American Journal of Obstetrics and Gynecology Volume 182(1, Part 1), January 2000, p 251
[Letters To The Editors]
Muramoto, Osamu MD, PhD
Regional Ethics Council, Kaiser Permanente Northwest Division and Northwest Permanente P.C., Portland, OR 97227
To the Editors: In his recent article deCastro [deCastro RM. Bloodless surgery: Establishment of a program for the special medical needs of the Jehovah's witness community-The gynecologic surgery experience at a community hospital. Am J Obstet Gynecol 1999;180(6 Pt 1):1491-8] tried to show that the cost, length of stay, and morbidity for Jehovah's Witnesses in his bloodless surgery program are equal to or less than those of the general population. However, it must be pointed out that he compared only cases of abdominal hysterectomy for benign conditions, which rarely required (only 4% in the control group) blood transfusions, and they composed only 30% of the gynecologic surgical cases of Jehovah's Witnesses in his hospital. As long as the need for life-saving blood transfusions is limited, there should be little difference between the 2 groups. His results can be explained by factors other than bloodless surgery: Since the Jehovah's Witness group was significantly younger than the control group and had less risk associated with surgery because of their nonsmoking doctrine and healthier lifestyle, fewer complications and better postoperative recovery should have been anticipated. Their higher level of satisfaction may simply be attributed to their additional religious satisfaction, which the control group lacked.
Then what is special about so-called bloodless surgery? Regardless of religion, very few patients would object to effective blood conservation techniques and restrictive strategies for blood transfusion. It has already been shown that such a blood conservation strategy is as effective as or probably superior to a liberal transfusion strategy,1 and it can be safely implemented in general surgical cases, particularly for uncomplicated elective procedures such as those in deCastro's study. What makes bloodless surgery programs truly unique is their compliance with the Jehovah's Witnesses directive not to transfuse even at the time of emergency to save their lives. In contrast, the general surgical population, while requesting similar blood conservation strategies, allow emergent, life-saving blood transfusions as a last resort. Thus the real difference between those 2 groups can be measured only by comparing a subset of the 2 groups-those who underwent complicated or emergency operations, which often involve blood transfusions to save a life. Only such a comparison will reveal the real impact of accommodating the Jehovah's Witnesses' unique directive on the final outcome.
deCastro asserted that "The basic tenet of the Bloodless Surgery Program is that a patient's autonomy and medical decision making be respected." Ironically, since the Watchtower doctrine denies the rights and freedom of choice for dissident and ambivalent members to receive blood transfusions,2 deCastro's Bloodless Surgery Program inadvertently supports the religion's internal policy, which is in direct violation of the "basic tenet" he is upholding.
Osamu Muramoto, MD, PhD
Regional Ethics Council, Kaiser Permanente Northwest Division and Northwest Permanente P.C., Portland, OR 97227
Views and opinions expressed herein are the author's and do not necessarily reflect those of Kaiser Permanente and Northwest Permanente P.C.
1. Hebert PC, Wells G, Blajchman MA, Marshall J, Martin C, Pagliarello G, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. N Engl J Med 1999;340:409-17.
2. Muramoto O. Bioethics of the refusal of blood by Jehovah's Witnesses. Part 1. Should bioethical deliberation consider dissidents' views? J Med Ethics 1998;24:223-30.
Accession Number: 00000447-200001010-00041