Blood: Whose Choice and Whose Conscience?
by J. Lowell Dixon, M.D.
Reprinted by permission of the New York State Journal of Medicine, 1988; 88:463-464, copyright by the Medical Society of the State of New York.
PHYSICIANS are committed to applying their knowledge, skills, and experience in fighting disease and death. Yet, what if a patient refuses a recommended treatment? This will likely occur if the patient is a Jehovah’s Witness and the treatment is whole blood, packed red blood cells, plasma, or platelets.
When it comes to the use of blood, a physician may feel that a patient’s choice of nonblood treatment will tie the hands of dedicated medical personnel. Still, one must not forget that patients other than Jehovah’s Witnesses often choose not to follow their doctor’s recommendations. According to Appelbaum and Roth,1 19% of patients at teaching hospitals refused at least one treatment or procedure, even though 15% of such refusals "were potentially life endangering."
The general view that "the doctor knows best" causes most patients to defer to their doctor’s skill and knowledge. But how subtly dangerous it would be for a physician to proceed as if this phrase were a scientific fact and to treat patients accordingly. True, our medical training, licensing, and experience give us noteworthy privileges in the medical arena. Our patients, though, have rights. And, as we are likely aware, the law (even the Constitution) gives greater weight to rights.
On the walls of most hospitals, one sees displayed the "Patient’s Bill of Rights." One of these rights is informed consent, which might more accurately be called informed choice. After the patient is informed of the potential results of various treatments (or of nontreatment), it is his choice what he will submit to. At Albert Einstein Hospital in the Bronx, New York, a draft policy on blood transfusion and Jehovah’s Witnesses stated: "Any adult patient who is not incapacitated has the right to refuse treatment no matter how detrimental such a refusal may be to his health."2
While physicians may voice concerns about ethics or liability, courts have stressed the supremacy of patient choice.3 The New York Court of Appeals stated that "the patient’s right to determine the course of his own treatment [is] paramount . . . [A] doctor cannot be held to have violated his legal or professional responsibilities when he honors the right of a competent adult patient to decline medical treatment."4 That court has also observed that "the ethical integrity of the medical profession, while important, cannot outweigh the fundamental individual rights here asserted. It is the needs and desires of the individual, not the requirements of the institution, that are paramount."5
When a Witness refuses blood, physicians may feel pangs of conscience at the prospect of doing what seems to be less than the maximum. What the Witness is asking conscientious doctors to do, though, is to provide the best alternative care possible under the circumstances. We often must alter our therapy to accommodate circumstances, such as hypertension, severe allergy to antibiotics, or the unavailability of certain costly equipment. With the Witness patient, physicians are being asked to manage the medical or surgical problem in harmony with the patient’s choice and conscience, his moral/religious decision to abstain from blood.
Numerous reports of major surgery on Witness patients show that many physicians can, in good conscience and with success, accommodate the request not to employ blood. For example, in 1981, Cooley reviewed 1,026 cardiovascular operations, 22% on minors. He determined "that the risk of surgery in patients of the Jehovah’s Witness group has not been substantially higher than for others."6 Kambouris7 reported on major operations on Witnesses, some of whom had been "denied urgently needed surgical treatment because of their refusal to accept blood." He said: "All patients received pretreatment assurances that their religious beliefs would be respected, regardless of the circumstances in the operating room. There were no untoward effects of this policy."
When a patient is a Jehovah’s Witness, beyond the matter of choice, conscience comes into the picture. One cannot think only of the physician’s conscience. What of the patient’s? Jehovah’s Witnesses view life as God’s gift represented by blood. They believe the Bible’s command that Christians must "abstain from blood" (Acts 15:28, 29).8 Hence, if a physician paternalistically violated such patients’ deep and long-held religious convictions, the result could be tragic. Pope John Paul II has observed that forcing someone to violate his conscience "is the most painful blow inflicted to human dignity. In a certain sense, it is worse than inflicting physical death, or killing."9
While Jehovah’s Witnesses refuse blood for religious reasons, more and more non-Witness patients are choosing to avoid blood because of risks such as AIDS, non-A non-B hepatitis, and immunologic reactions. We may present to them our views as to whether such risks seem minor compared to the benefits. But, as the American Medical Association points out, the patient is "the final arbiter as to whether he will take his chances with the treatment or operation recommended by the doctor or risk living without it. Such is the natural right of the individual, which the law recognizes."10
Related to this, Macklin11 brought up the risk/benefit issue regarding a Witness "who risked bleeding to death without a transfusion." A medical student said: "His thought processes were intact. What do you do when religious beliefs are against the only source of treatment?" Macklin reasoned: "We may believe very strongly this man is making a mistake. But Jehovah’s Witnesses believe that to be transfused . . . [may] result in eternal damnation. We are trained to do risk-benefit analyses in medicine but if you weigh eternal damnation against remaining life on earth, the analysis assumes a different angle."11
Vercillo and Duprey12 in this issue of the Journal refer to In re Osborne to highlight the interest in ensuring the security of dependents, but how was that case resolved? It concerned a severely injured father of two minor children. The court determined that if he died, relatives would materially and spiritually care for his children. So, as in other recent cases,13 the court found no compelling state interest to justify overriding the patient’s choice of treatment; judicial intervention to authorize treatment deeply objectionable to him was unwarranted.14 With alternative treatment the patient recovered and continued to care for his family.
Is it not true that the vast majority of cases physicians have confronted, or likely will, can be managed without blood? What we studied and know best has to do with medical problems, yet patients are human beings whose individual values and goals cannot be ignored. They know best about their own priorities, their own morals and conscience, which give life meaning for them.
Respecting the religious consciences of Witness patients may challenge our skills. But as we meet this challenge, we underscore valuable liberties that all of us cherish. As John Stuart Mill aptly wrote: "No society in which these liberties are not, on the whole, respected, is free, whatever may be its form of government . . . Each is the proper guardian of his own health, whether bodily, or mental and spiritual. Mankind are greater gainers by suffering each other to live as seems good to themselves, than by compelling each to live as seems good to the rest."15
[REFERENCES]
1. Appelbaum PS, Roth LH: Patients who refuse treatment in medical hospitals. JAMA 1983; 250:1296-1301.
2. Macklin R: The inner workings of an ethics committee: Latest battle over Jehovah’s Witnesses. Hastings Cent Rep 1988; 18(1):15-20.
3. Bouvia v Superior Court, 179 Cal App 3d 1127, 225 Cal Rptr 297 (1986); In re Brown, 478 So 2d 1033 (Miss 1985).
4. In re Storar, 438 NYS 2d 266, 273, 420 NE 2d 64, 71 (NY 1981).
5. Rivers v Katz, 504 NYS 2d 74, 80 n 6, 495 NE 2d 337, 343 n 6 (NY 1986).
6. Dixon JL, Smalley MG: Jehovah’s Witnesses. The surgical/ethical challenge. JAMA 1981; 246:2471-2472.
7. Kambouris AA: Major abdominal operations on Jehovah’s Witnesses. Am Surg 1987; 53:350-356.
8. Jehovah’s Witnesses and the Question of Blood. Brooklyn, NY, Watchtower Bible and Tract Society, 1977, pp 1-64.
9. Pope denounces Polish crackdown. NY Times, January 11, 1982, p A9.
10. Office of the General Counsel: Medicolegal Forms with Legal Analysis. Chicago, American Medical Association, 1973, p 24.
11. Kleiman D: Hospital philosopher confronts decisions of life. NY Times, January 23, 1984, pp B1, B3.
12. Vercillo AP, Duprey SV: Jehovah’s Witnesses and the transfusion of blood products. NY State J Med 1988; 88:493-494.
13. Wons v Public Health Trust, 500 So 2d 679 (Fla Dist Ct App) (1987); Randolph v City of New York, 117 AD 2d 44, 501 NYS 2d 837 (1986); Taft v Taft, 383 Mass 331, 446 NE 2d 395 (1983).
14. In re Osborne, 294 A 2d 372 (DC Ct App 1972).
15. Mill JS: On liberty, in Adler MJ (ed): Great Books of the Western World. Chicago, Encyclopaedia Britannica, Inc, 1952, vol 43, p 273.
Showing posts with label blood. Show all posts
Showing posts with label blood. Show all posts
Tuesday, March 24, 2009
Your Rights regarding Blood
You Have the Right to Choose
A current medical approach (called risk/benefit analysis) is making it easier for doctors and patients to cooperate in avoiding blood therapy. Doctors weigh factors such as the risks of a certain drug or surgery and the probable benefits. Patients too can share in such an analysis.
Let us use one example that people in many places can relate to-chronic tonsillitis. If you had this problem, likely you would go to a doctor. In fact, you might consult two, since health experts often recommend getting a second opinion. One might recommend surgery. He outlines what that means: length of hospital stay, amount of pain, and cost. As to risks, he says that severe bleeding is not common and death from such an operation is very rare. But the doctor giving a second opinion urges you to try antibiotic therapy. He explains the type of drug, likelihood of success, and expense. As to risk, he says that very few patients have life-threatening reactions to the drug.
Each competent physician likely considered risks and benefits, but now you have to weigh the risks and possible benefits, as well as other factors that you best know. (You are in the best position to consider such aspects as your emotional or spiritual strength, family finances, effect on the family, and your own ethics.) Then you make a choice. Possibly you give informed consent for one therapy but decline the other.
This would also be so if it was your child that had the chronic tonsillitis. The risks, benefits, and therapies would be outlined for you, the loving parents who are most directly affected and who will be responsible to cope with the results. After considering all aspects, you can make an informed choice on this matter involving your child’s health and even his or her life. Perhaps you consent to the surgery, with its risks. Other parents might choose the antibiotics, with their risks. As physicians differ in their advice, so patients or parents differ as to what they feel is best. Such is an understood feature of making informed (risk/benefit) choices.
What about use of blood? No one who objectively examines the facts can deny that blood transfusions involve great risk. Dr. Charles Huggins, who is the director of transfusion service at the large Massachusetts General Hospital, made this very clear: "Blood has never been safer. But it must be considered unavoidably non-safe. It is the most dangerous substance we use in medicine."-The Boston Globe Magazine, February 4, 1990.
