Bioethical aspects of the recent changes in the policy of refusal of blood by Jehovah's Witnesses

Policy changes

Judicial proceedings

In June 2000, the Watchtower Society issued a directive stating that the organisation would no longer disfellowship members who did not comply with the policy of refusal of blood. Its official statement to the media was that “if a baptized member of the faith wilfully and without regret accepts blood transfusions, he indicates by his own actions that he no longer wishes to be one of Jehovah's Witnesses. The individual revokes his own membership by his own actions, rather than the congregation initiating this step. This represents a procedural change instituted in April 2000 in which the congregation no longer initiates the action to revoke membership in such cases. However, the end result is the same: the individual is no longer viewed as one of Jehovah's Witnesses because he no longer accepts and follows a core tenet of the faith.”5 This directive was widely publicised in the press as a reversal of the policy regarding blood. 6 7 A similar policy was established in Bulgaria in 1998 with the European Commission of Human Rights,8 in which Bulgarian Jehovah's Witnesses were promised free choice to have blood transfusions “without control or sanction on the part of the association.” Although an official from the Watchtower Society denied any change in the policy then,9 that there is a need to issue a similar directive worldwide two years later indicates that there has been a major procedural change in the policy for Bulgaria and elsewhere.

To understand the real impact of this change it is important to understand how Jehovah's Witnesses are sanctioned for wrongdoing. Besides being disfellowshipped at the conclusion of a judicial process by which unrepentant offenders are expelled, a member may be automatically shunned if there is reason to believe that he or she has renounced a core tenet of the faith by some specific action such as joining another religion or the military and if the allegations are substantiated by an investigation. He or she is classified as having thereby “disassociated,” and this policy change puts the conscientious acceptance of blood in this category. According to the rules of Jehovah's Witnesses both disfellowshipped and disassociated members are considered outcasts. In both cases the religious community must ostracise and shun the wrongdoer as set out in the official statement, “the end result is the same.”10 According to dissidents, ostracism and shunning by family and friends work as strong deterrents against leaving the religion or acting against the church's teachings, thus compromising the freedom and autonomy of patients who are Jehovah's Witnesses.3

Nevertheless, the patient's autonomy differs importantly between the two procedures. Disassociation is initiated by the member's own action, whereas disfellowshipping is initiated by each congregation through a judicial committee.5 Under disfellowshipping the member is expelled when the committee rules him or her guilty and unrepentant. In contrast, disassociation automatically excludes a member from the congregation only when the member's offensive action becomes known through self disclosure or substantiating evidence of the offence. Simply put, if the act of receiving blood is kept strictly confidential, disassociation is highly unlikely, whereas disfellowshipping would still have resulted from interrogation initiated by the committee.

“Primary components” of blood must be refused, but Jehova's Witnesses can “conscientiously decide” whether to accept transfusions of fractions derived from the prohibited cellular components

(Credit: FAYE NORMAN/SCIENCE PHOTO LIBRARY)

Implication of the new policy on medical confidentiality

Under ideal protection of medical confidentiality, decisions on blood transfusion made by a patient who is a Jehovah's Witness would be known only to the patient and the medical team, not to the congregation. This means that the patient would have almost full control over whether he or she disassociates from the religion by his or her treatment decision being known to the congregation. If the patient personally believes that the decision to receive blood components of which the church disapproves does not violate God's commandment, as some dissident Witnesses do,3 then he or she could remain silent about the decision and continue membership provided his or her medical confidentiality is fully protected. Under the previous policy, any suspicion of receiving blood would prompt a judicial committee, which could elicit an involuntary confession from the patient and result in his or her disfellowshipping. For example, a red bag that a visitor casually observes hanging over the patient may be reported to the congregation without confirming whether it is a prohibited or permitted component. Such hearsay would have been sufficient ground to initiate a judicial committee. Under the new policy, such a formal inquiry is unlikely to happen, and the treatment would not be verified unless medical confidentiality is breached.

