Jehovah's witnesses refuse blood transfusions. The conflict arises when the patient, entitled to public health treatment, come to surgical centers without blood, to later claim the costs incurred.
ObjectivesTo analyze the legal claims for the refunding of costs by Jehovah's witnesses treated outside the public health system. To make a cost comparison regarding this, using Diagnosis Related Groups (DRGs) in a similar hypothetical healthcare model and equal to a stay in our hospital.
Material and methodsA retrospective study was made of the High, Constitutional, and Supreme Court rulings. A cost analysis was made using the clinical information obtained in the rulings, to process this in the DRG in our hospital using 3MHealth Information Systems.
Results/conclusionsThe State is not obliged to finance religious aspects or those outside the general interest. The establishment of working protocols would avoid ethical conflicts. There are very difficult to justify differences in the costs demanded, 431 001.66€, and compared to a model with an equal stay, 397 404.48€.
Los testigos de Jehová rechazan la transfusión sanguínea. El conflicto aparece cuando el enfermo, afiliado a la sanidad pública, acude a centros de cirugía sin sangre, para después reclamar los gastos creados.
ObjetivosAnálisis de reclamaciones jurídicas de reintegro de gastos en enfermos testigos de Jehová tratados fuera del sistema de salud pública. Comparación de costes, respecto a costes mediante Grupo de Diagnóstico Relacionado (GRD) en un modelo hipotético de asistencia similar e igual estancia en nuestro hospital.
Material y métodosEstudio retrospectivo de sentencias de tribunales Superior de Justicia, Supremo y Constitucional. Análisis económico: utilizamos información clínica obtenida en la sentencia, para procesarlo en GRD, de nuestro hospital con 3MHealth Information Systems.
Resultado/conclusionesEl Estado no tiene el deber de financiar aspectos religiosos o ajenos al interés general. El establecimiento de protocolos de actuación evitaría conflictos éticos. Diferencias difícilmente justificables en costes solicitados, 431.001,66 €, y en relación a un modelo con igual estancia, 397.404,48 €.
The Jehovah's Witnesses are members of a Christian denomination that follows a doctrine that is strongly tied to a specific translation of the Bible and rejects blood transfusions.
This repudiation is based on several scriptural references:
- •
Acts 15: 28–29 – “[…] abstain from things offered to idols, from blood, from things strangled, and from sexual immorality. If you keep yourselves from these, you will do well. Good health to you!”
- •
Acts 21: 25 – “As for the believers from among the nations, we have sent out, rendering our decision that they should keep themselves from what is sacrificed to idols as well as from blood and what is strangled and from fornication.”1,2
- •
Leviticus 17: 11–12 – “For the soul of the flesh is in the blood, and I myself have put it upon the altar for you to make atonement for your souls, because it is the blood that makes atonement by the soul. That is why I have said to the sons of Israel: “No one of your souls must eat blood and no foreign resident who is residing as a foreigner in YOUR midst should eat blood.”3
Jehovah's Witnesses consider that these Bible verses exclude them from accepting transfusions of blood, packed red blood cells and plasma, and the administration of platelets. The belief that blood should be discarded once it has been extracted from the organism also impedes them from accepting self-blood transfusions that have previously been stored. Lastly, Jehovah's Witnesses do not believe that the Bible makes direct allusions or references to organ transplants, therefore Witnesses should decide for themselves whether or not to receive solid tissue transplants.4–6
In our activities as physicians and surgeons, situations of conflict frequently arise between two fundamental legal values: the right to life and the right of free choice, protected by Articles 15 and 16 of the Spanish Constitution.
Art. 15 of the Spanish Constitution states that, “Everyone has the right to life and to physical and moral integrity […]”.7
Art. 16 of the Constitution states that, “Freedom of ideology, religion and worship of individuals and communities is guaranteed, with no other restriction on their expression than may be necessary to maintain public order as protected by law.”8
Within the context of this situation, there have been contradictory judicial decrees and decisions with regard to giving priority to patients’ lives, and consequently the lex artis of medical professionals, over the freedom of Jehovah's Witness patients, and vice versa. It is therefore necessary to reach a true ethical, legal and religious balance when contemplating this growing problem in a coherent manner, especially given the disparity of criteria.