With good reason, medical personnel have been advised: "It is necessary to reevaluate as well the risk part of the benefit/risk relationship for blood transfusion and to seek alternatives." (Italics ours.)-Perioperative Red Cell Transfusion, National Institutes of Health conference, June 27-29, 1988.
Physicians may disagree as to the benefits or risks in using blood. One may give many transfusions and be convinced that they are worth the risk. Another may feel the risks are unjustified, for he has had good results with nonblood management. Ultimately, however, you, the patient or the parent, must decide. Why you? Because your (or your child’s) body, life, ethics, and profoundly important relationship with God are involved.
YOUR RIGHT IS RECOGNIZED
In many places today, the patient has an inviolable right to decide what treatment he will accept. "The law of informed consent has been based on two premises: first, that a patient has the right to receive sufficient information to make an informed choice about the treatment recommended; and second, that the patient may choose to accept or to decline the physician’s recommendation. . . . Unless patients are viewed as having the right to say no, as well as yes, and even yes with conditions, much of the rationale for informed consent evaporates."-Informed Consent-Legal Theory and Clinical Practice, 1987.
Some patients have encountered resistance when they have tried to exercise their right. It might have been from a friend having strong feelings about a tonsillectomy or about antibiotics. Or a physician might have been convinced of the rightness of his advice. A hospital official might even have disagreed, based on legal or financial interests.
"Many orthopaedists elect not to operate on [Witness] patients," says Dr. Carl L. Nelson. "It is our belief that the patient has the right to refuse any type of medical therapy. If it is technically possible to provide surgery safely while excluding a particular treatment, such as transfusion, then it should exist as an option."-The Journal of Bone and Joint Surgery, March 1986.
A considerate patient will not pressure a physician to use a therapy at which the doctor is unskilled. As Dr. Nelson noted, though, many dedicated physicians can accommodate the patient’s beliefs. A German official advised: "The doctor cannot refuse to render aid . . . reasoning that with a Jehovah’s Witness not all medical alternatives are at his disposal. He still has a duty to render assistance even when the avenues open to him are reduced." (Der Frauenarzt, May-June 1983) Similarly, hospitals exist not merely to make money but to serve all people without discrimination. Catholic theologian Richard J. Devine states: "Although the hospital must make every other medical effort to preserve the patient’s life and health, it must ensure that medical care does not violate [his] conscience. Moreover, it must avoid all forms of coercion, from cajoling the patient to obtaining a court order to force a blood transfusion."-Health Progress, June 1989.
RATHER THAN THE COURTS
Many people agree that a court is no place for personal medical issues. How would you feel if you chose antibiotic therapy but someone went to court to force a tonsillectomy on you? A doctor may want to provide what he thinks is the best care, but he has no duty to seek legal justification to trample on your basic rights. And since the Bible puts abstaining from blood on the same moral level as avoiding fornication, to force blood on a Christian would be the equivalent of forcible sex-rape.-Acts 15:28, 29.
Yet, Informed Consent for Blood Transfusion (1989) reports that some courts are so distressed when a patient is willing to accept a certain risk because of his religious rights "that they make up some legal exceptions-legal fictions, if you will-to allow a transfusion to occur." They might try to excuse it by saying that a pregnancy is involved or that there are children to be supported. "Those are legal fictions," the book says. "Competent adults are entitled to refuse treatment."
Some who insist on transfusing blood ignore the fact that Witnesses do not decline all therapies. They reject just one therapy, which even experts say is fraught with danger. Usually a medical problem can be managed in a variety of ways. One has this risk, another that risk. Can a court or a doctor paternalistically know which risk is "in your best interests"? You are the one to judge that. Jehovah’s Witnesses are firm that they do not want someone else to decide for them; it is their personal responsibility before God.
If a court forced an abhorrent treatment on you, how might this affect your conscience and the vital element of your will to live? Dr. Konrad Drebinger wrote: "It would certainly be a misguided form of medical ambition that would lead one to force a patient to accept a given therapy, overruling his conscience, so as to treat him physically but dealing his psyche a mortal blow."-Der Praktische Arzt, July 1978.
LOVING CARE FOR CHILDREN
Court cases regarding blood mainly involve children. On occasion, when loving parents have respectfully asked that nonblood management be used, some medical personnel have sought court backing to give blood. Of course, Christians agree with laws or court action to prevent child abuse or neglect. Perhaps you have read of cases in which some parent brutalized a child or denied it all medical care. How tragic! Clearly, the State can and should step in to protect a neglected child. Still, it is easy to see how very different it is when a caring parent requests high-quality nonblood medical therapy.
These court cases usually focus on a child in a hospital. How did the youngster get there, and why? Almost always the concerned parents brought their child to get quality care. Even as Jesus was interested in children, Christian parents care for their children. The Bible speaks of ‘a nursing mother cherishing her own children.’ Jehovah’s Witnesses have such deep love for their children.-1 Thessalonians 2:7; Matthew 7:11; 19:13-15.
Naturally, all parents make decisions affecting their children’s safety and life: Will the family use gas or oil to heat the home? Will they take a child on a long-distance drive? May he go swimming? Such matters involve risks, even life-and-death ones. But society recognizes parental discretion, so parents are granted the major voice in nearly all decisions affecting their children.
In 1979 the U.S. Supreme Court stated clearly: "The law’s concept of the family rests on a presumption that parents possess what a child lacks in maturity, experience, and capacity for judgment required for making life’s difficult decisions. . . . Simply because the decision of a parent [on a medical matter] involves risks does not automatically transfer the power to make that decision from the parents to some agency or officer of the state."-Parham v. J.R.
That same year the New York Court of Appeals ruled: "The most significant factor in determining whether a child is being deprived of adequate medical care . . . is whether the parents have provided an acceptable course of medical treatment for their child in light of all the surrounding circumstances. This inquiry cannot be posed in terms of whether the parent has made a ‘right’ or a ‘wrong’ decision, for the present state of the practice of medicine, despite its vast advances, very seldom permits such definitive conclusions. Nor can a court assume the role of a surrogate parent."-In re Hofbauer.
Recall the example of parents choosing between surgery and antibiotics. Each therapy would have its own risks. Loving parents are responsible to weigh risks, benefits, and other factors and then to make a choice. In this connection, Dr. Jon Samuels (Anesthesiology News, October 1989) suggested a review of Guides to the Judge in Medical Orders Affecting Children, which took this position:
"Medical knowledge is not sufficiently advanced to enable a physician to predict with reasonable certainty that his patient will live or die . . . If there is a choice of procedures-if, for example, the doctor recommends a procedure which has an 80 per cent chance of success but which the parents disapprove, and the parents have no objection to a procedure which has only a 40 per cent chance of success-the doctor must take the medically riskier but parentally unobjectionable course."
In view of the many lethal hazards in medical use of blood that have surfaced and because there are effective alternative ways of management, might not avoiding blood even carry the lower risk?
Naturally, Christians weigh many factors if their child needs surgery. Every operation, with or without the use of blood, has risks. What surgeon gives guarantees? The parents may know that skilled physicians have had fine success with bloodless surgery on Witness children. So even if a physician or a hospital official has another preference, rather than cause a stressful and time-consuming legal battle, is it not reasonable for them to work with the loving parents? Or parents may transfer their child to another hospital where the staff is experienced in handling such cases and willing to do so. In fact, nonblood management will more likely be quality care, for it can help the family "to achieve legitimate medical and nonmedical goals," as we noted earlier.
[Footnotes]
See the medical article "Blood: Whose Choice and Whose Conscience?" reprinted in the Appendix, on pages 30-1.
[Box on page 18]
RELIEVING LEGAL CONCERNS
You may wonder, ‘Why are some doctors and hospitals quick to get a court order to give blood?’ In some places a common reason is fear of liability.
There is no basis for such concern when Jehovah’s Witnesses choose nonblood management. A doctor at Albert Einstein College of Medicine (U.S.A.) writes: "Most [Witnesses] readily sign the American Medical Association form relieving physicians and hospitals of liability, and many carry a Medical Alert [card]. A properly signed and dated ‘Refusal to Accept Blood Products’ form is a contractual agreement and is legally binding."-Anesthesiology News, October 1989.
Yes, Jehovah’s Witnesses cooperatively offer legal assurance that a physician or hospital will not incur liability in providing requested nonblood therapy. As recommended by medical experts, each Witness carries a Medical Document card. This is renewed annually and is signed by the person and by witnesses, often his next of kin.
In March 1990, the Supreme Court of Ontario, Canada, upheld a decision that commented approvingly on such a document: "The card is a written declaration of a valid position which the card carrier may legitimately take in imposing a written restriction on [the] contract with the doctor." In Medicinsk Etik (1985), Professor Daniel Andersen wrote: "If there is an unambiguous written statement from the patient saying that he is one of Jehovah’s Witnesses and does not want blood under any circumstances, respect for the patient’s autonomy requires that this wish be respected, just as if it had been expressed orally."
Witnesses will also sign hospital consent forms. One used at a hospital in Freiburg, Germany, has space where the physician can describe the information he gave the patient about the treatment. Then, above the signatures of the physician and the patient, this form adds: "As a member of the religious body of Jehovah’s Witnesses, I categorically refuse the use of foreign blood or blood components during my surgery. I am aware that the planned and needed procedure thus has a higher risk due to bleeding complications. After receiving thorough explanation particularly about that, I request that the needed surgery be performed without using foreign blood or blood components."-Herz Kreislauf, August 1987.
Actually, nonblood management may have a lower risk. But the point here is that Witness patients happily relieve any needless concerns so that medical personnel can move forward in doing what they are committed to do, helping people get well. This cooperation benefits all, as Dr. Angelos A. Kambouris showed in "Major Abdominal Operations on Jehovah’s Witnesses":
"Preoperative agreement should be viewed as binding by the surgeon and should be adhered to regardless of events developing during and after operation. [This] orients the patients positively toward their surgical treatment, and diverts the surgeon’s attention from the legal and philosophical considerations to the surgical and technical ones, thus, allowing him to perform optimally and serve his patient’s best interests."-The American Surgeon, June 1987.
[Box on page 19]
"Overuse of medical technology is a major factor in the increase of current health care expenditures. . . . Blood transfusion is of particular importance because of its cost and high risk potential. Accordingly, blood transfusion was classified by the American Joint Commission on Accreditation of Hospitals as ‘high volume, high risk and error prone.’"-"Transfusion," July-August 1989.
