ETHICS

The perioperative care of Learning objectives

Jehovah’s Witnesses After reading this article you should be able to:
C be aware of the legal aspects of the care of a Jehovah’s Witness

Emma Murphy C describe the surgical and anaesthetic considerations of these

Paul McConnell patients

C describe the techniques available to optimize perioperative care

of the Jehovah’s Witness

Abstract
Jehovah’s Witnesses are a Christian denomination with around 8
million members worldwide. They belief the teachings of the Bible pro- Beliefs about blood and blood products
hibit the transfusion of blood and blood components. Some blood
Jehovah’s Witnesses believe that human blood is sacred and a
products may be deemed acceptable as part of their beliefs and
potential vector for sin. As a result of their beliefs, they will not
they may be accepting of intraoperative techniques such as cell
accept red or white cells, plasma, or platelets. Following an
salvage. Jehovah’s Witnesses have the right to accept or refuse treat-
article published in the Watchtower in 1990 describing the
ment without providing a reason for doing therefore medical practi-
movement of blood fractions, namely plasma proteins and bili-
tioners must respect these even if this would pose threat to the
rubin, between mother and fetus, it was then possible that other
patient’s life. Care of the Jehovah’s Witness should employ a multidis-
products may be deemed acceptable to certain practitioners
ciplinary team approach with senior clinicians. Goals of management
(Table 1).
include to optimize oxygen delivery and haemoglobin synthesis,
Until 2000, a Jehovah’s Witness who had received blood or
reduce blood loss, and correct any coagulopathy.
blood products would have expelled from the faith and disowned
Keywords Advanced directive; blood transfusion; bloodless surgery; by other Jehovah’s Witnesses, in a policy known as disfellow-
capacity; informed consent; intraoperative cell salvage; Jehovah’s
ship. This practice was disbanded in 2000, and now any Jeho-
Witness
vah’s Witness who ‘wilfully and without regret’ accepts blood
Royal College of Anaesthetists CPD Skills Framework: Ethics
transfusion ‘revokes his own membership by his own actions’.
From a medical perspective, this policy does not change the legal
aspects surround administrating of blood and blood transfusion,
but it may be that individual Jehovah’s Witnesses interpret this
change as allowing them to accept transfusion under certain
In 2021, there were over 8 million Jehovah’s Witnesses world-
circumstances.
wide with almost 150,000 registered in the UK. The modern-day
organization of Jehovah’s Witnesses began at the end of the 19th
Century in Pittsburgh, USA with their analysis and interpretation Capacity and consent
of the Bible subsequently published in books and the journal, The legalities of consent for medical intervention in Jehovah’s
now known as The Watchtower e Announcing Jehovah’s Witness patients can be complex. An adult patient with capacity
Kingdom. The Jehovah’s Witness faith has a number of beliefs. can give consent to a procedure whilst withholding consent for
Of particular relevance to the medical profession, is their stance specific aspects of management (such as the administration of
on blood transfusion and its associated products. Jehovah’s blood components) provided that the refusal does not make the
Witnesses believe that both the Old and New Testament com-
mand followers to abstain from transfusion and accepting blood
and blood products is a sin (Genesis 9:4, Leviticus 17:10;
Blood product acceptability amongst Jehovah’s
Deuteronomy 12:23; Acts 15:28, 29).1 The care of patients of the
Witnesses
Jehovah’s Witness faith can therefore pose both ethical and
clinical challenges to the anaesthetist and the critical care Not accepted May be accepted
physician. This article firstly examines the legal complexities
surrounding Jehovah’s Witnesses and secondly the clinical Red blood cells Red cell fractions
management of such patients presenting for surgery. White blood cells White cell fractions
Plasma Platelet fractions
Whole blood Plasma fractions
Autologous pre-donation Cardiopulmonary bypass
Cell salvage
Emma Murphy MBCHB MRCP FRCA is a Speciality Registrar in Renal dialysis
Anaesthesia in the West of Scotland Deanery, UK. Conflicts of Epidural blood patch
interest: none declared. Solid organ and bone marrow
Paul McConnell MBCHB FRCA EDIC FFICM is a Consultant Anaesthetist transplant
in Anaesthesia at the Royal Alexandra Hospital, Paisley, UK and Chair Recombinant factors
of Ethics, European Society of Anaesthetists. Conflicts of interest:
none declared. Table 1

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 ETHICS
procedure as a whole impossible or completely unsafe. Patients
may do so without providing a valid reason and the medical
practitioners must respect the patient’s wishes even if such a
choice would place their life at risk. This holds true in the
management of patients of the Jehovah’s Witness faith and their
decisions regarding transfusion must be respected.
