Extract:
"... In essence, the philosophy of  Jehovah's Witnesses is that blood has been designed and created by God and should therefore be used as God intended it to be. Conflict between Jehovah's Witnesses and their physicians represents a conflict between 2 opposing principles: respect  for patient autonomy and professional commitment  to beneficence (duty to provide optimal patient care.
  The care of  Jehovah's Witnesses  raises 2 fundamental ethical issues. The first is the determination of appropriate treatment in light of ethical principles of autonomy, beneficence, and nonmaleficence; the second is that issues of justice and resource allocation arise because Jehovah's Witnesses refuse recommended treatment, such as blood transfusion, but demand alternative therapies of possible greater expense, questionable benefit, or greather harm. For example, in this case the use of erythropoietin was not reimbursed by the usual methods because it was not within the guidelines specified  by Australian Commonwealth. Fortunately, the cost was covered on compassionate grounds by the pharmaceutical company that manifactures the drug.
  Conflict between patients and pysicians has been dealt with using 3 different techniques: coercion, deception, or attempts at mutual respect for both patient and physician autonomy. An exemple of the use of coercion can be found in the treatment of minors. Courts will generally support blood transfusion for children of Jehovah's Witnesses parents on the basis that parental autonomy is not unlimited and children should not be martyrs to the parents' beliefs. A court order may be obtained and the child would receive a transfusion against the parents' wishes. However, it is preferable for all nonblood alternatives to be tested before coming to this point.
  An exemple of physicians who advocate the use of deception can be found in the results of a 1991 survey of 242 members of the European Society of intensive Care Medicine who were asked about attitudes toward the use of blood transfusions in a hypothetical case involving the exsanguination of a Jehovah's Witness patient. Twenty-six percent of the physicians stated that in these circumstances they would perform transfusion in these patients but would never inform yne patient.
  Both coercion and deception can be criticized using a consequetialist argument. This line of reasoning would suggest that if Jehovah's Witnesses knew that they would be forced to accept blood products or tricked into using them, then they would avoid coming to the hospital, cusing greater morbidity in the long-term. A similar argument has been raised in relation to involuntary human immunodeficency virus testing and disclosure. We are unaware of any research data to support the proposition that Jehovah's Witnesses avoid health care institutions because of concern regarding the use of coercion and deception, anda we areunaware of children of Jehovah's Witnesses being kept away from hospitals on this supposition.
  An alternative viewpoint, such as that suggested by the rulebased ethics, would suggest that both coercion and deception are simply wrong because they deny patients autonomy that is an essential part of human decision making. Indeed, any guarantee of religious freedom would seem to imply that individuals have the right to refuse blood and blood products for religious reasons, provided that they are competent to make such a decision. Most Jehovah's Witnesses carry medical directive cards that explicitly emphasize tha individual's refusal of blood transfusion under any circumstances, and these cards are given due weight by the law. Damages have been awarded to patients given blood products against their wishes. Jehovah's Witnesses can legally refuse any form of treatment, even if the refusal is to the detriment of their health.
  Several groups of researchers have examined the stability of patient's treatment choices expressed as avanced directives. These authors have shown that only approximately 15% of patients change their preferences for life-sustaining treatment over time, and even fewer patients change their preference if they have been expressed in written form. Nonethless, physicians should recognize that patients might change their minds about blood transfusion and attempts should be made to discuss blood transfusion privately with patients to avoid the possibility of coercion from family of religious groups. It seems possible that patients might wish to undergo transfusion but continue to refuse in the presence of a church elder or familiy member. However, if a patient does change his or her mind from a previously strongly held view, this change might be a consequence of  illness or stress impairing the patient's competence to decide.
  The governing body of Jehovah's Witnesses has published an informative and pratical guide to the medical treatment of Jehovah's Witnesses, and it also has set up hospital liaison committees in many major cities. These committees have 4 majio functions: (1) to help Jehovah's Witnesses find cooperative physicians and surgeons prepared to provide bloodless surgery, (2) to be on hand for patients anf thei families in difficult situation, (3) to provide a liaison for consultation with medical personnel, and (4) to research and make available to physicians and hospitals articles on alternative nonblood therapy from the medical literature..."
 

