Distinction between acceptable and unacceptable treatments
For physicians who treat JWs, one of the most puzzling aspects is that they are, in fact, accepting many blood-based treatments despite their belief in absolute abstinence from blood. Since this biblical law is said to be absolute, it is unclear why the WTS does not teach its members to simply refuse all medical use of blood. On one hand, they teach that God prohibits any intake of blood into the body regardless of the methods, whether eating 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 unacceptable, depending on the method. As new blood-based treatments become available, such classification has become a daunting task. 

Table 1 summarizes the current policy and practice of prohibited and acceptable treatments. Table 2 shows the complex conditions under which the same or similar material or procedure may become acceptable or unacceptable. Information in these tables is a composite from WTS publications, including their advance directive form, as well as articles by JW physicians.2,6 Many JWs do not understand or remember such complicated regulations. 
 
 
 

Table 1 Current policy and practice of WTS on prohibited and acceptable treatments
Prohibited Blood Components and Procedures	Acceptable Blood Components and Procedures
Whole blood	Plasma proteins (albumin, globulin, fibrin)
Red blood cells	Clotting factors
Platelets	Stem cells
Plasma	Hemodilution, cell saver
Hemoglobin solution	Bone marrow transplants
Stored autologous blood	Extracorporeal circulation  (heart-lung machine, dialysis, plasmapheresis)
Blood donation	Use of donated blood (to take acceptable components)

Table 2 Complex conditions that make similar components/procedures acceptable or unacceptable
	JWs May Not Accept ....	JWs May Accept ....
Whole blood2	IF taken as "blood transfusion" #	IF taken as contained in bone marrow transplants3
Plasma proteins2	IF taken together as "plasma" #	IF taken separately as individual blood component (albumin, globulin, clotting factors, fibrin)
White blood cells2	IF taken as "white blood cells" #	IF taken as "peripheral stem cells"4,5
Autologous blood2	IF tube connection to the patient's body is interrupted #	IF tube connection to the patient's body is maintained (hemodilution, cell saver)
	IF it is stored #	IF taken as "peripheral stem cells" (even if it is stored)4
Stem cells6	IF taken from umbilical cord blood7	IF taken from peripheral blood or bone marrow3,4
Major protein from prohibited component	IF taken from red blood cells (hemoglobin)6 #	IF taken from plasma (albumin)2
Heart-lung machine2	IF patient's blood is used to prime the machine #	IF patient's blood is used to circulate in the machine
Epidural blood patch8	IF blood is removed from vein and injected	IF injecting syringe is connected to vein via tube
Blood donation9	IF donated by JWs for use of JWs and others #	IF donated by non-JWs for use of JWs and others
Conditions 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 accept the machine as long as it is circulated with own blood.

These facts have prompted the WTS to form the "Hospital Information Service" (HIS) in its headquarters, a public relations office for the blood policy. It answers inquiries regarding "no-blood" treatment, and interprets the rules and conditions for patients and doctors. The HIS researches medical literature, recommends various no-blood treatments, and provides references to cooperative physicians. In addition, more than 1200 "Hospital Liaison Committees"(HLCs), which consist of selected elders who received special training from HIS, are established worldwide. Its members visit hospitals to present the policy. They provide the same service as HIS locally, and can intervene between JW patients and physicians as needed. 

Reform movement inside JWs
Since 1996, a growing number of JWs, including some members of HLCs, have expressed 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 by a complicated web of contradictory rules and conditions strictly enforced without biblical basis. Some members of HLCs have resigned because of what 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 anonymously, for a JW to voice any criticism of the WTS or propose any reform from within the organization, because such public expression almost certainly results in expulsion of the members.12

The significance of this reform movement for physicians is awareness of a growing diversity of values and beliefs among individual JWs, who have long been viewed as a uniform religious group. Such diversity requires physicians to scrutinize the patient's premolded medical directive more closely and take a more individualized approach. 

Freedom of choice in JWs' medical care
Although it is well known that the WTS has fought many years for freedom of choice 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 called 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 "judicial committee" will receive the harshest sanction of the religion, excommunication or "disfellowshipping." This is considered equal to betraying God and involves shunning, or isolation from normal association or fellowship with family and life-long friends who are members. Many former JWs testify to the psychological trauma associated with leaving the religion. 

