Summary and correction of Q&A between Rolf Furuli and the author
I appreciate Mr. Furuli's two letters  which attempted to address all of my questions raised in my two previous letters. I fully realize that some of the questions are difficult for him to answer. I appreciate Furuli's earnest effort in his reply, and I accept these letters as his genuine and final answers. In this letter, instead of pursuing further clarification from him, I would like to summarize several important points that have become clear so far in our dialogue, so that the readers can understand where our differences are. I will also correct some of his most erroneous statements.
RELIGIOUS BIAS AGAINST THE AUTHOR
Although I appreciate Furuli's reply, an unfortunate development of his discussion is that he now portrays this author as an "opposer" of Jehovah's Witnesses. He characterizes my letters as "an attempt to change the faith of the addressee and all other Jehovah's Witnesses". Why does he resort to such a distortion of the whole issue? He now introduces a religious bias in this debate by speculating my religious motive. It is probably the easiest way for Furuli to discredit my argument and trash my article by painting a religious color on me.
I have tried to avoid religious argument and to focus on bioethical aspects of the issue. During the course of my discussion, it is inevitable to be critical to certain aspects of Jehovah's Witnesses, but that is an inherent part of discussion such as this. Furuli's exaggeration that this is my attempt to "change the faith of all other Jehovah's Witnesses" is beyond comprehension. I have patients, friends and relatives who are Witnesses, and we are in good relationship without interfering with other's religious matters. It is unfortunate that a person such as Furuli who is familiar with academic debate has to resort to such ad hominem attacks to distract the readers from the substance of our discussion. I hope Furuli considers our discussion based on the merit of the substance, and I urge him to refrain from attacking the character of the messenger using religious bias in order to silence the message he dislikes.
WHO IS THE THIRD PARTY IN DOCTOR-PATIENT RELATIONSHIP?
I wonder if Furuli's definition of the term "third party" is different from mine. When we say "third party" in doctor-patient relationship, everybody else other than the doctor and the patient is considered the third party. Furuli repeatedly claims I am "a third party" and urges the readers not to listen to me because I am not a Witness. I am a physician facing with Witness patients. I am in the direct doctor-patient relationship, along with most other medical professionals. We are all "the second party." It appears that this is Furuli's another attempt to discredit the author and distract the audience by putting a false label of "a third party" on me.
Another peculiar usage of "third party" by Furuli is seen in his response to my question regarding the third party intrusion in doctor-patient relationship. Furuli states: "I do not view The Watchtower Society as a ‘third party’ but I view it the same way that my students view me, as a teacher". Although I can understand a teacher is the second party vis-à-vis students, and a religious leader is the second party vis-à-vis the followers, there is no place for The Watchtower Society coming into the doctor-patient relationship as the second party. Even a teacher may not enter the doctor-patient relationship of his students. With further thought, however, I found that his response raises an interesting point which is in fact quite relevant to my article. Perhaps, when he wrote that The Watchtower Society is not a third party, it was not his misunderstanding but his genuine feeling.
If Furuli cannot think of The Watchtower Society as a third party when he sits with a doctor, The Watchtower Society is the active party in his medical decision-making. It is no longer the matter between Furuli and the doctor. It is the matter between Furuli conjoined with The Watchtower Society and the doctor. That would explain very well many unanswerable questions we are discussing here. Or perhaps another explanation is that The Watchtower Society plays the role of his parent, and Furuli plays the role of an infant patient. If The Watchtower Society is Furuli's mother or his guardian, for example, Furuli is absolutely correct that The Watchtower Society is not a third party in his relationship with his doctor. In either case, that explains very well why Furuli, as an infant patient, thinks he is selecting various blood products based on his own conscience, but in fact his "mother" selects everything for him. That can explain why his own conscientious selection of blood products is always 100% identical with what his "mother" or The Watchtower Society has selected.
I wonder Furuli's relationship with The Watchtower Society is the same as a baby's relationship with his mother, instead of student-teacher relationship. At any rate, I find this framework of the doctor-patient relationship and the role of the third party quite interesting from the viewpoint of medical ethics. This would be a good topic to discuss among the readers in the medical ethics community.
