Care conflict over BC sextuplets sparks bloody row

National Review of Medicine, Canada/March 15, 2007
By Owen Dyer

It is written in the Book of Leviticus: "As for any man who eats any sort of blood, I shall certainly set my face against the soul that is eating the blood, and I shall indeed cut him off from among his people."

An injunction against cannibalism, perhaps? To most practising Christians, this is probably one of the lines in the Bible that is best skimmed over without too much analysis. But to Jehovah's Witnesses, it has become a central tenet of their faith — one that many are quite literally prepared to die for.

Or perhaps to let others die for. Coping with the unwillingness of Jehovah's Witnesses to accept blood transfusion has become an accepted feature of the doctor's job. In all western countries, the patient's right to refuse transfusion has been upheld again and again in the courts. But there remains the thorny problem of treating the children of Jehovah's Witnesses, especially premature neonates, who are very likely to need transfusion.

This quandary has landed on the doorstep of British Columbia's government in a big way, with the arrival of Canada's first known sextuplets, born prematurely to a family of Jehovah's Witnesses.

Before the birth, the parents had refused selective reduction, which would have terminated some fetuses to improve the chances of the others. All four boys and two girls were born weighing less than two pounds. Within a week two had died. Doctors at BC Children's and Women's hospitals insisted that the surviving infants needed transfusion, but the parents refused. The hospital then appealed to the provincial government to take the babies into protective custody, which it did. Two received transfusions. Almost nothing is known about their progress since, except that all four are still alive.

They are all now again in the legal custody of their parents, but the legal wrangle continues, with the anonymous parents accusing the government of not letting them present evidence to a court before going ahead with the transfusions. "We have been stripped of our parental rights and been labelled unfit," they say in their filing with the BC Supreme Court. Under a provision of the BC Child, Family and Community Service Act, the government may act before a scheduled hearing takes place, if it has reasonable grounds to believe a child's health is in danger.

Needless to say, the case generated a fine media storm, and put the church organization of Jehovah's Witnesses in Canada on the defensive. "It is important for the media and others to avoid making stereotypical assumptions regarding Jehovah's Witnesses," they said in a statement.

It's in the Blood

Jehovah's Witnesses are often painted as medical Luddites, but in fact they have no issues with most modern medical treatment — their objections are very tightly focused on blood products.

The Watch Tower Bible and Tract Society of Pennsylvania, based in Brooklyn, is the Jehovah's Witnesses' equivalent of the Vatican. It actually monitors medical developments rather closely, always on the lookout for ways to improve treatment of its members without breaching this fundamental ordinance.

The society has kept abreast of technologies like intraoperative blood salvage and isovolaemic haemodilution with autotransfusion, which recycle the patient's blood during surgery. As long as it remains in contact with their circulation, it's deemed acceptable. They've also moved to accept new minor blood fractions and substitutes as they've appeared. They also permit members to use vaccines, even though these are often made with albumin.

There's even a modern hospital which specializes in "blood avoidance" medicine for the children of Jehovah's Witnesses: Schneider Children's Hospital in New York. In fact Schneider provided the escape route last time British Columbia ran into a sticky ethics case. A 14-year-old Jehovah's Witness girl was required to undergo transfusion with her cancer therapy, and her refusal was overruled by the BC Supreme Court because she was a minor. A similar case, involving a 15-year-old Winnipeg girl with Crohn's disease, has just concluded with the girl being forced to undergo transfusions. The BC teen fled to Ontario, and was eventually treated at Schneider after that province negotiated a deal with her family.

Crossing the continent was evidently not feasible for four fragile neonates in incubators, however. What's more, the substitute therapies favoured by the church, such as recombinant human erythropoietin, are usually poorly suited to neonatal treatment. They often take time to work, and are usually treatments instituted when a patient has time to prepare for elective surgery.

This time, the doctors were insistent: transfusion was the only option. Under BC law, they had a duty to inform child protection workers if parents refused therapy they deemed essential to a child's health.

The basic assumptions of medical ethics as practised in Canada undoubtedly support the hospital's decision. University of Victoria bioethicist Eike-Henner Kluge summed up the position succinctly to the Globe and Mail: "While the parents are at liberty to make martyrs of themselves, their children are not."

But what about the parents? Jehovah's Witnesses are clearly willing to assume risk. Indeed, this is a church with 6.5 million "witnessing" members and perhaps another 10 million who attend services, yet whose doctrine preaches that only 144,000 elect will ascend to Heaven.

It's possible that the problem will go away on its own. The church is open to blood replacements, so a technical fix may be over the horizon. And the Watchtower Society may be softening its position. In 2000 it abandoned its long-held policy of "disfellowshipping" any member found to have accepted a blood transfusion. This essentially meant excommunication, and followed a formal investigation. There were even disturbing anecdotal reports of other Jehovah's Witnesses visiting hospital patients to check they were not transgressing.

Today, a Jehovah's Witness who accepts blood is held to have "disassociated" himself from the congregation. There is no investigative process, so if medical confidentiality is upheld, the patient can sneak a blood transfusion without being punished. The 2000 directive also made it clear that a member must take the blood "wilfully and without regret" to have broken a core tenet of the faith.

That would seem to leave the BC kids in the clear. It would also potentially open the door to transfusing unconscious adults. A 2003 survey of European doctors in the Postgraduate Medical Journal found that two-thirds would transfuse an unconscious Jehovah's Witness who was losing blood, and 41% said they would not tell the patient on awakening. God may see all our sins, but the Watchtower Society evidently does not.

The opinions expressed are those of the author and are not necessarily the views of the National Review of Medicine.