When Blood Transfusion Translates To An Early Death

Kat Piper

Mounting evidence that routinely giving blood transfusions to patients could actually increase their risk of death or other complications has prompted calls for medical staff to be more cautious about who they administer transfusions to.

Jehovah's Witnesses refuse blood transfusions based on a passage from the Bible, which forbids them to "eat blood," but many still successfully undergo operations including open-heart surgery. This, say some surgeons and anaesthetists, should be the way most operations are performed.

Higher death rates
The danger is not from infections such as HIV but from something to do with the blood itself. Many studies over the past ten years have shown that transfusions, particularly of those involving red blood cells, are linked to higher death rates in patients who have had a heart attack, heart surgery, or who are in critical care.

Although the exact nature of the link is not yet known, it seems likely that chemical changes in ageing blood, their impact on the immune system, and the blood's ability to deliver oxygen are key. "Probably 40 to 60 percent of blood transfusions are not good for the patients," said Bruce Spiess, a cardiac anaesthesiologist at Virginia Commonwealth University in Richmond, to New Scientist.

Transfusions first became part of medical procedure during World War One when they were used as a last resort to treat soldiers who had lost a lot of blood. Its usage is now no longer confined to cases of catastrophic bleeding, but is often employed as a routine treatment for patients undergoing surgery or intensive care.

Background
The rationale behind giving transfusions is that by giving patients red blood cells, oxygen is better transported around the body thereby increasing the chances of survival. A healthy person has 120 to 170 grams per liter of haemoglobin—the oxygen-carrying protein in red cells—in their blood, usually with 35 to 50 percent of their blood volume being composed of red cells. Doctors commonly decide to give patients a transfusion if the haemoglobin levels fall to between 70 and 100 grams per litre.

Less effective blood
A 1999 Canadian study of 838 critical care patients found that significantly fewer patients (22 versus 28 percent) died in hospital when treatment with transfusion was limited to patients with haemoglobin levels of less than 70 grams per litre. In 2004, a study published in the Journal of the American Medical Association showed that heart attack patients with red blood cell levels of over 25 percent were three times more likely to die or have another heart attack within 30 days of having a transfusion.

A U.K. study of almost 9,000 heart surgery patients between 1996 and 2003 supports this finding, and indicates a six-fold increase in the risk of death after 30 days with a three-fold increase in the risk within one year following surgery. Transfusions were also associated with more infections and higher incidences of stroke, heart attack, and kidney failure. These complications were usually linked to a lack of oxygen to body tissues.

Little benefit
"There is virtually no high-quality study in surgery, or in intensive or acute care—outside of when you are bleeding to death—that shows that blood transfusion is beneficial and many that show it is bad for you," said Gavin Murphy, a cardiac surgeon at the Bristol Heart Institute and leader of the U.K. study.

Recommendations ignored
Many experts are now worried that guidelines are being ignored. They suggest that transfusions should only be given as a last resort and that preventing blood loss in the first place whilst ensuring patients are not anaemic before they undergo surgery should be prioritised.

"Usually when there is any clinical uncertainty about a treatment you don't give it, but with transfusions we do," said James Isbister of the Royal North Shore Hospital in Sydney, Australia, who is an adviser to the Australian Red Cross Blood Service. But Mr. Isbister still encourages people to donate blood as it is used to treat other conditions as well as extreme blood loss.

The specific reasons why blood transfusions appear to be harmful to some patients are not yet fully understood and further research is being strongly encouraged by health authorities, including the U.S. National Institutes of Health.

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Bloodless Surgery Tops Agenda Among Non-Jehovah's Witnesses

JOSIE HUANG

Over the last five years, surgeons have replaced Iris Carr's knees, repaired a hip, removed a gall bladder. They have opened her chest to slice away a tumor from her heart.

Not one of those times was she given any blood.

A Jehovah's Witness, Carr is forbidden from getting blood transfusions. So she built up her blood level ahead of time by taking bioengineered drugs and intravenous iron supplements. During open-heart surgery, when blood loss is particularly heavy, Carr's doctors at Maine Medical Center in Portland suctioned off blood that had pooled around the incisions so it could be washed in a machine and returned to her body.

Carr returned home to Cape Elizabeth slightly anemic, but within a couple weeks her blood count was back to normal. And she did not develop any of the infections that can result from receiving someone else's blood: "I'm glad I went through with it," Carr, 89, said.

