Introduction

She was my first surgical patient; the Spanish lady in bed 16 admitted with acute biliary colic. Due to a shortage of patients another student actually `clerked' her whilst I just sat and listened, adding the odd constructive comment. We'd been told that our consultant generally regarded the social history as a waste of time so we skimmed over it. However it was just as well that we looked at her drug chart to check on some obscure medication: for there, in huge red letters, was scrawled `JW'. My fellow student, being unaware of JWs' stand on blood transfusions, did not consider this relevant information in a patient about to undergo an operation which, under normal circumstances, might need a blood transfusion. Mind you when she later asked me to explain the reasons behind this unique prohibition I found my knowledge woefully inadequate. It was that realisation which inspired me to research this article and I hope that it will be of use to any of you who are placed in a similar situation in the future.

A brief history of the Jehovah's Witness movement

The Jehovah's Witness movement was founded in 1884, in the United States, by Charles Taze Russell. Russell, reputedly a compelling speaker, had previously been a member of a conventional Christian church but then found reasons to disagree with much of its theology.[1] The movement, originally known as Zion's Watchtower Society, preaches a literal belief in the Bible, aided by Russell's own `Aid to Bible Understanding'. Whilst originally basing their doctrines on the King James Version, in 1961 they introduced their own version, `The New World Translation of the Holy Scriptures', with significant alterations from other, accepted translations. They deny, among other things, the Trinity, the personage of the Holy Spirit, the deity of Christ, bodily resurrection and a visible Second Coming. They represent one of the largest cults in the world today, publishing more material than all the other world cult groups combined.

The introduction of the blood transfusion taboo

The prohibition of blood transfusions was introduced by the Society towards the end of World War II. Its introduction was a relatively gradual process and followed prior objections to vaccination, inoculation and sorgan transplantation. (Since the 1950s acceptance of these treatments has been left up to the individual's conscience.) The first direct mention of the prohibition was in 1944: 'Not only as a descendant of Noah, but now also as one bound by God's law to Israel which incorporated the everlasting covenant regarding the sanctity of life-sustaining blood, the stranger was forbidden to eat or drink blood, whether by transfusion or by the mouth. [2]

In an attempt to strengthen the prohibition, Jehovah's Witnesses were referred to previous Watchtower articles which actually bore no relevance to the subject under discussion, being on other topics such as eating blood and murder.[3]

The whole subject seemed to be somewhat controversial, with a notorious quote, often cited as proof of doctrinal inconsistency by the Society's adversaries, in the September 1945 Dutch edition of 'Consolation':

'God never issued provisions prohibiting the use of medicine, injections or blood transfusion. It is an invention of the people who, like the Pharisees, leave Jehovah's mercy and love aside'[4]

In reality this quote merely shows the inadequacies of post-war communication and the arbitrary nature of the prohibition's introduction.

The prohibition was openly ignored by many members until 1951 when the first court case occurred in Chicago. The case involved Cheryl LaBrenz, the second child of Rhoda and Darrell LaBrenz, who suffered from haemolytic disease of the newborn.[5,6] It brought to light the practical problems which such a prohibition posed. From that point on Witnesses started to ask questions and a clearly defined stand, supposedly with biblical justification, was developed.

Many people have questioned why such a controversial doctrine was ever introduced. As Bergman [7] concludes there is probably no one reason but the need for world-wide cohesive unity and the re- establishment of a universal collective identity were clearly motivating factors. After all, World War I I marked the climax of the Witnesses' persecution when they were imprisoned in concentration camps in Nazi-occupied Europe, and marked out as social deviants in the USA for their stand as conscientious objectors and refusal to salute the flag or sing the National Anthem.[8] They also faced the prospect of a whole new administration, under Knorr's presidency, following the death of Judge Rutherford. In this context the complete avoidance of blood may well have been a means of `setting apart' Witnesses and consolidating their loyalty to the Society.

Biblical arguments

The Jehovah's Witnesses' claim that their prohibition of blood transfusions has a scriptural basis relies primarily on three passages: Genesis 9:4, Leviticus 17:11-14 and Acts 15:20, 29. It is based on the premise that a blood transfusion involves the use of blood as a nutrient, or food, and is therefore comparable to eating blood.

As regards Genesis 9:4, the Society teaches that this refers to a prohibition on eating blood which applies to all mankind, Jew or Gentile.[9,10] It seems that the verse is referring to the eating of animals which have been killed without being bled. Also the very use of the word lifeblood (NIV) emphasises the close relationship between blood and life. Throughout history many pagans believed that by eating life that is `in the blood (Lv 17:11 ) they could increase their own life-force. This verse serves to correct that misconception and to remind us that life is the precious and mysterious gift of God: 'Just as I gave you the green plants, I now give you everything'. (Gn 9:3).