The demand of Jehovah's Witnesses for a surgical option, even though it could entail a risk of death, has led to the creation and implementation of “bloodless surgery units”, which involve minimizing the need for using blood and/or blood products. The increased demand, although not the supply, for this type of centers in the public healthcare system has led private hospitals which offer surgical treatment without the need for blood transfusions to receive a continuous pilgrimage of Jehovah's Witness patients for treatment.
The conflict appears when the patient, who is covered under the public healthcare system and has been informed of the possibility of blood transfusion, if necessary, during appropriate medical-surgical treatment, rejects the lack of a guarantee of not receiving a transfusion, and requests to be discharged. The patient then goes to a private hospital that offers bloodless surgery and later sues the national healthcare system for the expenses incurred.
Thus, in our study we intend to:
- 1.
Analyze in detail the legal claims for reimbursement brought by Jehovah's Witness patients who have received medical services outside of the public healthcare system.
- 2.
Identify the expenses caused by the use of medical services outside the public healthcare system.
- a.
Compare the costs incurred and requested with the Groups Related to Diagnosis (GRD) costs in a hypothetical model of similar healthcare provided at the Hospital General de Ciudad Real, Spain.
- b.
Compare the costs incurred and requested with the GRD costs in a similar hypothetical healthcare model including the same length of hospital stay.
For the legal analysis, we carried out a retrospective study of rulings and sentences made by the Spanish High Courts of Justice, Supreme Court and Constitutional Court listed in the database of the Judicial Documentation Center (Cendoj) of the General Council of the Judiciary, regarding all the judicial information related with the reimbursement of expenses due to the use of medical services outside the public healthcare system. Likewise, we accessed the database of Editorial Aranzadi, S.A.
Based on the sentences found, we created a descriptive analysis of hospital stay and costs requested for reimbursement in each of the cases. We collected data on the associated disease, treatment, private hospitals, sentences from the different courts, legal grounds and court rulings.
For the cost analysis, we used the clinical information obtained from the sentence for its processing in GRD at the Hospital General de Ciudad Real, which enabled us to determine the expenditure per GRD (3MHealth Information Systems work station developed for the use of GRD).
The associated disease was identified from the court rulings and converted to the corresponding GRD at the Hospital General de Ciudad Real. We identified the mean hospital stay per GRD as well as cost per stay for each GRD (data from 2008) (Table 1).
Judicial and Cost Analysis of the Processes.
| Case | Pathology | GRD | Days in hospital | Cost, € | Court | Ruling |
| 1 | Femoral head fracture | 236 | 14 | 3548.99 | SC | Dismissed |
| 2 | Femoral head fracture | 236 | 5694.68 | HCJ | Dismissed | |
| 3 | Osteoarthritis of the hip | 244 | 5 | 6650.08 | HCJ | Dismissed |
| 4 | UGIH | 174 | 13 | 8255.80 | HCJ | Dismissed |
| 5 | UGIH (duodenal ulcer) | 176 | 21 | 4360.29 | SC, CC | Dismissed |
| 6 | Prostate adenocarcinoma | 307 | 4107.00 | HCJ | Dismissed | |
| 7 | Prostatic hyperplasia | 349 | 6 | 6800.00 | HCJ | Dismissed |
| 8 | Uterine fibroid | 359 | 2664.04 | HCJ | Dismissed | |
| 9 | Uterine fibroid | 359 | 6 | 2662.48 | HCJ | Dismissed |
| 10 | Interatrial communication | 135 | 2686.59 | HCJ | Dismissed | |
| 11 | Valvular Insufficiency | 135 | 2 | 2686.59 | HCJ | Dismissed |
| 12 | Carotid tumor | 145 | 5 | 3231.69 | HCJ, SC | Appeal by the Canary Island Healthcare Admin. dismissed |
| 13 | Rectal carcinoma | 149 | 24 491.42 | HCJ | Dismissed | |
| 14 | Rectal carcinoma + liver metastases | 172 | 14 | 350 000.00 | HCJ | Dismissed |
| 15 | Femoral head fracture | 236 | 4 | 5779.82 | HCJ, SC | Dismissed |
| 16 | Rectal carcinoma | 149 | 6872.51 | HCJ | Dismissed | |
| 17 | Endometrial carcinoma | 367 | 4 | 4202.96 | HCJ | Dismissed |
CC, Constitutional Court of Spain; HCJ, High Courts of Justice; SC, Supreme Court of Spain.
