JEHOVAH'S WITNESS REFUSAL OF BLOOD PRODUCTS

Jehovah's Witnesses are members of a biblically based, semi-Christian religious denomination that forbids its adherents from accepting transfusions of blood and blood products. This religious tenet is based on a literal interpretation of specific passages in the Bible. As a result of this doctrine, most baptized Jehovah's Witness believers refuse blood transfusions in their pursuit of medical treatment and healthcare. Some nonblood, transfusion-like replacement techniques and agents derived from minor blood fractions are left to individual believers to accept or reject. Jehovah's Witnesses do not subscribe to "faith healing," and thus seek the assistance of modern medicine as needed, excluding blood transfusions. This belief creates ethical questions and dilemmas related to patient autonomy, informed consent, advance directives, decisional capacity, surrogate decision making, professional integrity and promotion of patients' best interests, medical treatment for children, maternal–fetal conflicts, and the use of healthcare resources.

Historical Development and Organizational Structure

Jehovah's Witnesses trace their historical roots to Charles Taze Russell (1852–1916) and the nineteenth-century North American Adventist movement (a group of Christians who predicted an imminent "second coming" of Jesus Christ). In 1881, as a result of his teaching and writings, Russell founded the Zion's Watch Tower Tract Society. Russell had calculated and predicted that Jesus Christ would return in 1914, when God's direct rule would be established on earth and humanity would be restored to perfection. At the time of Russell's death, he had not appointed a successor.

Russell's religious movement floundered and fractionated until 1931, when Joseph Franklin Rutherford (1869–1942), a lawyer from Missouri, took over leadership. At a meeting of the renamed Watchtower Bible and Tract Society in Columbus, Ohio, in 1931, the name Jehovah's Witnesses was adopted and Rutherford became the group's president. Rutherford believed that because the Hebrew name for God was Jehovah, God's people should be known by the same name. In addition to authoring twenty books and numerous pamphlets that greatly influence the denomination's evolving belief system, Russell focused the lives of Jehovah's Witnesses on local congregations and places of assembly known as Kingdom Halls, which were established throughout the United States. A principle tenet of Jehovah's Witnesses is to inform the world about Jehovah's reign and kingdom via missionary activity, including door-to-door evangelization.

Nathan H. Knorr (1905–1977) succeeded Rutherford as the society's president in 1942. During Norr's term, the belief about the divine mandate to refuse blood transfusions was first introduced and promulgated in one of the Society's official publications, The Watchtower (July 1, 1945). By 2002, there were 6 million Jehovah's Witnesses participating in over 90,000 congregations in 230 countries.

Similar to other religious groups, Jehovah's Witnesses have developed a theologically justified organizational structure with accompanying degrees of hierarchical authority. God's will and direction are revealed primarily through the Bible, and secondarily through the leadership at the international headquarters of the Watchtower Bible and Tract Society, based in Brooklyn, New York. The teaching and organizational authority of the Society is composed of a president and a governing body of seventeen members who head up various committees.

Educational and instructional resources, including printed materials such as official publications (e.g., The Watchtower, and Awake!) are primarily written, produced, and published at the Brooklyn headquarters. Distribution of materials takes place through branch offices, districts, and circuits, the last consisting of approximately twenty congregations. Districts and circuits have overseers appointed by the society's governing body. Local Kingdom Halls, where individual congregations are centered, are presided over by elders responsible for worship, training, and evangelization.

