Jehovah's Witnesses' (JWs) refusal of blood transfusions has recently gained support in the medical community because of the growing popularity of "no-blood" treatment. Many physicians, particularly so-called "sympathetic doctors", are establishing a close relationship with this religious organization. On the other hand, it is little known that this blood doctrine is being strongly criticized by reform-minded current and former JWs who have expressed conscientious dissent from the organization. Their arguments reveal religious practices that conflict with many physicians' moral standards. They also suggest that a certain segment of "regular" or orthodox JWs may have different attitudes towards the blood doctrine. The author considers these viewpoints and argues that there are ethical flaws in the blood doctrine, and that the medical community should reconsider its supportive position. The usual physician assumption that JWs are acting autonomously and uniformly in refusing blood is seriously questioned.

(Journal of Medical Ethics 1998;24:223 230)

Keywords: Religion; Jehovah's Witnesses; blood transfusion; medical ethics; physician-patient relations; informed consent

Jehovah's Witnesses' (hereafter JWs) refusal of medical and surgical treatment using blood products is widely known in the medical community. They are supported by physicians who accept the challenge of "bloodless" treatment,' at least for adult cases. For example, the article, Surgical red blood cell transfusion practice policies, in The American Journal of Surgery-' recommends as "policy 1" to "accept the limitation that allogenic blood cannot be used". This policy recommends involving the local JW hospital liaison committee, appointed by the church organization (Watch Tower Bible and Tract Society, hereafter WTS), for assistance in making decisions. Most medical literature describes JWs' refusal of blood products as definitive, absolute and consistent. Many courts have ruled that a JW's directive not to receive blood products should be complied with even at the cost of the patient's life. On the other hand, medical and judicial decisions rarely take into account how this blood doctrine developed or is enforced in the JW community.

Certain little-known JW practices regarding blood are morally questionable and may require the medical community to re-evaluate its support of the doctrine. The JW religion recently has come under strong criticism by reformers and former members, including a former top official (governing body member) who wrote two books that detail WTS history, religious practices and internal conflicts,[3][4] and revealed for the first time the secret inner workings of this religion. The effects of the decisions and policies on the rank and file members of the religion are set out in the writings of other former members)[5][7] Another important development comes from easy Internet access which has enabled current and former JWs to "come out of the closet" and voice their opinions without fear of retribution? [8][10] Jehovah's Witnesses have been strongly discouraged from discussing critical religious issues with outsiders, particularly with former members, and can be "disfellowshiped" (excommunicated) for doing so. However, the medical community is generally unaware of these issues.

Thus, the following serious questions arise. Should we physicians continue accommodating the JW patient's request for non-blood treatment based on the "official" position of the WTS alone, disregarding the views of reformers and dissidents, and the resulting ethical questions? How can we avoid compromising our own sense of ethics when we know of unethical practices that may compromise the autonomy of individual JW patients? In part 1, I will review the perspectives provided by dissidents, and discuss the potential impact on medical professionals.

It is beyond the scope of this paper to present a detailed account of the history and doctrine of JWs. An excellent monograph is available) The religion informally began in Pennsylvania in the 1870s under the leadership of Charles Taze Russell. He borrowed many of his ideas from Second Adventists and other apocalyptic sects that speculated on "the end of the world" in Bible prophecy. In 1884 Russell founded the WTS, which became the legal corporation used by the International Bible Students, who changed their name to "Jehovah's Witnesses" in 1931. Russell taught that Jesus had invisibly returned from heaven to rule over the earth in 1874 by setting up God's kingdom, and that in 1914 Jesus would come to judge the earth and destroy this world's political, social, economic and religious institutions. When nothing supernatural happened in 1914 and Russell died disappointed in 1916, the religion almost fell apart. However, the second president, Joseph Franklin Rutherford, re-grouped the religion with his charisma and re-shaped the doctrinal system many times, including the prediction of the arrival of Armageddon in 1918, 1920 and 1925, and moving the invisible return of Jesus from 1874 to 1914. Jehovah's Witnesses consider themselves the only true Christians, with all other Christian denominations being so-called "apostate Christendom".

