The care of Jehovah’s Witnesses presents complex ethical, legal and medical issues for physicians. The Jehovah’s Witness patient will readily seek out medical relief, either electively or as an emergency, and will accept all aspects of treatment other than transfusions. This refusal of blood or blood products including whole blood, packed red blood cells, white blood cells, platelets, plasma, and autotransfusion of predeposited blood, creates a frustrating dilemma for the physician because a routine and potentially life-saving medical procedure is unacceptable to the patient. (1) Anesthesiologists are particularly affected because they are responsible for intraoperative transfusion management.
This paper will provide a brief history of the Jehovah’s Witnesses and their religious justifications for refusing transfusions, will discuss some of the ethical principles in conflict between physicians and Jehovah’s Witnesses patients, will mention pertinent and significant legal rulings and definitions, and will present methods or techniques utilized by anesthesiologists to overcome the challenges presented by the elimination of transfusion as a surgical option.
The Jehovah’s Witnesses are a fundamentalist Christian sect whose followers believe the Bible is the true word of God. (2) The Witnesses began as a small Bible study group led by Charles T. Russell in the late 1870’s near Pittsburgh, Pennsylvania. Originally called the “International Bible Students” or “Russellites,” their current name, adopted in 1931, is derived from the Biblical passage:
“Ye are my witnesses saith the Lord (Jehovah) and my servant whom I have chosen.” (Isaiah 43:10)
Charles Russell’s teachings were spread through the distribution of the group’s official journal, now known as the Watch Tower, which he began to publish in 1879. Witness groups proliferated across the country and in 1881 the Watch Tower Bible and Tract Society was formed. By 1909 the society had become an international organization and Russell moved his headquarters to the Brooklyn Tabernacle in New York City. In addition to the Watch Tower, Witnesses proselytized their beliefs through street corner speeches and door-to-door visits, a practice continued to this day. At present, the number of members worldwide approaches five million, with membership in the United States almost one million. (3)
Jehovah’s Witnesses have always based their beliefs on a literal interpretation of the Bible. They believe that any hope of eternal life or salvation is forfeited if they do not strictly adhere to biblical directives. In this regard, Jehovah’s Witnesses are deeply committed to the tenets of their faith, which include the refusal of blood transfusion. The Witnesses’ determination that blood transfusions violated God’s law was made in 1945 and is based on the following biblical passages: (4)
“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.” (Genesis 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 his people.” (Leviticus 17:10-16)
“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. If you keep yourselves from these things you will prosper.” (Acts 15:28, 29)
Regardless of an elective or emergent circumstance, the Jehovah’s Witness believes the biblical injunctions concerning blood describe human blood, and that the transfusion of blood through the veins is tantamount to “eating” blood. (5, 6) Even the use of their own blood, collected and deposited in a blood bank as preparation for an impending surgical procedure, is prohibited. (7, 8)
The ethical dilemma is obvious: physicians have pledged to preserve and prolong life to the best of their ability or judgment; yet, in the case of the Jehovah’s Witness patient, they are forbidden to use the one effective treatment that may be necessary to save a life. The physician must naturally suffer a severe struggle with his or her conscience when asked to stand by and allow a patient to die even though the physician sincerely believes the patient will survive if given a transfusion.
Conversely, to the Jehovah’s Witness, the transfusion of blood is a violation of God’s word and is as serious a wrong as engaging in false worship or sexual immorality. The Witnesses’ refusal to accept transfusions is based on an obedience to a “higher authority” and on the belief that their relationship with God is at stake. (9) What is the benefit for the Witness if, as Gardner Et al. point out, “their corporal malady is cured but the spiritual life with God, as they see it, is compromised, which leads to a life that is meaningless and perhaps worse than death itself?” (10)
From a legal perspective, the court’s interpretations of a patient’s right to refuse or consent to treatment is based on common law and, as such, is an evolving and modifying process. (11) The courts determinations become somewhat muddled as factors of incompetency, dependent children, minors, and emergency situations are taken under consideration.
