The Refusal of Blood Transfusions

The Refusal of Blood

Transfusions
RWS 1301
Brian Carbajal

The Refusal of Blood Transfusions

Abstract
The history of Jehovahs Witnesses date back to the 1800s when ideas of Adventism were
adopted into Christian beliefs by a man named Charles Taze Russell. This first began when he
tried to convert an Atheist into a Christian, but instead, converted him into the ideas. In 1879,
The Watch Tower, which later became the Watchtower Bible and Tract Society, was the teaching
ministry of Jehovahs Witnesses. He started a small group in which he named them Bible
Students teaching and spreading the word of Gods kingdom. The journey of Jehovahs
Witnesses has been to not only make disciples, but show people what the bible really teaches. It
has been to come down to the Truth and discover its greatest mysteries to understand life.
Jehovahs Witnesses have been known not only for their zealous preaching work, or their refusal
to participate in holiday traditions, but also for their refusal of blood transfusions. Small minor
fractions of blood have only been accepted because of the prohibiting of the consumption of
blood in the bible. Patients with a low Hb level that refused the transfusion, proved to live longer
than those with a higher Hb level that accepted it. It has raised many challenges for blood
surgeons to accomplish such a difficult task, but from the compromise of Jehovahs Witness
patients and blood surgeons, Jehovahs Witnesses have been able to fulfill their loyalty to their
beliefs to its fullest.

The Refusal of Blood Transfusions

The Refusal of Blood Transfusions
The refusal of blood transfusions has been the best known case of Jehovahs Witnesses. It
has raised many challenges for Gynecologic Surgeons to fulfill medical help for Jehovahs
Witness patients that have lost a great amount of blood. The official doctrine for the Kingdom
Hall of Jehovahs Witnesses that banned the acceptance of blood began in 1945. Acceptances of
whole blood, red blood cells, white blood cells, platelets, and plasma have been banned. But the
doctrine modified its stance on the issue of accepting blood in which now allows for minor
fractions of blood to be accepted by the individual based on their preference. Will this doctrine
for Jehovahs Witnesses ever change to fully accept blood or will the doctrine remain unchanged
up to this point in time? Have Jehovahs Witnesses been on the precarious edge of giving up
certain beliefs? If they are willing to make disciples of nations, with evidence of the possible
health risks alone, should abstinence from blood be continued to be exercised amongst Jehovahs
Witnesses and the people who are willing to become Jehovahs Witnesses?
What must first be understood is why Jehovahs Witnesses do not accept blood
transfusions. It is taken from the scripture in the book of Genesis that states, Only flesh with its
soul [or life] its blood- you must not eat. (Genesis 1:29). In the book of Leviticus, it also
states, As for any man who in hunting catches a wild beast or a fowl that may be eaten, he
must in that case pour its blood out and cover it with dust I said to the sons of Israel: You
must not eat the blood of any sort of flesh (Leviticus 17:13, 14) In this account in the bible,
animal meat could be eaten, but not the blood. The pouring of blood on the ground was a way of
returning the creatures life to God. Blood is very sacred and its consumption is not only
disrespect to life, but it is also a health risk. Many consumers know that when they buy meat, the
blood is supposed to be completely drained, because it is toxic when it is consumed. This is
because blood is so rich in iron that the body may suffer an overdose of iron. Blood transfusions,
in the same manner, can cause serious health risks such as transfusion-related acute lung injury,
allergic and febrile reactions, transfusion related immune modulation, transfusion-associated
circulatory overload, and transfusion-transmitted diseases. In the book, What the Bible Really
Teaches, written by the Watchtower and Tract Society, theres a section in which discusses the
subject of why blood transfusions are banned and it illustrates an analogy, If your doctor told
you to abstain from alcohol, would you have it injected into your veins?