Indeed the Society's teaching is inconsistent with their own teaching that:

`Jehovah's Witnesses (spiritual Jews) do not oppose the people's (spiritual Gentiles) use of transfusion, but allow each one to decide for himself what he can conscientiously do. The lsraelites felt bound to abide by God's law of forbidding the eating of meat with blood congealed in it, but still they had no objection whatever to those outside God's organisation doing it, and even supplied unbled carcasses to outsiders who regularly ate such things anyway.'[11]

So does Genesis 9:4, as part of the Noahic Law, apply to all or not? Deuteronomy 14:21 would initially seem to contradict the Genesis position, stating as it does that an Israelite could sell the undrained carcass of an animal to a Gentile. However, that is not necessarily the case 'if the Noahic Covenant is seen as superseded by the Old Covenant. The Society itself states:

`... After Jesus died, true worshippers were no longer obliged to keep the Mosaic law.' (Rom 6:14, 10:4, Col 2:13,14). 9

thereby implying that they are no longer bound by the dietary restrictions of Leviticus and negating their own argument (as regards Lv 17:11-14). In any case Leviticus 17:11-14 clearly refers to the blood of sacrificial animals, requiring the death of the animal, in contrast to blood transfusion where the donor retains their life.

The blood shed in such sacrifices was sacred, epitomising the life of the sacrificial victim, and therefore had to be treated with respect. The blood of the sacrifices pointed forward to the blood of the Lamb of God, who obtained for his people `eternal redemption' (Heb 9:12)for `without the shedding of blood there is no forgiveness'. (Heb 9:22)

Also, both Genesis 9:4 and Leviticus 17:11-14 relate to the blood of animals and birds and bear no reference to human blood, or indeed to that of fish which, interestingly, is not prohibited by Witnesses.

The final reference which the Society uses to justify its position is Acts 15:20,29, where the Jerusalem Council instructs believers to abstain from...blood'. The Society argues that this prohibition is a permanent injunction to all Christians against taking blood into their body in any form. Once again however there is no suggestion that the Bible is referring to human, as well as to animal, blood. Also this is clearly an edict to do with peace between Jews and Gentiles in a specific situation where the Jews were particularly repulsed by what they saw as the Gentiles' violations of Divine directives. In this instance the Gentiles were merely obeying rules which they did not perceive as necessary to obtain salvation simply in order to increase the chances of the Jews becoming believers. As Paul says, for the sake of the Gospel, `I have become all things to all men so that by all possible means I might save some' (1 Cor 9:19-23).

Bergman' states that `the Watchtower position is biblically indefensible' and that would certainly seem to be the case.

Other arguments

Witnesses use a variety of secular arguments to back up their position on blood transfusions. In the early years of the prohibition many of these were similar to arguments previously used against vaccina- tions. They believed that blood transfusion would incur mental contamination of the recipient resulting in individual, and accordingly, group pollution.[8] However, a similar belief is shared by adherents to the Indian caste system and consequently in India blood transfusion is a family affair; a patient accepts blood only from their next of kin.'[12] On these grounds therefore there would seem to be no grounds for forbidding transfusions among Witnesses. However the possibility that the donor might later defect from the Society and thus join the realm of Satan (in the Society's viewpoint) is considerable,[8] and is the reason cited by the Society in response to this question.

More recently Witnesses have been given a powerful secular ally in the form of AIDS. This has undoubtedly strengthened two of their arguments: namely that there are medical hazards inherent in all transfusions and that blood transfusions are often given unnecessarily, since the number of transfusions has decreased dramatically since the advent of HIV. However, as with any medical treatment, conscientious physicians weigh up the risks and benefits before proceeding and there is still no doubt that blood transfusions can, in certain circumstances, be life-saving.

Perhaps most importantly, however, it should be remembered that, in reality, any secular arguments, however justifiable, that the Society makes are irrelevant to the basic issue. For, as they themselves claim:

`Yet the stand taken by Jehovah's Witnesses is above all a religious one; it is a position based on what the Bible says'.[9]

Considering some practicalities

Since the introduction of the prohibition many questions about it have occurred in the 'Questions from Readers' pages of the Watchtower. Queries covered subjects such as whether a Witness surgeon should give a blood transfusion to a non-believer and the acceptability of blood fractions'[13] and autologous transfusions.'[14,15] Haemophiliacs were told that `... to accept such blood fractions one time could not be viewed objectionable...but to do so more than once would constitute a 'feeding' on such blood fractions and therefore be considered a violation...'[16]

Autologous blood transfusions are forbidden as they involve prior storage of the blood which, supposedly, contravenes Deuteronomy 12:16, `But you must not eat the blood; pour it out on the ground like water'.

Perhaps realising their inability to cope with the growing applications of blood products, The Society has now largely withdrawn from the debate about specific cases. Instead it chooses to appeal to the Witnesses' own consciences, resulting in unprecedented `grey areas', indistinct doctrinal territory within an otherwise absolutist ideological system. To help justify this position it claims that the research involved in checking the purity of the products is 'not the responsibility of the Christian, for, doing that, it would given him less time to preach'.[17]

The consequences of disobedience

Under Mosaic Law, (Lv 17:15,16), the punishment for breaking the law concerning blood was simply to bathe and wait until evening when you would be considered 'clean'. In contrast, in the Jewish ethical hierarchy, taking a life was a capital offence (Ex 21:12).