[Box on page 20]
United States: "Underlying the necessity for patient consent is the ethical concept of individual autonomy, that decisions about one’s own fate should be made by the person involved. The legal ground for requiring consent is that a medical act performed without the patient’s consent constitutes battery."-"Informed Consent for Blood Transfusion," 1989.
Germany: "The patient’s right of self-determination overrides the principle of rendering assistance and preservation of life. As a result: no blood transfusion against the will of the patient."-"Herz Kreislauf," August 1987.
Japan: "There is no ‘absolute’ in the medical world. Doctors believe that the course of modern medicine is the best and follow its course, but they should not force every detail of it as an ‘absolute’ on patients. Patients too must have freedom of choice."-"Minami Nihon Shimbun," June 28, 1985.
[Box on page 21]
"I have found the families [of Jehovah’s Witnesses] to be close knit and loving," reports Dr. Lawrence S. Frankel. "The children are educated, caring, and respectful. . . . There even appears to possibly be stronger compliance to medical dictates, which might represent an effort to demonstrate acceptance of medical intervention to the extent that their beliefs permit."-Department of Pediatrics, M. D. Anderson Hospital and Tumor Institute, Houston, U.S.A., 1985.
[Box on page 22]
"I fear it is not uncommon," comments Dr. James L. Fletcher, Jr., "for professional arrogance to supplant sound medical judgment. Treatments that are regarded as ‘the best today’ are modified or discarded tomorrow. Which is more dangerous, a ‘religious parent’ or an arrogant physician who is convinced that his or her treatment is absolutely vital?"-"Pediatrics," October 1988.
A current medical approach (called risk/benefit analysis) is making it easier for doctors and patients to cooperate in avoiding blood therapy. Doctors weigh factors such as the risks of a certain drug or surgery and the probable benefits. Patients too can share in such an analysis.
Let us use one example that people in many places can relate to-chronic tonsillitis. If you had this problem, likely you would go to a doctor. In fact, you might consult two, since health experts often recommend getting a second opinion. One might recommend surgery. He outlines what that means: length of hospital stay, amount of pain, and cost. As to risks, he says that severe bleeding is not common and death from such an operation is very rare. But the doctor giving a second opinion urges you to try antibiotic therapy. He explains the type of drug, likelihood of success, and expense. As to risk, he says that very few patients have life-threatening reactions to the drug.
Each competent physician likely considered risks and benefits, but now you have to weigh the risks and possible benefits, as well as other factors that you best know. (You are in the best position to consider such aspects as your emotional or spiritual strength, family finances, effect on the family, and your own ethics.) Then you make a choice. Possibly you give informed consent for one therapy but decline the other.
This would also be so if it was your child that had the chronic tonsillitis. The risks, benefits, and therapies would be outlined for you, the loving parents who are most directly affected and who will be responsible to cope with the results. After considering all aspects, you can make an informed choice on this matter involving your child’s health and even his or her life. Perhaps you consent to the surgery, with its risks. Other parents might choose the antibiotics, with their risks. As physicians differ in their advice, so patients or parents differ as to what they feel is best. Such is an understood feature of making informed (risk/benefit) choices.
What about use of blood? No one who objectively examines the facts can deny that blood transfusions involve great risk. Dr. Charles Huggins, who is the director of transfusion service at the large Massachusetts General Hospital, made this very clear: "Blood has never been safer. But it must be considered unavoidably non-safe. It is the most dangerous substance we use in medicine."-The Boston Globe Magazine, February 4, 1990.
With good reason, medical personnel have been advised: "It is necessary to reevaluate as well the risk part of the benefit/risk relationship for blood transfusion and to seek alternatives." (Italics ours.)-Perioperative Red Cell Transfusion, National Institutes of Health conference, June 27-29, 1988.
Physicians may disagree as to the benefits or risks in using blood. One may give many transfusions and be convinced that they are worth the risk. Another may feel the risks are unjustified, for he has had good results with nonblood management. Ultimately, however, you, the patient or the parent, must decide. Why you? Because your (or your child’s) body, life, ethics, and profoundly important relationship with God are involved.
YOUR RIGHT IS RECOGNIZED
In many places today, the patient has an inviolable right to decide what treatment he will accept. "The law of informed consent has been based on two premises: first, that a patient has the right to receive sufficient information to make an informed choice about the treatment recommended; and second, that the patient may choose to accept or to decline the physician’s recommendation. . . . Unless patients are viewed as having the right to say no, as well as yes, and even yes with conditions, much of the rationale for informed consent evaporates."-Informed Consent-Legal Theory and Clinical Practice, 1987.
Some patients have encountered resistance when they have tried to exercise their right. It might have been from a friend having strong feelings about a tonsillectomy or about antibiotics. Or a physician might have been convinced of the rightness of his advice. A hospital official might even have disagreed, based on legal or financial interests.
"Many orthopaedists elect not to operate on [Witness] patients," says Dr. Carl L. Nelson. "It is our belief that the patient has the right to refuse any type of medical therapy. If it is technically possible to provide surgery safely while excluding a particular treatment, such as transfusion, then it should exist as an option."-The Journal of Bone and Joint Surgery, March 1986.
A considerate patient will not pressure a physician to use a therapy at which the doctor is unskilled. As Dr. Nelson noted, though, many dedicated physicians can accommodate the patient’s beliefs. A German official advised: "The doctor cannot refuse to render aid . . . reasoning that with a Jehovah’s Witness not all medical alternatives are at his disposal. He still has a duty to render assistance even when the avenues open to him are reduced." (Der Frauenarzt, May-June 1983) Similarly, hospitals exist not merely to make money but to serve all people without discrimination. Catholic theologian Richard J. Devine states: "Although the hospital must make every other medical effort to preserve the patient’s life and health, it must ensure that medical care does not violate [his] conscience. Moreover, it must avoid all forms of coercion, from cajoling the patient to obtaining a court order to force a blood transfusion."-Health Progress, June 1989.
RATHER THAN THE COURTS
Many people agree that a court is no place for personal medical issues. How would you feel if you chose antibiotic therapy but someone went to court to force a tonsillectomy on you? A doctor may want to provide what he thinks is the best care, but he has no duty to seek legal justification to trample on your basic rights. And since the Bible puts abstaining from blood on the same moral level as avoiding fornication, to force blood on a Christian would be the equivalent of forcible sex-rape.-Acts 15:28, 29.
Yet, Informed Consent for Blood Transfusion (1989) reports that some courts are so distressed when a patient is willing to accept a certain risk because of his religious rights "that they make up some legal exceptions-legal fictions, if you will-to allow a transfusion to occur." They might try to excuse it by saying that a pregnancy is involved or that there are children to be supported. "Those are legal fictions," the book says. "Competent adults are entitled to refuse treatment."
Some who insist on transfusing blood ignore the fact that Witnesses do not decline all therapies. They reject just one therapy, which even experts say is fraught with danger. Usually a medical problem can be managed in a variety of ways. One has this risk, another that risk. Can a court or a doctor paternalistically know which risk is "in your best interests"? You are the one to judge that. Jehovah’s Witnesses are firm that they do not want someone else to decide for them; it is their personal responsibility before God.
If a court forced an abhorrent treatment on you, how might this affect your conscience and the vital element of your will to live? Dr. Konrad Drebinger wrote: "It would certainly be a misguided form of medical ambition that would lead one to force a patient to accept a given therapy, overruling his conscience, so as to treat him physically but dealing his psyche a mortal blow."-Der Praktische Arzt, July 1978.
LOVING CARE FOR CHILDREN
Court cases regarding blood mainly involve children. On occasion, when loving parents have respectfully asked that nonblood management be used, some medical personnel have sought court backing to give blood. Of course, Christians agree with laws or court action to prevent child abuse or neglect. Perhaps you have read of cases in which some parent brutalized a child or denied it all medical care. How tragic! Clearly, the State can and should step in to protect a neglected child. Still, it is easy to see how very different it is when a caring parent requests high-quality nonblood medical therapy.
These court cases usually focus on a child in a hospital. How did the youngster get there, and why? Almost always the concerned parents brought their child to get quality care. Even as Jesus was interested in children, Christian parents care for their children. The Bible speaks of ‘a nursing mother cherishing her own children.’ Jehovah’s Witnesses have such deep love for their children.-1 Thessalonians 2:7; Matthew 7:11; 19:13-15.
Naturally, all parents make decisions affecting their children’s safety and life: Will the family use gas or oil to heat the home? Will they take a child on a long-distance drive? May he go swimming? Such matters involve risks, even life-and-death ones. But society recognizes parental discretion, so parents are granted the major voice in nearly all decisions affecting their children.
In 1979 the U.S. Supreme Court stated clearly: "The law’s concept of the family rests on a presumption that parents possess what a child lacks in maturity, experience, and capacity for judgment required for making life’s difficult decisions. . . . Simply because the decision of a parent [on a medical matter] involves risks does not automatically transfer the power to make that decision from the parents to some agency or officer of the state."-Parham v. J.R.
That same year the New York Court of Appeals ruled: "The most significant factor in determining whether a child is being deprived of adequate medical care . . . is whether the parents have provided an acceptable course of medical treatment for their child in light of all the surrounding circumstances. This inquiry cannot be posed in terms of whether the parent has made a ‘right’ or a ‘wrong’ decision, for the present state of the practice of medicine, despite its vast advances, very seldom permits such definitive conclusions. Nor can a court assume the role of a surrogate parent."-In re Hofbauer.
Recall the example of parents choosing between surgery and antibiotics. Each therapy would have its own risks. Loving parents are responsible to weigh risks, benefits, and other factors and then to make a choice. In this connection, Dr. Jon Samuels (Anesthesiology News, October 1989) suggested a review of Guides to the Judge in Medical Orders Affecting Children, which took this position:
"Medical knowledge is not sufficiently advanced to enable a physician to predict with reasonable certainty that his patient will live or die . . . If there is a choice of procedures-if, for example, the doctor recommends a procedure which has an 80 per cent chance of success but which the parents disapprove, and the parents have no objection to a procedure which has only a 40 per cent chance of success-the doctor must take the medically riskier but parentally unobjectionable course."
