AT AGE 61, José, a Belgian from the small town of Oupeye, was told that he would need a liver transplant. "It was the shock of my life," he says. Just four decades ago, liver transplants were unthinkable. Even in the 1970's, the survival rate was only about 30 percent. Today, however, liver transplants are routinely performed, with a much higher success rate.
But there is still a major drawback. Since liver transplants often involve excessive bleeding, doctors usually administer blood transfusions during the operation. Because of his religious convictions, José did not want blood. But he did want the liver transplant. Impossible? Some might think so. But the chief surgeon felt that he and his colleagues had a good chance of operating successfully without blood. And that is precisely what they did! Just 25 days after his operation, José was back home with his wife and daughter.*
Thanks to the skills of those whom Time magazine calls "heroes of medicine," bloodless medicine and surgery is now more common than ever. But why is there such a demand for it? To answer that question, let us examine the troubled history of blood transfutions.
Blood Transfusions - A Long History of Controversy
"If red blood cells were a new drug today,
it would be very difficult to get it licensed."
—Dr. Jeffrey McCullough.
IN THE winter of 1667, a violent madman named Antoine Mauroy was brought to Jean-Baptiste Denis, eminent physician to King Louis XIV of France. Denis had the ideal "cure" for Mauroy's mania—a transfusion of calf's blood, which he thought would have a calming effect on his patient. But things did not go well for Mauroy. Granted, after a second transfusion, his condition improved. But soon madness again seized the Frenchman, and before long he was dead.
Even though it was later determined that Mauroy actually died from arsenic poisoning, Denis' experiments with animal blood provoked a heated controversy in France. Finally, in 1670 the procedure was banned. In time, the English Parliament and even the pope followed suit. Blood transfusions fell into obscurity for the next 150 years.
Early Hazards
In the 19th century, blood transfusions made a comeback. Leading the revival was an English obstetrician named James Blundell. With his improved techniques and advanced instruments—and his insistence that only human blood should be used—Blundell brought blood transfusions back into the limelight.
But in 1873, F. Gesellius, a Polish doctor, slowed the transfusion revival with a frightening discovery: More than half the transfusions performed had ended in death. Upon learning this, eminent physicians began denouncing the procedure. The popularity of transfusions once again waned.
Then, in 1878, French physician Georges Hayem perfected a saline solution, which he claimed could serve as a substitute for blood. Unlike blood, the saline solution had no side effects, did not clot, and was easy to transport. Understandably, Hayem's saline solution came to be widely used. Strangely, however, opinion soon favored blood again. Why?
In 1900, Austrian pathologist Karl Landsteiner discovered the existence of blood types, and he found that one type of blood is not always compatible with another. No wonder so many transfusions in the past had ended in tragedy! Now that could be changed, simply by making sure that the blood type of the donor was compatible with that of the recipient. With this knowledge, physicians renewed their confidence in transfusions—just in time for World War I.
 | World War II saw an increase in the demand for blood | |
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U.S. National Archives photos | ||
Blood Transfusions and War
During World War I, blood was liberally transfused into wounded soldiers. Of course, blood clots quickly, and previously it would have been all but impossible to transport it to the battlefield. But early in the 20th century, Dr. Richard Lewisohn, of Mount Sinai Hospital in New York City, successfully experimented with an anticoagulant called sodium citrate. This exciting breakthrough was regarded by some doctors as a miracle. "It was almost as if the sun had been made to stand still," wrote Dr. Bertram M. Bernheim, a distinguished physician of his day.
World War II saw an increase in the demand for blood. The public was bombarded with posters bearing such slogans as "Give Blood Now," "Your Blood Can Save Him," and "He Gave His Blood. Will You Give Yours?" The call for blood brought great response. During World War II, some 13,000,000 units were donated in the United States. It is estimated that in London more than 68,500 gallons [260,000 L] were collected and distributed. Of course, blood transfusions carried a number of health risks, as soon became clear.
