What Is the Most Precious Fluid of All?
“Blood is to health care as oil is to transportation.”—Arthur Caplan, director of the bioethics center at the University of Pennsylvania.
OIL. Is that the most precious of fluids? In these days when fuel costs often soar, many might think so. In truth, though, each one of us carries around a few quarts of a far more valuable fluid. Think of it: As billions of barrels of oil are extracted from the earth every year to quench mankind’s thirst for fuel, some 90 million units of blood are drained from humans in hopes of helping those who are ill.* That staggering figure represents the blood volume of some 8,000,000 people.
Still, like oil, blood seems to be in short supply. Medical communities worldwide warn of blood shortages. (See the box “Desperate Measures.”) What is it that makes blood so valuable?
A Unique Organ
Because of its amazing complexity, blood is often likened to an organ of the body. “Blood is one of the many organs—incredibly wonderful and unique,” Dr. Bruce Lenes told Awake! Unique indeed! One textbook describes blood as “the only organ in the body that’s a fluid.” The same reference calls blood “a living transportation system.” What does that mean?
“The circulatory system is like the canals of Venice,” says scientist N. Leigh Anderson. “It transports all the good things,” he continues, “and it also transports a lot of junk.” As blood makes its way through the 60,000 miles [100,000 km] of our circulatory system, it comes into contact with nearly every tissue in our body, including the heart, kidneys, liver, and lungs—vital organs that process and rely on blood.
Blood brings many “good things” to the cells of your body, such as oxygen, nutrients, and defensive help, but it also carries away “junk,” such as toxic carbon dioxide, the contents of damaged and dying cells, and other waste. The role of blood in waste removal helps to explain why it can be dangerous to come into contact with blood once it leaves the body. And no one can ever guarantee that all of the “junk” in blood has been identified and removed before it is given to someone else.
Without question, blood performs functions that are essential to life. That is why the medical community has made a practice of transfusing blood into patients who have lost blood. Many doctors would say that this medical use is what makes blood so precious. However, things have been changing in the medical field. In a sense, a quiet revolution has been underway. Many doctors and surgeons are not so quick to transfuse blood as they once were. Why?
Each unit contains 450 milliliters (1 pint) of blood.
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Medical experts estimate that 200 million more units of donated blood are needed worldwide each year. Developing lands are home to 82 percent of earth’s inhabitants, yet less than 40 percent of all blood donations come from such places. Many hospitals in those lands cope without blood. The Nation, a newspaper in Kenya, reports that ‘every day almost half of the procedures requiring blood transfusion are either canceled or postponed because of lack of blood.’
Blood shortages are also common in wealthy countries. As populations have aged and medical techniques have advanced, surgeries have increased. Additionally, more and more blood donors are turned down these days because of high-risk lifestyles or travel that may have exposed them to disease or parasites.
An atmosphere of desperation seems to have developed among those responsible for stocking blood. Youths, who generally have less-risky lifestyles, are sometimes targeted as a safe blood source. For example, schoolchildren now supply 70 percent of the blood in Zimbabwe. Blood-collection centers are keeping longer hours, and some countries even allow them to provide compensation in order to recruit and keep donors. A campaign in the Czech Republic invited citizens to quench their thirst with quarts of beer in exchange for some of their blood! In one area of India, authorities recently went knocking on doors looking for donors who might be willing to help replenish an exhausted blood supply.
Transfusion Medicine—Is Its Future Secure?
“Transfusion medicine will continue to be a little like walking through a tropical rainforest, where the known paths are clear but still require careful navigation, and new and unseen threats may still lurk around the next corner to trap the unwary.”—Ian M. Franklin, professor of transfusion medicine.
AFTER the worldwide AIDS epidemic cast the spotlight on blood in the 1980’s, efforts to eliminate its “unseen threats” intensified. Still, huge obstacles remain. In June 2005, the World Health Organization acknowledged: “The chance of receiving a safe transfusion . . . varies enormously from one country to another.” Why?