For those patients who do not have capacity, an appropriate
advance directive will guide whether a specific treatment may or
may not be administered. If such a directive does not exist,
treatment should be carried out on the basis of the patient’s best
interests. ‘Best interests’ must however extend beyond their
clinical best interests to take account of their wider social, psy-
chological and spiritual beliefs, ensuring that any decision is
correct for that individual patient.2 In the case of a practising
Jehovah’s Witness patient who lacks capacity, without an
advanced directive, the administration of a blood transfusion,
would be unlawful as it would be expected that they would
refuse such a treatment if they were able to do so.3
Patients of the Jehovah’s Witness faith should give consent to
accept, or decline based on their own personal and religious
beliefs and decisions should not be under the influence of family,
friends or religious advisors. A ‘next of kin’ has no legal right to
consent or to refuse consent, while a person who has been
granted Power of Attorney may do so (though not insist on a
treatment being given). Difficulties may arise in situations where
it is believed that the patient may be influenced to make
important treatment decisions by others as noted in the case of
Miss T (1992).4 Here a 20-year-old, 34 weeks pregnant ex-
Jehovah Witness, presented to hospital following a road traffic
accident. She required a caesarean section and transfer to
intensive care for ongoing treatment. On multiple occasions
(against medical advice) she refused to consent to a blood
transfusion. Her case was taken to the court by her father as there
was concern that she had not made an autonomous decision
regarding her rejection of blood administration, due to the in-
fluence of her mother (a devout Jehovah Witness), the sedative
effects of opioid drugs she had received and that she was ill-
advised concerning the limitations for the use of alternatives to
whole blood by medical staff. In this instance the court found in
favour of her father and ruled in favour of the preservation of life
with the decision for rejection of blood overruled. It must how-
ever be emphasized here though that the court found that Miss T
lacked capacity and therefore the administration was performed
in her best interest, were there no concerns regarding her ca-
pacity, the court would not have been able to order the admin-
istration of blood products.
Advanced directives
Jehovah’s Witness patients will usually have an advanced
directive in place. An advanced directive is a legal document
outlining individual preferences regarding what treatment they
would or would not accept if they lack capacity and can be made
by anyone aged 18 years of age (16 years in Scotland). An
advanced directive may only be used to consent to or refuse a
treatment and cannot insist on a therapy. In general, if an
advanced directive is specific to the situation at hand and is
appropriately witnessed and documented it is a binding expres-
sion of a patient’s wishes and must be followed. A recent court
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ruling in 2020 however overturned an advanced directive of a
Jehovah’s Witness and has added further complexities to the
ethical challenges.
In the case of Re PW, an 80-year old Jehovah’s Witness with
Alzheimer’s disease who was admitted with severe anaemia as a
result of a gastric malignancy, an advanced directive was over-
turned by the court to allow blood transfusion to be given as a
life-sustaining measure.5 The court ruled that although the
advanced directive had been correctly made in 2001, the pa-
tient’s actions were subsequently inconsistent with the wishes
set out in the advanced directive. By granting a Lasting Power of
Attorney to her family that did not stipulate her wishes regarding
blood products and transfusion, the court felt the stipulations set
in the advanced directive were no longer valid.
