This month I started a fellowship that predominantly involves taking care of women with cancer. Through surgery, chemotherapy, and other medications we do our best to cure or hold back malignancies of many kinds. In these past weeks, I have taken care of several patients who are Jehovah Witnesses, an experience that has been quite interesting.

In most cases, what religion a person subscribes to has little to no impact on their clinical outcome. We have an exception, however, when it comes to a Jehovah’s Witness with cancer. JHW patients to a rule will not accept blood products of any kind, which greatly limits their ability to be effectively treated for cancer. In some cases they cannot have surgery because the surgery they need is unsafe without the possibility of blood transfusion. In some cases they cannot take chemotherapy because blood transfusion is required to survive the associated myelosuppression. As surgery and chemotherapy are our two best treatments, they are at a major disadvantage.

When I was a resident, I had a pretty hard opinion about this. I heard a lot of different view on the topic, but the position of one of my attendings resonated best with me. He felt that his job as a physician was to protect the health of his patients, and that if a JHW was dying in front of him he was going to transfuse them whether they liked it or not. He was quite clear about this upfront, and told JHW patients that if they were not happy about this they should find another doctor. He even arranged for attending coverage for emergent issues if need be. He felt that the preventable death of a patient was an emotional trauma he didn’t want to be exposed to, almost as if the patient, through refusal of blood, was exposing him to unnecessary emotional violence. While this was a very hard line, I respected the boldness of it, and that he was being true to his internal values. I held a similar feeling for the first few years of my attendinghood, though I never had to test it until my third year out of residency.

The test came when a JHW presented to our hospital in Hawaii with severe vaginal bleeding, and had a hemoglobin of only 4 (normal being about 15). We did everything we could medically, but she continued to bleed off an on. She was utterly saveable with a blood transfusion and a subsequent hysterectomy. It would have been fairly routine. But in her case it wasn’t routine, because she would not take blood. We tried a number of approaches, but nothing really worked. There were so many things we could do with blood, but without it she was too unstable for us to act without killing her. And so she slowly declined until she was in high output heart failure. I had never seen someone’s hemoglobin drop so low, and was amazed that she didn’t actually die until she was down to 0.6, with blood so clear you could read the paper through it. I had previously stood with my hard line attending, but being put to the test I found myself more respectful of the patient’s wishes, and helped the team care for her the best we could until her death.

Since that time I’ve taken care of a few similar patients, some of which could be saved and some not. I was recently in a surgery where we were discussing whether or not Hespan was acceptable or not. As my patient was bleeding I was thinking that authors of the Bible didn’t know what Hespan was, that the whole things was a bit ridiculous. We gave the Hespan. Another recent patient had recurrent cancer and could not be effectively treated because of her low hemoglobin, and will eventually found her life cut very much shorter than it would have been if she had taken blood.

What’s interesting to me is that unlike my hardline attending, I have found very little emotional distress in these situations. While I would loved for these people to have good outcomes, I didn’t make them sick. I don’t share their religion, but I am pretty sure that robbing them of their faith and security would do far more harm to their personhood than a few pints of blood could ever heal. Everyone must die eventually, and it seems better for them to go on their own terms than to live on in fear that they have damaged their potential in eternity. I don’t know whether their religion has an accurate view of the long term consequences of taking blood or not. But that doesn’t matter. Making it matter wouldn’t be good doctoring.

There is a saying that a physician must strive to have great sympathy, but to do what they can to avoid empathy. The distinction is lost on many. Sympathy is when you care about how your patient is feeling, but empathy is when you feel it yourself. Empathy, in other words, is taking it personally. While some argue that such closeness with patients is a positive physician trait, I would argue that these people haven’t well considered the difference between sympathy and empathy, and the results of the execution of each. Patients appreciate their physician’s sympathy, but in the end depend on the physician’s lack of empathy. Without that, it is very difficult for the physician to give objective medical advice, and if need be to respect a patient’s right to refuse that advice. While it saddens me to some extent that a JHW might die for lack of blood, I feel enough sympathy for their decision to place their religious belief above their self preservation that I can ignore my empathic need for them to take blood. It’s not my life after all.

I think back to my attending that had the hard line, and think perhaps he had a little too much of his own ego involved. He was deeply invested in his patient’s outcomes, and therefore would be personally injured if his patient died a death that he thought was preventable. I used to see this as noble, but in the end it was not the most effective physicianhood. His patients would have been better served if it he didn’t take their outcome so personally.

Dr. Fogelson is a gynecologic surgeon and endometriosis specialist who practices at Northwest Endometriosis and Pelvic Surgery in Portland, OR. Call 503-715-1377 for clinical consultation or email nfogelson@nwendometriosis.com. http://www.nwendometriosis.com