Journal ofMedical Ethics 1998;24:295-301

Bioethics ofthe refusal ofblood by Jehovah'sWitnesses: part 2. A novel approach basedon rational non-interventional paternalismOsamu Muramoto Kaiser Permanente Northwest Division, and Northwest Permanente PC, Oregon, USA

AbstractMost physicians dealing with Jehovah 's Witnesses(JWs) who refuse blood-based treatment areuncertain as to any obligation to educate patientswhere it concerns the JW blood doctrine itself Theyoften feel they must unquestioningly comply whendemands are framed as religiously based. Recentdiscussion by dissidents and reformers of morallyquestionable policies by theJW organisation raiseethical dilemmas about "passive" support of thisdoctrine by some concerned physicians. In this paper,Part 2, I propose that physicians discuss themisinformation and irrationality behind the blooddoctrine with the J7Wpatient by raising questions thatprovide new perspectives. A meeting should be heldnon-coercively and in strict confidence, and thepatient's decision after the meeting should be fullyhonoured (non-interventional). A rationaldeliberation based on new information and a newperspective would enable a certain segment ofJWpatients to make truly informed, autonomous andrational decisions.(journal ofMedical Ethics 1998;24:295-301)Keywords: Religion; Jehovah's Witnesses; blood transfu-sion; medical ethics; physician-patient relations; informedconsent

1. IntroductionIn the companion paper, Part 1,1 I suggested thatphysicians faced with ethical dilemmas related totreating Jehovah's Witness (hereafter "JWs")patients who refuse blood products shouldconsider, not only the official position of the con-trolling religious organisation (Watch Tower Bibleand Tract Society, hereafter "WTS"), but alsodissident and reform views on the doctrine ofblood refusal. A growing body of evidence fromcurrent and former members, supported by WTSpublications, suggests that unethical practices,such as breaching JW patients' confidentiality, areencouraged. According to dissidents the doctrineis based on inconsistent and contradictory teach-ings and policies, and Jehovah's Witnesses aregiven misinformation and steered away from cor-

rect information and rational reasoning. Unlessonly marginally associated, they are well aware ofthe consequences of not holding to organisationalpolicies and that their privacy is subject toinvasion. It is likely that principles of patientautonomy and informed consent (or refusal) arecompromised. The critical perspectives of dissi-dents and reformers suggest that the medicalcommunity's supportive attitude towards theblood doctrine should be reconsidered.

Recently, Savulescu2 questioned the attitude ofphysicians who accept patients' decisions withoutmaking their own moral judgments. He proposedthe notion of "rational non-interventional pater-nalism" which recommends that physicians formconceptions of what is best for their patients andargue rationally with them. This approach to ethi-cal decisions retains the old-style paternalist'scommitment to deciding what is, all thingsconsidered, best for the patient, but rejectscompelling the patient to adopt that course. Morerecently, Savulescu and Momeyer3 argued thatinformed consent should be based on rationalbeliefs. They used the case ofJWs' refusal ofbloodtransfusions as an example of choice based onirrational beliefs. They further argued that if phy-sicians are to respect patient autonomy and helppatients choose and act rationally, they must notonly provide information but should care aboutthe theoretical rationality of their patients. Theyproposed that physicians act as "critical educa-tors" and concluded that a physician's failure so toact would ultimately be viewed as abandoningpatients to "autonomy-destroying theoretical irra-tionality".

In this paper I will expand on this argument andpropose that medical professionals familiarisethemselves with the inherent flaws of the blooddoctrine, and provide JW patients with newperspectives and rational reasoning by posing afew simple questions which can be presented in"non-interventional" fashion and without outsidepressure. These questions may enable patients toview their doctrine from new perspectives and

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give them a chance to make a more informed,autonomous and rational decision.