The doctrines crucial to understanding the JW mindset, as it relates to their adherence to the blood policy can be summarized as: 1) Armageddon is near, in which all mankind will be destroyed except faithful JWs who will live forever on earth; 2) The WTS governing body is believed to be the "faithful and discreet slave" referred to in Jesus' parable at Matthew 24:45, divinely appointed by Jesus Christ to lead the JWs; 3) The Bible cannot be understood without interpretation by the "faithful and discreet slave"; 4) JWs who openly criticize the leadership and the organization are regarded as apostates, disloyal to Jesus and God; 5) Salvation is contingent on how well they perform as loyal JWs.

Recent criticism by dissidents and internal reformers reveals several important JW practices that are critical to re-evaluating our moral support of their blood policy. Here I will review four practices that are repeatedly criticized: intimidation and punishment to enforce strict conformity to WTS policy; stifled freedom of speech, thought and decision; breach of confidentiality by inside informers, and inconsistencies and contradictions that are undisclosed to the JW rank and file. This material is based on WTS's own publications and the testimony of current and former JWs.

ENFORCEMENT OF CONFORMITY

Jehovah's Witnesses are directed to shun any friends or relatives who formally leave (disassociate) or who are forced to leave (are disfellowshiped from) the organization. Former JWs who voice disagreement with the leaders are labelled "apostate" and treated the same way as those who are excommunicated for "sexually immoral" conduct or other grave sins. The JWs' official magazine The Watchtower wrote about the shunning of "apostates" as follows.

"... if a relative, such as a parent, son or daughter, is disfellowshiped or has disassociated himself, blood and family ties remain. Does that mean, then, that in the family circle everything remains the same when one member is disfellowshiped? Definitely not. A disfellowshiped person has been spiritually cut off from the congregation; the former spiritual ties have been completely severed. This is true even with respect to his relatives, including those within his immediate family circle. Thus, family members--while acknowledging family ties--will no longer have any spiritual fellowship with him .... "[11]

"True Christians share Jehovah's feelings towards such apostates; they are not curious about apostate ideas. On the contrary, they "feel a loathing" towards those who have made themselves God's enemies, but they leave it to Jehovah to execute vengeance ...".[12]

Included amongst so-called "apostates" are substantial numbers of conscientious dissenters and those who unrepentantly received blood products. Current JWs are strictly charged to sever personal ties with them. Violators are themselves subject to disfellowshiping. Outsiders may not realize the trauma of leaving the organization, but for JWs it means total isolation from friends and family members who remain in the organization. Unless they repentantly seek reinstatement, there will be no chance of resurrection, and eternal annihilation is their only future. The psychological trauma is devastating. There is no honourable way for JWs to leave their organization.

LACK OF FREEDOM OF SPEECH AND THOUGHT

A most serious problem is that free speech, or more precisely, free thought and decision-making, are prohibited for JWs. These are crucial to self-determination of medical care, yet are seldom mentioned in medical literature. Former governing body member Raymond Franz states: "Watchtower training causes Jehovah's Witnesses to view 'independent thinking' as sinful, an indication of disloyalty to God and his appointed 'channel.'" [13] The Watchtower warns JWs against "independent thinking" in harsh language:

"Avoid independent thinking. From the very outset of his rebellion Satan called into question God's way of doing things. He promoted independent thinking. 'You can decide for yourself what is good and bad,' Satan told Eve. 'You don't have to listen to God. He is not really telling you the truth.'... How is such independent thinking manifested? A common way is by questioning the counsel that is provided by God's visible organization .... Yet certain ones have professed to know better. They have rebelled against such counsel and have done what is right in their own eyes. With what result? Very often they have become involved in sexual immorality and have suffered severe spiritual harm."[14]

"Apostates often appeal to the ego, claiming that we have been deprived of our freedoms, including the freedom to interpret the Bible for ourselves .... In reality, these would-be defilers offer nothing more than a return to the nauseating teachings of "Babylon the Great." [Which means all the other religions - note added by this author.[ True, such smooth talkers may look outwardly clean in a physical and moral way. But inside they are spiritually unclean, having given in to prideful, independent thinking."[15]

Such loaded language discourages discussing or even thinking about critical issues. In combination with the threat of excommunication -which means destruction at Armageddon and eternal annihilation, and the immediate loss of family and friends - it effectively coerces JWs to conform blindly to WTS policy.

