BRIEF REPORT

A Review of Materials and Medications

with Religious or Dietary Significance in
the Interventional Radiology Suite
Roger Wilson, MBBS, Zoe Hu, BSc, Cormac O’Brien, MB, Bch, Bao,
Emtenan Meer, MBBS, Aakanksha Agarwal, MBBS, MD, DNB, and
Timothy Murray, MB, MCh, MBA

ABSTRACT

A holistic approach to patient-centered care should include cultural and religious considerations. Certain cultural groups
have beliefs that may restrict the use of particular animal-derived products and chemicals. A working knowledge of
ingredients commonly used in the interventional suite with religious and cultural connotations may be helpful. This review
article highlights medications and medical devices with cultural or religiously sensitive ingredients used in interventional
radiology departments and provides a framework for addressing this common scenario.

Many major world religions and lifestyle practices prohibit
either the ingestion or usage of certain animal-derived
products or chemicals. The modern interventional radi-
ology armory contains many potentially prohibited sub-
stances such as heparin (derived from porcine intestine),
gelatin sponge (porcine collagen), intravenous hydrocoils
(bovine gelatin), plug-based vascular closure devices
(porcine collagen), and ethanol (alcohol). This article
reviews products found in interventional suites that may
have religious or lifestyle connotations. In addition, the
authors present an overview of approaches of various major
religions and lifestyle practices (Islam, Hinduism, Judaism,
and vegetarianism/veganism) regarding the use of animal
and non–animal-derived, religiously sensitive products,
describing mainstream beliefs and outlining cases in which
routine or emergency usage is permitted. This is a review
paper that features no patient data. Institutional review
board approval was not required.
RELIGIOUS/SECULAR RESTRICTIONS
Globalization is associated with commensurate broadening
of cultural diversity. Many of the world’s major religions
have adopted dietary restrictions or specific attitudes toward
food consumption; this can create a complex interplay
between religious and lifestyle practices (Table 1). Within
each of these groups, specific interventional radiology–
relevant devices (Table 2) or interventional radiology–
relevant medications (Table 3) may be of relevance. Of
© SIR, 2023
J Vasc Interv Radiol 2023; 34:1717–1721
https://doi.org/10.1016/j.jvir.2023.06.035
note, classification of devices (Table 2) and medications
(Table 3) can be arbitrary within interventional radiology,
such as in cases of hemostatic sponges, which can be
injected intravascularly or applied externally.
Almost one third of the world population identifies as
Christian (1). There are many branches and sects of
Christianity that vary in their beliefs; Christianity has not
adopted a single universal doctrine regarding dietary
restrictions (2). There are, however, individual sects and
orders that include specific restrictions such as fasting
during Lent, forgoing ethanol, or abstaining from ingestion
of meat (either totally or on certain days) (3). Some
examples of specific Christian denominations include
Jehovah’s Witnesses (who avoid blood products) and
Seventh-day Adventists (who abstain from animal products,
excluding eggs). Many branches of Christianity (including
the most populous branch of Catholicism) discourage meat
products on Fridays and particular religious holidays (4).
Judaism entails complex rules of Kashrut (1). In practice,
these restrictions prohibit the consumption of porcine and
shellfish products, along with other rules specific to animal
products. Followers are directed to consume kosher prod-
ucts, although there is considerable variation between the
interpretations of various groups within Judaism.
Islam has several sects, including Sunnites, Shiites, and
Sufis (5), and there are broadly shared restrictions across the
many different branches that typically prohibit the con-
sumption of all porcine products, all ethanol-containing
products, and all animal products that are not obtained
using the prescribed ritualistic (halal) method. Ethanol and
preparations containing ethanol are commonly used in
interventional radiology for sterilization of skin prior to
1718 Religious/Dietary Significance in Interventional Radiology Wilson, et al JVIR

