The CDC estimates that 5 million Americans receive blood transfusions every year. Some of them are Jehovah’s Witnesses, in spite of a strict edict against the practice in their faith. Most Jehovah’s Witnesses, though, are still willing to go to great lengths to adhere their belief that blood transfusions are out of the question, even if it’s a question of life or death.

“I grew up born and raised in a religion [where] blood transfusions were the worst possible thing you could ever do. 'Don’t take those under any circumstances, even if it meant you could die,'” says Linda Curtis, a former Jehovah’s Witness and author of Shunned: How I Lost My Religion and Found Myself. “To come along and take blood from other people and infuse it in our bodies when we’re ill is considered a great disrespect of the source of life.”

Curtis tells me that the rule is grounded in Biblical passages like Acts 15:29 which states, “keep abstaining from blood” and a quote from Leviticus 17:10 that says if a person chooses to ingest blood, god states: “I shall indeed cut him off from among his people.” The faith’s official website states that abstaining from blood is “as important as abstaining from sexual immorality and idolatry.” But it also refers to the sanctity of Jesus Christ’s blood sacrifice.

“Jesus Christ had to come to the earth, to live a perfect, unblemished, sin-free human life and give his life as a sacrifice that would then adequately cover all mankind’s human sins,” says Curtis. “So, spilling one’s own blood or taking blood from someone else is considered the ultimate form of disrespect.”

With more than 8 million members of the Jehovah’s Witness faith worldwide, doctors, nurses, and other medical professionals have had to develop alternatives to blood transfusions to keep patients alive. Jehovah’s Witnesses have also taken an active stance on educating the medical community on alternatives, with an outreach teams called Hospital Liaison Committees which impart both the importance of respecting the wishes of Jehovah’s Witness patients as well as evidence-based strategies that allow for blood-free treatments. Here are some techniques medical professionals employ when faced with a Jehovah's Witness patient who refuses a transfusion when he or she is in dire need of one.

Cell Salvage

For major surgical procedures, one of the most popular methods to avoid blood transfusions is through a technique called “cell salvage.” Cell salvage machines take blood from the patients’ surgical sites, save it an a machine that “cleans” the blood and then reintroduces it into the patient’s system if and when more blood is needed.

One of the keys to making blood transfusions like cell salvage acceptable to a Jehovah’s Witness patient seems to be maintaining the continuity of the blood within the patient’s system. If the patient can accept that the external tubing is a temporary extension of their body, and the blood is never actually cut off from the body, then they’re technically not breaking the rules.

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Vasoconstriction

Some doctors have looked to “vasoconstriction” to prevent blood loss during surgery. By using medications that constrict blood vessels and temporarily reduce blood flow, doctors can reduce the risk of a major bleed out that would necessitate a blood transfusion for recovery. Leonard Grossman, a plastic surgeon in New York City, says he has performed procedures on many Jehovah’s Witness patients who won’t take a transfusion even if massive blood loss occurs.

“What I’ve done in the past 22 years is use an extensively tumescent anesthesia in such patients. Tumescent anesthesia is basically a very dilute form of Lidocaine mixture combined with a small amount of adrenaline to help with vasoconstriction,” he says. “I also pay a great deal of attention to the detail, making sure that there are no bleeding vessels left alone and untreated at the end of any procedure. So far I've been quite fortunate and never had a patient who lost more than a few tablespoons of blood."

Erythropoietin

Other doctors have used a medication called Erythropoietin, which stimulates red blood cell production for patients who are in need of blood transfusions due to anemia.

Michael Mencias, senior medical director at the Metropolitan Jewish Health System in Brooklyn, says he remembers a specific case with a Jehovah’s Witness patient who had cancer and badly needed a blood transfusion. Because of her religious beliefs, Mencias and his treatment team found another option.

“It was a difficult situation where there was an immediate need for a blood transfusion but she refused," he says. "The workaround for that was that we would give intravenous fluids and an injectable medicine (Erythropoietin) to stimulate the blood counts, but that was the most that we could do. Initially it worked out okay, but for the medication to stimulate your counts to go up takes a few days to work. The blood transfusion would have had an immediate effect. As she got sicker and sicker and the need for immediate replacement was there, it was more difficult to bring her numbers up. But she stood by her beliefs and we respected her wishes.”

Blood Fractions

While accepting transfusions of whole blood is out of the question for Jehovah’s Witnesses, the faith does give members some latitude regarding blood “products,” like plasma, platelets, and red or white blood cells.

The June 15, 2000 issue of the Jehovah’s Witness publication “The Watchtower” addresses the questions of whether blood fractions are okay to accept since they’re not “whole blood.” The organization’s answer basically boils down to: “We cannot say. The Bible does not give details, so a Christian must make his own conscientious decision before God.”

Secrecy

“The patient would say ‘no visitors, no phone calls,’” says Allison Squires, a professor at the NYU Rory College of Nursing “They didn’t want members of their religious community to see what they were doing.”

Squires was a hospital staff nurse for ten years and worked with Jehovah’s Witness patients who had extensive vascular disease—which can lead to anemia—that sometimes necessitated a blood transfusion. Squires says she couldn’t remember a single case of a Jehovah’s Witness patient refusing a transfusion on her unit, but adds that those patients were adamant about hiding their decision from anyone outside of their treatment team.

Legal Interventions

When it comes to minors in emergency medical situations, blood transfusion alternatives sometimes just aren’t an option. Jay Requarth is a retired cardiothoracic surgeon who worked on a trauma case with a 15-year-old Jehovah’s Witness during his residency. The teen required a lifesaving blood transfusion, which the ER team implemented.

“When the family arrived,” Requarth says. “They rushed into the trauma bay and ripped down the blood. Obviously, this is a huge issue for the family and the caregivers, but the courts side with the physicians in these cases. In my case, we contacted the hospital’s lawyer who instructed us to proceed. The police were called to remove the family.

At the time, Curtis surmised that in this case, the child who had received the transfusion would not be excommunicated from the church, but that the community would consider the transfusion a great tragedy for the family. She said it would be “a case of great sadness” but “there would be no blame from the community or god’s point of view.”

*Media representatives from the Jehovah’s Witness organization were contacted to comment on this story, but they declined to do so.