Bloodless medicine used to be geared toward people with concerns about transfusions. But studies showing that skipping transfusions results in faster recoveries -- and therefore lower hospital costs -- has more medical leaders saying the practice should be for everybody. Maine's largest hospitals are the latest to join a movement among medical facilities to turn no-transfusion medicine from an offering by some of its doctors into a standard of care.

Eastern Maine Medical Center in Bangor started a blood management program with a medical director more than a year ago, while Maine Med this year hired a medical director to lead theirs. A committee of doctors from different departments at Central Maine Medical Center in Lewiston has been meeting on the issue since last spring.

All three hospitals have spent the last several years on reducing transfusions in cardiac surgery, which historically has higher rates of transfusion. Today, both EMMC and Maine Med transfuse roughly a quarter of their patients. CMMC did not provide figures.

"Patients always ask, 'What are the chances of me getting a blood transfusion?'" said Dr. Robert Kramer, a cardiac surgeon who works on quality improvement projects at Maine Med. "We used to say 50/50. Now it's less, and we're hoping to get it even lower and lower."

There still is a need for transfusion in certain situations: the victim of a car crash, or a woman who keeps bleeding after giving birth, may have lost so much blood that a transfusion is the only option.

But even in emergencies, blood conservation techniques can be used so that transfusions can be kept to a minimum, according to the Society for the Advancement of Blood Management, which represents more than 120 blood management programs around the country.

Not only is bloodless medicine safer, it removes the need to buy blood, an increasingly expensive commodity, the group said.

Ten years ago, a unit of blood cost $75 but now it is about $300, said Dr. Jonathan Waters, society president and Chief of Anesthesia Services at Magee-Womens Hospital of the University of Pittsburgh Medical Center. "Those costs have gone through the roof," Waters said. Most of the cost is coming from rigorous testing to make sure blood doesn't contain pathogens and viruses such as HIV or hepatitis. As a result the blood supply is the safest it has ever been, Waters said.

COMPLICATIONS STILL OCCUR

But blood recipients still risk developing transfusion-related problems such as renal or respiratory failure or an infection because the donor's blood is suppressing the patient's immune system. There is also the chance the patient will receive the wrong blood type and develop a bad reaction. For much of the last half-century, the medical community saw the benefits of transfusions as outweighing the risks. The value of donated blood gained wide recognition during the world wars, when advancements in blood storage and distribution helped to save soldiers on the front lines.

After World War II, American Red Cross blood centers and independent blood banks began to crop up across the country.

Interest in finding alternatives to transfusions began to surface with the rise of AIDS during the 1980s. There was also a growth in the number of Jehovah's Witnesses, who believe the Bible prohibits transfusions. An oft-cited verse comes from Genesis: "Only flesh with its soul -- its blood -- you must not eat."

Doctors, on an individual basis, have offered bloodless medicine for decades. In Maine, there are 90 of these doctors, up from just one in the 1970s, according to the Jehovah's Witnesses.

It took longer for hospitals to recognize transfusion-free medicine. The first hospital programs debuted in the 1990s, and began to use multiple blood conservation methods on a large scale.

In the weeks leading up to surgery, a patient could take synthetic erythropoietin or EPO, which stimulates production of red blood cells in the bone marrow.

On the day of the surgery, doctors could remove blood from the patient -- so fewer red blood cells will be shed -- to be returned to the body later. To make up for the lost volume, patient are injected with donated plasma -- the yellowish liquid that blood cells float in -- and saline solution.

OTHER STRATEGIES

Another strategy is to use a "cell-salvage" machine that collects blood pooling during the surgery and filters out the impurities for reinfusion into the body. After the surgery, doctors would make sure to draw smaller amounts of blood for testing than was taken in the past.

At Englewood Hospital, which has one of the oldest and busiest bloodless medicine programs in the country, the transfusion rate among patients receiving coronary artery bypass grafting -- one of the most common surgeries -- is down to 8 percent, said the program's medical director Dr. Aryeh Shander.

Maine hospitals are hoping for similar outcomes by formalizing blood management programs. Dr. Irwin Gross, who runs the EMMC program, said his challenge is to work with a medical establishment -- including doctors, nurses and technicians -- who have been hard-wired to see transfusions only as a life-saving tool.

