NO BLOOD
Medicine Meets the Challenge
Narrator: Dorothy MacPhee has a lifethreatening medical problem. An artery
that could burst at any time.
Doctor: "The normal way of doing this
operation is generally through the
abdomen a long vertical incision."
Narrator: Leslie is a young girl with a
serious spinal deformity.
Doctor: "The patient is a Jehovah's
Witness, and in a procedure of this
magnitude, it is unavoidable that some
blood loss will occur."
Narrator: Both patients need surgery. Yet
both patients have religious beliefs that
preclude their accepting a blood
transfusion. Medical science is now
providing doctors with alternative
strategies to treat successfully patients
who, for various reasons, avoid blood
transfusions. These new strategies may
soon benefit all patients.
NO BLOOD
Medicine Meets the Challenge
patients who have their own values and
their own position about certain issues."
Eileen Yost, R.N.: "There's a lot of
different cultures out there, and they have
entities specific to their own cultures that
we as health-care workers need to
understand."
Prof. Olivier Guillod: "I think the duty of
physician is not simply to preserve life. But
the first and foremost duty of physician is
to respect the patient."
Narrator: In the past, the medical
profession found it difficult at times to
respect the health care needs of one
religious group in particular, Jehovah's
Witnesses. This was because of their
avoidance of blood transfusions.
Alexis: "That was the easiest decision,
because there was, under no
circumstances would I accept blood."
Jessica: "One thing I heard, he says,
'blood transfusion,' and immediately I said,
'No, No!'"
Narrator: At the dawn of the 21st century,
society is becoming increasingly diverse.
People everywhere are being exposed to
different languages, customs, cultures,
and religious beliefs. Adapting to these
differences is a challenge to all strata of
human society. It is a singular challenge
for the medical community.
Wayne: "I couldn't live with myself if I
turned my back on my beliefs and my
God, and I wasn't going to accept a blood
transfusion."
Prof. Timothy W. Harding: "We're living
in a pluralistic society, and the doctor has
one set of values, but he or she will meet
Prof. Roland Hetzer: "There was
certainly a time in years back where
Jehovah's Witnesses were looked at by
physicians, and especially surgeons, in a
negative way."
Narrator: Their abstaining from blood
transfusions was often misunderstood by
the public.
Jamie Pollard, R.N.: "I think before I ever
met a Jehovah Witness, I had a certain
mindset that they were maybe a religious
fanatic type person."
Prof. Charles H. Baron: "Part of it, I'm
sure, is prejudice about a religious sect,
which the physician, or the judge, or the
lawyer, about which they may know next
to nothing."
Gene Smalley—JW spokesman: "A lot
of people nowadays have heard of
dangers or diseases that might be
contracted from blood and blood
transfusions. But frankly, for Jehovah's
Witnesses, central to their avoiding blood
transfusions, is because the Bible
highlights the preciousness of blood."
Eugene Rosam—JW spokesman: "It's a
very clear statement, by the way. It isn't
something that takes a lot of theological
study to determine, or work out. It says
very plainly in the Christian scriptures:
"Abstain . . . from Blood."—Acts 15:20.
Prof. Charles H. Baron: "From the point
of view of someone who's not a believer,
this seems an irrational act."
Prof. Edward Keyserlingk: "For some
people, it seems to be anti-medicine. It
seems to be somehow putting the patient
in jeopardy."
Diane Mitchell, LCSW, C.C.M.: "I think
some of us, myself included, was under
the impression that maybe Jehovah's
Witnesses didn't want the best medical
treatment, that they were sort of against
medical care."
Alec: "There's no question, it mattered to
me whether she lived or died. I brought
her to the hospital in the first place to help
her recover."
Cynthia: "I didn't want to just die, and I
don't think anybody wants that to happen."
Dr. Mark E. Boyd: "It's not some sort of
suicide pact that they want to enter into
with you. They want to live, they want to
have good health care, and I think that
you can work with them."
Diane Mitchell, LCSW, C.C.M.: "I
realized they wanted the best medical
care, but they just wanted it without
blood."
Prof. Edward Keyserlingk: "I think the
effort has to be made to remove the
perception of Jehovah's Witnesses are
somehow in a category by themselves."
Dr. Aryeh Shander: "Clearly, you can
point to many religions, they all have one
issue or another which you may or may
not agree, but that's not the issue."
Dr. Peter Carmel: "That this is a religious
precept. This is not illogical stubbornness.
This is a religious belief. And just as I
respect the religious beliefs of many other
religions, I think I have to respect that."