Biblical Beliefs about Blood

As noted above, the Jehovah's Witness belief system is biblically based. The exegetical method used to interpret biblical texts is a literal, or fundamentalist, method (what the words literally state or do not state), rather than a historicalcritical method (taking into consideration the human author's intention and the cultural and historical milieux of the text). Jehovah's Witnesses view the sixty-six books of the Bible as inspired by God and historically accurate. As a result of this literal exegesis of the scriptures, Jehovah's Witnesses find biblical support for pacifism; the practice of adult baptism by immersion; the practices of not saluting national flags and not celebrating birthdays or Christmas (because such celebrations are not mentioned or mandated in the Bible); a belief that the reign of God will be established on the earth, where people will live forever; and the belief that the number of the "spiritual sons of God" who will rule with Jesus Christ in heaven is limited to 144,000. The literal interpretation of the "Christian Greek Scriptures" (their official name for the New Testament) has led Jehovah's Witnesses to conclude that Jesus Christ is God's son, but is inferior to God and was the first of God's creations. This last set of beliefs about Jesus Christ technically places Jehovah's Witnesses outside of mainstream Christian denominations, which profess God as a trinity of "equal persons," including Jesus Christ as God incarnate.

A literal interpretation of the Bible helps to explain why, in 1945, the governing body of the Watchtower Bible and Tract Society determined that accepting blood or blood products for medical purposes violated the biblical word of God. Pertaining to blood, there are at least three scriptural passages that have great significance for Jehovah's Witness belief and practice. These passages are:

Every moving animal that is alive may serve as food for you. As in the case of green vegetation, I do give it all to you. Only flesh with its soul—its blood— you must not eat (Gen. 9:3–4).

As for any man of the house of Israel or some alien resident who is residing as an alien in their midst who eats any sort of blood, I shall certainly set my face against the soul that is eating the blood, and I shall indeed cut him off from among his people (Lev. 17:10).

The holy spirit and we ourselves have favored adding no further burden to you, except these necessary things, to keep abstaining from things sacrificed to idols and from blood and from things strangled and from fornication (Acts 15:28).

Viewed as inspired by God and to be interpreted literally, these three scriptural texts forbid the eating or ingestion of blood. An important step in the reasoning and interpretive process for Jehovah's Witnesses is that the relatively recent medical practice of intravenous blood transfusion is seen as a way of nourishing or feeding the human body. With this understanding and perception of blood transfusions, a literal interpretation and application of the cited biblical texts becomes clear: Through God's inspired and literal word contained in the Bible, he has expressly forbidden the eating of blood, and, when applied to modern medical practice, this means that God has forbidden the nourishing of the human body with blood transfusions. This divine prohibition applies in all circumstances, including emergency and life-threatening situations. Jehovah's Witnesses who knowingly and willfully accept transfusions of blood or blood products violate God's commandment and disassociate themselves from the congregation of believers.

What Is Forbidden and Permitted

Because of medicine's increasing abilities and techniques to collect, store, dissect, develop, infuse, and salvage blood and blood-based products, numerous and specific questions about what is forbidden and permitted have arisen among Jehovah's Witnesses, as well as among healthcare professionals who treat them. For example, can a Jehovah's Witness accept the use of an intraoperative cell-saver technique or the administration of albumin, erythropoietin, bone marrow, stem cells, or clotting factors for hemophilia?

Jehovah's Witnesses are officially and specifically prohibited from receiving whole blood, packed red blood cells, white blood cells, plasma, and platelets. This explicit prohibition remains the same regardless of the source of the blood, that is, whether the donation is autologous (derived from the same individual) or donated by someone else. Once blood has left the body and the body's circulatory system, it cannot be transfused into a Jehovah's Witness patient. Some techniques and blood-based agents, however, are left to the discretion and conscience of the individual believer. One example is an intraoperative cell-saver procedure that involves salvaging blood from a surgical field (e.g., a body cavity), cleansing the blood, and then returning the blood to the patient. If during this process a continuous, closed circulation of the blood is maintained as it moves from the body of the patient through the tubing of the salvaging machine and then back into the body, this external circulatory process can be viewed as an extension of the body's own circulation system, consequently the procedure can be acceptable. Also left to the individual believer's conscience and decision are the use of agents derived from minor fractions of blood components, such as immune globulins, albumin, clotting factors for hemophilia, as well as bone marrow and stem cells.