Jehovah’s Witnesses may carry a ‘blood refusal’ card, similar
to an advanced directive, that outlines which blood products they
would and would not accept. There is debate about the validity of
such cards as it is unclear the information provided to the patient
about the benefits and risks of blood transfusion, their under-
standing of refusal and the possibility of pressure to comply with
Jehovah’s Witnesses beliefs as a result of family or religious
pressure. In the case of Malette versus Shulman, a Canadian case
from the 1970s, a doctor, who had administered a blood trans-
fusion to an unconscious patient of the Jehovah’s Witness faith
who was carrying such a ‘blood refusal’ card was found guilty of
assault.6
Children and adolescents
Traditionally, in the medical management of children the power
to give or withhold consent to medical treatment on their behalf
lies with those who have parental responsibility. Legally, except
in an emergency, parental consent is necessary to perform any
medical procedure on a child. When those with parental re-
sponsibility refuse treatment on behalf of their child, it is often
cited that parents have a right to raise their child as they see fit
and with religious freedom to do so. It is on the basis of religious
freedom that Jehovah’s Witnesses argue that they can refuse
blood and blood products on behalf of their child.7 This is
however not necessarily a view taken by the courts particularly
when there is a risk of harm to the child.
A child or adolescent of the Jehovah’s Witness faith may have
limited understanding of the implications of the choices they
make regarding blood products and transfusion. Wooley suggests
the four main issues to consider, with a child under 16, who may
wish to make their own decisions regarding treatment are the
child’s capacity to consent to treatment; parental authority and
its limitations; whose views and beliefs should prevail when
there is differing views between parent and child; and the extent
of the courts’ powers over children and adolescents.7 Following
the Gillick versus West case, children and adolescents may be
deemed ‘Gillick competent’.8 To assess Gillick competency,
medical professionals must take into account child’s age, mental
capacity and maturity, their understanding of the issue, the risks,
implications and consequences that may arise from their deci-
sion, how well they understand any advice or information they
have been given, their understanding of any alternative options,
and their ability to explain a rationale around their reasoning and
decision making.9
473 Ó 2022 Published by Elsevier Ltd.
 ETHICS
On the basis of this, a Jehovah’s Witness child may therefore
consent or refuse transfusion unaided by their parents. If a
competent Jehovah’s Witness child consents to blood trans-
fusion, their parents have no authority to override their consent.
In this situation it would be advisable to discuss the position with
the hospital legal team as this is likely to be in opposition to the
parents’ beliefs. If a competent child refuses to consent to blood
transfusion, those with parental responsibility may override that
decision if transfusion is deemed to be in their best interests. A
referral for legal advice is highly recommended given the
complexity of such a situation. If both a competent child and
those with parental responsibility refuse consent for blood
products and transfusion, an application to the court must be
submitted under Section 8 of the Children’s Act 1989; seeking
lawful administration of blood and the need for consent to be set
aside. In a time-sensitive situation, the court can be contacted by
telephone out of hours. If deemed unable to wait for such advice,
clinicians should administer the blood if it is in the child’s best
interests to do so. In such situations, the court may override both
child and parent as was seen in the case of Re E.10 In this case a
Jehovah’s Witness aged 15 refused blood transfusions as part of
his treatment for leukaemia, with support from his parents.
Medical practitioners responsible for his care sought court
approval to treat him. His parents argued that his wishes should
be respected, as he was nearly 16, at which point his consent
would be required. In this instance, the judge agreed with the
medical team, deeming the child not ‘Gillick competent’10 and
therefore unable to refuse. Treatment would therefore be
administered in his best interests which the court decided were
best represented by the medical plan. In the true emergency
situation, time is unlikely to be afforded to seek legal advice and
in this instance General Medical Council (GMC) guidelines allow
clinicians to provide treatment that is immediately necessary to
save a life even if it is against the wishes of those with parental
responsibility.11
Medical staff and conscientious objection
A medical practitioner who believes a blood transfusion is a
necessary treatment option for a Jehovah’s Witness may refuse
to treat the patient if they decline such advice and decline
treatment. In this scenario the GMC advises doctors must not
express personal beliefs if it is likely to cause distress or harm,
but explain to patients if they have a conscientious objection to a
particular procedure and both inform them of their right to see
another doctor and make sure they have enough information to
exercise that right.11 Alternative arrangements should be made,
both in the elective and urgent situation, whereby a clinician
who is prepare to be involved is responsible for the care of this
patient. In the time-critical emergency situation, it would be ex-
pected that medical staff would treat the patient despite their
objection if an appropriate substitute cannot be found.