2. Ethical dilemmasJehovah's Witness patients who refuse life-savingblood transfusions may not only be irrational, asSavulescu and Momeyer3 argue, but may also bemisinformed, misguided and, to some degree,coerced, according to the information, based ondirect knowledge and experience, provided bydissidents and reformers. Knowing the basis forthe blood doctrine and how it is enforced,physicians face this question: should we ignorethis information and respect the patient's decisionno matter how irrational and misguided we thinkhe/she might be, or should we pursue in-depthdiscussion to encourage a rational and trulyautonomous decision? I argue that the lattercourse should be taken so far as circumstancespermit. Physicians may not be in the position ofjudging the validity of religious doctrine in anultimate sense, but they should still examine therationality and morality of decisions their patientsmake. I will first discuss reasons why physiciansshould explore further.

ARE JWS TRULY "INFORMED"?It is established practice to discuss procedures andtreatments with patients and disclose all benefits,risks and alternatives in order to obtain aninformed consent. It is uncommon to discuss thebasis for a patient's decision, out of a desire not toinfringe upon patient autonomy and privacy, or asin this case, religious freedom. The question Ipresent here is whether we should leave thepatient's decision unchallenged ifthere is evidencethat it is based on misinformation or information-control enforced by covert or, in some cases, overtcoercion.

DO JWS TRULY HAVE "AUTONOMY"?Do JWs have true autonomy in making decisions?There is considerable documentation that JWscan be subject to psychological coercion, as shownin Part 1. Ifwe suspect that a patient may be undersuch coercive persuasion, should we ignore thispossibility and simply comply with his or herrequest? I argue that such an attitude borders onpatient abandonment under the guise of pseudo-autonomy.

DOES CONSULTATION WITH CHURCH (WTS)OFFICIALS PROMOTE PATIENT AUTONOMY?It is common for JWs and treating physicians toconsult with church officials and members of theirhospital liaison committee for guidance on the

blood doctrine, as to what is prohibited and whatis allowed. Such consultation is recommended bywell-established guidelines for blood transfusion.4By obtaining such help can the physician becomebiased in favour of the doctrine and make hisdecision based more on WTS policy than protec-tion of the patient's health and life? How can suchconsultation promote patient autonomy whenorganisational rules make the position of the com-mittee non-negotiable, so that the patient mustalways refuse blood and the physician must alwaystreat without blood?The decisions of a physician which is based

solely on information provided by the churchbecomes ethically questionable when there areserious questions about the ethics of the churchitself. In many reported cases the elders of thechurch organisation applied pressure to a patientto conform to its blood policy, often causingreversal of an earlier patient decision.5 Can wetake the patient's decision after consultation withsuch an "advisor" as being autonomous, given theinformation-control and coercive practices of thisreligion?

CAN RATIONAL DELIBERATION CHANGE A PATIENT SVIEW?There are anecdotal reports of individuals whomade confused decisions and changed their mindsafter discussion with medical professionals.6 10-12Not all persons who belong to a religious organis-ation conform to its doctrines. IfJWs always actedidentically, their wishes, beliefs and answers wouldall be known from doctrines and official publica-tions, and there would be no need for deliberation.Yet many decisions made by physicians caring forJW patients are simply cut-and-dried. Mostphysicians spend little time inquiring about thepatient's decision and the circumstances underwhich he made it. However, individuals vary incommitment to and interpretation ofWTS policy.Certain treatments may be acceptable to one JWbut not to another.3 14 Some JWs may showambivalence or even willingness to be forced toreceive blood-based treatment as long as it is offi-cially noted as contrary to their wishes.'5 SomeJWs are willing to receive blood under the condi-tion of complete confidentiality.'6 Such cases showthat failure to explore individual iWs' views maycause physicians to let JWs die unjustifiably,whereas rational deliberation on an individualbasis can save lives.

