Medical consent, defined as patient’s voluntary agreement to treatment, examination, or other aspects of healthcare, must be considered as a continuously evolving process in the management of a patient. Consent must be obtained from competent adults prior to examination or treatment. A valid consent requires from the patient that [7]:

For this to be the case, the patient must be competent or have the capacity to give consent, which implies the patient is able to understand and retain the information given to him or her regarding a specific procedure and to use that information to decide whether or not to undergo that procedure. The terms capacity and competence are often used interchangeably, but the former is the one most commonly used in law.

Regarding pediatric practice, in most Western countries, adolescents more than 16 years of age are assumed to be legally competent, which however does not invalidate the parental right to consent on their behalf [8]. A young patient under the age of 16 may have the capacity to make decision, depending on his ability to understand what is involved. In the UK, validity of consent is best explored by the Gillick competence (i.e., ability to consent on his or her own medical treatment, regardless of parental permission or knowledge) [9]. For Lord Fraser, a child under 16 years of age could give valid consent in accordance with following guidelines [7]:

In addition, as for competent adult, consent of a young individual requires to be valid that it is given voluntarily and free from coercion.

Therefore, four issues may compete for children less than 16 years of age [10]:

In case consent is refused, an application to the court for a specific issue order can be made (parental authority and/or patient consent is removed and the procedure may go ahead). If there is not enough time for such an application, the doctors are empowered to act in the “best interest” of the patient [8].

It should be noted that, in most Western countries, the position of the courts in relation to parental objection to blood transfusion on religious grounds is now so well established that it is commonly possible for agreement to be reached without “going to law,” with an arrangement that blood, or blood products, will only be given in certain clinical circumstances or when required by the doctors’ duties to act in the child’s best interests.

Advance directives are legally binding documents outlining treatments an adult individual would not consent in the future, should he or she lack capacity. To be valid, these directives must fulfill the following:

Blood refusal cards are a form of advance directive distributed by the WTS. However, as WTS provide information about the risk but not the benefit of transfusion, there is a clear concern about the validity of the information given to make an informed decision. In addition, there is also concern about whether an individual’s decision to carry such a card is without external influence. Therefore in emergency situations, if any doubt exists on the validity of such blood refusal cards, some authors recommend treating in the patient’s best interest and transfusing blood [11].

Several hospitals have consent forms designed for Jehovah’s Witness patients that include a section for detailing specific exclusions from the consent. When obtaining restricted consent, the patient should be interviewed in the presence of an independent witness, the benefits and risks of blood transfusion explained, and an attempt made to help the patient understand the rationale for the recommended treatment. If the patient did not change his opinion, the precise nature of the restrictions placed on the doctor by the patient should be documented in the patient’s clinical chart. All parties involved should sign the consent form.

Anesthesia providers may feel that refusal of standard care in the operating room or in the postoperative period, such as blood transfusion, places them in a very difficult position of not being able to fulfill their professional duties. According to the guidelines for anesthesia care of patients with do-not-resuscitate orders or other directives that limit treatment developed by the ASA, anesthesiologists have the right in non-emergent situations to excuse themselves from a patient’s care nonjudgmentally as long as they refer the patient to another care provider in a timely fashion [12]. This referral could even be to another medical center that has developed expertise in caring for Jehovah’s Witness patients. In life-threatening situations, the anesthesiologist is obligated to care for the patient, trying “as much as possible” to adhere to patient’s wishes. If the anesthesiologist is concerned that he or she will not be able to comply, then he or she should inform the patient or his surrogate [1].

Elective surgery for Jehovah’s Witness patients should be conducted in centers having the appropriate facilities by a senior team sensitive to patient’s beliefs and with experience in techniques of “bloodless surgery.” Providing medical care to patients without the use of allogeneic blood transfusion is one aspect of patient blood management. By providing bloodless care to patients, valuable lessons have been learned, facilitating blood conservation in general and therefore expertise in the field of patient blood management. Requiring a holistic approach across the whole perioperative period, it is an example of the paradigm shift described in transfusion medicine, away from the component-centric model, toward the patient-centric approach [13]. Before surgery, there must be full discussion between the patient, surgeon, and anesthetist. All risks have to be explained and “rules” for management established before commencement. Physicians should question the patient on specific blood product interventions and alternatives that the physician may or may not use (Table 22.2). Surgery must be planned and tailored to the needs of the individual patient. Non-operative techniques and staging of major surgical procedures should be considered. Other specialists likely to be involved in the patient’s care should be advised and theater personnel informed so that any equipment, drug, and specialist will be available.