A practical approach, based on patient autonomy and clinical safety, for healthcare teams and lawyers facing transfusion refusal and the application of “bloodless medicine” strategies.
Legal–Healthcare Editorial | Cazar | Pesántez Abogados — December 13, 2025
In hospital and surgical settings, refusal of blood transfusions presents clinical and medical-legal challenges that cannot be resolved through intuition alone, but rather through protocols, documentation, and structured communication. This scenario arises frequently with Jehovah’s Witness patients, who—according to clinical guidelines—generally reject allogeneic blood and primary components, although certain fractions or blood derivatives may be subject to individual decision and must be agreed upon on a case-by-case basis.
In Ecuador, the regulatory framework requires that acceptance or refusal of a transfusion be documented in writing, with one significant exception: cases of urgency or emergency.
Recently, specialized volunteers who are members of Jehovah’s Witnesses participated in a training session together with Cazar | Pesántez Abogados, addressing clinical alternatives and their legal framework under Ecuadorian law.
Context and the Problem
1.1. Why This Issue Matters (Clinical + Liability)
In practice, tension arises when the following converge: life-threatening risk or perioperative hemorrhage; self-imposed therapeutic limits by the patient; and care-related pressure (on-call shifts, emergencies, lack of time). A poorly documented decision or incomplete communication may lead to claims, internal audits, conflicts with family members, and criminal or administrative exposure, even if the healthcare team acted in good faith.
1.2. Ecuadorian Legal Framework: Autonomy and Minimum Formalities
Two key pillars apply:
• The Constitution: recognizes rights related to personal integrity and informed decisions regarding health, forming the basis for patient autonomy in clinical contexts.
• The Organic Health Law (LOS), Article 77: expressly provides that acceptance or refusal of a transfusion “must be made in writing” by the recipient or their representative, except in cases of “emergency or urgency.” This provision is operationalized in clinical management through the Ministry of Public Health’s Informed Consent Model (A.M. 5316).
Analysis
2.1. “Refusal of Transfusion” Does Not Mean “Refusal of All Alternatives”
Clinical practice guidelines indicate that while some patients reject primary components (e.g., red blood cells, plasma, platelets), there are areas of individual choice (for example, certain derivatives such as albumin or coagulation factors). This requires a specific and well-documented discussion regarding what each patient accepts and what they refuse.
2.2. Clinical Strategies Commonly Used to Reduce or Avoid Transfusion
Without replacing institutional protocols, the literature and guidelines on “bloodless medicine” describe a phased approach:
• Preoperative (optimization): diagnosis and aggressive correction of anemia (e.g., iron, folate, vitamin B12, and in certain cases erythropoiesis-stimulating agents), along with coagulation assessment and advance planning.
• Intraoperative (bleeding control): meticulous hemostatic techniques, use of hemostatic agents (e.g., antifibrinolytics such as tranexamic acid, when indicated), and blood conservation techniques such as acute normovolemic hemodilution or cell salvage, when clinically appropriate and accepted by the patient.
• Postoperative (anemia tolerance + monitoring): minimizing blood draws, monitoring for bleeding, treating causes of coagulopathy, and prioritizing hematologic recovery.
This approach relies on interdisciplinary teams and systematic planning; even reviews in cardiovascular surgery describe viable outcomes when pre-, intra-, and postoperative measures are applied under a structured plan.
2.3. Medical-Legal Management: “How” the Decision Is Made Matters as Much as “What” Is Decided
In Ecuador, critical issues usually arise around:
• Quality of informed consent (clarity, risks, alternatives, consequences of refusal).
• Documentary traceability (forms, medical notes, specific agreements on blood derivatives and alternatives).
• Urgency/emergency scenarios (proper application of the Article 77 LOS exception and clinical support for the decision).
For minors, Informed Consent Model A.M. 5316 sets out rules for execution by legal representatives and operational criteria; therefore, prior training of healthcare teams reduces the risk of improvisation.
Practical Recommendations (for Clinics, Hospitals, and Professional Defense)
- Implement a “transfusion refusal admission package,” including:
○ specific consent forms,
○ a checklist of acceptable and non-acceptable alternatives,
○ a verification sheet for capacity and representation. - Standardize the clinical conversation:
○ relevant risks,
○ alternatives available within the institution,
○ consequences of refusing transfusion,
○ written record and signature. - Activate an early institutional pathway (not during a crisis):
○ anesthesia, surgery, hematology/transfusion medicine, ICU, legal counsel, and ethics committee (if applicable). - Adopt “patient blood management / bloodless medicine” practices that benefit many patients, not only those who refuse transfusion (anemia optimization, minimization of iatrogenic blood loss).
- Joint medical-legal training (clinicians + lawyers):
○ practical interpretation of Article 77 LOS (general rule and exception),
○ management of criminal and administrative risk,
○ handling conflicts with family members and crisis communication.
Conclusion
Refusal of transfusions—whether due to personal conviction or therapeutic preference—requires preparation: protocols, robust informed consent, reasonable clinical alternatives, and impeccable documentation. At Cazar | Pesántez Abogados, we support clinics and healthcare professionals through in-house training, review of consent forms, design of internal pathways, and response training for critical events, integrating clinical criteria with the requirements of Ecuadorian law.
Request a free consultation to assess the status of your informed consent forms, transfusion protocols, and institutional management of patients who refuse blood derivatives.
