There are few if any true substitutes for a blood transfusion if one is truly needed and an exhaustive discussion of these is beyond the scope of this chapter. However, there are some measures that can be taken to decrease the need for a blood transfusion. It is important to define which, if any of these, will be acceptable to an individual JW patient.

Just as in any organized religion, there can be a difference between official doctrine and personal belief. Therefore, it is not always the case that a patient professing to be a JW will not accept any blood products. In a study of pregnant JW patients, up to 10% of these patients stated that they would accept blood products in an emergency situation; however, it was not confirmed whether these patients were baptized [7]. Furthermore, there is a sect known as “Advocates for Jehovah’s Witness Reform on Blood” formerly called “Associated Jehovah’s Witnesses for Reform on Blood” whose members will accept blood and blood products in many circumstances [8, 9]. They have also worked to reform the Church from the inside [9]. Despite the fact that some JWs accept blood products, in general, few practicing Jehovah’s Witnesses will accept whole blood, packed red blood cells, plasma, platelet concentrates, or white blood cell transfusions [6]. Few practicing JWs will accept pre-donated autologous blood since the blood is out of contact with their body for a significant period of time, yet acute normovolemic hemodilution is acceptable to many of the faithful. With cell saver, acute normovolemic hemodilution (ANH), cardiopulmonary bypass, and renal dialysis, The Watchtower states that it is an individual JWs decision to receive these treatments if the blood is kept in a continuous circuit with their body and is not stored for any period of time. Cardiopulmonary bypass and dialysis would always involve a continuous circuit. Of course with cell saver and ANH a continuous circuit is not routinely used, but a continuous circuit can easily be created. Other products and procedures are also left to the “discretion of the practicing Christian” including albumin, cryoprecipitate, cryo-poor plasma, individual factors, as well as organ and bone marrow transplantation (Table 6.2).

When faced with major surgery, it is imperative that the anesthesiologist and surgeon determine, in as much detail as possible, what if any of the “optional” products the patient will accept. In addition, it will often become necessary to educate the patient not only on what each of these products and techniques entails, but also on the fact that they are indeed optional.

The ethical and legal right of capacitated adults to make medical decisions for themselves is well-established [10]. Autonomous decision making provides adults with the leeway to make authentic choices consistent with their beliefs and values [11]. If an adult patient makes a “bad decision,” the clinician may confirm capacity and attempt to use gentle persuasion to redirect the patient, but little precedent exists to override their refusal. It may even be considered battery if consent is not obtained from a capacitated adult patient and his or her known preferences are overridden.

When adult patients are unable to make medical decisions on their own behalf, clinicians try to identify a person to act as the patient’s “surrogate” and make decisions as his or her proxy. In other words, clinicians ask the surrogate to make decisions based on the patient’s previously expressed wishes (if known), or to make decisions consistent with the patient’s known values and interests. In pediatrics, children have developing and evolving decisional capacity as well as beliefs and values. Parental authority and familial autonomy over their developing, vulnerable child creates a unique dynamic that is different from the moral space in which surrogates make medical decisions [12].

Infants and children lack the ability to make autonomous medical decisions and therefore parents (or legal guardians) are presumed to have a liberty interest in the “care, custody, and management” of their children [13]. Furthermore, as children age and mature they are able to play an increasing role in the medical decision making process creating a triangle of decision making between patient, parent, and provider, which may raise additional complexities [14]. While parents are allowed broad discretion in medical decision making, this right is not absolute. As was noted in the case of Prince v Massachusetts, “…Parents may be free to become martyrs themselves. But it does not follow they are free, in identical circumstances, to make martyrs of their children before they have reached the age of full and legal discretion when they can make that choice for themselves” [15]. Responding to parents who are refusing a recommended medical intervention is often challenging to clinicians. It is the fiduciary responsibility of the clinician to advocate for the interests of his or her patient (the child) in a manner that promotes the child’s interests while minimizing infringements on familial autonomy and parental authority as a whole.

When a child has a reasonable prognosis, the parental refusal of a recommended therapy obliges physicians to (1) analyze the risks and benefits of the parental request versus the recommended intervention and (2) consider if other alternative interventions may be reasonable. It is generally helpful to engage in shared decision making with the family, involving colleagues skilled in communication if necessary, to reach a mutually agreeable decision. If persistent conflict cannot be resolved with referral to another clinician or through involvement with clinical ethics consultation, state intervention may be required. This is most often indicated when parental decision making is perceived to significantly violate a child’s best interest or put the child at risk of serious harm.