CAN IRREVOCABLE LOSS OF LIFE BE JUSTIFIED, BASED

ON THE INCONSTANT DOCTRINAL SYSTEM OF Jws?Although the basic blood doctrine has been inplace for 40 years, details have undergone many

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modifications, as shown in Part 1. There havebeen several doctrinal reversals on life-savingmedical treatments such as organ transplants,vaccination and allowance of certain bloodcomponents. Should physicians ignore this poten-tially unstable ground and stand idly by while apatient dies?

PHYSICIANS MAY INADVERTENTLY PROMOTEIRRATIONALITY AND UNETHICAL PRACTICES BY

GIVING UNQUESTIONING SUPPORT TO JW PATIENTS'DECISIONSRespecting patients' decisions and supportingtheir beliefs when these manifest inconsistent rea-soning are two different things. By cooperatingwith a JW's request for heroic effort, do"sympathetic doctors" inadvertently advance thechurch's cause, which may involve practices mor-ally repugnant to most physicians? Physicians tendto confine themselves to a narrow role, stayingwithin the framework of patient autonomy andreligious freedom. However, this passivity or one-sided effort to accommodate "no-blood" treat-ment, has further "standardised" the treatment ofJWs with little regard for the ethical question ofthe patient's decision-making process.Some physicians feel that the some of the

expensive alternative, intense and high-technological treatments could be allocated moreefficiently.7 18 For them, allocation of limitedhealth care resources is as important an ethicalprinciple as are autonomy and religious freedom.

3. A suggested approach to JW patientsbased on rational non-interventionalpaternalismTo lessen the ethical dilemmas, I suggest anapproach using principles of rational non-interventional paternalism.2 Before discussing thisapproach I should emphasise that this type ofethical deliberation is necessary only when there isno reasonable alternative to blood-based treat-ment, or when so-called "no-blood" treatmentwould incur significantly higher risk and cost.

EMERGENCY CASESFor obvious reasons the deliberative approachcannot be used in emergencies. In these casesautomatic acceptance of printed instructions onthe so-called "blood card" most JWs carry ispotentially dangerous and may violate the rights ofJWs who are ambivalent or who have recentlychanged their belief. There are anecdotal cases ofinvalid "blood cards", which are used as a form ofadvance directive. Particularly important is thecard's date. A card with no date or an old date

should not be automatically accepted since formermembers and current members who are consider-ing leaving the organisation may carry outdatedcards. Some JWs are under extreme pressure tocarry a card even though they disagree with thepolicy. A former JW might continue to carry ablood card for the sake ofpeace with a JW spouse,considering the strife it would cause if the believ-ing mate discovered the true views of the dissidentmate.On the other hand, emergency conditions do

not allow physicians to verify "blood card" statusor discuss the patient's conviction. It is thisauthor's opinion that if there is any doubt aboutthe patient's wishes the physician should first takewhatever steps are necessary to stabilize andremove the patient from immediate danger ofdeath or severe disability until a court ruling orother independent assessment of the applicabilityof the card can be obtained. This view is also sup-ported by others."2 19 20 In a Canadian court case, adoctor was found guilty ofbattery when he treatedwith blood transfusions an emergency patient whocarried an undated and unwitnessed card.21 Thisruling was criticised by the medical community inCanada.22.24

In the United States,25 the validity of a "bloodcard" was discounted in the case of an incompe-tent patient. In another the court ordered a trans-fusion for a comatose patient despite the card.12Similar court rulings involving incompetent JWpatients under emergency conditions have beenreported.26 Despite assurance from WTS officialsthat a physician is absolved from legal and ethicalresponsibility for withholding blood transfusions,wrongful death suits were brought against physi-cians by the families of JWs who died after theyrefused blood transfusions.25 27 One may view thissituation from the perspective that if we can besued either for treating or not treating with blood,we would rather it be for saving the patient's life.