In view of the many lethal hazards in medical use of blood that have surfaced and because there are effective alternative ways of management, might not avoiding blood even carry the lower risk?
Naturally, Christians weigh many factors if their child needs surgery. Every operation, with or without the use of blood, has risks. What surgeon gives guarantees? The parents may know that skilled physicians have had fine success with bloodless surgery on Witness children. So even if a physician or a hospital official has another preference, rather than cause a stressful and time-consuming legal battle, is it not reasonable for them to work with the loving parents? Or parents may transfer their child to another hospital where the staff is experienced in handling such cases and willing to do so. In fact, nonblood management will more likely be quality care, for it can help the family "to achieve legitimate medical and nonmedical goals," as we noted earlier.
[Footnotes]
See the medical article "Blood: Whose Choice and Whose Conscience?" reprinted in the Appendix, on pages 30-1.
[Box on page 18]
RELIEVING LEGAL CONCERNS
You may wonder, ‘Why are some doctors and hospitals quick to get a court order to give blood?’ In some places a common reason is fear of liability.
There is no basis for such concern when Jehovah’s Witnesses choose nonblood management. A doctor at Albert Einstein College of Medicine (U.S.A.) writes: "Most [Witnesses] readily sign the American Medical Association form relieving physicians and hospitals of liability, and many carry a Medical Alert [card]. A properly signed and dated ‘Refusal to Accept Blood Products’ form is a contractual agreement and is legally binding."-Anesthesiology News, October 1989.
Yes, Jehovah’s Witnesses cooperatively offer legal assurance that a physician or hospital will not incur liability in providing requested nonblood therapy. As recommended by medical experts, each Witness carries a Medical Document card. This is renewed annually and is signed by the person and by witnesses, often his next of kin.
In March 1990, the Supreme Court of Ontario, Canada, upheld a decision that commented approvingly on such a document: "The card is a written declaration of a valid position which the card carrier may legitimately take in imposing a written restriction on [the] contract with the doctor." In Medicinsk Etik (1985), Professor Daniel Andersen wrote: "If there is an unambiguous written statement from the patient saying that he is one of Jehovah’s Witnesses and does not want blood under any circumstances, respect for the patient’s autonomy requires that this wish be respected, just as if it had been expressed orally."
Witnesses will also sign hospital consent forms. One used at a hospital in Freiburg, Germany, has space where the physician can describe the information he gave the patient about the treatment. Then, above the signatures of the physician and the patient, this form adds: "As a member of the religious body of Jehovah’s Witnesses, I categorically refuse the use of foreign blood or blood components during my surgery. I am aware that the planned and needed procedure thus has a higher risk due to bleeding complications. After receiving thorough explanation particularly about that, I request that the needed surgery be performed without using foreign blood or blood components."-Herz Kreislauf, August 1987.
Actually, nonblood management may have a lower risk. But the point here is that Witness patients happily relieve any needless concerns so that medical personnel can move forward in doing what they are committed to do, helping people get well. This cooperation benefits all, as Dr. Angelos A. Kambouris showed in "Major Abdominal Operations on Jehovah’s Witnesses":
"Preoperative agreement should be viewed as binding by the surgeon and should be adhered to regardless of events developing during and after operation. [This] orients the patients positively toward their surgical treatment, and diverts the surgeon’s attention from the legal and philosophical considerations to the surgical and technical ones, thus, allowing him to perform optimally and serve his patient’s best interests."-The American Surgeon, June 1987.
[Box on page 19]
"Overuse of medical technology is a major factor in the increase of current health care expenditures. . . . Blood transfusion is of particular importance because of its cost and high risk potential. Accordingly, blood transfusion was classified by the American Joint Commission on Accreditation of Hospitals as ‘high volume, high risk and error prone.’"-"Transfusion," July-August 1989.
[Box on page 20]
United States: "Underlying the necessity for patient consent is the ethical concept of individual autonomy, that decisions about one’s own fate should be made by the person involved. The legal ground for requiring consent is that a medical act performed without the patient’s consent constitutes battery."-"Informed Consent for Blood Transfusion," 1989.
Germany: "The patient’s right of self-determination overrides the principle of rendering assistance and preservation of life. As a result: no blood transfusion against the will of the patient."-"Herz Kreislauf," August 1987.
Japan: "There is no ‘absolute’ in the medical world. Doctors believe that the course of modern medicine is the best and follow its course, but they should not force every detail of it as an ‘absolute’ on patients. Patients too must have freedom of choice."-"Minami Nihon Shimbun," June 28, 1985.
[Box on page 21]
"I have found the families [of Jehovah’s Witnesses] to be close knit and loving," reports Dr. Lawrence S. Frankel. "The children are educated, caring, and respectful. . . . There even appears to possibly be stronger compliance to medical dictates, which might represent an effort to demonstrate acceptance of medical intervention to the extent that their beliefs permit."-Department of Pediatrics, M. D. Anderson Hospital and Tumor Institute, Houston, U.S.A., 1985.
[Box on page 22]
"I fear it is not uncommon," comments Dr. James L. Fletcher, Jr., "for professional arrogance to supplant sound medical judgment. Treatments that are regarded as ‘the best today’ are modified or discarded tomorrow. Which is more dangerous, a ‘religious parent’ or an arrogant physician who is convinced that his or her treatment is absolutely vital?"-"Pediatrics," October 1988.
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.
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.
Blood VS Life
The Blood That Really Saves Lives
Certain points are clear from the foregoing information. Though many people view them as lifesaving, blood transfusions are fraught with risks. Each year thousands die as a result of transfusions; multitudes more get very sick and face long-term consequences. So, even from a physical standpoint, there is wisdom right now in heeding the Biblical command to ‘abstain from blood.’-Acts 15:28, 29.
Patients are protected from many hazards if they request nonblood medical management. Skilled physicians who have accepted the challenge of applying this on Jehovah’s Witnesses have developed a standard of practice that is safe and effective, as is proved in numerous medical reports. Physicians who provide quality care without blood are not compromising valued medical principles. Rather, they show respect for a patient’s right to know risks and benefits so that he can make an informed choice as to what will be done to his body and life.
We are not being naive in this matter, for we realize that not all will agree with this approach. People differ as to conscience, ethics, and medical outlook. Hence, others, including some doctors, may find it hard to accept a patient’s decision to abstain from blood. One New York surgeon wrote: "I will never forget 15 years ago, as a young intern when I stood at the bedside of a Jehovah’s Witness who bled to death from a duodenal ulcer. The patient’s wishes were respected and no transfusions were given, but I can still remember the tremendous frustration as a physician I felt."
He no doubt believed that blood would have been lifesaving. The year after he wrote that, however, The British Journal of Surgery (October 1986) reported that prior to the advent of transfusions, gastrointestinal hemorrhage had "a mortality rate of only 2.5 per cent." Since transfusions became customary, ‘most large studies report a 10-percent mortality.’ Why a death rate four times as high? The researchers suggested: "Early blood transfusion appears to reverse the hypercoagulable response to haemorrhage thereby encouraging rebleeding." When the Witness with the bleeding ulcer refused blood, his choice may actually have maximized his prospects for survival.
This same surgeon added: "The passage of time and treating many patients has a tendency to change one’s perspective, and today I find the trust between a patient and his physician, and the duty to respect a patient’s wishes far more important than the new medical technology which surrounds us. . . . It is interesting that the frustration has now given way to a sense of awe and reverence for that particular patient’s steadfast faith." The physician concluded: ‘It reminds me that I should always respect a patient’s personal and religious wishes regardless of my feelings or the consequences.’
You may already realize something that many physicians come to appreciate with "the passage of time and treating many patients." Even with the best of medical care in the finest of hospitals, at some point people die. With or without blood transfusions, they die. All of us are aging, and life’s end is approaching. That is not fatalistic. It is realistic. Dying is a fact of life.
The evidence shows that people who disregard God’s law on blood often experience immediate or delayed harm; some even die from the blood. Those who survive have not gained endless life. So blood transfusions do not save lives permanently.
Most people who, for religious and/or medical reasons, refuse blood but accept alternative medical therapy do very well. They may thus extend their life for years. But not endlessly.
That all humans are imperfect and are gradually dying leads us to the central truth of what the Bible says about blood. If we understand and appreciate this truth, we will see how blood can actually save life-our life-lastingly.
THE ONLY BLOOD THAT IS LIFESAVING
As noted earlier, God told all mankind that they must not eat blood. Why? Because blood represents life. (Genesis 9:3-6) He explained this further in the Law code given to Israel. At the time the Law code was ratified, the blood of sacrificed animals was used on an altar. (Exodus 24:3-8) Laws in that code addressed the fact that all humans are imperfect; they are sinful, as the Bible puts it. God told the Israelites that by means of animal sacrifices offered to him, they could acknowledge the need to have their sins covered. (Leviticus 4:4-7, 13-18, 22-30) Granted, that was what God asked of them back then, not what he asks of true worshipers today. Yet it has vital import for us now.
God himself explained the principle underlying those sacrifices: "The soul [or, life] 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 in it. That is why I have said to the sons of Israel: ‘No soul of you must eat blood.’"-Leviticus 17:11, 12.
On the ancient festival called Atonement Day, Israel’s high priest took blood of sacrificed animals into the most sacred part of the temple, the center of God’s worship. Doing that was a symbolic way of asking God to cover the people’s sins. (Leviticus 16:3-6, 11-16) Those sacrifices did not actually do away with all sin, so they had to be repeated each year. Still, this use of blood set a meaningful pattern.
A major teaching in the Bible is that God would eventually provide one perfect sacrifice that could fully atone for the sins of all believers. This is called the ransom, and it focuses on the sacrifice of the foretold Messiah, or Christ.
The Bible compares the Messiah’s role to what was done on Atonement Day: "When Christ came as a high priest of the good things that have come to pass, through the greater and more perfect [temple] not made with hands, . . . he entered, no, not with the blood of goats and of young bulls, but with his own blood, once for all time into the holy place [heaven] and obtained an everlasting deliverance for us. Yes, nearly all things are cleansed with blood according to the Law, and unless blood is poured out no forgiveness takes place."-Hebrews 9:11, 12, 22.
