Email Rolf J. Furuli:
MURAMOTO'S NEW INTERPRETATIONS OF THE MEANING OF THE CONCEPT "INFORMED
CONSENT"
It is rather sensational for a physician to urge his fellow physicians to be less supportive than
previously towards a particular patient group in need of surgery. Yet this is what Dr. Muramoto has
done. It is no less sensational that the reason for this is that he finds "ethical flaws in the blood
doctrine" and that it is "inconsistent", "illogical", and "irrational"; thus there is a value judgement of the
beliefs of the Witnesses that justifies this suggestion.(1) Medical science is descriptive, religion is
normative, thus Dr Muramoto's approach in this case is religious rather than medical. This new
interpretation of "informed consent", where physicians are supposed to evaluate the nature of the
patient's decision, is called "rational non-interventional paternalism"(2)
Concerning my words "you ask for an acceptance of the correctness of your viewpoints" and "you
suggest that doctors should try to persuade sick Witnesses to change their minds.", Dr Muramoto
writes at the end of his letter, "I sincerely hope this is not Furuli's malicious attack on me, but if he is
indeed a civilized and responsible Witness, a formal apology is in order." (3) I am not a native
speaker of English and I may choose words which have connotations leading to someone being
offended. If that is the case, I regeret it; I am just as opposed to ad hominem attacks as Dr Muramoto
is. However, I cannot apologize for my words quoted above because they are true, as I will show.
THE MAJORITY VIEW OF THE MEANING OF " INFORMED CONSENT"
The understanding of the concept "informed consent" in the medical community in Norway (and
probably in other countries as well) is as follows: The physician and the patient discuss the situation.
The physician outlines possible ways to treat the illness, discusses the pros and cons, including the
risks of operating without recourse to blood, but the patient makes the final decision. Apart from the
physician and the patient, other persons should not play any role in the decision, if the patient has not
specifically asked for it. The physician has no right to question the quality or the correctness of the
patient's decision, but he or she has the right to refuse to treat the patient on his or her conditions.
Showing respect for the autonomy of the patient and the physician, as outlined above, does not
exclude the influence from other parties in connection with the decisions both of the patient and the
physician. The physician may feel the influence or pressure from collegues and the hospital
administration, from ethical comittees or governmental agencies, and from the courts. However,
neither of these are " third parties" who influences the physician in an unjust way, because it is the
physician who, based on his or her free will, makes the decision. The patient may feel the influence
from family and friends and from the members of the congregation, but I consciously leave out the
word 'pressure' because, after 40 years as a Witness, I experience that to abstain from blood is one
of the beliefs that is deepest rooted in the conscience of each Witness, because it is clearly stated in
the Bible. It is the patient who, on the basis of his or her free will, makes the decision to abstain from
blood.
While physicians of Norway generally respect the autonomy of each Witness, they also feel the
responsibility to make sure that the decision not to accept blood is the patient's own decision and
that it is final. Therefore they usually explain the situation for the patient, and ask the patient if he or
she will refuse blood even if death should be the outcome. Some doctors also ask why the patient
refuses blood, and how long the patient has had this conviction. When they find that the decision is
final, they usually decide to treat the patient on his or her conditions. This is really an ideal situation of
what is called "informed consent" - full respect for both the autonomy of the physician and the patient
without any intrusion into the personal sphere of any of them. I see no ethical problems with this fine
physician-patient relationship.
MURAMOTO'S VIEW OF THE MEANING OF " INFORMED CONSENT"
In the article in BMJ Dr Muramoto writes "An in-depth discussion of the entire blood policy with
individual patients may become necessary to ensure truly autonomous decisions on blood based
treatment. Their advance directives and so called "blood cards" should be re-evaluated with the
patients in light of the new policy."(4) These words seem harmless enough, but underlying them we
find suggestions of a new way of treating Witness patients which is a threat to the principle of
"informed consent" as it is understood by the majority. This is seen in the article which he refers to in
his note (2) and to the later follow-up article. A reference to both articles are found in my notes (1) and
(2).
Dr Muramoto follows the suggestion of Savulescu and Momeyer(5 ) who suggests that physicians
should act as "critical educators" who should reason with those patients whose decision they deem
as irrational. Writes Dr Muramoto: "In this paper I will expand on this argument and propose that
medical professionals familiarize themselves with the inherrent flaws of the blood doctrine, and
provide JW patients with new perspectives and rational reasoning by proposing a few simple
questions which can be presented in "non-interventional" fashion and without outside pressure.
