In 20th century Canada, Jehovah’s Witnesses were persecuted for their proselytizing and wartime pacifism. Fighting back in court, the Watchtower Society helped advance Canadian human rights including when, in 1990, they successfully won recognition of a patient’s right to refuse medical treatment, even if death will result.

The legal challenge stemmed from the Watchtower Society rule that Jehovah’s Witnesses may not accept blood transfusions. In 1990, it appeared to the Court that a well-informed and freely held religious belief was in need of defending.

But times have changed.

Now that the internet enables former Jehovah’s Witnesses to post information about religious practices, whether individual Jehovah’s Witnesses are truly free to make an informed decision is seriously in doubt.

Not all Jehovah’s Witnesses refuse blood, just as not all Catholics refuse contraception.

Yet the Watchtower Society – which governs adherents – adopts and encourages behaviour that raises questions about whether many Jehovah’s Witnesses may express an enlightened and free decision about blood transfusions.

Writing anonymously because of their fear of losing family and friends, some Jehovah’s Witnesses have taken to the internet to expose the pressure applied to followers to comply with the ban against blood transfusions.

Also speaking out is a former Jehovah’s Witness, Lawrence Hughes, who has already suffered the punishment of estrangement from family and friends. The claims of Hughes and of anonymous writers about poor information and lack of freedom suggest that patients do not have sufficient capacity to make medical decisions about blood transfusion.

These critics detail that the Watchtower Society teaches that blood transfusions are unsafe using outdated medical articles from the 1960s and alarmist articles from the 1980s, when HIV was in the blood supply. The official website for the Jehovah’s Witnesses instructs adherents that saline is a sufficient alternative, which is factually incorrect in many cases of life-threatening hemorrhage.

The Watchtower Society presents difficulties in the exercise of free choice. Anonymous followers and former followers claim that the Society compromises patient freedom by encouraging “disfellowshipping,” a type of shunning that applies “even with respect to [the adherent’s] relatives, including those within his immediate family circle.”

The coercive pressure to refuse blood was described by a Jehovah’s Witness to one of the authors in this way: “If I accepted blood, I would be as good as dead any way. […] Jehovah’s Witnesses who ‘choose wrongly’ have a price to pay, which is excommunication and the loss of their family and loved ones. I could die from no blood, or I could ‘die’ taking blood, by losing my family.”

Critics also claim that Watchtower Society officials shadow patients in the hospital to ‘encourage’ the patient to abide by the blood ban. Lawrence Hughes said in an interview with the CBC, “Just having those people in the next room, to me, is enough undue influence.”

The Watchtower Society prohibition of blood transfusions is at the centre of the recent case of a young woman in Quebec, who died after facing complications during childbirth. Eloise Dupuis, a Jehovah’s Witness, died Oct. 12, six days after a hemorrhage that occurred after delivering a baby by C-section at a hospital near Quebec City.

The Quebec coroner is investigating Dupuis’ death and the death of Mirlande Cadet, a Jehovah’s Witness who died Oct. 3 after experiencing complications following the birth of her son at a Montreal hospital.

Under Quebec law, healthcare providers must normally respect the wishes of adults with capacity even if death might ensue.

The Society requires members to sign, to update annually and to always carry with them a document titled “No Blood.” Yet, internet revelations claim that many Jehovah’s Witnesses have neither accurate information regarding blood transfusion safety, the freedom to sign or not sign without repercussion, nor the encouragement to obtain independent legal advice.

The Watchtower Society apparently polices compliance.The freedom to make an independent legal decision is compromised when a person in authority is present. Therefore, the document has highly questionable legal validity.

The internet revelations and allegations were not available to the Ontario Court of Appeal that decided the 1990 case. Therefore no court has wrestled with the essential problems of poor information and lack of voluntariness experienced by many Jehovah’s Witnesses. The Watchtower Society’s behaviour in misstating the risks and benefits of blood, and encouraging, if not requiring, the shunning of friends and family, raise serious doubt as to whether patients have sufficient information and freedom to accept or to refuse blood transfusion.

Given such decision-making challenges, health care providers should look to the law for better guidance than that offered in the Mallette v. Shulman case.

In the interim, they should act in the patient’s best interest by setting aside legally dubious blood cards, seeking consent only when the patient is alone, executing medical decisions confidentially, and taking charge of who enters the patient’s room and who may be in the hallways. The best interests of the patient are paramount.

Internet revelations should cause the Quebec Coroner to inquire, “Given the allegations of Watchtower Society behaviour, may any Jehovah’s Witness make an enlightened and free medical decision-making regarding blood transfusion?”

And if the answer is no, then what guidance will lawmakers and judges offer to doctors?

Juliet Guichon, Ian Mitchell and Christopher Doig are faculty members in the Cumming School of Medicine, University of Calgary.