EVANGELICKÁ

TEOLOGICKÁ Jméno: Ernán Acosta

FAKULTA Číslo Studenta: 38849324
Univerzita Karlova 1 ročník
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Health, Culture and Society – PhD. Eva Křížová 2021

Blood transfusions and Jehova’s Witnesses

Is there an alternative in risk of death to preserve religious principles?

Abstract: In this essay we are going to delve into one of the most controversial topics related to the
Christian religious community known as Jehovah's Witnesses: blood transfusions and the role that
this entails in medical processes that can be complicated.

Introduction
The Christian community of Jehovah's Witnesses refuses to receive blood transfusions based on the
biblical passages that cite the following:
Genesis 9:4    Only flesh with its life—its blood—you must not eat.
Leviticus 17:10 “‘If any man of the house of Israel or any foreigner who is residing in your midst eats
any sort of blood, I will certainly set my face against the one, who is eating the blood, and I will cut
him off from among his people.
Deuteronomy 12:23 Just be firmly resolved not to eat the blood, because the blood is the life, and you
must not eat the life, with the flesh.
Acts of Apostles 15:28-29  For the holy spirit and we ourselves have favored adding no further burden
to you except these necessary things:  to keep abstaining from things sacrificed to idols, from blood,
from what is strangled, and from sexual immorality. If you carefully keep yourselves from these
things, you will prosper. Good health to you!”
The Jehovah's Witnesses website states the following: “Jehovah's Witnesses do not accept blood
transfusions for religious reasons rather than medical reasons, both the Old and New Testaments
mandate us to abstain from blood. In addition, for God, blood represents life, so we witnesses obey
the biblical mandate" [Watch Tower Bible and Tract Society of Pennsylvania: Why don’t Jehovah’s
witnesses accept blood transfusions?]
Now that we know the position of the Jehovah's Witnesses, the most logical thing is to know about
the history and the antecedents of blood transfusions in medicine.
Blood and medicine
Since the appearance of Homo sapiens and given the link between blood loss and health and death,
mystical and healing properties have been attributed to blood.
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References to the therapeutic possibilities of human blood date back to ancient times, from the time
of the Roman Empire, when man already thought that blood was essential for life. In 1665, the first
reference to an intravenous injection in a human being as a therapeutic element was published and
100 years ago the first transfusion was carried out in the world. This therapeutic procedure begins
successfully after 1900, when an Austrian doctor, Karl Landsteiner, was discovered in 1901, the blood
groups of the ABO system. receiving for his work the Nobel Prize in Physiology and Medicine in 1930.
For transfusions it is critical to determine blood compatibility between the donor and the patient. If
someone with type A blood gets type B, she may experience a severe hemolytic reaction. The result
can be the destruction of red blood cells and the rapid death of the patient. Although blood typing
and cross matching are now routine procedures, errors do occur. Every year people die from
hemolytic reactions.
Blood is the essential raw material for blood banks, its benefit in medical therapy is indisputable,
however, its application is not 100% safe, it includes infectious (viral, bacterial, parasitic) and non-
infectious risks that can have consequences serious or fatal. Dr. Douglas H. Posey Jr. writes: “Almost
30 years ago Sampson described blood transfusion as a relatively dangerous procedure. Since then,
at least 400 other antigens have been identified and characterized in red blood cells. There is no
doubt that this number will continue to increase, because the red blood cell membrane is extremely
complex".
However, according to the author Gil Agramonte, in her research on "Epidemiology of transfusions in
the Central Military Hospital" Dr. Carlos J. Finlay ”mentions that the World Health Organization
reported in 2009 that more than 81 million units of blood were collected annually in the world and it
was estimated that around 80 million units were transfused, of which , more than 40% between
Europe and the United States. Obtaining and availability of blood components have a high social and
financial cost, it is a priority resource, often scarce and therefore requires correct use.
Blood transfusion today
Blood transfusion is the means by which tissue is transplanted, in this case being a blood transplant;
It is a process that is subject to rigorous legislation to establish an indicator that certifies the safety
and quality of the transfusion. Both the promotion of blood donation and transfusion is a
fundamental part of today's healthcare system.
Transfusion therapy requires solid knowledge to plan and execute a comprehensive work plan to
achieve the well-being of the person who requires it. The personnel who develop their profession in
aspects related to blood transfusions must be in a continuous update of knowledge, oriented to
develop new techniques as well as security measures.
On the other hand, the application of an appropriate protocol will prevent the serious complications
that may occur in a reaction; These protocols must be based on the main bioethical principles.
Blood is the essential raw material for blood banks, from which plasma, red blood cells, white blood
cells, platelets, blood products and other biological products are obtained for therapies in transfusion
medicine.
Whole blood can provide better O2 transport capacity, volume expansion, and clotting factor
replacement, and was previously recommended for rapid and massive blood loss. However, as
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treatment with blood products it is just as effective and represents a more efficient use of donated
blood.
From the elements of blood we can obtain:
RBCs: Red blood cells (sedimented) are generally the blood product of choice to increase Hb. One
unit of erythrocytes increases the average adult hemoglobin by about 1 g / dL and the hematocrit by
about 3% above its pre-transfusion value. Washed erythrocytes, in patients with severe plasma
reactions.
In patients with multiple blood group antibodies or with antibodies to very common red blood cell
antigens, rare frozen red blood cells are used.
Erythrocytes with leukocyte depletion indicated in patients who have presented non-hemolytic
febrile transfusion reactions, received exchange transfusions, among other uses.
Leukocytes: granulocytes can be transfused when sepsis occurs in a patient with severe persistent
neutropenia (neutrophils <500 / μL) who is unresponsive to granulocytes.
Immunoglobulins: Anti-Rh immunoglobulin (RhIg), administered IM or IV, prevents the development
of maternal anti-Rh antibodies that may be due to fetomaternal bleeding.
Other immunoglobulins intended for post-exposure prophylaxis for patients exposed to a number of
infectious diseases, including cytomegalovirus, hepatitis A and B, measles, rabies, respiratory
syncytial virus, rubella, tetanus, smallpox, and chickenpox.
Platelets: Platelet concentrates
- To prevent bleeding in severe asymptomatic thrombocytopenia (platelet count <10,000 / μL
- For patients with less severe bleeding and thrombocytopenia (platelet count <50,000 / μL)
- For patients with bleeding and platelet dysfunction due to antiplatelet drugs but with a
normal platelet count
- For patients receiving massive transfusion causing dilutional thrombocytopenia.
Other Products: Irradiated blood products are used to prevent graft versus host disease in patients at
risk. Attempts are currently underway to regenerate erythrocytes and platelets from various stem cell
sources.
Blood products and crystalloids are used in resuscitation to perform volume replacement and
guarantee adequate tissue perfusion that guarantees the delivery of oxygen to the tissues.
Fresh frozen plasma
Fresh frozen plasma (PFC) is an unconcentrated source of all clotting factors, without platelets. The
indications are the correction of a hemorrhage secondary to factor deficiencies for which there is no
replacement of specific factors, the multifactor deficiency states.