procedures, for hand washing, for equipment sterilization,

and for ablation procedures. Consumption of ethanol for the
purpose of intoxication is prohibited in many Islamic cul-
tures. There is little evidence of the level of systematic
absorption during ablation procedures. A study on ethanol
sclerotherapy of venous malformations from 2001 found
systemic concentrations related to ablation procedures
ranging from 0 to 1.16 g/L (mean, 0.33 g/L) (6). A study
from 2007 found that the overall dermal absorption of
ethanol from the use of hand rubs containing up to 95%
concentration of ethanol was between 0.5% and 1.1% (7).
Although a review of different teachings related to alcohol
in the Islamic religion is beyond the scope of this article,
alcohol that is not suitable for drinking but is designed for
medical purposes was reviewed by the Assembly of Muslin
Jurists of America in 2020 (8), who declared that it is
permissible to use pharmaceuticals that contain alcohol,
when there is no alternative, in amounts essential to the
production process or as an external sterilizer for wounds,
as antibacterial agents, and as an ingredient in creams and
oils for external uses, because declaring it impermissible to
use in these cases could lead to prolonged sickness, pain, or
death for many of the ill and injured. It would probably be
reasonable to use ethanol products for uses such as sterili-
zation when there is no alternative; however, when using
systemic ethanol for ablation, informed discussion on a
patient-by-patient basis may be appropriate.
Multiple medications have historically been derived
from animal toxin-based compounds, some of which were
produced from purified venom (batroxobin [reptilase], and
bivaluridin [leech saliva]) and some of which are syntheti-
cally produced (captopril, enalapril, eptifibatide, and tir-
ofiban) (9). Some sects of Islam forbid the ingestion of
substances derived from animals with fangs with toxins/
poisons that produce ill effects. There is a principle of
Dharurah (10), whereby it can be permissible to use med-
icine from nonhalal sources if there is a medical necessity to
save a life. The practical use of this principle in the use of
venom-derived medicines would be one that would be best
decided in the clinical and cultural context in which patient
care is being delivered. To our knowledge, captopril, ena-
lapril, and bivaluridin are now produced synthetically.
Buddhism is a world religion/philosophical tradition that
exists in several forms and many ethnic variations (5).
Although not all Buddhists follow a fixed set of restrictions,
some Buddhists are vegetarian and do not consume any
animal products.
Hinduism is another diverse religion, without a central
doctrinal authority (3). Hindus typically espouse the
concept of reincarnation for all living beings, and as such,
the majority of these observers are lactovegetarian (3). For
those who are not vegetarian, bovine products, porcine
products, and alcohol are still generally avoided. Sikhism
differs significantly from Hinduism; however, the 2 reli-
gions share a duty-based approach to ethical decision
making (11). Sikhism allows for individual choice toward
meat consumption; therefore, not all Sikhs are vegetarian
STUDY DETAILS
Study type: Social science study
(3). Others might eat meat but not if slaughtered according
to the guidelines of other religions (halal or kosher), and
some avoid beef or pork (3,12).
In addition to these religious affiliations, there are also a
variety of personal beliefs and lifestyle practices that have
their corresponding restrictions. Veganism is one such
practice in which observers refrain from consumption of all
animal products, including eggs.
INCORPORATION INTO CLINICAL
PRACTICE
Autonomy refers to the right of competent adults to make
informed decisions about their own medical care. This
Table 1. Dietary Restrictions of Specific Religions
Religion Specific restriction
Christianity Some denominations have specific
restrictions during Lent or choose to forgo
animal products and ethanol. Certain
weekdays or holy days may also preclude
meat/dairy consumption.
Jehovah’s Witnesses Avoid blood products (ie, blood transfusions).
(Christian Denomination)
Seventh-day Adventist Some choose to refrain from consuming
(Christian Denomination) animal products (excluding eggs).
Judaism Strict followers may only consume kosher
products.
All porcine and shellfish products are
prohibited.
Land animals consumed must be mammals
that chew their cud and have cloven hooves.
Birds of prey are prohibited.
Islam Strict followers may only consume animal
products obtained through ritualistic method
(halal).
Porcine products and ethanol are prohibited.
Hinduism Majority of followers are vegetarian and
abstain from all animal products, including
eggs.
Those who are not vegetarian still abstain
from bovine and porcine products, along with
ethanol.
Buddhism No universal restrictions.
Those who are vegetarian refrain from
consuming all animal products, including
eggs.
Sikhism Dietary restrictions are an individual choice.
Those who are vegetarian refrain from
consuming all animal products, including
eggs.
Those who are not vegetarian may abstain
from consuming bovine and porcine
products, along with ethanol.
All products obtained from other religious
guidelines (halal, kosher) are prohibited.
Veganism All animal products, including eggs, are
prohibited.
Volume 34 Number 10 October 2023 1719