The landmark case confirming a competent adults right to refuse treatment occurred in 1914 in Schloendorff vs. Society of New York Hospital. (12) In this case, a woman agreed to an examination under anesthesia but refused consent for any operative procedure. Once under anesthesia, however, an operative procedure was performed. Additionally, it was discovered postoperatively that the woman suffered a brachial plexus injury resulting in intense pain and the eventual amputation of some of her fingers. Though the patient lost her case because the hospital was a charitable institution and therefore immune from liability, the presiding judge stated that, “Every human being of adult years and sound mind has a right to determine what shall be done with his own body.”
It is this case that established the underlying premise of informed consent and a patient’s right to choose. Coupled with a United States citizen’s right to freedom of religion, a competent adult Jehovah’s Witness patient has the protected right to refuse transfusion even though the result of such a refusal may be death. It appears then, that the key determinations in a patients right to refuse life-saving treatment are “competency” and “adulthood”.
According to Drs. Phil Fontanarosa and Gary Giorgio of the Northeastern Ohio Universities College of Medicine in Akron, a patient may be unable to make a competent decision if they have:
1. abnormal or unstable vital signs
2. altered mental status
3. evidence of impaired judgment as from a central nervous system injury or illness, or
4. any sign of alcohol or drug intoxication.
If a patient’s mental status is normal, the Ohio physicians recommend the Schiller test: “Does the patient have sufficient mind to reasonably understand the condition, the nature and effect of the proposed treatment?”. If the answers are all “yes,” the patient is considered cognitively competent. If not, the physician may have to rely on an alternative decision maker — usually the patient’s spouse, adult child, or other close relative or friend. (13)
In addition, the argument that a patient who refuses a transfusion is therefore suicidal, and thus incompetent, is an unsubstantiated contention and generally not an issue. The Jehovah’s Witness patient wants to live and has sought out medical treatment to enable them to live. In fact, their religion actually forbids suicide the same as it forbids transfusion. (14)
The Schloendorff precedent notwithstanding, there are several court rulings wherein a patient’s right to refuse treatment was superseded by the states interest in the welfare of the patient. For instance, in Raliegh Fitkin-Paul Morgan Memorial Hospital vs. Anderson, the court ordered a blood transfusion in a pregnant woman to save both her life and the life of the fetus. (15) In Powell vs. Columbia Presbyterian Medical Center, the court ordered transfusion in a competent woman with minor children, arguing that, should she die, the children could become wards of the state and therefore place an undue burden on the state. (16)
In regard to the definition of a minor, an individual is generally considered too young to make a decision for themselves if they are under the age of 18; however, exceptions can be made for “self-sufficient minors” and “emancipated minors”. From California Civil Code Section 34.6, a self-sufficient minor is one who is age 15 or older and:
1. lives separate and apart form his or her parents or legal guardian, whether with or without the consent or acquiescence of the parent or legal guardian, and
2. manages his or her own financial affairs, regardless of the source of income. (17)
Under California Civil Code Section 62, an emancipated minor is any person under the age of 18 who:
1. has entered into a valid marriage, whether or not such marriage was terminated by dissolution, or
2. is on active duty with any of the armed forces of the United States of America, or
3. has received a declaration of emancipation pursuant to California Civil Code Section 64. (18)
In their rulings on minors, courts have ordered transfusions for children in life-threatening situations despite the objections of their parents or legal guardians. (19) The courts have reasoned that the legal principle of “parens patriae” obligates the state to take an overriding interest in the health and welfare of its citizens. Consequently, the state exercises broader control over the treatment of children than over that of adults. The landmark case concerning a minor child frequently cited in subsequent cases was Prince vs. Massachusetts in 1944. (20) The case did not actually involve a blood transfusion, but in the ruling, the Supreme Court stated the following:
“Parents may be free to become martyrs 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 a choice for themselves.”
In instances in which it appears the minor’s “life is not immediately imperiled by his physical condition,” the court has generally ruled that “the State does not have an interest of sufficient magnitude outweighing a parent’s religious beliefs precluding medical treatment”. (21)
In regard to incompetent adults, the same reasoning that was extended to minors unable to make decisions for themselves is generally applied. It appears that when an emergency procedure, such as transfusion therapy, is necessary to save the life of an incompetent adult patient, the court has predominantly ruled that a physician has a legally recognized right to proceed even over the objections of the family or loved ones of the patient. (22, 23)
Physiology of Anemia
Understandably, the medical care of Jehovah’s Witnesses presents a series of challenges for the anesthesiologist; primary being the restriction against blood transfusion. Naturally, the question arises: what advantage is there in transfusing blood?
