Politics in Practice: Intense Conversations in Intensive Care

By Erin Talati

As Holly Lynch describes in her recent post, the upcoming election brings a number of bioethics questions directly to the public. Two of the three ballot questions in Massachusetts invite discussion and debate on the controversial issues of physician-assisted suicide and the medical use of marijuana. The introduction of these issues as ballot initiatives offers physicians the opportunity for rich discussion on important topics with their patients. But, how much should physicians and other health care providers share with patients regarding their own views on these issues?
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Upcoming Event: Harvard Med School Public Forum


THURSDAY, OCTOBER 25, 2012 4:00 – 6:00 PM

Harvard Medical School Carl W. Walter Amphitheater Tosteson Medical Education Center 260 Longwood Avenue, Boston

Should a physician licensed in Massachusetts–at the request of a capable, terminally ill, adult patient (meeting certain conditions)–be allowed to prescribe medication that could end that person’s life?  The answers to this ballot question are just two: yes or no. The questions, though, are countless.


Lachlan Forrow, MD, Chair, Massachusetts Expert Panel on End of Life Care

Carol Powers, JD, President, Community Voices in Medical Ethics, Inc.

Ellen Weinstein, JD, Assistant General Counsel, Boston Medical Center

Marcia Angell, MD, Signer, Initiative Petition for MA Death With Dignity Act


Robert Truog, MD, Professor of Medical Ethics, Anesthesiology, & Pediatrics, HMS

Christine Mitchell, RN, Associate Director, Clinical Ethics, Harvard Medical School

Sponsored by the HMS Division of Medical Ethics

Refusals and Reasons: Is the Best Interests Principle the Best Standard?

By Erin Talati

In my last post, I puzzled over the boundaries of the state’s right to step in to protect the interests of children over the religious wishes of their parents, prompted by the question of whether it would be appropriate to prophylactically transfuse the child of a Jehovah’s Witness in order to minimize the risk of future harm.   As I continue to think about this question, I remain convinced that the boundaries are exceedingly fuzzy and do not necessarily seem to distinguish circumstances in a way that favors action “in the best interests of the child.” Rather, in looking at another situation in which the interests of the child may come into conflict with the religious or other interests of the parent, on the whole, it seems that the decision to intervene rests more on the legal basis for intervention rather than overall promotion of the best interests principle.

Take, for example, the general approach to vaccine refusals by parents.  The rights of parents to refuse vaccines for their children, generally, can be grounded in medical, philosophical, or religious objections.  Medical exemptions, based on medical contraindications to vaccination, remain the most robust mechanism of parental refusal. All states permit exemption from mandatory vaccination on the basis of medical exemptions.  Exemption for medical contraindication is consistent with the best interests principle as vaccination in these cases arguably is not in the best interests of the child.  Fewer states permit vaccine refusal on the basis of moral or philosophical objections. In almost all states, excepting Mississippi and West Virginia, parents can refuse vaccines for religious reasons, with states requiring varying levels of support for refusals grounded in religious objection.  It seems reasonable that, from the standpoint of protection of individual liberties, states would preference religious beliefs of parents in allowing refusals. Still, when either a religious or philosophical objection are not concurrently accompanied by a medical contraindication to vaccination, neither justification for refusal promotes action in the best interests of the child.

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Pushing the Boundaries: Revisiting Transfusion of Blood Products in the Children of Jehovah’s Witnesses

By Erin Talati

In the intensive care unit, almost every decision can be made into life or death.  For some children whose parents are Jehovah’s Witnesses the need for a blood transfusion becomes quite literally a life or death decision.  As clinicians, we struggle with maintaining a relationship with the family, while advocating for what we believe is in the best interests of a sick child.  Asking a family taxed by the knowledge that their child is critically ill to step back and to choose to sin to save the life of their child or instead to choose death seems impossible; and, usually, we don’t expect families to make this decision.  In many situations where a blood transfusion is required to protect a child from what is thought to be imminent death, a variety of approaches have allowed hospitals and courts to remove decision making power from the family to permit blood transfusion of a child against the family’s religious beliefs.

Decisions over transfusion of Jehovah’s Witness children are not new.  A long line of cases dating to the late 1960s examines the balance between parental domain over decisions for their children and the interest of the state to protect the best interests of children.  Since the 1960s, the debate has taken many forms. In life threatening situations, precedent allows doctors and hospitals to take some form of protective custody over a child in order to do what is thought to be best for the child.  Early iterations of the debate focused on state intervention into the private sphere of the family only when the medical community agreed on the proposed intervention, the intervention would be the right decision for the child, and the child would face imminent death without the intervention. The justification for this approach is that while parents are generally best suited to determine what is in the best interests of their children, when the parents beliefs endanger a child’s future ability to decide for himself, the state can step in to protect the future interests of the child.

The decision to allow transfusion of children of Jehovah’s Witnesses over the wishes of their parents, however, is not universal. Read More