Management of blood loss in children of Jehovah's Witnesses

BMJ 1996;312:380-381 (10 February)

Letters

Management of blood loss in children of Jehovah's Witnesses

EDITOR,--David Busuttil and Adrian Copplestone's editorial onthe management of blood loss in Jehovah's Witnesses toucheson, but does not resolve, the clinical and ethical issues oftreating children of Jehovah's Witnesses.¹ The authors concentrateon the use of recombinant erythropoietin in the postoperativemanagement of anaemia at the expense of considering other pharmacologicalagents, such as aprotinin or desmopressin, which can reduceintraoperative blood loss. As paediatric surgeons we are awareof the need to preserve circulating blood volume and have beenearly to adopt techniques that provide improved haemostasis.Use of predeposited autologous blood, intraoperative autotransfusion,and haemodilution are not readily adaptable to neonates havingextensive surgery, although they may be appropriate for olderchildren.²

After our success in resecting a large sacrococcygeal teratomawith minimal blood loss when we used aprotinin in the childof Jehovah's Witnesses³ we have observed both subjective andobjective reductions in blood loss and transfusion requirementsin neonates having surgery for sacrococcygeal teratoma, necrotisingenterocolitis, and massive cervical cystic hygroma when we useda bolus of aprotinin (10000 kIU/kg (=1 ml/kg)) on inductionof anaesthesia followed by an infusion at 1 ml/kg/h during theoperative period. Our only other experience in the perioperativeuse of desmopressin is in patients with von Willebrand's disease.We suggest that further evaluation of the use of aprotinin perioperativelymay obviate the need for expensive recombinant erythropoietinto treat postoperative anaemia.

The legal recourse available when transfusion is necessary deservesclarification. While the courts may uphold the decision of anadult Jehovah's Witness to refuse transfusion, parents wouldbe charged with neglect for failing to seek, or permit, desirablemedical treatment for their children, even if that treatmentwere to contravene religious doctrine. Parental refusal of transfusiondoes not necessarily necessitate making the child a ward ofcourt and thereby removing all parental authority as in mostcases this is a conflict of interest between religious beliefsand the wellbeing of the child. Parents may be absolved of thisparticular responsibility by a specific issue order, which giveslegal sanction to only the action identified, such as the administrationof blood. A specific issue order is made under the private lawprovisions of the 1989 Children Act, and the High Court is approacheddirect.