Transfusion of blood is mainly intended to increase arterial oxygen carrying capacity and not to expand intravascular volume. Even though crystalloids and colloids are useful for maintaining intravascular volume and are acceptable to Jehovah’s Witnesses, they do little to improve oxygen content. (24) Oxygen content is essential in perioperative management, although most healthy patients can tolerate low hemoglobin levels without a measurable decline in oxygen delivery to the tissues. Following is a brief review of oxygen transport and compensatory mechanisms for decreased oxygen delivery.
Arterial oxygen content (CaO2) consists of the amount of oxygen carried by hemoglobin (Hb) and the amount of dissolved oxygen in plasma. O2 content (ml / 100 ml blood) = 1.39 x Hb x O2 Sat + 0.0031 x PaO2, where O2 Sat is the saturation of hemoglobin with oxygen and PaO2 is the arterial partial pressure of oxygen. (25) Normal arterial oxygen content is 20 ml/100 ml blood. Dissolved oxygen, 0.3 ml/100 ml blood, normally is only 1.5% of total oxygen content.
A 33% decrease in the Hb from 15 to 10 g/dl results in a proportional decrease in the arterial oxygen content; however, increasing the PaO2 above 100 mmHg has little effect in increasing the oxygen content. In an anemic patient who is breathing 100% oxygen, the dissolved oxygen portion (0.0031 x PaO2) will be a much higher percentage of total oxygen content.
If there is a decline in red cell mass, such as with large surgical blood loss or an underlying anemia, how is tissue oxygenation maintained? The body has well-defined mechanisms to compensate for reduced oxygen availability. (Table 1)
Table 1 - Maintaining Tissue Oxygenation During Anemia Decreased blood viscosity Lowered peripheral resistance Increased venous return Autoregulation Redistribution of tissue blood flow Increased cardiac output Tachycardia Increased contractility Greater tissue oxygen extraction Shift of hemoglobin dissociation curve Increase in 2,3-diphosphoglycerate
A primary mechanism is an increased tissue blood flow that improves the oxygen supply to the organs without increasing cardiovascular work or oxygen requirements. As the hematocrit (HCT) is lowered, blood viscosity is decreased and blood flow will increase in the microvascular bed, resulting in a larger volume of blood to compensate for the lowered oxygen content. For example, in a healthy adult male with a stable blood volume, a change in the HCT from a norm of 45% to 30% will result in an increased cardiac output but unchanged cardiovascular work. However, as the HCT continues to decline to 25% or less, additional compensatory factors come into play. These include an increase in oxygen extraction and a shift of the hemoglobin dissociation curve. (26)
The oxyhemoglobin dissociation curve (Diagram 1) describes the relationship between SaO2 and PO2. The P50 on the dissociation curve represents the partial pressure of oxygen at which hemoglobin is 50% saturated. The P50 of normal adult hemoglobin is 26 mmHg. Movement of the curve to the right represents an increase in P50 and a decrease in hemoglobin affinity for oxygen. Metabolic changes attendant with a right-curve movement are acidemia, hyperthermia and anemia, and an increase in the 2,3-diphosphoglycerate in red blood cells. (27)
In summary, tissue vasodilation, increased oxygen extraction and displacement of the oxygen-dissociation curve to the right all contribute to maintaining tissue oxygenation.
Diagram 1 – Oxyhemoglobin Dissociation Curve
The importance of the oxygen-carrying capacity of blood notwithstanding, the following is a compilation of techniques and methodology available to the anesthesiologist to enable a successful operation and still accommodate the Jehovah’s Witnesses’ choice of non-blood management.
Anesthesia care begins with preoperative assessment with discussion between the patient, his or her family, and the surgical team. This includes the exploration of all options to identify the patient’s preferences or preclusions. Once all parties involved are in agreement on how to proceed with medical management, the physician is ethically and legally obligated to adhere to limitations which may have been imposed by the patient; particularly in the instance of the refusal of blood transfusion by a Jehovah’s Witness.
