Medical Examiner

How I Treat Patients Who Refuse Blood Transfusions

Why can’t Jehovah’s Witnesses have a Shabbes goy make medical decisions for them?

Photo Essay At Hospital Haut Leveque University Hospital Of Bordeaux, France. Preparation Of The Placental Blood Pouch To Send It To The Blood Bank.
A placental blood pouch is prepared to be sent to a blood bank at Hospital Haut Leveque University Hospital of Bordeaux, France.

Photo By BSIP/UIG via Getty Images

When you are performing the first interview of a new patient at the high-risk obstetric clinic where I work, question No. 14 on the intake computer form is: “Do you have any prior preterm deliveries?”

Question No. 15 is: “Do you have any lung or respiratory diseases, including asthma?” (This is when everyone remembers that they do, in fact, have asthma.)

Question No. 16 is: “Would you accept a blood transfusion if you needed one to save your life?” It’s a yes/no question. If you type “No,” the line turns a brilliant and alarming red.

That question is there, of course, because of Jehovah’s Witnesses. This Christian sect was founded in 1872 by Charles Russell, and its members’ stance on blood transfusion is derived from their interpretation of Genesis 9 and Leviticus 17 to “not eat from the bread of life,” as well as the verses in Acts 15:20, Acts 21:25, and elsewhere that Christians must “abstain from … blood.” Adherents do not accept blood products, regardless of the possibility of death. For Jehovah’s Witnesses, receiving blood products may lead to excommunication from their community and fear of eternal damnation.

It’s not uncommon for my clinic to have a Jehovah’s Witness patient. These patients are often not the ones who give us the most trouble in terms of transfusion—the sickle cell patient who has been transfused so many times that it’s very hard to find blood that she’s not allergic to is another example. We work closely with the blood bank, and no transfusion is given lightly to any patient (or, unless in an emergency, without formal written consent).

Not all Jehovah’s Witnesses feel the same way about transfusion; some may opt to allow some blood products but not others, some may allow us to use certain techniques but not others. And some, when faced with the occasionally harsh and always direct discussion (and paperwork) involved in the refusal of all blood products, find that, in the end, their reservations about transfusions have left them.

But there was one patient I took care of several years ago who was especially worrisome. She was entering her third trimester with a pregnancy that had various complications related to her uterus and placenta that were going to necessitate a cesarean delivery, and quite likely a cesarean hysterectomy.

A cesarean hysterectomy is a difficult and frightening surgery. It’s daunting to try to take out the uterus of a pregnant woman right after a baby has left it: The blood vessels feeding it are bringing one-fifth of her blood volume to it every minute, and new blood vessels have formed in every direction, following no solid anatomical rules, because the pregnancy has strongly requested them since the day it set up shop. During the surgery, you clamp and tie off arteries that are the size of your pinky finger and sometimes your thumb; they bleed, you clamp and tie them again. Ultimately, the surgical saying goes, all bleeding stops. But we’d prefer it to be because we have a successful surgery and not because there’s no blood left.

For this patient, the plan for cesarean hysterectomy was made because, at this time, it was this patient’s only option. However, it is unusual to get through a cesarean hysterectomy safely without a blood transfusion. It was terrifying to me to have to consider not having the option.

There are, of course, multiple techniques that can help minimize the risk. Self-donation of blood is accepted by some Jehovah’s Witness patients; surgical tools that recirculate lost blood back into the patient’s blood stream are another.

All of these, and more, were discussed with our patient. But she had another idea. “I want,” she said. “I want my cousin to be my deputy.” Her cousin was not a Jehovah’s Witness. In the event that the patient lost consciousness, she wanted her cousin to make her choices. She was very precise: Her cousin was not her health care proxy. A health care proxy, a more usual legal arrangement, would appoint a deputy who has to make the decisions the patient would make herself if she were able to do so. No—she delegated the cousin to make the decisions he wanted to make at the time of her inability to speak, rather than her own. It seemed to her team that she was very clearly choosing someone who was not a Jehovah’s Witness, someone who would not make a Jehovah’s Witness choice. Someone who would allow us to save her life.

As a former student of Talmud, this scenario felt very familiar. In Jewish law, because you are forbidden to turn on the light on Shabbat, a friendly gentile can perform that service—the Shabbes goy. If you own forbidden yeast or leavened products at the time of Passover, you can temporarily sell them (even though they stay within the walls of your house) to another friendly gentile. In its own way, it’s a markedly pluralistic way of seeing the world: It’s not wrong to do these things, it’s just wrong for me. Enter the legal wranglings and complicated contracts that then make it possible for the light to be turned off, and the bread to be intact, and society to function, all without sin.

During the conversation with this patient, I thought: Of course. She needs a blood equivalent of a Shabbes goy. She needs … a transfusion atheist.

I thought: This is brilliant. This is brilliant! This is a way out. All the Jehovah’s Witnesses could choose a transfusion atheist—I’ll do it for the whole hospital, even though I’m Jewish. Nobody would need to die, or be shunned, or have to face this terrible choice between their God and their life, between their community and their self, ever again.

I tried bringing this idea up with the next Jehovah’s Witness patient I had, and I was met with a gentle “No” and more than a bit of confusion. I tried to ask a few Jehovah’s Witness ministers (I got their numbers through my institution’s chaplain), but nobody returned my calls. I spent a long while on the phone and sent several very carefully composed follow-up emails to the Jehovah’s Witness media center, and was sent repeatedly to this page, which I found completely inadequate. I meant all my inquiries with the utmost respect but also the utmost urgency: Could we solve this?

After reaching out to several of those Jehovah’s Witness leaders and failing to have a serious conversation with them, I still don’t know. Right now I’m left with the thought that maybe the reluctance to talk around, to negotiate, to manage this rule is the true and deep cultural divide here. For me, the refusal of blood transfusions is a problem, a problem that I want to solve. I am willing—more than willing, in fact, eager—to walk backward around this rule and tie it up in knots and call that “keeping it” because a maternal death is the worst news I have ever had to break to a family.

And maybe that’s the point. For the truly devout among Jehovah’s Witnesses, the refusal of transfusion is not a problem; perhaps it is a divine command. In that setting, all my machinations, even on their behalf, may appear woefully inadequate, and perhaps—although meant with respect—insulting, compared with gracious acceptance. Getting out of the problem is not the point for them; it is not, perhaps, a problem to be solved.

And that is where we cannot agree. Because I will always believe that debate and manipulation, and even falsification, in pursuit of the life of a woman are sacred things, indeed.