1945, the Watchtower Bible and Tract Society (WTS), the controlling
organization of Jehovah's Witnesses (JWs), has promulgated to all its
a doctrine to refuse blood and certain blood products for their medical
treatment. They teach that the biblical command, "you must not eat
(Leviticus 17:12) and "abstain from blood" (Acts 15:29), means "not
it into our bodies at all," including prohibition of the medical use of
blood.1 For the
past half century, this doctrine has
brought numerous challenges in medical care of JW patients, and
tragic premature deaths. Although the doctrine is said to be an
law" of God, it has recently undergone major revisions. In this review,
I will discuss some of these developments, which impact on the medical
care of approximately ten-million adherents world-wide for whom blood
may be an issue.
progress in bloodless medicine, the care of Jehovah's Witness patients
who refuse blood-based treatments is difficult .
signed by the organization at the European Commission of Human Rights
that Jehovah's Witnesses should have free choice to receive blood
without any control or sanction from the organization.
emergence of reform Jehovah's Witnesses, who petition for a right to
of personal choice to accept or refuse blood transfusions, indicates a
growing diversity among the followers in their attitudes toward the
approach to each patient, respecting their diversity of beliefs and
has become increasingly important.
used in text: JW=Jehovah's Witness, WTS=Watchtower Bible and Tract
HIS=Hospital Information Service; HLC=Hospital Liaison Committee;
Jehovah's Witnesses for Reform on Blood
between acceptable and unacceptable treatments
physicians who treat JWs, one of the most puzzling aspects is that they
are, in fact, accepting many blood-based treatments despite their
in absolute abstinence from blood. Since this biblical law is said to
absolute, it is unclear why the WTS does not teach its members to
refuse all medical use of blood. On one hand, they teach that God
any intake of blood into the body regardless of the methods, whether
it in the biblical era, or infusing it in modern medicine. On the other
hand, they have meticulously sorted out various methods of blood intake
in medical settings, and classified them either as acceptable or
depending on the method. As new blood-based treatments become
such classification has become a daunting task.
1 summarizes the current policy and practice of prohibited and
treatments. Table 2 shows the complex conditions under which the same
similar material or procedure may become acceptable or unacceptable.
in these tables is a composite from WTS publications, including their
directive form, as well as articles by JW physicians.2,6
Many JWs do not understand or remember such complicated
1 Current policy and practice of WTS on prohibited and
Blood Components and Procedures
Blood Components and Procedures
proteins (albumin, globulin, fibrin)
machine, dialysis, plasmapheresis)
donated blood (to take acceptable components)
2 Complex conditions that make similar components/procedures
May Not Accept ....
May Accept ....
taken as "blood transfusion" #
taken as contained in bone marrow transplants3
taken together as "plasma" #
taken separately as individual blood component (albumin, globulin,
taken as "white blood cells" #
taken as "peripheral stem cells"4,5
tube connection to the patient's body is interrupted #
tube connection to the patient's body is maintained (hemodilution, cell
it is stored #
taken as "peripheral stem cells" (even if it is stored)4
taken from umbilical cord blood7
taken from peripheral blood or bone marrow3,4
protein from prohibited component
taken from red blood cells (hemoglobin)6 #
taken from plasma (albumin)2
patient's blood is used to prime the machine #
patient's blood is used to circulate in the machine
blood is removed from vein and injected
injecting syringe is connected to vein via tube
donated by JWs for use of JWs and others #
donated by non-JWs for use of JWs and others
marked by # are observed by JWs without exception. Other conditions are
observed by many JWs but with exceptions. For example, JWs never accept
a heart-lung machine primed with blood, but most, if not all, JWs
the machine as long as it is circulated with own blood.
facts have prompted the WTS to form the "Hospital Information Service"
(HIS) in its headquarters, a public relations office for the blood
It answers inquiries regarding "no-blood" treatment, and interprets the
rules and conditions for patients and doctors. The HIS researches
literature, recommends various no-blood treatments, and provides
to cooperative physicians. In addition, more than 1200 "Hospital
Committees"(HLCs), which consist of selected elders who received
training from HIS, are established worldwide. Its members visit
to present the policy. They provide the same service as HIS locally,
can intervene between JW patients and physicians as needed.
