Personal convictions

Refusal of Treatment for Religious Reasons

Under review

CLINICAL CASE  
Marie, age 16, is brought in by ambulance following a road accident; she is conscious but in shock from active hemorrhaging. She refuses to be transfused because she is a Jehovah’s Witness. Her family confirms her religious allegiance and her expressed refusal.
What do you do?

Regardless of the reason invoked and in spite of the physician’s opinion, a free and informed refusal from a person capable of giving consent must be respected, in accordance with the rights recognized in the Canadian and Québec charters of rights and freedoms, and the principles of autonomy and inviolability of the person. A conviction, notably a religious one, may be one of the reasons for which a person may refuse treatment. For example, refusal to submit to a blood transfusion is in keeping with the precepts recognized by Jehovah’s Witnesses.

Among the rights recognized by the Canadian and Québec charters is the right to religious freedom. However, even in this case, physicians must ensure that all of the conditions for free and informed refusal have been respected when adapting their assessment to a religious conviction. In particular, they must verify and document the strength of the religious conviction as well as the patient’s ability to refuse. The general principles for free and informed consent or refusal have only one application in this case, a particularly difficult one.

Person of full age

As stipulated in the Civil Code of Québec, refusal of a blood transfusion expressed by a capable person must be respected, even in emergency situations (Art. 13, par. 2), if there is no doubt about the refusal expressed. If there is reasonable doubt about the refusal, the transfusion may not be administered unless it is an emergency situation AND there is hope of saving the person’s life.

A Minor Person 

Here, the situation varies slightly with the person’s age.

Minor under 14 years of age — The minor person may not consent alone to care or refuse care. If it is an emergency, and it is not possible to reach the persons having parental authority, the transfusion may then be administered. But if the parents can be
reached and refuse the transfusion for their child, the latter cannot be administered, unless the parents’ refusal is deemed to be unjustified, which an authorization by the court could be able to confirm.

Minor 14 years of age or over — The minor 14 years of age or over may consent alone to the care required by his state of health, but he may not always refuse it. If he refuses it, the court may intervene to overrule his refusal and make it possible to take action. In emergency situations, the law stipulates that the consent of the person having parental authority is sufficient to take action. However, the law does not necessarily provide for cases where the person having parental authority decides to respect the decision of the minor and refuses care likely to save his life. Opinions differ as to what the physician must do in these difficult situations. Should he respect this refusal from both sides or not take them into account if he feels the refusals are unjustified? If the physicians opt for the second solution, he or she should address the situation to the court as soon as possible.

Validating the Refusal

According to Ontario jurisprudence, namely the Mallette v. Schulman decision, and to the Civil Code of Québec, religious conviction is clearly a valid and accepted reason for refusing treatment. The principles invoked are self-determination and respect for the autonomy and inviolability of the person. The emergency situation does not always permit an exception. To transfuse a patient who has clearly and freely expressed her refusal exposes the physician to prosecution for assault, even if the life of the person in danger was saved by the transfusion.

Refusal of treatment for reasons of religious belief poses an additional problem, given the hold coreligionists may have over the patient’s will, consequently making it difficult for the patient to choose freely, which is a frequent phenomenon among followers of sects. On the other hand, the right to freedom of conscience and belief presumes that one may choose freely to adhere to a faith and make its precepts one’s own. When there is an emergency, and the patient is a minor, the situation is not easy to judge.

In this case and for any other refusal of treatment, the physician must “validate” the refusal. In case of reasonable doubt, the presumption must seek the good of the patient. But the physician must demonstrate that the refusal was doubtful. Similarly, if the refusal is based on religious allegiance, it is up to the physician to demonstrate that it is reasonable to doubt that religious allegiance. In such case, the physician would have to cite arguments to explain why, in the circumstances, it was reasonable not to take the refusal into account.

2011-04-04