ILLEGAL BREACH OF CONFIDENTIALITY OF INCIDENTAL MEDICAL INFORMATION
Regarding medical confidentiality, Furuli introduces an example of a case of HIV-positive patient who might cause danger to a third party and general public, in order to show the occasional needs to breach medical confidentiality in certain situations. It is true that this is a common ethical dilemma we face in daily medical practice. Another typical case is a psychiatrist who sees in his patient a sign of impending impulse to commit murder. Should medical confidentiality be breached for the good of public safety? It is indeed a difficult ethical dilemma we face on daily basis.
However, these situations are totally different from the case of "Mary" who violated the law to breach medical confidentiality. Under no circumstances, even in the situation Furuli mentioned, is it legal or ethical for a medical worker, such as "Mary", who incidentally obtained medical information of another patient while processing medical records as a medical assistance, to breach confidentiality. The ethical dilemma of the HIV-positive patient Furuli mentioned, and the psychiatrist treating a potential murderer, all involve direct doctor-patient relationship. Doctors obtained critical information during the course of their professional relationship. "Mary" has no fiduciary relationship with the patient. She is not legally authorized to obtain any medical information whatsoever. Her action is outright illegal and unethical.
We physicians never recommend to violate the law even in the cases mentioned above. First thing we recommend is to bring up the case to an ethics committee or any equivalent of professional review board to find out the most ethical way to handle the situation. If there is a real emergency, there are many appropriate legal resources. There is no parallel between "Mary" and the situation Furuli mentioned. "Mary" committed an outright illegal act even without any emergency, and was praised by The Watchtower Society for her action. We physicians handle such "dangers" in medical ethics committees and legal procedures without resorting to illegal action.
One thing that concerns me in Furuli's comment is that he dismisses this illegal practice because "such a situation occurs so rarely". I am certain that illegal actions happen rarely in Jehovah's Witnesses. I am fully aware that Witnesses are generally law-abiding people. The question is how they behave in rare situation of distress. I am totally perplexed by the fact that Furuli as a Jehovah's Witness condones and dismisses such an illegal action just because it is "rare". I am sure murder is "rare" and stealing is "rare" among Jehovah's Witnesses. Rare occurrence has nothing to do with moral value of the action. And even if it is rare, as long as this recommendation to breach confidentiality is not formally rescinded, psychological pressure to Witness patients never goes away. Unfortunately, we have not heard any assurance from Furuli that the Watchtower Society will stop this illegal practice of violating medical confidentiality any time soon.
"THE BIBLE ALONE" DOES NOT DETERMINE WHICH BLOOD FRACTION TO REFUSE
Obviously I am not in the position to debate Biblical exegesis with Furuli, but even without much knowledge of the Bible, I see an obvious discrepancy in his statement. He asserts "it is a bold and utterly false claim to say that the Watchtower Society is the authority for Jehovah's Witnesses and not the Bible". He goes on saying "my basis for being a Witness I find in the Bible and in the Bible alone". Yet he fails to explain how "the Bible alone" tells someone to die by refusing "major" components, but to live by accepting "minor" components, when he keeps citing The Encyclopedia Britannica, discussing mother's milk and placenta, "what clearly [he feels] is blood (haima)" etc, yet never cites any scriptural passage to determine this critical difference between the "major" and "minor" components. Nor did he explain how "the Bible alone" can change the position on hemoglobin from 1998 to 2000. Please keep in mind that these are not just a minor doctrinal adjustment. These changes determine the life and death decisions of millions of people worldwide.
"USING BLOOD AS A NUTRIENT IS FORBIDDEN IN THE BIBLE"
Another obvious difficulty comes from Furuli's assertion in his earlier letter that "[..] we have reached the following conclusion which we regard as consistent. What is expressedly forbidden in the Bible is using blood as a nutrient." Who are "we"? Isn't this conclusion his own? He then jumps to his assertion without any evidence that "99 % of my fellow believers [..] reject oral and parentereal feeding (transfusion) by blood (haima)".Of course, there may be other Witnesses who may have reached the same conclusion by studying the Bible as much as Furuli does, but how come 99% of six million followers reach the same conclusion at the same time for something the Bible never mention (transfusion), unless it was orchestrated by a strong controlling power, or it was Furuli's presumptuous proposition which ignores individuality of millions of people?