STABLE CASESIn the case of stable patients requiring electivetransfusions, I propose that each physician firstvalidate the patient's status as a JW. In one case awoman was presented as "a fervent JW" by herJWmother28 but her status was later officially deniedby the WVTS.2 This shows that we have reason notto accept at face value the word of anyone otherthan the patient regarding his or her status as a JW,particularly family and friends. After the status isconfirmed with a competent patient, I proposethat each physician have a confidential meetingwith the patient about informed refusal of bloodproducts. A most important condition of this dis-cussion would be an atmosphere in which the

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patient could feel free from influence by churchofficials or peers, including family members. Justas the physician does not intervene in a family andchurch-based discussion, so it is important thatthe physician himself be able to speak with thepatient without influence by others.As mentioned before, a number of case reports

exist in which a patient's initial decision wasreversed to conform to WTS policy after churchofficials visited the patient. Therefore, it is recom-mended that consultation with church officials bemade only when requested by the patient, andonly when he is free from outside pressure and hasnormal mental status. The consultation should belimited to the information needed for immediatepatient care. Otherwise, such consultation wouldcomplicate the doctor-patient relationship andinvade the privacy of doctor-patient decisionmaking, allowing further outside intervention. Aprivate meeting between only the physician andthe patient is preferred.

In this meeting the prognosis of each scenarioshould be explicitly discussed. This shouldinclude not only the possibility of death, but pro-longed disability and suffering along with aburden on the family and society. The WITS hasrepeatedly emphasised that death due to lack ofblood transfusions is nothing compared to theeternal life they can obtain by refusing blood. ButJWs have given little consideration to the pro-longed suffering and disability that can result.

QUESTIONS THAT MAY BE ASKEDThe physician can then ask several questionsabout the basis for the refusal of blood. If the phy-sician is versed with the appropriate Biblepassages, he may discuss the difficulties with WTSBible interpretation. Although JWs may be gener-ally prepared to answer a few common questions,they invariably are unaware of the fundamentalcontradictions as pointed out in Part 1. Physicianswho are not interested in Bible discussion may stillpose many questions regarding the irrationalitiesof the doctrine. The following three points giveexamples that might be presented to the patient ina non-coercive fashion. A small brochure has beenprepared to assist physicians and could be used inthis session.30

Since initiating such an approach may comeacross to the JW patient as a frontal assault on hisbelief system, it would be appropriate to prefacethe discussion with some introductory remarks,such as:

"I respect sincerely your concern for conscienceand your desire to do what is right according toyour belief. And I hope you will believe me when I

say that I am also guided by my conscience and aconcern to do what is right based on what Ibelieve. There are certain things that are worthdying for. At the same time I want to feel assuredthat a patient has considered matters with fullinformation and is satisfied that his or her decisionhas a solid and stable foundation. It would helpme feel more free from concern in my effort topreserve your health if I could hear your thoughtson certain points that, at least to me, seem difficultto reconcile."

Then the following questions may be introduced:1. "I am concerned by my knowledge that there

have been a number of significant changes inrelated understandings by the WTS. Probablyyou know that vaccination and organ trans-plants were for some time ruled unacceptableand morally wrong. These are now consideredacceptable. But I think you would agree thatthe previous rulings may have had some quiteserious effects - illness, disability, even death -while they were in force. It would seem that aperson would want to consider what the futuremight yet bring in further changes of view-point. Ifholding to some present policy were toresult in disability or even death in your owncase, and that policy were reversed next year orsome years from now, do you feel that such losswould have been worthwhile and justified? Iunderstand these changes are viewed as 'newlight' and I wonder if you have given anythought to the possibility of 'new light' on anyof the policies regarding blood?"