Obviously this potentially greater autonomy under the new policy hinges greatly on the integrity of medical confidentiality. Even though this change seems to facilitate the so called “don't ask” policy on the part of the congregation by not initiating judicial inquiry, it does not address breaches of medical confidentiality regarding blood transfusions or the “don't tell” policy on the part of the patient.14 In fact, in response to my proposal for a “don't ask, don't tell” policy for refusal of blood, Donald Ridley, legal counsel for the Watchtower Society, flatly denied such a possibility by saying that “it would encourage Witnesses to act privately in a manner they publicly declare to be wrong.”15 He implied that the private medical decision of Witnesses should be restricted by the church's public policy, even though some Jehovah's Witnesses do not personally agree with it.3 This religion has a history of tacitly instructing its members to breach medical confidentiality when other members are non-compliant with the religion's medical policy. 16 17 This tradition was not changed in the recent directive. As long as unsolicited visitors and hospital workers who belong to the religion closely monitor the blood based treatment of patients who are Jehovah's Witnesses, there remains a possibility that the patient will be forced to disassociate from the religion because of a breach of confidentiality.

Increasing importance of doctors' participation

The immediate impact of these changes on the medical care of Jehovah's Witnesses may seem subtle but is still important. Because the change in judicial proceedings has a different meaning to different Jehovah's Witnesses, and this change has not been announced through their official magazines to rank and file members so far, doctors are likely to encounter patients who are Jehovah's Witnesses who have diverse views on the consequences of accepting blood. Some patients may reconsider their previous stance on the refusal of blood in light of this procedural change.

Because of these recent changes the use of various blood products is also viewed differently by patients who are Jehovah's Witnesses. The new policy is somewhat arbitrary about whether a product is considered “primary” or “secondary.” Any product derived from a “primary component” can be considered secondary; however, there are many grey areas. For example, red cells are processed by leucocyte reduction, irradiation, and rejuvenation, and plasma may be processed through fractionation and treatment with solvent detergents into a secondary product. It is not at all clear whether these products are considered primary or secondary under this new policy. Some Jehovah's Witnesses may feel such distinction is left up to their conscientious decision. Others may consider only whole blood is unacceptable in view of the expanding list of approved blood fractions.

An in-depth discussion of the entire blood policy with individual patients may become necessary to ensure truly autonomous decisions on blood based treatment. Their advance directives and so called “blood cards” should be re-evaluated with the patients in light of the new policy. For example, doctors may ask patients who are Jehovah's Witnesses, “In view of the changing blood policy of the Watchtower Society, the component you now refuse may be considered acceptable in a few years. Are you sure you want to refuse it and die now even if you may not have to do so in the near future?” The doctor might add, “If your conscience allows you to receive this blood component but you are afraid that others may not approve your action, you might want to know that the Watchtower Society informed the media on 14 June 2000 that they ended the procedure of disfellowshipping for those who accept blood transfusions. Instead, you may be considered disassociated if your action is known to the congregation, but I assure you that your medical confidentiality is legally protected.” Needless to say, all medical information on the use of blood products in these cases should be protected from unauthorised review. Otherwise legal liability may arise because of unintended sanction based on breached medical confidentiality.

Conclusion

Probably the most important advice to doctors at this time of flux in the policy of refusal of blood is to treat individual patients who are Jehovah's Witnesses independently of the church's official policy. Each case needs to be discussed and treated individually. Although this has essentially always been so, in actual practice most doctors and hospitals have treated this group collectively according to the church's official policy instead of thoroughly exploring personal conviction and preference. Doctors have often been encouraged to contact the church's representative (its hospital liaison committee) to decide individual treatment. Such practice should be re-evaluated in view of the increasing divergence and variability among the members. At the present time, premature death of exsanguinating patients who are Jehovah's Witnesses on the basis of this changing policy should be averted, as further changes in the near future may prevent such deaths completely.