boy was obtunded, refused transfusion for him. The hospital obtained a court order to transfuse him. Once awake, the boy told us that he didn't believe the way his parents did, and was glad we transfused him."

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On January 26, 1999, Alexis Demos lacerated her spleen in a snowboarding accident. Demos was taken to Berkshire Medical Center's emergency room. Upon examination, it was determined that in order to keep her blood count at a stable level a blood transfusion might become necessary to keep Demos alive. Both Demos and her Jehovah's Witnesses parents indicated that they would not consent to a blood transfusion. The hospital then filed a complaint for declaratory relief in the Superior Court seeking authority to administer a blood transfusion if the same became necessary to treat her injury. At a hearing, the hospital presented medical evidence that there was a potential need for this authority in the event a blood clot broke loose from the spleen laceration, which might result in a massive hemorrhage, which in turn might require a blood transfusion to sustain her life. At this hearing, the wishes of the parents and those of Demos through her attorney were made known to the judge. Based on the best interests of Demos and the State's interest in the preservation of life and protection of the welfare of a minor, the judge entered a temporary order allowing Demos' physicians to administer a blood transfusion in the event of a life-threatening, traumatic event. At a subsequent hearing, the judge entered a final order authorizing the hospital "to administer a blood transfusion to [Demos] in the event that a life-threatening, traumatic event occurs during her treatment that requires, in the medical opinion of her treating physicians, the administration of a blood transfusion." On the day after the presentation of oral argument at the appellate level, Demos was discharged from the hospital in good health. On appeal, the appellate court vacated the trial court's final order, stating in part:

"The sole issue in this case is whether the judge erred in concluding that the best interests of an unemancipated minor and the State's interest in the protection of a child's welfare and in the preservation of a child's life mandated judicial authorization for administering a blood transfusion to Rena, if, in the opinion of her physicians, a life-threatening event occurred in the course of her treatment. Rena argues that the judge committed error in failing to consider her maturity to make an informed decision in determining her best interests.

"The law is well settled in this Commonwealth that a competent adult may refuse medical treatment even if the treatment is necessary to save her life. ... The law is also clear that when parents refuse medical treatment necessary for the preservation of an unemancipated child's life, a court may authorize the treatment to be administered after weighing the child's best interests, the parents' interests, and the State's interests. ... The best interests of a child are determined by applying the same criteria applicable in substituted judgment cases, namely (1) the patient's expressed preferences, if any; (2) the patient's religious convictions, if any; (3) the impact on the patient's family; (4) the probability of adverse side effects from the treatment; (5) the prognosis without treatment; and (6) the present and future incompetency of the patient in making that decision. ... In assessing the child's expressed preference, religious convictions, and present and future incompetency, it is appropriate for a judge to consider the maturity of the child to make an informed choice.

"The Illinois Supreme Court has determined that the test that should be applied in circumstances such as this is whether the minor is mature enough to make an informed decision. In Re E.G. ... (1989). This concept has been adopted by our Legislature in allowing a judge to authorize a minor to have an abortion without parental consent if the judge determines that the minor is mature enough to make an informed decision. ...

"We recognize that our laws provide no bright line as to when a minor reaches an age to make certain decisions in life. ... An emancipated minor and a minor who is married, divorced, or widowed may consent to his or her own medical treatment, including abortion and sterilization. ...

"Although the judge did consider Rena's wishes and her religious convictions in this matter, he made no determination as to her maturity to make an informed choice. While recognizing and appreciating the obvious conscientiousness of the judge throughout this proceeding, we think this was error particularly in the circumstances of this case where Rena will soon attain the age of eighteen. In addition, in assessing Rena's preferences and religious convictions, he should not have relied solely on the representations made by her attorney and her parents but should have heard Rena's own testimony on these issues where she apparently had the testimonial capacity to answer questions. Only after evaluating this evidence in light of her maturity could the judge properly determine her best interests.

"Because the Supreme Judicial Court has not decided that the State's interest in preserving a child's life will invariably control in every case where State intervention is sought for life-saving measures, ... we ordinarily would remand this case to the Superior Court for an expedited hearing to determine the best interests of the child in light of this opinion and to reassess the three-part balancing test of Rena's best interests, the rights of her parents, and the interests of the State. The hospital has informed us, however, that on the day after the presentation of oral argument in this case, Rena was discharged from the hospital. Consequently, there no longer appears to be an immediate need for the hospital's authorization or judicial intervention in this matter. We, therefore, vacate the final order, not on the merits, but because it has become moot."