"There's a lot of work to do in terms of education, changing physician practices and changing hospitals systems so the care is uniform," Gross said. The American Red Cross said the rise of bloodless medicine has taken some of the pressure off the donor blood supply.

"If somebody uses a blood conservation method -- and not a unit of blood -- that makes the unit available to another patient who may need it," said Dr. Patricia Pisciotto, chief medical officer of the Northeast Division of the Red Cross.

But Pisciotto added that bloodless medicine is not commonplace enough to reduce the need for volunteer donors. The Red Cross in Maine said it typically has only several days' worth of blood at any given time.

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Bloodless Surgery: Safer And Cost Saving For Patients

ANI
The pioneer of transfusion-free bloodless surgery has revealed just why the technique is so beneficial, especially for patients wary of transfusions or those whose religion does not allow for it.

People such as Jehovah's Witness patients believe that accepting blood from a source other then themselves defies the scriptural teachings that their religion holds steadfast.

"Jehovah's Witness patients no longer have to die for want of blood," says Patricia Ford, MD, a hematologist/oncologist and Medical Director of the Center for Bloodless Medicine and Surgery at Pennsylvania Hospital, part of the PENN Medicine hospital network.

Dr. Ford is one of the pioneers of bloodless surgery and has been teaching its technique to doctor's around the world.

One technique a bloodless surgery can employ is called "cell salvage" in which blood lost during surgery is siphoned from the body, passed through a filter for cleaning and returned to the body.

The physician can also use it during surgery to limit blood loss and to avoid the need for transfusion of blood from sources other than the patient.

Originally developed to meet the needs of the Jehovah's Witness community, bloodless surgery is transfusion-free and is acceptable to Jehovah Witness followers because they are being reinfused with their own blood.

Bloodless surgery and medicine is a viable and life-saving option for these patients and those wary of the safety of the blood supply, and it is safe for a growing number of surgical and medical conditions, except for acute leukaemia and traumatic injury.

"Bloodless procedures have proven to be safer than blood transfusion because they help eliminate complications resulting from transfusions such as immunosuppression, infection, diseases from emerging pathogens for which our blood supply is not yet tested," said Dr. Ford.

"The hospital stay is also shorter for our bloodless patients, a cost savings for the patient and the institution," she continues.

Pennsylvania Hospital in Philadelphia is one of the pioneering centres for bloodless medicine and surgery.

Dr. Ford likens the weeks-old blood often used for transfusions to "water from a dirty fish tank." Depleted of most of its oxygen-carrying capacity, the stored blood is not maximally beneficial to any patient.

Prior to surgery, Dr. Ford prepares patients carefully - using medicines to build red blood cells, and managing their haemoglobin count. A higher haemoglobin level lowers the risk of transfusion.

Dr. Ford has performed the largest number of successful stem cell transplants without blood transfusion of anyone in the world. Among the procedures for which Dr. Ford has prepared patients for bloodless medicine and surgery are cardiothoracic surgery; radical hysterectomies, prostatectomies, cystectomies, and repair of aneurysms, chemotherapy management, and total hip and knee surgery.

The bloodless team at Pennsylvania Hospital has saved the lives of many Jehovah's Witness patients who otherwise would not have received care.

"We see patients from all over the country who come to us for our expertise in bloodless medicine. The needs of the Jehovah's Witness community have helped us develop practices that can not only save their lives, but can also benefit the entire patient community," concluded Dr. Ford.

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Qualitative Alternatives To Blood Transfusion

You might feel, 'Transfusions are hazardous, but are there any high-quality alternatives?' A good question, and note the word "quality."

Everyone, including Jehovah's Witnesses, wants effective medical care of high quality. Dr. Grant E. Steffen noted two key elements: "Quality medical care is the capacity of the elements of that care to achieve legitimate medical and nonmedical goals." (The Journal of the American Medical Association, July 1, 1988) "Nonmedical goals" would include not violating the ethics or Bible-based conscience of the patient. —Acts 15:28, 29.

Are there legitimate and effective ways to manage serious medical problems without using blood? Happily, the answer is yes.

Though most surgeons have claimed that they gave blood only when absolutely necessary, after the AIDS epidemic arose their use of blood dropped rapidly. An editorial in Mayo Clinic Proceedings (September 1988) said that "one of the few benefits of the epidemic" was that it "resulted in various strategies on the part of patients and physicians to avoid blood transfusion." A blood-bank official explains: "What has changed is the intensity of the message, the receptivity of clinicians to the message (because of an increased perception of risks), and the demand for consideration of alternatives." —Transfusion Medicine Reviews, October 1989.