FEAR OF BREACH OF CONFIDENTIALITY

Jehovah's Witnesses face coercion by a potential threat produced by informers among fellow JWs. They are taught to report to congregation elders significant infractions of organizational rules by their fellows. The following article from The Watchtower illustrates the attitude. The article, titled "A time to speak-When", discusses whether a hypothetical Mary, who works at a hospital, should report confidential medical information on fellow JWs to congregation elders:

"Mary works as a medical assistant at a hospital. One requirement she has to abide by in her work is confidentiality. She must keep documents and information pertaining to her work from going to unauthorized persons. Law codes in her state also regulate the disclosure of confidential information on patients. One day Mary faced a dilemma. In processing medical records, she came upon information indicating that a patient, a fellow Christian, had submitted to an abortion. Did she have a Scriptural responsibility to expose this information to elders in the congregation, even though it might lead to her losing her job, to her being sued, or to her employer's having legal problems?"[16]

After discussing "Bible principles" that apply to this hypothetical situation, the article tells how Mary acted:

"Mary was somewhat apprehensive about the legal aspects but felt that in this situation Bible principles should carry more weight than the requirement that she protect the privacy of the medical records .... So when Mary analyzed all the facts available to her, she decided conscientiously that this was a time to 'speak', not to 'keep quiet'."

The article argues that "there may be times when a Christian is obligated to bring a matter to the attention of the elders", because the law of God outweighs the demands of "lesser authorities". The article concludes:

"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."

Obviously this teaching applies to JWs who have incidental access to confidential medical information about blood transfusions that may have been secretly given to fellow JWs. While the article gives a hypothetical example, the following footnote shows that JWs apply its counsel in real-life situations:

"Mary is a hypothetical person facing a situation that some Christians have faced. The way she handles the situation represents how some have applied Bible principles in similar circumstances."

This article and other testimonies indicate that there is coercion due to fear of breach of confidentiality by inside informers. Where JWs are employed as medical workers, JW patients have no assurance of doctor-patient confidentiality since, according to WTS teaching, "the law of God" implies that the end justifies the means.

Physicians know little of the history of the blood policy and its enforcement, which raises questions in light of medical ethics. I believe the lack of this knowledge in the medical community contributes to the generally supportive attitude, even though many physicians do not agree with the practice.

CHANGING MEDICAL DOCTRINES

The WTS has a long history of changing doctrines regarding medical issues. This includes a campaign against aluminium cookware and attacks on the American Medical Association and medical professionals as can be noted from the following:

"We do well to bear in mind that among the drugs, serums, vaccines, surgical operations, etc, of the medical profession, there is nothing of value save an occasional surgical procedure. Their so-called 'science' grew out of Egyptian black magic and has not lost its demonological character.., we shall be in a sad plight when we place the welfare of the race in their hands." [17]

Few remember that the WTS once denounced vaccinations and organ transplants in severe terms and with flaming rhetoric. They based their prohibitions on the same scriptural interpretations as the current blood prohibition; those practices were "against Jehovah's everlasting covenant with mankind (Genesis 9:4)". They called vaccination "a crime, an outrage, and a delusion" and "the most barbarous practice",[18] and prohibited organ transplants as "cannibalism",[19] only quietly to reverse these positions as those practices became standard medical care. Most JWs accepted this reversal without questioning whatever tragedies were caused by the misguided doctrines. Once denounced as strongly as blood transfusions, vaccinations and organ transplants are now considered "matters of conscience" by the WTS. Most JWs receive these treatments routinely, and recent WTS publications describe positively the benefits of vaccination[20] and successful heart transplants.[21]

While most people dislike constantly changing religious doctrines, JWs are taught to welcome such changes, based on Proverbs 4:18: "the path of the righteous is like the first gleam of dawn, shining ever brighter till the full light of the day." 32 They are taught that changing doctrines should be welcomed as "new light" or "new understanding" from God and are proof that they are on "the path of the righteous".

BIBLICAL BASIS OF BLOOD DOCTRINE

Prohibition of blood transfusions was first promulgated in The Watchtower of July 1, 1945. There has been no clear explanation why this medical treatment was suddenly prohibited at that time, even though it had been used since World War I. One cultural anthropologist has suggested that it was promulgated to re-establish the sect's internal cohesiveness.[23] The doctrine is based on three Biblical passages, which we will discuss from JWs' and dissidents' viewpoints. Note that since Bible writers knew nothing of blood transfusions, the WTS must equate transfusions with eating blood in order to argue that transfusions are unscriptural. This is discussed at length below.

