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J. Richard Bowen, MD, write that posterior spinal fusion “has been successfully accomplished for 20 [Witness] minors” (unpublished data, August 1981).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.

Appendix

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.