In many lands there are no nationally coordinated programs to ensure safety standards for the collection, testing, and transport of blood and blood products. Sometimes blood supplies are even stored dangerously—in poorly maintained domestic refrigerators and picnic boxes! Without safety standards in place, patients can be adversely affected by the blood drawn from someone who lives hundreds—if not thousands—of miles away.
Disease-Free Blood—A Moving Target
Some countries claim that their blood supply has never been safer. Yet, there are still reasons for caution. A “Circular of Information” prepared jointly by three U.S. blood agencies states on its first page: “WARNING: Because whole blood and blood components are made from human blood, they may carry a risk of transmitting infectious agents, eg, viruses. . . . Careful donor selection and available laboratory tests do not eliminate the hazard.”
Not without reason does Peter Carolan, the senior officer of the International Federation of Red Cross and Red Crescent Societies, say: “Absolute guarantees on blood supplies can never be given.” He adds: “There will always be new infections for which at that moment there is no test.”
What if a new infectious agent were to appear—one that, like AIDS, remains in an undetectable carrier state for a long time and is readily transmitted by means of blood? Speaking at a medical conference in Prague, Czech Republic, in April 2005, Dr. Harvey G. Klein of the U.S. National Institutes of Health called that prospect sobering. He added: “The blood component collectors would be scarcely better prepared to interdict a transfusion-transmitted epidemic than they were during the early days of AIDS.”
Mistakes and Transfusion Reactions
What are the greatest transfusion-related threats to patients in developed countries? Errors and immunologic reactions. Regarding a 2001 Canadian study, the Globe and Mail newspaper reported that thousands of blood transfusions involved near-misses because of “collecting blood samples from the wrong patient, mislabelling samples and requesting blood for the wrong patient.” Such mistakes cost the lives of at least 441 people in the United States between 1995 and 2001.
Those who receive blood from another person face risks essentially similar to those undergoing an organ transplant. Immune responses tend to reject foreign tissue. In some cases, blood transfusions can actually prevent the activation of natural immune responses. Such immunosuppression leaves the patient vulnerable to postoperative infections and to viruses that had previously been inactive. It is no wonder that Professor Ian M. Franklin, quoted at the outset of this article, encourages clinicians to “think once, twice and three times before transfusing patients.”
Experts Speak Out
Armed with such knowledge, a growing number of health-care workers are taking a more critical look at transfusion medicine. Reports the reference work Dailey’s Notes on Blood: “Some physicians maintain that allogeneic blood [blood from another human] is a dangerous drug and that its use would be banned if it were evaluated by the same standards as other drugs.”
Late in 2004, Professor Bruce Spiess said the following about transfusing a primary blood component into patients undergoing heart surgery: “There are few if any [medical] articles that support transfusion actually improving patient outcome.” In fact, he writes that many such transfusions “may do more harm than good in virtually every instance except trauma,” increasing “the risk of pneumonia, infections, heart attacks and strokes.”
It surprises many to learn that the standards for administering blood are not nearly as uniform as one would expect. Dr. Gabriel Pedraza recently reminded his colleagues in Chile that “transfusion is a poorly defined practice,” one that makes it “difficult to . . . apply universally accepted guidelines.” No wonder Brian McClelland, director of Edinburgh and Scotland Blood Transfusion Service, asks doctors to “remember that a transfusion is a transplant and therefore not a trivial decision.” He suggests that doctors ponder the question, “If this was myself or my child, would I agree to the transfusion?”
In truth, more than a few health-care workers express themselves as did one hematologist, who told Awake!: “We transfusion-medicine specialists do not like to get or to give blood.” If this is the feeling among some well-trained individuals in the medical community, how should patients feel?
Will Medicine Change?
‘If transfusion medicine is so fraught with dangers,’ you might wonder, ‘why is blood still used so extensively, particularly when there are alternatives?’ One reason is that many doctors are simply reluctant to change treatment methods or are unaware of therapies that are currently used as alternatives to transfusions. According to an article in the journal Transfusion, “physicians make transfusion decisions based upon their past teaching, enculturation, and ‘clinical judgment.’”