The first passage is Genesis 9:4, where God (Jehovah) established a covenant with Noah: "But you must not eat meat that has its lifeblood still in it". The WTS says that the prohibition against eating blood is a part of the "eternal covenant with mankind". However, this is inconsistent with some of their other interpretations. The WTS does not prohibit birth control which is a clear breach of the first part of this covenant: "Be fruitful and increase in number and fill the earth." (Genesis 9:1). The inconsistency is that they obey one part of the covenant but ignore the other part. Parenthetically, the majority of Christian Bible scholars believe that the Noachian covenant was no longer binding on mankind after the New Covenant of Jesus Christ was established.

The second passage is from Leviticus 17:10-16 where God gave a law to Moses, saying: "None of you may eat blood, nor may an alien living among you eat blood." (Leviticus 17:12) This indeed indicates that God prohibited the Jews from eating blood. However, the WTS teaches that Christians are not under the Mosaic Law, which includes the dietary laws such as the prohibition on eating pigs and eels. They inconsistently argue that only one dietary law is binding. This can be seen from Leviticus 3:17: "This is a lasting ordinance for the generations to come, wherever you live: You must not eat any fat or any blood." Clearly, the Law prohibited eating fat and blood in the same terms; yet the WTS only prohibits the eating of blood, and hence blood transfusions.

The third passage is from Acts 15 where James proposed to write a letter to Gentile Christians, urging them to follow Jewish customs as follows:

"It seemed good to the Holy Spirit and to us not to burden you with anything beyond the following requirements: You are to abstain from food sacrificed to idols, from blood, from the meat of strangled animals and from sexual immorality. You will do well to avoid these things. Farewell." (Acts 15:28,29).

One problem with the WTS application of this verse to blood transfusions is the lack of evidence that this verse was meant as an everlasting command for all Christians in an absolute sense. Most scholars view the context of Acts 15 this way: the so-called Jerusalem Council was held because a dispute arose about whether the Gentile Christians should be circumcised in accordance with the Mosaic Law. The council decided that Christians were not under the Mosaic Law, but in order to maintain a peaceful relationship between Jewish and Gentile Christians the council decided to ask Gentiles to follow the touchiest Jewish traditions, including avoiding eating blood. This interpretation is supported by Paul, who taught that eating food sacrificed to idols is a matter of conscience even though Acts 1 5 mentions it in the same terms as eating blood.(1 Corinthians 8:4-8)

Ironically, the founder of the WTS, Charles Taze Russell, interpreted Acts 15 in line with many Bible scholars, and considered abstaining from eating blood as "a basis of common fellowship between" Jews and Gentiles and "necessary to the peace of the church", not as an everlasting law for all Christians.[24] If Russell's interpretation were adopted by the WTS today, the blood prohibition would not exist. Most JWs do not know this.

BLOOD TRANSFUSION THE SAME AS EATING BLOOD

The WTS argues that since the Bible forbids eating blood, JWs should not take it into the body by any route including transfusion. Since this conclusion is not stated in the Bible, they resort to circuitous argumentation to equate blood-based medical treatment with eating blood. In support of this, they quote 17th century anatomist Thomas Bartholin[25] and French physician Jean Baptiste Denys[26] to show that blood transfusion was equated with nourishing the body by mouth. The WTS fails to mention that modern medicine had abandoned this concept many decades ago. Current blood transfusions merely replace functions lost due to blood loss, such as oxygen transport - a concept entirely different from that held by certain 1 7th-century physicians. The WTS has used the following analogy:

"A patient in the hospital may be fed through the mouth, through the nose, or through the veins. When sugar solutions are given intravenously, it is called intravenous feeding. So the hospital's own terminology recognizes as feeding the process of putting nutrition into one's system via the veins. Hence the attendant administering the transfusion is feeding the patient blood through the veins, and the patient receiving it is eating it through his veins."[27]

A more recent version of the scenario is:

"In a hospital, when a patient cannot eat through his mouth, he is fed intravenously. Now, would a person who never put blood into his mouth but who accepted blood by transfusion really be obeying the command to 'keep abstaining from . . . blood'?(Acts 15:29) To use a comparison, consider a man who is told by the doctor that he must abstain from alcohol. Would he be obedient if he quit drinking alcohol but had it put directly into his veins?"[28]