Furuli either does not know the purpose of blood component therapy, or intentionally ignores it. Here, I will summarize the purpose of each component therapy.
- Red blood cells = to restore oxygen delivery to the peripheral tissue
- White blood cells = to treat infection by restoring deficient white cells
- Platelets = to restore platelet function for uncontrollable hemorrhage
- Plasma = to restore the blood coagulability by adding coagulating factors
Of course there are many other purposes for component therapy, but those are the main purposes in current practice, which anybody can read in elementary medical textbooks. There is no role of "nourishing" or "feeding" in those "major" components. Ironically, there is one blood component which is occasionally used to correct malnutrition. That is albumin which is permitted to use according to the Watchtower Society. Hypoalbuminemia occurs in people with poor nutrition. Administering albumin is one of the quickest ways to correct this problem. It quickly increases serum albumin level, which is one of the indicators of malnutrition, and alleviate the symptoms of malnutrition. If Furuli and the Watchtower Society truly believes "nourishing" with blood products is prohibited by the Bible, albumin should be refused, not red cells or platelets.
BIBLE-BASED INDIVIDUAL CONSCIENCE OF 99% OF WITNESSES IS THE SAME AS FURULI'S
Despite these basic facts of the current transfusion practice, Furuli asserts "99%" of the Witnesses reject blood products based on the same reason of "feeding by blood" as Furuli concluded. Once again, I repeat, I fully respect Furuli's personal conclusions from his Biblical exegesis even if I feel they are totally inconsistent. The issue is not whether Furuli's conviction is consistent with the Bible. (I am sure this is the issue for dissident Witnesses - that is a different issue.) Nor is it my desire to change the (apparently illogical) belief. The issue I am pursuing here is, regardless of "what clearly [Furuli feels] is blood (haima)", more than six million people including unknown number of dissident Witnesses have no freedom to select which blood product to accept without using Furuli's criteria.
Suppose Furuli is correct that 99% of six million of Witnesses believe and behave almost identically as Furuli does in every detail of blood products. Still 1% or 6,000 of Witnesses and unknown number of their children are deprived of freedom to choose their medical treatment, and freedom to live according to their own Bible-based conscience on blood products, which happen to be different from Furuli's. Assuming everything Furuli stated is correct, there is still a serious problem of medical ethics and the basic human rights of 6,000 people!
CAN BIBLE-BASSED INDIVIDUAL CONSCIENCE OF EACH WITNESS DETERMINE WHICH BLOOD PRODUCT TO ACCEPT?
It is quite noteworthy to the readers that this question, which is the most essential part of my article and this discussion, is still not answered in unequivocal term. Furuli wrote in his first reply, "I would respect a position based on the sincere conscience of another Witness, whether or not it is different from mine." Yet he made an exception of "stealing", implying accepting blood may be a similar exception. In his second reply, he wrote, "the answer is ‘yes’, but I will add that while I respect everyone’s right to follow his or her conscience, nobody can refer to this to prove that I condone their choices." In essence, he would "respect" other's conscientious choices of blood products, but he may not "condone" their choices.
To all fairness to Furuli, I see he is genuinely struggling with a very difficult and delicate balance between being a conscientious individual Jehovah's Witness and being an organizational man to be loyal to every word of The Watchtower Society. By reading through his series of letters, the readers can easily see his "crisis of conscience": he first started with a bold statement "the conscience of the individual Jehovah's Witness as a basis for refusing blood", then enforced his position by declaring that the basis of his position is "in the Bible alone", but at the end, he concluded his last letter, "As a conclusion I will say that the official position of Jehovah’s Witnesses is that we do not accept an infusion of whole blood or its major components. This is the view of all the Witnesses that I know."
