Substituted Judgement Under Uncertainty in Emergency Trauma Care
Document Type
Conference Proceeding - Restricted Access
Publication Date
5-8-2026
Abstract
Autonomy, a principle of medical ethics, holds that clinicians should generally respect a patient's right to make informed decisions about their own care, even when those decisions increase the risk of adverse health outcomes. An example is the refusal of blood products on religious grounds by Jehovah's Witnesses. In emergency scenarios, patients are typically treated under presumed consent, and ethical uncertainty arises when blood transfusion refusal is alleged in the absence of direct patient communication. This is particularly true when a patient urgently requires transfusion, lacks documented blood refusal or a reachable surrogate, and members of the patient's religious community assert that transfusion would be contrary to the patient's wishes. This case examines how clinicians assess credibility and truth in substituted judgment under medical urgency and evidentiary uncertainty.
The patient is a 52-year-old male with a history of T2DM, HTN, and prior CABG on aspirin who was transferred from an outside hospital following a motor vehicle collision. Prior to arrival, he was intubated and received sedation and resuscitation with intravenous fluids. On admission, he had a GCS of 6T with evidence of severe polytrauma. Imaging demonstrated extensive injuries, including blunt cerebrovascular injury with internal carotid artery dissection and traumatic middle cerebral artery occlusion, multifocal intracranial hemorrhages, bilateral pneumothoraces with pulmonary contusions, and pneumomediastinum. Initial evaluation was notable for hemorrhagic shock due to diffuse thoracic bleeding, prompting urgent operative planning with anticipated need for blood transfusion. At that time, members of a local Jehovah's Witness congregation asserted that the patient would refuse blood products. However, no documentation or family was immediately reachable to confirm this preference.
This case highlights the challenge of assessing the credibility of claimed patient preferences in substituted judgment when no verified surrogate is available. It underscores the need for clinicians to balance beneficence with respect for autonomy by critically assessing the credibility and evidentiary weight of claims about a patient's wishes before constraining life-sustaining care. The case also illustrates how variability in, or the absence of, documented transfusion preferences can complicate decision-making in emergency settings.
Recommended Citation
Pardington J, Rick H, Armstrong M. Substituted judgement under uncertainty in emergency trauma care. Presented at: Research Day Corewell Health West; 2026 May 8; Grand Rapids, MI.
Comments
2026 Research Day Corewell Health West, Grand Rapids, MI, May 8, 2026. Abstract 2061