Ethical Decision Making in Endoscopic Treatment of a Jehovah's Witness With Severe Upper Gastrointestinal Bleeding

Introduction: For endoscopic procedures, informed consent elevates patient autonomy and circumvents medical paternalism. However, when procedures carry significant risk of harm, clinicians may unintentionally overlook patient preferences when making decisions. We present the case of a Jehovah’s Witness with upper gastrointestinal bleeding who was offered endoscopic intervention despite a high risk of peri-procedural mortality, with emphasis placed on the shared-decision making process. Case Description/Methods: A 77-year-old female Jehovah’s Witness presented with hematemesis and hemoglobin of 4.9 grams/deciliter (g/dL). Endoscopy demonstrated a duodenal ulcer with a visible vessel. Due to the inability to transfuse blood and risk of provoking further bleeding, the decision was made to forego clipping or cauterization and treat only with hemostatic powder (Figure 1). On hospital day 3 she experienced new melena with decrease in hemoglobin to 2.8 g/dL. Although providers were hesitant to offer repeat endoscopy given her lack of hemodynamic reserve, a nuanced discussion with the patient elucidated her wish to undergo all possible interventions even at high risk of death (Figure 2). Endoscopy was performed despite low hemoglobin, which redemonstrated the duodenal ulcer with a large pulsatile visible vessel. The ulcer was injected with epinephrine and an over-the scope clip was successfully placed (Figure 3). She initially stabilized, however on hospital day 5 she developed recurrent melena with hemodynamic instability. After discussion with her family, she was transitioned to comfort care measures and expired that evening. Discussion: When faced with the possibility of patient harm, gastroenterologists may intentionally withhold interventions due to a desire to act in what is perceived to be in the best interest of the patient. Ethically, however, acting by omission devalues both patient autonomy and the right to self-determination in care. This effect may be amplified by pre-existing stigma such as with the Jehovah’s Witness wherein refusal of blood products may be erroneously interpreted to imply a broader refusal of other life-saving treatments. In this case, through juxtaposition of two procedures, we demonstrate that this phenomenon can be circumvented via thoughtful discussion of all potential options with patients, regardless of physician preference. We hope to highlight the importance of this ethical concept when approaching patients for informed consent.Figure 1.: Ulcer with visible vessel on initial endoscopy, treated only with hemostatic powder. (2) Four-box model approach to ethical decision making in this case. (3) Same ulcer on repeat endoscopy, now with a pulsatile visible vessel, treated with an over-the-scope clip.