As any medical professional knows, this argument is false. Orally ingested alcohol is absorbed as alcohol and circulates as such in the blood, whereas orally eaten blood is digested and does not enter the circulation as blood. Blood introduced directly into the veins circulates and functions as blood, not as nutrition. Hence blood transfusion is a form of cellular organ transplantation. And as mentioned before, organ transplants are now permitted by the WTS. These inconsistencies are apparent to physicians and other rational people, but not to JWs because of the strict policy against viewing critical arguments. They continue to view the WTS's illogical analogy as "the Truth".

ARBITRARY RULES ON PROHIBITED VERSUS PERMITTED BLOOD-BASED TREATMENTS

The WTS's initial prohibition of the use of blood covered whole blood transfusions, but over the years many rules and exceptions were developed. For example, the WTS once published an article instructing JWs not to treat their pets with blood transfusions and not to use fertilizer containing blood.[29] Medical use of leeches also was prohibited. [30] Those practices were also defined as "against God's Word".

More recently, since medical treatments mostly involve blood components instead of whole blood, "'the WTS has created a list of prohibited and permitted components. The most notable publication among JWs and the medical community regarding their rules of blood treatments appeared in 1981 in The Journal of the American Medical Association.[31] The article summarized the basic guidelines for treating JWs using blood products. It was written by a JW physician, Dr Lowell Dixon, who was head of the medical department at Watchtower headquarters in Brooklyn, New York. This concise article clearly communicated to the medical community the JW position on treatments using blood components. The article has since been referenced in much medical literature as a guideline for treatment of JWs.

The current JW position includes unconditional refusal of whole blood, packed red blood cells, white blood cells, platelets and plasma. However, they may accept albumin, immunoglobulin, and haemophiliac preparations. Those components are considered a "conscience matter". Perhaps the most peculiar and inconsistent aspect of the JW policy is that they may accept all of the individual components of blood plasma, as long as they are not taken at the same time. In addition, JWs do not even accept autologous transfusion of their own predeposited blood, though intraoperative salvage (or cell saver) is accepted as long as extracorporeal circulation is uninterrupted via a tube. They may also accept treatment by heart-lung and haemodialysis machines. More recently induced haemodilution has been permitted.

The WTS offers no biblical explanation for differentiating between prohibited treatments and treatments which are considered a "matter of conscience". The distinction is entirely based on decisions arbitrarily made by the governing body. When a new blood-based treatment becomes available, the governing body ultimately determines its acceptability before use.[32][33]Jehovah's Witnesses are required to adhere strictly to these rules on the premise of them being Bible-based "Truth".

The governing body teaches that the "prohibited" blood components are "major", whereas acceptable components are "minor" or "small fractions", stating that the major components are limited to only those that pass through the placental barrier during pregnancy, and that on this basis a JW may accept them in good conscience. ,.[34] This might seem reasonable were it not for the fact that medical science has shown that most "major components" can also pass through the placental barrier."

One subtle irony that most JWs are not aware of is that albumin (one of the permitted components) constitutes 2.2 % of blood volume, whereas white blood cells, and platelets (forbidden components) constitute 1%, and 0.17% respectively. Jehovah's Witnesses patients and their doctor must somehow rationalize why certain "small fractions" can be permitted when the WTS teaches adamantly that "abstaining from blood means not taking it into our bodies at all".'" The WTS also fails to explain why it is permissible for vast quantities of blood to be donated, stored, and processed to produce the "small fractions" JWs are permitted to accept. Yet it teaches JWs that blood must not be used in any purposeful way, prohibiting blood donation with the same punishment as receiving blood.[37]

EXAGGERATED NEGATIVE CAMPAIGN AGAINST BLOOD TRANSFUSIONS

Many WTS publications emphasize the danger of blood transfusions and the advantages of alternatives to blood transfusions. Their magazines contain tragic stories and negative quotes from medical journals and news media about the danger of blood. Needless to say, there are significant risks in blood transfusions, and patients should be informed about them. However, the WTS presents a distorted picture because it fails to report any benefits of blood-based treatments. Just as with its campaign against organ transplants and vaccinations, it uses exaggeration and emotionalism to create paranoia against blood transfusions in JWs' minds, while it fails to present an objective analysis of risk versus benefit. It ignores increased risks and cost of some alternatives, nor does it acknowledge that there are no alternatives in some situations. The following paragraph from their official magazine illustrates the persecution mentality the WTS perpetuates, wherein blood transfusions become "orchestrated by Satan".

