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A recent loosening of restrictions among Jehovah’s Witnesses — allowing individual decisions about the use of one’s own blood in certain medical procedures — has reignited a debate increasingly present in clinical practice: the role of blood transfusion and the advancement of blood-conservation strategies.
The change does not alter the prohibition on allogeneic (donor) blood, but it expands patient autonomy by allowing each believer to decide, according to their conscience, whether to allow the collection, storage, and later reinfusion of their own blood.
The organization says it has about 9 million active members worldwide, including 938,000 in Brazil, a sizeable number that underscores the relevance of the issue.
According to the official statement from the Jehovah’s Witnesses Information Department in Brazil, “since the Bible does not specifically address the use of a person’s own blood, each Christian decides before God how their own blood may be used in all medical and surgical procedures,” which now includes deciding whether to permit removal, storage, and subsequent reinfusion of blood.
Although the discussion originates in religion, experts say the issue goes beyond that realm and connects with current trends in evidence-based medicine and patient blood management, which aim to reduce unnecessary transfusions and optimize the treatment of anemia and blood loss.
Approach Goes Beyond Religion
Biancca Cabral , a physician who lectures on nontransfusion strategies, said blood-conservation approaches are not beneficial only to patients with religious restrictions. “This autologous approach can benefit all patients and society as a whole. The benefits of nontransfusion treatments include reduced mortality, shorter hospital stays, and a lower risk of infection, and they represent cost savings for the health system,” she said. She adds that these strategies should be expanded. “Ideally, nontransfusion treatment would be the standard protocol for all patients.”
Cabral noted that the infrastructure needed already exists in the country. “Brazilian hospitals have the capacity to manage surgery without transfusion. All nontransfusion treatments are supported by the Unified Health System (Brazil’s public health system) and by Brazilian law. Today we have hospitals with specific protocols, including centers with structured programs for bloodless surgery.”
Data compiled in the literature support the physician’s statements. They indicate that transfusion does not always translate into clinical benefit and that more restrictive transfusion thresholds are safe in many scenarios. Comparisons of restrictive and liberal strategies show lower mortality with more conservative hemoglobin thresholds, without increased complications, reinforcing the adoption of personalized transfusion criteria.
A Brazilian study that analyzed clinical trials and observational studies found that increases in hemoglobin after transfusion are not consistently associated with improved tissue oxygenation or better clinical outcomes. In some evaluated scenarios, transfusion was linked to higher rates of complications, increased mortality and a worse clinical course, especially when used liberally. The same study also highlights the tendency of physicians and patients to overestimate transfusion benefits and underestimate its risks.
Planning and Bloodless Surgery
In practice, management of patients who refuse transfusion — or when the goal is to reduce the use of blood products — begins before surgery. Preoperative planning includes investigating and treating anemia, optimizing iron stores, and defining intraoperative strategies to minimize blood loss.
Common measures include intravenous iron, erythropoietin, minimally invasive surgical techniques, strict hemostasis control, intraoperative blood recovery, and strategies to increase physiologic tolerance to anemia.
Guidelines for bloodless medicine also describe pharmacologic and technical strategies to reduce or avoid transfusions. These include iron, folic acid, vitamin B12, and erythropoietin to treat anemia, along with antifibrinolytics and systemic hemostatic agents such as tranexamic acid, desmopressin, and coagulation factor concentrates to reduce intraoperative bleeding.
Topical hemostatic agents — such as fibrin sealants, collagen hemostats, and gelatin sponges — are also used for local hemorrhage control. These strategies can be employed in emergencies and urgent surgeries when the patient refuses transfusion.
Another relevant strategy is intraoperative blood salvage, which allows collection of blood lost during the procedure and reinfusion into the same patient, reducing the need for allogeneic blood products. Acute normovolemic hemodilution may also be used: blood is removed at the start of surgery and reinfused later, decreasing the effective loss of red blood cells. Recommendations also include avoiding excessive laboratory draws, using smaller-volume tubes, and optimizing oxygenation to increase tolerance to anemia.
In Cabral’s assessment, the main obstacle today is not lack of resources but dissemination of knowledge: “What needs to advance is medical training and inclusion of the topic in medical schools. Thousands of people could benefit from nontransfusion treatments, not just one religious group. In addition, there has been an observed reduction in mortality, shorter hospital stays, and a lower risk of infection.”
Patient Autonomy and Legal Implications
This change carries important legal implications. José Geraldo Romanello Bueno , MD, is a physician, lawyer, and professor of civil law at Mackenzie Presbyterian University in São Paulo, Brazil, with expertise in medical law, bioethics, and civil liability, emphasizes that it does not alter the established legal principle of patient autonomy: “From a legal standpoint, what binds the physician is not an internal religious rule but the patient’s valid, informed expression of will.”
He said the option to use the patient’s own blood may even expand therapeutic alternatives within this context. “The recent change now allows removal, storage, and later return of the patient’s own blood in certain scheduled procedures, while continuing to prohibit allogeneic blood.”
The expert emphasizes that Brazilian case law already recognizes the right to refuse transfusion. “The Supreme Federal Court, Brazil’s highest court, has held that competent adults may refuse transfusions for religious reasons, and it is incumbent on the state and health services to seek alternative therapies.”
Bueno added that this scenario increases the need for careful documentation. “In these cases, consent should be more detailed than usual, specifying the procedures accepted and refused and documenting the risks of nontransfusion.”
In practice, it is recommended to record the patient’s decisions and the chosen treatment course in the medical record in detail, attach any advance directives, and formalize the therapeutic refusal in a free and informed consent form. To document autonomous decisions and reduce legal conflicts in the event of adverse outcomes, some recommend using a waiver of liability signed by the medical team and the institution when the patient chooses nontransfusion strategies.
Thus, the possibility of individualized decisions about the use of one’s own blood broadens the range of therapeutic options and requires prior definition of each patient’s acceptable limits.
How to Proceed When a Patient Refuses Transfusion
In practice, several measures can help document the patient’s decision and reduce clinical and legal risks:
- Record in detail in the medical chart the patient’s decisions and the progression of the chosen treatment to show that the care was based on autonomous choice. If there are advance directives, attach them to the chart to protect the clinician and care team.
- Allow the patient to complete the record of therapeutic refusal through a free and informed consent form. This document formalizes the informed decision and can protect the medical team in cases of unfavorable outcomes related to that option.
- Consider obtaining a waiver of liability from the medical team and the institution when a patient opts out of transfusion. This instrument can be used by health services to document autonomous patient decisions and reduce legal disputes in the event of adverse results.
This story was translated from Medscape’s Portuguese edition.
