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Introduction: For endoscopic procedures, informed consent elevates patient autonomy and circumvents medical paternalism. However, when procedures carry significant risk of harm, clinicians may unintentionally overlook patient preferences when making decisions. We present the case of a Jehovah's Witness with upper gastrointestinal bleeding who was offered endoscopic intervention despite a high risk of peri-procedural mortality, with emphasis placed on the shared-decision making process. Case Description/Methods: A 77-year-old female Jehovah's Witness presented with hematemesis and hemoglobin of 4.9 grams/deciliter (g/dL). Endoscopy demonstrated a duodenal ulcer with a visible vessel. Due to the inability to transfuse blood and risk of provoking further bleeding, the decision was made to forego clipping or cauterization and treat only with hemostatic powder (Figure 1). On hospital day 3 she experienced new melena with decrease in hemoglobin to 2.8 g/dL. Although providers were hesitant to offer repeat endoscopy given her lack of hemodynamic reserve, a nuanced discussion with the patient elucidated her wish to undergo all possible interventions even at high risk of death (Figure 2). Endoscopy was performed despite low hemoglobin, which redemonstrated the duodenal ulcer with a large pulsatile visible vessel. The ulcer was injected with epinephrine and an over-the scope clip was successfully placed (Figure 3). She initially stabilized, however on hospital day 5 she developed recurrent melena with hemodynamic instability. After discussion with her family, she was transitioned to comfort care measures and expired that evening. Discussion: When faced with the possibility of patient harm, gastroenterologists may intentionally withhold interventions due to a desire to act in what is perceived to be in the best interest of the patient. Ethically, however, acting by omission devalues both patient autonomy and the right to self-determination in care. This effect may be amplified by pre-existing stigma such as with the Jehovah's Witness wherein refusal of blood products may be erroneously interpreted to imply a broader refusal of other life-saving treatments. In this case, through juxtaposition of two procedures, we demonstrate that this phenomenon can be circumvented via thoughtful discussion of all potential options with patients, regardless of physician preference. We hope to highlight the importance of this ethical concept when approaching patients for informed consent.

three MDRO outbreaks in Dutch hospitals were reported in the literature with 21 patients suffering from a clinical infection based on a microorganism proven to be transmitted by a duodenoscope. In that time period, approximately 203.500 ERCP procedures were performed. Hence, for every 1 out of 9690 procedures one patient developed a clinically relevant infection amounting to a DAI risk of 0.010%. Conclusion: The risk of developing a DAI is at least 30 to 180 times higher than the risks that were previously reported for all types of endoscopyassociated infections. Importantly, the current calculated risk of 0.010% constitutes a bare minimum risk of DAI because endoscope related infections are under-reported. Apart from DAI risk there is also the risk of patients becoming colonized with MO through contaminated endoscopes but without developing symptoms of a clinical infection. These data call for consorted action of medical practitioners, industry and government agencies to minimize and ultimately ban the risk of exogenous endoscope associated infections and contamination. As a first step, the FDA recently recommended health care facilities and manufacturers begin transitioning to duodenoscopes with disposable components.

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