Education and debate

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

Osamu Muramoto, council member. 

Regional Ethics Council, Kaiser Permanente, Interstate Medical Office East, Portland, OR 97227, USA

muramoto@aracnet.com

The medical community generally knows that Jehovah's Witnesses refuse blood transfusions. Jehovah's Witnesses reject red and white blood cells, platelets, and plasma, even at the cost of their lives, but they accept so called minor fractions such as albumin and globulin as a personal choice.¹ The church organisation, the Watchtower Society, introduced the policy on refusal of blood in 1945. Since 1961 the church has enforced it by "disfellowshipping" or expelling un-repentant members who wilfully accept prohibited blood components. Other members are then instructed by the church to ostracise and shun the expelled individual. Internal dissidents have criticised this practice, which they feel coerces those who have divergent views on this issue and compromises autonomous decision making in medical care. ^{2 3} I analyse the recently publicised changes in this policy from a bioethical viewpoint to help understand the impact of this controversial policy on clinical practice.⁴

Judicial proceedings
In June 2000, the Watchtower Society issued a directive stating that the organisation would no longer disfellowship members who did not comply with the policy of refusal of blood. Its official statement to the media was that "if a baptized member of the faith wilfully and without regret accepts blood transfusions, he indicates by his own actions that he no longer wishes to be one of Jehovah's Witnesses. The individual revokes his own membership by his own actions, rather than the congregation initiating this step. This represents a procedural change instituted in April 2000 in which the congregation no longer initiates the action to revoke membership in such cases. However, the end result is the same: the individual is no longer viewed as one of Jehovah's Witnesses because he no longer accepts and follows a core tenet of the faith."⁵ This directive was widely publicised in the press as a reversal of the policy regarding blood. ^{6 7} A similar policy was established in Bulgaria in 1998 with the European Commission of Human Rights,⁸ in which Bulgarian Jehovah's Witnesses were promised free choice to have blood transfusions "without control or sanction on the part of the association." Although an official from the Watchtower Society denied any change in the policy then,⁹ that there is a need to issue a similar directive worldwide two years later indicates that there has been a major procedural change in the policy for Bulgaria and elsewhere.

Wider selection of acceptable blood products
The other policy change came in the form of an article in the 15 June 2000 issue of the official magazine Watchtower.¹¹ After defining the "primary components" of blood (red and white blood cells, platelets, and plasma) that must be refused, the article stated that "beyond that, when it comes to fractions of any of the primary components, each Christian, after careful and prayerful meditation, must conscientiously decide for himself." Although some of these fractions, such as albumin and globulin, had already been considered a matter of personal decision, this new policy declared that "fractions of any of the primary components" are now acceptable. One of the most noteworthy points of this change is that the fractions or parts derived from prohibited cellular components are now permitted. The new policy cites interferons and interleukins as examples, but the most profound impact will be seen when and if haemoglobin based blood substitutes are introduced into general use. As recently as 1998 two representatives of the Watchtower Society wrote to a journal for researchers of blood substitutes stating that "[Jehovah's Witnesses] do not accept hemoglobin which is a major part of red blood cells . . . According to these principles then, Jehovah's Witnesses do not accept a blood substitute which uses hemoglobin taken from a human or animal source."¹² As haemoglobin based blood substitutes are now used in clinical trials with some success, this reversal of the ban on haemoglobin may have a major impact on the medical care of patients who are Jehovah's Witnesses who may participate in such trials.¹³

Under ideal protection of medical confidentiality, decisions on blood transfusion made by a patient who is a Jehovah's Witness would be known only to the patient and the medical team, not to the congregation. This means that the patient would have almost full control over whether he or she disassociates from the religion by his or her treatment decision being known to the congregation. If the patient personally believes that the decision to receive blood components of which the church disapproves does not violate God's commandment, as some dissident Witnesses do,³ then he or she could remain silent about the decision and continue membership provided his or her medical confidentiality is fully protected. Under the previous policy, any suspicion of receiving blood would prompt a judicial committee, which could elicit an involuntary confession from the patient and result in his or her disfellowshipping. For example, a red bag that a visitor casually observes hanging over the patient may be reported to the congregation without confirming whether it is a prohibited or permitted component. Such hearsay would have been sufficient ground to initiate a judicial committee. Under the new policy, such a formal inquiry is unlikely to happen, and the treatment would not be verified unless medical confidentiality is breached.