It thus becomes plain why we need to have God’s view of blood. In accord with his right as Creator, he has determined its exclusive usefulness. Israelites of old may have reaped health benefits by not taking in animal or human blood, but that was not the most important point. (Isaiah 48:17) They had to avoid sustaining their lives with blood, not primarily because doing otherwise was unhealthy, but because it was unholy to God. They were to abstain from blood, not because it was polluted, but because it was precious in obtaining forgiveness.
The apostle Paul explained about the ransom: "By means of him [Christ] we have the release by ransom through the blood of that one, yes, the forgiveness of our trespasses, according to the riches of his undeserved kindness." (Ephesians 1:7) The original Greek word found there is properly translated "blood," but a number of Bible versions err in substituting the word "death." Hence, readers might miss the emphasis on our Creator’s view of blood and the sacrificial value that he has linked to it.
The Bible’s theme revolves around the fact that Christ died as a perfect ransom sacrifice but did not remain dead. Following the pattern that God set on Atonement Day, Jesus was raised to heaven to "appear before the person of God for us." He presented there the value of his sacrificial blood. (Hebrews 9:24) The Bible emphasizes that we must avoid any course that would amount to ‘trampling on the Son of God and esteeming his blood as of ordinary value.’ Only thus may we keep a good relationship and peace with God.-Hebrews 10:29; Colossians 1:20.
ENJOY LIFE SAVED BY BLOOD
When we understand what God says about blood, we come to have the greatest respect for its lifesaving value. The Scriptures describe Christ as the one who ‘loves us and who loosed us from our sins by means of his own blood.’ (Revelation 1:5; John 3:16) Yes, by means of Jesus’ blood, we can gain full and lasting forgiveness of our sins. The apostle Paul wrote: "Since we have been declared righteous now by his blood, shall we be saved through him from wrath." That is how lasting life can be saved by blood.-Romans 5:9; Hebrews 9:14.
Jehovah God long ago gave assurance that by means of Christ ‘all the families of the earth can bless themselves.’ (Genesis 22:18) That blessing includes restoring the earth to a paradise. Then believing mankind will no longer be afflicted with sickness, aging, or even death; they will enjoy blessings that far exceed the temporary aid medical personnel can now offer us. We have this marvelous promise: "He will wipe out every tear from their eyes, and death will be no more, neither will mourning nor outcry nor pain be anymore. The former things have passed away."-Revelation 21:4.
How wise, then, for us to take to heart all of God’s requirements! That includes obeying his commands about blood, not misusing it even in medical situations. We thus will not live just for the moment. Rather, we will manifest our high regard for life, including our future prospect of everlasting life in human perfection.
[Box on page 25]
God’s people refused to sustain their lives with blood, not because doing that was unhealthy, but because it was unholy, not because blood was polluted, but because it was precious.
[Picture on page 24]
"By means of him [Jesus] we have the release by ransom through the blood of that one, yes, the forgiveness of our trespasses."-Ephesians 1:7
[Picture on page 26]
Saving life with Jesus’ blood opens the way to endless, healthy life in an earthly paradise
Certain points are clear from the foregoing information. Though many people view them as lifesaving, blood transfusions are fraught with risks. Each year thousands die as a result of transfusions; multitudes more get very sick and face long-term consequences. So, even from a physical standpoint, there is wisdom right now in heeding the Biblical command to ‘abstain from blood.’-Acts 15:28, 29.
Patients are protected from many hazards if they request nonblood medical management. Skilled physicians who have accepted the challenge of applying this on Jehovah’s Witnesses have developed a standard of practice that is safe and effective, as is proved in numerous medical reports. Physicians who provide quality care without blood are not compromising valued medical principles. Rather, they show respect for a patient’s right to know risks and benefits so that he can make an informed choice as to what will be done to his body and life.
We are not being naive in this matter, for we realize that not all will agree with this approach. People differ as to conscience, ethics, and medical outlook. Hence, others, including some doctors, may find it hard to accept a patient’s decision to abstain from blood. One New York surgeon wrote: "I will never forget 15 years ago, as a young intern when I stood at the bedside of a Jehovah’s Witness who bled to death from a duodenal ulcer. The patient’s wishes were respected and no transfusions were given, but I can still remember the tremendous frustration as a physician I felt."
He no doubt believed that blood would have been lifesaving. The year after he wrote that, however, The British Journal of Surgery (October 1986) reported that prior to the advent of transfusions, gastrointestinal hemorrhage had "a mortality rate of only 2.5 per cent." Since transfusions became customary, ‘most large studies report a 10-percent mortality.’ Why a death rate four times as high? The researchers suggested: "Early blood transfusion appears to reverse the hypercoagulable response to haemorrhage thereby encouraging rebleeding." When the Witness with the bleeding ulcer refused blood, his choice may actually have maximized his prospects for survival.
This same surgeon added: "The passage of time and treating many patients has a tendency to change one’s perspective, and today I find the trust between a patient and his physician, and the duty to respect a patient’s wishes far more important than the new medical technology which surrounds us. . . . It is interesting that the frustration has now given way to a sense of awe and reverence for that particular patient’s steadfast faith." The physician concluded: ‘It reminds me that I should always respect a patient’s personal and religious wishes regardless of my feelings or the consequences.’
You may already realize something that many physicians come to appreciate with "the passage of time and treating many patients." Even with the best of medical care in the finest of hospitals, at some point people die. With or without blood transfusions, they die. All of us are aging, and life’s end is approaching. That is not fatalistic. It is realistic. Dying is a fact of life.
The evidence shows that people who disregard God’s law on blood often experience immediate or delayed harm; some even die from the blood. Those who survive have not gained endless life. So blood transfusions do not save lives permanently.
Most people who, for religious and/or medical reasons, refuse blood but accept alternative medical therapy do very well. They may thus extend their life for years. But not endlessly.
That all humans are imperfect and are gradually dying leads us to the central truth of what the Bible says about blood. If we understand and appreciate this truth, we will see how blood can actually save life-our life-lastingly.
THE ONLY BLOOD THAT IS LIFESAVING
As noted earlier, God told all mankind that they must not eat blood. Why? Because blood represents life. (Genesis 9:3-6) He explained this further in the Law code given to Israel. At the time the Law code was ratified, the blood of sacrificed animals was used on an altar. (Exodus 24:3-8) Laws in that code addressed the fact that all humans are imperfect; they are sinful, as the Bible puts it. God told the Israelites that by means of animal sacrifices offered to him, they could acknowledge the need to have their sins covered. (Leviticus 4:4-7, 13-18, 22-30) Granted, that was what God asked of them back then, not what he asks of true worshipers today. Yet it has vital import for us now.
God himself explained the principle underlying those sacrifices: "The soul [or, life] 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 in it. That is why I have said to the sons of Israel: ‘No soul of you must eat blood.’"-Leviticus 17:11, 12.
On the ancient festival called Atonement Day, Israel’s high priest took blood of sacrificed animals into the most sacred part of the temple, the center of God’s worship. Doing that was a symbolic way of asking God to cover the people’s sins. (Leviticus 16:3-6, 11-16) Those sacrifices did not actually do away with all sin, so they had to be repeated each year. Still, this use of blood set a meaningful pattern.
A major teaching in the Bible is that God would eventually provide one perfect sacrifice that could fully atone for the sins of all believers. This is called the ransom, and it focuses on the sacrifice of the foretold Messiah, or Christ.
The Bible compares the Messiah’s role to what was done on Atonement Day: "When Christ came as a high priest of the good things that have come to pass, through the greater and more perfect [temple] not made with hands, . . . he entered, no, not with the blood of goats and of young bulls, but with his own blood, once for all time into the holy place [heaven] and obtained an everlasting deliverance for us. Yes, nearly all things are cleansed with blood according to the Law, and unless blood is poured out no forgiveness takes place."-Hebrews 9:11, 12, 22.
It thus becomes plain why we need to have God’s view of blood. In accord with his right as Creator, he has determined its exclusive usefulness. Israelites of old may have reaped health benefits by not taking in animal or human blood, but that was not the most important point. (Isaiah 48:17) They had to avoid sustaining their lives with blood, not primarily because doing otherwise was unhealthy, but because it was unholy to God. They were to abstain from blood, not because it was polluted, but because it was precious in obtaining forgiveness.
The apostle Paul explained about the ransom: "By means of him [Christ] we have the release by ransom through the blood of that one, yes, the forgiveness of our trespasses, according to the riches of his undeserved kindness." (Ephesians 1:7) The original Greek word found there is properly translated "blood," but a number of Bible versions err in substituting the word "death." Hence, readers might miss the emphasis on our Creator’s view of blood and the sacrificial value that he has linked to it.
The Bible’s theme revolves around the fact that Christ died as a perfect ransom sacrifice but did not remain dead. Following the pattern that God set on Atonement Day, Jesus was raised to heaven to "appear before the person of God for us." He presented there the value of his sacrificial blood. (Hebrews 9:24) The Bible emphasizes that we must avoid any course that would amount to ‘trampling on the Son of God and esteeming his blood as of ordinary value.’ Only thus may we keep a good relationship and peace with God.-Hebrews 10:29; Colossians 1:20.
ENJOY LIFE SAVED BY BLOOD
When we understand what God says about blood, we come to have the greatest respect for its lifesaving value. The Scriptures describe Christ as the one who ‘loves us and who loosed us from our sins by means of his own blood.’ (Revelation 1:5; John 3:16) Yes, by means of Jesus’ blood, we can gain full and lasting forgiveness of our sins. The apostle Paul wrote: "Since we have been declared righteous now by his blood, shall we be saved through him from wrath." That is how lasting life can be saved by blood.-Romans 5:9; Hebrews 9:14.
Jehovah God long ago gave assurance that by means of Christ ‘all the families of the earth can bless themselves.’ (Genesis 22:18) That blessing includes restoring the earth to a paradise. Then believing mankind will no longer be afflicted with sickness, aging, or even death; they will enjoy blessings that far exceed the temporary aid medical personnel can now offer us. We have this marvelous promise: "He will wipe out every tear from their eyes, and death will be no more, neither will mourning nor outcry nor pain be anymore. The former things have passed away."-Revelation 21:4.
