Jehovah’s Witnesses and blood transfusion refusal: what next?

In their recent article published in this journal, Gupta and Colleagues addressed the question of whether UK gynaecology and obstetrics wards have set up policies for female Jehovah’s Witness patients and parturients refusing blood transfusion¹. This is an important issue for four main reasons: (i) pelvic surgery and delivery carry risks of serious bleeding with activation of anticlotting factors, increasing the severity of the haemorrhage; (ii) there is a fair number of female Jehovah’s Witnesses of reproductive age or older at risk of gynaecological pathologies requiring conventional surgery; (iii) these women, report Gupta et al., are increasingly of African origin/ancestry with a higher risk of fibroid pathology than the Caucasian female population; and (iv) one of the main hazards in transfusion in 2012 in wealthy countries is the delay in transfusion or the absence of transfusion - and no longer transfusion hazards linked to the blood products themselves, especially infectious ones². Indeed, the article by Gupta and colleagues was intended to report the findings of their survey, which was based on a questionnaire sent to a large number of obstetrics and gynaecology wards. They did not pretend to dissert on the behaviour of the medical staff in charge; however, the burning questions remain, “What to say to patients and what to do?”. Facing the refusal of a Jehovah’s Witness to accept a blood transfusion, when absolutely necessary for vital reasons, is probably one of the most frustrating situations in medical wards. There may be a furious temptation to overcome this refusal when the situation becomes critical or irreversible. To address this issue broadly, it can be useful to consider possible sociological differences between Latin and Anglo-Saxon cultures and, of course, to understand what blood transfusion means to a Jehovah’s Witness.

Different laws applied in different countries may reflect the cultural environment of each country and impregnation of prevailing religious sentiment³. In general, Anglo-Saxon laws and, by and large, cultural habits are highly respectful of patients’ wishes when repeatedly expressed by individuals not suffering from cognitive impairment. They also respect the requests of the family when a relative cannot confirm a patient’s wishes. In the USA, as well as in the UK and other English-speaking countries, there have been several legal directives allowing teenagers or even children to refuse blood transfusion (many of whom consequently died)⁴. In the UK, Gillick competence is given to teenagers aged 16–18 years, meaning that their ability to give consent to medical treatment overcomes that of their parents. Some children below the age of 16 may be deemed Gillick competent under certain circumstances. This was initially intended for contraceptive choices, but is applied in the case of Jehovah’s Witnesses as well³. In contrast, in Romance culture countries it usually takes more time to adopt a convergent rule. In these countries, children are barely considered bearers of their own opinion and they are subjected to either their parents’ will or to state decisions. This is an important issue because maturity for Jehovah’s Witnesses -who in general obey, but do not agree with, general country regulations (e.g., voting, military service, civil jury service, saluting flags)- is acquired by the time of baptism, before the age of 18. For example, a child aged 15 or 16 years is mature when baptised within the Jehovah’s Witness community but still considered immature for legal emancipation in France. In France -a Romance culture country with regards to ethical issues- several laws have reinforced on the one hand the patient’s right to be completely and honestly informed about his/her disease and the treatment options, and on the other hand the patient’s right not to suffer excessively aggressive therapy or resuscitation. These laws were passed, respectively, in 2002 (named after Kouchner) and 2005 (named after Leonetti). The Kouchner Law has simplified the case for adolescents aged under 18 years in Jehovah’s Witness families by giving full authorisation to medical staff to overcome parental wishes. By contrast, this law has not eased the support of other situations with regard to transfusion and relationships with the Jehovah’s Witness community (e.g., in elderly, incapacitated people). It is also not uncommon that actions against the law are initiated by medical staff (for expected good reasons). Jehovah’s Witnesses have set up a very well constituted network of scrutinisers, lawyers, and even physicians patrolling hospitals. They are also quick to litigate. Why is that? One has to consider that Jehovah’s Witnesses simply rely on the physicians’ own pledge, “First, do not harm!” (“Primum non nocere” the principle of non-maleficence). This is also intended to mean, “Do not harm my soul just as you do not intend to harm my body!”

Jehovah’s Witnesses are a group of non-conventional millenarist and fundamentalist Christians who believe literally the “Word of the Lord” reported in the Gideon Bible, which is a part of the actual Catholic and Reformed Protestant Bibles. They pay great attention to the last Book, called “Revelation”, and otherwise known as the “Apocalypse”. In the main body of the Bible, especially the Old Testament, there are words against the absorption of, or contact with blood, a widespread cultural thought among the Hebraic and ancient Judaic populations. This is in sharp contrast to the credence of conventional Christians, who value the salvaging power of the Holy Blood (of Jesus Christ) differently. All blood apart from Christ’s blood is considered by Jehovah’s Witnesses to be a vector of sin. In contrast to conventional Christians, they do not believe in the forgiveness of sins by confession or self-conscience examination. Sinning thus irremediably compromises the eternal life (of the soul). Jehovah’s Witnesses think that a very limited number (144,000) of believers will be saved, which is an infinitesimal proportion if one considers the number of human beings having ever existed on earth. Any compromise regarding sinning abolishes the rare chance of being saved: “What means 80 years of life on earth, i.e., in this valley of tears, compared to an eternity in paradise (as opposed to hell)?” One has to understand that this view is deeply entrenched among Jehovah’s Witnesses and they sincerely believe there is no matter of debate or compromise or otherwise there would be absolutely no chance for redemption. Unbelievers sometimes have trouble understanding what religious faith means, but Jehovah’s Witnesses’ faith is extremely strong. Respect for this faith is sometimes challenged in the case of Jehovah’s Witnesses because, depending on the country, their religion is either considered legal (e.g., in the USA), or a sect. Various intermediate cases exist; in France, for example, the Jehovah’s Witness faith is considered a religious cult with sectarian drifting, imposing particular surveillance by the ad hoc legal establishment.

In conclusion, initiatives such as Dr Gupta’s appear mostly valuable to help Jehovah’s Witnesses and members of some other religious groups to overcome the death penalty of delivery with fatal bleeding and refusal of blood transfusion for religious reasons. Indubitably people are increasingly prepared to pay attention to ethical issues and respect patients’ wishes, even when their traditional and cultural habits suggest doing otherwise. The issue of blood transfusion in Jehovah’s Witnesses is probably far from reaching a happy ending in general because of the slowness in obtaining suitable alternatives to blood transfusion. Nonetheless, Jehovah’s Witnesses dominate research programmes that are driving physicians to achieve consistent progress in bloodless surgery and anaesthesiology. Although Jehovah’s Witnesses do not reject either organ transplantation or red blood cell-depleted stem cell transplants (because there are no explicit statements forbidding these in the Bible), it can be questioned as to whether they are likely to accept induced pluripotent stem cells or mesenchymal stem cell-derived red blood cells⁵, currently one of the most promising alternatives. This remains to be determined because such cells are, in some way, still blood. Indeed, Jehovah’s Witnesses usually refuse autologous blood (as this is a split part of the body, having been kept separated from the body and soul of the donating person for some time), although there is some debate on this matter⁵. Compassion for and understanding of Jehovah’s Witness patients will not solve all transfusion-refusal matters in life-threatening conditions, but may help in some of them. Furthermore, they may relieve the feeling of guilt that can occur in the medical staff involved.