Managing a Jehovah’s Witness in the perioperative period
Preoperative
Early communication and multidisciplinary team (MDT) plan-
ning are essential for Jehovah’s Witness patients, although in the
emergency situation adequate preoperative planning may not
always be feasible. The goals in preparation for such patients
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attending for surgery are to optimize oxygen delivery and hae-
moglobin synthesis, reduce blood loss, and correct any coagul-
opathy at the earliest opportunity. The MDT should involve a
senior surgeon, anaesthetist, and haematologist. The Association
of Anaesthetists 2019 guideline, ‘Anaesthesia and peri-operative
care for Jehovah’s Witnesses and patients who refuse blood’
recommends the use of a preoperative optimization checklist to
ensure robust preoperative planning and management is
undertaken.12
It is important in the preoperative period to ascertain the in-
dividual beliefs and determine what treatment options the pa-
tient would accept or not accept. At this point in the surgical
planning, it is vital to consider whether alternative non-surgical
options are available, or if other less invasive or minimal ac-
cess techniques may be more appropriate. Discussions may
include family members or religious advisors. The final decision
however lies with the patient. Care must be taken that undue
pressure and influence from either the medical team or family
members occurs.4 A representative from the local Jehovah’s
Witness hospital liaison committee is available at all hospitals to
offer advice.
Preoperative investigations should include as a minimum full
blood count, ideally 6 weeks prior to surgery.13 A clotting screen,
iron studies and B12 and folate are also likely to be of value. A
target haemoglobin of 130g/litre is recommenced in all patients
undergoing elective surgery with iron replacement, and blood
transfusion if required. In Jehovah’s Witnesses whereby
achieving this target with preoperative treatment is not possible,
it may be appropriate to lower the acceptable threshold for
proceeding with surgery. It has been demonstrated in Jehovah’s
Witnesses undergoing medical and surgical procedures, deaths
that were attributed to anaemia had haemoglobin levels less than
5g/litre.14 It may therefore be appropriate to accept a lower
threshold of 10g/litre in those with a history of cardiorespiratory
disease and 8g/litre in those with no risk factors for ischaemia.
Threshold setting should from part of the preoperative MDT
discussion.
In those with evidence of iron deficiency anaemia, oral iron
replacement should be commenced promptly. In those patients
for whom surgery must take place within 6 weeks due to clinical
need or those who are intolerant of oral iron supplements,
intravenous (IV) iron should be considered. Various preparations
of IV iron are available and may be given within 3e42 days of
surgery but there is no clear evidence for optimal timing and the
2020 PREVENTT did not demonstrate a reduction in need for
blood transfusion in those who received IV iron compared with
placebo.
Although not licensed for use in the UK, consideration may be
given to the use of erythropoietin (EPO) preoperatively to in-
crease red cell production. In critically ill patients, EPO infusion
of 40,000 units/week for 3 weeks reduced blood transfusion
rates, however; the evidence in Jehovah’s Witnesses is lacking.15
In the absence of renal failure, high doses of EPO are needed to
elevate haemoglobin concentration. The first dose of EPO is
usually given 3 weeks before surgery and the final dose given on
the day of surgery. It should not be given if haemoglobin is >130
g/litre due to the risk of thrombotic events. EPO may be con-
traindicated in those with significant hypertension, recent
myocardial infarction or stroke, unstable angina, chronic kidney
474 Ó 2022 Published by Elsevier Ltd.
 ETHICS
disease, pregnancy and history of thrombosis. A rise in haemo-
globin would be expected within 10 days. It is important to
clarify which type of EPO is being used as some formulations
contain albumin which may not be acceptable to a Jehovah’s
Witness.
Any bleeding or clotting disorders should be investigated and
treated where appropriate prior to surgery. It may also be
appropriate to discontinue anti-platelet and anti-coagulant drug
therapies, however doing so must be weighed against the risks of
thrombotic and ischaemic events which will be patient and
procedure specific.