We calculated the total and individual costs for the processes requested for reimbursement in the court sentences for their overall and individual comparisons with the normal costs per process (GRD) at the Hospital General de Ciudad Real in 2008.
Likewise, we made another identical comparison, but in this case using the length of hospital stay reported in the court documentation. In order to determine the cost per process/GRD that would be incurred at the hospital in this hypothetical model, we multiplied the cost of hospitalization by GRD per day by the length of hospital stay described in the court sentences (hypothetical hospitalization).
ResultsLegal Analysis (Table 1)Case 1Pathology: left femoral head fracture; GRD: 236; Hospitalization: 14 days; Cost: 3548.99€
Court: Supreme Court, Social Law Chamber, Madrid (1993); Ruling: case dismissed
Legal grounds related to the unjustified refusal of treatment: “The beneficiaries [of Social Security healthcare] are not granted a right to opt for private medical services; the provision of private medical care is exceptional in nature and should be justified by the beneficiaries to the Court.”; “…The Public Administration will not reimburse expenses as a result of the use of medical services outside of their realm of responsibility.”
With regard to religious freedom: “We conclude that any and all consequences (including financial) that are based on the observance of the religious precepts at hand must be the responsibility of whosoever follows such precepts.”
Case 2Pathology: right femoral head fracture; GRD: 236; Cost: 5694.68€
Court: High Courts of Justice, Social Law Chamber, Bilbao (2001); Ruling: case dismissed
Legal grounds related to the unjustified refusal of treatment: “The possibility for reimbursement of expenses only exists in the following cases: (a) the medical care provided was emergency care; (b) the care needed to be immediate; (c) the care was life-saving.”
With regard to religious freedom: “The existence of religious beliefs that do not allow a patient to be treated as prescribed under the Social Security healthcare system does not justify the use of private medical services.”
Case 3Pathology: osteoarthritis of the right hip; GRD: 244; Hospitalization: 5 days; Cost: 6650.08€
Court: High Courts of Justice, Social Law Chamber, La Coruña (1997); Ruling: case dismissed
Legal grounds related to the unjustified refusal of treatment: “The Public Administration will not reimburse the expenses caused by the use of services other than those that corresponded to the beneficiary.”
With regard to religious freedom: “The State should respect religious freedom, but it is not responsible for financing those aspects of religious freedom that are not deserving of protection nor should be promoted from a general standpoint.”
Case 4Pathology: upper digestive tract hemorrhage; GRD: 174; Hospitalization: 13 days; Cost: 8255.80€.
Court: High Courts of Justice, Social Law Chamber, Bilbao (2002); Ruling: case dismissed
Legal grounds related to the unjustified refusal of treatment: “The entities responsible for providing medical services will not pay the expenses incurred when the beneficiary uses medical services other than those that have been allocated to him or her.”; “…life-threatening risk, or loss of organs or extremities that are fundamental for normal daily living.”
Case 5Pathology: upper digestive tract hemorrhage (duodenal ulcer); GRD: 176; Hospitalization: 21 days; Cost: 4360.29€
Court: Supreme Court, Social Law Chamber, Madrid (1994); Constitutional Court (1996); Ruling: dismissed and denied
Legal grounds related to the unjustified refusal of treatment: “…the beneficiary can opt between public and private medicine and even refuse the treatment prescribed by physicians […] but the Public Administration will not pay for the expenses.”
Case 6Pathology: prostate adenocarcinoma; GRD: 307; Cost: 4107€
Court: High Courts of Justice, Social Law Chamber, La Coruña (2005); Ruling: case dismissed
Legal grounds related to the unjustified refusal of treatment: “According to current regulations, in the case that Social Security beneficiaries use medical services other than those they have been allocated, the entities responsible for providing healthcare services will not pay for the costs that may be incurred.”
Case 7Pathology: prostate hyperplasia; GRD: 349; Hospitalization: 6 days; Costs: 6800€
Court: High Courts of Justice, Social Law Chamber, Oviedo (2003); Ruling: case dismissed
Legal grounds related to the unjustified refusal of treatment: “The Public Administration will not pay for the expenses that may be caused by the use of services other than those that correspond to the beneficiary.”
Case 8Pathology: uterine fibroid; GRD: 359; Cost: 2664.04€
Court: High Courts of Justice, Social Law Chamber, Valencia (1997); Ruling: case dismissed
Legal grounds related to the unjustified refusal of treatment: “…there is no right to reimbursement by voluntarily refusing public medicine to be treated in a private medical facility.”