How wise, then, for us to take to heart all of God’s requirements! That includes obeying his commands about blood, not misusing it even in medical situations. We thus will not live just for the moment. Rather, we will manifest our high regard for life, including our future prospect of everlasting life in human perfection.
[Box on page 25]
God’s people refused to sustain their lives with blood, not because doing that was unhealthy, but because it was unholy, not because blood was polluted, but because it was precious.
[Picture on page 24]
"By means of him [Jesus] we have the release by ransom through the blood of that one, yes, the forgiveness of our trespasses."-Ephesians 1:7
[Picture on page 26]
Saving life with Jesus’ blood opens the way to endless, healthy life in an earthly paradise
Monday, March 23, 2009
Blood Vital For LIfe
Blood-Vital for Life
How can blood save your life? This no doubt is of interest to you because blood is linked to your life. Blood carries oxygen through your body, removes carbon dioxide, helps you adapt to temperature changes, and aids in your fight against disease.
The linkage of life to blood was made long before William Harvey mapped the circulatory system in 1628. The basic ethics of major religions focus on a Life-Giver, who expressed himself about life and about blood. A Judeo-Christian lawyer said of him: "He himself gives to all persons life and breath and all things. For by him we have life and move and exist."
People who believe in such a Life-Giver trust that his directions are for our lasting good. A Hebrew prophet described him as "the One teaching you to benefit yourself, the One causing you to tread in the way in which you should walk."
That assurance, at Isaiah 48:17, is part of the Bible, a book respected for ethical values that can benefit all of us. What does it say about human use of blood? Does it show how lives can be saved with blood? Actually, the Bible shows clearly that blood is more than a complex biologic fluid. It mentions blood over 400 times, and some of these references involve the saving of life.
In one early reference, the Creator declared: "Everything that lives and moves will be food for you. . . . But you must not eat meat that has its lifeblood still in it." He added: "For your lifeblood I will surely demand an accounting," and he then condemned murder. (Genesis 9:3-6, New International Version) He said that to Noah, a common ancestor highly esteemed by Jews, Muslims, and Christians. All humanity was thus notified that in the Creator’s view, blood stands for life. This was more than a dietary regulation. Clearly a moral principle was involved. Human blood has great significance and should not be misused. The Creator later added details from which we can easily see the moral issues that he links to lifeblood.
He again referred to blood when he gave the Law code to ancient Israel. While many people respect the wisdom and ethics in that code, few are aware of its serious laws on blood. For instance: "If anyone of the house of Israel or of the strangers who reside among them partakes of any blood, I will set My face against the person who partakes of the blood, and I will cut him off from among his kin. For the life of the flesh is in the blood." (Leviticus 17:10, 11, Tanakh) God then explained what a hunter was to do with a dead animal: "He shall pour out its blood and cover it with earth. . . . You shall not partake of the blood of any flesh, for the life of all flesh is its blood. Anyone who partakes of it shall be cut off."-Leviticus 17:13, 14, Ta.
Scientists now know that the Jewish Law code promoted good health. It required, for example, that excrement be deposited outside the camp and covered and that people not eat meat that carried a high risk of disease. (Leviticus 11:4-8, 13; 17:15; Deuteronomy 23:12, 13) While the law about blood had health aspects, much more was involved. Blood had a symbolic meaning. It stood for life provided by the Creator. By treating blood as special, the people showed dependence on him for life. Yes, the chief reason why they were not to take in blood was, not that it was unhealthy, but that it had special meaning to God.
The Law repeatedly stated the Creator’s ban on taking in blood to sustain life. "You must not eat the blood; pour it out on the ground like water. Do not eat it, so that it may go well with you and your children after you, because you will be doing what is right."-Deuteronomy 12:23-25, NIV; 15:23; Leviticus 7:26, 27; Ezekiel 33:25.
Contrary to how some today reason, God’s law on blood was not to be ignored just because an emergency arose. During a wartime crisis, some Israelite soldiers killed animals and "fell to eating along with the blood." In view of the emergency, was it permissible for them to sustain their lives with blood? No. Their commander pointed out that their course was still a grave wrong. (1 Samuel 14:31-35) Hence, precious as life is, our Life-Giver never said that his standards could be ignored in an emergency.
BLOOD AND TRUE CHRISTIANS
Where does Christianity stand on the question of saving human life with blood?
Jesus was a man of integrity, which is why he is so highly regarded. He knew that the Creator said that taking in blood was wrong and that this law was binding. Hence, there is good reason to believe that Jesus would uphold the law about blood even if he was under pressure to do otherwise. Jesus "did no wrong, [and] no treachery was found on his lips." (1 Peter 2:22, Knox) He thus set a pattern for his followers, including a pattern of respect for life and blood. (We will later consider how Jesus’ own blood is involved in this vital matter affecting your life.)
Note what happened when, years after Jesus’ death, a question arose about whether someone becoming a Christian had to keep all of Israel’s laws. This was discussed at a council of the Christian governing body, which included the apostles. Jesus’ half brother James referred to writings containing the commands about blood stated to Noah and to the nation of Israel. Would such be binding on Christians?-Acts 15:1-21.
That council sent their decision to all congregations: Christians need not keep the code given to Moses, but it is "necessary" for them to "keep abstaining from things sacrificed to idols and from blood and from things strangled [unbled meat] and from fornication." (Acts 15:22-29) The apostles were not presenting a mere ritual or dietary ordinance. The decree set out fundamental ethical norms, which early Christians complied with. About a decade later they acknowledged that they should still "keep themselves from what is sacrificed to idols as well as from blood . . . and from fornication."-Acts 21:25.
You know that millions of people attend churches. Most of them would probably agree that Christian ethics involve not giving worship to idols and not sharing in gross immorality. However, it is worth our noting that the apostles put avoiding blood on the same high moral level as avoiding those wrongs. Their decree concluded: "If you carefully keep yourselves from these things, you will prosper. Good health to you!"-Acts 15:29.
The apostolic decree was long understood as binding. Eusebius tells of a young woman near the end of the second century who, before dying under torture, made the point that Christians "are not allowed to eat the blood even of irrational animals." She was not exercising a right to die. She wanted to live, but she would not compromise her principles. Do you not respect those who put principle above personal gain?
Scientist Joseph Priestley concluded: "The prohibition to eat blood, given to Noah, seems to be obligatory on all his posterity . . . If we interpret [the] prohibition of the apostles by the practice of the primitive Christians, who can hardly be supposed not to have rightly understood the nature and extent of it, we cannot but conclude, that it was intended to be absolute and perpetual; for blood was not eaten by any Christians for many centuries."
WHAT OF USING BLOOD AS MEDICINE?
Would the Biblical prohibition on blood cover medical uses, such as transfusions, which certainly were not known in the days of Noah, Moses, or the apostles?
While modern therapy employing blood did not exist back then, medicinal use of blood is not modern. For some 2,000 years, in Egypt and elsewhere, human "blood was regarded as the sovereign remedy for leprosy." A physician revealed the therapy given to King Esar-haddon’s son when the nation of Assyria was on the leading edge of technology: "[The prince] is doing much better; the king, my lord, can be happy. Starting with the 22nd day I give (him) blood to drink, he will drink (it) for 3 days. For 3 more days I shall give (him blood) for internal application." Esar-haddon had dealings with the Israelites. Yet, because the Israelites had God’s Law, they would never drink blood as medicine.
Was blood used as medicine in Roman times? The naturalist Pliny (a contemporary of the apostles) and the second-century physician Aretaeus report that human blood was a treatment for epilepsy. Tertullian later wrote: "Consider those who with greedy thirst, at a show in the arena, take the fresh blood of wicked criminals . . . and carry it off to heal their epilepsy." He contrasted them with Christians, who "do not even have the blood of animals at [their] meals . . . At the trials of Christians you offer them sausages filled with blood. You are convinced, of course, that [it] is unlawful for them." So, early Christians would risk death rather than take in blood.
"Blood in its more everyday form did not . . . go out of fashion as an ingredient in medicine and magic," reports the book Flesh and Blood. "In 1483, for example, Louis XI of France was dying. ‘Every day he grew worse, and the medicines profited him nothing, though of a strange character; for he vehemently hoped to recover by the human blood which he took and swallowed from certain children.’"
What of transfusing blood? Experiments with this began near the start of the 16th century. Thomas Bartholin (1616-80), professor of anatomy at the University of Copenhagen, objected: ‘Those who drag in the use of human blood for internal remedies of diseases appear to misuse it and to sin gravely. Cannibals are condemned. Why do we not abhor those who stain their gullet with human blood? Similar is the receiving of alien blood from a cut vein, either through the mouth or by instruments of transfusion. The authors of this operation are held in terror by the divine law, by which the eating of blood is prohibited.’
Hence, thinking people in past centuries realized that the Biblical law applied to taking blood into the veins just as it did to taking it into the mouth. Bartholin concluded: "Either manner of taking [blood] accords with one and the same purpose, that by this blood a sick body be nourished or restored."
This overview may help you to understand the nonnegotiable religious stand that Jehovah’s Witnesses take. They highly value life, and they seek good medical care. But they are determined not to violate God’s standard, which has been consistent: Those who respect life as a gift from the Creator do not try to sustain life by taking in blood.
Still, for years claims have been made that blood saves lives. Doctors can relate cases in which someone had acute blood loss but was transfused and then improved rapidly. So you may wonder, ‘How wise or unwise is this medically?’ Medical evidence is offered to support blood therapy. Thus, you owe it to yourself to get the facts in order to make an informed choice about blood.
[Footnotes]
Paul, at Acts 17:25, 28, New World Translation of the Holy Scriptures.
Similar prohibitions were later written in the Qur’an.
[Box on page 4]
"The precepts hereby set down in a precise and methodical manner [in Acts 15] are qualified as indispensable, giving the strongest proof that in the apostles’ minds this was not a temporary arrangement, or a provisional measure."-Professor Édouard Reuss, University of Strasbourg.
[Box/Picture on page 5]
Martin Luther pointed to the implications of the apostolic decree: "Now if we want to have a church that conforms to this council, . . . we must teach and insist that henceforth no prince, lord, burgher, or peasant eat geese, doe, stag, or pork cooked in blood . . . And burghers and peasants must abstain especially from red sausage and blood sausage."
