There will be blood?
Jehovah’s Witnesses and the law and
ethics of ‘bloodless’ transplants.
Dr. Tracey Elliott
Lecturer in Health Care Law
School of Law
University of Leicester
www.le.ac.uk
The biblical prohibition
• Genesis 9:4:
“Only flesh with its life—its blood—you must not eat.”
• Leviticus 17:14:
“For the life of every sort of flesh is its blood, because the life is in it.
Consequently, I said to the Israelites: “You must not eat the blood of
any sort of flesh because the life of every sort of flesh is its blood.
Anyone eating it will be cut off.”
• Deuteronomy 12:23:
“Just be firmly resolved not to eat the blood, because the blood is the
life, and you must not eat the life with the flesh.”
• Acts 15:29:
“...to keep abstaining from things sacrificed to idols, from blood, from
what is strangled, and from sexual immorality....”
JW: Revised Policy 2000
• “...when it comes to fractions of any of the primary
components, each Christian, after careful and
prayerful meditation, must conscientiously decide
for himself.”
• “Such therapies are not transfusions of these
primary components; they usually involve parts or
fractions thereof. Should Christians accept these
fractions in medical treatment? We cannot say. The
Bible does not give details, so a Christian must make
his own conscientious decision before God.”
Matters of personal choice
• Blood fractions:
–
–
–
–
–
–
–
Haemoglobin
Albumin
Globulins
Clotting factors
Wound healing factor
Interferons
Interleukins
• Cryoprecipitate
• Erythropoietin
• Use of blood salvage technology: provided circuit
uninterrupted.
Organ transplants: 1967 guidance
“When men of science conclude that this normal process
will no longer work and they suggest removing the organ
and replacing it directly with an organ from another
human, this is simply a shortcut. Those who submit to
such operations are thus living off the flesh of another
human. That is cannibalistic. However, in allowing man
to eat animal flesh Jehovah God did not grant permission
for humans to try to perpetuate their lives by
cannibalistically taking into their bodies human flesh,
whether chewed or in the form of whole organs or body
parts taken from others”
Revised guidance 1980
“While the Bible specifically forbids consuming
blood, there is no Biblical command pointedly
forbidding the taking in of other human tissue. For
this reason, each individual faced with making a
decision on this matter should carefully and
prayerfully weigh matters and then decide
conscientiously what he or she could or could not do
before GOD. It is a matter for personal decision.”
Kidney transplants
• Kidney: reported since 1980s (Kaufman)
• Kidney & pancreas: reported 2004 (Boggi)
• Kidney transplant between living related HLA
antibody incompatible JWs: reported 2013
(Greenberg)
• Graft and patient survival equivalent to non JWs
Heart and Lung Transplants
• Studies indicate:
– technically feasible in a select number of JWs.
– Outcomes reflect mortality rates similar to nonJWs.
• Heart
– First reported 1986 (Corno).
• Lung:
– First reported 1999 (Conte).
Liver transplants
• First reported transplant 1994.
• Transplants involve both living and deceased donors.
• Transplant may be offered relatively early.
• Reported studies indicate that carefully prepared
and selected JW might receive liver transplants with
results equal to those
obtained re general
population
JW living donors
• Liver lobe donation in particular carries significant
risks.
• JW donors ‘higher risk’.
• Recommendations:
– Donor should be assessed for their willingness to accept
fractions and blood scavenging technology.
– Donors accepting fractions and blood scavenging technology
should be further considered for organ donation.
– Donors refusing should not be considered: risk/benefit ratio.
– Conscientious objection for staff troubled by transfusion
refusal.
Management of JW transplant surgery
• Choice of patient/donor
• Careful discussion re:
– Risks
– Specifics of blood conservation techniques
– Some blood cells in solid organs
• Pre-operative optimization of blood volume: treatment with
erythropoietin, iron, folic acid.
• Intraoperative control of blood loss: optimal use of
acceptable drugs & therapies.
• Specialist surgical teams: ‘bloodless’ centres.
Incapacitated Adult
• MCA: best interests
• Courts likely to order use of blood products to
safeguard life.
• Re S [2013] NIFam 8
“...the declaration only permits the use of blood products in
circumstances where it is necessary and that has been put to
the court on the basis that it is necessary to ensure that S's
life is preserved.”
Re T (Adult: Refusal of Treatment) [1993]
• Lord Donaldson MR:
“...every adult has the right and capacity to decide
whether or not he will accept medical treatment,
even if a refusal may risk permanent injury to his
health or even lead to premature death.
Furthermore, it matters not whether the reasons for
the refusal were rational or irrational, unknown or
even non-existent.”
Coercion
• Lord Donaldson, MR:
“The real question in each such case is "Does the patient really
mean what he says or is he merely saying it for a quiet life, to
satisfy someone else or because the advice and persuasion to
which he has been subjected is such that he can no longer think
and decide for himself?" In other words "Is it a decision expressed
in form only, not in reality?“....Persuasion based upon religious
belief can also be much more compelling and the fact that
arguments based upon religious beliefs are being deployed by
someone in a very close relationship with the patient will give them
added force and should alert the doctors to the possibility - no
more - that the patient's capacity or will to decide has been
overborne. In other words the patient may not mean what he
says.”
Justice and scarce resources
• Reduction of chances of graft survival?
• In conflict with expectations of donor/donor’s
family?
• Use of a scarce resource: entitled to optimise
chances of success?
• Some centres accept JWs for transplant on basis they
agree to rescue transfusion if necessary (Boggi).
• But might this be regarded as coercive?
Benefits?
• Blood a scarce resource.
• Transfusions not without risk:
– vCJD
– West Nile virus
• Encouraging good practice re control of blood loss.
• Developments re ‘bloodless’ therapies: experience
gained from treating JWs offers benefits to wider
surgery.