Email Rolf J.Furuli:
I do not want to continue the discussion regarding Dr. Muramoto's article, but I would like to make a
few concluding remarks regarding his two last letters.
CALCULATION OF MORTALITY RATES
Dr Muramoto has made some calculations regarding the risks of refusing blood transfusion that are
so extremely misleading that they cannot go unchallenged. A student of mine who had handled
statistics in the way Dr Muramoto has done would not have gotten his exam. Dr Muramoto writes:
"The accurate number itself is not as important as the magnitude of the risk. Available data indicates
that the mortality of refusing blood is close to one hundred times greater than the mortality of being
transfused. In the United States alone, about 1.5% of population has conditions requiring blood
transfusion each year according to the statistics of the American Association of Blood Banks. That
means about 15,000 of Witnesses in the United States will face such conditions each year. Not all of
them need transfusion for major surgeries, but suppose half of them had major surgeries, about
7,500 Witnesses have about 1% of additional mortality according to Kitchens. To put this in
perspective, 75 Witnesses are dying each year in the United States alone due to refusal of blood
transfusion, whereas only about 0.01% of mortality, or life of less than one Witness, is spared by
refusing blood transfusion and avoiding transfusion-related death. We never know the exact number
of life lost and life saved by refusing blood transfusion. However we can estimate the magnitude of
mortality from this practice with reasonable certainty. If we accumulate the above number over the
past thirty years and extend to other countries, "hundreds and thousands of deaths from the blood
refusal policy" is not at all an exaggeration."(1)
Those being engaged in scientific research know that numbers cannot just be compared or
extrapolated, but all the factors that influence the groups to which the numbers refer must be taken
into consideration as well. When discussing dangers and advantages of blood transfusion, a host of
factors from the past, present and future must be taken into consideration. And the question should
be discussed both generally (from a statistical point of view) and specifically (from the point of view of
the individual patient which needs surgery).
GENERAL STATISTICS
In order to make statistics regarding the advantages and dangers of blood transfusions which have
some plausibility, we should compare two groups of patients which are as similar as possible, one
getting blood transfusions and the other being treated with alternatives.(2) We should also be certain
that each patient has received the very best treatment.(3) Not only deaths which probably were
caused by blood transfusion or by the lack of such should be compared, but diseases and deaths
that later occurred and which probably were caused by the transfusion or by the lack of such. Dr.
Muratmoto's statistics is very far from fulfilling these criteria because it concentrates on just one
factor and ignore the others.
I shall not argue at length with quotations from medical journals about the dangers of blood
transfusion. A glance at any group of hemophiliacs and their high frequency of diseases caused by
blood fractions, definitely shows that infusion of blood components is not safe. But I would like to
show that even though blood banks have worked hard to eliminate risks, there is no substantially
reduction in the dangers today compared with 15 years ago. In 1988 a journal wrote: "Hepatitis that is
attributed to transfusion... develops in [about] 7%-10% of blood recipients in the United States... This
frequency of hepatitis occurs even among recipients of volunteer blood, but in recipients of paid-donor
blood the frequency is three to four times higher. " (4) Last year professor Neil Blumberg,
director of Transfusion Medicine Unit and Blood bank, University of Rochester, New York commented
on the situation in the US. In a taped interview he estimates that in the US between 10.000 and
50.000 persons die each year from transfusion related causes.(5)
If we take the whole situation into account, both during and shortly after an operation and some time
later, we find the reverse of what Dr Muramoto has claimed, thousands upon thousands of people
have died *because* they have been treated with blood components. The numbers above show
some of the dangers in the industrilized Western countries. But how less safe are blood transfusions
in South Africa where 20 % of the people are HIV carriers? What about the rest of Africa, Eastern
Europe, Russia, Japan and other countries in the Far East? There can be no doubt that Jehovah's
Witnesses have been protected against diseases by their standpoint to abstain from blood!
Dr Muramoto's claim that the costs are higher in bloodless medicine are wrong. True, individual
cases may be more expensive than similar cases treated with blood. But by and large bloodless
surgery is cheaper than surgery where blood components are used. For instance, a Norwegian study
of costs of bloodless coronary bypass surgery in 3.637 patients showed a total saving of $
1.500.000.(6)
THE INDIVIDUAL PATIENT
The patient in need of major surgery does not benefit from statistics, because each patient's
situation is special. However, the statistics above show that the alternative, from a medical point of
view is not 'a safe treatment with blood components versus a dangerous one without using blood'.
While the Witness patient refuses blood because of the Bible's prohibition, the dangers of
transfusions, together with the fact that almost any kind of surgery can be performed without using
blood components if it is well planned, is also taken into consideration.
A patient with breast cancer may illustrate the the situation. She may have three options, 1) to remove
the tumor only, 2) to remove the tumor and the whole breast, or 3) to remove the whole breast and all
the lymph glands around. The physician will explain the prognoses in the different cases, and the
patient will make her decision. Perhaps she chooses just to remove the tumor because she does
not want to loose a breast, even though the physician recommends alternative 2) or 3) as being safer,
but she has the right to decide. This is what informed consent is all about, and the physician cannot
overrule her decision because he or she thinks it is irrational. In this case any statistics are irrelevant;
what counts is the patient's informed decision.
The Witness patient wants to be treated in a similar way. He or she has voluntarily made a decision
not to accept major blood components, and what he or she wants is to get the best possible
treatment. Statistics is completely irrelevant in this situation; what counts is the informed decision of
the individual patient. Because Witnesses take repsonsibility for their own situation, their Hospital
Liaison Comittees have made a tremendous lot of work to find doctors who are willing to treat them
without using blood, and to inform about the latest achievements in bloodless medicine. This has
resulted in cooperation with more than 100.000 physicians world wide.