With regard to religious freedom: “…according to the Supreme Court, the right to life prevails over religious freedom, and this does not justify the demand of not accepting blood transfusions; therefore, this motive is not legitimate for the abandonment of public medicine with a right to reimbursement.”
Case 9Pathology: uterine fibroid; GRD: 359; Hospitalization: 6 days; Cost: 2662.48€
Court: High Courts of Justice, Social Law Chamber, Madrid (1998); Ruling: case dismissed
Legal grounds related to the unjustified refusal of treatment: “…given the possibility to be treated at the Fundación Jiménez Díaz without blood transfusion… and with the use of blood transfusion at any of the Social Security hospitals.”
Case 10Pathology: interatrial communication; GRD: 135; Cost: 7512.65€.
Court: High Courts of Justice, Social Law Chamber, Zaragoza (2000); Ruling: case dismissed
Legal grounds related to the unjustified refusal of treatment: “The Public Administration will not reimburse the expense that may be caused by the use of services other than those that correspond to the beneficiary.”
With regard to religious freedom: “The State should respect religious freedom, but it is not responsible for financing those aspects of religious freedom that are not deserving of protection nor should be promoted from a general standpoint.”
Case 11Pathology: valvular insufficiency; GRD: 135; Hospitalization: 2 days; Cost: 28 604.17€
Court: High Courts of Justice, Social Law Chamber, Madrid (1998); Ruling: case dismissed
Legal grounds related to the unjustified refusal of treatment: “In its activities, the Social Security Administration has to follow pre-established norms regarding the reach of its protective actions in order to guarantee both efficacy and equality in the services provided, as well as the necessary stability of the system.”
With regard to religious freedom: “The State should respect religious freedom, but it is not responsible for financing those aspects of religious freedom that are not deserving of protection nor should be promoted from a general standpoint.”
Case 12Pathology: carotid glomus tumor; GRD: 145; Hospitalization: 5 days; Cost: 3231.69€
Court: High Courts of Justice, Social Law Chamber, Las Palmas (2004); Supreme Court, Social Law Chamber, Madrid (2005); Ruling: dismissal and rejection of appeals by the Canary Island Healthcare Administration
Legal grounds related to the unjustified refusal of treatment: “The judge considers that there has been refusal to provide healthcare as the appellant had surgical techniques available that did not require blood transfusion but did not perform these, which makes this situation a clear refusal to provide medical care.”
Case 13Pathology: familial polyposis of the colon, rectal carcinoma; GRD: 149; Cost: 24 491,42€.
Court: High Courts of Justice, Social Law Chamber, Valencia (2009); Ruling: case dismissed
Legal grounds related to the unjustified refusal of treatment: “The entities responsible for providing medical services will not pay the expenses incurred when the beneficiary uses medical services other than those that have been allocated to him or her.”
Case 14Pathology: colon cancer, liver metastases; GRD: 172; Hospitalization: 14 days; Cost: 350 000.00€.
Court: High Courts of Justice, Chamber for Contentious Administrative Proceedings, Madrid (2009); Ruling: case dismissed
Legal grounds related to the unjustified refusal of treatment and religious freedom: “…refused to receive the treatment offered due to religious beliefs, therefore there is not any observed infraction of the Lex Artis by the healthcare services of the mentioned centers, who had made available all the measures necessary, and the intervention was not performed because of the patient's refusal.”
Case 15Pathology: femoral head fracture; GRD: 236; Hospitalization: 4 days; Cost: 5779.82€
Court: High Courts of Justice, Social Law Chamber, Barcelona (2007); Supreme Court, Madrid (2009); Ruling: case dismissed
Legal grounds related to the unjustified refusal of treatment: “…obtaining healthcare with the most advanced techniques cannot reasonably constitute the content of the protective action of a system characterized by the limitation of means and by its projection of coverage with universal vocation.”
With regard to religious freedom: “…obtaining healthcare with the most advanced techniques cannot reasonably constitute the content of the protective action of a system characterized by the limitation of means and by its projection of coverage with universal vocation.”