2. [The physician mentions different blood com-ponents and asks if the JW patient knowswhich are allowed and which are prohibited.Many would not know. The division of accept-able and non-acceptable components couldthen be stated and then the physician asks:]"Could you clarify for me why immunoglobu-lins, albumin and clotting factors may beaccepted but plasma must not be accepted,when plasma is basically the combination ofwater plus those acceptable components? Iread the WTS explanation that 'abstainingfrom blood means not taking it into our bodiesat all'. Could you help me understand how it isthat many components of blood are allowed tobe taken into the body, some of which requirethe storing of very large amounts of blood toextract the specific blood components in-volved? Could you show me anything in theBible that actually discusses such matters asacceptance or non-acceptance of specific bloodcomponents? Since this is not directly consid-ered in the Bible, is it not a case of an organi-

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sational policy involved rather than actual bib-lical teaching? If that is so, and since there iscertainly no scientific basis for such policy,have you considered the possibility that thecomponent you are refusing now could later bedetermined by the WTS as acceptable, perhapseven in the near future?"

3. "I think you recognize that blood transfusionsare nowhere specifically discussed in the Bible,although it does say we should abstain fromeating blood. Do you think eating blood andblood transfusions are the same? Do you knowwhat happens if you eat blood? It will bedigested and broken down to small moleculesand no longer function as blood. By contrast, ifthe blood is introduced into your blood stream,it will continue to function as blood and carryoxygen. Therefore, eating and transfusion havean entirely different effect on your body. Redblood cells are a type of organ that carries oxy-gen, and blood transfusions are a transplanta-tion of this cellular organ into the bloodstream. The transplanted blood cells functionas blood cells, and are not digested andabsorbed as nutrients. Therefore blood trans-fusion is a form of organ transplant. Iunderstand the WTS considers organ trans-plants a matter of conscience and that they maybe accepted, am I correct? If I told you that youshould abstain from meat because you have aheart disease due to high cholesterol, do youthink I would have meant to abstain from hearttransplants? Just like the difference betweeneating and transplanting an organ, there is acomplete difference in effect on your bodybetween eating and transfusing blood."

Additional points of contradiction and irrational-ity may be discussed at the physician's discretion.Sample questions are presented in the appendix tothis paper. In discussing those questions, I suggestthe following three precautions be carefullyheeded.

First, this discussion should be held when thereis no imminent danger to the patient's life, and heor she is neither in any great distress nor hasimpaired mental status. Otherwise, the physician'sattitude may be viewed by JWs as coercive andabusive of his authority.

Second, the patient should be assured from theoutset that doctor-patient confidentiality will bestrictly observed and whatever decision thepatient makes in this meeting and thereafter willnot be made known to the family or congregationmembers. Again, integrity with regard to basicprinciples of medical ethics and patient confiden-tiality is crucial because of the existence of medi-cal personnel informants among JW peers, and

the patient should be reassured that special carewill be taken in his or her case.

Third, I suggest not debating any religious con-victions, such as the nature of God, the doctrine ofthe end of the world, moral conduct and so forth,that are beyond what is necessary for the immedi-ate treatment. The physician should keep upper-most in mind that these questions are to give thepatient different perspectives from what he hasbeen taught by the WTS, and to draw the patientinto rational thinking with correct information.Note the crucial difference between classic

paternalism and this new approach of rationalnon-interventional paternalism. It is not thepurpose of the meeting to win an argument withthe patient, using the physician's authority. Apeaceful and rational discussion, avoiding argu-ment, followed by suggestion that the patientthink about the questions before giving a finaldecision should be most effective. Then the finaldecision made by the patient must be fullyrespected.

4. DiscussionTo my knowledge this is the first article in medicalliterature that addresses the need of physicians tounderstand and deal with the fundamentalproblems of the JW blood doctrine. Traditionallymost physicians are uncertain of their obligationto educate patients about the doctrine itself,because such activity may be viewed as invadingthe patient's religious freedom. Physicians oftenfeel that they must unquestionably comply whenany demands or refusal of certain treatment fromthe patient is framed as religious.Such "passive" support in the medical commu-