AUTONOMOUS AND INFORMED DECISIONS
I fully agree with Dr Muramoto's statement , "What is important to physicians is to look at this
individual person, and obtain the truly autonomous and informed decision from this one person,
regardless of how thousands of others believe." (7) I would just like to add that the 9 dissidents (Dr
Muramoto and his 8 aquaintances) must be included in "the thousands of others" whose beliefs are
irrelevant. I therefore welcome the situation when a Witness is hospitalized and no other Witnesses
influence his or her decision regarding blood except someone whom he or she specifically asks to
do so, and where no dissident is allowed to influence the decision except those specifically called to
do so. However, this is not what the dissidents want.
On the E-mails sent by the founder of the group of dissidents, with the pseudonym Lee Elder, we find
their stated goal. As a description of the members we read: "All have volunteered their time and
energies in an effort to bring about an end to a tragic and misguided policy that has claimed
thousands of lives, many of them children."(8) Dr Muramoto has already shown that most Witnesses
stick to their decision to refuse blood when he said, "In reality, I do not expect any significant number
of JWs will easily change their stance after one or two private meetings with a physician."(9). Thus
the group whom he recommends, represents the very opposite of what Dr Muramoto calls for. They
do not respect "the truly autonomous and informed decision" of the Witnesses who refuses blood,
but "use their time and energies to [try to] bring about an end" to such decisions. This group has the
right to make their own decisions but should not be allowed to influence the physician-patient
relationship when Witnesses are hospitalized.
Before he or she comes to the hospital, the typical Witness has written a document which is signed
by him- or herself and two witnesses, where it is specified which treatment that is refused. In
addition, the Witness has given a detailed explanation of his or her position to two close friends or
family members, and these are authorized to make decisions on the part of the Witness if he or she
becomes unconscious. This suggests that the standpoint of the Witness is a "truly autonomous and
informed decision". In addition, the physician may want to speak with the Witness in order to make
sure that this is the case. By this Muramoto's requirements, in which I agree, are fulfilled.
In order to reach their goal to "bring an end" to the "policy" of refusing blood, the 8 dissidents try to
ruin the reputation of the Witnesses by claiming that they cannot answer particular questions
regarding their decision to refuse blood. For instance, the dissidents ask: "Where can we read in the
Bible that each of the 'major components' are included in the concept haima? This is an impossible
question, because, what is found in the Bible is the word haima and not the definition of it. The
definition must be given by us as Christians, and this is of course a human judgement. I have in my
letters tried to show why I find the Witness standpoint logical and consistent. Others may disagree,
but this is our sincere opinion, and this is what counts when an informed decision is to be taken. The
claims of the dissidents that we cannot answer questions regarding our standpoint is just a part of
their war strategy. It is quite ironic that what Dr Muramoto claims he is working for, is what each
Witness most of all wants, namely, to be treated as an individual patient who can make an informed
choice. But by introducing the fictional situation that it is the Watchtower Society that makes the
decisions for each patient, and that the patient does not necessarily mean what she has written and
signed, it is he who asks the physicians to treat the Witnesses en bloc rather than as individuals.
CONCLUSION
I have stated that "it can be more dangerous to accept a transfusion than to refuse one". Dr Moramoto
has claimed that "blood conservation medicine is a safe"(10) and has tried to counter my claim by
arguing that the mortality rate in connection with surgery is higher among those who refuse blood
than among those who takes blood. He ignores the two basic requirements for making a sound
scientific statistic, namely, 1) to compare similar groups, and 2) to include all diseases and deaths
which are caused by taking blood/not taking blood, and not only those occurring at the time of the
operation. Even if just requirement 2) is fulfilled, my claim is justified, as the statistics above show.
(1) Muramoto, O. http://www.bmj.com/cgi/eletters/322/7277/37, 19 March 2001.
(2) Due to the nature of major surgery it is not possible to use a control group.
(3) In bloodless surgery this could mean that patients were treated with EPO and intravenous iron
before the operation, that hemodilution was used or cellcaver was available, and that, as a routine
the operation was stopped if the hemoglobin level dropped below a certain level, in order to complete
the operation later. For instance, if a team does not have the routine that they stop when the
hemoglobin comes down to a certain level, the hemoglobin may become so low and the patient be
so weak that the body does not manage to rise the hemoglobin level. If such a person dies, she will
statistically be included among those where lack of blood transfusion contributed to their death.
However, if the team had taken the right precautions, the patient may not have died.
(4) Seeff, L. B. et al., 95 "Gastroenterology", 530 (1988), 531.
(5) See the video "Transfusion-Alternative Strategies - Simple, Safe, Effective". (2000) Watch Tower
Bible and Tract Society of Pennsylvania.
(6) Ovrum, E. et al., "Autotransfusion in coronary bypass surgery reduces costs", Tidsskrift for den
Norske Laegeforening, 18 (1997);117:2616-8.
(7) Muramoto, O. http://www.bmj.com/cgi/eletters/322/7277/37, 13 March 2001.
(8) Personal E-mail.
(9) Muramoto, O. "Bioethics of the refusal of blood by Jehovah's Witnesses: Part 2. Anovel approach
based on rational non- intervenational paternalism." Journal of Medical Ethics - October 1998, p 300.
(10) Muramoto, O. http://www.bmj.com/cgi/eletters/322/7277/37, 19 March 2001.