Obviously this potentially greater autonomy under the new policy hinges greatly on the integrity of medical confidentiality. Even though this change seems to facilitate the so called "don't ask" policy on the part of the congregation by not initiating judicial inquiry, it does not address breaches of medical confidentiality regarding blood transfusions or the "don't tell" policy on the part of the patient.¹⁴ In fact, in response to my proposal for a "don't ask, don't tell" policy for refusal of blood, Donald Ridley, legal counsel for the Watchtower Society, flatly denied such a possibility by saying that "it would encourage Witnesses to act privately in a manner they publicly declare to be wrong."¹⁵ He implied that the private medical decision of Witnesses should be restricted by the church's public policy, even though some Jehovah's Witnesses do not personally agree with it.³ This religion has a history of tacitly instructing its members to breach medical confidentiality when other members are non-compliant with the religion's medical policy. ^{16 17} This tradition was not changed in the recent directive. As long as unsolicited visitors and hospital workers who belong to the religion closely monitor the blood based treatment of patients who are Jehovah's Witnesses, there remains a possibility that the patient will be forced to disassociate from the religion because of a breach of confidentiality.

The immediate impact of these changes on the medical care of Jehovah's Witnesses may seem subtle but is still important. Because the change in judicial proceedings has a different meaning to different Jehovah's Witnesses, and this change has not been announced through their official magazines to rank and file members so far, doctors are likely to encounter patients who are Jehovah's Witnesses who have diverse views on the consequences of accepting blood. Some patients may reconsider their previous stance on the refusal of blood in light of this procedural change.

Because of these recent changes the use of various blood products is also viewed differently by patients who are Jehovah's Witnesses. The new policy is somewhat arbitrary about whether a product is considered "primary" or "secondary." Any product derived from a "primary component" can be considered secondary; however, there are many grey areas. For example, red cells are processed by leucocyte reduction, irradiation, and rejuvenation, and plasma may be processed through fractionation and treatment with solvent detergents into a secondary product. It is not at all clear whether these products are considered primary or secondary under this new policy. Some Jehovah's Witnesses may feel such distinction is left up to their conscientious decision. Others may consider only whole blood is unacceptable in view of the expanding list of approved blood fractions.

An in-depth discussion of the entire blood policy with individual patients may become necessary to ensure truly autonomous decisions on blood based treatment. Their advance directives and so called "blood cards" should be re-evaluated with the patients in light of the new policy. For example, doctors may ask patients who are Jehovah's Witnesses, "In view of the changing blood policy of the Watchtower Society, the component you now refuse may be considered acceptable in a few years. Are you sure you want to refuse it and die now even if you may not have to do so in the near future?" The doctor might add, "If your conscience allows you to receive this blood component but you are afraid that others may not approve your action, you might want to know that the Watchtower Society informed the media on 14 June 2000 that they ended the procedure of disfellowshipping for those who accept blood transfusions. Instead, you may be considered disassociated if your action is known to the congregation, but I assure you that your medical confidentiality is legally protected." Needless to say, all medical information on the use of blood products in these cases should be protected from unauthorised review. Otherwise legal liability may arise because of unintended sanction based on breached medical confidentiality.

Probably the most important advice to doctors at this time of flux in the policy of refusal of blood is to treat individual patients who are Jehovah's Witnesses independently of the church's official policy. Each case needs to be discussed and treated individually. Although this has essentially always been so, in actual practice most doctors and hospitals have treated this group collectively according to the church's official policy instead of thoroughly exploring personal conviction and preference. Doctors have often been encouraged to contact the church's representative (its hospital liaison committee) to decide individual treatment. Such practice should be re-evaluated in view of the increasing divergence and variability among the members. At the present time, premature death of exsanguinating patients who are Jehovah's Witnesses on the basis of this changing policy should be averted, as further changes in the near future may prevent such deaths completely.

The views and opinions expressed are those of the author and do not necessarily reflect those of Regional Ethics Council, Kaiser Permanente, and Northwest Permanente PC.

Competing interests: The author has no competing financial interest. He is neither a current nor former Jehovah's Witness. His religious position is neutral and is not affiliated with any organised religion. He has served since 1997 as a volunteer medical consultant without compensation to the Associated Jehovah's Witnesses for Reform on Blood, a Jehovah's Witness group that advocates a reform of the Watchtower Society's policy on blood. He has relatives who are Jehovah's Witnesses and whose interest may be affected by publication of this paper.

(Accepted 11 September 2000)