A surgeon’s skills also make a difference. Dr. Beverley Hunt, of London, England, writes that “blood loss is highly variable between surgeons, and there is increasing interest in training surgeons in adequate surgical haemostasis [methods to stop bleeding].” Others claim that the costs of transfusion alternatives are too high, although reports are emerging that prove otherwise. Many doctors, however, would agree with medical director Dr. Michael Rose, who says: “Any patient who receives bloodless medicine is, in essence, the recipient of the highest quality surgery that is possible.”*
The highest quality of medical care—is that not what you would want? If so, you have something in common with the people who brought you this magazine. Please read on to learn about their remarkable stance on the matter of blood transfusions.
See the box “Alternatives to Blood Transfusion,” on page 8.
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“Think once, twice and three times before transfusing patients.”—Professor Ian M. Franklin
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“If this was myself or my child, would I agree to the transfusion?”—Brian McClelland
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Death by TRALI
Transfusion-related acute lung injury (TRALI), first reported in the early 1990’s, is a life-threatening immune reaction following a blood transfusion. It is now known that TRALI causes hundreds of deaths each year. Experts, however, suspect that the numbers are much higher, as many health-care workers do not recognize the symptoms. Although it is not clear what causes the reaction, according to the magazine New Scientist, the blood that causes it “appears to come primarily from people who have been exposed to a variety of blood groups in the past, such as . . . people who have had multiple transfusions.” One report states that TRALI is now near the top of the list for causes of transfusion-related deaths in the United States and Britain, making it “a bigger problem for blood banks than high-profile diseases like HIV.”
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The Composition of Blood
Blood donors generally give whole blood. In many cases, though, they donate plasma. While some countries transfuse whole blood, more commonly, blood is separated into its primary components before it is tested and used in transfusion medicine. Note the four primary components, their function, and the percentage of total blood volume each represents.
PLASMA constitutes between 52 and 62 percent of whole blood. It is a straw-colored fluid in which blood cells, proteins, and other substances are suspended and transported.
Water constitutes 91.5 percent of plasma. Proteins, from which plasma fractions are derived, constitute 7 percent of the plasma (including albumins, which make up about 4 percent of the plasma; globulins, about 3 percent; and fibrinogen, less than 1 percent). The remaining 1.5 percent of plasma is made up of other substances, such as nutrients, hormones, respiratory gases, electrolytes, vitamins, and nitrogenous wastes.
WHITE BLOOD CELLS (leukocytes) constitute less than 1 percent of whole blood. These attack and destroy potentially harmful foreign matter.
PLATELETS (thrombocytes) constitute less than 1 percent of whole blood. These form clots, blocking blood from exiting wounds.
RED BLOOD CELLS (erythrocytes) constitute between 38 and 48 percent of whole blood. These cells keep tissue alive by bringing oxygen to it and taking carbon dioxide away.
Just as blood plasma can be a source of various fractions, other primary components can be processed to isolate smaller parts, or fractions. For example, hemoglobin is a fraction of the red blood cell.
OTHER SUBSTANCES 1.5%
Page 9: Blood components in circles: This project has been funded in whole or in part with federal funds from the National Cancer Institute, National Institutes of Health, under contract N01-CO-12400. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government
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Alternatives to Blood Transfusion
Over the past six years, Hospital Liaison Committees for Jehovah’s Witnesses worldwide have distributed tens of thousands of copies of the video program Transfusion-Alternative Strategies—Simple, Safe, Effective in some 25 languages to those within the medical community.* The program shows world-renowned physicians discussing effective strategies currently used to treat patients without blood transfusions. People are taking note. For example, after viewing the program in late 2001, the National Blood Service (NBS) in the United Kingdom sent a letter with a copy of this video to all blood-bank managers and consultant hematologists throughout the country. They were encouraged to watch the program because of “increasing recognition that one of the aims of good clinical care is to avoid blood transfusion wherever possible.” The letter acknowledged that “the general message [in the video] is praiseworthy and is one the NBS strongly supports.”