THE RIGHT TO CHOOSE TREATMENT
David C. Day, Q.C.: "All patients, as a
general rule, have the right to receive
treatment or to refuse to receive that
treatment, after they've had full, open, and
candid discussion with the treating
physician."
Prof. Olivier Guillod: "I believe the basic
element of patients' right is the right of
self-determination. That is, the right of any
patient to decide what shall be done with
his or her own body."
Narrator: Patient rights not withstanding,
some have claimed that declining what
they consider lifesaving medical treatment
is irrational.
Prof. Timothy W. Harding: "I think it's
wrong to equate a refusal of a treatment
with suicide, which is a conscious choice
to end one's life."
Prof. Edward Keyserlingk: "There is
always a legitimate question about a
patient's competence, but just the mere
refusal of blood in itself is not any kind of
such indication."
Dr. Hooshang Bolooki: "I can tell you, I
have done over 200 Jehovah's Witness
patients. I have never lost a patient
because I could not give the patient
blood."
Narrator: Why, then, does blood
transfusion remain the standard treatment
for serious blood loss?
Dr. Stephen M. Cohn: "I don't believe that
refusal of treatment is irresponsible or
irrational. I think that just because one
person chooses to not take this pill or that
fluid or this kind of solution, is their own
personal choice."
Dr. Peter Carmel: "I think that physicians
have been brought up with the idea that
blood is the gift of life and that, inherently,
blood is good for you."
Dr. Nicholas Namais: "We have patients
who say that they don't want to be on a
mechanical ventilator, they don't want a
breathing tube."
Dr. Avroy Fanaroff: "The refusal to
accept a blood transfusion bothers and
concerns many physicians because
they're worried that without the transfusion
the well-being of the patient is
jeopardized."
Dr. Mark E. Boyd: "It's an everyday event
for a patient who has malignancy or
cancer to refuse some treatment or other.
They don't want to have chemotherapy,
they don't want to have radical surgery. So
the idea that patients refuse treatment is
something that I work with, . . . don't take
as a personal insult."
Narrator: These facts are often obscured
by news stories claiming that someone
died because he refused a blood
transfusion.
Dr. Aryeh Shander: "To say that one has
died because of refusal of blood, I think, is
a very general, misleading statement."
Dr. Mark E. Boyd: "That's an
oversimplification . . . of the tragic event."
Dr. Peter Carmel: "It's rarely, if ever, the
case that a patient refused a blood
transfusion and therefore died."
Dr. Aryeh Shander: "People die because
of either a medical disease, or a
consequence of trauma, or surgery where
there has been complications."
Narrator: To appreciate fully why
physicians feel this way, one needs to
understand a little about blood and why
transfusions are given.
THE FLUID OF LIFE—BLOOD
Narrator: Blood circulates through the
body by means of an amazingly intricate
system of conduits called veins and
arteries. Arteries carry oxygenated blood
away from the heart, eventually branching
into tiny vessels called capillaries. These
deliver the oxygen-rich red blood cells to
every part of the body. Nutrients and
oxygen are exchanged for carbon dioxide
and other wastes at the cellular level.
Veins then transport the oxygen-depleted
blood back to the heart, which pumps it to
the lungs. There the carbon dioxide is
exchanged for oxygen and the cycle
begins anew. This cycle is absolutely
essential to life.
Dr. Nicholas Namais: "If there's no blood
to bring the oxygen to the cells, the cells
die, the body dies."
Narrator: When someone suffers severe
blood loss, doctors have two urgent
priorities.
Dr. Edwin A. Deitch: "The most critical,
immediate need is to stop the bleeding."
Prof. Francesco Mercuriali: "Blood
transfusion, traditionally considered a
normal adjunct to surgery, presently is
considered something that has to be
avoided."
Dr. Nicholas Namais: "Everything takes
back seat to stopping the bleeding."
Dr. Willem de Groot: "There are real
risks as far as transfusions are
concerned."
Dr. Stephen M. Cohn: "And number two
is to restore the volume within your
system."
Dr. Gerard A. Kaiser: "There are
concerns about blood born pathogens,
and certainly the concern about AIDS."
Narrator: What can happen when a
patient loses too much blood volume?
Dr. Richard K. Spence: "It's a biological
product. It can have diseases, etc. We
screen for most of them, but there are
some there that we just don't know about."
Dr. Edwin A. Deitch: "Then you don't
deliver blood to the brain or the other
organs and a person can die."