Case 16Pathology: rectal carcinoma; GRD: 149; Cost: 6872.51€
Court: High Courts of Justice, Social Law Chamber, Madrid (2008); Ruling: case dismissed
Legal grounds related to the unjustified refusal of treatment: “…obtaining healthcare with the most advanced techniques cannot reasonably constitute the content of the protective action of a system characterized by the limitation of means and by its projection of coverage with universal vocation.”
With regard to religious freedom: “…obtaining healthcare with the most advanced techniques cannot reasonably constitute the content of the protective action of a system characterized by the limitation of means and by its projection of coverage with universal vocation.”
Case 17Pathology: endometrial carcinoma; GRD: 367; Hospitalization: 4 days; Cost: 4202.96€
Court: High Courts of Justice, Social Law Chamber, La Coruña (2008); Ruling: case dismissed
Legal grounds related to the unjustified refusal of treatment: “…obtaining healthcare with the most advanced techniques cannot reasonably constitute the content of the protective action of a system characterized by the limitation of means and by its projection of coverage with universal vocation.”
Economic AnalysisAs for the comparison of the expenses incurred and solicited versus the costs defined by GRD for the diagnoses described in a hypothetical model of similar healthcare services at the Hospital General de Ciudad Real, the total cost requested for reimbursement was 475 438.58€.
The hypothetical cost for treatment of patients with similar GRD in our hospital in the year 2008 would have been 44 436.92€. The difference is 431 001.66€, and it would be difficult to justify the public healthcare system financing this amount, especially after observing the legal grounds specified in the aforementioned sentences.
As for the comparison of the expenses incurred and requested versus the costs, as defined by GRD, in a hypothetical similar healthcare model at the Hospital General de Ciudad Real, entailing the same hospitalization, the total cost would be 26 691.80€. If we eliminated those cases for which the hospitalizations periods were not defined in the sentences, the total cost requested for reimbursement would be 424 096.28€. The difference is 397 404.48€, a reimbursement that would be highly unjustifiable once having viewed the legal grounds specified in the sentences described (Table 2).
Analysis of Claimed Expenses, Actual Costs and Those of a Hypothetical Model.
| Case | Hypothetical No. of days, GRD | Actual cost of stay, GRD | Hypothetical cost | Actual cost per process, GRD | Expenses claimed |
| 1 | 14 | 173.25 | 2425.50 | 2743.04 | 3548.99 |
| 2 | 5 | 427.00 | 2135.50 | 2743.04 | 6650.08 |
| 3 | 13 | 370.71 | 4819.23 | 3016.84 | 8255.80 |
| 4 | 21 | 188.25 | 3953.25 | 2353.06 | 4360.29 |
| 5 | 6 | 195.27 | 1171.62 | 1578.40 | 6800.00 |
| 6 | 6 | 670.51 | 4023.56 | 3518.56 | 2662.48 |
| 7 | 2 | 239.87 | 479.74 | 2686.59 | 28 604.17 |
| 8 | 5 | 223.06 | 1115.30 | 1598.58 | 3231.69 |
| 9 | 14 | 286.51 | 4011.14 | 4584.22 | 350 000.00 |
| 10 | 4 | 173.25 | 693.00 | 2743.04 | 5779.82 |
| 11 | 4 | 466.24 | 1864.96 | 3030.58 | 4202.96 |
Hypothetical cost, cost resulting from the multiplication of the hypothetical hospitalization and actual hospitalization cost (GRD) at the Hospital General; Hypothetical stay, estimated stay for the calculation of cost at the Hospital General identical to the stay of the case identified in the court sentence.
In all the cases, and in each of the hypothetical models analyzed, the costs requested for reimbursement are higher than the expense that similar medical services would cost within the setting of the public healthcare system.
DiscussionReimbursement of the expenses incurred by treatment at private hospital centers that do not adhere to the Spanish national healthcare system has always been a controversy that is difficult to resolve. On one side of the question is the determination of the level of care provided by the Social Security Administration with regard to parameters of efficacy and costs. On the other are Jehovah's Witness beneficiaries, who feel it is their right to choose the type of medical assistance and demand equal conditions in exchange.
Article 18 of Decree 2766/1967 presents several regulations for the reimbursement of medical expenses under the Social Security system:
“The Social Security Administration is not responsible for those expenses derived from medical services provided by healthcare centers unaffiliated with the Social Security System when these services have been used by one's own choice.”
It also established exceptions to this rule: if the beneficiary turns to outside services due to unjustified refusal to provide healthcare; or, if the unaffiliated services are used due to an emergency, life-threatening situation.
