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Blood substitutes. Personal autonomy. Professional autonomy. Introduction The ethical, moral and legal transformations linked to the technical and scientific progress that has taken place over recent years have given rise to new situations in healthcare practices, modifying the relationship between professionals and their patients, with focus shifting from moral duties and obligations deontology towards respect for autonomy and moral pluralism bioethics.

These characteristics are accentuated when it is the professional who unilaterally defines the therapeutic decisions to be taken. In such cases professionals are putting excessive weight on the ideal of beneficence, which, in practice, leads to them taking a paternalistic position, taking decisions on behalf of others. The limit of beneficence is autonomy. One of these new situations of ethical and moral conflict in healthcare is the application of new treatments using hemocomponents and hemoderivatives to patients who are Jehovah's Witnesses.

Nowadays, hemocomponents and hemoderivatives play an important role in blood-based treatment and are widely used in medicine and dentistry. These biomaterials have made it possible to create and extend a large number of different techniques and improve comfort, accelerating and improving healing after surgery.

The process of regeneration the formation of tissues that are functionally and morphologically restored, with the same properties and structure as the tissues that have been lost tends to be naturally substituted by repair, with distinctly inferior density and qualities. Only the last of these is exclusively independent of the surgical technique employed and can be improved by using blood-based biomaterials.

Brazil is a secular country and freedom of religious pluralism is guaranteed by the constitution. According to The Watchtower published on 1st December of , the prohibition against eating blood that is found in the Bible should be extended to medical treatments. On the other hand, there is no restriction on individual Jehovah's witnesses following their own interpretations of the matter, which extends the list of prohibitions.

However, many physicians and dentists are either unaware of this fact or simply do not know that their patient is a Jehovah's witness, since they do not tend to ask the question when taking a patient's history, which in itself creates an a priori concrete problem with relation to respect for these patients' autonomy. There is no prohibition whatsoever on hemoderivatives minor fractions , because they are not considered blood soul by the religion's doctrine.

Other treatments with fresh autologous material such as extracorporeal circulation, cell salvage, hemodialysis and platelet-rich plasma are generally accepted. This combination of different interpretations and lack of knowledge or interest on the part of health professionals means that, according to Engelhardt, in the eyes of "moral strangers" physicians and dentists who are not witnesses they are simply religious people who "do not accept blood", which makes this a fertile field for conflicts.

Specific objectives were to study the degree of knowledge about and acceptance of these treatments by Jehovah's Witnesses; to analyze the sociocultural profile of those investigated; to identify whether health professionals concern themselves with the religion of their patients when taking histories; and to propose a bioethical framework for solving any conflicts that are encountered.

Methods This was a cross-sectional, qualitative, descriptive study. The sample was a random sample of convenience of practicing Jehovah's Witnesses from the Distrito Federal in Brazil. The exclusion criteria were illiteracy and refusal to take part. The Jehovah's Witnesses Hospital Liaison Committee HLC authorized the research, contacted the participants, provided information and helped in the distribution of questionnaires. The questionnaire was composed of closed questions and was divided into two parts: part I general information contained three questions on the age, sex and educational level of the respondent; and part II specific questionnaire with six questions designed to meet the study objectives.

All of the questionnaires were returned duly completed. The answers to the first question in part II of the questionnaire specific questionnaire , -Has your doctor ever asked you what your religion is? The answers to the second question in part II, -Has your dentist ever asked you what your religion is?

Even though there was no space provided to do so, some respondents added comments, as follows: a none of the above because each procedure should be analyzed in depth 1 person ; b the results are irrelevant to Witnesses' position on the subject 2 people ; c I reject these treatments 1 person ; d I need information on each procedure 1 person.

The answers to the fifth question, The hemocomponents described above can be divided into even smaller pieces, called hemoderivatives example: albumin, fibrinogen, immunoglobulins and coagulation factors. Even though there was no space provided to do so, some respondents added comments, as follows: a I would only be offended because I had not been told 1 person ; b I would be offended by any treatment 1 person ; e c Despite having given authorization, I must be told about every procedure 4 people.


The seventh question in part II of the questionnaire, was Would you feel morally offended if a doctor or dentist who was treating you with your permission carried out a treatment involving interopperative use of FRESH material derived from your own blood example: acute normovolemic hemodilution, extra-corporeal circulation, intraoperative cell salvage, hemodialysis, platelet-rich plasma without informing you of this fact? Even though there was no space provided to do so, some respondents explained their answers as follows: a Especially because I was not told 4 people ; b The doctor or healthcare professional should explain everything to me in advance treatments, procedures, etc.

In the case of emergencies or unconsciousness, I have a formal document registered with a notary detailing what I accept and what I reject 1 person ; c I would be offended by any treatment 1 person ; d Only if I was not told, because I accept some treatments that use my own blood 1 person ; e I must be informed of every procedure 14 people ; e f Ethics demand that I be informed before every procedure" 7 people.

Cross-referencing the sociodemographic results with the blood-specific results did not reveal any statistically relevant features. Discussion A well-taken patient history can avoid clinical, ethical and legal complications, in addition to allowing dialogue between people with discrepant relationships and strengthening patient autonomy.

This is the first contact between the professional and the patient and should be used to obtain the information required to provide integral care, not merely clinical care. In this context, it can provide better information with relation to possibly using blood components, since it helps with correct therapeutic planning, which is of particular relevance for Jehovah's Witnesses.

This conduct is not in compliance with the legislation of Brazil, which is where this research was conducted and which is a country that is constitutionally secular and religiously pluralist. Ethical conflicts are more common between people who are what Engelhardt describes as "moral strangers",18 i. Indeed, the scientific literature does describe countless undesirable reactions to the use of blood.

However, the rule is to reject blood. The religion allows for personal interpretations and these primarily take the form of rejecting more than is explicitly prohibited, since there are Witnesses who believe that even hemoderivatives are blood soul , and do not accept "anything" that is in any way related to blood. With regard to hemoderivatives, the Jehovah's Witnesses' dogma does not define them as blood, because they are extremely small fractions of the tissue.

While this does not contradict the doctrinal guidance that these fractions are not blood, the significant level of refusal is notable.

There is one correlation between the blood questions and the sociocultural data which is worthy of mention: respondents with higher educational level were more likely to believe in the harmful results of treatments with blood. It was also this group that were most averse to hemocomponents and least averse to hemoderivatives. It is possible that educational level, which is directly related to access to scientific literature, may be related to this stance.

It should be pointed out that, despite the variations in interpretation identified in this study, the Jehovah's Witnesses are a single community. For them, sharing a common morality does not mean they must always agree on everything: these small differences do not prevent them from cooperating or from recognizing themselves as moral friends, without losing the unity that their religion offers.

If these details were better publicized among health professionals many legal, ethical and moral conflicts would undoubtedly be avoided. There are nowadays many different treatments that employ this technique instead of traditional transfusions of whole stored heterologous blood. Conclusions The Bible is the primary doctrinal source for Jehovah's Witnesses' refusal of blood. The most common justifications for refusal are a desire for good health and the fact that blood represents people's souls, in addition to the fact they also believe that blood can be harmful to health.

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