Now that we know the position of Jehovah's Witnesses, the history of blood transfusions and the use
of blood in medical therapies, we are going to present and analyze the case of a rhinosinusal tumor
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operation without the use of blood. in a Jehovah's Witness patient. This case is of special interest
because head and neck operations are the surgical interventions in which the patient loses the
greatest amount of blood.
Sinosinudal tumor surgery without blood transfusions for Jehovah's Witnesses
A 53-year-old female patient, Jehovah's Witness, with no relevant morbid history, reports a two-
month history of epistaxis through the right nostril, of mild to moderate amounts. Progressively, she
presented pain, facial pressure and right nasal obstruction. She does not report fever, hyposmia,
anterior or posterior nasal discharge, weight loss, or cervical masses. The patient consulted the
emergency department on several occasions for epistaxis that initially resolved with anterior
tamponade. Given the persistence of epistaxis episodes that did not subside with anterior
tamponade, she was referred to the otolaryngology service. In the first control, an increase in volume
with a purplish appearance is evidenced at the anterior rhinoscopy, which completely occludes the
right, friable nostril, bleeding spontaneously.
A computerized axial tomography with contrast of the paranasal cavities is requested, which shows
an increase in volume of vascular appearance of 6x4x4 cm, which occupies the right nostril
completely, displacing the medial maxillary wall, without compromising it. There is no evidence of
invasion of the lamina papyracea, septum, floor of the nasal fossa or the base of the skull. Then, due
to the vascular aspect, a cerebral angiography is performed that shows afferences of the
sphenopalatine artery and ethmoid arteries dependent on the ipsilateral ophthalmic artery towards
the tumor.
During the tumor study, oral treatment with ferrous sulfate was indicated. The need for surgical
resection is discussed, with a high risk of intraoperative bleeding. The patient refused the option of
transfusion of blood products, despite implying the result of death. Due to this situation of high
surgical risk, the case is presented to the ethics committee of the healthcare complex, where it is
evaluated. It is suggested to respect the will of the patient, performing all medical acts in order to
minimize the risks of perioperative bleeding. A multidisciplinary evaluation is carried out with the
anesthesia, interventional neuroradiology and otorhinolaryngology teams. Informed consent is
signed, where the limits of therapeutic action desired by the patient are clearly expressed.
Twenty-four hours prior to surgery, an embolization is performed with particles of vascular trunks
dependent on the right internal maxillary artery, after identifying a tumor blush dependent on the
external carotid artery, achieving the exclusion (devascularization) of the tumor. The anesthesia team
prepares the patient. Prior to surgery, mild anemia is observed; with a hematocrit of 34.9% and
hemoglobin of 11.8 g / dL. It is decided to have a Cell Saver equipment (an autologous blood
recovery system) in case of massive bleeding. During surgery, the patient is maintained with
normovolemic hemodilution and infusion of tranexamic acid, maintaining adequate blood volume
and hemodynamic stability. Given the impossibility of vascular control of the anterior ethmoidal
territory prior to tumor resection, a ligation of the right anterior ethmoidal artery is performed
externally with endoscopic support, placing two vascular clips and carefully performing bipolar
electrocautery.
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Endoscopically, a complete debulking of the tumor is performed, showing a cleavage plane, without
compromising the maxillary sinus, roof of the nostril or choanas. The area of insertion of the tumor occurs in
the armpit of the middle turbinate, which is resected. Surgery is performed maintaining adequate blood
volume and hemodynamic stability. The use of intraoperative autologous blood was not necessary. The
delayed biopsy shows a sinonasal, squamous, keratinizing carcinoma, with extensive, poorly differentiated
areas and necrosis. A positron emission tomography (PET-CT) was requested, which did not show areas of
hyperuptake or masses of secondary appearance. Then, the case is presented to the oncology committee, a
tumor of the nasal cavity T1N0M0 is defined, and an adjuvant treatment with radiotherapy is indicated, which
the patient rejects. The patient progressed favorably, with no macroscopic evidence of tumor recurrence at
one year of postoperative follow-up.