Table 2. Interventional Radiology–Relevant Devices

Product Generic Contained Interventional suite–specific products Religious/secular Considerations
name name animal product restrictions
Collagen/ Absorbable Bovine or Hemostatic gelatin sponge (Gelfoam: porcine, Hinduism, Jainism, Islam can use halal-approved bovine gelatin/
gelatin Gelatin porcine collagen Surgifoam: porcine) veganism, Islam (if collagen (ie, Surgispon).
Biopsy collagen plugs (Hunter biopsy sealing not halal), Hinduism,
device) Sikhism
Collagen vascular sealing devices (Angioseal:
bovine, Vasoseal, Quickseal)
Heparin Heparin Heparin derived Guidewire with heparin coating (InQwire with Judaism, Islam, Alternative non–animal-derived products should
Sodium from porcine or heparin coating, Starter wire with heparin Hinduism, Sikhism, be the first option; however, if no suitable
bovine intestinal coating) Buddhism alternatives are available or if alternatives are
mucosa Dialysis catheters (Palindrome Precision H inadequate, then an animal-derived medication
Chronic Dialysis Catheter) is generally acceptable because it would be the
Thermodilution catheters (Anthron-coated only way to conserve life.
thermodilution catheters)
Coated vascular stents/grafts (heparin-coated
Palmaz-Schatz stent, Acuseal/Propaten
vascular graft, Viabahn endoprosthesis with
heparin bioactive surface, Viabahn VBX balloon
expandable endoprosthesis)

remains a founding tenet of medical ethics and is paramount
to a patient-centered care model. To enable informed con-
sent, discussion of any planned medication or material that
may conflict with a person’s cultural or individual beliefs
should be undertaken.
In the elective setting, preprocedural screening may flag
patients for whom additional consultation regarding rele-
vant animal-derived products (and viable alternatives) may
add value. It is also important to note that in emergency life-
saving procedures, discussion regarding certain medica-
tions/materials may not be feasible. The choice of material
or medication used should, therefore, be at the clinician’s
discretion, with the caveat that if a culturally appropriate
medication or ingredient is readily available and equally
efficacious, it should preferentially be used. In agreement
with this, most religious leaders from major religions advise
that although products without prohibited animal-derived
ingredients should be the first option, if no suitable alter-
native is available, an animal-derived product is acceptable
to conserve life (13). There are a variety of consequences
for patients who have broken with guidance, ranging from
acceptance without consequence to requirement for
rebaptizement, physical punishment, perceived loss of
eternal life, and excommunication from their religious
community. There is wide variation down to the level of
individuals in terms of the definition of, enforcement of, and
suitability for medical exemptions when these guidelines
are transgressed. The ethical dilemma that interventional
radiologists may face with this approach is defining what
constitutes an emergency procedure; even this definition
may vary between clinicians and institutions.
DISCUSSION
A challenge in formulating a standardized approach to
treatment decision making with regard to religious/dietary
restrictions is the significant discrepancy in opinion
between and among major religions. Different denomina-
tions within a single major religion frequently have varying
dietary restrictions. In addition, there may be contrasting
opinions among religious leaders within a single denomi-
nation regarding the interpretation of religious texts with
regard to dietary restrictions. Although many of the main-
stream beliefs of the major religions have been outlined, it is
impossible to summarize all views comprehensively. To
help address this, early involvement of a religious/cultural
liaison officer may add clarity if available.
Time and administrative cost related to extensive patient
discussion with regard to religious/dietary restrictions are
also important to consider. There has been a shift in case
law in some jurisdictions to place less emphasis on what
clinicians judge to be reasonable, with more emphasis on
what patients expect to know. This is best exemplified in the
United Kingdom landmark case Montgomery v Lanarkshire
Health Board 2005, which specifically states that “A
reasonable person in the patient’s position would be likely
to attach significance to the risk, or the doctor is or should
reasonably be aware that the particular patient would be
likely to attach significance to it” (14). Although rare, the
use of animal-derived products in medical procedures has
been the source of litigation when informed consent was not
appropriately obtained (15).
One of the other major obstacles encountered when
investigating the presence of animal-derived products is
lack of comprehensive listings of interventional suite
products with potential religious/dietary restrictions (12,16).
The authors’ experience while investigating specific ingre-
dients used in medical products was that manufacturers’
descriptions were frequently either unclear or difficult to
obtain. In many cases, this was not directly specified in
product brochures and could only be inferred from an
allergy section in extended instructions for use that stated
1720 Religious/Dietary Significance in Interventional Radiology Wilson, et al JVIR

