The issues surrounding transfusion of Jehovah’s Witnesses should be examined in the broader context of medical ethics. Two aspects of medical ethics are important in this discussion: informed consent, and Do Not Resuscitate (DNR) orders. Patients are normally informed about their treatment plans. They have the right to refuse any care, as long as they are both competent and have capacity to make health care decisions. Many Jehovah’s Witnesses refuse transfusion of blood or some blood products because of their interpretation of certain passages in the Bible. Because other patients have the same right to refuse blood transfusion, it is not appropriate to argue with patients about their reasons for refusal. If they are competent, they have the right to refuse.

It is important to determine whether the patient is competent and has the capacity to make medical decisions, and to determine exactly what the patient refuses. Some patients are willing to accept reinfusion of their own blood, or transfusion of some blood components such as fresh frozen plasma. Jehovah’s Witnesses are as diverse a group as any other religious group. It is wrong to assume from the fact that a patient is a Jehovah’s Witness that she or he refuses blood transfusion. It is also important that there is no coercion of the patient, intended or unintended, because of the presence of family members or clergy. This is best done by speaking with the patient alone. It is important, in obtaining informed consent, to make it very clear that patients do not necessarily die as a result of withholding of transfusion. They may have strokes, myocardial infarction, or other organ damage. Thus the patient needs to understand that, if transfusion is withheld, she or he may emerge from the anesthetic with permanent impairment.

All participating caregivers must understand the patient’s wishes and agree to the same plan. Surgeons have been known to refuse to perform surgery on patients who refuse transfusion. The type of surgery to be performed, urgency of the surgery, and likelihood of blood loss are all important. Participating nurses must agree with the plan. Even though the anesthesiologist will give or withhold blood products, if the patient dies or has some other adverse outcome related to anemia, all on the care team will share the pain of this bad, and in a sense avoidable, outcome.

Often, Do Not Resuscitate (DNR) orders are suspended in the perioperative period. Transfusion of blood or blood products is often part of resuscitation. DNR orders are on most patients’ charts because of some terminal disease the patient has. When these patients need surgery for palliation or for some unrelated problem, they are generally willing to have their DNR orders cancelled for the perioperative period. They may need airway management or administration of resuscitation medicines to maintain appropriate vital signs during surgery. Their DNR status will resume after surgery.

Jehovah’s Witnesses, on the other hand, are often quite healthy, and they may want every form of resuscitation other than blood transfusion. The situation can be even more troubling if the Jehovah’s Witness wants transfusion withheld from a child or an elderly parent. Thus the refusal of a Jehovah’s Witness, or of any other patient, of perioperative transfusion is somewhat contrary to accepted hospital procedures related to perioperative resuscitation.