ILLUSTRATION BY REBEKKA DUNLAP
This is the first in a three-part series, “Medicine Without Blood,” about the ways that Jehovah’s Witnesses have changed how doctors think about blood transfusion. Read the second and third installments, “Should Anyone Be Given A Blood Transfusion?” and “The Ethics of Bloodless Medicine.”
In the Book of Acts, the apostle Paul urges congregants to abstain “from things sacrificed to idols, from blood, from what is strangled, and from sexual immorality.” Jehovah’s Witnesses, apparently alone among Christian groups, believe this verse, along with others, prohibits them from accepting blood transfusions, no matter how dire the circumstance. As Joan Ortiz, a Witness in her sixties, recently told me, it’s as much a sin to take a blood transfusion as to have an extramarital affair. In this interpretation of Scripture, those who comply will prosper and enjoy good health. Those who don’t can be cut off from their people and denied resurrection. “Everything about us is carried in our blood,” said Ortiz. “Our personality, our sicknesses, all the good things about us. It’s who we are. It’s our soul.” It should not be mixed, even if life depends on it.
Though Witnesses accept virtually all other medical interventions, the stricture against transfusion can affect their care. Patients may need donor blood when they lose their own blood rapidly, as a result of a car crash or surgery, or when they develop severe anemia—for instance, during cancer treatment. In the past several decades, specialty programs in “bloodless medicine” that cater to Jehovah’s Witnesses have grown up at dozens of hospitals.
Surprisingly, doctors’ experience in these programs has often led them to order blood far less frequently for other patients, as well. Some bloodless medicine experts have also helped lead a national movement calling for more sparing use of transfusion. Donor blood comes with risks for all patients, including the potential for immune reactions and infections. And clinical trials have shown that, for a broad range of conditions, restrictive transfusion practices do not lead to worse outcomes than liberal ones. In recent years, the American Medical Association has listed transfusion as among the most overused therapies in medicine.
An institution that has pioneered work in bloodless medicine is Englewood Hospital and Medical Center, in New Jersey. Englewood has long drawn patients from around the country and the world to its specialty program, and it is where, in early March, I met up with Joan Ortiz. By eight o’clock in the morning, she had been prepped for surgery and was waiting anxiously in a gleaming O.R, as staff members disentangled tubing, hung bags of fluid, and prepared to remove a large tumor from her abdomen and spine. A blue and white surgical gown was draped over her small frame. Her dyed-black hair, gathered earlier that morning into a youthful side ponytail, was now loose around her shoulders. Ortiz lives in Florida, but she was born in the Bronx to a Jewish mother and Christian father and she spent much of her life on Long Island. At the age of seventeen she married her first husband, and at age eighteen she began to think seriously about religion. When Jehovah’s Witnesses knocked on her door one day and offered to study the Bible with her, she was receptive to their outreach. As the conversation progressed, she found their textual knowledge compelling, along with the promise that the righteous would live for eternity on Earth. “I never wanted to live up in heaven,” she said. “I didn’t want wings.” Eventually, she was baptized as a Jehovah’s Witness, and then she and members of her new community persuaded the rest of her family to join the religion, too.
Ortiz had never before been in an operating room. She had, in fact, “never had anything worse than a cold or the flu.” But in January, she had begun to feel a slight pressure in her side, as though she had to go to the bathroom. Over the next few days, the pain intensified and she began to hobble. After consulting with doctors and receiving a CT scan, she was diagnosed with a spinal and retroperitoneal schwannoma, a tumor that arose from a nerve in the spine and ballooned outward into her abdomen. Biopsies showed that it was not malignant, but it had grown unchecked, probably for years, and wrapped itself around nervous tissue, blood vessels, and bone.
In hindsight, Ortiz said she thinks this type of tumor runs in her family. Decades earlier, her mother, who was living at her house, had felt dizzy and lightheaded and hurried to the bathroom. A few minutes later, what looked like “this big huge thing the size of a football dropped out of her and splashed in the toilet and blood shot up everywhere.” Her mother hadn’t known about a tumor, but when it broke loose, “I could just hear the blood running out of her, ‘glug, glug, glug.’ ” She was wrapped in thick black rubber and rushed to the hospital by ambulance, but died shortly thereafter. “She knew there was nothing she could do,” Ortiz said. “She was faithful and loyal. So she said a prayer and went to sleep.”