movement inside JWs
1996, a growing number of JWs, including some members of HLCs, have
anonymously their dissent to the blood policy.10 They
formed a group called the Associated Jehovah's Witnesses for Reform on
Blood (AJWRB).11,12 They call
for a reform of the blood policy which, according to them, is plagued
a complicated web of contradictory rules and conditions strictly
without biblical basis. Some members of HLCs have resigned because of
they call "Pharisaic" rules. The WTS has dismissed them as "disaffected
ones" and discredited them because of AJWRB's anonymity.13,14
However, according to AJWRB, it is not possible, other than
for a JW to voice any criticism of the WTS or propose any reform from
the organization, because such public expression almost certainly
in expulsion of the members.12
significance of this reform movement for physicians is awareness of a
diversity of values and beliefs among individual JWs, who have long
viewed as a uniform religious group. Such diversity requires physicians
to scrutinize the patient's premolded medical directive more closely
take a more individualized approach.
of choice in JWs' medical care
it is well known that the WTS has fought many years for freedom of
to refuse blood transfusions vis-á-vis legal authorities and medical
professions - members within the WTS are not accorded the same freedom
of choice to receive blood transfusions without penalty. The fact that
the very freedom that the WTS has demanded outside the organization has
been denied inside the organization is another major point of reform
for by the AJWRB. Any JW who openly and willfully receives a prohibited
blood-based treatment and does not repent of the action before a
committee" will receive the harshest sanction of the religion,
or "disfellowshipping." This is considered equal to betraying God and
shunning, or isolation from normal association or fellowship with
and life-long friends who are members. Many former JWs testify to the
trauma associated with leaving the religion.
punitive measure may soon change. One of the most important
of the blood policy of JWs in recent years is the public agreement
in 1998 between the WTS and the government of Bulgaria at the European
Commission of Human Rights. The WTS agreed that JWs in Bulgaria "should
have free choice" to receive blood transfusions "without any control or
sanction on the part of the association."15,16
This apparent compromise was made in exchange for registration of JWs
a religion in that country. The WTS has been reticent with their
about their promise of "free choice" in Bulgaria, and only issued a
and a press release stating that there has been no change in the blood
Nevertheless, a WTS representative, quoting
the charter accepted by the Bulgarian government, now states that the
"may not exercise control over free will of believers but allows them
exercise their conscience consistent with godly Bible principles." He
states that the WTS does not "arbitrarily apply sanctions in connection
with the medical care that Jehovah's Witnesses conscientiously seek for
themselves and children," and this, according to him, is the
beliefs of JWs internationally.14
statements appear to conflict with the enforced policy of expelling and
ostracizing those who conscientiously receive blood transfusions and do
not repent. According to AJWRB, these WTS statements could be
to mean that each member may exercise personal conscience to choose
blood components are acceptable in medical treatment, since the "godly
Bible principles" are silent over what is or is not acceptable in blood
components. On the other hand, the statements allow the WTS to
apply sanctions" and to continue to "exercise control over free will."
We should expect further clarification from the WTS to explain this
In the meantime, it is an indication that JWs may soon be given the
to choose their own medical care, including acceptance or refusal of
without organizational control.
and legal issues of the blood card and informed refusal
use of the "blood card," a wallet-sized advance directive created by
WTS and carried by JWs, has been controversial. The card is intended to
document the JW's informed refusal of blood in the event of an
Yet, the validity of the card has been questioned, particularly when a
JW patient presents to the emergency room unconscious and
with the blood card being the only expression of will.17
There are two main reasons to challenge the validity of such
it is unclear whether such a directive was signed as a spontaneous and
personal decision, or as an obligation to comply with the
rules as a member. Every year in January, new cards are handed out to
JWs to sign. Group leaders are instructed to ensure that every member
the card during a private group meeting. Such a signing procedure could
be coercive due to strong peer pressure.
there is a serious concern whether JWs were adequately informed of the
risk versus benefit analysis of blood-based treatments when they signed
the card. In their official magazines, horrifying stories about tragic
cases of blood-based treatments collected from medical journals and
media have been presented, yet there has never been any article that
weighs the benefit of blood transfusions against the risk. Such biased
information raises serious concern about the validity of the informed
expressed in the blood card.
