Margo A. Peyton
Baltimore, Maryland, United States

Tammy said that her throat looked like that of a bullfrog croaking on an August night. At her local emergency room, her blood pressure was 240/40 mmHg due to profound aortic valve insufficiency complicated by an aortic aneurysm. Her condition necessitated high-risk cardiac surgery, a procedure that carries the potential for devastating blood loss. Most patients undergoing this procedure require at least some blood transfusions; many need to be massively transfused just to survive the operating room. But, as a member of the Jehovah’s Witness community, Tammy would not accept a blood transfusion. For six months, hospital after hospital turned Tammy away because they were unwilling to assume the risk of performing the surgery without blood transfusion.¹

Jehovah’s Witnesses believe in a strict literal interpretation of the Bible that prohibits blood transfusion, even in the most desperate of circumstances. In the Book of Acts, the apostle Paul instructs congregants to “abstain from things sacrificed to idols, and from blood, and from what is strangled.”² Consequently, Jehovah’s Witnesses seeking medical treatment that may require blood transfusion must weigh death from blood loss with deeply held Biblical convictions. Tammy’s commitment to her faith, however, did not mean she wanted to die on the operating table.

Tammy discovered that most doctors and hospitals equated her refusal of blood products with an irrational refusal of care. Her experience was not unique. Medicine often struggles with providing care for Jehovah’s Witnesses because the denial of blood transfusion seemingly sets two pillars of medical ethics against one another: autonomy and beneficence.³ In a 2008 Swiss study, 59% of anesthesiologists and 30% of surgeons reported that they would override clear refusal of blood products if it was necessary for patient survival. One rationale given for overriding was that the patient did not understand what it meant to die and, therefore, did not competently make the decision to refuse blood products.⁴ This highlights physicians’ own cognitive dissonance with their helplessness to save a patient, and illustrates the potential limits of physician respect for patient autonomy.⁵ While the emotional burden of standing by while a patient dies may lead a physician to violate a patient’s autonomy in the name of beneficence, such an approach preserves beneficence as defined by the physician’s values, not the patient’s. In order to respect patient rights in this situation, physicians must control their own discomfort.⁶

The history of blood transfusion illustrates why medicine adopted the practice so rapidly and decidedly, and why it may no longer be considered the cure-all it once was. After centuries of slow progress, marred by well-documented deaths due to an incomplete understanding of blood compatibility, blood transfusion soared to popularity during World War II for the treatment of wounded soldiers. The United States Army believed that liberal use of blood and plasma reduced mortality by half for soldiers brought to field hospitals compared to those in World War I.⁷ That was proof enough, and blood transfusion was soon standard practice on the home front as well. As a result, blood transfusion became routine despite a lack of clinical trials or other sources of objective data on its benefits and risks.⁸

The research gap was particularly challenging for the Jehovah’s Witness community. There was little motivation in the medical community to develop bloodless alternatives because the benefits of blood transfusion were broadly perceived to outweigh the risks. A small number of physicians, however, wanted to serve the medical needs of the Jehovah’s Witness community. In the early 1990s, Dr. Aryeh Shander, anesthesiologist at Englewood Hospital and Medical Center in suburban New Jersey, pioneered bloodless care for Jehovah’s Witnesses. The son of a Holocaust survivor, Dr. Shander cites the emphasis on defending human rights in his childhood home as his motivation to help underserved communities.⁹ In addition, the HIV epidemic turned the tide against liberal use of blood transfusion in the 1980s. Widespread fear of transfusion-transmitted infection brought into question the all-reward-no-risk attitude toward transfusion.¹⁰ But no one knew what would happen to critically ill patients without blood. And, despite recognition of transfusion-related risk, most physicians were uncomfortable with a clinical trial comparing patients willing and able to receive blood transfusions to patients who refused. From the physician’s perspective, the lifesaving legacy of blood transfusion made randomization to a “no transfusion” group unethical.¹¹

After six months, Tammy finally found an advocate in Andrew Pippa at Johns Hopkins. Mr. Pippa, an elder of the Jehovah’s Witness community who acts as a liaison between the community and Hopkins, saw Tammy’s courage as inspiring rather than risky. Their partnership is an example of one of many forged between the Jehovah’s Witness community and medicine. For her surgery, Dr. Steven Frank, the medical director of the Center for Bloodless Medicine and Surgery at Hopkins, and the cardiac anesthesia team used several strategies to prevent blood loss and protect against it if it were to happen.

Preoperatively, Tammy received infusions of intravenous iron and erythropoietin to boost her hemoglobin level. During the surgery, the team used a blood salvage technique to collect and return blood that was shed on the surgical field in a closed circuit attached to Tammy’s body. This is important as many Jehovah’s Witnesses will not accept their own blood that has been stored externally. In recovery, the team drew blood with the smallest phlebotomy tubes for any necessary lab tests.¹² The application of these approaches, as well as expert surgical technique, helped Tammy to survive her surgery without need for blood transfusion. Although bloodless surgical methods have been refined through the help of Jehovah’s Witness patients, efforts to reduce blood loss during surgery and avoid the danger of transfusion benefit all patients.

