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Wayne: "I just 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." Narrator: Their abstaining from blood transfusions was often misunderstood by the public. Prof. Roland Hetzer: "There was certainly a time, years back, when Jehovah's Witnesses were looked at by physicians, and especially surgeons, in a negative way." Jamie Pollard, R.N.: "I think that before I ever met a Jehovah's Witness, I had a certain mind-set, 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 SmalleyJW spokesman: " 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 RosamJW 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 is not a believer, it 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 C.C.M.: "I think that 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 her to 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, C.C.M.: "I realized that they wanted the best medical health care, but they just wanted it without blood." Prof. Edward Keyserlingk: "I think the effort has to be made to remove the perception that Jehovah's Witnesses are somehow in a category by themselves."

Narrator: Dorothy McPhee has a life-threatening

medical problem. An artery that could burst at any time."The normal way of doing this operation is, generally through the abdomen, a long vertical incision . . . " Leslie is a young girl with a serious spinal deformity. "The patient is a Jehovah's Witness, and in a procedure of this magnitude, it's unavoidable that some blood loss will occur. 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. N BOD OLO
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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. 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 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. Oliver Guillod: "I think the duty of physicians is not simply to preserve life, but the first and foremost duty of physicians is to respect the patient." Narrator: In the past the medical profession found it difficult, at times, to respect the health care need of one religious group, in particularJehovah'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 said: 'blood transfusion,' and immediately I said: 'No! No!' . . . "

Dr. Aryeh Shander: "Clearly, you can point to many religions, they all have one issue or another, with which you may or may not agree, but that's not the issue." Dr. Peter Carmel: "If 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."

Dr. Aryeh Shander: "People die because of either a medical disease, or a consequence of trauma, or surgery where there has been complications." 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. 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. 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." Narrator: To appreciate fully why physicians feel this way, one needs to understand a little about blood and why transfusions are given.

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. Oliver Guillod: "I believe that the basic element of patient's rights is the right of self-determination. That is, the right of any patient to decide what shall be done to his or her own body." Narrator: Patients' rights not withstanding, some have claimed that declining, what they say, is 'life-saving medical treatment,' is irrational. Prof. Timothy W. Harding: "It's wrong to equate a refusal of 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. 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 to take this pill, or that fluid, this kind of solution, is their own personal choice." 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. Mark E. Boyd: "It's an everyday even, for a patient who has a malignancy or cancer, to refuse some treatment of other. They don't want to have chemotherapy, they don't want to have radical surgery, so the idea that patient's refuse treatment, is something that I work with, not take it . . . I don't take it 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 . . . of the tragic event." Dr. Peter Carmel: "It's rarely, if ever, the case that a patient refused a blood transfusion and therefore died."

THE FLUID OF LIFEBLOOD

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 cell diesthe 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." Dr. Nicholas Namais: "Everything takes 'backseat' to stopping the bleeding." Dr. Stephen M. Cohn: "And number 2, is to restore the volume within your system." Narrator: "What can happen when a patient looses too much blood volume 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. Francesco Mercuriali: "Blood transfusion, traditionally considered a normal adjunct to surgery, presently is considered something that has to be avoided." Dr. Willem de Groot: "There are real risks as far as transfusions are concerned." Dr. Gerard A. Kaiser: "There are concerns about blood bore pathogens, and certainly the concern about AIDS." 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 we just don't know about." 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 ten weeks, ten years, or a hundred years, nobody can say." Dr. Concha Lewand: "We have Hepatitis C, Hepatitis B, transmitted, and the social costs of that are very high." Dr. Todd K. Rosengart: "There are transfusion reactions that occur, they are very rare, but they can potentially dangerous or even life-threatening." Dr. Richard K. Spence: "We could mix the blood up and cause a catastrophe. Patients have died and do die from getting the wrong blood." Prof. Donat R. Spahn: "It is interesting to realize now, that during the late 90s or early 2000s that the blood transfusion, to a certain extent, does not do what we always used blood transfusions for." Prof. Neil Blumberg: "We've 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 a lack of surgical skills, but are in fact, the complications of transfusions."

[Minimize Blood Loss; Conserve Red Blood Cells; Stimulate Blood Production; Recover Lost Blood]

Prof. Donat R. Spahn: "That involves an aesthetic factor, it involves the use of certain substances, and certainly involves also the surgical technique."
MINIMIZE BLOOD LOSS

Prof. Johannes Scheele: "The most important technique to control bleeding is to avoid bleeding. . . . so that with less bleeding during surgery, the result of that is better, and the outcome is more likely to be smoother." 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 90s." Dr. Mark E. Boyd: "The 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." Narrator: A variety of instruments are now available to help surgeons minimize bleeding. Dr. Nicholas Namais: "There are strategies for interoperatively using electrocautery instead of scalpels." Prof. Johannes Scheele: "If there is some bleeding persisting, there are coagulation techniques. The best of which is, at the moment, Argon-Beam Coagulator." Narrator: There are non-invasive 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 the 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

ALTERNATIVE STRATEGIES
Narrator: These concerns have spurred a wide range of alternative strategies, treatments that are acceptable to many of Jehovah's Witnesses, an others who also choose to avoid blood transfusions. Alternative strategies can be grouped around four organizing principles.