Table 3. Interventional Radiology–Relevant Medications

Product name Generic name Contained animal product Potential restricted groups
Fragmin Dalteparin Porcine intestinal mucosa Judaism, Islam, Hinduism, Sikhism,
Buddhism
Prothrombinex-VF Human prothrombin complex Porcine heparin Judaism, Islam, Hinduism, Sikhism,
Buddhism
Gelofusine Gelatin succinylate Bovine collagen Hinduism, Jainism, veganism, Islam
(if not halal), Hinduism, Sikhism
Haemaccel Polygeline Bovine lactoferrin Hinduism
Recombinate Octocog-α Trace amount of murine, Hinduism
hamster, and bovine proteins
Tisseel VH S/D solution Aprotinin - Factor XIII Human plasma Jehovah’s Witnesses
- Fibrinogen, calcium, chloride
dihydrate - thrombin
Clotting factor replacement, eg, eg, Octocog-α Chinese hamster ovary or murine cells
Advate,
Adynovate, Benfix, Hemilibra,
Kogenate,
Recombinate, Xyntha
Metalyse Tenecteplase Chinese hamster ovary cells
Actilyse Alteplase Chinese hamster ovary cells
Rixibus Recombinant factor IX, Chinese hamster ovary cells
Nonacog
gamma (rch)
Pulmozyne Dornase-α Chinese hamster ovary cells
Ceprotin Protein C Trace amount of murine protein or Hinduism, Jainism, veganism,
heparin Hinduism, Sikhism
Tachosil Human fibrinogen and human Equine collagen
thrombin
Diprivan Propofol Egg Veganism, Buddhism
Human insulin Insulin Fish (protamine) Veganism, Jainism
Protamine Protamine sulfate Fish Veganism, Jainism
Chitosan Crustacean Judaism

that the product was not suitable for use in patients with a
known allergy to a specific animal. New products have
come to market in recent years that provide an alternative
treatment option, such as SmartFoam (PL Micromed,
Gyeongsangnam-do, Republic of Korea), which is derived
from fish collagen. There may be a role for increased
transparency by pharmaceutical and medical device com-
panies with regard to ingredients in potentially religiously
sensitive products as well as a central database to facilitate
ease of investigation (as is maintained for magnetic reso-
nance imaging device safety) (17). Additionally, adopting
religion-specific approval for certain medical products akin
to kosher council/halal certification may provide standard-
ization and clarity.
In conclusion, formulating an approach to the use of
animal-derived products in the interventional radiological
setting is difficult because of a wide range of varying patient
beliefs and difficulty in finding relevant drug manufacturing/
ingredient information. Education of interventional radiolo-
gists regarding this potential issue is a key step in ensuring
patient autonomy in their treatment choices. Engaging with
patients and respecting their autonomy may prevent inad-
vertent or avoidable self-perceived patient harm. A compre-
hensive online database of relevant ingredients may
overcome current difficulties in fact finding within a frac-
tured landscape of product information, whereas developing
a local pathway for dealing with specific cases would seem to
be an area worthy of future development.
AUTHOR INFORMATION
From the Department of Radiology (R.W., C.O.B., A.A., T.M.), St Paul’s
Hospital, and Department of Radiology (R.W., C.O.B., T.M., E.M.), University
of British Columbia, Vancouver, Schooland School of Medicine (Z.H.),
Queen’s University, Kingston, Ontario, Canada. Received November 17,
2022; final revision received June 7, 2023; accepted June 24, 2023. Address
correspondence to C.O., Department of Radiology, The University of British
Columbia, 2775 Laurel Street, 11th Floor, Vancouver, BC, Canada V5Z 1M9;
E-mail: cormacobrien88@gmail.com; Twitter handle: @cormac1983
None of the authors have identified a conflict of interest.
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