The Refusal of Blood Transfusions

In 1962, 500 open heart surgeries were performed on Jehovahs Witnesses without the
utilization of blood transfusions. Since then, many clinical and pharmacologic procedures and
strategies have been developed over the years for Jehovahs Witness patients to avoid allogeneic
transfusions. 100 bloodless surgery centers have been available to Jehovahs Witnesses across the
United States giving them a chance to fulfill their loyalty of their beliefs. This proves that
surgical and pharmaceutical procedures without blood can be performed. (J Blood Med, 2015)
But with the recent modification of the doctrine prohibiting the acceptance of blood transfusions,
which now relies on the patients own spiritual level to decide if they want to accept a small
fraction of blood or no blood at all. In surgical and pharmaceutical terms, these are called minor
blood fractions and there are many different kinds such as albumin, which is made in the liver
which makes up to a 4% volume in plasma and used to restore blood volume. Colony stimulating
factors which stimulates the bone marrow to produce white blood cells. Hemoglobin-based
Oxygen Carriers are the hemoglobin molecules that are removed from red blood cells and are
used to treat anemia or severe blood loss in a patient. Immunoglobulins are antibodies that are
produced by plasma cells and lymphocytes when toxins and infections enter the body. This
creates up to 3% of plasma and is often used for patients with tetanus, rabies, and Hepatitis B.
Sealants are used to stop bleeding and are used from many minor fractions of blood such as
gelfoam which is from purified pork skin and is a non-blood product, coseal which is also a nonblood product, tisseel which is from human fibrogen, thrombin, and bovine aprotinin, fibrin glue
which is also from a human fibrogen, and thrombin, topical thrombin which is spawned from
bovine, and platelet gel which are platelets derived from the patients own blood, calcium, and
thrombin. RH Factor is an immunoglobulin that comes from pooled plasma and is often for
pregnant patients when the mother whose Rh negative may be exposed to her Rh positive baby
preventing her antibodies from attacking the Rhesus antigens of the pregnancy. Interleukin is a
protein, active in inflammation, enabling communication among white blood cells and other
cells. Interferon are produced by white blood cells and is carried in plasma to fight viral
infections. Erythropoietin produced in the kidneys serves two purposes: a hormone that
stimulates bone marrow to produce red blood cells and is used to diminish oxygen in the blood
of the patient. Clotting factors are any various fractions of plasma which involves the
coagulation of blood, including prothrombin, calcium ions, and fibrinogen. It involves
cryoprecipitate which is from plasma that separates when plasma is frozen and then thawed.

The Refusal of Blood Transfusions

Fibrinogen is a protein secreted by the liver into blood plasma and is formed into fibrin as a part
of the clotting process. These are the many options for minor blood fractions to choose from for
the patient. (Swedish Medical Center, 2015)
Now, the procedures involve blood patch which is treated for spinal headache. About 10
30 ml of the patients own blood is injected into the spine of the patient. Platelet gel involves
plasma being extracted from the patients own blood mixed with thrombin and calcium and is
applied to a wound to stop bleeding and allow for the body to heal. Dialysis is a method in which
the blood of the patient is cleaned by a machine which serves as a kidney substitute. Heart
Lung bypass is the procedure in which the patients blood supply is pumped by a machine to the
arterial side bypassing the heart and lungs when the patient is undergoing surgery. Cell tagging is
when less than 10 ml of the patients blood is removed and mixed with radioisotopes and is
returned to the patient to determine the location of bleeding. Blood salvage is the collecting of
blood and tissue from the surgical area and is cleaned returning the red blood cells to the patient.
Apheresis is when certain cellular or fluid elements of the patients blood is removed, sometimes
called plasmapheresis, which removes plasma from the blood and the rest is returned to the
patient. These are the procedures that Jehovahs Witness patients undergo depending on the
patients condition. (Swedish Medical Center, 2015)
Jehovahs Witnesses are provided a document which states their position on blood
transfusions and their signature must be witnessed by two adults. The document states their
refusal of whole blood, red blood cells, platelets, and plasma as well as the procedure consent
form of the refusal and allows for no deviation, even in life-threatening situations. There is also a
non-blood directive form that includes two options for the patient: (1) no blood component
transfusions, even at the risk of death or organ failure and (2) blood conservation that allows for
the patient to recycle his/her own blood or pretreat the patients blood with hormones in case of
anemia. (Varisco, 2015) This allows for Jehovahs Witnesses to fulfill their loyalty and for
doctors to respect the wishes of the patients.
A study was conducted to discover how many Jehovahs Witness patients, median age
being 58, would accept blood transfusions and the results showed that none of them accepted
whole blood, red cells, white cells, platelets or plasma. Rather they accepted or entirely refused
the minor blood fractions given to them. To demonstrate, these were the results:

The Refusal of Blood Transfusions

Albumin
Accept

40 (98%)

Refuse

1 (2%)

Erythropoietin
Accept

40 (98%)

Refuse

1 (2%)

Immunoglobulins
Accept

40 (98%)

Refuse

1 (2%)

Clotting factors
Accept

36 (90%)

Refuse

4 (10%)

Not answered

Fractional agents
Accept

31 (89%)

Refuse

4 (11%)

Not answered

Topical tissue adhesives/hemostatics

Accept

39 (98%)

Refuse

1 (2%)

Not answered

Cryoprecipitates

The Refusal of Blood Transfusions

Accept

35 (88%)

Refuse

5 (12%)

Not answered

Intraoperative hemodilution and fractionation

Accept

41 (100%)

Refuse

0 (0%)

Hemodialysis equipment
Accept

41 (100%)

Refuse

0 (0%)

Intraoperative autologous blood salvage

Accept

40 (98%)

Refuse

1 (2%)

Postoperative blood salvage/reinfusion

Accept

37 (100%)

Refuse

0 (0%)

Not answered

Cardiopulmonary bypass
Accept

36 (100%)

Refuse

0 (0%)

Not answered

The Refusal of Blood Transfusions

Organ donation
Accept

8 (50%)

Refuse

8 (50%)