Migden and Braen stated,17
it appears that the real
purpose of the blood card is not to ensure that JWs make an informed
regarding blood-based treatment, but rather to prevent JWs from
blood. Under such strict organizational directives imposed by the WTS,
autonomy of JW patients, which is a prerequisite of informed consent,
be suppressed. Considering these factors, Migden and Braen concluded
a good faith decision to transfuse an unconscious adult JW in emergent
need of blood is justified if the patient does not have a blood refusal
advance directive that is informed and can survive a high level of
Proctor, right, mother of Jadine Russell, a pedestrian who died after
hit by a drunk driver, wipes away a tear outside the courtroom after
driver's trial. The victim, a Jehovah's Witness, refused a blood
which the defense argued actually caused her death.
view of such potential problems of the blood card, the WTS in recent
has put more emphasis on filling out a full advance directive form for
refusal of blood, in conjunction with a health-care power of attorney
form prepared by the WTS for each state. JWs are encouraged to fill out
these forms and submit them for their health care providers to have on
record. The forms include legal references for judges and hospital
who may question or challenge the legality of the blood policy. The
detail WTS-approved alternatives for blood treatment, and instruct as
what treatments JWs must not accept under any circumstances, even to
their lives. The forms also list which blood components and procedures
may be allowed and under what circumstances, subject to an individual's
conscience (see Table 1 and 2). The WTS now encourages JWs to indicate
on the blood card that they have executed the advance directive forms
management of JW patients
no life-threatening condition exists, and alternative bloodless
is readily available without excessive cost or risk, treatment of JWs
be no different from other patients. They do not refuse other medical
and are generally conscientious about their own health and respectful
ethical controversy arises when there are limited or no alternatives to
blood-based treatment. Until the WTS publishes more simplified rules,
allows all medical treatment decisions to be based on individual
the care of such JW cases will remain complicated. It is not sufficent
to either blindly comply with the pre-molded directive, or flatly
treatment and refer to another hospital or doctor.
patient's personal beliefs and understanding of the risk versus benefit
should be carefully discussed in private conference. Religious
need not be avoided since organizational control of patients' choices
inseparable from their religious conviction.18 Only
a small number of JWs understand the complex rules and conditions of
policy of their own organization. For this reason, I recommend that any
medical professionals dealing with JW patients obtain a small brochure
Do Jehovah's Witnesses Really Abstain From Blood? published by AJWRB 19
for reference in such discussions. It is written by JWs themselves and
concisely discusses the questions of the blood policy. It is also
to seek ethics consultation in complicated cases.
is acceptable or unacceptable treatment should ultimately be determined
by the individual patient, in concert with advice from treating
Some JW patients may delegate their decision to the WTS and ask the HLC
to intervene on their behalf. Others may be autonomous enough to make
decisions based on new perspectives.
decision the patient makes, extra precaution must be taken to ensure
privacy and confidentiality of those decisions. The WTS once published
an article in its official magazine that encouraged JWs who work in the
medical field to divulge confidential medical information of fellow JW
patients who secretly receive medical treatment prohibited by the WTS.20
emergency treatment of exsanguinating JW patients continues to be
There is no time to obtain informed consent to transfuse blood. Every
should be made to stabilize the patient so that valid and
informed consent can be obtained. If the patient is unable to express a
contemporaneous decision and there is no valid advance directive, or
is reasonable doubt about the validity of the blood card, emergency
transfusions may be given until the patient is relieved from imminent
are several reasons to support this course of action. First, emergency
exception to consent has been an established medicolegal principle. The
Pennsylvania Supreme Court held that "...where there is an emergency
for an immediate decision, nothing less than a fully conscious
decision by the patient will be sufficient to override evidence of
Second, JWs who were unconsciously transfused
are not subject to the religion's judicial process or sanctions. Third,
as reviewed here, since there is an indication of change in the policy
on the horizon, premature death at the present time due to blood loss
of JW parents should be given treatment independently from their
religion. As the Committee of Bioethics of the American Academy of
stated, "constitutional guarantees of freedom of religion do not permit
children to be harmed through religious practices."22
In emergency situations where there is risk of harm to the child by
blood-based treatment, immediate danger should be relieved, including,
if necessary, giving blood-based treatment. Decisions regarding "mature
minors" or adolescent children are more problematic. The maturity of
child is different, and so is the child's understanding and commitment
to the blood policy. If there is any unsolved ethical or legal issue
JW children, it is most appropriate to obtain a court order before
Views and opinions expressed herein are the author's and do not
reflect those of Kaiser Permanente and Northwest Permanente P.C. The
has served as a medical consultant to the AJWRB since 1997 without
He has never been a Jehovah's Witness.