Contact one of Jehovah’s Witnesses to view the DVD program Transfusion Alternatives—Documentary Series, published by Jehovah’s Witnesses.
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Fractionation—The Use of Blood’s Lesser Ingredients in Medicine
Science and technology make it possible to identify and extract elements from blood through a process called fractionation. To illustrate: Seawater, which is 96.5 percent water, can be divided through fractionation processes in order to capture the remaining substances present, such as magnesium, bromine and, of course, salt. Likewise, blood plasma, which makes up more than half the volume of whole blood, is over 90 percent water and can be processed to harvest fractions including proteins, such as albumin, fibrinogen, and various globulins.
As part of a treatment or therapy, a doctor might recommend concentrated amounts of a plasma fraction. An example of such is protein-rich cryoprecipitate, which is obtained by freezing and then thawing plasma. This insoluble portion of plasma is rich in coagulation factors and is usually given to patients to stop bleeding. Other treatments may involve a product that contains a blood fraction, whether in trace amounts or as a primary ingredient.* Some plasma proteins are used in routine injections that can help to increase immunity after exposure to infectious agents. Nearly all blood fractions being used in medical applications consist of the proteins found in blood plasma.
According to Science News, “scientists have identified only several hundred of the estimated thousands of proteins typically coursing through a person’s bloodstream.” As understanding of blood grows in the future, new products derived from these proteins may emerge.
Fractions from animal blood are also used in some products.
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Some medical workers are very cautious about coming into contact with blood
The Real Value of Blood
“The global community shares a common life source: blood. It is the life force in all human beings, regardless of colour, race or religion.”—President of the General Assembly of the United Nations.
WITHOUT question, there is a measure of truth in that quote. Blood is essential to all human life. It is a precious resource. Are you convinced, though, that it is safe and wise for humans to share that fluid for medical purposes?
As we have learned, worldwide safety standards are highly variable, and treatments with blood are riskier than many assume. Furthermore, physicians differ widely in their use of blood because of education, skills, and viewpoints. Yet, many are increasingly cautious about transfusing blood. A significant and growing number of doctors are showing a preference for medical treatments that avoid the use of blood.
That brings us back to a question posed at the outset of the first article of this series. Just what is it that makes blood so valuable? If the medical use of blood is increasingly questionable, is there another purpose that blood fulfills?
Our Creator and Blood
Back in the days of Noah, an ancestor of all mankind, God laid down a remarkable law. While granting humans the right to eat the flesh of animals, he forbade them to consume the blood. (Genesis 9:4) He also gave them his reason, equating blood with the soul, or life, of the creature. He later said: “The soul [or life] is in the blood.” In the eyes of the Creator, blood is sacred. It represents the precious gift of life that each living soul possesses. God restated this principle again and again.—Leviticus 3:17; 17:10, 11, 14; Deuteronomy 12:16, 23.
Shortly after Christianity was founded some 2,000 years ago, believers were given the divine commandment to “abstain from . . . blood.” The prohibition was based, not on health concerns, but on the sacredness of blood. (Acts 15:19, 20, 29) Some argue that this God-given restriction applies only to the eating of blood, but the word “abstain” speaks for itself. If a doctor told us to abstain from alcohol, we would hardly feel at liberty to inject it into our veins.
The Bible further explains why blood is so sacred. The shed blood of Jesus Christ, representing the human life that he gave in behalf of mankind, is key to the Christian hope. It means forgiveness of sins and hope of eternal life. When a Christian abstains from blood, he is in effect expressing his faith that only the shed blood of Jesus Christ can truly redeem him and save his life.—Ephesians 1:7.
Jehovah’s Witnesses are well known for taking these Bible commands to heart. They reject all transfusions involving whole blood or the four primary blood components—red cells, plasma, white cells, and platelets. As for the various fractions derived from those components—and products that contain such fractions—the Bible does not comment on these. Therefore, each Witness makes his own personal decision on such matters. Does this Bible-based stand mean that Witnesses reject medical treatment or view their health and life lightly? Not at all!—See the box “Jehovah’s Witnesses and Health.”