nity, with little critical evaluation of the religiouspractice itself, has created in many parts of theworld an atmosphere of automatically acceptingthe martyrish request of JW patients that physi-cians make heroic efforts, which may involvegreater risks and costs. A physician's alternativesare to transfer patients to a "sympathetic doctor"or let them die due to lack of any otheralternatives. In this and the companion paper, Isuggest that physicians should reconsider the"status quo" of "passive support" by carefullyevaluating dissident views and critical infor-mation, and thereby take a more active role byexploring patients' decision making in rationaland intelligent discussion.Some may argue that these questions make a

value judgment of religious beliefs under the guiseof medical discussion, and that this should bebeyond the scope of the doctor-patient relation-ship. Another argument would be that posingthose questions is manipulative towards the

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patient's religious faith. However, a WTS lawyerblamed physicians who transfused a JW patientfor not exploring the patient's value system andreligious conviction.3' This indicates that at leastsome iWs would welcome such discussion. Thepurpose of asking pointed questions is to separateout the JWs who might reconsider the doctrineonce they are presented with viewpoints they hadnever considered. These are not questions ofwhether their faith itself is true or false; rather,they concern the facts and rationality on which theblood doctrine is supposed to be based.

Hypothetical religionTo illustrate the difference, consider a hypotheti-cal religion whose leader is believed to be thereincarnation of Jesus. Questioning a member asto whether the leader is truly the reincarnation ofJesus would be a direct challenge to the faith itself;questioning if he knows the facts about theleader's immoral behavior which are not disclosedto the followers may give him new information.Continuing to believe the leader is the reincarna-tion of Jesus after learning of his immoral behav-ior is irrational, but still can be held as "truth" bysome followers. Others may reevaluate their beliefsystem in light of the new information, and aban-don the irrationality.Another argument would be that "no-blood"

treatment is beneficial in most cases, and that thephysician's focus on the blood doctrine may biashim away from such safer treatment. As statedpreviously, I do not suggest that this proposedapproach is necessary when a "no-blood" optionis readily available for the treatment of a particu-lar JW patient, without significantly greater risksand costs. However, at the present time, there arestill many medical and surgical conditions whichcan be treated only with blood products, or whichcan be treated without blood products but onlywith expensive, risky and high-technologicalinterventions that put the patient, the physicianand the hospital in jeopardy.What would be accomplished by this type of

discussion? Because it is non-interventional, thefinal outcome will be up to individual JW patients.In reality, I do not expect any significant numberofJWs will easily change their stance after one ortwo private meetings with a physician. However,in view of emerging developments taking place inthis religion, as more adherents are given a chanceto review their religion objectively, I expect thatsome JWs will be impacted by this approach andwill avoid unnecessary death and disability.

Aside from the lives saved by reevaluation of theblood doctrine, this approach will also fulfil themoral obligation of physicians, whose values

should be as much respected as the patients'.Savulescu' argued that medicine should have acommitment to some value. Automatic accept-ance of religious policy that contradicts aphysician's values, particularly if that policy isbased on irrationality and unethical practices,should be challenged. Savulescu wrote that, whileattempting to convince a patient that he is wrongin choosing some course may threaten hisautonomy, using rational argument will enable apatient to act and choose more autonomously. Inorder to have rational discussion with a JWpatient, both the use of misinformation andcontradictions inherent in the blood doctrine needto be presented and corrected. Provided with newperspectives, the patient's choice will becomemore spontaneous, and more an expression of hisautonomy.While this author uses the case ofJW refusal of

blood transfusions to propose an approach usingrational non-interventional paternalism, the sameapproach can be applied to any authoritarian reli-gious groups that control the information itsmembers receive, or coerce by intimidation andpromote irrational beliefs and practices in medicalcare. These ethical dilemmas are not experiencedwith members of more traditional religions. In hisrebuttal to articles that discussed a JW patientwho did not make an autonomous decision, a JWphysician stated that "adherents of all religions donot make free, autonomous decisions of con-science because of what their church teaches".32This generalisation ignores the fact that only thosemembers of "high-control" religious groups, suchas the JWs, experience much intimidation andcoercion to accept misinformation. While wevalue patient autonomy regardless of religiousaffiliation, I propose that misinformation andcoercion under the guise of pseudo-autonomyshould be challenged by each medical profes-sional.