Conclusion

As we mentioned initially, hemorrhages and subsequent anemia are frequent in patients undergoing head and
neck surgeries, with blood transfusions usually being part of the treatment. Considering that anemia in a
surgical patient is an independent predictor of morbidity and mortality, it is extremely important to seek
alternatives to the use of blood transfusions in patients who cannot receive them, such as Jehovah's
Witnesses. In these patients, management must be multidisciplinary.

Preoperative evaluation is one of the main pillars in all surgery, mainly in this type of patient, at which point
the steps to follow are decided. This includes a complete medical history, considering comorbidities, mainly
personal and family history of coagulopathies, use of medications that affect coagulation, in addition to
requesting related tests such as a hemogram and coagulation tests, and it is also useful to estimate possible
blood losses. Recombinant erythropoietin is one of the available drugs to be used, which has been shown to
increase preoperative hemoglobin and decrease the frequency of blood transfusions. It is recommended to
administer concomitantly with iron supplementation in anemic patients, which maximizes its action. There are
other techniques that can be performed by interventional radiologists, such as preoperative endovascular
embolization, which has shown a significant reduction in bleeding in surgery for otorhinolaryngological
vascular tumors.

Bibliography
1. HOLMBERG, Jorge;  WAISSBLUTH, Sofia; ROSENBLUT, Andrés; MARTONI, Mariano; ROBLES,
Maximiliano; PALMA, Soledad. Jehovah's Witnesses patients in otorhinolaryngological surgery: A case
regarding a sinonasal tumor resection. Magazine of otorhinolaryngology head and neck surgeries
vol.80 no.1 mar. 2020.
2. FERNANDEZ MENDOZA, Lázara Esther; TORRES CANCINO, Indira Isel; GONZALEZ GRACIA, Isahiris;
HOYOS MESA; Anette Julia; GARCÍA BELLOCQ Mayalin; MEDINA TÁPANES  Elizabeth. Importance of
voluntary blood donations. Blood and blood products. Electronic medical magazine vol.42 no.1 jan.-
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3. What Does the Bible Really Teach? Watch Tower Bible and Tract Society of Pennsylvania 2014
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approach to transfusion medicine risk management. Transfusion and Apheresis Science magazine Vol.
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