While it may be straightforward to see the benefit of medical research when outcomes are positive, as in Tammy’s case, the medical contribution of Jehovah’s Witness patients has been particularly significant when outcomes are poor. A poignant example of the generosity of the Jehovah’s Witness community is a patient of Dr. Patricia Ford, a hematologist who performed the first bloodless stem cell transplant at Pennsylvania Hospital in 1995. Dr. Ford was treating the twenty-one-year-old patient for Hodgkin’s lymphoma with the second-ever bloodless stem cell transplant. Following the transplant, the patient died of severe anemia, leading Dr. Ford to reconsider continuing the procedure. Even though there was enthusiasm from the Jehovah’s Witness community, she worried that she was providing substandard care to a particular group of people. What urged her to go forward, however, was the young patient’s parents. Despite the devastation of losing their child, her parents persuaded Dr. Ford to continue to provide hope for other members of the community in need of transplant. They valued the opportunity their daughter had been given and wanted it for others.¹³ Today, the Center for Transfusion-Free Medicine at Pennsylvania Hospital, under Dr. Ford’s leadership, extends to nearly every realm of surgery and cares for all patients.

The Jehovah’s Witness community’s participation in the medical system has continued to answer many of medicine’s hematological questions. Due to the rapid acceptance of blood transfusion by clinicians and patients, there was an incomplete understanding of severe anemia and how best to treat it. The non-standardized answer was somewhere between transfusing the patient below a hemoglobin of 9-10 g/dL, or transfusing when the patient became symptomatic (e.g., abnormally rapid heart heat or shortness of breath). The lack of research-supported standardization may have contributed to unnecessary transfusions or missed therapeutic windows to transfuse.

In 2009 Dr. Aaron Tobian, director of the Division of Transfusion Medicine at Johns Hopkins, published a landmark manuscript that chronicled the outcomes of 117 Jehovah’s Witness patients who underwent surgery without transfusion and had a postoperative hemoglobin level of 6 g/dL or lower. This research provided the long-needed answer that it was “imperative”¹⁴ to transfuse patients who would accept a blood transfusion once their hemoglobin fell below 5-6 g/dL in order to have the best chance of avoiding the severe complications of anemia. Dr. Tobian noted that many of the Jehovah’s Witness patients who ultimately died due to severe anemia did not decline rapidly, unless their hemoglobin was 2 g/dL or less. Generally, these patients did not die until several days after their lowest hemoglobin level. This revealed that there is a therapeutic window in which to transfuse a patient, and the window may occur before a patient becomes symptomatic. Above all, the research determined that there were no definitive warning signs or tests to adequately predict patient decline, and provided an evidence-based rationale for blood transfusion of patients with hemoglobin less than 5 g/dL.¹⁵ The study advanced the standard of care for all severely anemic patients, regardless of their faith.

Despite experiences of misunderstanding, Jehovah’s Witnesses have been willing to engage the medical system in order to advance hematological knowledge and the practice of bloodless surgery. Through their bravery, untestable hypotheses have been scrutinized, and the larger population has benefitted from new bloodless practices that reduce transfusion-related morbidity and mortality. Although often known for the frustration they may cause physicians, Jehovah’s Witnesses should be celebrated for their generous and courageous contribution to medical practice.

References

1. Johns Hopkins Medicine, Bloodless Medicine: Tammy’s Story, accessed October 5, 2019, https://www.hopkinsmedicine.org/health/video/bloodless-medicine–tammys-story.
2. Amanda Schaffer, “How Jehovah’s Witnesses Are Changing Medicine,” The New Yorker, August 12, 2015, 2.
3. D. John Doyle, “Blood Transfusions and the Jehovah’s Witness Patient:,” American Journal of Therapeutics 9, no. 5 (September 2002): 417–24, https://doi.org/10.1097/00045391-200209000-00009.
4. John D. Banja, “Overriding the Jehovah’s Witness Patient’s Refusal of Blood: A Reply to Cahana, Weibel, and Hurst,” Pain Medicine 10, no. 5 (July 2009): 878–82, https://doi.org/10.1111/j.1526-4637.2009.00648.x.
5. David M. Rogers and Kendall P. Crookston, “The Approach to the Patient Who Refuses Blood Transfusion,” Transfusion 46, no. 9 (September 2006): 1471–77, https://doi.org/10.1111/j.1537-2995.2006.00947.x.
6. Banja, “Overriding the Jehovah’s Witness Patient’s Refusal of Blood.”
7. Lester S. King, “Blood Program in World War II. Medical Department, United States Army,” JAMA: The Journal of the American Medical Association 191, no. 11 (March 15, 1965).
8. Amanda Schaffer, “Should Anyone Be Given a Blood Transfusion?,” The New Yorker, August 13, 2015, 1–7.
9. Schaffer.
10. Schaffer.
11. Amanda Schaffer, “The Ethics of Bloodless Medicine,” The New Yorker, August 14, 2015, 1–8.
12. Kenrick Berend and Marcel Levi, “Management of Adult Jehovah’s Witness Patients with Acute Bleeding,” The American Journal of Medicine 122, no. 12 (December 2009): 1071–76, https://doi.org/10.1016/j.amjmed.2009.06.028.
13. Schaffer, “The Ethics of Bloodless Medicine.”
14. Aaron A.R. Tobian et al., “Time Course and Etiology of Death in Patients with Severe Anemia,” Transfusion 49, no. 7 (July 2009): 1398, https://doi.org/10.1111/j.1537-2995.2009.02134.x.
15. Tobian et al., “Time Course and Etiology of Death in Patients with Severe Anemia.”