When Ortiz received the schwannoma diagnosis, she was committed to avoiding her mother’s fate, but said that, like her mother, she would never consider a transfusion. She signed herself in to a hospital in Florida that she believed would be sensitive to her beliefs. The doctors there, however, said that surgery would involve too much blood loss and could not be performed safely without transfusion. At a second hospital, also in Florida, Ortiz was once again turned away. “We have to use blood,” she said a doctor told her, “and if you’re not going to take it we can’t do anything here.” Finally, she reached out to Englewood, which, since the nineteen-nineties, has developed a reputation for performing complex neurological, vascular, and orthopedic surgeries, many of which can involve substantial blood loss, without the use of transfusion. Abe Steinberger, a neurosurgeon who has been treating Witnesses for twenty years, agreed to work with Ortiz. “We’ll just have to be meticulous in the dissection of the tumor and make sure we stop the bleeding before it starts,” Steinberger told her, with brisk confidence. Ortiz decided to travel north.
Still, bloodless medicine requires more than surgical skill, as Steinberger himself also stressed. It rests on a myriad of small precautions and coördinated, blood-saving techniques that begin well in advance of surgery. When Ortiz had pre-operative testing done in Florida, on the advice of a nurse who was familiar with Witnesses, she insisted that the phlebotomist use pediatric tubes and draw the minimum amount possible.
In the O.R. at Englewood, Ortiz lay on her stomach, on a large cushion designed to prevent the compressing of veins, as a young anesthesiologist named Margit Kaufman cheerfully and confidently double-checked the tubes around her. Kaufman first rotated through Englewood in 2012, while completing a fellowship in critical-care medicine. The hospital’s culture of respect for patients’ wishes, borne of its work with Jehovah’s Witnesses, drew her in—as did the skills its doctors had cultivated in caring for these patients. The hospital now minimizes the use of transfusion even in those who do not object to the practice, and who, at other institutions, would be likely to receive blood. Kaufman said that it was almost a year before she transfused a single operating-room patient at Englewood, a stark contrast to her experience during training, where she provided the procedure multiple times per month.
On Kaufman’s signal, a nurse anesthetist began to draw blood from Ortiz. It was startling, at first, to see rich, maroon liquid flow out of her body and enter the long thin plastic tubes through which it would travel to a collection bag on the floor. But the plan was to keep this blood in reserve, until the end of the operation (or a moment of crisis) when it could be re-infused. In the meantime, a pale fluid, called hetastarch, flowed into Ortiz’s body, diluting her circulation so that when she bled she would lose fewer red cells. Kaufman had promised never to detach the tubing connecting Ortiz’s body to the blood; it would remain part of a supplementary circuit—in her view, never actually “leaving.” (Many Jehovah’s Witnesses object to transfusions of their own blood if it has been stored externally for a prolonged period.)
When Steinberger made an incision in Ortiz’s back and began to work down to her spine, suctioned blood also flowed into a small device on the floor, called a cell-salvage machine. The blood passed first through a filter, which trapped bits of fat and bone, then entered the reservoir, where a centrifuge spun it to separate out the red blood cells. These were then washed with saline and filtered again, so that they could be returned to the body later on. Typically, the team salvages every possible red cell, even suctioning blood from bits of gauze used at the surgical site, Kaufman told me. “In most O.R.s, they throw all that away.”
Of course, not every case goes according to plan. One older Jehovah’s Witness who underwent surgery at Englewood had severe anemia and died in the I.C.U. when his organs failed, a situation that transfusion might well have averted. “That was very difficult,” said Kaufman, who was directly involved in the case but declined to share other details. “But we had to remind ourselves we were respecting his wishes. Patients have the right to determine their care.” In another case, when Steinberger was operating on a young woman from Louisiana who had a large brain tumor, she began to hemorrhage, and he decided to stop the surgery. He and his colleagues closed her up and waited several weeks, during which time she was treated to build up her red cell count. Then she returned to the O.R. and Steinberger completed the surgery.
By early afternoon, he had disconnected the tumor from Ortiz’s spine, and a second team arrived to work on the portion in her abdomen. “Now if they yank on it, I’m not worried we’ll have a horrendous disaster,” in which her spinal cord would be damaged and might become paralyzed, he said. Operating-room staff turned Ortiz onto her side, and the incoming surgeons positioned themselves on opposite sides of the table and then made a fresh incision. Leaning in, with headlamps nearly touching, they cut through muscle and exposed the bulk of the tumor: a luminous white orb tinged with blood. Eventually, they disentangled it from a phalanx of blood vessels. Lyall Gorenstein, a thoracic surgeon who had been at Englewood for around a year, headed into the doctors’ lounge, visibly relieved. He had performed four or five surgeries on Jehovah’s Witnesses but this had been one of the largest. “It’s very stressful as a surgeon, dealing with a tumor that has the potential for massive bleeding and knowing you don’t have the option of transfusion,” he told me. “It’s like being a trapeze artist with no safety net.”
A few hours later, when Ortiz awoke, she could sit up by herself in a chair. The next day, she was able to stand and take a few steps. The doctors told her she would need to “walk, walk, walk,” which, she joked, is what Jehovah’s Witnesses like to do anyway, going door to door and talking about their faith.