Correspondingly, physicians and health care facilities must ensure that the Jehovah’s Witness patient has signed a consent form memorializing their request to not transfuse under any circumstances. Most Jehovah’s Witnesses are aware of, and often carry, a standard consent form such as the one developed by the California Association of Hospitals and Health Systems, “Refusing to Permit Blood Transfusion”. (28) The document has been found to be binding and protective in the event of a malpractice proceeding as noted by the Supreme Court. (29)
Under usual circumstances, standard preoperative preparation would also include the practice of storing the patients blood for use during surgery; however, Jehovah’s Witnesses will not accept autologous transfusion of pre-deposited blood. (30) Alternatively, in order to maximize hemoglobin levels, the patient can be placed on a regimen of oral iron therapy for 3-4 weeks before surgery. (31) Intraoperatively, the minimization of oxygen consumption and the maximization of oxygen delivery are factors which help reduce transfusion dependency. To that end, techniques that may be employed include acute normovolemic hemodilution, cell-saver scavenging devices as a form of autotransfusion, hypotensive anesthesia, and deliberate hypothermia. No technique will be satisfactory, though, unless the surgeon pays scrupulous attention to minimizing operative blood loss and securing hemostasis.
Acute normovolemic hemodilution (ANH) is a method that reduces, or may even eliminate, the need for blood transfusion during surgery. ANH has been used in patients of all ages for several different procedures, including, but not limited to: gynecological, orthopedic, craniofacial, cardiothoracic, and neurosurgical surgery. In addition, this technique has been used in surgeries in which the patient is difficult to cross match or for those patients who wish to avoid the inherent risks sometimes associated with blood transfusion such as hepatitis or AIDS. ANH may be done with either arterial or venous blood and should be completed prior to surgery since surgical blood loss during hemodilution may result in acute hypovolemia. Hypotension, tissue hypoxia, and tissue damage are potential complications associated with hypovolemia. (32, 33) Also, hypovolemia may interfere with the body’s tendency to increase cardiac output, which is the primary compensatory mechanism for reduced blood oxygen content. Lastly, with a reduced amount of hemoglobin and the resultant decrease in oxygen availability; it is important to monitor tissue perfusion, the change in the HCT, and the volume status of the patient.
The amount of blood to be removed during hemodilution is determined by the following formula:
V = EBV x (HCTi – HCTf) / HCTav
where V = amount of blood removed, EBV = estimated blood volume, HCTi = initial hematocrit, HCTf = final hematocrit, and HCTav = average of HCTi and HCTf. (34)
A moderate hemodilution would be the instance where HCTf is in the range of 20 to 25%. Severe hemodilution would represent a HCTf of 20% or less. (35) One advantage of hemodilution is that, intraoperatively, the surgical blood lost will contain fewer red blood cells. Even though hemodilution reduces the oxygen carrying capacity of blood by decreasing the hemoglobin level, oxygen transport to the tissues may be maintained due to decreased blood viscosity and increased tissue blood flow. (36)
Jehovah’s Witnesses will not accept stored or banked blood under any circumstances; however, adapting the hemodilution process to effect a continuous system of blood withdrawal and reinfusion has been acceptable to some Witness patients. (37) This adaptation is accomplished by phlebotomizing the patient from a central catheter or a large bore peripheral catheter via gravity drainage into an appropriate blood storage bag; appropriate in the sense that the patient is secure in the belief that their blood is still part of their circulatory system.
Replacement fluid can be either crystalloid or a colloid. If crystalloid is used, replacement is with 3 ml. of crystalloid for every 1 ml. of blood withdrawn. If colloid is used, a ratio of 1 to 1 is usually sufficient. The principal disadvantage of crystalloids, and the reason a larger ratio is needed, is the rapid distribution of the fluid to the interstitial space; resulting in a depleted intravascular volume. The disadvantage of colloids is they are much more expensive and may be associated with coagulopathies. However, they may offer more stable hemodynamics. Albumin is a colloid which can be used for hemodilution but is unacceptable to most Jehovah’s Witnesses because it is derived from human plasma. (38)
It should be noted that judicious management of autologous blood is paramount for a Jehovah’s Witness patient since premature transfusion would deplete the only available source of blood. It would be considered prudent to withhold the blood until surgical bleeding subsides. In total, this technique may be used successfully in children or adults, and if used in conjunction with general anesthesia and mild hypothermia, will minimize or prevent the need for blood transfusion.
