When a Jehovah's Witness forbids a transfusion, I can only rage against the mysteries of faith.
In the New Testament (Acts 15:28-29) there is a passage that reads:
"For the holy spirit and we ourselves have favored adding
no further burden to you, except these necessary things, to keep
abstaining from things sacrificed to idols and from blood and
from things strangled and from fornication. If you carefully
keep yourselves from these things, you will prosper."
Based on this text, Jehovah's Witnesses will not accept blood
transfusions, I must admit that this proscription has always struck
me as somewhat absurd. Placed next to "Thou shalt not kill"
ad "Thou shalt honor thy father and thy mother," the
notion that "Thou shalt not accept transfusion of blood and
blood products" seems to lack moral force. But until one
night recently, I had never had to confront the beliefs of Jehovah's
Witnesses other than to say "no, thank you" to an occasional
proselytizer who approached me on the street.
I have never actually spoken with Ms. Peyton, either. On the
night of our only encounter I was the doctor screening patients
who were being transferred to the coronary care unit. She was
confused and barely conscious and her heart was dying, fiber by
fiber, from lack of blood. The calls that asked me to evaluate
Ms. Peyton all started with the same apology: "I'm sorry
to hand you this problem, but
" The story that unfolded
was a tragic mismatch between faith and disease.
Ms. Peyton was only 42 when she came to her doctor after noticing
a small amount of blood in her urine. This is a fairly common
complaint from women who are prone to bladder infections, but
Ms. Peyton's bleeding didn't get better with antibiotics - it
got worse. She was sent to a urologist for further evaluation.
A fiber-optic scope threaded through the urethra into the bladder
revealed that ms. Peyton had a bladder tumor.
As is usual with this type of growth, the tuner had not invaded
the bladder wall, and the surgeons were able to remove it through
the scope. These tumors tend to recur, however, and Ms. Peyton
was told she could expect to undergo periodic procedures to remove
them, but in the usual scheme of things such an illness should
not be fatal. And so for several years she had repeated episodes
of bloody urine followed by urologic procedures to eradicate the
source of bleeding. She came, I suppose, to accept a tinged urine
as a way of life. Her bone marrow, with a bit off iron supplementation,
was able to match the cells that were lost, one for one. But
this last time she had waited too long to see her doctor. She
was bleeding more heavily than usual and was severely anemic and,
as a result, was constantly weak and tired.
A woman Ms. Peyton's age normally has a hematocrit - a red blood
cell measure - around 40, but hers was only 17. Her primary doctor,
who had admitted her to the hospital, told her that she would
require transfusion until the bleeding could be stopped. Ms.
Peyton, resolute in her faith, refused. She wanted every available
medical treatment - chemotherapy, surgery, cardiopulmonary resuscitation
- everything, that is, except transfusion.
She was an intelligent woman, I was told, who totally understood
the implications of her decision. But her judgment, it seemed
to me, arose from a blind spot imposed by her faith.
Over the next week things went from bad to worse. Nothing the
urologists tried could stem her bleeding, and her blood count
dropped lower and lower until she was no longer a reasonable candidate
for surgery. It was simply too risky to take a person with a
hematocrit below 20 to the operating room. "You are probably
going to die without a transfusion," her doctors reminded
her daily. She was unmoved.
Gradually, as her blood count dropped further, Ms. Peyton became
short of breath. The body's organs need a certain amount of oxygen
to function. That oxygen is carried from the lungs to the periphery
by hemoglobin molecules in the red cells. When we breathe room
air, the hemoglobin molecules are not 100 percent saturated with
oxygen. Their oxygen uptake can be improved by a patient's breathing
oxygen-enriched vapor. The medical team gave Ms. Peyton supplemental
oxygen through a mask until she was breathing virtually pure O2.
The few red cells she had were fully loaded - but there just
weren't enough vehicles left to transport the fuel her body needed.
Her hunger for air increased. Her respiratory rate climbed.
She became more and more groggy, and finally - inevitably - the
muscle fibers of her heart declared their desperate need for oxygen.
She developed crushing, severe chest pain.
A heart attack: Her perfectly healthy heart was dying because
her blood was too thin to sustain it. And so, with apologies,
I was called to preside over this untenable situation. By law
she had to be moved to the coronary care unit since she had expressed
her wishes to be resuscitated. And, also be law, we were prevented
from performing the one intervention that would save her: a transfusion.
As I walked into the room, carrying my portable cardiac monitor,
I was awed by the scene in front of me. At the center of everyone's
attention was a large woman with an oxygen mask, gasping for air,
breathing faster than seemed humanly possible. At the head of
the bed were three friends, fellow church members, coaching her
through her moment of wretched glory. At her side were several
doctors - one monitoring her falling blood pressure, another coaxing
some blood from an artery. The fluid slowly filled the syringe
had the consistency of Hawaiian Punch; tests on the sample later
revealed a red cell count of only 9. Hanging from the bed rail
was a bag of cherry-red urine. The woman was dying. Her cardiogram
tracings showed the deep valleys that signal a heart in pain.
Within a matter of hours the damage they represented would become
To bring this woman to a coronary care unit made no medical sense;
and to withhold blood from her dying heart seemed opposed to my
Hippocratic oath. Uncertain how to proceed, I called the hospital
administrator. Since Ms. Peyton had not minors who depended on
her, I was told, she had a legal right to refuse transfusion.
I walked back to her room to talk with the other church members
to make sure they understood the implications of their friend's
decision. I felt confident they did not, I was intercepted at
the door by a woman in a silk dress. "This must seem insane
to you," she said, and she was right.