AppendixThe following additional questions can be used inthe private meeting with JW patients.1. If storing your own blood for an autologous

transfusion is wrong, why does the WTSpermit the use of various blood componentsthat must be donated and stored before beingused by JWs? Why can JWs accept those bloodcomponents and benefit from the blood thatothers donate, but will not donate blood them-selves? Would giving blood to help save others'lives, including the lives of your spiritualbrothers and sisters (other JWs), be the lovingand Christian thing to do?

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2. Have you ever seen the WTS publications dis-cuss the fact that the only effective life-savingtreatment for rapid and massive haemorrhageis emergency blood transfusions? [The answershould be no.] Why does the WTS need tokeep such critical information from beingmade known to JWs, and why does it alwaysemphasise the negative aspects of blood-basedtreatment?

3. I understand that JWs believe blood should notbe eaten because it is sacred as it symbolizeslife. Then could you help me understand howthe symbol could be of greater value than thereality it symbolises? When there is a massiveand rapid haemorrhage and blood transfusionis the only life-saving measure, is it acontradiction in itself to let a person die byplacing more importance upon the symbolthan the reality which it symbolises?

Author's noteAt the proof stage, an important development inthe blood policy of Jehovah's Witnesses wasrevealed in the Internet. In an agreement at theEuropean Commission of Human Rights (http://194.250.50.201/eng/28626.28.html) between theWatch Tower Society and the government of Bul-garia, the society claimed that the members now"have free choice" to receive blood "without anycontrol or sanction". As of July 1998, there isobvious confusion among the members; someview this as change in policy, whereas the societydenies such. It is unclear how this denial couldreconcile with the above public agreement.

Osamu Muramoto, MD, PhD, is a member of theethics committee at Kaiser Permanente NorthwestDivision, and a Neurologist at Northwest Permanen-tePC, Portland, Oregon, USA. Address correspondenceto: Kaiser East Interstate Medical Office, 3414 NKaiser Center Drive, Portland, Oregon 97227, USA.E-mail: muramotosa@kpnw. org

DisclaimerViews and opinions expressed herein are personaland do not reflect those of Kaiser Permanente andNorthwest Permanente PC.

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26 Anonymous [editorial]. Battery claim of Jehovah's Witnessrejected by Michigan Court. Hospital Law Newsletter 1992;9:4-7.

27 Sacks DA, Koppes RH. Caring for the female Jehovah'sWitness: balancing medicine, ethics, and the First Amendment.American J7ournal of Obstetrics and Gynecology 1994;170:452-5.

28 Anonymous [editorial]. Court says doctors were right to treatJehovah's Witness. British Medical J'ournal 1992;305:272. Thecase was referred as Re T (adult: refusal of treatment) [1992] 4All ER 649 (CA).

29 Brace JWA. Treating Jehovah's Witnesses. British Medical Jour-nal 1992;305:588-9.

30 A small brochure is being produced by the collaborating formerJWs and internal reformers. At the time of writing, it is beingprinted. This brochure is also available and downloadable atthe web page of the reformers' website: http://www.visiworld.com/starter/newlight/abstain.htm. Availabilityof the printed version will be posted in this website. Additionaluseful information regarding biblical and historical aspects ofthe blood policy which may be used in discussion with JWpatients is also downloadable from the same website.

31 Ridley DT. Jehovah's Witnesses and the refusal of blood. TheJ7ournal of Clinical Ethics 1990;1:254-7.

32 Thomas JM. Jehovah's Witnesses and the transfusion debate:"We are not asking for the right to die". Canadian MedicalAssociation Journal 1991;145:1559-60.

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