Dr. John Doyle, MD, PhD
Professor Doyle served as a consultant to AJWRB for many years and authored several articles on blood transfusion refusal risks published at AJWRB. He passed away in 2025 at the age of 66. AJWRB gratefully acknowledges his service and contributions. He will be missed.
Although much has been made about a medical rethinking of the risk/benefit properties of blood transfusions as a result of HIV, AIDS, and Patient Blood Management (PBM), understanding blood transfusion refusal risks remains essential to life in a large number of clinical situations. Patients who refuse a blood transfusion deemed absolutely medically necessary by a physician put themselves at risk of dying from severe anemia. For example, Carson et al. studied 125 surgical patients who were Jehovah’s Witnesses and thus refused blood transfusion. It was found that over 60% of patients whose preoperative hemoglobin fell below 6 g/dL died following the surgery. [1] Full data is given below.
Clinical Data on Blood Transfusion Refusal Risks in Severe Anemia
| Preoperative Hemoglobin | Mortality |
|---|---|
| < 6 g/dL | 61.5% |
| 6.1 – 8 g/dL | 33% |
| 8.1 – 10 g/dL | 0% |
| > 10 g/dL | 7.1% |
When is a blood transfusion “necessary?”
A reasonable answer might be whenever failure to transfuse puts the patient at “high risk” of injury when transfusion itself is not highly risky. For example, when evaluating blood transfusion refusal risks, if the chance of suffering a heart attack (myocardial infarct), stroke (cerebrovascular accident), or similar complication from severe anemia is 15%, while the risk of transmitting a blood-borne pathogen is only 0.5%, many physicians would regard the risk/benefit ratio of transfusing as quite acceptable.
However, in real life, specific numbers are generally not available, which is why in practice one must rely on clinical judgment and published guidelines to appropriately manage blood transfusion refusal risks. For example, Carson (American Journal of Surgery 1995;170(6A supp): 325) suggests that patients with cardiopulmonary disease should have their hemoglobins kept at or above 10 g/dL, while otherwise healthy patients should be kept at or above 7 g/dL (see full chart below).
| Keep Hb > 10 g/dL | Keep Hb 7-10 g/dL |
|---|---|
| • patients with coronary artery disease | • young patients |
| • patients with a history of congestive heart failure | • patients with good life expectancy |
| • patients with chronic obstructive pulmonary disease | • patients who are otherwise healthy |
| • patients with peripheral vascular disease | |
| • patients with a history of stroke | |
| • use of beta blockers | |
| • situations where heavy blood losses are expected | |
| • elderly patients | |
| • patients with poor life expectancy |
Summary of Clinical Guidelines
Patients should ordinarily have their hemoglobin maintained above 7 g/dL if they are otherwise healthy, with a higher threshold of 10 g/dL applying to patients with significant cardiopulmonary disease. Should a severely anemic patient undergo surgery without necessary blood support, the clinical mortality rate becomes exceptionally high. Specifically, there is an over 60% mortality rate for patients presenting with a preoperative hemoglobin below 6 g/dL. Understanding these blood transfusion refusal risks is vital for both patients and healthcare providers when navigating complex, life-threatening medical decisions. Jehovah’s Witnesses commonly have questions about these risks.
Reference Data: [1] Lancet 1988 Apr 2;1(8588):727-9. “Severity of anaemia and operative mortality and morbidity.” Carson JL, Poses RM, Spence RK, Bonavita G. Department of Medicine, University of Medicine and Dentistry of New Jersey/Robert Wood Johnson Medical School, New Brunswick.
“In a case-control study of 125 surgical patients who declined blood transfusions for religious reasons, operative mortality was inversely related to the preoperative haemoglobin level, rising from 7.1% for patients with levels above 10 g/dl to 61.5% for those with levels below 6 g/dl. Mortality rates were also related to blood loss during surgery, rising from 8% for patients who lost less than 500 ml to 42.9% fo
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