An alternative to hemodilution acceptable for some Jehovah’s Witness patients is the use of cell-saver scavenging devices. These devices aspirate blood from the patient, filtrate or centrifuge it, and reinfuse the processed red blood cells. To the Jehovah’s Witness patient, this may satisfy the condition of a continuous circuit of blood collection, and is also a useful technique for open-heart surgery. This technique of intraoperative blood salvage is generally effective if there is anticipated blood loss of more than 2 units. (39) Complications associated with the use of these devices include coagulation disturbances and hemolytic reactions. (40)
Deliberate hypotension, or hypotensive anesthesia, is a technique used intraoperatively that helps to minimize surgical blood loss, thereby decreasing the need for blood transfusion. Its careful application can be done safely in most patients, including children, and for a variety of surgical procedures. (41, 42) The indications for deliberate hypotension and the decision to use this technique should be discussed in advance between the surgeon and the anesthesiologist. The technique entails the controlled lowering of blood pressure and is defined as a reduction of the systolic blood pressure to between 80-90 mmHg. An alternative definition is a decrease in mean arterial pressure (MAP) to 50-70 mmHg in a normotensive patient. (43)
Contraindications to deliberate hypotension include conditions that are associated with hypoxemia such as cardiovascular disease and severe anemia. Other cardiovascular pathologies, such as congestive heart failure and poorly controlled hypertension, preclude the use of hypotensive anesthesia. Raised intracranial pressure and coexistent central nervous system pathology are additional contraindications.
The anesthesiologist must be aware of special physiologic considerations during deliberate hypotension. In the central nervous system, cerebral circulation must be maintained within a range so that sufficient oxygen is available and delivered to the brain to prevent ischemia. The range of arterial pressure should be maintained at levels between 50-70 mmHg, although another method of determining the range is to reduce the arterial pressure to no more than 30-40 mmHg below the patient’s normal readings. (44)
In the respiratory system, deliberate hypotension affects pulmonary gas exchange by increasing alveolar dead space and increasing intrapulmonary shunt. Therefore, frequent monitoring of arterial blood gases, combined with controlled ventilation, is necessary to maintain normocapnia in the patient. (45)
In the cardiovascular system, decreased blood flow to the heart during deliberate hypotension may precipitate ischemia in patients with impaired coronary function. However, in patients with normal myocardium, ischemic events are uncommon. (46)
In the kidneys, deliberate hypotension can reduce renal blood flow, thereby decreasing perfusion. Close monitoring of urine output during this period is necessary to insure sufficient renal blood flow. Evidence of adequate perfusion would be a urine output measured at 0.5 to 1 cc per kg of body weight per hour. (47)
Deliberate hypotension is induced or effected by a variety of pharmacological agents and nonpharmacological supplements. Although there are other techniques, pharmacological agents can generally be divided into two categories: peripheral vasodilators and inhalation agents.
The three most commonly used vasodilators are: sodium nitroprusside (SNP), nitroglycerin (NTG), and trimethaphan. (48, 49)
SNP — SNP acts as a vascular smooth muscle relaxant and has a rapid onset but brief duration of action. Its primary influence is on arteriolar and venous vessels, but without significant myocardial effects. Great care is required in its administration because of its potency, cyanide toxicity, cardiovascular side-effects, and rebound hypertension. Within its effective range, tachycardia may be expected and countered by Beta-blocking agents in small doses.
NTG — Nitroglycerin reduces blood pressure by relaxing venous smooth muscle and, like SNP, has rapid onset of action but short duration. NTG is less toxic than SNP and has less rebound hypertension following cessation of IV infusion. However, it is more difficult to fine-tune the degree of hypotension with NTG since it is less potent than SNP in its capacity to reduce blood pressure.
Trimethaphan– Trimethaphan produces hypotension through ganglionic blockade and direct vasodilator properties. It is also short acting and provides tight control of blood pressure. Its disadvantages include the side effect of mydriasis, which may delay for hours the assessment of valuable neurological information and evaluation of the patient.