Medical Management of Jehovah's Witnesses

With the exception of transfusions of blood and blood products, Jehovah's Witnesses do not have religious objections to any other medical treatment or procedure that promotes the patient's health. In fact, seeking medical treatment for disease and the promotion of health are seen as concrete ways for believers to respond appropriately to God's gift of life. Thus, as long as blood transfusions are not involved, and when medical necessity arises, Jehovah's Witnesses will seek solid organ transplantation, surgery (including coronary artery bypass grafting, dialysis, and various lifesustaining measures such as intubation and ventilatory support), and medically supplied nutrition and hydration.

When blood loss is a likely risk with an accompanying decrease of hematocrit, hemoglobin, and blood pressure (such as during many surgeries), Jehovah's Witnesses hope for and encourage the medical team to engage in a variety alternative medical and surgical methods that obviate the need for blood transfusions. These methods include limiting phlebotomies or using pediatric needles for blood draws; inducing hormonal suppression of menstruation; stimulating red-blood-cell production through administration of recombinant (synthetic) erythropoietin; utilizing proven and published techniques to reduce surgical blood loss (e.g., cooling a patient to lessen oxygen needs; electrocautery; using laparoscopic and minimally invasive instruments; administration of desmopressin, aprotinin, antifibrinolytics); or preventing shock (from inadequate blood flow to the body's peripheral tissues) by use of nonblood volume expanders such as saline solution, lactated Ringer's solution, and dextran.

To promote respect for their beliefs and help educate healthcare professionals, many Jehovah's Witness congregations and circuits have formed Hospital Liaison Committees to educate healthcare professionals and hospital administrators about the nuances of what is forbidden and permitted, according to Jehovah's Witness beliefs. Committee members have available current literature and bibliographies, usually from prestigious peer-reviewed clinical journals, that reference bloodless management and blood-substitute treatment techniques that have had successful outcomes.

Most of this medical reference material is also available from the Brooklyn headquarters. Hospital Liaison Committees also strives to identify physicians, especially surgeons and anesthesiologists, who are willing to treat Jehovah's Witness patients while respecting their beliefs about blood. Of special significance for Jehovah's Witnesses are hospitals and surgery centers that are willing to develop and advertise bloodless surgery programs (deCastro). Hospital Liaison Committees promote a five-step protocol addressed to healthcare professionals treating Jehovah's Witnesses:

1. Review nonblood medical alternatives and treat the patient without using homologous blood.
2. Consult with other doctors experienced in nonblood alternative management at the same facility.
3. Contact the local Hospital Liaison Committee for locating experienced and cooperative doctors at other facilities to consult on alternative care.
4. Transfer the patient, if necessary, to a cooperative doctor or facility before the patient's condition deteriorates.
5. In a rare situation, if the above steps have been exhausted and governmental or court intervention is deemed necessary, the patient, the parents, or the guardian should be notified as soon as possible of such intended action.

Ethical Evaluation and Analysis

In general, informed adult patients with decisional capacity have an ethically supported right to refuse medically recommended treatment, including treatment that is life-sustaining and death-preventing. This is true regardless of the patient's motive or rationale and whether the refusal is religiously based or not. The American Hospital Association's "Patient's Bill of Rights" echoes this ethical and legal consensus when it states: "The patient has a right to make decisions about the plan of care prior to and during the course of treatment and to refuse a recommended treatment or plan of care to the extent permitted by law and hospital policy" (Right # 3). Some ethical and legal limitations on this right have been argued when the adult refusing treatment has dependent minor children; that is, when there are innocent third parties who will be affected by the adult's refusal.

Thus, adult Jehovah's Witnesses with decisional capacity have the right to refuse blood transfusions, even in lifethreatening situations. Although the recommended treatment of a blood transfusion can be presumed in most situations to be in the patient's best interests, a patient's right to self-determination (i.e., autonomy) and the corresponding norm of informed consent, ethically and legally "trump" a physician's or medical team's recommendations and perception of the patient's best interests.