By following his thought process of starting with "the individual conscience" and "the Bible alone" and ending up with "the official position" of "all the Witnesses", the readers can clearly see a typical mind-set of a loyal Witness, who genuinely believes he is acting on "the individual conscience" based on "the Bible alone", is in fact conforming to "the official position" of The Watchtower Society which universally binds "all the Witnesses".
Another conspicuous pattern in Furuli's writing is that he consistently avoided to discuss individual blood products, and to try to discuss only generic concept of "blood" and the murky distinction between the "major" and "minor" components. In clinical setting, what matters is which product the patient receives, not any abstract concept of "blood", "major" or "minor". "Abstaining from (conceptual) blood" must be translated into a selection of a specific blood product, but this discussion is conspicuously absent in Furuli's writing. In order to illustrate his problem, I will hereby take "a platelet product" as an example of a specific blood product which belongs to the "major". It can be any blood product, but discussing one representative product will make our discussion much closer to our clinical setting.
IS DISASSOCIATION/DISFELLOWSHIPPING JUSTIFIED?
The next question is what Furuli would actually do with those who disagree with him in selection of blood products. He then discusses how disfellowhipping or disassociation of those who conscientiously accepted "a platelet product" (an example of major component) are justified. He introduces two examples, an unfaithful husband who Furuli considers disassociated from his wife, and a doctor who attacked colleagues and who Furuli also considers disassociated from the colleagues. Where is the similarity between a Witness who accepted a platelet product to treat his uncontrollable hemorrhage and a husband who is unfaithful to his wife?
I suppose Furuli wants to say that in both cases, the other party generates such a strong emotional repugnance against the "sinner" that he or she does not want to have such a person in his or her company. In short, Furuli would still "respect" a Witness who accepted a platelet product, but he would not greet with that person or eat with him from the same table, and certainly not worship in the same congregation, even if that person is his close friend or family member.
DISASSOCIATION - A PUNISHMENT WITHOUT A FAIR PROCEDURE
While I agree with Furuli that the way he would treat those dissident Witnesses reflects the reality of the current practice of Jehovah's Witnesses, namely ostracism and shunning, whether such a practice is acceptable in our society in general, and particularly in the medical community, is a different matter. There are several problems which raise serious concern among doctors and ethicists about this practice. Since most doctors and ethicists are unfamiliar with this practice, I will expand this discussion here.
The first problem is that, even though Furuli claims that the disassociation was initiated by the action of the "sinner", it is perceived as a punishment from the viewpoint of the "sinner". Furuli's expression "all persons must accept the consequences of their acts" implies that "disassociation" is the consequence of the sinner's act. This sounds a matter of fact, but it is only a political euphemism to evade the responsibility of delivering the punishment. Does it make any sense to Furuli if he heard the Chinese government saying "the arrest and imprisonment of Jehovah's Witnesses in China is the consequences of their acts"? There is always an authoritative power behind the execution of any punishment. No matter how paraphrase the expression to avoid social responsibility, "disassociation", or ostracism and shunning, is a punishment established and executed by the authority of a Jehovah's Witness congregation.
The next problem is that a punishment cannot be applied in an arbitrary process in our civilized society. This is also true even with the examples Furuli cited, namely unfaithful husband and a doctor attacking colleagues. In an ideal situation, a fair trial or judicial process takes place before a punishment is delivered. If, for example, that doctor were to be ostracized by the colleagues without a fair procedure, he can sue the group for undue discrimination. One of the most serious problems of "disassociation" of Jehovah's Witnesses is the fact that the punishment is applied to any "sinner" without a fair trial or judicial procedure.