Commonly used inhalation agents, or volatile anesthetic agents, include halothane, isoflurane and enflurane. The concentration of a volatile anesthetic agent produces a dose-dependent decrease in mean arterial pressure. Halothane, and to a lesser degree, enflurane, generate the decrease in pressure primarily by the production of myocardial depression concomitant with a decline in cardiac output. Isoflurane exerts its hypotensive effect by reducing systemic vascular resistance. These agents should be supplemented with other pharmacological techniques because of the tendency to “over anesthetize” and the difficulty in quickly reversing the induced hypotension. (50)
Spinal and epidural anesthesia can also be used to effect controlled hypotension. Unfortunately, these techniques require large infusions of IV fluids and the deliberate hypotension can be erratic and difficult to control. (51)
Two nonpharmacological techniques which may assist in obtaining desired levels of hypotension are alterations in body position and controlled mechanical ventilation.
The last technique discussed, deliberate hypothermia, is the controlled lowering of body temperature in order to decrease metabolic oxygen requirements. It has been used to produce a significant reduction in oxygen consumption in Jehovah’s Witness patients. (52, 53) The decrease in oxygen consumption is approximately 7% for every 1 degree C reduction in temperature. A target core temperature of 30-32 degree C is typically chosen because at this level cardiac complications are minimal; yet, oxygen consumption is significantly reduced. (54) Hypothermia can be accomplished by: 1) lowering the ambient operating room temperature to between 15-20 degree C, 2) use of a cooling mattress, 3) eliminating insulation, or 4) reduction in temperature of IV fluids. (55) Neuromuscular blocking agents and ventilatory support should be used with this technique to minimize oxygen consumption from shivering.
Some effects of hypothermia on organ system function are: 1. increased systemic vascular resistance in the cardiovascular system, 2. decreased cerebral oxygen consumption in the central nervous system, and 3. hematologically, an increased blood viscosity. (56) The latter effect can be offset through hemodilution.
As previously mentioned, it is imperative the surgical team make every effort to minimize blood loss and secure hemostasis in the Jehovah’s Witness patient. There are a variety of pharmacological agents which can be used to eliminate or diminish the need for transfusion.
Desmopressin (DDAVP) is a synthetic analog of antidiuretic hormone which elevates factor VIII activity and von Willebrand’s factor. (57) It has been used effectively in Jehovah’s Witnesses, both intraoperatively and postoperatively, to improve hemostasis and reduce blood loss. (58) Aminocaproic acid, which is another hemostatic agent, and platelet protective agents such as aprotinin and prostacyclin, are potential therapies for patients with bleeding problems where blood conservation is a priority. (59) In addition, blood production can be maximized with recombinant human erythropoietin, a glycoprotein growth factor that stimulates erythropoiesis. Erythropoietin has been documented in several instances where it has been used successfully in Jehovah’s Witness patients. (60, 61)
Lastly, in development are red blood cell substitutes which may possibly be used to transfuse Jehovah’s Witnesses; however, they are generally limited to perfluorocarbons (PFC) because stroma-free hemoglobin is purified from outdated banked blood, an unacceptable alternative for Jehovah’s Witnesses. The initial generation of PFC’s were clinically unsuccessful because of their insufficient oxygen carrying capacity, except for use in patients undergoing percutaneous angioplasty. Fortunately, second generation PFC’s are showing more promise. (62)
There are several techniques and alternatives available to the anesthesiologist to accommodate the Jehovah’s Witnesses’ choice of non-blood medical management. However, the elimination of transfusion as a surgical option introduces the possibility that a patient will die even though a means exists to save his or her life. Expectedly, there is a conflict of conscience between the physician and the Jehovah’s Witness patient in this instance of equally compelling but different and exclusive courses of action. An involved review of the ethical issues and a detailed medicolegal analysis can be found in more comprehensive articles. (63, 64) Nevertheless, it is readily apparent that, prior to surgery, there should be established lines of communication between the Jehovah’s Witness patient, the anesthesiologist, the surgeon, hospital administration and legal counsel. Hopefully, such dialogue will provide the exchange of concerns, motivations, and potential complications and establish a spirit of cooperation and understanding which would minimize future conflict and preclude the need for court intervention. To that end, anesthesiologists might obtain and read a copy of the Watch Tower’s 1990 publication entitled “How Can Blood Save Your Life?” (65) Concomitantly, Jehovah’s Witnesses should understand the ethical and moral burden they place on physicians, as well as the possibility that their refusal to accept blood transfusions may result in increased demands of time and expense. Lastly, if a hospital or other health care facility anticipates they might be administering emergency care to Jehovah’s Witnesses, it should establish a protocol for such treatment to help avoid any medical, ethical, or legal dilemmas which may arise.
