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Jehovah's Witnesses

Background

In the 1870s Charles Taze Russell led members of a Bible-based religious community to form an adventist group that believed that society was so fundamentally flawed that it was about to end in Armageddon, the final battle between God and Satan. Their only chance of survival into a new life depended on strict adherence to precise rules of conduct that emphasize living a pure lifestyle (refusing cigarettes and illicit drugs, although tolerating alcohol), refusing all participation in military service, in political movements, and in nationalistic activities such as pledging allegiance to a national flag; even contact sports are forbidden. Many of these beliefs were based on literal interpretations of the Bible, including belief in the actual presence of Satan in the world as the cause of all social injustice. There can be no ultimate cure for human disease in this flawed world. Evil will cease only after Armageddon, and only believers will be saved.

The question of whether or not Jehovah's Witnesses are a Christian sect is hotly debated; you will find some comments in Wikipedia and elsewhere on the web.

Clinical Relevance

Blood Transfusion
Jehovah's Witnesses respect medical science, but they reject both unnatural prolongation of life and also interventions that may shorten life (so euthanasia and suicide are not tolerated). Formerly they also refused vaccinations, but these are now accepted. Pain management and other forms of supportive care are acceptable, but interventions involving blood transfusion are not. This was based on an interpretation of three Bible passages (see below, Nerd's Corner) and was promulgated in 1945 but has been refined several times since then as a result of changing techniques such as the use of blood components. For example, in 2000, the Watchtower Bible and Tract Society (the governing authority for Jehovah's Witnesses) permitted the use of hemoglobin products, and also permitted autologous transfusions as long as this occurs as part of the actual therapy, as opposed to storage of the patient's own blood in anticipation of subsequent surgery. Hence, hemodilution, blood cell tagging and blood patch are likely to be permitted, all of which involve removal of the patient's own blood, temporary storage and re-infusion.

Transplantation may be acceptable, as long as blood is removed from the organ to be transplanted. However, transplantation procedures undertaken without access to rescue blood transfusions place Jehovah’s Witness patients at significant risk of death if complications arise (Boggi U, et al. Kidney and pancreas transplants in Jehovah’s Witnesses: ethical and practical implications. Transplantation Proceedings 2004; 36:501-502.).  However, various perioperative measures can avoid the need for rescue transfusion, making the outcome for transplantation in Jehovah’s Witnesses comparable to that of other patients (Figueiro J, et al. Simultaneous pancreas-kidney transplantation in Jehovah’s Witness patients. Clinical Transplantation 2003; 17:140-143).

Ethical Challenges
The rejection of blood transfusions forms the most common instance of refusal of treatment that you will encounter. It is exceedingly challenging to participate in a life or death situation that could readily be resolved, but in which the clinician may be constrained from acting. Indeed, the Jehovah's Witness position stimulated the development of ethical guidelines on autonomy, informed consent and advanced directives for care.

If the patient steadfastly refuses transfusion, you should accede to the extent that your own moral conviction allows you. Use other therapies as long as these do not confer greater risk. If this is impossible for you, you may need to stabilize the patient and refer them to a colleague. In an emergency situation and when there are no advance directives and the patient cannot make their wishes known, it is defensible to perform whatever procedure is necessary to stabilize the patient. But always check, because Witness patients carry "no blood cards"; if signed, dated and witnessed these are to be taken as authority and you cannot override them. Where possible, communicate with the patient, and document every decision you take. (Guidelines based on an excellent chapter on Jehovah's Witness bioethics by O. Muramoto in The Cambridge Textbook of Bioethics, ed: PA Singer and AM Viens, Cambridge UP, 2008)

The Jehovah's Witness position is complex and is modified from time to time; individual Witness members may be unclear as to precisely what the rules are; there are differences in perspective between individual members, and the rules are likely to evolve in future years, so you are well advised to check with authorities. Finally, you should also try to separate the individual patient's personal perspective from that of his or her religion: you can support the patient in reaching an autonomous decision, but this does not necessarily mean obediently following the perceived dictates of their religion. They may have been guided by misinformation over the true policy of the Society, and respecting the autonomy of your patient as a person does not necessarily mean you must respect them as a member of a religious organization. Encourage the patient to contact the elders of their congregation for advice.

Mental Health
Mental illness may be viewed by Witnesses as spiritual weakness, or as a result of evil influences. Witnesses may therefore distrust psychiatric therapy, preferring to treat mental illness within their own group. Nonetheless, an issue may be that the strict nature of the religious practices demanded by members, the focus on imminent cataclysmic disaster, and the shunning of members who have left the faith, may form fertile ground for the development of mental distress.
Nerd's Corner…(click here)
Biblical sources quoted…
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Nerd's Corner

Biblical sources quoted as justification for health beliefs (King James version)
Blood transfusions:
  Genesis 9:4 "... but flesh with the life thereof, which is the blood thereof, shall ye not eat."
  Leviticus 17:12 "Therefore I said unto the children of Israel, No soul of you shall eat blood, neither shall any stranger that sojourneth among you eat blood."
  Acts 15:29 "That ye abstain from meats offered to idols, and from blood, and from things strangled, and from fornication: from which if ye keep yourselves, ye shall do well. Fare ye well."
Mental health:
  James 5:13-16 "Is any among you afflicted? Let him pray. Is any merry? Let him sing psalms.
Is any sick among you? let him call for the elders of the church; and let them pray over him, anointing him with oil in the name of the Lord: And the prayer of faith shall save the sick, and the Lord shall raise him up; and if he have committed sins, they shall be forgiven him.
Confess your faults one to another, and pray one for another, that ye may be healed. The effectual fervent prayer of a righteous man availeth much."