Dr. Nicholas Namais: "And what you
need to do is restore volume, restore
profusion, and restore oxygenation."
Dr. Edwin A. Deitch: "A way of correcting
that decrease in blood volume is by giving
other fluids intravenously. This can be
done using any one of a number of fluid
types and doesn't necessarily require
blood."
CHANGING ATTITUDES
Narrator: Increasing numbers of patients
are opting to avoid blood transfusions for
personal reasons.
Prof. Lawrence T. Goodnough: "If
you've ever had a conversation with a
patient the night before surgery and you
were to ask them if they had a preference,
would they prefer to avoid a blood
transfusion, the answer is always Yes."
Prof. Roland Hetzer: "I would say that
today at least 80 percent of the patients
would strongly favor not to have blood
transfusions."
Prof. Neil Blumberg: "We've certainly
seen some horrendous new diseases in
the form of HIV come along that probably
didn't exist in the past. Whether the next
disease will come along in 10 weeks, in 10
years, or 100 years, nobody can say."
Dr. Concha Lawand: "We have Hepatitis
C, Hepatitis B, that are transmitted, and
the costs, social costs of that are very
high."
Dr. Todd K. Rosengart: "There are
transfusion reactions that occur. They are
very rare, but they can be potentially
dangerous or even life-threatening."
Dr. Richard K. Spence: "We can mix the
blood up and cause catastrophe. Patients
have died and do die from getting the
wrong blood."
Prof. Donat R. Spahn: "It is interesting to
realize now in the late 90's or early 2000's
that the blood transfusion, to a certain
extent, does not do what we always use
blood transfusion for."
Prof. Neil Blumberg: "We have become
persuaded, over the years, that many of
the bad things that happen to patients
after surgery are in fact not bad luck, are
not lack of surgical skill, but are, in fact,
the complications of transfusion."
Dr. Nicholas Namais: "There are
strategies for intraoperatively using
electrocautery instead of scalpels."
ALTERNATIVE STRATEGIES
Narrator: These concerns have spurred
the development of a wide range of
alternative strategies, treatments that are
acceptable to many of Jehovah's
Witnesses, and others who also choose to
avoid blood transfusions. Alternative
strategies can be grouped around four
organizing principles.




Minimize Blood Loss
Conserve Red Blood Cells
Stimulate Blood Production
Recover Lost Blood
Prof. Donat R. Spahn: "That involves
anesthetic factors, it involve[s] the use of
certain substances, and it certainly
involves also the surgical technique."
 MINIMIZE BLOOD LOSS
Prof. Johannes Scheele: "The most
important technique to control bleeding is
to avoid bleeding . . . that with less
bleeding during surgery the result at the
end is better and the outcome is more
likely to be smooth."
Dr. Richard K. Spence: "Careful surgery
means preventing blood loss. Age is no
factor. We have operated on newborns.
We have operated on people in their 90's."
Prof. Johannes Scheele: "If there is
some bleeding persisting, there are
coagulation techniques, best of which is,
at the moment, Argon-Beam coagulation."
Narrator: There are noninvasive tools that
enable the surgeon to see inside the body,
minimizing surgical incisions.
Dr. Richard K. Spence: "You can use
drugs, topical application of different
products that will help prevent blood loss."
Prof. Roland Hetzer: "We have now
several methods available, like the fibrin
glue.
Narrator: Fibrin glue, made from blood
fractions, stimulates coagulation upon
contact.
Prof. Johannes Scheele: "The fibrin
tissue adhesive is certainly very, very
useful because it does not harm the
tissue."
Dr. Nicholas Namais: "In a Jehovah's
Witness, where blood loss is so, so, so
critical, I think you have to be very
extremely meticulous not to lose even a
drop of blood."
 CONSERVE RED BLOOD CELLS
Dr. Mark E. Boyd: "A surgeon who
operates without losing large amounts of
blood is almost invariably a good and
careful surgeon. One who loses large
amounts of blood is most often the
reverse."
Dr. Peter Carmel: "There are new
technologies of hemodilution and
reinfusion that make the operation easier
and which are acceptable to people who
have a religious precept against blood
transfusions."
Narrator: A variety of instruments are now
available to help surgeons minimize
bleeding.
Dr. Linda Stehling: "The principles of
hemodilution in terms of reduction of blood
loss are really quite simple."
Dr. Concha Lawand: "Basically, we use a
closed circuit on the patient. We draw off
blood from the patient, keep it in contact
with the patient, and substitute it with
fluids."
would always prepare the cell saver
system."