Ethics Council and Department of Neurology,
Permanente Northwest Division, and Northwest Permanente P.C.,
to: Dr Muramato
East Interstate Office, 3414 N.W.
Center Drive, Portland, OR 97227
You Can Live Forever in Paradise on Earth. Brooklyn:
Bible and Tract Society of Pennsylvania, 1989, p216.
Dixon JL, Smalley MG. Jehovah's Witnesses. The surgical/ethical
JAMA 1981; 246:2471-2472.
Questions from readers. The Watchtower; 1984 May 15:31.
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. Arch Intern Med 1998; 157:1753-1757.
Muramoto O. Medical ethics in the treatment of Jehovah's Witnesses. Arch
Intern Med 1998; 158:1155-1156.
Malak J Jehovah's Witnesses and medicine: an overview of beliefs and
in their care. J Med Assoc Ga 1998; 87:322-327.
Questions from readers. The Watchtower; 1997 Feb 1:29.
Kanumilli V, Kaza R, Johnson C, Nowacki. Epidural blood patch for
Witness patient. Anesth Analg 1993; 77:872-873.
Questions from readers. The Watchtower; 1961 Jan 15:64.
Muramoto O. Bioethics of the refusal of blood by Jehovah's Witnesses:
1. Should bioethical deliberation consider dissidents' views? J Med
Ethics 1998; 24:223-230.
"New Light on Blood. Official site of The Associated Jehovah's
for Reform on Blood:" http://www.visiworld.com/starter/newlight/index.htm.
The Liberal Elder. Reply to Malyon on respecting the autonomy and
of Jehovah's Witness patients. J Med Ethics (Submitted for
Malyon D. Transfusion-free treatment of Jehovah's Witnesses: respecting
the autonomous patient's rights. J Med Ethics 1998;
Malyon D. Transfusion-free treatment of Jehovah's Witnesses: respecting
the autonomous patient's motives. J Med Ethics 1998;
Communique issued by the Secretary to the European Commission of Human
Rights. INFORMATION NOTE No. 148 on the 276th Session of the European
of Human Rights. (Strasbourg, Monday 2 March-Friday 13 March 1998). http://188.8.131.52/eng/E276INFO.148.html.
Muramoto O. Jehovah's Witnesses and blood transfusions. Lancet
Wilcox P. Jehovah's Witnesses and blood transfusions. Lancet
Migden DR, Braen GR. The Jehovah's Witness blood refusal card: ethical
and medicolegal considerations for emergency physicians. Acad Emerg
Med 1998; 5:815-824.
Muramoto O. Bioethics of the refusal of blood by Jehovah's Witnesses:
2. A novel approach based on rational non-interventional paternalism. J
Med Ethics 1998; 24:295-301.
Do Jehovah's Witnesses really abstain from blood? Boise: The Associated
Jehovah's Witnesses for Reform on Blood. 1998 (available by writing to
AJWRB, PO Box 190089 Boise, ID 83719-0089, or on-line at http://www.ajwrb.org/physicians/index.shtml).
"A time to speak" - when? The Watchtower; 1987 Sept 1:12.
Re Estate of Darrell Dorne, 534 A.2d 452 (Pa. 1987).
American Academy of Pediatrics Committee on Bioethics. Religious
to medical care. Pediatrics 1997; 99:279-281.