1. Dixon JL, Smalley MG. Jehovah’s Witnesses: The Surgical/Ethical Challenge. J Am Med Assoc 1981; 246: 2471-2.
2. Harrison BG. Visions of Glory: A History and Memory of Jehovah’s Witnesses. New York: Simon and Schuster, 1978.
3. Yearbook of Jehovah’s Witnesses, 1995. Brooklyn: Watchtower Bible and Tract Society, Inc., 1995.
4. Jehovah’s Witnesses and the Question of Blood. New York: Watchtower Bible and Tract Society of New York, Inc., 1977.
5. How Can Blood Save Your Life? Brooklyn: Watchtower Bible and Tract Society, Inc., 1990.
6. Jehovah’s Witnesses and the Question of Blood, p. 9.
7. The Truth that Leads to Eternal Life. New York: Watchtower Bible and Tract Society of New York, Inc., 1968.
8. Blood Transfusions: Why Not for Jehovah’s Witnesses? New York: Watchtower Bible and Tract Society of New York, Inc., 1977.
9. Jehovah’s Witnesses and the Question of Blood, p. 19.
10. Gardner B, Bivona J, Alfonso A, Et al. Major Surgery in Jehovah’s Witnesses. NY State J Med 1976; 76: 765-6.
11. Benson KT. The Jehovah’s Witness patient: Considerations for the anesthesiologist. Aneth Analg 1989; 69: 647-56.
12. Schloendorff vs Society of New York Hospital, 105 N.E. 92, (1914).
13. Fontanarosa PB, Giorgio GT. The role of the emergency physician in the management of Jehovah’s Witnesses. Annals of Emerg Med 1989; 18: 1089.
14. Jehovah’s Witnesses and the Question of Blood, p. 21.
15. Raliegh Fitkin-Paul Morgan Memorial Hospital vs Anderson, 42 N.J. 421, 201 A. 2d 537, cert. denied 377 U.S. 985, 84 S. Ct. 1984, 12 L.E. 2d 1032 (1964).
16. Powell vs Columbia Presbyterian Medical Center, 49 Misc 2d 215, 216, 267 NYS 2d 450, 452 (Sup Ct NY County, 1965).
17. West’s Ann. Cal. Civ. Code, Section 34.6.
18. West’s Ann. Cal. Civ. Code, Section 62.
19. In re E.G., a Minor, 133 Ill. 2d 98, 549 N.E. 2d 322, 323 (1989).
20. Prince vs Commonwealth of Massachusetts, 321 U.S. 158 (1944).
21. In re Green, 292 A. 2d. 387 (1972).
22. John F. Kennedy Memorial Hospital vs Heston, 279 A. 2d 670 (N.J. 1971).
23. Luka vs Lowrie, 136 N.W. 1106 (1912).
24. Mann MC, Votto J, Kambe J, Et al. Management of the Severely Anemic Patient Who Refuses Transfusion: Lessons learned during the care of a Jehovah’s Witness. Annals of Int Med 1992; 117: 1042-8
25. Stoelting RK, Dierdorf SF. Anesthesia and Co-Existing Disease. 3rd ed. New York: Churchhill Livingstone, 1993; 393-406.
26. Rogers MC, Tinker JH, Covino BG, Et al. Principles and Practice of Anesthesiology. 2 vols. St Louis: Mosby, 1993; 2: 341-56.
27. Stoelting, Anesthesia and Co-Existing Disease, p. 394.
28. Consent Manual – A Reference for Consent and Related Health Care Law. 21st ed. Sacramento: Calif Assoc of Hosp and Health Systems, 1994; p. 4-2.
29. Benson, The Jehovah’s Witness Patient, p. 653.
30. Questions from readers. The Watchtower, March 1, 1989; 30-1.
31. Mann, Management of the Severely Anemic Patient, p. 1045.
32. Lerman J. Special Techniques: Acute Normovolemic Hemodilution, Controlled Hypotension, and Controlled Hypothermia. Pediatric Anesthesia. Ed, Gregory GA. 2nd ed. 2 vols. New York: Churchhill Livingstone, 1989; 2: 767-801.
