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Jehovah’s Witness Patients–Consent, Legal Duties & Blood-Sparing Anaesthetic Care

Documentation Checklist

1. Verify official Watchtower “Patient Blood Management” card / hospital form.
2. List in notes exactly which products / procedures the patient accepts or declines
3. Have patient sign “Blood Refusal Statement” + witness (≥ 14 yr) + interpreter details.
4. Attach to anaesthetic chart and hand-off sheet; flag in EMR and on theatre whiteboard.
5. For minors: file Children’s Act Form 34 (surgery) + clinician affidavit if court order sought.

Acceptability Matrix (confirm individually)

Category	Usually declined	Individual decision	Usually accepted
Major components	RBCs, plasma, platelets, granulocytes	—	—
Fractions	—	Albumin, immunoglobulins, clotting factors, haemoglobin solutions, cryoprecipitate	—
Procedures	—	Cell salvage (closed circuit), acute normo-/hypervolaemic haemodilution, cardiopulmonary bypass, ECMO, plasmapheresis, epidural blood patch	Crystalloids, colloids, rEPO, tranexamic acid, fibrin glue, artificial O₂ carriers

• Record each patient’s choice–variations are common.

Legal & Ethical Landscape

Blood Products

• Blood transfusion = medical treatment under SA law–administration of any substance (incl. blood products) is explicitly listed as “medical treatment,” not “surgical operation” (Children’s Act 38-2005 s 129(2)–(5))
• Consent threshold for minors differs from surgery–a child ≥ 12 yr who is “sufficiently mature” may self-consent or refuse a transfusion, whereas the same child still needs a parent/guardian co-signature for surgery (s 129(2) vs s 129(3))
• Professional guidance aligns–HPCSA Informed Consent Booklet 9 (2021) and the SANBS 2023 transfusion-consent guideline both list transfusion under “medical treatment” requiring specific informed consent
• Case-law commentary supports this view–SAMJ review (112:509-10, 2022) confirms transfusion disputes fall under the Act’s medical-treatment clauses (s 129(2)/(4)), not the surgical clauses (s 129(3)/(5))
• Practical take-aways
  • Competent adults: their documented refusal/consent to transfusion is binding.
  • Mature minors (≥ 12 yr): may consent to or refuse transfusion, but a court can override refusal if life-saving.
  • Younger/immature minors: parent or guardian consents; if refusal jeopardises life, a High-Court order or Head-of-Health authorisation permits transfusion in the child’s best interests

Elective (time Available ≥ hours–days)

Scenario	Capacity in law	Immediate plan	Escalation / legal route
Minor (12–17 yr) competent, refuses blood; parent says yes	Child may consent to–or refuse–medical treatment (Children’s Act §129 (2)); refusal can be overridden if life-saving	• MDT counselling + JW HLC • Optimise blood-sparing plan • Record child’s refusal & parent consent	If transfusion is likely life-saving → apply urgently to High Court or Provincial Head of Health for authorisation
Minor competent accepts blood; parent says no	Child’s informed consent for medical treatment suffices (CA §129)	Proceed with transfusion if required; document discussion	If procedure is surgical and parent still refuses → Social Development / High-Court consent in child’s best interests
Minor incompetent; parent refuses	Parent is default surrogate	Optimise bloodless strategy; involve JW HLC	If refusal endangers life/health → urgent High-Court order or Head-of-Dept authorisation to transfuse
Adult competent, refuses blood	Autonomy absolute (Constitution §12)	Honour refusal; document advance directive or blood card; full conservation measures	—
Adult incompetent; caregiver refuses	Surrogate decision stands unless it conflicts with best interests or written directive (NHA §7)	Search for advance directive; ethics/MDT review + JW HLC	If transfusion clearly life-saving & no directive → seek High-Court order to override surrogate

• Children’s Act 38/2005
  • §129(2) treats blood transfusion as medical treatment–a mature child (≥ 12 yr) may self-consent or refuse.
  • §129(3)–(5) require parental co-signature only for surgical operations.
  • §7 states that the best interests of the child are paramount; courts can override parental or child refusal when transfusion is life-saving.
  • Hay v B (WLD, 2003) confirms High-Court power to authorise transfusion over a competent minor’s refusal when best-interest test is met.
• National Health Act 61/2003 §7–permits treatment without consent if delay will result in death or serious, irreversible harm and no legally valid refusal or advance directive exists.
• Constitution of South Africa §12 & HPCSA Booklet 9 (2021)–uphold an autonomous adult’s right to accept or refuse any medical intervention, including blood products.
• Surrogate decisions–valid unless they conflict with the patient’s documented wishes or the best-interests test (NHA §7; SAMA medico-legal guidance 2022)
• Release forms: A JW “no-blood” waiver does not remove liability for negligence; it simply records informed refusal. Always document the capacity assessment and alternatives discussed.
• Hospital Liaison Committee (HLC): 24 h JW support line–078 491 1745 (Western Cape). Engage early for elective planning or crisis mediation.

