The article by Sniecinski et al. (1) on the treatment of two Jehovah's Witnesses with coagulopathy presents a laudable approach toward improved communication with patients who may offer a rather unique medical challenge. Three aspects of this paper merit comment.
First, the paper highlights how far we have come in the past few decades in the treatment of Jehovah's Witnesses. Notice, for example, that the postoperative hematocrit in these two patients were 23% and 20% respectively, and that both patients had “good outcomes.” Actually, this is not unusual in the reports on patients who are Jehovah's Witnesses. Yet, it was not that long ago that some physicians generally applied the “10/30” rule as a transfusion trigger. We have learned much about alternatives for treating anemia and now coagulopathy, as this paper shows.
Second, the authors commendably capture the issue here that the decision on whether to receive these processed blood fractions was up to the two patients. This is not, though, some recent “official” change of position. The decision on blood fractions for Jehovah's Witnesses has long been understood to be up to the individual. For example, in a 1981 position paper in JAMA, Dixon and Smalley (2) reported: “While these verses [Genesis 9:3, 4; Leviticus 17:13, 14; Acts 15:19–21] are not stated in medical terms, Witnesses view them as ruling out transfusion of whole blood, packed RBCs, and plasma, as well as WBC and platelet administration. However, Witnesses' religious understanding does not absolutely prohibit the use of components such as albumin, immune globulins, and hemophiliac preparations; each Witness must decide individually if he can accept these” (2). That is still the basic position of Jehovah's Witnesses.
Third, in their paper reporting two good outcomes, Sniecinski et al. (1) conclude that their use of blood fractions “likely contributed to the good outcomes of these patients.” That may be true, but one can never say for sure. Would the patients have survived and done well had they elected not to take these fractions? Over the years, countless papers across all medical specialties have documented good outcomes for Jehovah Witness patients, even when they seemed contrary to expectations. With Witness patients, as the authors rightly note, each individual decides whether to accept minor blood fractions. That decision may be based partly on the information we physicians provide. We need to take care not to “talk a patient into something.” Both these patients received cryoprecipitate, a product pooled from many patients. Though the safety of such products has improved markedly with viral detection and inactivation methods, review of the literature reveals that there is, and will likely continue to be, some element of hazard (3–6). What if a Witness patient received a blood-borne pathogen or had another severe effect (West Nile, Creutzfeldt-Jakob disease, etc.) from our conscientious care? If we had not carefully explained this possibility, he or she might think it was worse than ironic.
Despite our enlightened medical opinion, we know that, morally and legally, the decision about the risks of any procedure must rest with the patient. The article rightly concludes that the physician should “thoroughly discuss what processed blood fractions are acceptable to each individual in this patient population.”
Occasionally, this may seem frustrating. The physician may find that a particular medical procedure or fraction is acceptable to one Witness patient but not to another. Still, is that not what the patient's faith and conscience call on him to do, to make his own decision? And is not the physician's responsibility to help inform the patient and then to do our best within the boundaries defined by the patient's faith and conscience?
1. Sniecinski RM, Chen EP, Levy JH, et al. Coagulopathy after cardiopulmonary bypass in Jehovah's witness patients: management of two cases using fractionated components and factor VIIa. Anesth Analg. 2007;104:763–5.
2. Dixon JK, Smalley MG. Jehovah's witnesses: the surgical/ethical challenge. JAMA 1981;246:2471–2.
3. O'Shaughnessy DF, Atterbury C, Bolton Maggs P, et al; for British Committee for Standards in Haematology, Blood Transfusion Task Force. Guidelines for the use of fresh-frozen plasma, cryoprecipitate and cryosupernatant. Br J Haematol 2004;126:11–28.
4. Fritsma MG. Use of blood products and factor concentrates for coagulation therapy. Clin Lab Sci 2003;16:115–19.
5. Evatt BL, Austin H, Leon G, et al. Haemophilia therapy: assessing the cumulative risk of HIV exposure by cryoprecipitate. Haemophilia 1999;5:295–300.
6. Brown P. The risk of blood-borne Creutzfeldt-Jakob disease. Dev Biol 2000;102:53–9.