Intraoperative
A number of strategies can also be employed intraoperatively to
minimize blood loss and improve oxygen delivery. It is vital prior
to commencing the case that the patient’s wishes regarding blood
products and transfusion are discussed with the whole team as
part of the surgical safety checklist. The Association of Anaes-
thetists of Great Britain and Ireland (AAGBI) recommends the
use of a blood transfusion checklist to clarify which products the
patient would and would not receive.12 They also recommend
introducing to the World Health Organization Surgical Safety
checklist, the question ‘is everyone aware of the answers to the
blood transfusion checklist and the techniques we will use to
minimize blood loss in this case?’ for those patients who refuse
blood and associated products.12
Careful attention should be paid to surgical technique with
meticulous haemostasis and minimal tissue damage to reduce
surgical blood loss. Patient positioning should be discussed at the
surgical brief as this may have an impact on cardiovascular ef-
fects and bleeding. Hypothermia, acidosis and hypocalcaemia
should be avoided as this may result in coagulopathy and
increased blood loss. Antifibrinolytics, such as tranexamic acid,
have been shown to reduce surgical blood loss and perioperative
blood transfusion rates in a wide range of surgeries. Determining
the appropriate dose and timing is a topic of debate with doses of
10e20 mg/kg typically given. In Jehovah’s Witnesses where
blood loss is expected to be greater than 500ml, a bolus dose at
induction followed by an infusion may be appropriate.
Perioperative cell salvage may be acceptable to Jehovah
Witnesses if the blood remains in continuity with their circula-
tion and should be discussed Perioperatively as a possible intra-
operative strategy. The AAGBI recommends the use of
intraoperative cell salvage in surgery where the estimated blood
loss is greater than 500 ml.13 In the postoperative period, salvage
of blood from surgical drains may be considered, although this
may not be acceptable to all Jehovah’s Witness patients as the
blood has not remained in contiguity with the body.
Acute normovolaemic haemodilution involves the removal of
blood that is replaced by crystalloid or colloid solution. This
technique results in surgical blood loss having a lower haema-
tocrit and allows for the blood to be re-transfused at the end of
surgery. Again, it is important to clarify with the patient if they
would be accepting of this strategy as some may decline if a
closed circuit is not used. One drawback of acute normovolaemic
haemodilution, in comparison with intraoperative cell salvage, is
the availability and lack of expertise regarding this technique.
Permissive hypotension, whereby the systolic blood pressure
is maintained below 90 mmHg, mean arterial pressure (MAP) of
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50e65 mmHg or a reduction in MAP by 30%, may be an
appropriate strategy to reduce blood loss. Hypotensive anaes-
thesia can be achieved by a range of techniques, including pa-
tient positioning, central neuraxial techniques and opioid
infusion such as remifentanil. Permissive hypotension has been
shown to reduce blood loss in a range of surgeries. This should
however be used with caution in patients with pre-existing hy-
pertensive or cardiovascular disease and recent work has shown
low intraoperative blood pressure is associated with poorer
outcomes.
Tourniquets are widely used in orthopaedic surgery as a
measure to reduce intraoperative blood loss and may be an
appropriate intraoperative strategy, however; evidence suggests
they do not reduce total blood loss and may potentially worsen
blood loss with the release of inflammatory mediators as a result
of limb ischaemia. Consideration may be given to the use of
tamponade balloons and intervention radiology techniques, such
as intravascular balloons and embolization, in the emergency
patient with ongoing bleeding. Topical agents, such as fibrin
glues and sealants, may be used but again their use should be
clarified with the patient preoperatively.
Blood sampling should be minimized, and paediatric blood
sampling bottles used when sampling is required. Point of care
testing, such as thromboelastrography, should be used to guide
management. Although, patients are unlikely to accept platelet
concentrate or fresh frozen plasma, cryoprecipitate and pro-
thrombin complex concentrate may be accepted. By using such
products, the fibrinogen concentration may be raised allowing
for partial compensation of a low platelet count on haemo-
stasis.13 Desmopressin, at a dose of 0.3ug.kg1 may improve
platelet activity and is often acceptable to Jehovah’s Witnesses.
Factor VII is also normally accepted by patients.