These questions may enable patients to view their doctrine from new perspectives and give them a
chance to make a more informed, autonomous and rational decision."(6)
This suggestion reminds me of the anecdote of the physician who said to the patient: "Your
depression is caused by unfavorable experiences in your childhood. " The patient answered: "But I
had a very happy childhood with no unfavorable experiences." The physician concluded: "You
certainly had such bad experiences, but you do not remember them because you have suppressed
them in your mind." Regardless of what the patient says, she is at the mercy of the physician. If the
situation was not so serious for the Witness patient, the approach of Dr Muramoto could be quite
amusing: The physician decides that the decision of the patient is irrational, and then, without
intruding the autonomy of the patient or influencing her, the physician helps the patient to make a
rational decision!
But this is not all; not only is the view of the physician placed above the view of the patient, in effect
overruling it, but the view of a third party is even used as a criterion by which to judge the Witness
patient. Writes Dr Muramoto: "Jehovah's Witness patients who refuse life- saving blood transfusions
may not only be irrational, as Savulescu and Momeyer argue, but may also be misinformed,
misguided and, to some degree, coerced according to the information, based on direct knowledge
and experience provided by dissidents and reformers."(7) This puts the situation completely upside
down and jeopardizes the autonomy of the patient. The basic authority is a small group of
anonymous dissidents who are called 'reformers'. Their claims that the Witnesses are misinformed
and coerced are uncritically accepted. The Witnesses are judged as 'irrational', and on this basis it is
fair that the physician acts as a 'critical educator' who will 'help' the Witness to reach a rational
decision.
A LOOK INTO THE " CRITICAL EDUCATING" OF THE WITNESSES
As a member of the HLC for many years I have worked carefully and responsibly with the blood issue
both practically and theoretically, and I find no inconsistency and no irrational side of the position held
by the Witnesses. I have had in-depth discussions with many surgeons and anaestetists who have
asked critical questions about the basis for our standpoint. While not agreeing with our conviction,
they have found the standpoint logical and rational, given that the words of the Bible are authoritative.
So many intelligent and balanced people do not share the accusations of the dissidents that our view
is inconsistent and irrational. This handful of dissidents are partisans and they are not presenting
their case in a fair way.
I refer to my five letters in this chain where I have tried to explain the view of the Witnesses in a logical
way. In short the consistency can be thus outlined: We have found that the Bible prohibits *any* use
whatsoever of the blood of other creatures. So we will abstain from everything which is included in
the concept 'blood'. No other arguments are necessary to outline the basis for our faith regarding
blood, and the allembracing scope makes it perfectly consistent. Actions described by Greek words
such as 'porneia' (fornication), 'aselgeia' (loose conduct), 'farmakia' (druggery, spiritism), 'komos'
(revelry) and others are so grave that "those who practice such things will not inherit God's
kingdom."(8) Yet after all philological tools have been utilzed to find the semantic range of their
meaning and references, still there are some judgments that must be made, and similarly with the
word 'haima' (blood). Any 'judgement' can be criticized by those who view the case differently, but a
different interpretation does not make a standpoint irrational.
Sixty years ago 'blood' was 'whole blood'. In the course of time, more and more products have been
produced on the basis of blood, and as responsible people we have needed time to consider each
product in relation to the concept 'blood'.(9) The view of fractions have not moved back and forth, but
only in one direction, i.e. after having studied a fraction and found that we cannot definitely say that
'this is included in the concept 'blood'' or 'this is not included in the concept 'blood'',the conscience
of each person must decide whether to use it or not(10)(for instance, I still remember how we
struggled with cryoprecipitate around 1965). We are not able to see that plasma, red cells, white cells
and platelets can be excluded from the Biblical concept 'blood', but the use of any other fraction is a
matter of conscience.