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"It is well-settled law in this, and most other jurisdictions, that a competent adult has a common-law right to refuse medical treatment. ... However, when the patient is a minor, the court must act parens patriae (in place of the parents); because parents may throw their own lives away, if they wish, but they cannot make martyrs of their children.

"Counsel for the patient and his parents posed the following legal question. Does an intelligent, articulate young man, just weeks shy of his 18th birthday, have due process right to demonstrate his capacity to make medical decisions for himself consistent with his values and convictions before he loses the right to control what is done to his body? This concept has been recently adopted by the highest court in Illinois. The Supreme Court of Illinois said, 'If the evidence is clear and convincing that the minor is mature enough to appreciate the consequences of her actions, and that the minor is mature enough to exercise the judgment of an adult, then the mature minor doctrine affords her the common law right to consent to or refuse medical treatment.' Tennessee has also accepted the 'mature minor' doctrine. The Supreme Court of Tennessee noted that the mature minor doctrine is not a recent development in Tennessee law. It stated, 'recognition that minors achieve varying degrees of maturity and responsibility (capacity) has been part of the common law for well over a century.'

"Should one equate the right to consent to medical treatment with the right to refuse medical treatment? If so, there are numerous instances in our State's statutory law that permit minors to consent to treatment for out-patient mental health services; treatment for substance abuse; and treatment for sexually transmitted diseases. In addition, minors over the age of 16 can consent to in-patient mental health treatment. Pregnant minors and minors who are parents are treated like adults for decision-making capacity for their own and their children's health care. ...

 

"While this court believes there is much merit to the "mature minor" doctrine, I find that Phillip Malcolm is not a mature minor. Therefore, his refusal to consent to blood transfusions is not based upon a mature understanding of his own religious beliefs or of the fatal consequences to himself. It is recommended that the Legislature or the appellate courts take a hard look at the "mature minor" doctrine and make it either statutory or decisional law in New York State."

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In June/July 1989, an unidentified 20 year-old Jehovah's Witness female died after refusing to consent to blood transfusions made necessary by her aplastic anemia -- a particularly severe blood disorder that requires intensive treatment, including blood transfusions. The young JW still lived at home with her JW Parents, who apparently agreed with her choice to die. Doctors described the 20 year-old red-headed, blue-eyed, female as having a nearly "translucent" fair complexion. The JW had taken canthaxanthin "tanning pills" until such had turned her skin a bright orange. During the four months that followed, she developed aplastic anemia, which had symptoms including headaches, fatigue, easy bruising, and weight loss. After finally seeking medical treatment, she was transported from her home "in the Midwest" to Vanderbilt University Hospital, where doctors did all they could, but could not save her life without blood transfusions. She and her parents checked out, and she returned home to die, which happened soon thereafter.

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IN RE LAWRENCE TURNER was a 1961 New Jersey court decision. In December 1961, an African-American 19 year-old Jehovah's Witness, named Lawrence Turner Jr., of Philadelphia, Pennsylvania, was admitted to Atlantic City Hospital, in critical condition, in need of a blood transfusion due to his sickle cell anemia disease. When Lawrence Turner Sr. refused to consent to the needed transfusion, the hospital sought and obtained court intervention. However, Turner Junior died two days later.

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MATURE MINORS DOCTRINE

Much critical analysis of the issue of forced treatment of decisionally competent adolescents focuses exclusively on competence and questions why mature minors may not decide for themselves. ... a focus on decision-making competence alone is too narrow. Before one may legally give or refuse consent to medical treatment, three conditions must be met: competence, adequate information, and lack of coercion. ... in addition to fulfilling existing statutory duties to report a child in need of protection, health care professionals caring for acute patients of JW families should actively look for evidence that the patient has accurate medical information and is acting without coercion. Coercion by actual or threatened shunning and excommunication can occur, and these factors may affect adolescent decision-making. In this context, a court order authorizing medical treatment can, therefore, be seen as enhancing patient freedom.

Lack of information on which to base decision-making.

Critics of the orthodox WTS blood dogma, ... claim that the WTS inaccurately finds justification for its blood ban in Biblical passages ... concerning rules governing meat preparation, which have nothing to do with blood transfusion. Critics state that it is illogical for the WTS to claim that a blood transfusion is an "eating" of blood, because a transfusion is more akin to a cellular organ transplant than the administration of nutrition.