Yet to the Jehovah's Witnesses the reverse is true - the prohibition against blood transfusions stands even if it involves a direct choice between life and death. In the early years of the injunction however, disobedience resulted only in supernatural consequences, the Society refusing to take spiritual action against anyone. Yet as the application of transfusions increased it was stated, in 1961, that the taking of a transfusion would be followed by excommunication (`disfellowshipping'), with no reason to hope that a pardon from God could be expected. [8,9] The only exception to this is the situation where the decision to give a transfusion is not made by a Witness, such as when a child is made a ward of court. Today, individual Witnesses are remarkably reluctant to say unequivocally whether or not they believe that disobedience results in eternal damnation; after all it seems a rather harsh punishment in anybody's eyes.

From a biblical point of view it should be remembered that God's view of those who obey human commandments unnecessarily is merciful (Je 35:18,19). This is in marked contrast to his view of those who make such commandments (Mk 7:1-9).

The legal position

All adult members of the Society carry cards, renewed annually, clearly stating their refusal to accept blood transfusion, (and their acceptance of possible non-blood alternatives such as Hartmann's solution), and releasing hospital staff from any liability for any untoward effects that might occur as a consequence of the prohibition.

Whether or not such a document is legally binding was tested in Ontario in 1988 when Dr David Shulman was found guilty of battery and fined $Can 20,000 for giving an unconscious patient, Georgette Malette, a life-saving blood transfusion after seeing such a card.[18,19] The Medical Protection Society was not prepared to give any specific advice as to what a British doctor's legal position would be in such a situation. However it should be borne in mind that it is very rare to be faced in a clinical setting, with an unconscious patient where a non-blood alternative, such as Haemaccel, cannot be used, at least as a temporary measure. After all, extensive blood loss does not in itself necessarily cause unconsciousness.

As yet in Britain no clinician has ever been sued for giving a patient a blood transfusion against their will. However in England, adult patients of sound mind do have a basic human right, protected by common law, to refuse medical treatment even in the face of death. If for some reason, such as unconsciousness, the patient is unable to make their views known, then the effect of a close relative objecting to treatment is only effective as evidence of what would have been likely to be the patient's own wish (ie. the next of kin objecting to a blood transfusion would only have legal weight 'if the patient had previously expressed their own refusal of transfusions by, for example, carrying a card).

There has however been a recent case in Britain, highlighted by the court ruling that doctors could lawfully continue giving blood to a critically ill 20 year old woman despite her refusal to accept transfusion.[20,21] This case does not alter the basic principles of law but merely suggests there is scope for challenging the validity of a patient s refusal on the grounds that the wrong information was given, the emergency that arose was not foreseen, or the decision was influenced by a relative or friend. In this instance the woman (not herself a JW) had unexpectedly said that she did not want a blood transfusion, before the possible need for one had arisen, whilst her mother, a fervent Jehovah's Witness, was visiting the hospital.

The legal position is more complicated, and more emotive if the patient in question is a child. Under normal circumstances parents have a right to decide what medical treatment their child should receive but this can be overridden if they fail to act in the child's best interest.[22] In this instance doctors or social workers can apply to make the child a ward of court. As soon as a ward-ship summons is issued medical treatment can only be authorised by a High Court judge. In 1981 in a non-J W related case an English judge said (with regard to a child with Down's syndrome who had duodenal atresia):

'It is not the right of the parents to determine the matter. They may make martyrs of themselves, they cannot make martyrs of their children.'[23]

Conclusions

Jehovah's Witnesses themselves recognise the ethical dilemmas which their stand may create for doctors. Consequently, aiming towards co-operation rather than confrontation, they have developed a network of doctors, across the specialties, who are willing to treat Witnesses whilst respecting their religious beliefs. Therefore, as far as the elective treatment of adult Witnesses is concerned the dilemma is to an extent resolved in that, if necessary, we can pass on the responsibility to someone more experienced. Indeed, as numerous scientific papers point out, in some ways we should be grateful to Witnesses for improving surgical technique and challenging us all to re-examine our attitudes to blood transfusions.

Yet emergency cases[24] and those involving children[25] still pose a significant problem. In Britain several people have died as a result of the prohibition and I hope that I am never placed in such an invidious position as to be forced to choose between my patient's right of free choice and my conscience. Conversely, where minors are concerned, whilst I am not suggesting for a moment that steps should not be taken to enforce treatment if necessary, the position of the parents must be virtually intolerable: on the one hand they may lose their child, on the other, they may feel that their child is condemned to eternal damnation. What a choice!

However, the one thing that has really struck me whilst researching this article is that the real tragedy is not whether a Jehovah Witness's stand on blood transfusions may shorten their earthly life but the fact that its misguided scriptural basis may well ruin their prospects of eternal life.

Whilst as doctors we will have an obligation, as with all our patients, to treat them sensitively respecting their viewpoints, as Christians we have an even greater obligation to challenge them to re-examine the Scriptures.

For as the Society itself asks: 'Whose blood is it that really saves lives?'[10]