Blood Transfusions—No Medical StandardEach year in the United States alone, more than 11,000,000 units of red cells are transfused into 3,000,000 patients. In view of that large number, one would assume that there is a strict standard among physicians when it comes to administering blood. Yet, The New England Journal of Medicine notes that there is surprisingly little data "to guide decisions about transfusions." Indeed, there is a wide variation in practice, not only regarding precisely what is transfused and how much but also regarding whether a transfusion is administered at all. "Transfusion depends on the doctor, not on the patient," says the medical journal Acta Anæsthesiologica Belgica. Considering the above, it is hardly surprising that a study published in The New England Journal of Medicine found that "an estimated 66 percent of transfusions are administered inappropriately." |
Blood-Borne Disease
After World War II, great strides in medicine made possible some surgeries that were previously unimaginable. Consequently, a global multibillion-dollar-a-year industry sprang up to supply the blood for transfusions, which physicians began to consider standard operating procedure.
Soon, however, concern over transfusion-related disease came to the fore. During the Korean War, for example, nearly 22 percent of those who received plasma transfusions developed hepatitis—almost triple the rate during World War II. By the 1970's, the U.S. Centers for Disease Control estimated the number of deaths from transfusion-related hepatitis at 3,500 a year. Others put the figure ten times higher.
Thanks to better screening and more careful selection of donors, the number of cases of hepatitis-B contamination declined. But then a new and sometimes fatal form of the virus—hepatitis C—took a heavy toll. It is estimated that four million Americans contracted the virus, several hundred thousand of them through blood transfusions. Granted, rigorous testing eventually reduced the prevalence of hepatitis C. Still, some fear that new dangers will appear and will only be understood when it is too late.
Another Scandal: HIV-Contaminated Blood
In the 1980's, it was found that blood can be contaminated with HIV, the virus that leads to AIDS. At first, blood bankers were loathe to consider that their supply might be tainted. Many of them initially greeted the HIV threat with skepticism. According to Dr. Bruce Evatt, "it was as though someone had wandered in from the desert and said, 'I've seen an extraterrestrial.' They listened, but they just didn't believe it."
Nevertheless, country after country has seen scandals break out exposing HIV-contaminated blood. It is estimated that in France, between 6,000 and 8,000 people were infected with HIV through transfusions that were administered between 1982 and 1985. Blood transfusions are held responsible for 10 percent of HIV infections throughout Africa and for 40 percent of the AIDS cases in Pakistan. Today, because of improved screening, HIV transmission through blood transfusions is rare in developed nations. However, such transmission continues to be a problem in developing nations that lack screening processes.
Understandably, in recent years there has been an increased interest in bloodless medicine and surgery. But is this a safe alternative?
The Growing Demand for Bloodless Medicine and Surgery
"All those dealing with blood and caring for
surgical patients have to consider bloodless surgery."
—Dr. Joachim Boldt, professor of anesthesiology,
THE tragedy of AIDS has compelled scientists and physicians to take additional steps to make the operating room a safer place. Obviously, this has meant more stringent blood screening. But experts say that even these measures do not ensure zero-risk transfusions. "Even as society expends great resources on making the blood supply safer than ever," says the magazine Transfusion, "we believe patients will still try to avoid allogeneic [donor] transfusions simply because the blood supply can never be completely safe."
Not surprisingly, many doctors are becoming wary of administering blood. "Blood transfusions are basically no good, and we are very aggressive in avoiding them for everybody," says Dr. Alex Zapolanski, of San Francisco, California.
The general public too is becoming aware of the dangers of transfusions. Indeed, a 1996 poll revealed that 89 percent of Canadians would prefer an alternative to donated blood. "Not all patients will refuse homologous transfusions as do Jehovah's Witnesses," states the Journal of Vascular Surgery. "Nonetheless, the risks of disease transmission and immunomodulation offer clear evidence that we must find alternatives for all of our patients."
What Some Doctors Say
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| Dr. Joachim Boldt |
'Bloodless surgery is not only for Jehovah's Witnesses but for all patients. I think that every doctor should be engaged in it.'—Dr. Joachim Boldt, professor of anesthesiology, Ludwigshafen, Germany.
"While blood transfusions are safer today than in the past, they still pose risks, including immune reactions and contracting hepatitis or sexually transmitted diseases."—Dr. Terrence J. Sacchi, clinical assistant professor of medicine.
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| Dr. Terrence J. Sacchi |
"Most physicians have knee-jerk reactions with transfusions and just give them out liberally and indiscriminately. I don't."—Dr. Alex Zapolanski, director of cardiac surgery at the San Francisco Heart Institute.
"I don't see any conventional abdominal operation that in a normal patient routinely requires blood transfusion."—Dr. Johannes Scheele, professor of surgery, Jena, Germany.