[Critics] claim it is also illogical to permit some blood parts but not others when the Bible itself does not distinguish among blood components. ... the WTS claims that the Bible prohibits transfusions of whole blood, packed red blood cells and plasma, as well as white blood cells and platelet administration. The WTS asserts that these Biblical passages do permit adherents to use components such as albumin, immune globulins and hemophiliac preparations, and to receive organ transplants.

Critics particularly condemn the inconsistancy of medical bans generally and of the blood ban in particular. They note that the WTS used to ban vaccinations and organ transplantations but has reversed these positions, and that the WTS has altered the blood dogma itself over time. According to neurologist Muramoto, "Official church publications show that the use of serum was prohibited by the church from 1964 to 1973, the use of clotting factors by hemophiliacs was prohibited until 1978, and the use of albumin was forbidden until 1981". The anesthesiologist Doyle states that the WTS reversed its position on the acceptability of the use of hemoglobin-based blood substitutes in two years (1998 to 2000). ...

According to Kerry Louderback-Wood, the official WTS pamphlet describing the blood policy "How Can Blood Save Your Life?" misrepesents secular facts, historians' writings, the current medical risk of accepting a blood transfusion, the necessity for blood in certain medical situations, the safety and efficacy of medical alternatives to blood transfusion, and the organization's policy in 2005 as to the scope of allowed products.

Lack of voluntariness in decision-making.

Concerns about voluntariness have also been raised. Quoting the official WTS publication, The Watchtower, Muramoto claims that JWs are warned in harsh language against reflecting upon the WTS Biblical interpretations:

"Avoid independent thinking. From the very outset of his rebellion, Satan called into question God's way of doing things. He promoted independent thinking. 'You can decide for yourself what is good and bad,' Satan told Eve. 'You don't have to listen to God.' How is such independent thinking manifested? A common way is by questioning the counsel that is provided by God's visible organization [ie, The Watchtower Society] ... ."

This WTS's discouragement of the independent gathering and sharing of information is the general background against which a number of specific autonomy-limiting practices are said to take place. ... these practices include: 

-- the completion of advance directives during group Bible study sessions, without the provision or encouragement of private, independent legal advice; 

-- the official church suggestion that it is ethically appropriate for hospital personnel to breach patient medical confidentiality and to report the religiously unauthorized medical treatment of a JW to religious leaders;

-- the requirement that orthodox JWs disassociate themselves from and actively shun members who have accepted religiously unauthorized medical treatment;

-- and the excommunication of JW members who accept religiously unauthorized medical treatment.

These practices of shunning and excommunication have been known to cause severe emotional distress to estranged JWs, occasionally even leading to their suicides. Indeed, one individual described the loss of family and friends through shunning and excommunication as a fate "worse than death".

RELEVANCE OF CONCERNS TO PEDIATRIC PRACTICE

Before one may legally give or refuse consent to medical treatment, three conditions must be met: competence, information and voluntariness. Cases involving adolescents in [Jehovah's Witnesses] families can be confusing because they may focus attention solely on the first condition: competence. Yet, competence alone is not a sufficient condition for valid consent. Even if conscious and alert, and with sufficient cognitive function and maturity to comprehend and appreciate information, a patient may still be unable legally to give or refuse consent. If a patient does not understand and appreciate the risks and benefits of a proposed procedure or a course of treatment, the patient is not in a position to accept or reject the proposal. Patients need reliable information.

They also need the third element of consent: voluntariness. It may be difficult to accept a treatment option if that particular choice will lead to the loss of important relationships. To give or refuse consent to medical treatment, the law requires not just decision-making competence but also accurate information and lack of coercion. ...

Lack of information.

In [three court cases involving three Jehovah's Witness teenagers needing blood transfusions,] the judges in two of those cases determined that the [Jehovah's Witness leaders and other members surrounding the teenage patient] contradicted the statements made by medical personnel. In [one of those cases], the judge ruled that: "Because of incorrect information, and the behaviour of some around her, [JWTeen] now believes that she will not die if she does not have the transfusions ... .[T]he undue influence put upon her in the last few weeks has taken away her ability to make an informed choice."

In [a second] case, the court specifically admonished the [Jehovah's Witness] lawyer for attempting to give false information: "Counsel, you're spinning. You're saying something the doctor has not said". The JW lawyer was attempting to argue that osteogenic sarcoma is not serious when clearly it is.

In addition to being offered misinformation regarding the medical situation, patients and their families can be presented with problems if they seek independently to evaluate the alleged Biblical basis of the blood ban.