"Your friend is going to die," I told her. My words
were direct. "I will take her up to the coronary care unit
because I legally have to, but there will be nothing effective
I can do. We will give her oxygen, but her blood is already carrying
all the oxygen it can hold. We will giver he medicines to keep
her blood pressure up, When they cease to work, we will pound
on her chest to force the blood out of her thorax and into her
limbs. We will shock her hear with jolts of electric current
to stimulate its conduction system to fire. But without red cells
to bring nutrients to her heart, nothing we can do will save her."
I recalled an old expression I learned in medical school: You
can't shock hamburger meat. "You are asking us to resuscitate
her with our hands tied behind out back," I went on. "It
may take hours, but without a transfusion she will die tonight."
By this time Ms. Peyton's other two friends were at the door,
and they listened patiently, wincing as I described some of the
more ghoulish aspects of the night to come.
They clearly understood my point. But this was not a rational
matter. "I'm sorry, this is going to be a lot of trouble
for you," one of them said. "It may not make any sense
to you. But she does understand that she might die."
Two worlds collided. As I hooked Ms Peyton to the portable EKG
monitor in preparation for her trip to intensive care, a flurry
of emotions besieged me. First, frustration at not being able
to talk to her myself when she was conscious. Second, confusion
that these obviously intelligent women could be so accepting of
the needless death of a friend.
As we rolled her bed out into the hall, bumping into sinks and
walls and getting stuck in narrow doorways, my mood turned to
anger. Without a transfusion, Ms. Peyton's chance for survival
was unambiguously zero. Nonetheless, here I was in all seriousness
taking her to the coronary care unit. Finally, as I rolled Ms.
Peyton's body through the elevator doors, I was joined by that
other chilling companion that accompanies me on every such transport:
fear - the fear that Ms. Peyton could go into cardiac arrest
at any second, that the doors would close with her alive on the
fifth floor and open with her dead one floor below.
Once in the coronary care unit, Ms. Peyton was treated with the
efficiency that the nurses display toward all patients, dead or
alive. She was transferred onto a cot (weighed in the process)
and hooked up to a cardiac monitor. A large catheter connected
to a transducer was slipped into the artery in her groin to serve
as a constant probe of her blood pressure. She did not utter
a sound; I gave up my hope that she would awaken and change her
The charade continued. A full EKG showed that he heart muscle
was dying even faster now. We put a tube down her throat, into
her lungs, in a futile attempt to improve oxygen delivery. We
switched to a stronger pressure medication. Fifteen minutes later
her heart was so weak, it could no longer pump effectively, and
the blood pressure tracing fell flat. She was in cardiac arrest.
We started cardiopulmonary resuscitation, rhythmically pushing
useless fluid through her veins.
The doctor in charge was barking out orders. I placed a large
intravenous line into a deep vein in Ms Peyton's thigh and then
relieved the nurse doing chest compression's. One one thousand,
two one thousand, three one thousand
my mind counted
the hypnotic tempo as I pressed rhythmically on Ms Peyton's chest.
In the background I could hear the noises of the rescue effort.
A variety of cardiac stimulants were pushed into Ms. Peyton's
veins and her heart was prodded with shocks.
Epinephrine, Atropine. Shock with 300 joules. We have a rhythm.
Hold compressions. She's got a pulse. She's slowing again.
Resume compressions. Epinephrine again. Atropine. Shock at
360. Continue CPR
I marveled at Ms. Peyton as she lay still in the center of this
An hour later the floor was littered with EKG tracings, the bed
with syringe tops and blood. Finally, the doctor in charge decided
enough was enough. "Stop compressions. We're calling this.
Thank you, everyone, for coming." It is the official way
we end all failed resuscitations. I was grateful that this one
had ended quickly. As I left the room to find the other Witnesses,
a few surviving cells in Ms. Peyton's heart sent out their last
electrical signals to the monitor.
I always feel hollow when reporting a death - even one that is
inevitable. Ms. Peyton's friends were gracious and made it easy.
The woman in the silk dress thank me, repeating again, "This
must seem crazy." I turned to leave them, and then paused.
"No, I don't think her refusing blood is entirely crazy,"
I began to answer. You see, during the last hour I had given
considerable thought to the question. Resuscitation efforts involve
endless, repetitive, small mechanical actions - pressing 72 times
a minute on a chest, squeezing a burst of air into the lungs every
four seconds - and in the depths of a long resuscitation there
is ample time for meditation. I could fully comprehend that there
are things in life that might be worth dying for. People have
risked their lives for their religion, for their family, for the
thrill of winning a grand prix, for the honor of being the first
to reach the South Pole.
My problem, I explained to Ms. Peyton's friends, is that if you
have come to terms with death as a consequence of your belief,
why not let it happen naturally? Why spend the last moments of
life with people thrusting tubes down your throat and pounding
their fists into your ribs? We knew she could not live without
transfusion so why stage this ghoulish mock battle?
I continued my tirade, accompanied by the beeps of monitors and
the whoosh of the ventilators. When I paused for air, I noticed
the same patient expression on the women's faces. "This
doesn't make sense to you, I know," the woman in the silk
dress repeated. "You see, we believe
" She began.
I saw the Watchtower peeking out from her bag.
All of a sudden I couldn't wait to leave; the gap between her
world and mine yawned open. "I'm sorry Ms. Peyton died,"
I said. "I wish there was something we could have done."
And with that I retreated back into the coronary care unit.
Elisabeth Rosenthal is a resident in internal medicine.