This right to refuse can be extended to include patients who once had, but no longer have, decisional capacity, if such patients have indicated their wishes through an advance directive. In anticipation of such situations, many Jehovah's Witnesses sign and carry a specially prepared, wallet-size medical directive/release card indicating their wishes not to receive blood transfusions "even though physicians deem such vital to my health or life." In general, such an advance directive should be honored unless there is clear evidence that the patient revoked the advance directive or completed it when coerced or inadequately informed.

An adequate informed-consent process has great ethical significance for Jehovah's Witnesses' refusals of blood products. In the usual fashion for informed consent, the nature, purpose, risks, benefits, and alternatives associated with consenting to or refusing blood products should be explained to Jehovah's Witnesses. This proactive process is even more important prior to medical and surgical interventions that risk significant blood loss. Many hospitals and surgery centers have informed-consent forms that specifically address the use of blood transfusions. However, a form signed by a patient is less important than the conversation and education between physician and patient, which can be triggered by the presentation of a form to be signed.

Unless there has been an acute event or an emergency situation, there is usually time for physicians to present sensitively and clearly the likely outcomes should blood be needed and not provided, and for patients to be queried about their willingness, for each projected outcome, to consent to blood, blood products, agents partially derived from blood, and nonblood alternatives. Also, during such discussions, physicians should communicate their willingness (or unwillingness) to honor Jehovah's Witnesses' refusals of blood transfusions. Because physicians' professional integrity should be protected and respected as much as possible, the transfer of a Jehovah's Witness patient to another qualified physician, who is willing to limit treatment according to the patient's religious beliefs, might become necessary and is ethically supportable as long as continuity of the patient's care is preserved.

When Jehovah's Witness patients have lost decisional capacity and healthcare decisions must be made, the healthcare team may need to involve surrogate decision makers (often family members or someone specifically designated by the patient through a medical-power-of-attorney document). The surrogate should provide a substituted judgement on behalf of the patient; that is, consent to or refuse a specific treatment in accord with the patient's wishes, values, and beliefs. Providing a substituted judgement may be especially difficult for a surrogate who does not share the patient's beliefs and if the outcome could be death or serious debilitation (e.g., a stroke) if blood is not transfused.

When the interests of innocent third parties will be affected by a refusal of treatment, additional cautions and considerations are in order. Such situations occur when a pregnant woman refuses life-sustaining treatment, or when a parent's refusal of treatment will likely result in death or serious and permanent disability and any dependent children will subsequently be abandoned or lose parental support and nurturing. An analysis of the latter situation should include whether support is available from other family members or the community. In such instances, some courts have intervened in the decision process in favor of preserving life (Raleigh-Fitkin Hospital v. Anderson; Werth v. Taylor), while other courts have supported the patient's refusal (Fosmire v. Nicoleau; Norwood Hospital v. Munoz; Stamford Hospital v. Vega). Because neither a consistent ethical nor legal consensus exists for such third party circumstances, in actual cases of this kind professionals should seek the guidance and support of institutional ethics committees, hospital legal counsel, or the courts.

When the Patient Is a Child

Jehovah's Witnesses who are parents generally refuse to give permission for blood transfusions for their children when transfusions are needed. Members of healthcare teams usually experience such refusals as much more troublesome and problematic than when adult patients refuse recommended treatments for themselves. With treatment decisions involving children, it is usually not a situation of patient autonomy clashing with medical perception of best interests, but rather parental perception of best interests (based on parental religious beliefs) clashing with medical perception of best interests.

At least for younger children who have not achieved a level of cognitive and emotional development to make their own decisions, most ethicists and legal commentators echo the sentiments of the 1944 U. S. Supreme Court conclusion that, "Parents may be free to make martyrs of themselves. But it does not follow [that] they are free, in identical circumstances, to make martyrs of their children before they have reached the age of full and legal discretion when they can make that choice for themselves" (Prince v. Massachusetts). Especially in life-threatening situations, there is ethical support (based primarily on a best interest standard) for providing needed blood transfusions for patients who have never had decisional capacity.