Note, there are alternatives! This becomes understandable when we review why blood is transfused.

The hemoglobin in the red cells carries oxygen needed for good health and life. So if a person has lost a lot of blood, it might seem logical just to replace it. Normally you have about 14 or 15 grams of hemoglobin in every 100 cubic centimeters of blood. (Another measure of the concentration is hematocrit, which is commonly about 45 percent.) The accepted "rule" was to transfuse a patient before surgery if his hemoglobin was below 10 (or 30 percent hematocrit). The Swiss journal Vox Sanguinis (March 1987) reported that "65% of [anesthesiologists] required patients to have a preoperative hemoglobin of 10 gm/dl for elective surgery."

But at a 1988 conference on blood transfusion, Professor Howard L. Zauder asked, "How Did We Get a 'Magic Number'?" He stated clearly: "The etiology of the requirement that a patient have 10 grams of hemoglobin (Hgb) prior to receiving an anesthetic is cloaked in tradition, shrouded in obscurity, and unsubstantiated by clinical or experimental evidence." Imagine the many thousands of patients whose transfusions were triggered by an 'obscure, unsubstantiated' requirement!

Some might wonder, 'Why is a hemoglobin level of 14 normal if you can get by on much less?' Well, you thus have considerable reserve oxygen-carrying capacity so that you are ready for exercise or heavy work. Studies of anemic patients even reveal that "it is difficult to detect a deficit in work capacity with hemoglobin concentrations as low as 7 g/dl. Others have found evidence of only moderately impaired function." —Contemporary Transfusion Practice, 1987.

While adults accommodate a low hemoglobin level, what of children? Dr. James A. Stockman III says: "With few exceptions, infants born prematurely will experience a decline in hemoglobin in the first one to three months . . . The indications for transfusion in the nursery setting are not well defined. Indeed, many infants seem to tolerate remarkably low levels of hemoglobin concentration with no apparent clinical difficulties." —Pediatric Clinics of North America, February 1986.

Such information does not mean that nothing need be done when a person loses a lot of blood in an accident or during surgery. If the loss is rapid and great, a person's blood pressure drops, and he may go into shock. What is primarily needed is that the bleeding be stopped and the volume in his system be restored. That will serve to prevent shock and keep the remaining red cells and other components in circulation.

Volume replacement can be accomplished without using whole blood or blood plasma.* Various nonblood fluids are effective volume expanders. The simplest is saline (salt) solution, which is both inexpensive and compatible with our blood. There are also fluids with special properties, such as dextran, Haemaccel, and lactated Ringer's solution. Hetastarch (HES) is a newer volume expander, and "it can be safely recommended for those [burn] patients who object to blood products." (Journal of Burn Care & Rehabilitation, January/February 1989) Such fluids have definite advantages. "Crystalloid solutions [such as normal saline and lactated Ringer's solution], Dextran and HES are relatively nontoxic and inexpensive, readily available, can be stored at room temperature, require no compatibility testing and are free of the risk of transfusion-transmitted disease." —Blood Transfusion Therapy —A Physician's Handbook, 1989.

You may ask, though, 'Why do nonblood replacement fluids work well, since I need red cells to get oxygen throughout my body?' As mentioned, you have oxygen-carrying reserves. If you lose blood, marvelous compensatory mechanisms start up. Your heart pumps more blood with each beat. Since the lost blood was replaced with a suitable fluid, the now diluted blood flows more easily, even in the small vessels. As a result of chemical changes, more oxygen is released to the tissues. These adaptations are so effective that if only half of your red cells remain, oxygen delivery may be about 75 percent of normal. A patient at rest uses only 25 percent of the oxygen available in his blood. And most general anesthetics reduce the body's need for oxygen.

HOW CAN DOCTORS HELP?

Skilled physicians can help one who has lost blood and so has fewer red cells. Once volume is restored, doctors can administer oxygen at high concentration. This makes more of it available for the body and has often had remarkable results. British doctors used this with a woman who had lost so much blood that "her haemoglobin fell to 1.8 g/dlitre. She was successfully treated . . . [with] high inspired oxygen concentrations and transfusions of large volumes of gelatin solution [Haemaccel]." (Anaesthesia, January 1987) The report also says that others with acute blood loss have been successfully treated in hyperbaric oxygen chambers.