 STIMULATE BLOOD PRODUCTION
Prof. Donat R. Spahn: "That results in a
diluted blood, and therefore, the patient
loses only diluted blood rather than native,
or concentrated, blood."
Dr. Linda Stehling: "When the patient
bleeds intraoperatively, the red-cell loss is
less."
Dr. Herbert Dardik: "It would be like
taking a quart of milk and turning it, adding
water so you have 3 gallons of it now, but
the original quart is still in there. But if you
were to spill it into something, it would be
a lot of water and a little fraction of the
milk. And then at the end you get rid of the
water, and then you're back to where you
started."
Dr. Aryeh Shander: "And we use that
routinely in this institution, especially for
those patients who have anticipated
significant blood loss."
Dr. Concha Lawand: "I think that's
probably nowadays besides, not just for
Jehovah's Witnesses, a pretty good
standard of care for large volume loss
surgery."
 RECOVER LOST BLOOD
Dr. Richard K. Spence: "If we do lose
blood, this is the kind of case where we
use a cell saver. We will suction up any
blood that's lost. We wash it, we clean it,
we process it. We filter it, then we'll give it
back to you."
Prof. Donat R. Spahn: "Cell salvage is a
very important technique, because when
you use cell salvage, the blood lost by the
surgeon is not lost for the patient."
Prof. Johannes Scheele: "In any trauma
patient with a significant blood loss, I
Narrator: "A key element in stimulating
the body's ability to replenish its own
blood supply is a hormone called
erythropoietin.
Dr. Blair Siefert: "Erythropoietin is a
natural substance. It is formed in the
kidneys, other organs as well, but primarily
the kidney, to help our bone marrows form
the red blood cells that are going to carry
our oxygen."
Narrator: Blood cell production takes
place primarily in the sternum, the ribs, the
vertebra, and the pelvis. Recombinant
Erythropoietin boosts the body's natural
production of red blood cells.
Dr. Nicholas Namais: "If I know the
patient is going to be in the hospital a long
time, I may start them on some
recombinant erythropoietin so they can
start building up their own blood stores."
Prof. Francesco Mercuriali: "This can be
a very cost effective strategy to reduce the
utilization of allogenic blood transfusion."
Dr. Richard K. Spence: "One of the most
exciting things about this whole field in
transfusion alternatives is that the majority
of things that we talk about are within the
reach of physicians and hospitals around
the world."
Dr. Peter Carmel: "There are now
available techniques in almost every
subspecialty of surgery and medicine that
allow bloodless treatment."
Major Spry—JW spokesman:
"Alternatives, like any other therapy, are
not necessarily free from risk. So a
patient, a Witness patient in particular,
may want to become informed about the
benefits and the risks that are associated
with any particular treatment."
Dr. Edwin A. Deitch: "They should be a
prudent consumer."
Narrator: How effective are these
alternative strategies in helping doctors
treat patients who do not want blood
transfusions?
CASE HISTORIES
Leslie Lacks had just begun elementary
school when it became apparent that she
had a degenerating spinal deformity.
Doctors diagnosed Leslie's condition as a
severe form of scoliosis.
Dr. Tarek Mardam-Bey: "Scoliosis is a
curvature of the spine, so we have to
correct it as much as the spine flexibility
allows us."
Narrator: After a brace failed to correct
her condition, doctors recommended an
extensive surgical procedure.
Dr. Tarek Mardam-Bey: "We used
essentially a series of hooks and metal
rods made out of stainless steel that are
implanted in the patient's back and used
to essentially distract the spine and
achieve alignment."
Narrator: The Lacks wanted the surgery
performed without a blood transfusion. So
they found a surgical team that had
experience using bloodless techniques.
Before the surgery, Leslie's doctors
boosted her blood through the use of iron
and recombinant erythropoietin.
Dr. Tarek Mardam-Bey: "So it was
essential that we do the surgery without
excessive blood loss. The way that we
were able to achieve this is using two
techniques basically, one of them is what's
called the cell saver. The other technique
we used is called hemodilution. It is safer
in that it is the patient's own blood and it
has remained in continuous circulation
with the patient, so there's no chance for
contamination or blood transmitted
diseases."
Narrator: The surgery was a success, and
no blood transfusion was administered.
Within days, Leslie was up and walking.
Bobbie Lacks: "She's so happy. She's
going to be able to stand. She's now. She
always said, 'Mommy, I'm as tall as you
now!'"