A Preferred Method
Thankfully, there is an alternative—bloodless medicine and surgery. Many patients view it not as a last resort but as a preferred treatment, and with good reason. Stephen Geoffrey Pollard, a British consultant surgeon, notes that the morbidity and mortality rates among those who receive bloodless surgery are "at least as good as those patients who receive blood, and in many cases they are spared the postoperative infections and complications often attributable to blood."
How did bloodless medical treatment develop? In one sense the question is rather odd, since bloodless medicine actually predates the use of blood. Indeed, it was not until the early 20th century that transfusion technology had advanced to the point where it was routinely used. Nevertheless, in recent decades some have popularized the field of bloodless surgery. For example, during the 1960's noted surgeon Denton Cooley performed some of the first open-heart operations without the use of blood.
With the rise of hepatitis among transfusion recipients during the 1970's, many doctors began looking for alternatives to blood. By the 1980's a number of large medical teams were performing bloodless surgery. Then, when the AIDS epidemic broke out, these teams were repeatedly consulted by others who were eager to adopt the same techniques. During the 1990's many hospitals developed programs that offer bloodless options to their patients.
Doctors have now successfully applied bloodless techniques during operations and emergency procedures that traditionally required transfusions. "Major cardiac, vascular, gynaecological and obstetrical, orthopaedic, and urological surgery can be performed successfully without using blood or blood products," notes D.H.W. Wong, in the Canadian Journal of Anaesthesia.
One advantage of bloodless surgery is that it promotes better-quality care. "The surgeon's skill is of the greatest importance in the prevention of blood loss," says Dr. Benjamin J. Reichstein, a director of surgery in Cleveland, Ohio. A South African legal journal says that in certain instances surgery without blood can be "quicker, cleaner and less expensive." It adds: "Certainly the aftercare treatment in many instances has proved cheaper and less time-consuming." These are just some of the reasons why there are currently more than 180 hospitals around the world that have programs specializing in bloodless medicine and surgery.
Blood and Jehovah's Witnesses
For Bible-based reasons, Jehovah's Witnesses refuse blood transfusions.* But they do accept—and vigorously pursue—medical alternatives to blood. "Jehovah's Witnesses actively seek the best in medical treatment," said Dr. Richard K. Spence, when director of surgery at a New York hospital. "As a group, they are the best educated consumers the surgeon will ever encounter."
Doctors have perfected many bloodless surgery techniques on Jehovah's Witnesses. Consider the experience of cardiovascular surgeon Denton Cooley. Over a period of 27 years, his team performed bloodless open-heart surgery on 663 of Jehovah's Witnesses. The results clearly demonstrate that cardiac operations can be successfully performed without the use of blood.
True, many have criticized Jehovah's Witnesses for their refusal of blood. But a guide published by the Association of Anaesthetists of Great Britain and Ireland calls the Witnesses' position "a sign of respect for life." In truth, the Witnesses' rigorous stand has been a major force behind safer medical treatment becoming available for all. "Jehovah's Witnesses in need of surgery have shown the way and exerted pressure for improvements in an important sector of the Norwegian health service," writes Professor Stein A. Evensen, of Norway's National Hospital.
To assist doctors in providing treatment without the use of blood, Jehovah's Witnesses have developed a helpful liaison service. Presently, more than 1,400 Hospital Liaison Committees worldwide are equipped to provide doctors and researchers with medical literature from a data base of over 3,000 articles related to bloodless medicine and surgery. "Not only Jehovah's Witnesses, but patients in general, are today less likely to be given unnecessary blood transfusions because of the work of the Witnesses' Hospital Liaison Committees," notes Dr. Charles Baron, a professor at Boston College Law School.#
The information on bloodless medicine and surgery that has been compiled by Jehovah's Witnesses has been of benefit to many in the medical field. For example, in preparing material for a book entitled Autotransfusion: Therapeutic Principles and Trends, the authors asked Jehovah's Witnesses to provide them with information about alternatives to blood transfusion. The Witnesses gladly granted their request. With gratitude the authors later stated: "In all our reading on this subject, we have never seen such a concise, complete list of strategies to avoid homologous blood transfusion."
Progress in the medical field has caused many to consider bloodless medicine. Where will this lead us? Professor Luc Montagnier, discoverer of the AIDS virus, states: "The evolution of our understanding in this field shows that blood transfusions must one day die out." In the meantime, alternatives to blood are already saving lives.
The Patient's Role
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