Not answered

25

Organ transplantation
Accept

8 (50%)

Refuse

8 (50%)

Not answered

25

The results showed that none of them accepted whole blood, red cells, white cells,
platelets or plasma. Rather they accepted or entirely refused the minor blood fractions given to
them. (J Blood Med, 2015) The Houston Methodist Hospital reported to have 105 successful
bloodless transplants through their programs study developing bloodless transplant techniques
for the medical field. No deaths after the surgeries were reported, but this shows a success in
finding solutions to respect the values and beliefs of Jehovahs Witnesses making nothing
impossible in finding successful procedures in bloodless transplant surgeries. (Varisco, 2015) To
prove that patients suffering a blood loss can survive with a low percentage or Hb level
(hemoglobin found in red blood cells) with the refusal of blood transfusions, a 1994 study on 154
Jehovahs Witness patients proved that 50 deaths of the 154 were reported and had a Hb level of
more than 8g/dL. Out of the 50 patients, 23 of them were due to anemia, 3 suffering death after
cardiac surgery, and the rest passed with Hb levels of about 5g/dL. 25 patients were reported to
have survived with a Hb level of no more than 5g/dL. In 2002, a study found that out of 300
Jehovahs Witness patients, 48 passed with a Hb level of no more than 8g/dL. The mortality rate
raised the scales when the Hb level fell below 5mg/dL, but was extended to a period of 30 days.
In 2009, a study found that Jehovahs Witness patients that refused blood and passed away with

The Refusal of Blood Transfusions

very low Hb levels, survived for extended periods. But if the refusal of blood will still guarantee
death and only postpone death, does the refusal of blood truly matter? In this case, these studies
prove that blood transfusions should only be taken into consideration depending on the patients
severity and symptoms not so much the level of Hb. (Transfusion, 2015)

The Refusal of Blood Transfusions

To conclude, it has now been understood how many surgical procedures have been
developed over the decades and how Jehovahs Witnesses have changed their doctrines over the
years, in this case, concerning the acceptance of blood transfusions. This is not in any way to
accuse Jehovahs Witnesses of inconsistencies, but rather that some ideas are becoming
compromised into ideas that were not accepted as such with the acceptance of minor blood
fraction in patients that are Jehovahs Witnesses. Now does this in any way demonstrate the loss
of loyalty of Jehovahs Witnesses? No. This is because not all religious questions can be
answered with the limited historical evidence that we have found, but again, depends on our
level of understanding. Now, level of understanding would mean that at some point in time, the
acceptance of blood transfusions will be fully understood because life is about understanding
reality as it is. In this case, we understand the human concept of survival and what we are willing
to do and sacrifice for our loved ones. This idea has moved from a strict concept to a more
understanding of human intent. But one idea that seems to be omnipresent in this subject is the
analogy, If your doctor told you to abstain from alcohol, would you have it injected in your
veins? Another is the how the bible mentions that blood must not be eaten and the respect for
life is just something about living that is timeless counsel. The doctrine which recently modified
into accepting minor blood fractions is perfect for the patient and what the situation calls for and
should remain as is because the respect for blood and what the bible states should always be
honored, at least among Jehovahs Witnesses. But again, time will tell if the doctrine will modify
itself again or whether it will remain this way until the ending of the system of things.

The Refusal of Blood Transfusions

References
Leonard I. Boral, Andrew Bernard, Todd Hjorth, Daniel Davenport, Daoping Zhang1 and
Duncan C. MacIvor. Published on January 9, 2015. How do I implement a more restrictive
transfusion trigger of hemoglobin level of 7 g/dL at my hospital? Retrieved from
http://onlinelibrary.wiley.com/doi/10.1111/trf.12982/full
Lynn Gillam. Published on January 14, 2015.Fifty years of paediatric ethicsRetrieved from
http://onlinelibrary.wiley.com/doi/10.1111/jpc.12793/full
Nimesh P. Nagarsheth, Nikhil Gupta, Arepta Gupta, Erin Moshier, Herbert Gretz, and Aryeh
Shander, Published on December 24, 2014. Responses of advanced directives by Jehovahs
Witnesses on a gynecologic oncology service Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4284050/
Jessica Varisco and Scott A. Scheinin. Published on January 2015. Leading Medicine Through
bloodless Transplantation Retrieved from
http://www.tandfonline.com/doi/pdf/10.1080/15265161.2015.975604
Andreea Seicean, MPH, PhD, Nima Alan, BS, Sinziana Seicean, MD, PhD, MPH, Duncan
Neuhauser, PhD, Warren R. Selman, MD5, and Nicholas C. Bambakidis, MD Published on Aoril
10, 2015. Risks associated with preoperative anemia and perioperative blood transfusion in
open surgery for intracranial aneurysms Retrieved from
http://thejns.org/doi/abs/10.3171/2014.10.JNS14551
Swedish Medical Center. 2015. Glossary. Retrieved from http://www.swedish.org/services/bloodmanagement/glossary