Blood and Surgical challenges

Jehovah’s Witnesses-The Surgical/Ethical Challenge
Reprinted with permission of the American Medical Association from The Journal of the American Medical Association (JAMA), November 27, 1981, Volume 246, No. 21, pages 2471, 2472. Copyright 1981, American Medical Association.
Physicians face a special challenge in treating Jehovah’s Witnesses. Members of this faith have deep religious convictions against accepting homologous or autologous whole blood, packed RBCs [red blood cells], WBCs [white blood cells], or platelets. Many will allow the use of (non-blood-prime) heart-lung, dialysis, or similar equipment if the extracorporeal circulation is uninterrupted. Medical personnel need not be concerned about liability, for Witnesses will take adequate legal steps to relieve liability as to their informed refusal of blood. They accept nonblood replacement fluids. Using these and other meticulous techniques, physicians are performing major surgery of all types on adult and minor Witness patients. A standard of practice for such patients has thus developed that accords with the tenet of treating the "whole person." (JAMA 1981;246:2471-2472)
PHYSICIANS face a growing challenge that is a major health issue. There are over half a million Jehovah’s Witnesses in the United States who do not accept blood transfusions. The number of Witnesses and those associated with them is increasing. Although formerly, many physicians and hospital officials viewed refusal of a transfusion as a legal problem and sought court authorization to proceed as they believed was medically advisable, recent medical literature reveals that a notable change in attitude is occurring. This may be a result of more surgical experience with patients having very low hemoglobin levels and may also reflect increased awareness of the legal principle of informed consent.
Now, large numbers of elective surgical and trauma cases involving both adult and minor Witnesses are being managed without blood transfusions. Recently, representatives of Jehovah’s Witnesses met with surgical and administrative personnel at some of the largest medical centers in the country. These meetings improved understanding and helped resolve questions about blood salvage, transplants, and the avoidance of medical/legal confrontations.
WITNESS POSITION ON THERAPY
Jehovah’s Witnesses accept medical and surgical treatment. In fact, scores of them are physicians, even surgeons. But Witnesses are deeply religious people who believe that blood transfusion is forbidden for them by Biblical passages such as: "Only flesh with its soul-its blood-you must not eat" (Genesis 9:3-4); "[You must] pour its blood out and cover it with dust" (Leviticus 17:13-14); and "Abstain from . . . fornication and from what is strangled and from blood" (Acts 15:19-21).1
While these verses are not stated in medical terms, Witnesses view them as ruling out transfusion of whole blood, packed RBCs, and plasma, as well as WBC and platelet administration. However, Witnesses’ religious understanding does not absolutely prohibit the use of components such as albumin, immune globulins, and hemophiliac preparations; each Witness must decide individually if he can accept these.2
Witnesses believe that blood removed from the body should be disposed of, so they do not accept autotransfusion of predeposited blood. Techniques for intraoperative collection or hemodilution that involve blood storage are objectionable to them. However, many Witnesses permit the use of dialysis and heart-lung equipment (non-blood-prime) as well as intraoperative salvage where the extracorporeal circulation is uninterrupted; the physician should consult with the individual patient as to what his conscience dictates.2
The Witnesses do not feel that the Bible comments directly on organ transplants; hence, decisions regarding cornea, kidney, or other tissue transplants must be made by the individual Witness.
MAJOR SURGERY POSSIBLE
Although surgeons have often declined to treat Witnesses because their stand on the use of blood products seemed to "tie the doctor’s hands," many physicians have now chosen to view the situation as only one more complication challenging their skill. Since Witnesses do not object to colloid or crystalloid replacement fluids, nor to electrocautery, hypotensive anesthesia,3 or hypothermia, these have been employed successfully. Current and future applications of hetastarch,4 large-dose intravenous iron dextran injections,5,6 and the "sonic scalpel"7 are promising and not religiously objectionable. Also, if a recently developed fluorinated blood substitute (Fluosol-DA) proves to be safe and effective,8 its use will not conflict with Witness beliefs.
In 1977, Ott and Cooley9 reported on 542 cardiovascular operations performed on Witnesses without transfusing blood and concluded that this procedure can be done "with an acceptably low risk." In response to our request, Cooley recently did a statistical review of 1,026 operations, 22% on minors, and determined "that the risk of surgery in patients of the Jehovah’s Witness group has not been substantially higher than for others." Similarly, Michael E. DeBakey, MD, communicated "that in the great majority of situations [involving Witnesses] the risk of operation without the use of blood transfusions is no greater than in those patients on whom we use blood transfusions" (personal communication, March 1981). The literature also records successful major urologic10 and orthopedic surgery.11 G. Dean MacEwen, MD, and J. Richard Bowen, MD, write that posterior spinal fusion "has been successfully accomplished for 20 [Witness] minors" (unpublished data, August 1981). They add: "The surgeon needs to establish the philosophy of respect for a patient’s right to refuse a blood transfusion but still perform surgical procedures in a manner that allows safety to the patient."
Herbsman12 reports success in cases, including some involving youths, "with massive traumatic blood loss." He admits that "Witnesses are somewhat at a disadvantage when it comes to blood requirements. Nevertheless it’s also quite clear that we do have alternatives to blood replacement." Observing that many surgeons have felt restrained from accepting Witnesses as patients out of "fear of legal consequences," he shows that this is not a valid concern.
