Education And Debate

Bioethical aspects of the recent changes in the policy of refusal of blood by Jehovah's Witnesses

BMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7277.37 (Published 06 January 2001) Cite this as: BMJ 2001;322:37

Risk of blood transfusion / Illegal breach of confidentiality: Addendum to reply to Furuli

In addition to my previous reply to Furuli,[1] I would like to add one correction to Furuli's error on the risks of blood transfusions, and a response on illegal breach of medical confidentiality.

RISK OF ACCEPTING TRANSFUSION VERSUS REFUSING TRANSFUSION

In his attempt to minimize the death toll of the Watchtower blood policy, Furuli wrote[2]:

In an editorial, C.D. Kitchens refers to 16 studies with 1404 Witness patients, and reports that the authors "... implicated a lack of blood as the primary cause of death in 8 patients (0.6%) and contributing to death in another 12 patients, yielding a total of 20 deaths (1.4%)." The author continues, "Other complications were not increased in Jehovah�fs Witness patients". Then he draws the interesting conclusion: "Less clear is how much morbidity and mortality are avoided by this practice [refusal of blood], but they probably exceed the risk of being transfused."(6) Because it can be more dangerous to accept a transfusion than to refuse one, a person who refuses one and dies for this reason or another, cannot rightly be accused for suicide, and it is even more illogical to accuse his or her fellow believers for killing the person. (emphasis added)

Thomas Daniels[3] already addressed this issue, and I will provide additional data to shed more light. Specifically, the focus of my discussion is Furuli's comment "it can be more dangerous to accept a transfusion than to refuse one." This notion is rampant among Jehovah's Witnesses; they are simply lead to believe that refusing blood transfusion is safer. I will show from available data that it is a typical "false belief" which is deeply embedded among Jehovah's Witnesses including Furuli. First, since Furuli misquoted Kitchens (he omitted "not" before "being transfused"), I will quote the pertinent sentences from the Kitchens' original article.[4]

The Jehovah's Witness patients' decision to forego transfusions for major surgical procedures appears to add 0.5% to 1.5% mortality to the overall operative risk. Less clear is how much morbidity and mortality are avoided by this practice, but they probably exceed the risk of not being transfused.

In this comment, Kitchens did not know the exact "risk of being transfused". Kitchens speculated that the risk of being transfused probably exceeds the risk of not being transfused. Obviously Kitchens did not fully research the available data on "the risk of being transfused", as his focus was on the risk of refusing transfusion. However the mortality of transfusion had already been known in 1993 when the Kitchens' paper was published. The study by Sazama in 1990[5] analyzed 355 blood transfusion-associated deaths reported to the United States Food and Drug Administration. The study was able to estimate the overall mortality associated with blood transfusion. The short-term mortality rate, which corresponds to Kitchens' estimate of short-term mortality rate from refusing blood, was 1 to 1.2 per 100,000 patients who received blood transfusions. In other words, receiving blood transfusion increased the mortality by 0.001 to 0.0012%, whereas refusing blood transfusion increased the mortality by 0.5% to 1.5%.

Furuli may argue that the data by Sazama is too old, since more transfusion-related complications have become known since this study. The risk of blood transfusion was again extensively reviewed in the "Medical Progress" review in the New England Journal of Medicine in 1999.[6][7] In this progress review, the overall number of deaths from blood transfusion is estimated between 23 and 44 deaths per million units of blood. These numbers include every complications from blood transfusion, not just short-term mortality as in Sazama's report. The short-term mortality which corresponds to Kitchens' estimate should be smaller than these numbers. Thus, a typical blood transfusion of two units carry the risk of 46 to 88 overall deaths per million patients, or 0.0046 to 0.0084%. If a larger amount of blood is transfused, this risk will increase further, to 0.01 to 0.03%.

