2004 The Medicine Publishing company Ltd Vol 5 issue 2
Jehovahs Witnesses - Fiona K McIlveney and Nick A Pace
Fiona K McIlveney is a Specialist Registrar in Anaesthesia at Gartnavel General Hospital and the Western Infirmary, Glasgow. She qualified from Glasgow University and has trained primarily in the west of Scotland. Her interests include obstetric anaesthesia and intensive care medicine
Nick A Pace is Consultant Anaesthetist at Western Infirmary, Glasgow. He qualified from Glasgow University and trained at the Glasgow Western and Royal Infirmaries, University Hospital of South Wales and Parkland Memorial Hospital, Dallas, Texas. His interests include airway management and anaesthesia for renal and adrenal diseases. He is a member of the British Transplant Society’s Ethics Committee, and is currently completing a PhD in medical law.
The Jehovah’s Witness Christian movement was founded in North Eastern USA more than 120 years ago. It developed a worldwide following and now has more than 5.9 million members in 230 countries. A fundamental belief of the faith is the rejection of blood transfusions and certain other blood products. This is based on biblical teaching (Genesis 9: 3, 4; Leviticus 17: 11, 12; Acts 15: 28, 29).
In the past, some other medical treatments were also banned. For example, vaccinations were banned from 1929 to 1952 and organ transplants were banned from 1967 to 1980. However, it is the policy concerning refusal of blood that is most associated with the movement. This policy dates from 1945 and was rigorously enforced from 1961. Administration of blood products to an individual led to that person being excommunicated from the church, followed by ‘enforced shunning’ and social isolation because other members were instructed to ostracize the expelled individual.
In June 2000, a change in this policy was announced by the headquarters of the church, the Watchtower and Bible Tract Society. Although acceptance of blood products through personal choice still means disassociation from the church, if the individual repents, spiritual support is offered and subsequent redemption is possible. Furthermore, it is the individual who now revokes his or her own membership through self-disclosure, rather than the congregation initiating ‘disfellowshipping’ through a judicial committee. Therefore, if the act of receiving blood is kept confidential, dis association is highly unlikely. The importance of medical confidentiality cannot be stressed too strongly.
Blood products
The definition of acceptable blood products has changed recently. Primary components (i.e. red and white cells, platelets and plasma) continue to be unacceptable. However, the society now appears to permit the use of fractions of any of the primary components, the so-called secondary components. At what point a primary product becomes a secondary product is not defined and appears to rely on each individual’s interpretation. Processed or piecemeal products, such as albumin, immunoglobulins and clotting factors, seem to be acceptable. Red cells stripped of their outer membrane may be given in the form of haemoglobin transfusions, and haemo globinbased blood substitutes may also be acceptable. Bone marrow transplants and stem cell donation are often viewed as organ transplantation. Because individuals may be confused about what is acceptable, Jehovah’s Witnesses Hospital Liaison Committees have been set up to try to resolve these difficulties.
Blood transfusion remains controversial. The use of preoperative autologous donation, storage and re-infusion of blood isunacceptable because, in general, Jehovah’s Witnesses believe in the disposal of blood that leaves the circulation. Thus, they object to techniques involving intraoperative collection, storage and haemodilution. However, provided there is continuity with the circulation, many Jehovah’s Witnesses consent to autotrans fusion as continuing blood salvage with re-infusion, such as occurs during cardiopulmonary bypass. Isovolaemic haemodilution may also be acceptable. An epidural blood patch may be acceptable provided that the venous blood is connected to the circulation and the epidural space by tubing and a three-way delivery system, thereby maintaining circulatory continuity.
Consent
Any competent adult Jehovah’s Witness is entitled to accept or refuse all or specified parts of any proposed treatment. This is based on the ethical principle of respect for autonomy. It is enshrined not only by most legal systems but also by the European Convention on Human Rights. Detailed advanced healthcare directives are often prepared and left with general practitioners, relatives or friends. In addition, individuals may also carry personal directives expressing their wishes and absolving medical staff from liability for any consequences. Doctors who knowingly breach the terms of these directives may find themselves charged and found guilty of assault. If possible, a full discussion should take place regarding which blood products are to be declined or accepted and the potential consequences of any refusal. In the past, many hospitals used a specific detailed consent form for this process, but the new policy, advocating that members should decide for themselves, means a more individualized consent process is now required. Clear documentation of the discussion and its outcomes should also be made in the medical notes, bearing in mind the need for confidentiality.