"The faith of Jehovah's Witnesses is under attack from all sides-by the clergy of Christendom who hate the Kingdom message we take from house to house, by apostates who collaborate with Christendom's clergy, by medical authorities who want to impose blood transfusions on us and our children .... All this opposition is orchestrated by Satan, the ruler of darkness and ignorance, the enemy of accurate knowledge."[38]

As a result of such rhetoric, many JWs are led to believe that receiving blood transfusions is as dangerous as playing Russian roulette.[30] They cannot see that if blood transfusions did not have proven effectiveness in saving lives, blood would not have been used to the extent it has by physicians whose main concern is to save lives and heal disease.

In this critical review, I have presented the history and religious practices behind JWs' refusal of blood products. Most of the information was researched by reformers and dissidents and is found in the WTS's own publications, yet none of these perspectives are presented objectively to the JW rank and file. Such viewpoints are considered "apostasy" and therefore JWs are warned against them. The coercion in the JW community not to review and examine critical information is both covert and overt.

How can a physician's attitude towards JW patients take the above viewpoints into account? First, he or she can note that coercive practices and misinformation raise a question regarding the autonomy of JW patients. For patients to be truly autonomous, they must be free from undue organizational intimidation and fear of reprisal, and must be given sufficient information, including alternative views. The information presented here suggests a fundamental flaw in most physicians' assumption that JWs are acting autonomously in refusing blood.

Physicians could also scrutinize JW patients more as individuals and recognize that individual JW patients may hold a wider variation in viewpoint than heretofore realized. The current practice of categorical treatment of JW patients should be reassessed, and the possibility of "unorthodox" belief should be explored.

One may argue that JWs joined the religion of their own free will, and that once inside the organization, following the rules established by the leaders, regardless of the inner conflict, is their free choice. It may be further argued that religious freedom includes the freedom to believe in irrational ideas and join coercive groups. Giving consideration to dissident views may be seen as intervening in the internal affairs of the religion.

This argument, however, should be tempered by knowledge of the psychological manipulation, including information control and coercive practices, of certain religious organizations. Many former and current JWs agree that the JW organization has many such elements. I suggest that the autonomy of the members of such groups be scrutinized in light of their unethical practices.

Some may question the reliability of information from dissidents and reformers, particularly those on the Internet, where ethics is yet at a somewhat primitive stage. Although caution must be exercised in relying on the Internet for collecting controversial information, I argue that it provides an unprecedented forum where not only dissidents, but also JWs themselves may voice concerns on issues without reprisal from the WTS, due to the anonymity the Internet affords. Since there is essentially no other avenue available for JWs to "go public" anonymously, bioethicists should consider 'using the Internet to explore "unofficial" but important information regarding the patients who belong to such religious groups.

In the companion paper, part 2,[40] I will suggest, based on the viewpoints presented here, a rational approach to JW patients who refuse blood products.

Views and opinions expressed herein are personal and do not reflect those of Kaiser Permanente and Pacific Permanente PC.

A reply to this paper, by David Malyon, chairman of the JW Hospital Liaison Committee, Luton, will appear in the October issue of the journal.

1 Robb N. Jehovah's Witnesses leading education drive as hospitals adjust to no blood requests. Canadian Medical Association Journal 1996;154:557-60.

2 Spence RK. Surgical red blood cell transfusion practice policies. The American Journal of Surgery, 1995;170(6a):3S15S.

3 Franz R. Crisis of conscience. Atlanta: Commentary Press, 1992.

4 Franz R. In search of Christian freedom. Atlanta: Commentary Press, 1991.

5 Penton MJ. Apocalypse delayed. The story of Jehovah's Witnesses. Toronto: University of Toronto Press, 1985.

6 Botting H, Botting G. The Orwellian world of Jehovah's Witnesses. Toronto: University of Toronto Press, 1984.

7 Reed DA. Blood on the altar. Confessions of a Jehovah's Witness minister. Amherst: Prometheus Books, 1996. See also book review: Mann M. Jehovah's Witnesses. Journal of American Medical Association 1997; 277: 425.