This punitive measure may soon change. One of the most important developments of the blood policy of JWs in recent years is the public agreement established 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 as a religion in that country. The WTS has been reticent with their members about their promise of "free choice" in Bulgaria, and only issued a letter and a press release stating that there has been no change in the blood policy.16a Nevertheless, a WTS representative, quoting the charter accepted by the Bulgarian government, now states that the WTS "may not exercise control over free will of believers but allows them to exercise their conscience consistent with godly Bible principles." He also 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 established beliefs of JWs internationally.14

These 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 interpreted to mean that each member may exercise personal conscience to choose which 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 "non-arbitrarily apply sanctions" and to continue to "exercise control over free will." We should expect further clarification from the WTS to explain this discrepancy. In the meantime, it is an indication that JWs may soon be given the right to choose their own medical care, including acceptance or refusal of blood, without organizational control. 

Ethical and legal issues of the blood card and informed refusal
The use of the "blood card," a wallet-sized advance directive created by the 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 emergency. Yet, the validity of the card has been questioned, particularly when a JW patient presents to the emergency room unconscious and exsanguinating, with the blood card being the only expression of will.17 There are two main reasons to challenge the validity of such cards. 
 

First, it is unclear whether such a directive was signed as a spontaneous and personal decision, or as an obligation to comply with the organizational rules as a member. Every year in January, new cards are handed out to all JWs to sign. Group leaders are instructed to ensure that every member sign the card during a private group meeting. Such a signing procedure could be coercive due to strong peer pressure.  Second, 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 news media have been presented, yet there has never been any article that objectively weighs the benefit of blood transfusions against the risk. Such biased information raises serious concern about the validity of the informed refusal expressed in the blood card.  As Migden and Braen stated,17 it appears that the real purpose of the blood card is not to ensure that JWs make an informed decision regarding blood-based treatment, but rather to prevent JWs from receiving blood. Under such strict organizational directives imposed by the WTS, autonomy of JW patients, which is a prerequisite of informed consent, may be suppressed. Considering these factors, Migden and Braen concluded that 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 scrutiny.
		Catheryn Proctor, right, mother of Jadine Russell, a pedestrian who died after being hit by a drunk driver, wipes away a tear outside the courtroom after the driver's trial. The victim, a Jehovah's Witness, refused a blood transfusion, which the defense argued actually caused her death. Victoria Arocho/Associated Press.

 

In view of such potential problems of the blood card, the WTS in recent years 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 (proxy) 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 lawyers who may question or challenge the legality of the blood policy. The forms detail WTS-approved alternatives for blood treatment, and instruct as to what treatments JWs must not accept under any circumstances, even to save 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 of their state. 

Clinical management of JW patients
When no life-threatening condition exists, and alternative bloodless treatment is readily available without excessive cost or risk, treatment of JWs should be no different from other patients. They do not refuse other medical treatment and are generally conscientious about their own health and respectful of physicians. 

Major ethical controversy arises when there are limited or no alternatives to blood-based treatment. Until the WTS publishes more simplified rules, and allows all medical treatment decisions to be based on individual conscience, the care of such JW cases will remain complicated. It is not sufficent to either blindly comply with the pre-molded directive, or flatly refuse treatment and refer to another hospital or doctor. 

The patient's personal beliefs and understanding of the risk versus benefit should be carefully discussed in private conference. Religious discussion need not be avoided since organizational control of patients' choices are inseparable from their religious conviction.18 Only a small number of JWs understand the complex rules and conditions of blood 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 important to seek ethics consultation in complicated cases. 

What is acceptable or unacceptable treatment should ultimately be determined by the individual patient, in concert with advice from treating physicians. 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 individualized decisions based on new perspectives. 