[Credit Line]
Woodcut by Lucas Cranach
[Box on page 6]
"God and men view things in very different lights. What appears important in our eye is very often of no account in the estimation of infinite wisdom; and what appears trifling to us is often of very great importance with God. It was so from the beginning."-"An Enquiry Into the Lawfulness of Eating Blood," Alexander Pirie, 1787.
[Picture on page 3]
Medicine and the Artist by Carl Zigrosser/Dover Publications
[Picture on page 4]
At a historic council, the Christian governing body confirmed that God’s law on blood is still binding
[Picture on page 7]
Whatever the consequences, the early Christians refused to violate God’s law on blood
[Credit Line]
Painting by Gérôme, 1883, courtesy of Walters Art Gallery, Baltimore
How can blood save your life? This no doubt is of interest to you because blood is linked to your life. Blood carries oxygen through your body, removes carbon dioxide, helps you adapt to temperature changes, and aids in your fight against disease.
The linkage of life to blood was made long before William Harvey mapped the circulatory system in 1628. The basic ethics of major religions focus on a Life-Giver, who expressed himself about life and about blood. A Judeo-Christian lawyer said of him: "He himself gives to all persons life and breath and all things. For by him we have life and move and exist."
People who believe in such a Life-Giver trust that his directions are for our lasting good. A Hebrew prophet described him as "the One teaching you to benefit yourself, the One causing you to tread in the way in which you should walk."
That assurance, at Isaiah 48:17, is part of the Bible, a book respected for ethical values that can benefit all of us. What does it say about human use of blood? Does it show how lives can be saved with blood? Actually, the Bible shows clearly that blood is more than a complex biologic fluid. It mentions blood over 400 times, and some of these references involve the saving of life.
In one early reference, the Creator declared: "Everything that lives and moves will be food for you. . . . But you must not eat meat that has its lifeblood still in it." He added: "For your lifeblood I will surely demand an accounting," and he then condemned murder. (Genesis 9:3-6, New International Version) He said that to Noah, a common ancestor highly esteemed by Jews, Muslims, and Christians. All humanity was thus notified that in the Creator’s view, blood stands for life. This was more than a dietary regulation. Clearly a moral principle was involved. Human blood has great significance and should not be misused. The Creator later added details from which we can easily see the moral issues that he links to lifeblood.
He again referred to blood when he gave the Law code to ancient Israel. While many people respect the wisdom and ethics in that code, few are aware of its serious laws on blood. For instance: "If anyone of the house of Israel or of the strangers who reside among them partakes of any blood, I will set My face against the person who partakes of the blood, and I will cut him off from among his kin. For the life of the flesh is in the blood." (Leviticus 17:10, 11, Tanakh) God then explained what a hunter was to do with a dead animal: "He shall pour out its blood and cover it with earth. . . . You shall not partake of the blood of any flesh, for the life of all flesh is its blood. Anyone who partakes of it shall be cut off."-Leviticus 17:13, 14, Ta.
Scientists now know that the Jewish Law code promoted good health. It required, for example, that excrement be deposited outside the camp and covered and that people not eat meat that carried a high risk of disease. (Leviticus 11:4-8, 13; 17:15; Deuteronomy 23:12, 13) While the law about blood had health aspects, much more was involved. Blood had a symbolic meaning. It stood for life provided by the Creator. By treating blood as special, the people showed dependence on him for life. Yes, the chief reason why they were not to take in blood was, not that it was unhealthy, but that it had special meaning to God.
The Law repeatedly stated the Creator’s ban on taking in blood to sustain life. "You must not eat the blood; pour it out on the ground like water. Do not eat it, so that it may go well with you and your children after you, because you will be doing what is right."-Deuteronomy 12:23-25, NIV; 15:23; Leviticus 7:26, 27; Ezekiel 33:25.
Contrary to how some today reason, God’s law on blood was not to be ignored just because an emergency arose. During a wartime crisis, some Israelite soldiers killed animals and "fell to eating along with the blood." In view of the emergency, was it permissible for them to sustain their lives with blood? No. Their commander pointed out that their course was still a grave wrong. (1 Samuel 14:31-35) Hence, precious as life is, our Life-Giver never said that his standards could be ignored in an emergency.
BLOOD AND TRUE CHRISTIANS
Where does Christianity stand on the question of saving human life with blood?
Jesus was a man of integrity, which is why he is so highly regarded. He knew that the Creator said that taking in blood was wrong and that this law was binding. Hence, there is good reason to believe that Jesus would uphold the law about blood even if he was under pressure to do otherwise. Jesus "did no wrong, [and] no treachery was found on his lips." (1 Peter 2:22, Knox) He thus set a pattern for his followers, including a pattern of respect for life and blood. (We will later consider how Jesus’ own blood is involved in this vital matter affecting your life.)
Note what happened when, years after Jesus’ death, a question arose about whether someone becoming a Christian had to keep all of Israel’s laws. This was discussed at a council of the Christian governing body, which included the apostles. Jesus’ half brother James referred to writings containing the commands about blood stated to Noah and to the nation of Israel. Would such be binding on Christians?-Acts 15:1-21.
That council sent their decision to all congregations: Christians need not keep the code given to Moses, but it is "necessary" for them to "keep abstaining from things sacrificed to idols and from blood and from things strangled [unbled meat] and from fornication." (Acts 15:22-29) The apostles were not presenting a mere ritual or dietary ordinance. The decree set out fundamental ethical norms, which early Christians complied with. About a decade later they acknowledged that they should still "keep themselves from what is sacrificed to idols as well as from blood . . . and from fornication."-Acts 21:25.
You know that millions of people attend churches. Most of them would probably agree that Christian ethics involve not giving worship to idols and not sharing in gross immorality. However, it is worth our noting that the apostles put avoiding blood on the same high moral level as avoiding those wrongs. Their decree concluded: "If you carefully keep yourselves from these things, you will prosper. Good health to you!"-Acts 15:29.
The apostolic decree was long understood as binding. Eusebius tells of a young woman near the end of the second century who, before dying under torture, made the point that Christians "are not allowed to eat the blood even of irrational animals." She was not exercising a right to die. She wanted to live, but she would not compromise her principles. Do you not respect those who put principle above personal gain?
Scientist Joseph Priestley concluded: "The prohibition to eat blood, given to Noah, seems to be obligatory on all his posterity . . . If we interpret [the] prohibition of the apostles by the practice of the primitive Christians, who can hardly be supposed not to have rightly understood the nature and extent of it, we cannot but conclude, that it was intended to be absolute and perpetual; for blood was not eaten by any Christians for many centuries."
WHAT OF USING BLOOD AS MEDICINE?
Would the Biblical prohibition on blood cover medical uses, such as transfusions, which certainly were not known in the days of Noah, Moses, or the apostles?
While modern therapy employing blood did not exist back then, medicinal use of blood is not modern. For some 2,000 years, in Egypt and elsewhere, human "blood was regarded as the sovereign remedy for leprosy." A physician revealed the therapy given to King Esar-haddon’s son when the nation of Assyria was on the leading edge of technology: "[The prince] is doing much better; the king, my lord, can be happy. Starting with the 22nd day I give (him) blood to drink, he will drink (it) for 3 days. For 3 more days I shall give (him blood) for internal application." Esar-haddon had dealings with the Israelites. Yet, because the Israelites had God’s Law, they would never drink blood as medicine.
Was blood used as medicine in Roman times? The naturalist Pliny (a contemporary of the apostles) and the second-century physician Aretaeus report that human blood was a treatment for epilepsy. Tertullian later wrote: "Consider those who with greedy thirst, at a show in the arena, take the fresh blood of wicked criminals . . . and carry it off to heal their epilepsy." He contrasted them with Christians, who "do not even have the blood of animals at [their] meals . . . At the trials of Christians you offer them sausages filled with blood. You are convinced, of course, that [it] is unlawful for them." So, early Christians would risk death rather than take in blood.
"Blood in its more everyday form did not . . . go out of fashion as an ingredient in medicine and magic," reports the book Flesh and Blood. "In 1483, for example, Louis XI of France was dying. ‘Every day he grew worse, and the medicines profited him nothing, though of a strange character; for he vehemently hoped to recover by the human blood which he took and swallowed from certain children.’"
What of transfusing blood? Experiments with this began near the start of the 16th century. Thomas Bartholin (1616-80), professor of anatomy at the University of Copenhagen, objected: ‘Those who drag in the use of human blood for internal remedies of diseases appear to misuse it and to sin gravely. Cannibals are condemned. Why do we not abhor those who stain their gullet with human blood? Similar is the receiving of alien blood from a cut vein, either through the mouth or by instruments of transfusion. The authors of this operation are held in terror by the divine law, by which the eating of blood is prohibited.’
Hence, thinking people in past centuries realized that the Biblical law applied to taking blood into the veins just as it did to taking it into the mouth. Bartholin concluded: "Either manner of taking [blood] accords with one and the same purpose, that by this blood a sick body be nourished or restored."
This overview may help you to understand the nonnegotiable religious stand that Jehovah’s Witnesses take. They highly value life, and they seek good medical care. But they are determined not to violate God’s standard, which has been consistent: Those who respect life as a gift from the Creator do not try to sustain life by taking in blood.
Still, for years claims have been made that blood saves lives. Doctors can relate cases in which someone had acute blood loss but was transfused and then improved rapidly. So you may wonder, ‘How wise or unwise is this medically?’ Medical evidence is offered to support blood therapy. Thus, you owe it to yourself to get the facts in order to make an informed choice about blood.
[Footnotes]
Paul, at Acts 17:25, 28, New World Translation of the Holy Scriptures.
Similar prohibitions were later written in the Qur’an.
[Box on page 4]
"The precepts hereby set down in a precise and methodical manner [in Acts 15] are qualified as indispensable, giving the strongest proof that in the apostles’ minds this was not a temporary arrangement, or a provisional measure."-Professor Édouard Reuss, University of Strasbourg.
[Box/Picture on page 5]
Martin Luther pointed to the implications of the apostolic decree: "Now if we want to have a church that conforms to this council, . . . we must teach and insist that henceforth no prince, lord, burgher, or peasant eat geese, doe, stag, or pork cooked in blood . . . And burghers and peasants must abstain especially from red sausage and blood sausage."