Emergency Framework (<2h)

Scenario (emergency, < 2 h)	Legal trigger / authority	Immediate action
Minor (competent) refuses blood; parent consents	Child’s refusal is not decisive if transfusion is life-saving (Children’s Act §7 & §129; High-Court precedent Hay v B, 2003)	Transfuse; record parent’s consent, note child’s objection; inform High Court within 24 h
Minor (competent) consents; parent refuses	Child ≥ 12 yr may self-consent to medical treatment (CA §129(2)); parent cannot veto in an emergency	Transfuse immediately; document parental refusal; notify Dept. Social Development
Minor incompetent; parent refuses	National Health Act §7(1)(e)–clinician may act without consent to avert death or irreversible harm	Transfuse at once; phone Manager: Medical Services/consultant; write best-interests note; alert Child-Protection team
Adult competent refuses	Constitutional autonomy (Bill of Rights §12) & HPCSA Booklet 9–refusal binding even in extremis	Do not transfuse; maximise blood-conservation; counter-sign capacity assessment; contact JW Hospital Liaison Committee
Adult incompetent; caregiver refuses	NHA §7(1)(e) allows treatment if delay fatal and no valid advance directive	Begin transfusion while notifying MMS; start urgent court application if time permits

• Children’s Act §129: blood transfusion = medical treatment–a mature minor’s consent is valid, but a refusal can be overridden when necessary to save life (confirmed in Hay v B, 2003).
• National Health Act §7(1)(e): permits treatment without consent for any patient (child or adult) when delay will cause death or serious, irreversible harm and no valid directive bars it.
• Constitution §12 & HPCSA Booklet 9: a capacitated adult’s refusal of treatment is absolute, including in emergencies.
• Best-interests principle (Children’s Act §7; common-law): for minors or incapacitated adults, clinicians and courts must prioritise survival and long-term welfare, hence the High-Court or Head-of-Dept pathways to authorise transfusion when surrogates refuse.

Links

• Haematology and Blood testing
• Blood conservation
• Blood transfusions and conservation strategies
• Morbidity and mortality in Anaesthesia

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References:

1. West, James M.. Ethical issues in the care of Jehovah’s Witnesses. Current Opinion in Anaesthesiology 27(2):p 170-176, April 2014. | DOI: 10.1097/ACO.0000000000000053
2. Lawson, T. and Ralph, C. (2015). Perioperative jehovah’s witnesses: a review. British Journal of Anaesthesia, 115(5), 676-687. https://doi.org/10.1093/bja/aev161
3. Nicola Caine and Karin Zybrands. “The Challenges of Treating Jehovah’s Witnesses.” Medical Protection, May 2014. Accessed July 25, 2024. MPS
4. Association of Anaesthetists. Anaesthesia and peri-operative care for Jehovah’s Witnesses and patients who refuse blood. Anaesthesia 2019;74:74-82. anaesthetists.org
5. Health Professions Council of South Africa. Guidelines on Informed Consent (Bk 9), 2021.
6. FRCA Mind Maps. (2024). Retrieved June 5, 2024, from https://www.frcamindmaps.org/
7. Anesthesia Considerations. (2024). Retrieved June 5, 2024, from https://www.anesthesiaconsiderations.com/
8. National Health Act 61/2003, Chapters 2 & 8.
9. Children’s Act 38/2005, §129; Regulations 33-47.
10. Hay v B 2003 (3) SA 492 (W).
11. Nair N. Durban High Court interim order: blood transfusion for JW children. TimesLIVE 26 Feb 2019. timeslive.co.za
12. Barrington MJ, Kluger R. Cell salvage in JW surgery. Reg Anesth Pain Med 2023;48:155-63.
13. Medical Protection Society. The challenges of treating Jehovah’s Witnesses (Casebook) 2014.
14. Malikane, B. H. and McQuoid‐Mason, D. (2022). Right of reply. South African Medical Journal, 509-510. https://doi.org/10.7196/samj.2022.112i8.16603

Summaries
JW

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Copyright

© 2025 Francois Uys. All Rights Reserved.

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