Lack of voluntariness.

Coercion can be a great concern in pediatric cases involving [Jehovah's Witness] families. Breach of medical confidentiality can permit coercive practices to begin. Even though the fact that a person is in hospital is a private matter, the confidential medical information of children of JW families can become nationally and even internationally broadcast, ... The public attention from the news broadcasts can place the patient in a difficult and potentially coercive situation by becoming the focus not just of the patient's own congregation, but of [Jehovah's Witnesses] congregations internationally.

With media involvement, discussions and positions may become more rigid. The patient may feel the pressure of being the focus of such attention, in addition to the pressure of threats of shunning and excommunication. The religious advice may be positioned as if it were as accurate as the medical advice.

The power of all these pressures should not be underestimated. For example, the father who rejected [WatchTower Society] teaching by agreeing to a blood transfusion for his daughter, (when his daughter's hemoglobin was at 45 g/L), sat alone on one side of the courtroom (during appeal hearings); while his wife, healthy daughters, and former JW friends sat on the other.

SUGGESTIONS FOR MEDICAL MANAGEMENT

Possibly compromised information.

In such a charged atmosphere, it is especially important to maintain mutual respect among families and health care professionals. It is often possible both for agreement to be reached on a treatment plan, and for the child's life to be safeguarded. But a pediatrician cannot ignore the possibility of contradictory medical information, and the reality of sanctions for those who do not follow official [WatchTower Society] rules. The physicians should verify with the patient alone, and with her family, on an ongoing basis, that they individually, and as a group, understand the physician's assessment of the patient's medical condition, the risks of blood transfusion, and the risks of foregoing blood transfusion when it is urgently recommended.

Communication of medical information may be the source of the greatest difficulty. If the patient and/or parents consistently request that [Jehovah's Witness "Elders"] be present, the pediatrician should direct his or her comments and information to the patient and family, notwithstanding the presence of others. The pediatrician needs to recognize that because of the threat of sanctions, it would be unwise to ask the patient when [Jehovah's Witnesses] are in the room, whether the patient will accept blood or blood products. ...

We agree that, in general, patients are more likely to be better served by too much information rather than too little. While we do not suggest that pediatricians engage in theological disputation, questioning that attempts to elucidate the patient's belief [IS] within the scope of a physician's duty. ...

Possibility of coercion.

A patient may want to accept blood or blood products but refuse because of fear of social and religious effects of such a choice. Physicians should speak to decisional-competent pediatric patients when they are alone, and also with their families, and explain that blood [CAN] be administered in the absence of visitors. Physicians and hospital administrators should ensure that a patient's medical information is kept strictly confidential and should preface any discussion with "What we are about to discuss is confidential ... ."

Physicians should also consider it [PROBABLE] that the [Jehovah's Witness family and] patient [would] welcome the intervention of the legal system. ... the [WatchTower Society] does not require [Jehovah's Witnesses] to shun members who have received a transfusion under court order. By taking the apparent choice out of the [Jehovah's Witness family and] patient's hands, the law can remove the young person from an impossible social position.

Triggering the intervention of the state may be difficult for health care professionals in these situations. But, physicians and all other adult members of [civilized] society (irrespective of their occupations) have a legal obligation to report that the child is in need of intervention or protection when the child's life is in danger. If, after a hearing, the court transfers custody to the Director of Child Welfare, the Director will consult with the physicians regarding the appropriate medical treatment. It is not a question of physicians forcing a transfusion, but the state ensuring that minors receive essential medical treatment. ...

Conclusion.

A teenager's ability to consent must be assessed by looking for all its constituent parts: competence, information and freedom from coercion. Such assessment may reveal that patients in [Jehovah's Witnesses] families, even though competent, can be in the unusual position of not having two of the three legal elements necessary for consent to, or refusal of, blood transfusion. -- Medical Emergencies in Children of ... Jehovah's Witness Families, Juliet Guichon and Ian Mitchell, Paediatrics & Child Health, December 2006. Excerpted/edited.

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RECOMMENDED READING:

Wifely Subjection: Mental Health Issues in Jehovah's Witness Women

Blood Transfusions: A History and Evaluation of the Religious, Biblical, and Medical Objections (Jehovah's Witnesses perspective)

Blood, Medicine, and the Jehovah's Witnesses: The Hidden History of the Watchtower's Position on the Blood Issue

Jehovah's Witnesses and the Problem of Mental Illness

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