It should also be remembered that, regardless of previously expressed views, Jehovah’s Witnesses have the right to change their mind at any time (as does any competent adult) and, if their wishes are expressed of their own volition and without duress, then they should be respected. Documentation of this change of heart should be noted contemporaneously and witnessed. The issue of undue influence is important and the law has negated a refusal to receive blood products if the patient has been coerced by another party (e.g. the English case of Re T (Adult: Refusal of Medical Treatment) [1992] 3 Med LR 306; [1992] 4 All ER 649).
In the emergency situation, where consent cannot be obtained and the individual Jehovah’s Witness’s views are unknown, life saving transfusion should not be withheld. The Jehovah’s Witness in these circumstances has not given consent and therefore religious sanctions should not apply. The views of relatives and friends may be sought in less urgent cases, but they cannot refuse transfusion on the patient’s behalf. Production of an advancedirective is legally binding in the UK, though there may be concerns about the level and accuracy of knowledge available before its completion, especially if it was made before the new policy changes described above.
Children
In the UK, children under the age of 16 years who are capable of understanding the issues surrounding transfusion may give or withhold consent, contrary to the wishes of their parents or guardian. However, the legal consequences of this are unclear, especially with regard to the refusal of accepting life-saving medical treatment, and the law has not always been applied consistently (see Anaesthesia and Intensive Care Medicine 4:1: 1). In an elective situation, if transfusion is expected to save the child’s life or to maintain well-being, it may be necessary to apply to make the child a ward of court if there is a dispute between child and parents or between parents. In the emergency situation, insufficient time is available for this process and life-saving transfusion should be administered irrespective of the parents’ wishes. A second medical opinion is always helpful to support the reasoning of the doctor involved. The courts generally uphold the decision of the doctors, but this cannot be guaranteed.
Managing Jehovah’s Witnesses
In an elective situation, anaesthetists (and surgeons) may choose not to treat Jehovah’s Witnesses, but should transfer their care to other practitioners. However, in the emergency situation, they are obliged to provide appropriate care and to respect the patient’s beliefs, when known.
Preoperative management: ideally, a preoperative consultation should occur, well in advance of the date of surgery, to allow for any necessary preparations and optimization of the patient’s condition. Privacy and confidentiality are essential to allow the patient free expression of their own wishes without undue influence from family or members of the religious order. At the patient’s request, members of the Hospital Liaison Committee may be present in order to clarify issues for both parties. At this stage, acceptable procedures should be established and documented, with full disclosure of the risks and consequences of refusal. It is unlawful, and ethically unacceptable, to fail to respect the patient’s wishes and is likely to lead to civil or criminal proceedings. Preoperative anaemia should be addressed; supplemental iron and folic acid therapy is beneficial in most cases. The use of erythropoietin has been advocated by some, but is slow to provide benefit and may not be useful or cost effective. Consideration should also be given to staging major procedures over several operations, thereby limiting acute blood loss. It is also beneficial to discontinue drugs that have an effect on coagulation (e.g. aspirin) before surgery.
Intraoperative management: consultant surgeons and anaesthetists should be involved in the care of the patient. Consideration should be given to techniques that minimize intraoperative blood loss, such as careful positioning to avoid venous congestion, preoperative haemodilution, hypotensive anaesthesia, use of appropriate tourniquets, meticulous haemostasis and vasoconstrictors. Obstetric procedures may be associated with significant haemorrhage. ‘Cell saver’ systems may be acceptable to some Jehovah’s Witnesses and are appropriate in circumstances where blood loss is unlikely to be contaminated (e.g. orthopaedic surgery) or can be decontaminated (e.g. following Caesarean section). Drugs shown to reduce fibrinolysis (e.g. tranexamic acid, aprotinin) should be considered. These act prophylactically to reduce bleeding, but have little effect on active haemorrhage.
Postoperative care: haemoglobin levels of 8–10 g/dl are safe, even in the presence of cardiorespiratory disease. Critical levels of oxygen delivery in otherwise fit, resting adults occur at about5 g/dl. Prompt attention to postoperative blood loss is required with careful assessment and documentation of continuing losses. Direct compression, if appropriate, and early re-exploration of wounds may be beneficial. Postoperatively, elective ventilation, sedation and paralysis limit oxygen consumption. Active cooling may also be helpful, but can impair coagulation mechanisms. Perfluorocarbon solutions and hyperbaric oxygen therapy have also been advocated. Desmopressin may stimulate factor VIII production, though thisis unlikely to be helpful if coagulation is normal. Jehovah’s Witnesses who have accepted blood transfusion or the administration of other controversial products, should receive them outside visiting times and care should be taken to maintain patient confidentiality. This can be compromised by unsolicited visitors or other healthcare workers. Medical records and fluid documentation should be stored away from the bedside