Royal Decree 63/1995, abrogated by RD 1030/2006, modifies this regulation, with the disappearance of the reference to reimbursement due to unjustified refusal of healthcare. Nonetheless, this situation is confusing as there are different lines of interpretation: (a) reimbursement due to unjustified refusal disappeared from the decree without any substitution; (b) subsistence with no clear legal framework; (c) the unjustified refusal subsists through the pecuniary responsibility of the Administration before the contentious-administrative order.9,10
The legal grounds alleged by Jehovah's Witnesses in this situation are specified in the recourse of protection before the Constitutional Court, No. 3164/199911:
“Fundamental right to equality as guaranteed by the Constitution: Article 14 of the Spanish Constitution recognizes the right to endure no discrimination, which occurs when recurring to private medical services because Social Security physicians do not guarantee treatment, in accordance with certain religious beliefs, that excludes blood transfusion during required surgical interventions.”
Furthermore, the refusal to reimburse medical expenses incurred and requested is considered a penalization of these religious beliefs.
The argument is that there exists infringement upon basic rights, such as equality and religious freedom. The legal grounds regarding reimbursement of expenses are expressed in sentences by the Spanish Supreme and Constitutional Courts. It is considered that religious freedom, recognized as a basic right in Article 16.1 of the Spanish Constitution and regulated by Organic Law 7/1980 (5th July), protects the decision of a Social Security beneficiary to not accept the indicated medical-surgical treatment, and any coercion would infringe upon this right.12
However:
The State should respect religious freedom, but it is not responsible for financing those aspects of religious freedom that are not deserving of protection or should not be promoted from a general standpoint.
The consequences, even financial ones, derived from the observation of religious precepts should be the responsibility of those who choose to observe them.
The public healthcare administration is obliged to provide healthcare services without imposing criteria different from those of the physicians responsible for the case, which would affect professional ethics.
The Social Security Administration is obliged to provide medical services without acquiring, assembling or applying technical means that are not required under standard coverage, which would be contrary to the demands of cost-effectiveness and equality.
These conclusions regarding the reimbursement of expenses due to the refusal of healthcare, life-threatening emergency, equality and religious freedom are the legal grounds used in the sentences presented.13–31
The lack of dialog between physicians and patients, and the continuous implementation of defensive medicine that exempts doctors from legal suits before a judge, are leading to Jehovah's Witnesses being treated less and less in the public healthcare system. Bloodless surgery centers have become an attraction for them as well as a source of claims against the public administration for the reimbursement of the expenses incurred.
The establishment of plans of action would avoid doubts and ethical conflicts, as well as the development of defensive medicine and delays in treatment of these patients.32
There has been only one case where expenses were reimbursed. This occurred when the patient was not offered treatment that could have been provided within the public healthcare system: “The judge considers that there has been refusal to provide healthcare as the appellant had surgical techniques available that did not require blood transfusion and did not perform these, which makes this situation a clear refusal to provide medical care.”
The differences in the costs claimed for reimbursement of expenses by the Jehovah's Witnesses compared with a hypothetical model including similar patients with similar GRD treated at the Hospital General de Ciudad Real in 2008, which was 431 001.66€, and the difference when compared with this model and same length of hospital stay, which was 397 404.48€, can be considered excessive in light of the supported legal arguments. A future approach between the Administration and Jehovah's Witnesses could result in a model similar to what we have which would at least allow for some type of reimbursement, not of the entire expense but at least of costs equivalent to the hypothetical treatment under the tutelage of the public healthcare system. Beforehand, however, there should be improvement, normalization and homogenization of the medical information systems in order to determine the exact cost for each treatment.
The use of our hypothetical GRD financing model is complex and involves a large variety of fees per activity. For the moment, the lack of homogenization of the healthcare information systems for processing in GRD necessitates the use of a mathematical model for the reimbursement of expenses for each hospital, hindering any possible universality.
Conflict of InterestsThe authors have no conflict of interests to declare.
Please cite this article as: Padilla D, Villarejo P, Marcote MA, Molina M, Menéndez P, Ballester N, et al. ¿Es justificable el reintegro del gasto en enfermos quirúrgicos testigos de Jehová tras asistencia sanitaria ajena al sistema público de salud? Cir Esp. 2013;91:287–293.