The accurate number itself is not as important as the magnitude of the risk. Available data indicates that the mortality of refusing blood is close to one hundred times greater than the mortality of being transfused. In the United States alone, about 1.5% of population has conditions requiring blood transfusion each year according to the statistics of the American Association of Blood Banks. That means about 15,000 of Witnesses in the United States will face such conditions each year. Not all of them need transfusion for major surgeries, but suppose half of them had major surgeries, about 7,500 Witnesses have about 1% of additional mortality according to Kitchens. To put this in perspective, 75 Witnesses are dying each year in the United States alone due to refusal of blood transfusion, whereas only about 0.01% of mortality, or life of less than one Witness, is spared by refusing blood transfusion and avoiding transfusion-related death. We never know the exact number of life lost and life saved by refusing blood transfusion. However we can estimate the magnitude of mortality from this practice with reasonable certainty. If we accumulate the above number over the past thirty years and extend to other countries, "hundreds and thousands of deaths from the blood refusal policy" is not at all an exaggeration.

Finally, Furuli should carefully read the conclusion of this authoritative review article in the New England Journal of Medicine.[6]

The use of blood transfusion has declined, in large part because of concern about the safety of the blood supply. It is unlikely that any level of hemoglobin can be used as a universal threshold for transfusion. The advent of a very safe blood supply suggests that outcomes should now be monitored to identify patients in whom transfusion may be underused in addition to identifying patients who receive unnecessary transfusions. Techniques or strategies to avoid blood transfusion will no longer be driven by the known risks of death from blood transfusion, since they are now so low that no alternative is currently as safe as a blood transfusion. Instead, blood conservation will be driven more by issues related to the costs and inventory of blood.
(emphasis added)

There are two pertinent points to our discussion in this conclusion.

  1. The risks of death from blood transfusion are now so low that no alternative is currently as safe as a blood transfusion.
  2. We should identify patients who may not receive necessary blood transfusion, in addition to identifying patients who receive unnecessary transfusions.


The following is the conclusion of the part two of this review article.[7]

Increased attention to the costs of health care delivery has caused the relative benefits and costs of blood conservation to be scrutinized. The prospective identification of surgical candidates who will need transfusion and therefore will truly benefit from blood conservation must be based on patient-specific factors, such as the baseline hematocrit and the anticipated blood loss during surgery. The challenge for physicians will be to educate their patients that the decision to conserve blood should no longer be based on the safety of the blood supply, but on evidence that blood conservation is safe and of value for individual patients. (emphasis added)

If we compare these conclusions in the authoritative review of blood transfusion medicine with the popular misconception among the Witnesses that "accepting blood transfusion is more dangerous than refusing blood transfusion", we can clearly see how "false beliefs" are effectively permeated throughout the Jehovah's Witness population through the "bloodless surgery" campaign driven by the Watchtower Society. See also the end note below about the "bloodless surgery".

JUSTIFICATION OF ILLEGAL BREACH OF MEDICAL CONFIDENTIALITY

Regarding breaching medical confidentiality, Furuli has not been able to grasp the difference between legal and illegal breach of medical confidentiality. In his attempt to show another example of justifiable breach of confidentiality, Furuli even cited the confidentiality of child molesters.[8] It is not illegal in most states and countries for health care workers to breach confidentiality of child molesters. To the contrary, it is mandatory to report those cases in most jurisdictions. There is no parallel with reporting violators of the Watchtower rules, which is illegal. Ironically, it is some Jehovah's Witness elders who did not report child molestation that happened in their congregation.[9]

Regarding hypothetical case of "Mary" who worked as a medical assistant processing medical records and breached medical confidentiality of a fellow Witness patient who received abortion,[10] Furuli cited several cautionary comments in the same article. There is no question that those warnings were necessary because "Mary" after all committed an illegal act. The Watchtower Society could not explicitly promote an illegal act in its main magazine. However, we should not be distracted by the cautionary comments Furuli cited. Although Furuli stated "we Jehovah�fs Witnesses never recommend to violate the law in the cases mentioned above", he failed to mention the important exception to this rule. This exception is clearly stated in the article in which the "Mary" story was featured.

