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Management of blood loss in Jehovah's Witnesses

BMJ  VOLUME 311    28 OCTOBER 1995

 The Jehovah's Witness religion was founded in the late 1 870s by  Charles Russell in Pittsburgh, Pennsylvania. There are 5 million Jehovah's Witnesses worldwide and 125 000 in the United Kingdom. Members of this sect do not accept blood transfusions, a stand based on passages from the Bible, such as this from Leviticus: (xvii) "As for any man who eats any sort of blood, I shall certainly set my face against the soul that is eating the blood, and I shall indeed cut him off from among  his people." Blood transfusion is interpreted as the eating of blood, and Jehovah's Witnesses believe that all hope of eternal life will be forfeited if transfusion is accepted. Autologous transfusion is also prohibited because they believe that once blood has left the body, it is then unclean. These prohibitions present ethical and clinical challenges to doctors who look after seriously ill or injured Jehovah's Witnesses and prompt a search for alternatives to blood.

The courts have consistently upheld Jehovah's Witnesses' decisions to refuse transfusions on the grounds that any adult of sound mind has the right to determine what shall be done with his or her own body. Nevertheless, two thirds of European doctors working in intensive care units would give transfusions to an unconscious Jehovah's Witness who was losing blood, and 41% would not inform the patient later.

Doctors from France, Spain, and Italy are more inclined to give transfusions, while those from the United Kingdom, the Netherlands, and Scandinavia would rather avoid transfusion. Doctors need to be aware of their legal liability if they ignore a Jehovah's Witness's advance directive not to be given a transfusion. In the case of  children legal recourse is available and can remove the responsibility of medical decisions from the parents and transfer it to the courts. After acute blood loss there is usually a one week lag before the packed cell volume starts to recover properly. This is related to the need

to produce erythropoietin and to mobilise iron stores. During this period erythropoietin mediated proliferation, differentiation, and maturation of  erythroid precursor cells must occur. Patients may also experience continuing blood loss because of diagnostic phlebotomies. In one study in an intensive care unit, patients from whom blood samples were taken four times a day lost a mean of about 1 litre during a mean hospital stay of 20 days.



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