33. Rogers, Principles and Practice of Anesthesiology, p. 948-52.
34. Ibid, p. 949.
35. Benson, The Jehovah’s Witness patient, p. 654.
36. Messmer K, Sunder-Plassman L, Jesch F, Et al. Oxygen supply to the tissues during limited normovolemic hemodilution. Res Exp Med, 1973; 159: 152-66.
37. Questions from readers, p. 31.
38. Stoelting RK. Pharmacology and Physiology in Anesthetic Practice. 2nd ed. Philadelphia: JB Lippincott, 1991; 570-9.
39. Gettinger A. Rational Use of Blood Products. Refresher Courser in Anesthesiology. Ed. Barash PG. Philadelphia: JB Lippincott, 1993; 21: 95-106.
40. Mann, Management of the Severely Anemic Patient, p. 1044.
41. Nelson CL, Bowen WS. Total hip arthroplasty in Jehovah’s Witnesses without blood transfusion. Jour Bone Joint Surg 1986; 68: 350-3.
42. Lerman, Special Techniques, p. 778.
43. Van Aken H, Van Hemelrijck J. “Deliberate Hypotension.” 1993 Review Course Lectures, 67th Congress of Intl Anes Res Soc. San Diego, March 19-23, 1993.
44. Stoelting, Anesthesia and Co-Existing Disease, p. 205-7.
45. Van Aken, “Deliberate Hypotension,” p. 22.
46. Rogers, Principles and Practice of Anesthesiology, p. 2422-26.
47. Stoelting, Anesthesia and Co-Existing Disease, p. 301-2.
48. Ibid, p. 205-6.
49. Stoelting, Pharmacology and Physiology in Anesthetic Practice, p. 324-30.
50. Ibid, p. 33-69.
51. Van Aken, “Deliberate Hypotension,” p. 23.
52. Lichtiger B, Dupuis JF, Seski J. Hemotherapy during surgery for Jehovah’s Witnesses: a new method. Anest Analg 1982; 61: 618-9.
53. Henderson AM, Maryniak JK, Simpson JC. Cardiac surgery in Jehovah’s Witnesses. A review of 36 cases. Anaesthesia 1986; 41: 748-53.
54. Michenfelder JD, Uihlein A, Daw EF, Et al. Moderate hypothermia in man: haemodynamic and metabolic effects. Br J Anaest 1965; 37: 738-45.
55. Rogers, Principles and Practice of Anesthesiology, p. 2514-9.
56. Sladen RN. “Temperature Regulation in the Operating Room.” 1993 Review Course Lectures, 67th Congress of Intl Anes Res Soc. San Diego, March 19-23, 1993.
57. Stoelting, Pharmacology and Physiology in Anesthetic Practice, p. 573.
58. Stone DJ, DiFazio CA. DDAVP to reduce blood loss in Jehovah’s Witnesses. Anesthesiology 1988; 69: 1028.
59. Spiess BD. “Intraoperative Blood Conservation.” 1994 Annual Refresher Course Lectures and Clinical Update Program, Annual Meeting of Amer Soc of Anes. San Francisco, Oct 15-19, 1994.
60. Johnson PW, King R, Slevin ML Et al. The use of erythropoietin in a Jehovah’s Witness undergoing major surgery and chemotherapy. Br J Cancer 1991; 63: 476.
61. Jim RT. Use of erythropoietin in Jehovah’s Witness patients. Hawaii Med J 1990; 49: 209.
62. Tremper KK. “Blood Substitutes: What’s Needed, What’s Available, and What Will be Available.” 1994 Annual Refresher Course Lectures and Clinical Update Program, Annual Meeting of Amer Soc of Anes. San Francisco, Oct 15-19, 1994.
63. Rothenberg DM. The approach to the Jehovah’s Witness patient. Anesthesiology Clinics of North America 1990; 8(3): 589-607.
64. Benson, The Jehovah’s Witness patient, p. 647-56.
65. How Can Blood Save Your Life?, p. 1-31.