Physicians can also help their patients to form more red cells. How? By giving them iron-containing preparations (into muscles or veins), which can aid the body in making red cells three to four times faster than normal. Recently another help has become available. Your kidneys produce a hormone called erythropoietin (EPO), which stimulates bone marrow to form red cells. Now synthetic (recombinant) EPO is available. Doctors may give this to some anemic patients, thus helping them to form replacement red cells very quickly.

Even during surgery, skilled and conscientious surgeons and anesthesiologists can help by employing advanced blood-conservation methods. Meticulous operative technique, such as electrocautery to minimize bleeding, cannot be overstressed. Sometimes blood flowing into a wound can be aspirated, filtered, and directed back into circulation.#

Patients on a heart-lung machine primed with a nonblood fluid may benefit from the resulting hemodilution, fewer red cells being lost.

And there are other ways to help. Cooling a patient to lessen his oxygen needs during surgery. Hypotensive anesthesia. Therapy to improve coagulation. Desmopressin (DDAVP) to shorten bleeding time. Laser "scalpels." You will see the list grow as physicians and concerned patients seek to avoid blood transfusions. We hope that you never lose a great amount of blood. But if you did, it is very likely that skilled doctors could manage your care without using blood transfusions, which have so many risks.

SURGERY, YES —BUT WITHOUT TRANSFUSIONS

Many people today will not accept blood. For health reasons, they are requesting what Witnesses seek primarily on religious grounds: quality medical care employing alternative nonblood management. As we have noted, major surgery is still possible. If you have any lingering doubts, some other evidence from medical literature may dispel them.

The article "Quadruple Major Joint Replacement in Member of Jehovah's Witnesses" (Orthopaedic Review, August 1986) told of an anemic patient with "advanced destruction in both knees and hips." Iron dextran was employed before and after the staged surgery, which was successful. The British Journal of Anaesthesia (1982) reported on a 52-year-old Witness with a hemoglobin level under 10. With the use of hypotensive anesthesia to minimize blood loss, she had a total hip and shoulder replacement. A surgical team at the University of Arkansas (U.S.A.) also used this method in a hundred hip replacements on Witnesses, and all the patients recovered. The professor heading the department comments: "What we have learned from those (Witness) patients, we now apply to all our patients that we do total hips on."

The conscience of some Witnesses permits them to accept organ transplants if done without blood. A report of 13 kidney transplants concluded: "The overall results suggest that renal transplantation can be safely and efficaciously applied to most Jehovah's Witnesses." (Transplantation, June 1988) Likewise, refusal of blood has not stood in the way even of successful heart transplants.

'What about bloodless surgery of other types?' you may wonder. Medical Hotline (April/May 1983) told of surgery on "Jehovah's Witnesses who underwent major gynecological and obstetric operations [at Wayne State University, U.S.A.] without blood transfusions." The newsletter reported: "There were no more deaths and complications than in women who had undergone similar operations with blood transfusions." The newsletter then commented: "The results of this study may warrant a fresh look at the use of blood for all women undergoing obstetric and gynecological operations."

At the hospital of Göttingen University (Germany), 30 patients who declined blood underwent general surgery. "No complications arose that could not also have arisen with patients who accept blood transfusions. . . . That recourse to a transfusion is not possible should not be overrated, and thus should not lead to refraining from an operation that is necessary and surgically justifiable." —Risiko in der Chirurgie, 1987.

Even brain surgery without using blood has been done on numerous adults and children, for instance, at New York University Medical Center. In 1989 Dr. Joseph Ransohoff, head of neurosurgery, wrote: "It is very clear that in most instances avoidance of blood products can be achieved with minimal risk in patients who have religious tenets against the use of these products, particularly if surgery can be carried out expeditiously and with a relatively short operative period. Of considerable interest is the fact that I often forget that the patient is a Witness until at the time of discharge when they thank me for having respected their religious beliefs."

Finally, can intricate heart and vascular surgery without blood be performed on adults and children? Dr. Denton A. Cooley was a pioneer in doing just that. As you can see in the medical article reprinted in the Appendix, on pages 27-9, based on an earlier analysis, Dr. Cooley's conclusion was "that the risk of surgery in patients of the Jehovah's Witness group has not been substantially higher than for others." Now, after performing 1,106 of these operations, he writes: "In every instance my agreement or contract with the patient is maintained," that is, to use no blood.