I find the suggestion that a physician should have the right to make a quality evaluation of the
patient's decision, and when finding it 'irrational' should have the right to 'educate' the patient as an
intrusion into the rights of the patient. But worse still, some of Dr Muramato's suggestions of *how* to
'educate' the patient can best be described as manipulation. Just look at his first example of how a
physician is recommended to speak:
"I am concerned by my knowledge that there have been a number of significant changes in related
understandings by the WTS. Probably you know that vaccination and organ transplants were for
some time ruled unacceptable and morally wrong. These are now considered acceptable. But I think
you would agree that the previous rulings may have had some quite serious effects - illness,
disability, even death - while they were in force. It would seem that a person would want to consider
what the future might yet bring in further changes of viewpoint. If holding to some present policy were
to result in disability or even death in your own case, and that policy were reversed next year or some
years from now, would you feel that such loss would have been worthwile and justified.."(11)
I am not afraid that many Witnesses will change their mind because of this 'education',(12) but in my
view this kind of reasoning is unethical because it manipulates the patient by posing hypothetical
scenarios and by hiding (probably unconsciously) important information. Let us use vaccination as
an example. The physician leads the patient to believe that the negative view of vaccination among
the Witnesses before 1949 was bad, because it led to illness, disability, and death for some
Witnesses. What is not told, is that vaccines before this year contained much blood, were impure,
and caused a number of deaths. So, also from a medical point of view it was not given that to accept
vaccines was the best choice. To hide the fact that vaccines could be dangerous at this time and
cause death, and instead saying that *not* to take them could be fatal, is a blatant example of what
Dr Muramoto and the dissidents accuse the Watchtower Society of doing, namely, to hide information.
I do not doubt the sincerity of Dr Muramoto. I view him in a positive way as a fellow human being, and I
think that his standpoint regarding blood also has a professional basis. However, his suggestions
that the physician should have the right to make a quality evaluation of the patient's decision (read:
religious faith), and if found irrational, the doctor should 'educate' the patient (try to change the faith
from being irrational to being rational), introduces a strong religious element through the backdoor.
This is truly a religious approach, because science is descriptive while religion is normative. I
therefore find that my words about his intent to change(13) the faith of the Witnesses regarding blood,
has being justified; and I will not apologize for them.
CONCLUSION
The hospital liaison comittees of Jehovah's Witnesses have for more than ten years worked hard to
help physicians give effective treatment to Witnesses refusing blood. We have urged them to learn
new techniques for saving blood, and we have supplied them with the latest medical information
regarding the treatment of different kinds of surgery or chemotherapy without using blood. For
instance, we distribute free of charge a CD with several thousand abstracts and references to
medical articles discussing bloodless treatment; and it is updated regularly. Our work, together with
the growing understanding that blood is potentially dangerous, has paved the way for a situation
where even the most complicated cases can be treated without blood.
This fine support from the medical community has been greatly appreciated, and it has, without
excluding the possibility that the treatment of any disease may be fatal, given the Witnesses a feeling
of security. Now they need not both fight with their medical problems and at the same time fight with
the physicians in order to get a bloodless treatment. And suddenly a physician stands up and urges
his fellow physicians to be less supportive! The reason for the suggestion is that he believes in the
unverified claims of a small group of dissenters (who will not even disclose their identity), claims
which for the most part are rejected as exaggerated or false by experienced witnesses as myself. So,
because Dr Muramoto and this group think that the standpoint of the Witnesses regarding blood is
irrational, they want the doctors to 'critically educate' the Witnesses in order to 'change their stance'. I
am very much concerned that the good relationship between the medical community and the
Witnesses may be harmed by the work of this group. They take care of their own interests and not
those of the community of Witnesses. A handfull of dissenters should not be allowed to influence the
treatment of thousands of Witnesses who are determined to abstain from blood and cooperate with
the physicians. I hope that physicians realise the improbability of the claim of this group that the
standpoint the Witnesses express in a signed statement and further express in words when they
come to a hospital, is not necessarily what they mean; so an evaluation of the quality of their decision
is needed.
APPENDIX: BREACH OF CONFIDENTIALITY.
Dr Muramoto writes: "I am totally perplexed by the fact that Furuli as a Jehovah's Witness condones
and dismisses such an illegal action [a breach of confidentiality of a medical worker] because it is
"rare"."(14) This is a wrong interpretation of my words, and Dr Muramoto's accusation is false. I do
not condone an illegal action even if it just occurs once. What I was discussing was that Dr Muramoto
presented cases which are extremely rare, if they ever occur (such as vigils to avoid blood tranfusion)
as typically for the Witnesses, and in this connection I wrote that difficult cases where a Witness had a
dilemma regarding confidentiality were extremely rare.