Narrator: Although Leslie will have to
wear a brace for a while, doctors are
confident she will lead a normal life.
Leslie Lacks: "I'd like to skate, and
skateboard, maybe learn how to
snowboard, stuff like that."
Narrator: Sometimes alternative
strategies involve new surgical techniques
to reduce blood loss in patients that don't
want a transfusion. 75-year-old Dorothy
MacPhee suffered an abdominal aortic
aneurysm, a life threatening condition that
traditionally requires extensive surgery.
Dr. Herbert Dardik: "The normal way of
doing this operation is generally through
the abdomen, a long vertical incision from
the lower chest down to the pubic area,
having to work around and behind the
entire intestinal tract. Hospitalization range
ranging at best days, 4 to 5 days, to an
average of a week or even more,
presuming there are no operative
complications."
Narrator: Since Dorothy is one of
Jehovah's Witnesses, her physicians used
a surgical technique that minimizes
bleeding.
Dr. Herbert Dardik: "What we did today is
called endovascular aortic surgery,
specifically endovascular, meaning we’re
working within the artery. Through that
artery, we place our catheters, our wires,
all the instruments that we steer right up
into where the aneurysm is. And then we
can visualize the aneurysm by doing
fluoroscopy, x-ray technology."
Narrator: Dorothy's surgeons inserted a
wire mesh called a stent, and were thus
able to repair her aorta without a large
surgical incision that would have caused a
lot of bleeding.
Dr. Herbert Dardik: "A small incision in
the groin, all the manipulations through
that, a virtually pain free, complication
free, post-operative course. Home
generally 24 hours. So everybody is a
winner!"
Dorothy MacPhee: "I feel fine. I never
would have believed it, but I do."
Narrator: Two days after her surgery,
Dorothy was sent home. She recovered
nicely.
can't treat you because I can't administer
penicillin.' No, he simply says, 'We'll give
you a medical alternative. We'll give you
another antibiotic.' And he gets on with
treating the patient."
Narrator: This enlightened approach to
patient care has exciting implications for
the public at large.
Dr. Stephen M. Cohn: "The fact that we
couldn't use blood on Jehovah's
Witness[es], we learned how we didn't
have to use blood in many, many other
situations. So, it has actually propelled us
in the right direction."
Dr. Richard K. Spence: "Transfusion
alternatives clearly are good medical
practice, sound medical practice, safe
practice for our patients."
Dr. Linda Stehling: "Indeed, it is a
standard that should be available to all
patients."
A NEW STANDARD
A growing number of health care providers
are willing to meet the challenge of
treating patients who avoid blood
transfusions.
Prof. Roland Hetzer: "With the
development of all those techniques, there
is nothing really specific about Jehovah's
Witnesses anymore. We know that they
don't want blood transfusion, and we have
the technology to follow their wish."
Dr. Stephen M. Cohn: "The belief that
you don't want a blood transfusion should
not in any way, that should be a tiny part
of the whole medical-care environment.
That should be acknowledged, be put over
to the side, fine, now's the other 99
percent of your care."
Major Spry—JW spokesman: "I guess it
could be likened to a patient who is
allergic to penicillin. You wouldn't expect
the physician to say, 'Well, I'm sorry, I
Dr. Peter Carmel: "What we're talking
about here is going to be a moot point.
Because bloodless medicine and surgery
will become in the next five to ten years so
widespread, that it won't be novel
anymore."
Eugene Rosam—JW spokesman:
"Jehovah's Witnesses have had the
unique privilege, because of their religious
position on the matter, of helping doctors
to learn better ways to treat patients
without subjecting them to the risks of
blood transfusions."
Prof. Charles H. Baron: "What I have
seen in my own experience is that they
have turned the medical profession
around to the point where the gold
standard of treatment, frequently now, is
to treat people without blood."
Narrator: Already some 100,000
physicians worldwide are making
bloodless medicine and surgery available
to any patient who does not want a blood
transfusion. Many experts agree that in
the near future medicine and surgery
without the use of blood transfusions will
be the standard of care for all patients.
"There are now available techniques in
almost every sub-specialty of surgery and
medicine that allow bloodless treatment,
that we are getting away from blood
transfusions in general."
"As a heart surgeon, I guess it's unusual
for the guy not to like blood. He should
love blood. But I don't. I'm very proud
when our patient [who] comes out of the
operation room has not received any
transfusion."
"I can see, within the next few years, us
getting to a point where we do not have to
even think about giving blood."
[THE END]