Refusal of Blood Transfusion in Jehovah’s Witnesses: An ethical dilemma

1. Refusal of Blood Transfusion in Jehovah’s Witnesses: An ethical dilemma Diana Escobar Azusa Pacific University

2. History • Founded in 1972 in the US by Charles Taze Russell • A denomination of more than 6 million followers • Follow the conservative doctrine of the New World Translation of the Bible • The doctrine of The Watchtower and Bible Tract Society form the church’s legislative body & policy • In 1945 the policy was introduced prohibiting the transfusion of whole blood, autologous or allogenetic • In 1956 Publication Awake expands to include the ban of transfusing any blood components • Incompliance with church policies results in the disfellowship of JW, social & familial repudiation, & ban from eternal paradise (Wong, 2012).

3. Biblical Foundation • Current restriction over blood transfusion is based on the church’s belief that blood serves as a body nutrient, & that life is contained within blood • Genesis 9:4 “But you shall not eat flesh with its life, that is, its blood.” • Acts 15:29 “You must abstain from eating food offered to idols, from consuming blood or the meat of strangled animals, and from sexual immorality. If you do this, you will do well. Farewell” • Leviticus 17:10 “And if any native Israelite or foreigner living among you eats or drinks blood in any form, I will turn against that person and cut him off from the community of your people.” • Awake!, August 2006 p. 11, "He also gave them his reason, equating blood with the soul, or life, of the creature. He later said: 'The soul [or life] is in the blood.' In the eyes of the Creator, blood is sacred. It represents the precious gift of life that each living soul possesses.” (West, 2014, p.170-171)

4. Current Policy • In 2000 JW administration officially changed the consequences of receiving blood transfusions, members would not be automatically disfellowshipped, but the choice of transfusion would result in voluntary disfellowship (West, 2014) • Current legislature upholds the decision to refuse treatment of a rational JW adult, who has been informed of the consequences & treatment options, and mandates that alternative treatment be explored (Effa-Heap, 2009). • In cases where a patient is under 18yrs parents/legal guardians make treatment decisions • Patients older than 16yrs who desire autonomy over their care can bring the case before an ethics committee/court (Hivey et al., 2009). • 1999,‘No Blood’ cards developed • Signed advanced directives, power of attorney used to ensure refusal of transfusion (Effa-Heap, 2009).

5. Ethical Debate • Beneficence: A Clinician’s Responsibility to “Do Good” • Clinician’s responsibility to provide the best care possible • Nonmaleficence: A Clinician’s Responsibility to “Do No Harm” • Balancing Physical, Psychosocial, & Spiritual Health • Autonomy: A patient’s right to decide over their care • Includes their right to consent to or refuse treatment • Dependant on mental competence • Clinician Autonomy to refuse to participate in particular care options • should not result from coercion • Justice: Assurance that all individuals receive the best medical care regardless of individual beliefs • Despite personal opinion, clinicians are required to explore and present alternative treatment options to JW • Disagreement: Hospital Ethics Committees, State or Federal Courts • (Panico et al., 2011), (Wong, 2012), (Hivey et al., 2009), (West, 2014)

6. Treatment Options • Popular treatment Options: • administration of vitamin K, albumin and erythropoietin, oxygen therapy, cardiopulmonary bypass during major procedures, recombinant factor VII and IX, and acute normovolemichemodilution, volume expanders • Some JW will accept bone marrow & organ transplants, plasma & platelet concentrates, & WBC transfusions • Treatment options depend on availability of resources, care facilities, scope of practice of clinicians, & patient financial resources • Special attention to patients with: CHF, CKF, HIV, etc • JW Resources: Hospital Information Services, Hospital Liaison Committees, Patient Visitation Groups (West, 2014, p.170-171)

7. Clinical Example • JW Caucasian male admitted to ED in 1990 • He was in hypovolemic shock & undated but signed “No Blood” card was found in his wallet. • Attending physician proceeded with transfusion despite card, claiming clinical duty to save life. • Patient’s daughter arrived and requested the discontinuation of the transfusion • Physician refused & was eventually prosecuted and convicted of battery. (Panico et al., 2011)

8. Nursing Implications • Nursing Implications: • Respect for Patient Autonomy • Be informed: Patient Rights, Current Judicial Hospital Policy, JW doctrine, & treatment options • Patient Education • Patient Advocacy: Communication Medium • Identify and Report Coercion • Provide psychosocial & spiritual resources & support • Support, encourage, & care for patient • Protect Patient Privacy • Nonjudgmental care

9. Conclusion • My Position: JW bloodless beliefs should be respected • Respect Patient Autonomy • When a patient is deemed rational/mature • Religious liberty • Given there is no coercion • Justice • JW patients leading focus of research • in bloodless treatment • Future Research Options: • Clearer definition of treatment rights for minors & pregnant women • Expansion of Education & treatment option availability in hospitals

10. References • Effa-Heap, G. (2009). Blood transfusion: implications of treating a Jehovah’s Witness patient. British Journal of Nursing, 18 (3), 174-177. • Hivey, S., Garside, J.P., & Wolf, A.R. (2009). Pro-con debate: religious practice, blood transfusion, and major medical procedures. Pediatric Anesthesia, 19, 934-946. doi:10.1111/j.1460-9592.2009.03139.x • Knapp van Bogaert, D. & Ogunbanjo, G.A. (2013). Ethics and medicine: Jehovah’s Witnesses and the new blood transfusion rules. South African Family Practice, 55(1), S6-S9. • Panico, M., Jenq, G.Y., & Brewster, U.C. (2011). When a patient refuses life-saving care: issues raised when treating Jehovah’s Witnesses. American Journal of Kidney Disease, 58(4), 647-653. • West, J.J.M. (2014). Ethical issues in the care of Jehovah’s Witnesses. Current Opinion in Anesthesiology, 27(2), 170-176. • Wong, D.S.Y. (2012). Blood transfusion and Jehovah’s Witnesses revisited: implications for surgeons. Surgical Practice, 16, 128-132. doi:10.1111/j.1744-1633.2012.00612.x