1. Jehovah’s Witnesses: A People Among Us Dane R. Sommer, D. Min., BCC Director Chaplaincy Services dsommer@cmh.edu Copyright © 2007 The Children’s Mercy Hospital

2. Objectives Participants will understand the biblical and theological imperatives that guide Jehovah’s Witness patients and families to refuse blood transfusions and all blood products Participants will review the key ethical elements of consent and how they may be influenced by religious values

3. Jehovah’s Witnesses represent a cross section of average Americans

4. Facts about Jehovah’s Witnesses Founded in late 19 th century by Charles Taze Russel 7M adherents worldwide More than 100,000 congregations worldwide Do not believe in the deity of Christ or the trinity Separate themselves from all other believers (there are only 144,000 true believers)

5. Socially Separated Do not observe Christmas or birthdays Do not vote Do not recite the Pledge of Allegiance or sing national anthems Avoid military service (pacifist)

6. Every member is required to proselytize Seven million members worldwide 270 door to door calls for every new member Publish 100,000 books and 800,000 tracts…every day!

7. Jehovah’s Witnesses refuse blood transfusions and blood products Acts 15: 28-29: “For it has seemed good to the Holy Spirit and to us to lay upon you no greater burden than these necessary things: that you abstain from what has been sacrificed to idols and from blood and from what is strangled and from unchastity.” Genesis 9:4: “Only you shall not eat flesh with its life, that is, its blood.”

8. Refusal of blood: a Biblical imperative Leviticus 17: 10: “If any man of the house of Israel or of the strangers that sojourn among them eats any blood, I will set my face against that person who eats blood, and will cut him off from among his people.” Guided by the some of the same biblical imperatives that lead some to keep kosher

9. Important Implications A competent adult may elect to refuse blood or blood products even if it causes death Although rare, it is not infrequent for an adult Witness to die from exsanguination

10. Implications Although life could be saved through a blood transfusion or use of blood products, death and the prospect of eternal life are preferable to separation from Jehovah Jehovah’s Witnesses do not believe in hell. Death for the unrighteous simply means an end of life

11. What constitutes a blood transfusion? Any blood or blood product given intravenously This includes: red blood cells, FFP, albumin, immunoglobulin, cryoprecipitate, antithrombin III* Topical blood product: thrombin, fibrin glue* *Courtesy of Marilyn Hamilton, CMH Pathologist

12. Other Particulars The use of any blood factor product The use of any mechanical device that takes blood “out of a circuit” The use of any mechanical device that must be “primed” with others’ blood (e.g., hemodialysis, ECMO) The use of directed donations

13. Some Witness families will be aware of all of these “agents” and more, and want to avoid them Other Witness families may choose just to avoid red blood cells

14. What can be used? Non-blood expanders Cell savers that immediately return blood to the patient Non-blood pharmaceuticals (EPO, IV iron) Non-blood surgical techniques Some medical techniques advanced by Witness have now become standard medical therapy

15. What else? It is important not to confuse Jehovah’s Witness families with other groups, such as Christian Scientists, whose beliefs withhold all medical care Jehovah’s Witness families want all available medical care except blood and blood products”

16. Some hospitals have developed “bloodless” surgical programs Bloodless programs utilize clinical advances to avoid the use of blood (Care must be taken with any referral)

17. Our challenge How do we respect the wishes of Jehovah’s Witness families and protect the lives of our non-adult patients? We must be honest and straightforward about our policies and practices

18. Our great challenge Some parents will vehemently refuse to give consent for the use of blood or blood products under any circumstances Others will explain their wishes and ask us to do everything we can to avoid blood, and then give consent based on the desire to save their child’s life

19. Conversational strategies Conversations with Jehovah’s Witness families have better outcomes when we avoid rushing to the conclusion that we will need to get court order to proceed Listen first, even in emergent situations when time is of the essence Involve the Jehovah’s Witness Hospital Liaison to provide support for Witness families

20. Elective or Emergent? In elective cases we can refuse to treat the patient and refer the patient to another facility Emergent situations require more communication and problem solving In both elective and emergent situations, chaplaincy, social work and legal affairs can help Some cases may benefit from referral to the Hospital Ethics Committee

21. Cases for discussion 25 week preemie, developed NEC, needed surgery JW parents refused surgery because it would have required blood transfusions Prognosis was guarded to begin with, but doctors weren’t sure if this was an appropriate reason to withhold life-sustaining treatment Feudtner, Meadow et al. Pediatrics. 2010.

22. Cases for discussion 16 yo with Stage IV osteosarcoma, predicted survival rate of 5% with radiation and chemo Wanted “everything done” but did not want blood transfusions Asked doctors to start chemo, EPO, and Iron

23. “Respect is not fear and awe; it the ability to see a person as he is, to be aware of his unique individuality. Respect, thus, implies the absence of exploitation…[to] want the loved person to grow and unfold for his own sake, and in his own ways…” - E. Fromm Respect

24. How does respect influence the manner in which we listen to those whose beliefs are radically different from ours?

25. How do we interpret suffering in our clinical practice? “I consider that the sufferings of this present time are not worth comparing with the glory about to be revealed to us.” - Romans 8: 1

26. Conclusions Adults have the right to refuse blood and blood products, even if it will lead to their death They do not have the same right to refuse for their children Often, care can be modified to accommodate the beliefs of JWs