Health: When others suffer for your faith: Patients' beliefs can put health resources under strain, reports Roger Dobson

Robert Bain died for his beliefs. He died in hospital after a motorway car crash. The surgeons say they could have saved his life. For two hours Mr Bain lay trapped in the wreckage of the car with a partly severed leg. He refused blood transfusions because he was a Jehovah's Witness.

His passenger, Mark Andrew, also refused blood transfusions while he lay trapped in the car for 90 minutes, and later in hospital. He was at various stages warned by doctors that he would die but stuck to his beliefs. His leg was amputated from below the knee and he spent three-and-a-half months in hospital.

'They were quite blunt, they said I was going to die. But for us there was no choice, it was not negotiable. All my life I had held that belief and now I was being put to the test,' he said.

The cause of the accident on the M40 on the outskirts of Oxford will never be known. No other vehicle was involved and the car ended up impaled on a motorway crash barrier.

The dilemma for doctors and paramedics at the scene began when both men refused blood while still trapped. 'It took the emergency teams about an hour and half to cut me from the wreckage. I was slipping in and out of consciousness. I remember Robert and I both saying we did not want transfusions. We made that point very clearly as soon as people started appearing on the scene. I was conscious when I arrived at hospital. I don't think the pressure to have them was that great.

'My recollection is of being taken straight into the operating theatre and one of the doctors saying that as a result of the accident they had to amputate a leg.'

For Mr Andrew, a lifelong Jehovah's Witness, and for the 130,000 witnesses in the UK and 4 million worldwide, the issue is simple: the Bible says no blood, so no transfusions, a belief based mostly on an interpretation of Acts XV, verses 28 and 29.

But for surgeons and for the NHS the case is not so clear- cut. Not giving blood resulted in the treatment being more expensive, and in Mr Andrew's case, longer than it would have been had he been treated conventionally.

The case has reopened the debate over patients refusing established and effective treatment on non-medical grounds - in a health service where resources are finite and where rationing is on the agenda.

Simon Finfer was the consultant surgeon who led the team treating the two witnesses; he wrote about the case in the British Medical Journal in July, without naming the patients.

Dr Finfer, then of Oxford's John Radcliffe Hospital and now working in Australia, said, 'If the first patient (Mr Bain) had accepted blood he would not have required admission to intensive care or the additional, expensive treatment. Our legal duty to treat him according to his wishes conflicted with our moral duty to use our finite resources efficiently.

'Doctors are legally obliged to respect a patient's wish and may thus deny scarce resources to other patients.'

For some hospital staff their dilemma deepened when it was calculated at the John Radcliffe that the predicted survival rates for both of the men, had they received normal treatment was high - 99 per cent in both cases. Dr Finfer said: 'Despite repeated explanations of the risk to his life, Mr Bain continued to refuse blood transfusion. He had a cardiac arrest from which he could not be resuscitated. The early death must be attributed to his refusal to accept blood transfusion.'

Dr Finfer said that reaction to the death among staff was mixed. 'Not everyone was able to accept it as a necessary consequence of deeply held religious beliefs.'

Tony Brace, hospital co-ordinator with the Jehovah's Witnesses said, 'We keep a confidential register with around 2,400 consultants in Britain.

Throughout the world we have a list of 45,000 specialists. Any doctor who wants to refer a patient who is a Jehovah's Witness can contact one of our hospital liaison committees in 36 locations in Britain and in more than 1,000 cities worldwide.'

Doctors can legally hand over the care of their patient to another doctor.

That is feasible in routine, planned operations, but in an emergency such as that at the John Radcliffe, it would be almost impossible.

The British Medical Association's latest ethical guidelines for doctors state that if a rational adult who has been fully apprised of the consequences of not receiving this treatment persists in a refusal, the decision should be respected. In practice the dilemma seldom has a simple answer.

The law poses an additional problem. The Court of Appeal has ruled that those who treat Jehovah's Witnesses against their known wishes, do so at their own peril. They risk assault charges. Earlier this year Lord Donaldson, former Master of the Rolls, advised the BMA on the position. In cases of doubt, he said, the decision should be in favour of preserving life.

'Doctors faced with a refusal have to give very careful and detailed consideration to the patient's capacity to decide at the time the decision was made,' he said. 'What matters is that doctors should consider at that time that he had a capacity commensurate with the gravity of the decision he purported to make. The more serious this decision, the greater the capacity required. If the patient had the requisite capacity, they are bound by his decision. If not, they are free to treat him in what they believe to be his best interests.'

Mark is now rebuilding his life after the accident which killed his friend and left him disabled. 'Doctors have ethics, but not having a blood transfusion is a central belief for me. I knew they believed I was going to die, but I had no hesitation in refusing a transfusion and I would not hesitate again.'

(Photograph omitted)