Case Scenario

A 33-year-old woman presents with symptomatic anemia. She reports a long history of abnormal uterine bleeding and is currently menstruating. On admission, her blood pressure is 105/90 mm Hg, and her heart rate is 113 beats per minute. She reports lightheadedness when standing and dyspnea on exertion. Her hemoglobin (Hb) is 4.9 g per dL (49.0 g per L), with a mean corpuscular volume of 61.0 μm³ (61.0 fL), which indicates severe iron deficiency. I recommend transfusion of two units of packed red blood cells; however, she tells me that she and her husband are practicing Jehovah's Witnesses, and she provides a blood-refusal advance directive card.

What is my role as a physician when a patient refuses a potentially lifesaving blood transfusion? Are there any circumstances in which physicians have an ethical responsibility to prioritize lifesaving treatment over the requests of a patient or their family members?

Commentary

Critically anemic patients who refuse blood transfusions have an inverse relationship between Hb levels and morbidity and mortality, particularly for Hb levels less than 5.0 g per dL (50.0 g per L).^1–3 For every 1 g per dL (10.0 g per L) drop in Hb below 8 g per dL (80.0 g per L), the risk of death increases 2.5-fold.⁴ Blood transfusions are a foundational component of treating severe anemia and are considered a lifesaving therapy.⁵ This makes caring for patients with severe anemia who refuse blood transfusions challenging. Physicians are bound by the four principles of medical ethics: autonomy, beneficence, nonmaleficence, and justice.⁶ To honor a patient's autonomous decision, a physician may face violating the other principles they have sworn to uphold. Respecting a patient's autonomy generally outweighs the other principles when treatment is refused.⁷ Importantly, declining a specific treatment modality does not imply refusal of all medical care and should not require patients to sign documentation of declining treatment against medical advice.⁵