8 Beacon light for former Jehovah's Witnesses: http://WWW.xjw.com/

9 New light on blood. Official site of the associated Jehovah's Witnesses for reform on blood: http://www,visiworld.com/starter/newlight/index.htm

10 All along the watchtower: http://home.sol.no/jansh/wteng/ jwindex.html

11 Anonymous. If a relative is disfellowshiped . . . The Watchtower 1981 Sept 15:28.

12 Anonymous. Search through me, O God. The Watchtower 1993 Oct 1:19.

13 See reference 4:409.

14 Anonymous. Exposing the devil's subtle designs The Watchtower. 1983 Jan 15: 2.

15 Anonymous. Are you remaining clean in every respect? The Watchtower 1987 Nov 1:19

16 Anonymous. A time to speak - when? The Watchtower 1987 Sept 1:12.

17 Shelton HM. Eugenics and barbarism. The Golden Age. 1931 Aug 5: 727-8.

18 Richards HR. Vaccination. The Golden Age 1929 May 1: 502.

19 Anonymous. Questions from readers. The Watchtower 1967 Nov 15:702.

20 Anonymous. Efforts to save the children. Awake! 1994 May 8:4.

21 Anonymous. Bloodless heart transplant. Awake/ 1994 May 22:7.

22 Proverbs 4:18. The Bible. All the Bible quotes in this article are from the New International Version.

23 Singelenberg R. The blood transfusion taboo of Jehovah's Witnesses: origin, development and function of a controversial doctrine. Social Science and Medicine 1990; 31:515-23.

24 Russell CT. Settling doctrinal differences. The Watchtower 1909 Apr 15:117.

25 Anonymous. How can blood save your life? Brooklyn: Watch Tower Bible and Tract Society of Pennsylvania, 1990:6.

26 Anonymous. Respect for the sanctity of blood. The Watchtower 1961 Sept 15:558.

27 Anonymous. Questions from readers. The Watchtower 1951 Jul 1: 415.

28 Anonymous. Reasoning from the scriptures. Brooklyn: Watch Tower Bible and Tract Society of Pennsylvania, 1989:73.

29 Anonymous. Questions from readers. The Watchtower 1964 Feb 15:127.

30 Anonymous. Questions from readers. The Watchtower 1982 Jun 15:31.

31 Dixon JL, Smalley MG. Jehovah's Witnesses. The surgical/ ethical challenge. Journal of the American Medical Association 1981;246:2471-2.

32 Kerridge I, Lowe M, Seldon M, Enno A, Deveridge S. Clinical and ethical issues in the treatment of a Jehovah's Witness with acute myeloblastic leukemia. Archives of Internal Medicine 1998;157:1753-7.

33 Muramoto O. Medical ethics in the treatment of Jehovah's Witnesses. Archives of Internal Medicine 1998; 158:1155 6.

34 Anonymous. Questions from readers. The Watchtower 1990 Jun 1:31.

35 Simpson JL, Elias S. Isolating fetal cells in maternal circulation for prenatal diagnosis. Prenatal Diagnosis 1994;14:1229-42.

36 Anonymous. Godly respect for life and blood. The Watchtower 1969 Jun 1:327.

37 Anonymous. Questions from readers. The Watchtower 1961 Jan 15:64.

38 Anonymous. Why we need accurate knowledge. The Watchtower 1989 Dec 1:12.

39 Anonymous. Gift of life or kiss of death? Awake! 1990 Oct 22:9.

40 Muramoto O. Bioethics of the refusal of blood by Jehovah's Witnesses: part 2. A novel approach based on rational non-interventional paternalism. Journal of Medical Ethics 1998; 24: (in press).

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By Osamu Muramoto, Kaiser Permanente, Portland, Oregon, USA

Osamu Muramoto, MD, PhD, is a member of the ethics committee at Kaiser Permanente Northwest Division, and a neurologist at Northwest Permanente PC, Portland, Oregon, USA. Address correspondence to him at: Kaiser East Interstate Medical Office, 3414 N Kaiser Center Drive, Portland, Oregon 97227, USA. e-mail muramotosag@kpnw.org