The American Academy of Pediatrics (AAP) supports such a stance: "The AAP … advocates that children, regardless of parental religious beliefs, deserve effective medical treatment when such treatment is likely to prevent substantial harm or suffering or death" (AAP, 1997). This position can be extended to include patients with severe mental retardation, regardless of chronological age. However, outside of life-threatening situations, and when nonblood alternatives have a reasonable likelihood of being effective, physicians should give serious consideration to honoring the parent's religious tenets that the child not be given transfusions. If a decision is made to seek a court order to permit blood transfusions, the parents should be informed about this decision before it is carried out.

More ethically complex are cases of adolescent Jehovah's Witness patients who have not reached the legal age of majority or adulthood (usually age 18), or who have not been declared emancipated minors by a court, and who refuse blood transfusions. Some of these adolescents may have the requisite cognitive skills to give an informed consent or refusal (Leikin; Weir; Weithorn). From an ethical perspective, healthcare professionals should use the same criteria for assessing decisional capacity (Grisso) and the same process of informed consent and information disclosure as is used for legal adults. Some courts in North America have affirmed this judgement, specifically if adolescent patients can demonstrate sufficient cognitive skills to consent to or refuse medical treatment (Robb).

Use of Resources

From one perspective, Jehovah's Witnesses could be accused of increasing medical expenses and the use of scarce medical resources because of their idiosyncratic beliefs. Although there have not been comprehensive studies comparing and calculating costs for medically managing Jehovah's Witness patients versus non–Jehovah's Witness patients with similar diseases, many physicians and hospitals caring for Jehovah's Witness patients could likely provide individual case reports demonstrating a greater use of resources for some specific patients. A few published reports have claimed an increase in expenses because the usual standard of care could not be followed due to patient wishes (Busuttil). As healthcare teams work for good medical outcomes while honoring patients' refusals of blood transfusions in some individual cases, there can be increases in hospital lengths-of-stay, occupancies of intensive-care beds, time in operating rooms, and costs for medications.

But from another perspective, Jehovah's Witnesses could argue that respect for their religious beliefs has occasioned discoveries and developments that conserve a scarce resource—blood products—while benefiting all patients. Jehovah's Witnesses can make the claim that their refusals of blood have accelerated research and the adoption of innovative practices that reduce, eliminate or substitute for the use of blood transfusions. Further, because transfusions of blood and blood products always involve some risk to recipients, any reduction of transfusion therapy by using safe and effective nonblood alternatives and techniques decreases potential medical risks for all patients.

Treating some Jehovah's Witnesses within the context of their beliefs about blood may indeed increase costs and the use of resources in comparison to the general population. But without sufficient comparative studies, such claims remain hypothetical. Even if it can be shown that Jehovah's Witness beliefs increase healthcare costs, would that be sufficient justification for either not honoring refusals of blood therapy or expecting Jehovah's Witnesses to contribute more financially for their healthcare (e.g., in the form of higher insurance premiums)? Such a conclusion seems to fail, based on fairness, until such time as all or most individual behaviors and decisions that increase demands on healthcare resources (e.g., smoking, routinely eating foods high in fat, not wearing seat belts) result in those individuals being either denied treatment or paying more for their healthcare as well.