Surgeons have observed that good attitude is another factor with Jehovah's Witnesses. "The attitude of these patients has been exemplary," wrote Dr. Cooley in October 1989. "They do not have the fear of complications or even death that most patients have. They have a deep and abiding faith in their belief and in their God."

This does not mean that they assert a right to die. They actively pursue quality care because they want to get well. They are convinced that obeying God's law on blood is wise, which view has a positive influence in nonblood surgery.

Professor Dr. V. Schlosser, of the surgical hospital at the University of Freiburg (Germany), noted: "Among this group of patients, the incidence of bleeding during the perioperative period was not higher; the complications were, if anything, fewer. The special view of illness, typical of Jehovah's Witnesses, had a positive influence in the perioperative process." —Herz Kreislauf, August 1987.

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Jehovah's Witnesses Have High Survival Rate After Surgery

Dan Oakes

The Age

SURGEONS could save lives by treating people as if they were Jehovah's Witnesses, a visiting US specialist told a conference yesterday.

Addressing the the annual scientific meeting of the Australian and New Zealand College of Anaesthetists, cardiothoracic specialist Bruce Spiess said blood transfusions hurt more people than they helped.

Jehovah's Witnesses refuse to accept blood transfusions, but Professor Spiess said a study in Sweden of 499 Witnesses showed their survival rates were higher than people who received transfusions.

He described blood transfusions as "almost a religion", because physicians practised them without any solid evidence that they helped.

"Blood transfusion has evolved as a medical therapy and it's never been tested like a major drug," he said. "A drug is tested for safety and efficacy, blood transfusion has never been tested for either one.

"There's a number of people around the world who are coming to these same conclusions and it's becoming more obvious that the old risks of hepatitis and AIDS have been defeated by blood bankers, and now what we're dealing with are events that make patients worse."

Transfusions increased the probability of post-operative complications, including pneumonia and wound infections.

"I think we need to focus on every possible mechanism we can to keep your own blood," Professor Spiess said.

"If you come to surgery, we should ethically treat every patient as if they were a Jehovah's Witness and say, my goal is to not to transfuse you and to use every other technique I possibly can, and then only as a very last result transfuse you."

He emphasised that in cases of severe trauma, blood transfusions were necessary, but pointed out that the majority of transfusions were of comparatively small amounts of blood.

Another area in which Professor Spiess is prominent is that of synthetic blood, which is composed of teflon-like fluorocarbons that carry oxygen far better than our own blood.

"We've just completed a study with traumatic brain injury — you're talking motor vehicle accidents and guns and head trauma — and we've just had a dramatic breakthrough with head trauma using the fluorocarbons as a way to deliver oxygen to the traumatised brain."

Professor Spiess is also researching the use of synthetic blood as a cure for decompression sickness, on behalf of the US Navy.

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Care conflict over BC sextuplets sparks bloody row

Owen Dyer

It is written in the Book of Leviticus: "As for any man who eats any sort of blood, I shall certainly set my face against the soul that is eating the blood, and I shall indeed cut him off from among his people."

An injunction against cannibalism, perhaps? To most practising Christians, this is probably one of the lines in the Bible that is best skimmed over without too much analysis. But to Jehovah's Witnesses, it has become a central tenet of their faith — one that many are quite literally prepared to die for.

Or perhaps to let others die for. Coping with the unwillingness of Jehovah's Witnesses to accept blood transfusion has become an accepted feature of the doctor's job. In all western countries, the patient's right to refuse transfusion has been upheld again and again in the courts. But there remains the thorny problem of treating the children of Jehovah's Witnesses, especially premature neonates, who are very likely to need transfusion.

This quandary has landed on the doorstep of British Columbia's government in a big way, with the arrival of Canada's first known sextuplets, born prematurely to a family of Jehovah's Witnesses.

Before the birth, the parents had refused selective reduction, which would have terminated some fetuses to improve the chances of the others. All four boys and two girls were born weighing less than two pounds. Within a week two had died. Doctors at BC Children's and Women's hospitals insisted that the surviving infants needed transfusion, but the parents refused. The hospital then appealed to the provincial government to take the babies into protective custody, which it did. Two received transfusions. Almost nothing is known about their progress since, except that all four are still alive.