Dr Muramoto accepts that there are situations where a medical worker face an ethical dilemma; he
even adds an example of "a psychiatrist who sees in his patient a sign of impending impulse to
commit murder". He states: "We physicians never recommend to violate the law even in the cases
mentioned above (15)." I accept this, but I suppose that different 'cases' are discussed in the ethical
sessions where medical students are educated. I further think that if teachers discuss child
molesters, while they do not recommend a breach of confidentiality even in cases where an adult
may harm more children, they will understand a health worker who notifies the police in such cases.
I want to make a statement: We Jehovah's Witnesses never recommend to violate the law in the
cases mentioned above, or in other cases involving Jehovah's Witnesses, and we never recommend
an intrusion of the physician- patient relationship! It is therefore a false statement when Dr Muramoto
asks me to write a letter to stop the "recommendation that Jehovah's Witness health care workers
breach medical confidentiality of fellow Jehovah's Witnesses and to refrain from intruding on the
physician-patient relationship". The article (The Watchtower 1 September 1987:12-15) to which Dr
Muramoto refers does not contain such a recommendation. A hypothetical case is discussed where
a Witness who is a medical worker comes upon information that a fellow Christian has committed
fornication and then killed the baby by taking an abortion. Two important Biblical laws are broken, and
after deciding the matter for some time "Mary" approaches the fellow Witness and speaks with her
about the matter. The article says:
"Circumstances can vary greatly. Hence, it would be impossible to set forth a standard procedure to
be followed in every case, as if everyone should handle matters as Mary did. Indeed, each Christian,
if ever faced with a situation of this nature, must be prepared to weight all the factors involved and
reach a decision that takes into consideration Bible principles as well as any legal implications and
that will leave him or her with a clear conscience before Jehovah."
I suppose that if we remove the words referring to God and the Bible in the quote above, few, if any
would object to the quote being used in a session about medical ethics, where a case had been
discussed in which a doctor had informed the police about a person who had molested children. Still
it could rightly be said that "We physicians never recommend to violate the law even in cases of child
molesting."
(1) Muramoto, O. "Bioethics of the refusal of blood by Jehovah's Witnesses: Part 1. Should bioethical
deliberation consider dissidents' views? " Journal of Medical Ethics - August 1998, pp. 223-230.
(2) Muramoto, O. "Bioethics of the refusal of blood by Jehovah's Witnesses: Part 2. Anovel approach
based on rational non-intervenational paternalism. Journal of Medical Ethics - October 1998.
(3) Muramoto, O. http://www.bmj.com/cgi/eletters/322/7277/37, 9 March 2001.
(4) Muramoto, O. http://www.bmj.com/cgi/eletters/322/7277/37, 6 January 2001.
(5) Savulescu, J., Momeyer, R. W., "Should informed consent be based on rational beliefs? " J Med
Ethics 1997:203-208.
(6) Muramoto, O. "Bioethics of the refusal of blood by Jehovah's Witnesses: Part 2. A novel approach
based on rational non-intervenational paternalism." Journal of Medical Ethics - October 1998 Osamu
Muramoto, pp 295,296.
(7) op. cit. p 296.
(8) The New Testament, Galatians 5:21.
(9) When Dr Muramoto claims that the leadership has all power and with reference to this says: "This
is why hemoglobin was prohitibited by God in 1998 but now permitted by God in 2000, as I discussed
in my article", he utters tendentious words, indicating that he does not understand lexical semantics
and its use in Bible understanding, and neither the thinking of Jehovah's Witnesses.
(10) Please remember that we have never 'authorized' the use of a fraction made from blood. To say
that each one's conscience must decide is not the same as an authorization.
(11) Muramoto, O. "Bioethics of the refusal of blood by Jehovah's Witnesses: Part 2. Anovel approach
based on rational non-intervenational paternalism." Journal of Medical Ethics - October 1998 Osamu
Muramoto, p 298.
(12) Dr Muramoto agrees: "In reality, I do not expect any significant number of JWs will easily change
their stance after one or two private meetings with a physician." "Bioethics of the refusal of blood by
Jehovah's Witnesses: Part 2. Anovel approach based on rational non- intervenational paternalism."
Journal of Medical Ethics - October 1998 Osamu Muramoto, p. 300.
(13) Look at the quote in note 13 where Dr Muramoto himself uses the expression �change their
stance�.
(14) Muramoto, O. http://www.bmj.com/cgi/eletters/322/7277/37, 9 March 2001.
(15) The other case was a physician who knew that the man whom his daughter was about to marry
was HIV-positive, but the dauther did not know. Should the father inform his daughter about the
man's condition?