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 transfusion." Dr. Linda Shehling: "The principles of hemodilution, in terms of reduction of blood loss, are really quite simple."

Dr. Concha Lewand: "Basically, we do the closed circuit on the patient. We draw off blood from the patientkeep it in contact with the patientand substitute it with fluids." Prof. Donat R. Spahn: "That results in a diluted blood, and therefore, the patient looses only diluted blood, rather than native, or concentrated blood." Dr. Linda Shehling: "When the patient bleeds interoperatively, the red cell lose is less." Dr. Herbert Dardik: "It would be like taking a quart of milk and turning it. . . or adding water so that 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 waterand a fraction of the milkthen at the end, you get rid of the water, and then you're back 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 Lewand: "I think that's nowadays, besidesI think that for Jehovah's Witnesses its a pretty good standard of care for large volume loss surgery."
RECOVER LOST BLOOD

Dr. Richard K. Spence: "One of the most exciting things about this whole field, is that the majority of things that we talk about is within the reach of physicians and hospitals around the world." Dr. Peter Carmel: "There are now available, techniques in almost every sub-specialty of surgery and medicine that allow bloodless treatment." Major SpryJW 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?

CS H T R S A E IS O IE
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's 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 are used essentially to 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 erythropoetin. 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 called the cell saver. The other technique we used is called hemodilution. It is safer in that, it's the patient's own blood and its 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 can completely stand, now she says, 'Mommy, I'm almost as tall as you now!' Narrator: Although Leslie will have to wear a brace for a whiledoctors are confident she will lead a normal life.

Dr. Richard K. Spence: "If we do loose blood, this is the kind of case where we'll use a cell saver. We will suction up any blood that's lostwe wash it, we clean it, we process it, we filter itand 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 would, always, prepare the cell saver system."
STIMULATE BLOOD PRODUCTION

Narrator: "A key element in stimulating the body's ability to replenish its own blood supply is a hormone called erythropoetin. Dr. Blair Siefert: "Erythropoetin is a natural substance. It is formed in the kidneys, other organs as well, but primarily the kidney, to help our bone marrows to 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 Erythropoetin boosts the body's natural production of red blood cells. Dr. Nicholas Namais: "So if I know the patient is going to be in the hospital a long time, I may start them on some recombinant erythropoetin so they can start building up their own blood storage." Prof. Francesco Mercuriali: "This can be a very cost effective strategy, to reuse the utilization of allergenic blood transfusion."

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 McPhee 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 rangingat best, days, 4 or 5 days, to averaging a week or even morepresuming that 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. Essentially that's; Endo meaning we are working within the artery. Through that artery we place our catheters, our wires, all the instruments that we steal right up to where the aneurysm is. And then we can visualize the aneurysm by doing coroscopy, x-ray technology. Narrator: Dorothy's doctors inserted a wire mesh called a stint, 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 through the groin, all the manipulation through thata virtually pain-free, complication-free, in post-operative, of coursehome, generally in 24-hoursso, everybody's a winner! Dorothy McPhee: "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!

Major SpryJW 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 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.' Then 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 in Jehovah's Witnesses, we learned how we didn't have to use blood in 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 practicesafe practice, for a patient." Dr. Linda Shehling: "Indeed it is a standard that should be available to all patients." Dr. Peter Carmel: "What we're talking about here is going to be a mute point, because bloodless medicine and surgery will become in the next 5 to 10 years, so widespread that, it won't be novel anymore." Eugene RosamJW spokesman: "Jehovah's Witnesses have had the unique privilege, because of their religious position on the matter, of helping doctors 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, where the gold standard, is to treat people without blood." Narrator: Already some 100,000 physicians worldwide, are making bloodless medicine and surgery available to anyone who does not want a blood transfusion. Many experts agree that in the new future medicine and surgery without the use of blood transfusions will become 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, so that we are getting away from blood transfusions in general." "As a heart surgeon, I guess it's unusual for a guy not to like blood, he should like blood, but I don'tI'm very proud when my patient comes out of the operation room, and has not received any transfusion." "I can see within the next few years, us getting to a point of where we do not have to even think about getting blood." [THE END]

AN W T N A D E SADR
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's nothing really specific about Jehovah's Witnesses anymore. We know that they don't want blood transfusions 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 acknowledgedput over to the side, finenow to the other 99 percent of your care!"