The Observer, September 21, 2007
Volume XL, Issue 4
Medicine Today: The art of asking the right questions
Jehovah's Witnesses' refusal to accept blood products such as transfusions on the religious grounds that blood is holy and should not be consumed stands as one of the paramount cases in modern clinical medical ethics.
It was no surprise then, that during my recent observation session in the labor and delivery wing of University Hospitals, my interest was instantly piqued when I heard a first-year resident inquiring where to find the form with which to properly document the wishes of her patient, a Jehovah's Witness.
I joined the first-year resident along with a supervising second-year resident to go see the patient and had a chance to observe what is both a very simple and absolutely critical exchange between doctor and patient. The goal? Nothing more than the physician understanding exactly what his or her patient desires.
As an undergraduate at the University of Chicago, I did research into the history of the bioethics committee and used the University of Chicago Hospitals' MacLean Center for Clinical Medical Ethics as a case study. In the course of my research into the ethics consultation service that the MacLean Center offers, associate director Dr. Lainie Ross explained that ethics consults are often summoned not when there is some grand, controversial bioethical disagreement, but rather when there is a simple misunderstanding or case of poor communication between involved parties. In the pursuit of providing the highest quality of care – medically and ethically – resolving such communication difficulties is nothing short of critical.
Ms. A., our patient, is a black woman in her mid-30s, 34 weeks pregnant (where 40 weeks is considered full term) with her fourth child. She was admitted to obstetrics for early contractions and high blood pressure, and periodic dips in the fetus's heart rate have been observed since her arrival.
The second-year resident introduced himself and me and proceeded to ask her a very simple question: "I have been told you are a Jehovah's Witness. Is this correct?" Instead of relying on what someone else told him and what may have very likely been passed along a busy line of telephone in the bustling labor and delivery wing, he chose to ask her for himself. And it's a good thing he did: "No, I'm not. My husband is a Jehovah's Witness."
The second-year followed up one seemingly obvious question with another: "What are your thoughts on blood products and blood transfusions?" In general, Ms. A. doesn't really want blood products and in the past has used transfusions of her own blood (donated and stored before a surgical procedure, for instance, but not an option now).
"In the event of an emergency," the second-year went on, "we need to know what you would like us to do…" Ms. A. cut him off: "Then you do whatever you have to." The first-year resident put the special legal form away for use with another patient and another case; in a five-minute conversation consisting of three simple questions, the need for any special forms disappeared.
This was not an attempt by the second-year resident to somehow steer Ms. A. toward the decision to accept blood products because that is what is medically dictated as the best course of action in an emergency situation. Rather, it was an attempt to uncover what the patient's beliefs actually are.
Such straightforward but probing questions are necessary to make sure the patient really understands the situation (such as that blood transfusions would only be used in dire circumstances) and that it is the patient's beliefs (and not Ms. A.'s husband's) that are coming out. Ms. A. is free to take her husband's beliefs into consideration when formulating her own, but from the physician's perspective it is only Ms. A.'s beliefs that matter in the end; she is, after all, the patient.
George L. Anesi is a first-year medical student and graduate student in the department of bioethics. He can be contacted at george.anesi@case.edu.