LEGAL CONCERNS AND MINORS
Witnesses readily sign the American Medical Association form relieving physicians and hospitals of liability,13 and most Witnesses carry a dated, witnessed Medical Alert card prepared in consultation with medical and legal authorities. These documents are binding on the patient (or his estate) and offer protection to physicians, for Justice Warren Burger held that a malpractice proceeding "would appear unsupported" where such a waiver had been signed. Also, commenting on this in an analysis of "compulsory medical treatment and religious freedom," Paris14 wrote: "One commentator who surveyed the literature reported, ‘I have not been able to find any authority for the statement that the physician would incur . . . criminal . . . liability by his failure to force a transfusion on an unwilling patient.’ The risk seems more the product of a fertile legal mind than a realistic possibility."
Care of minors presents the greatest concern, often resulting in legal action against parents under child-neglect statutes. But such actions are questioned by many physicians and attorneys familiar with Witness cases, who believe that Witness parents seek good medical care for their children. Not desirous of shirking their parental responsibility or of shifting it to a judge or other third party, Witnesses urge that consideration be given to the family’s religious tenets. Dr. A. D. Kelly, former Secretary of the Canadian Medical Association, wrote15 that "parents of minors and the next of kin of unconscious patients possess the right to interpret the will of the patient. . . . I do not admire the proceedings of a moot court assembled at 2:00 AM to remove a child from his parent’s custody."
It is axiomatic that parents have a voice in the care of their children, such as when the risk-benefit potentials of surgery, radiation, or chemotherapy are faced. For moral reasons that go beyond the issue of the risk of transfusion,16 Witness parents ask that therapies be used that are not religiously prohibited. This accords with the medical tenet of treating "the whole person," not overlooking the possible lasting psychosocial damage of an invasive procedure that violates a family’s fundamental beliefs. Often, large centers around the country having experience with the Witnesses now accept patient transfers from institutions unwilling to treat Witnesses, even pediatric cases.
THE PHYSICIAN’S CHALLENGE
Understandably, caring for Jehovah’s Witnesses might seem to pose a dilemma for the physician dedicated to preserving life and health by employing all the techniques at his disposal. Editorially prefacing a series of articles about major surgery on Witnesses, Harvey17 admitted, "I do find annoying those beliefs that may interfere with my work." But, he added: "Perhaps we too easily forget that surgery is a craft dependent upon the personal technique of individuals. Technique can be improved."
Professor Bolooki18 took note of a disturbing report that one of the busiest trauma hospitals in Dade County, Florida, had a "blanket policy of refusing to treat" Witnesses. He pointed out that "most surgical procedures in this group of patients are associated with less risk than usual." He added: "Although the surgeons may feel that they are deprived of an instrument of modern medicine . . . I am convinced that by operating on these patients they will learn a great deal."
Rather than consider the Witness patient a problem, more and more physicians accept the situation as a medical challenge. In meeting the challenge they have developed a standard of practice for this group of patients that is accepted at numerous medical centers around the country. These physicians are at the same time providing care that is best for the patient’s total good. As Gardner et al19 observe: "Who would benefit if the patient’s corporal malady is cured but the spiritual life with God, as he sees it, is compromised, which leads to a life that is meaningless and perhaps worse than death itself."
Witnesses recognize that, medically, their firmly held conviction appears to add a degree of risk and may complicate their care. Accordingly, they generally manifest unusual appreciation for the care they receive. In addition to having the vital elements of deep faith and an intense will to live, they gladly cooperate with physicians and medical staff. Thus, both patient and physician are united in facing this unique challenge.
REFERENCES
1. Jehovah’s Witnesses and the Question of Blood. Brooklyn, NY, Watchtower Bible and Tract Society, 1977, pp. 1-64.
2. The Watchtower 1978;99 (June 15):29-31.
3. Hypotensive anesthesia facilitates hip surgery, MEDICAL NEWS. JAMA 1978;239:181.
4. Hetastarch (Hespan)-a new plasma expander. Med Lett Drugs Ther 1981;23:16.
5. Hamstra RD, Block MH, Schocket AL:Intravenous iron dextran in clinical medicine. JAMA 1980;243:1726-1731.
6. Lapin R: Major surgery in Jehovah’s Witnesses. Contemp Orthop 1980;2:647-654.
7. Fuerst ML: ‘Sonic scalpel’ spares vessels. Med Trib 1981;22:1,30.
8. Gonzáles ER: The saga of ‘artificial blood’: Fluosol a special boon to Jehovah’s Witnesses. JAMA 1980;243:719-724.
9. Ott DA, Cooley DA: Cardiovascular surgery in Jehovah’s Witnesses. JAMA 1977;238:1256-1258.
10. Roen PR, Velcek F: Extensive urologic surgery without blood transfusion. NY State J Med 1972;72:2524-2527.
11. Nelson CL, Martin K, Lawson N, et al: Total hip replacement without transfusion. Contemp Orthop 1980;2:655-658.
12. Herbsman H: Treating the Jehovah’s Witness. Emerg Med 1980;12:73-76.
13. Medicolegal Forms With Legal Analysis. Chicago, American Medical Association, 1976, p. 83.
14. Paris JJ: Compulsory medical treatment and religious freedom: Whose law shall prevail? Univ San Francisco Law Rev 1975;10:1-35.
15. Kelly AD: Aequanimitas Can Med Assoc J 1967;96:432.
16. Kolins J: Fatalities from blood transfusion. JAMA 1981;245:1120.
17. Harvey JP: A question of craftsmanship. Contemp Orthop 1980;2:629.
18. Bolooki H: Treatment of Jehovah’s Witnesses: Example of good care. Miami Med 1981;51:25-26.
19. Gardner B, Bivona J, Alfonso A, et al: Major surgery in Jehovah’s Witnesses. NY State J Med 1976;76:765-766.