In recent years more than a few doctors have recognized that Witnesses have benefited medically from adhering to the Bible’s standard. For instance, a spine surgeon recently spoke out in favor of choosing alternatives to blood transfusions. He said: “It’s absolutely the safest thing to do, not just for Jehovah’s Witnesses, but for everyone.”
Serious health decisions can cause a great deal of stress and are often difficult to make. Regarding the common practice of transfusing blood, note the words of respirologist and medical director Dr. Dave Williams: “It’s important that we respect people’s wishes, . . . and we need to be very careful about what we put into our bodies.” Those words ring true—and never more so than today.
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What Are Hemoglobin-Based Oxygen Carriers?
Within each red blood cell are some 300 million hemoglobin molecules. Hemoglobin represents about one third of the volume of a mature red cell. Each molecule contains the protein globin and a pigment called heme—which includes an iron atom. When a red blood cell passes through the lungs, oxygen molecules penetrate the cell and attach themselves to hemoglobin molecules. Seconds later, the oxygen is discharged into body tissue, sustaining the life of the cells.
Some manufacturers now process hemoglobin, releasing it from human or bovine red blood cells. The extracted hemoglobin is then filtered to remove impurities, chemically modified and purified, mixed with a solution, and packaged. The end product—not yet approved for use in most lands—is called a hemoglobin-based oxygen carrier, or HBOC. Since the heme is responsible for the rich red color of blood, a unit of HBOC looks just like a unit of red blood cells, the primary component from which it is taken.
Unlike red blood cells, which must be refrigerated and discarded after a few weeks, the HBOC can be stored at room temperature and used months later. And since the cell membrane with its unique antigens is gone, severe reactions due to mismatched blood types pose no threat. However, compared with other blood fractions, the HBOC presents more challenges to conscientious Christians, who seek to obey God’s law on blood. Why? As long as the HBOC is derived from blood, there are two objections that may be raised. One, the HBOC carries out the key function of a primary component of blood, the red cells. Two, hemoglobin, from which the HBOC is derived, makes up a significant portion of that component. Regarding this and similar products, then, Christians face a very serious decision. They must carefully and prayerfully meditate on Bible principles concerning the sacredness of blood. With a keen desire to maintain a good relationship with Jehovah, each must be guided by his Bible-trained conscience.—Galatians 6:5.
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An Inviting Option
“A growing number of hospitals are offering an alternative: ‘bloodless’ surgery,” reported The Wall Street Journal. “Originally developed to accommodate Jehovah’s Witnesses,” states the journal, “the practice has gone mainstream, with many hospitals promoting their bloodless-surgery programs to the general public.” Hospitals around the world are discovering numerous benefits, particularly to patients, when implementing strategies that curtail the use of blood transfusions. Currently, thousands of doctors are treating patients without resorting to transfusions.
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Jehovah’s Witnesses and Health
Jehovah’s Witnesses, some of whom are physicians and nurses, are known worldwide for their rejection of transfusions involving whole blood or primary blood components. Does their united stand against this practice stem from a man-made doctrine or a belief that a person’s faith can heal medical ailments? That is far from the truth.
Cherishing their life as a gift from God, the Witnesses strive to do their best to live according to the Bible, which they believe is “inspired of God.” (2 Timothy 3:16, 17; Revelation 4:11) That book encourages worshippers of God to avoid practices and habits that harm health or endanger life, such as overeating, smoking or chewing tobacco, abusing alcohol, and using drugs for recreational purposes.—Proverbs 23:20; 2 Corinthians 7:1.
By keeping our body and surroundings clean and getting some physical exercise for health reasons, we are acting in harmony with Bible principles. (Matthew 7:12; 1 Timothy 4:8) When Jehovah’s Witnesses get sick, they demonstrate reasonableness by seeking medical care and accepting the vast majority of available treatment options. (Philippians 4:5) True, they obey the Bible command to “keep abstaining from . . . blood,” insisting on nonblood medical management. (Acts 15:29) And this choice often results in a higher quality of treatment.