Postoperative
A thorough verbal and written handover should be provided in
the postoperative care outlining the patient’s wishes and pre-
determined MDT plan. Postoperative aims are to continue to
minimize ongoing blood loss, correct coagulopathy, and opti-
mize oxygen delivery. Blood loss should be carefully monitored
with prompt treatment of ongoing bleeding. Again, blood sam-
pling should be minimized.
Summary
Jehovah’s Witnesses patients can pose many ethical and legal
dilemmas for the anaesthetist and critical care physician. It is
essential that healthcare professionals respect the decisions made
by a Jehovah Witness patient. There is no standardized approach
for these patients and care should be focused on a patient-centred
approach utilizing the MDT to ensure early preoperative dis-
cussions and optimization. A
REFERENCES
1 Jehovah's Witnesses. New world translations of the holy bible.
2022, https://www.jw.org/en/library/bible/nwt/books/ (accessed 4
January 2022).
2 Aintree University Hospital NHS Foundation Trust v James. 2013
(UK Supreme Court), http://www.bailii.org/uk/cases/UKSC/2013/
67.html (accessed 22 January 2022).
475 Ó 2022 Published by Elsevier Ltd.
 ETHICS
3 Briggs v Briggs. 2016 (England and Wales Court of Protection),
http://www.bailii.org/ew/cases/EWCOP/2016/53.html (accessed
24 January 2022).
4 Re T (adult: refusal of medical treatment). 1992 (All England Law re-
ports), https://www.globalhealthrights.org/wp-content/uploads/2013/
03/EWCA-1992-In-re-T-adult-refusal-of-medical-treatment.pdf
5 Re: PW (Jehovah’s Witness: Validity of advance decision). 2020,
https://www.bailii.org/ew/cases/EWCOP/2021/52.html (accessed
27 January 2022).
6 Malette versus Shulman. 1990 (Ontario Court of Appeal), https://
ctdj.ca/en/jurisprudence/malette-v-shulman-1990-72-o-r-2d-417-
c-a/ (accessed 23 January 2022).
7 Woolley S. Children of Jehovah’s Witnesses and adolescent Je-
hovah’s Witnesses: what are their rights? Arch Dis Childhood
2005; 90: 715e9.
8 Gillick v West Norfolk and Wisbech. 1986, http://cirp.org/library/
legal/UKlaw/gillickvwestnorfolk1985/ (accessed 3 January 2022).
9 Griffith R. What is Gillick competence? Hum Vaccines Immuno-
therapeutics 2016; 12: 244e7. https://doi.org/10.1080/21645515.
2015.1091548
ANAESTHESIA AND INTENSIVE CARE MEDICINE 23:8 476
Descargado para Anonymous User (n/a) en Universidad Libre de ClinicalKey.es por Elsevier en enero 21, 2023. Para uso personal
exclusivamente. No se permiten otros usos sin autorización. Copyright ©2023. Elsevier Inc. Todos los derechos reservados.
10 Re E (A minor) (wardship: medical treatment), 1993.
11 Council GM. Personal beliefs and medical practice. 2022, https://
www.gmc-uk.org/-/media/documents/personal-beliefs-and-
medical-practice-20200217_pdf-58833376.pdf (accessed 5
January 2022).
12 Klein AA, Bailey CR, Charlton A, et al. Association of Anaesthe-
tists: anaesthesia and peri-operative care for Jehovah’s Wit-
nesses and patients who refuse blood. Anaesth 2019; 74: 74e82.
https://doi.org/10.1111/anae.14441
13 Klein AA, Arnold P, Bingham RM, et al. AAGBI guidelines: the use
of blood components and their alternatives 2016. Anaesthesia
2016; 71: 829e42. https://doi.org/10.1111/anae.13489
14 Viele MK, Weiskopf RB. What can we learn about the need for
transfusion from patients who refuse blood ? The experience with
Jehovah's Witnesses. Transfusion 1994; 34: 396e401. https://doi.
org/10.1046/j.1537-2995.1994.34594249050.x
15 Corwin HL, Gettinger A, Pearl RG, et al. Efficacy of recombinant
human erythropoietin in critically ill patients - a randomized controlled
trial. J Am Med Assoc 2002; 288: 2827e35. https://doi.org/10.1001/
jama.288.22.2827
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