Whatever decision the patient makes, extra precaution must be taken to ensure the 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

Life-threatening emergency treatment of exsanguinating JW patients continues to be problematic. There is no time to obtain informed consent to transfuse blood. Every effort should be made to stabilize the patient so that valid and contemporaneous informed consent can be obtained. If the patient is unable to express a contemporaneous decision and there is no valid advance directive, or there is reasonable doubt about the validity of the blood card, emergency blood transfusions may be given until the patient is relieved from imminent danger of death.17

There 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 calling for an immediate decision, nothing less than a fully conscious contemporaneous decision by the patient will be sufficient to override evidence of medical necessity."21 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 must be averted. 

Treatment of children
Children of JW parents should be given treatment independently from their parents' religion. As the Committee of Bioethics of the American Academy of Pediatrics 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 withholding 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 each 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 regarding JW children, it is most appropriate to obtain a court order before proceeding further. 

Disclaimer/Disclosure Views and opinions expressed herein are the author's and do not necessarily reflect those of Kaiser Permanente and Northwest Permanente P.C. The author has served as a medical consultant to the AJWRB since 1997 without compensation. He has never been a Jehovah's Witness. 

Osamu Muramoto 

Regional Ethics Council and Department of Neurology, 
Kaiser Permanente Northwest Division, and Northwest Permanente P.C., 
Portland, 
Oregon 

Correspondence to: Dr Muramato 

Kaiser East Interstate Office, 3414 N.W. 
Kaiser Center Drive, Portland, OR 97227 

muramotosa@kpnw.org

Sources and References 

1. You Can Live Forever in Paradise on Earth. Brooklyn: Watch Tower Bible and Tract Society of Pennsylvania, 1989, p216. 

2. Dixon JL, Smalley MG. Jehovah's Witnesses. The surgical/ethical challenge. JAMA 1981; 246:2471-2472. 

3. Questions from readers. The Watchtower; 1984 May 15:31. 

4. 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. 

5. Muramoto O. Medical ethics in the treatment of Jehovah's Witnesses. Arch Intern Med 1998; 158:1155-1156. 

6. Malak J Jehovah's Witnesses and medicine: an overview of beliefs and issues in their care. J Med Assoc Ga 1998; 87:322-327. 

7. Questions from readers. The Watchtower; 1997 Feb 1:29. 

8. Kanumilli V, Kaza R, Johnson C, Nowacki. Epidural blood patch for Jehovah's Witness patient. Anesth Analg 1993; 77:872-873. 

9. Questions from readers. The Watchtower; 1961 Jan 15:64. 

10. Muramoto O. Bioethics of the refusal of blood by Jehovah's Witnesses: Part 1. Should bioethical deliberation consider dissidents' views? J Med Ethics 1998; 24:223-230. 

11. "New Light on Blood. Official site of The Associated Jehovah's Witnesses for Reform on Blood:" http://www.visiworld.com/starter/newlight/index.htm. 

12. The Liberal Elder. Reply to Malyon on respecting the autonomy and motives of Jehovah's Witness patients. J Med Ethics (Submitted for publication). 

13. Malyon D. Transfusion-free treatment of Jehovah's Witnesses: respecting the autonomous patient's rights. J Med Ethics 1998; 24:302-307. 

14. Malyon D. Transfusion-free treatment of Jehovah's Witnesses: respecting the autonomous patient's motives. J Med Ethics 1998; 24:376-381. 

15. Communique issued by the Secretary to the European Commission of Human Rights. INFORMATION NOTE No. 148 on the 276th Session of the European Commission of Human Rights. (Strasbourg, Monday 2 March-Friday 13 March 1998). http://194.250.50.201/eng/E276INFO.148.html. 

16. Muramoto O. Jehovah's Witnesses and blood transfusions. Lancet 1998; 352:824. 

16a. Wilcox P. Jehovah's Witnesses and blood transfusions. Lancet 1999; 353:757-758. 

17. 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. 

18. Muramoto O. Bioethics of the refusal of blood by Jehovah's Witnesses: Part 2. A novel approach based on rational non-interventional paternalism. J Med Ethics 1998; 24:295-301. 

19. 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). 

20. "A time to speak" - when? The Watchtower; 1987 Sept 1:12. 

21. Re Estate of Darrell Dorne, 534 A.2d 452 (Pa. 1987). 

22. American Academy of Pediatrics Committee on Bioethics. Religious objections to medical care. Pediatrics 1997; 99:279-281.