We present a 59-year-old female Jehovah's Witness patient transferred from another facility to our tertiary center as an emergency case owing to anemia due to gastrointestinal bleeding. A computed tomography scan and gastroscopy confirmed an invasion of the duodenum by a malignant process. The patient underwent a Whipple procedure and a right hemicolectomy refusing blood transfusion. On the 17th postoperative day, the patient was discharged following a successful surgery. This article's objectives are to first highlight the moral and ethical quandary and then share our surgical experiences with this particular patient population. In conclusion, Jehovah's Witnesses' management of major abdominal surgery poses considerable clinical, moral, and legal difficulties. Despite them, doctors must put the patients' needs first while also honoring their religious convictions. However, urgent situations continue to arise, forcing medical professionals to weigh their religious convictions against the need to save a patient's life.

Ewing’s sarcoma is a bone and soft tissue neoplasm, whose management is related to hematological toxicity. This aspect represents a medical and ethical challenge in Jehovah’s Witnesses patients, who, due to their religious beliefs, reject the blood component transfusion, with the risk of discontinuing chemotherapy or using suboptimal doses. We present the case of a 34-year-old Colombian woman, Jehovah’s Witness, diagnosed with Ewing’s sarcoma with clinical stage IIB (T1N0M0) in the left maxillary and mandibular regions, treated with chemotherapy, who presented a hemoglobin nadir of up to 4.5 g/dL, and surgical indication as part of the treatment. In these patients, the transfusion decision has ethical implications that require therapeutic alternatives and a multidisciplinary approach.

Jehovah's Witnesses (JWs) refuse blood transfusions due to religious issues. This situation may impact kidney transplantation (KT) outcomes in case of hemorrhagic complications. We evaluated demographic characteristics of this population, hematologic safety, and graft outcomes.

This was a retrospective, single-center study comparing KT outcomes in JW patients versus a non-JW control group. Hematologic endpoints included clinical indication for blood transfusion (hemoglobin <7 g/dL), decrease of hemoglobin >2 g/dL or hematocrit >5% in the first week after KT, hemorrhagic complications requiring surgery, and de novo prescription of erythropoiesis-stimulating agents. Secondary endpoints included delayed graft function, treated biopsy-proven acute rejection, renal function, mortality, and graft survival at 12 months.

From January 1989 to September 2018, we identified 143 JW (10 pediatric) and selected 142 matched control (non-JW) patients. There were no differences in the incidence of clinical indication for transfusion (13.3% versus 11.3%, P = 0.640), but a higher proportion of non-JW patients received transfusions (2.1% versus 9.2%, P = 0.010). There were no differences in the proportion of patients with decreased hemoglobin concentration, in reinterventions due to hemorrhagic complications, in the use of erythropoiesis-stimulating agents at hospital discharge, in the incidence of acute rejection, in renal function, and in mortality or graft survival rate at 12 months.

In summary, this matched control cohort study suggests that, when clinically indicated, blood transfusions can be safely avoided in the majority of JW kidney transplant, who achieve and maintain comparable hemoglobin concentrations during the first year after transplantation compared with non-JW patients.

While Jehovah's Witness (JW) patients refuse transfusions of blood or blood products, they are willing to accept renal allograft transplantation. We describe here a case of what we believe is the oldest (a 70-year-old) JW candidate to undergo a deceased donor kidney transplant reported in the literature. Prior to transplantation, discussions ensued amongst the multidisciplinary transplant team, weighing the potential benefits vs. risks of performing a kidney transplant on this patient due to her refusal (due to religion) to accept any blood transfusions or blood products combined with her advanced age and having longstanding insulin-dependent, type 2 diabetes mellitus with extensive peripheral vascular disease. Preoperatively, we believed that the odds were in favor of performing the kidney transplant safely without the need for any blood product usage. However, her post-operative course was complicated by severe anemia, which developed by post-transplant day 4. The anemia incapacitated the patient's physical and psychological state, creating medical, social and financial burdens on the patient, family, medical team and hospital. Both family and patient grew concerned about her overall condition. Blood transfusion was offered in order to improve her weakness and shortness of breath that developed due to the severe anemia, but the patient (along with her family) refused such treatment. During the 17 days of hospitalization, it was a continuous struggle between the transplant team, patient, and family for her to continue with the recovery process; at times we had even considered that performing the transplant had been a mistake. While organ transplantation can be performed safely in Jehovah's Witnesses, there are multiple factors seen in this particular case that warrant analyzing: (I) the potential use of stricter transplant exclusionary criteria, given the recipient's advanced age and preexisting co-morbidities, which likely increased her risk of developing severe anemia post-operatively, and (II) the recipient's emotional/psychological post-operative state of high anxiety, which developed while she was experiencing the severe anemia; in hindsight, her anxiety level may have been reduced if we had offered daily post-operative psychological counseling sessions. While the patient's allograft is currently doing well, we probably did not have strict enough criteria for proper selection of a JW candidate for kidney transplantation.