[Credit Line]
Woodcut by Lucas Cranach
[Box on page 6]
"God and men view things in very different lights. What appears important in our eye is very often of no account in the estimation of infinite wisdom; and what appears trifling to us is often of very great importance with God. It was so from the beginning."-"An Enquiry Into the Lawfulness of Eating Blood," Alexander Pirie, 1787.
[Picture on page 3]
Medicine and the Artist by Carl Zigrosser/Dover Publications
[Picture on page 4]
At a historic council, the Christian governing body confirmed that God’s law on blood is still binding
[Picture on page 7]
Whatever the consequences, the early Christians refused to violate God’s law on blood
[Credit Line]
Painting by Gérôme, 1883, courtesy of Walters Art Gallery, Baltimore
Wednesday, March 11, 2009
Blood Transfusions or Safe Alternatives?
Transfusions—The Key to Survival?
IN 1941 Dr. John S. Lundy set a standard for blood transfusions. Apparently without any clinical evidence to back him up, he said that if a patient’s hemoglobin, the oxygen-carrying component of blood, goes down to a level of ten grams or less for every deciliter of blood, then the patient needs a transfusion. Thereafter that number became a standard for doctors.
This ten-gram standard has been challenged for nearly 30 years. In 1988 The Journal of the American Medical Association flatly stated that the evidence does not support the guideline. Anesthesiologist Howard L. Zauder says it is "cloaked in tradition, shrouded in obscurity, and unsubstantiated by clinical or experimental evidence." Others simply call it a myth.
Despite all this vigorous debunking, the myth is still widely revered as a sound guideline. To many anesthesiologists and other doctors, a hemoglobin level of below ten is a trigger for transfusion to correct the anemia. It’s virtually automatic.
No doubt, that helps account for the vast overuse of blood and blood products today. Dr. Theresa L. Crenshaw, who served on the Presidential Commission on the Human Immunodeficiency Virus Epidemic, estimates that in the United States alone, some two million unnecessary transfusions are administered every year and that about half of all transfusions of banked blood could be avoided. Japan’s Health and Welfare Ministry decried "the indiscriminate use of transfusions" in Japan, as well as the "blind belief in their efficacy."
The problem with trying to correct anemia with a blood transfusion is that the transfusion can be more deadly than the anemia. Jehovah’s Witnesses, who refuse blood transfusions primarily on religious grounds, have helped to prove the point.
You may have seen newspaper headlines reporting that one of Jehovah’s Witnesses died because of refusing a blood transfusion. Sadly, such reports rarely tell the whole story. Frequently, it is the doctor’s refusal to operate, or to operate soon enough, that spells death for the Witness. Some surgeons refuse to operate without freedom to transfuse if the hemoglobin level drops below ten. However, many surgeons have successfully operated on Witnesses with hemoglobin levels of five, two, and even less. Says surgeon Richard K. Spence: "What I’ve found with the Witnesses is that the lower hemoglobin does not relate to mortality at all."
A Wealth of Alternatives
‘Blood or death.’ That is the way some doctors describe the alternatives facing a Witness patient. Yet, in reality, there are many alternatives to blood transfusion. Jehovah’s Witnesses are not interested in dying. They are interested in alternative treatments. Because the Bible forbids the ingesting of blood, they simply don’t consider blood transfusions an alternative.
In June 1988, the Report of the Presidential Commission on the Human Immunodeficiency Virus Epidemic suggested that all patients be given just what the Witnesses have been requesting for years, namely: "Informed consent for transfusion of blood or its components should include an explanation of the risks involved . . . and information about appropriate alternatives to homologous blood transfusion therapy."
In other words, patients should be given a choice. One such choice is a type of autologous transfusion. The patient’s own blood is salvaged during the operation and recirculated back into the patient’s veins. Where such a process is simply an extension of the patient’s own circulatory system, it is quite acceptable to most Witnesses. Surgeons also stress the value of increasing the patient’s blood volume with nonblood expanders and letting the body replenish its own red cells. Such techniques have been used in place of transfusions without increasing mortality. In fact, they can improve safety.
A promising drug called recombinant erythropoietin has recently been approved for limited use. It speeds up the body’s own production of red blood cells, in effect helping a person to make more of his own blood.
Scientists are still searching for an effective substitute for blood that imitates its remarkable oxygen-carrying capacity. In the United States, the makers of such substitutes find it hard to get approval for their products. Yet, as one such maker objected: "If you thought about bringing blood to the FDA [Food and Drug Administration] to be approved, you wouldn’t have a prayer of ever getting it tested it’s so toxic." Still, hopes are high that an effective chemical will be found that will be approved as an oxygen-carrying substitute for blood.
So there are choices. Those mentioned here are but a few of those available. As Dr. Horace Herbsman, a professor of clinical surgery, wrote in the journal Emergency Medicine: "It’s . . . quite clear that we do have alternatives to blood replacement. Indeed, perhaps our experience with Jehovah’s Witnesses might be interpreted to mean that we do not need to rely on blood transfusions, with all their potential complications, as much as we once thought." Of course, none of this is really new. As The American Surgeon noted: "The fact that major operations can be safely performed without blood transfusions has been amply documented in the past 25 years."
But if blood is dangerous, and there are safe alternatives to its use, then why are millions of people transfused unnecessarily—many of them without knowing it, others actually against their will? The report of the presidential commission on AIDS notes in part the failure to educate doctors and hospitals about the alternatives. It blames another factor too: "Some regional blood centers have been hesitant to promote strategies that minimize the use of transfusion therapies, since their operating income is derived from the sale of blood and blood products."
In other words: Selling blood is big business.
IN 1941 Dr. John S. Lundy set a standard for blood transfusions. Apparently without any clinical evidence to back him up, he said that if a patient’s hemoglobin, the oxygen-carrying component of blood, goes down to a level of ten grams or less for every deciliter of blood, then the patient needs a transfusion. Thereafter that number became a standard for doctors.
This ten-gram standard has been challenged for nearly 30 years. In 1988 The Journal of the American Medical Association flatly stated that the evidence does not support the guideline. Anesthesiologist Howard L. Zauder says it is "cloaked in tradition, shrouded in obscurity, and unsubstantiated by clinical or experimental evidence." Others simply call it a myth.
Despite all this vigorous debunking, the myth is still widely revered as a sound guideline. To many anesthesiologists and other doctors, a hemoglobin level of below ten is a trigger for transfusion to correct the anemia. It’s virtually automatic.
No doubt, that helps account for the vast overuse of blood and blood products today. Dr. Theresa L. Crenshaw, who served on the Presidential Commission on the Human Immunodeficiency Virus Epidemic, estimates that in the United States alone, some two million unnecessary transfusions are administered every year and that about half of all transfusions of banked blood could be avoided. Japan’s Health and Welfare Ministry decried "the indiscriminate use of transfusions" in Japan, as well as the "blind belief in their efficacy."
The problem with trying to correct anemia with a blood transfusion is that the transfusion can be more deadly than the anemia. Jehovah’s Witnesses, who refuse blood transfusions primarily on religious grounds, have helped to prove the point.
You may have seen newspaper headlines reporting that one of Jehovah’s Witnesses died because of refusing a blood transfusion. Sadly, such reports rarely tell the whole story. Frequently, it is the doctor’s refusal to operate, or to operate soon enough, that spells death for the Witness. Some surgeons refuse to operate without freedom to transfuse if the hemoglobin level drops below ten. However, many surgeons have successfully operated on Witnesses with hemoglobin levels of five, two, and even less. Says surgeon Richard K. Spence: "What I’ve found with the Witnesses is that the lower hemoglobin does not relate to mortality at all."
A Wealth of Alternatives
‘Blood or death.’ That is the way some doctors describe the alternatives facing a Witness patient. Yet, in reality, there are many alternatives to blood transfusion. Jehovah’s Witnesses are not interested in dying. They are interested in alternative treatments. Because the Bible forbids the ingesting of blood, they simply don’t consider blood transfusions an alternative.
In June 1988, the Report of the Presidential Commission on the Human Immunodeficiency Virus Epidemic suggested that all patients be given just what the Witnesses have been requesting for years, namely: "Informed consent for transfusion of blood or its components should include an explanation of the risks involved . . . and information about appropriate alternatives to homologous blood transfusion therapy."
In other words, patients should be given a choice. One such choice is a type of autologous transfusion. The patient’s own blood is salvaged during the operation and recirculated back into the patient’s veins. Where such a process is simply an extension of the patient’s own circulatory system, it is quite acceptable to most Witnesses. Surgeons also stress the value of increasing the patient’s blood volume with nonblood expanders and letting the body replenish its own red cells. Such techniques have been used in place of transfusions without increasing mortality. In fact, they can improve safety.
A promising drug called recombinant erythropoietin has recently been approved for limited use. It speeds up the body’s own production of red blood cells, in effect helping a person to make more of his own blood.
Scientists are still searching for an effective substitute for blood that imitates its remarkable oxygen-carrying capacity. In the United States, the makers of such substitutes find it hard to get approval for their products. Yet, as one such maker objected: "If you thought about bringing blood to the FDA [Food and Drug Administration] to be approved, you wouldn’t have a prayer of ever getting it tested it’s so toxic." Still, hopes are high that an effective chemical will be found that will be approved as an oxygen-carrying substitute for blood.
So there are choices. Those mentioned here are but a few of those available. As Dr. Horace Herbsman, a professor of clinical surgery, wrote in the journal Emergency Medicine: "It’s . . . quite clear that we do have alternatives to blood replacement. Indeed, perhaps our experience with Jehovah’s Witnesses might be interpreted to mean that we do not need to rely on blood transfusions, with all their potential complications, as much as we once thought." Of course, none of this is really new. As The American Surgeon noted: "The fact that major operations can be safely performed without blood transfusions has been amply documented in the past 25 years."
But if blood is dangerous, and there are safe alternatives to its use, then why are millions of people transfused unnecessarily—many of them without knowing it, others actually against their will? The report of the presidential commission on AIDS notes in part the failure to educate doctors and hospitals about the alternatives. It blames another factor too: "Some regional blood centers have been hesitant to promote strategies that minimize the use of transfusion therapies, since their operating income is derived from the sale of blood and blood products."
In other words: Selling blood is big business.
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