Conclusion

In general, there is strong ethical and legal support for honoring Jehovah's Witnesses' informed refusals of blood transfusions. Some exceptions to this general principle do exist, however. Because persons can have varying degrees of commitment to religious beliefs, and because the Jehovah's Witness leadership leaves some issues for individual judgement and decision, physicians and healthcare professionals should explore the limits and desires for specific treatments with each Jehovah's Witness. For this patient population, as much as possible, safe and effective nonblood alternatives should be used to promote restoration of health and preserve life. Healthcare professionals and others do not need to agree with Jehovah's Witnesses' beliefs and biblical exegesis in order to show them respect, honor their religiously based refusals of transfusion therapy, and provide them with high-quality care.

martin l. smith

SEE ALSO: Authority in Religious Traditions; Autonomy; Children: Rights of Children; Competence; Coercion; Conscience; Conscience, Rights of; Infants

BIBLIOGRAPHY

American Academy on Pediatrics, Committee on Bioethics. 1995. "Informed Consent, Parental Permission, and Assent in Pediatric Practice." Pediatrics 95: 314–317.

American Academy of Pediatrics, Committee on Bioethics. 1997. "Religious Objections to Medical Care." Pediatrics 99: 279–281.

Busuttil, David, and Adrian Copplestone. 1995. "Management of Blood Loss in Jehovah's Witnesses: Recombinant Human Erythropoietin Helps But Is Expensive." British Medical Journal 311: 1115–1116.

Cumberland, William H. 1986. "The Jehovah's Witness Tradition." In Caring and Curing: Health and Medicine in the Western Religious Traditions, edited by Ronald L. Numbers and Darrel W. Amundsen. New York: Macmillan.

deCastro, Roberto M. 1999. "Bloodless Surgery: Establishment of a Program for the Special Medical Needs of the Jehovah's Witness Community—The Gynecologic Surgery Experience at a Community Hospital." American Journal of Obstetrics and Gynecology 180: 1491–1498.

Fosmire v. Nicoleau. 551 N.E.2d 77, N.Y. (1990).

Grisso, Thomas, and Appelbaum Paul S. 1998. Assessing Competence to Consent to Treatment, A Guide for Physicians and Other Health Professionals. New York: Oxford University Press.

Leikin, Sanford L. 1983. "Minors' Assent or Dissent to Medical Treatment." Journal of Pediatrics 102: 169–176.

Norwood Hospital v. Munoz. 409 MA 116,564 N.E.2d 1017 (1991).

Prince v. Massachusetts. 321 US 158 (1944).

Raleigh-Fitkin Hospital v. Anderson. 201 A2d 537, New Jersey (1964).

Robb, Nancy. 1994. "Ruling on Jehovah's Witness Teen in New Brunswick May Have 'Settled the Law' for MDs." Canadian Medical Association Journal 151: 625–628.

Smith, Martin L. 1997. "Ethical Perspectives on Jehovah's Witnesses' Refusal of Blood." Cleveland Clinic Journal of Medicine 64: 475–481.

Stamford Hospital v. Vega. 674 A.2d 821, Conn (1996).

Thomas, J. Mervyn. 1994. "The Worldwide Need for Education in Nonblood Management in Obstetrics and Gynaecology." Journal of the Society of Obstetricians and Gynaecologists of Canada 16: 1483–87.

Watchtower Bible and Tract Society of New York. 1992. Family Care and Medical Management for Jehovah's Witnesses. New York: Watchtower Bible and Tract Society of New York.

Watchtower Bible and Tract Society of Pennsylvania. 1990. How Can Blood Save Your Life? New York: Watchtower Bible and Tract Society of New York.

Weir, Robert F, and Charles Peters. 1997. "Affirming the Decisions Adolescents Make about Life and Death." Hastings Center Report 27(6): 29–40.

Weithorn, Lois A., and Susan B. Campbell. 1982. "The Competency of Children and Adolescents to Make Informed Treatment Decisions." Child Development 53: 1589–1598.

Werth v. Taylor. 475 N.W.2d 426, 427, Mich. Ct. App (1991).

INTERNET RESOURCES

American Hospital Association. 1992. "A Patient's Bill of Rights." Available from <http://www.hospitalconnect.com/aha>.

Watchtower Bible and Tract Society of New York. 2003. Available from <http://www.watchtower.org/>.