This command from the Highest Level of authority in the universe put the responsibility upon each Israelite to report to the judges any serious wrongdoing that he observed so that the matter might be handled. While Christians are not strictly under the Mosaic Law, its principles still apply in the Christian congregation. Hence, there may be times when a Christian is obligated to bring a matter to the attention of the elders. True, it is illegal in many countries to disclose to unauthorized ones what is found in private records. But if a Christian feels, after prayerful consideration, that he is facing a situation where the law of God required him to report what he knew despite the demands of lesser authorities, then that is a responsibility he accepts before Jehovah. There are times when a Christian "must obey God as ruler rather than men."-Acts 5:29. (p13)

There may be occasions when a faithful servant of God is motivated by his personal convictions, based on his knowledge of God's Word, to strain or even breach the requirements of confidentiality because of the superior demands of divine law. Courage and discretion would be needed. (p15) (emphasis added)

According to this article, there is one exception to obeying the law of medical confidentiality. That is, when obeying "the law of God" or "the superior demands of divine law" conflicts with obeying "the demands of lesser authorities." Unfortunately, whether abortion or accepting blood transfusion, those actions are clearly violating "the law of God" according to the current Watchtower teaching. Despite Furuli's assertion, "we Jehovah�fs Witnesses never recommend to violate the law in the cases mentioned above",[8] the instruction from the Watchtower Society made a major exception to "Caesar's things to Caesar" or obeying the secular authority.

No matter how many excuses Furuli cites, the "Mary" story has the following three facts which cannot be disputed.

  1. Mary committed an illegal act of breaching medical confidentiality of a fellow Witness patient who received a prohibited medical procedure.
  2. The Watchtower Society in this article condoned Mary and did not censure her.
  3. The Watchtower Society taught Witnesses that, where "the law of God" requires them to breach medical confidentiality, then doing so "despite the demands of lesser authorities" is their responsibility before Jehovah.

Of course, illegal breach of medical confidentiality is not an easy act, and has to be done cautiously because of the potentially serious consequences as the article warned. The article spent a great amount of space discussing risks and implications involved in this act, including an oath some employees took for confidentiality. Why the Watchtower Society needed to discuss all those implications in great length? Because the Watchtower Society did not simply say "don't do it." Instead of simply forbidding the Witnesses from committing this illegal act, it taught "do it, but be careful not to get in trouble." As the article stated, "courage and discretion would be needed." Still, if the circumstances allow, the Jehovah's Witness healthcare workers could act the same way as Mary did with "courage and discretion". This teaching remains a threat to our law-abiding society at large.

END NOTE ON BLOODLESS MEDICINE

The author believes blood conservation medicine is a safe, scientifically sound and cost-effective approach to reduce unnecessary blood transfusions, as extensively reviewed by the recent review article cited above.[7] However, "bloodless" medicine as promoted by the Watchtower Society, which means no blood under any circumstances at the cost of patient's harm and death, is an unsafe and costly religious practice under the name of "medicine".

REFERENCES

  1. Muramoto O: Autonomy of individual Witnesses should not be sacrificed by "the majority" - Reply to Furuli http://www.bmj.com/cgi/eletters/322/7277/37#EL93
  2. Furuli R: Re: Muramoto's reply R. Furuli, The conscience of the individual Jehovah's Witness http://www.bmj.com/cgi/eletters/322/7277/37#EL66
  3. Daniels T: Re: Furuli's reply to Muramoto http://www.bmj.com/cgi/eletters/322/7277/37#EL71
  4. Kitchens CS. Are transfusions overrated? Surgical outcome of Jehovah's Witnesses. Am J Med 1993;94:117-119
  5. Sazama K: Reports of 355 transfusion-associated deaths: 1976 through 1985. Transfusion 1990;30:583-90
  6. Goodnough LT, Brecher ME, Kanter MH, et al.: Transfusion medicine. First of two parts--blood transfusion. N Engl J Med 1999;340:438-47
  7. Goodnough LT, Brecher ME, Kanter MH, et al.: Transfusion medicine. Second of two parts--blood conservation. N Engl J Med 1999;340:525-33
  8. Furuli R: Muramoto's new interpretation of the meaning of the concept "informed consent" http://www.bmj.com/cgi/eletters/322/7277/37#EL87
  9. Jehovah's Witnesses' policy on child molesters attacked. Church says it follows laws on reporting suspected abuse. Courier Journal (Louisville, Kentucky) February 4, 2001. Available from URL: http://www.courier-journal.com/localnews/2001/02/04/ky_jeh.html
  10. The Watchtower Bible and Tract Society. "A time to speak"-when? The Watchtower; 1987 Sept 1:12

Competing interests: No competing interests

21 March 2001
Osamu Muramoto
Regional Ethics Council
Kaiser Permanente, Interstate Medical Office East, Portland, OR 97227, USA