The refusal of Jehovah's Witnesses to use blood products can limit access to cardiac surgery, as patients may not be offered surgery for complex disease, especially revision surgery. We report a successful, complex adult congenital heart disease (ACHD) surgery with intraoperative and perioperative optimization. We have tried to highlight through this case that complex ACHD surgeries can be performed in Jehovah's Witness patients with skilled perioperative and intraoperative management. The role of bovine hemoglobin in this population is being defined and was found helpful in this case.

Introduction Patients who are Jehovah's Witnesses pose difficult ethical and moral dilemmas for surgeons because of their refusal to receive blood and blood products. This article outlines the personal experiences of six Jehovah's Witnesses who underwent major abdominal surgery at a single institution and also summarises the literature on the perioperative care of these patients. Methods The patients recorded their thoughts and the dilemmas they faced during their surgical journey. We also reviewed the recent literature on the ethical principles involved in treating such patients and strategies recommended to make surgery safer. Results All patients were supported in their decision making by the clinical team and the Hospital Liaison Committee for Jehovah's Witnesses. The patients recognised the ethical and moral difficulties experienced by clinicians in this setting. However, they described taking strength from their belief in Jehovah. A multitude of techniques are available to minimise the risk associated with major surgery in Jehovah's Witness patients, many of which have been adopted to minimise unnecessary use of blood products in general. Nevertheless, the risks of catastrophic haemorrhage and consequent mortality remain an unresolved issue for the treating team. Conclusions Respect for a patient's autonomy in this setting is the overriding ethical principle, with detailed discussion forming an important part of the preparation of a Jehovah's Witness for major abdominal surgery. Clinicians must be diligent in the documentation of the patient's wishes to ensure all members of the team can abide by these.

Many studies have focused on advanced directives. However, the type of treatment that citizens would choose in critical health situations and whether their decision varies with their sociodemographic characteristics and their experiences of life both within and outside the family context, are unknown. This study analyzes the factors associated with choosing or refusing life support treatment in hypothetical situations of differing clinical complexity. This transversal descriptive study was carried out by questionnaires given to 1051 participants from primary care centres. The Life Support Preferences Questionnaire (LSPQ) used to assess preferences of life-sustaining treatment, describes six scenarios with different prognoses. Analysis of the sociodemographic characteristics and life experiences of the subjects led to the following findings. In situations of very severe prognosis, treatment is mostly rejected. When there is chance of recovery, treatment is mostly accepted, especially in the least aggressive cases and when deciding for another person. A greater propensity to reject treatment was observed among subjects over 55 years, those in poor health and those who had observed a terminal illness in a family member. Practising Catholics are more likely to accept treatment in all medical situations described. Preferences for life support treatment are linked to sociodemographic characteristics and life experiences of patients. Physicians should bear in mind these characteristics when confronted with critical clinical situations, involving difficult decisions.

The aims of this paper are to discuss three different ethical frameworks; to briefly consider some of the philosophical positions concerning the nature of personhood. Clear consideration of these issues demonstrates the complexity of decision making in persisting disorders of consciousness.

Three different ethical frameworks, Kantian deontology, act utilitarianism and rule utilitarianism, are described and three different accounts of personhood are presented and analysed.

These result in very different approaches to the management of patients in permanent vegetative states (PVSs), making it possible to argue for withdrawal of clinically assisted nutrition and hydration in all cases, considering the issues on a case by case basis or continuing to treat all patients whatever their wishes.

These results explain why doctors often have different views on how to treat patients in PVS, particularly with regard to the withdrawal of clinically assisted nutrition and hydration. Understanding such issues may help clinicians articulate more clearly the reasons for their intuitions surrounding the management of patients in PVSs. Implications for Rehabilitation Patients with persisting disorders of consciousness pose significant dilemmas for clinicians and family members. Utilitarianism is a consequentialist theory, that is, it is concerned with the outcome of our actions to determine their morality. It is the concept that the right action is the one that will result in "the greatest amount of good for the greatest number". Deontological ethics suggests that there are certain sorts of acts that are wrong in themselves independent of the result of such actions. Personhood can be approached from a variety of perspectives including biological, relational, religious and psychological. Understanding different ethical frameworks, and the nature of personhood, may help clinicians articulate more clearly the reasons for their intuitions.