Extract:
  "As part of their religious belief Jehovah's Witnesses reject the use of blood transfusions. The right of a patient to practice religion freely may oppose the ethics of a physician who cannot watch a patient bleed to death without intervention. In the case of adult patients the courts have consistently supported the right to refuse blood on a religious basis. Transfusing patients against their will can result in charges of battery and civil monetary penalties (1).
  A patient's right to self determination is not absolute. It can be violated if there is a pressing state superior interest. A recent case (Stamford Hospital v Vega, 236 Conn.646, 1996) involved a Jehovah's Witness mother who bled severely after delivery. An emergencv court order was issued to transfuse the mother against her will, in part because preserving the family and providing a child with a mother were considered a state superior interest. This case was eventually appealed to the Connecticut Supreme Court, which unanimously found that the lower court erred. Ms. Vega's common-law right of  bodilv self-determination was violated.
  Other state courts have also come to similar conclusions (2). Divorce, skydiving, and auto racing could all be banned to parents if their rights were secondary to the family unit. Proving a state superior interest is becoming increasingly difficult. Physicians who care for Jehovah's Witnesses must be prepared to withhold blood as a therapy no matter how necessary this treatment becomes.
  Children are a different story. The U.S. Supreme Court in Prince v Commonwealth of Massachusetts (3)  has ruled that, "Parents may be free to become martyrs themselves, but it does not follow that they are free, in identical circumstances, to make martyrs of their children." The court determined that the right to practice  religion freely does not include liberty to expose  children to ill health or death. This ruling has been used   in supporàng the constitutionality of mandatory vaccination programs and forced school attendance.
  Transfusions of minors against parental wishes were  tested in Jehovah 's Witnesses v Kings County (Harborview) (4).  This was a class action suit that sought to enjoin all physicians and hospitals in the state of Washington from  administering blood to plaintiffs in the future. Ten children were included in this suit. The court ruled that  Prince v Commonwealth of Massachussetts was pertinent
and upheld the state of Washington's child neglect reg ulations that allowed minors to be removed from their parent's care for necessary transfusions. The law is fairly clear; lifeksaving transfusions can be given to minors against parental wishes!
  The question of who is a child is not straighdorward. It varies not only among coutries but also from state to state. In New York state any competent person older than 18 years of age can give medical consent, but there are many  exceptions for special circumstances (i.e., any married person can consent, any parent can consent for a child, any pregnant person can consent for prenatal care, any physician whose judgrnent suggests an emergency exist and attemps to secure proper consent will
result in increased risks can consent for his or her patient) (5). In addition, some states have adopted the concept of "mature minnor."  This doctrine originated  in Illinois and states that a minor who is mature enough  to understanf  the consequences of his or her actions  and exercises the judgment of an adult can reject or  consent to medical treatment. If patients are legally al lowed to give consent for themselves, many courts support their right to refuse treatment.
  An approach to dealing with Jehovah's Witness patients include the following steps:

    1 . Find out exacfly what the patient will and will not  accept. Whole blood, packed red blood cells, white  blood cells, plasma, and platelets, although strictly   forbidden by the church, may be acceptable to some patients. Albumen, fibrinogen, Rh immunoglobulin, specific factors, transplantation, and  erythropoietin (6)are considered a "matter of conscience" and left to the individual's discretion.
   2. Be prepared to let the adult patient bleed without  transfusion. If the physician has an ethical prob lem with this, the Hospital Information Services of  the Jehovah's Witnesses in Brooklyn, NY ([718] 625-3600) may be helpfial in finding a "bloodless medicine and surgery center" and a physician experienced in dealing with Jehovah's Witnesses.
   3. Discuss with the patient and use appropriate blood  conservation techniques such as preoperative use of erythropoietin, aprotinin, desmopressin, artificial hemoglobin, perfluorocarbon emulsions, intraoperative hypotension, hypothermia, hemodilution, and blood salvage.
   4. If the patient is a minor and cannot legally give consent, a detailed discussion must take place with the guardians. Forcing the parents to sign a consent allowing a transfusion puts them in a stressful situation. Even if no transfusion is performed, just consenting to it may cause emotional scars with social and religious stigma. A better form acknowl edges the parent's refusal to allow transfusions while stating that if an emergencv exist the physician will notify child welfare authorities. If there  is no time, a transfusion will be given as the law and  courts require. This type of form allows the parents  the dignity of rejecting a forbidden treatment while informing them that blood will be given if  necessary for the child's survival. Therefore this is  not a consent form but an acknowledgment of the  parent's wishes and the physician's responsibility.

  Courts permit transfusion against parental authority to save a child's life; however, with proper planning and the use of blood conserving technologies this should be a very rare occurrence. To avoid future problems all centers performing surgery should consider how they will deal with the Jehovah's Wltness child scheduled for elective surgery. Establishing policies and procedures
can avoid confusion later."

  REFERENCES
 1. Malette v  Shulman.  Dominion  Law Reports  (Canada) 1990;67:3221-39.
 2. Fosmire v Nicoleau, 75 NY 2d 218 (1990).
 3. Prince v Commonwealth of Massachusetts, 321 US 158 (1944).
 4. Jehovah's Witnesses in State of Washington v King County Hospital, 278 F Supp 488 (1967).
 5. NY Pulblic Health Law ch 45, article 25, §2504.
 6. Jansen AR Blood transfusion and Jehova's Witnesses. Crit Care Clin 1986; 2:91-100.