47. Jehovah's Witness

Question 1

What is the basis for Jehovah’s Witnesses not accepting blood?

Answer 1

(‘Their drink offering of blood I will not offer nor take up their names into my
lips’), Jehovah’s Witnesses have refused transfused blood or blood products.
The acceptance of blood is considered to be a violation of God’s laws. This
belief is further based on Genesis, Leviticus and Acts, all of which describe the
prohibition of the consumption of blood.

A reform movement now exists, called ‘The Associated Jehovah’s Witnesses
for Reform on Blood’, who are campaigning for the abolition of the blood
transfusion policy

Question 2

What methods are available for minimising blood loss in a
Jehovah’s Witness?

Pre-operatively

Answer 2

1. Discussion with the patient regarding which
   (if any) blood products they are prepared to accept.
   Patients are frequently highly informed.
   At the patient’s request, a member of the Jehovah’s Witness Hospital
   Liaison Committee may need to be involved.
   Similarly, the patient will need to be seen on his or
   her own as well.
2. Full investigation of anaemia
3. Involvement of a haematologist (consider pre-op erythropoietin or iron)
4. Consultant involvement
5. In obstetric cases, discuss the increased risk of hysterectomy (for PPH) and
   the use of an ultrasound scan to determine the placental site.

Question 3

Intra-operatively

Answer 3

Intra-operatively

1. Positioning (avoiding venous congestion)
2. Staged procedures
3. Use of local or regional anaesthesia means the patient can stay awake and
   retract their prohibition if they feel the need
4. Hypotensive anaesthesia – of proven use but important to weigh risks
   against benefits
5. Haemodilution techniques–both hypervolaemic and normovolaemic
6. Tourniquets
7. Meticulous surgical technique/experienced surgeon
8. Vasoconstrictor use
9. Use of drugs that affect coagulation, e.g. tranexamic acid, aprotinin and
   desmopressin
10. Cell-saver use will need to be discussed with the individual patient
    (Watchtower, 1989)
11. Balloon occlusion/ligation of arteries that supply the bleeding area

Question 4

Post-operatively

Answer 4

Minimal blood letting for laboratory testing

ICU

Erythropoietin

GI bleeding prophylaxis

Methods to decrease O2 consumption:
IPPV/barbiturates/neuromuscular
blockers/hypothermia/hyperbaric oxygen therapy

Perfluorocarbons

Progesterone to decrease menstrual bleeding.

Question 5

Tell us about the legal aspects of giving blood to adults and
children and consent validity

Answer 5

It is unlawful to administer blood to a patient who has refused it by the
provision of an Advanced Directive or by its exclusion in a consent form. To
do so may lead to criminal proceedings.

Properly executed Advance Directives must be respected and special
Jehovah’s Witness consent forms should be widely available.

A child’s right to life is paramount and must be considered before the
religious beliefs of his or her parents.

If a child under 16 years old wishes to receive blood against their parents’
wishes they must be shown to be ‘Gillick competent’.

In a life-threatening emergency in a child unable to give competent
consent, all life-saving treatment should be given, irrespective of the
patients’ wishes.

In children of Jehovah’s witnesses under the age of 16 years the well-being
of the child is overriding. If the parents refuse to give permission for blood
transfusion, it may be necessary to apply for a legal ‘specific issue order’.

This is a serious step that should be taken by two consultants.

In the case of children, application to the high court for a ‘specific issue
order’ should only be made when it is felt entirely necessary to save the
child in an elective or semi-elective situation.

Except in an emergency, a doctor can decline to treat a patient if they feel
pressurised to act against their own beliefs. The patient’s management
should be passed to a colleague.