They are all now again in the legal custody of their parents, but the legal wrangle continues, with the anonymous parents accusing the government of not letting them present evidence to a court before going ahead with the transfusions. "We have been stripped of our parental rights and been labelled unfit," they say in their filing with the BC Supreme Court. Under a provision of the BC Child, Family and Community Service Act, the government may act before a scheduled hearing takes place, if it has reasonable grounds to believe a child's health is in danger.

Needless to say, the case generated a fine media storm, and put the church organization of Jehovah's Witnesses in Canada on the defensive. "It is important for the media and others to avoid making stereotypical assumptions regarding Jehovah's Witnesses," they said in a statement.

IT'S IN THE BLOOD
Jehovah's Witnesses are often painted as medical Luddites, but in fact they have no issues with most modern medical treatment — their objections are very tightly focused on blood products.

The Watch Tower Bible and Tract Society of Pennsylvania, based in Brooklyn, is the Jehovah's Witnesses' equivalent of the Vatican. It actually monitors medical developments rather closely, always on the lookout for ways to improve treatment of its members without breaching this fundamental ordinance.

The society has kept abreast of technologies like intraoperative blood salvage and isovolaemic haemodilution with autotransfusion, which recycle the patient's blood during surgery. As long as it remains in contact with their circulation, it's deemed acceptable. They've also moved to accept new minor blood fractions and substitutes as they've appeared. They also permit members to use vaccines, even though these are often made with albumin.

There's even a modern hospital which specializes in "blood avoidance" medicine for the children of Jehovah's Witnesses: Schneider Children's Hospital in New York. In fact Schneider provided the escape route last time British Columbia ran into a sticky ethics case. A 14-year-old Jehovah's Witness girl was required to undergo transfusion with her cancer therapy, and her refusal was overruled by the BC Supreme Court because she was a minor (see "BC teen ordered to get treatment despite religious objections" May 30, 2005 , Vol 2, No 10). (A similar case, involving a 15-year-old Winnipeg girl with Crohn's disease, has just concluded with the girl being forced to undergo transfusions.) The BC teen fled to Ontario, and was eventually treated at Schneider after that province negotiated a deal with her family.

Crossing the continent was evidently not feasible for four fragile neonates in incubators, however. What's more, the substitute therapies favoured by the church, such as recombinant human erythropoietin, are usually poorly suited to neonatal treatment. They often take time to work, and are usually treatments instituted when a patient has time to prepare for elective surgery.

This time, the doctors were insistent: transfusion was the only option. Under BC law, they had a duty to inform child protection workers if parents refused therapy they deemed essential to a child's health.

The basic assumptions of medical ethics as practised in Canada undoubtedly support the hospital's decision. University of Victoria bioethicist Eike-Henner Kluge summed up the position succinctly to the Globe and Mail: "While the parents are at liberty to make martyrs of themselves, their children are not."

But what about the parents? Jehovah's Witnesses are clearly willing to assume risk. Indeed, this is a church with 6.5 million "witnessing" members and perhaps another 10 million who attend services, yet whose doctrine preaches that only 144,000 elect will ascend to Heaven.

It's possible that the problem will go away on its own. The church is open to blood replacements, so a technical fix may be over the horizon. And the Watchtower Society may be softening its position. In 2000 it abandoned its long-held policy of "disfellowshipping" any member found to have accepted a blood transfusion. This essentially meant excommunication, and followed a formal investigation. There were even disturbing anecdotal reports of other Jehovah's Witnesses visiting hospital patients to check they were not transgressing.

Today, a Jehovah's Witness who accepts blood is held to have "disassociated" himself from the congregation. There is no investigative process, so if medical confidentiality is upheld, the patient can sneak a blood transfusion without being punished. The 2000 directive also made it clear that a member must take the blood "wilfully and without regret" to have broken a core tenet of the faith.

That would seem to leave the BC kids in the clear. It would also potentially open the door to transfusing unconscious adults. A 2003 survey of European doctors in the Postgraduate Medical Journal found that two-thirds would transfuse an unconscious Jehovah's Witness who was losing blood, and 41% said they would not tell the patient on awakening. God may see all our sins, but the Watchtower Society evidently does not.

The opinions expressed are those of the author and are not necessarily the views of the National Review of Medicine.

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