Furuli stated, "what counts is the sum of his or her acts and the attitude of the heart, i.e. does the actions of the person show that he or she has dissasociated himself or herself from the congregation." A logical question that follows this Furuli's statement is "who judges the ‘the attitude of the heart’ of a Witness who accepted a platelet product?" Furuli, or congregation elders, or God? It is totally unclear who makes the final judgment, particularly when there is no formal judicial process for a "sinner" who accepted a platelet product. The only explanation I can think of from the Furuli's account is that "the attitude of the heart" on which the punishment of ostracism and shunning is based is "the attitude of the heart" toward the leaders of the congregation and The Watchtower Society, not "the attitude of the heart" toward God. That is the only explanation I can think of, unless Furuli or someone in the leadership plays "God."
To conclude this discussion on punishment of accepting a "major" blood component, I have to emphasize to the readers that a Jehovah's Witness who conscientiously accepted a "major" blood product can be punished without a fair trial, and only with arbitrary and subjective judgment of "the attitude of the heart" which is judged by the leaders such as Mr. Furuli. It is reminiscent of a group lynching of a mob without fair hearing. We physicians need to remind ourselves that we have a fiduciary relationship with our Witness patient. We carry our moral obligation to protect our patient even if he or she is considered a "sinner". The above discussion by Furuli only enforces my proposal to protect Witness patients who might have different views on blood products from the controlling power of the Watchtower Society.
FALSE STATEMENTS REQUIRE FORMAL CORRECTION/APOLOGY
Furuli's letters also contain many errors and misinformation, particularly numerical and quantitative aspects of blood transfusion risks. I may address those in my later letters if I have a chance. I will finish this letter by correcting Furuli's gross false statements which I sincerely hope is not his intended malicious attack.
Furuli states "[..] you ask for an acceptance of the correctness of your viewpoints, and that we cannot do." Where did I ask for an acceptance of the correctness of my viewpoints? I am asking only to consider another viewpoint. Whether it is accepted as correct or not is up to individual Witnesses. Furuli also states "… you suggest that doctors should try to persuade sick Witnesses to change their minds." Again, his assertion is totally false. As anyone can read in my article above, I suggested doctors to present the patient a chance to reconsider their previous position. This attitude is totally different from to "persuade to change their minds". I sincerely hope this is not Furuli's malicious attack on me, but if he is indeed a civilized and responsible Witness, a formal apology is in order.
He then continues: "If you respect our consciences, why don’t you not follow your own decision but leave us alone?" I repeatedly wrote that I respect Furuli's conscience. Yes, I will leave Furuli alone as a patient in this matter. However, I will not leave the next Witness patient alone, because it is my professional responsibility to give the best care that this next Witness patient deserves. His or her "individual conscience" can be different from Furuli's. As a physician, I have an obligation to find out how he or she personally feels about the major and minor components, and which blood product they want to accept, without any misinformation or pressure. I will respect their final decisions, but I will never leave them alone, as Furuli urges. I have no obligation to follow the universal "official position" of The Watchtower Society by leaving the Witness patient alone. To do so is totally irresponsible, and I urge my fellow physicians not to "leave alone" Witness patients. After all, who are you, Mr. Furuli, who determines the life and death decision of six million people by saying "leave us alone" instead of saying "leave me alone"? You have no right to say anything about their conscience for six million of other people by using the pronoun "us", let alone 1% (according to your own estimate) or 6,000 of Witnesses who might disagree with you!
- 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
- Furuli R: Re:Muramoto: Questions unanswered by Furuli http://www.bmj.com/cgi/eletters/322/7277/37#EL74
- Muramoto O: Reply and questions to Rolf Furuli Re: The conscience of the individual Jehovah's Witness http://www.bmj.com/cgi/eletters/322/7277/37#EL58
- Muramoto O: Is the individual conscience truly the basis of blood refusal? Questions unanswered by Furuli http://www.bmj.com/cgi/eletters/322/7277/37#EL70
- The Watchtower Bible and Tract Society. "A time to speak"-when? The Watchtower; 1987 Sept 1:12
- Furuli R: Why do Jehovah's Witnesses abstain from blood? http://www.bmj.com/cgi/eletters/322/7277/37#EL63
- Furuli R: The conscience of the individual Jehovah's Witness as a basis for refusing blood http://www.bmj.com/cgi/eletters/322/7277/37#EL52
Competing interests: No competing interests