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Background: Transcultural nursing recognises the significance of cultural backgrounds in providing patients with quality care. This study investigates the opinions of master's students in nursing and midwifery regarding the attitudes of Jehovah's Witnesses towards refusing blood transfusions., Methods: 349 master's students in nursing and midwifery participated in a quantitative study and were surveyed via the Web to evaluate their awareness of the stance of Jehovah's Witnesses on blood transfusions and the ethical and legal dilemmas associated with caring for Jehovah's Witness (JW) patients., Results: The study yielded three significant findings. It unequivocally demonstrates that nursing and midwifery students possess inadequate knowledge regarding Jehovah's Witnesses' stance on blood transfusions and their acceptance of specific blood products and medical procedures. Despite being cognisant of the ethical and legal dilemmas of caring for JW patients, students lack an understanding of patients' autonomy to reject blood transfusions and their need for bloodless medicine. Students also articulated educational needs regarding cultural competencies regarding the Jehovah's Witnesses' beliefs on blood transfusions and non-blood management techniques., Conclusions: Healthcare professionals need the knowledge and skills necessary to provide holistic, patient-centred and culturally sensitive care. This study emphasises the urgent need for university curricula and nursing postgraduate training to include modules on transcultural nursing and strategies for minimising blood loss., (© 2024. The Author(s).)

This article argues for a ban on the performance of medically unnecessary genital normalizing surgeries as part of assigning a binary sex/gender to infants with intersex conditions on the basis of autonomy, regardless of etiology. It does this via a dis/analogy with the classic case in bioethics of Jehovah Witness (JW) parents' inability to refuse life-saving blood transfusions for their minor children. Both cases address ethical medical practice in situations where parents are making irreversible medical decisions on the basis of values strongly held, identity, and relationship-shaping values-such as religious beliefs or beliefs regarding the inherent value of binary sex/gender-amidst ethical pluralism. Furthermore, it takes seriously-as we must in the intersex case-that the restriction of parents' right to choose will likely result in serious harms to potentially large percentage of patients, their families, and their larger communities. I address the objection that parents' capacity to choose is restricted in the JW case on the basis of the harm principle or a duty to nonmaleficence, given that the result of parent choice would be death. I provide evidence that this is mistaken from how we treat epistemic uncertainty in the JW case and from cases in which clinicians are ethically obligated to restrict the autonomy of nonminor patients. I conclude that we restrict the parents' right to choose in the JW case-and should in the case of pediatric intersex surgery-to secure patient's future autonomy., (© 2024 The Authors. Bioethics published by John Wiley & Sons Ltd.)

Nineteen people refusing a blood transfusion in anticipation of thoracic surgery were met at the Clinical Ethics Center (AP-HP, Paris, France). The article reflects on the right place that respect for autonomy plays in medical decisions regarding (non)transfusion when medical practice would recommend it. Three patient profiles emerge: "categorical refusals", "refusals while affirming the need to live" and "refusals accompanied by doubt". Without neglecting the arguments relating to other principles of biomedical ethics (beneficence, non-maleficence, justice), the idea is to enable healthcare professionals to better assess the different situations they face and in particular those in which respect for autonomy seems essential. If the majority of people concerned by the issue are Jehovah's Witnesses, and although this religion is sometimes stigmatized, this work sheds light on the place of their wishes hold in medical decisions on (non)transfusion. Healthcare professionals could contact ethics units and ask them to carry out this same assessment in their own different., (© 2024 médecine/sciences – Inserm.)

Background: Prehospital and early in-hospital use of low titer group O whole blood (LTOWB) for life-threatening bleeding has been independently associated with improved survival compared to component therapy. However, when RhD-positive blood products are administered to RhD-negative females of childbearing potential (FCP), there is a small future risk of hemolytic disease of the fetus and newborn (HDFN). This raises important ethical questions that must be explored in order to justify the use of RhD-positive blood products, including LTOWB, both in clinical practice and research., Methods: This essay explores the ethical challenges related to RhD-positive blood product administration to RhD-negative or RhD-unknown FCPs as a first-line resuscitation fluid in the trauma setting. These ethical issues include: issues related to decision-making, ethical analysis based on the doctrine of double effect (DDE), and attendant obligations incurred by hospitals that administer RhD-positive blood to FCPs., Results: Ethical analysis through the use of the DDE demonstrates that utilization of RhD-positive blood products, including LTOWB, in the early resuscitation of FCPs is an ethically appropriate approach. By accepting the risk of HDFN, hospitals generate obligations to promote blood donation, evaluate for alloimmunization and counsel patients on the future risk of HDFN, and maintain an understanding of the ethical rationale for RhD-positive blood transfusion., (© 2024 AABB.)

Competing Interests: The authors declare no conflicts of interest.

In this case study, I consider Mr. A, a Jehovah's Witness with chronic vertebral osteomyelitis in need of surgical debridement. Prior to proceeding to the OR, he was unwilling either to explicitly consent to or refuse blood transfusion, while indicating he was open to transfusion intraoperatively, if the team judged it necessary. Ethics was consulted to determine if it would be morally justifiable for the team to proceed with blood transfusion during the course of surgery without Mr. A's documented consent to being transfused. I argue that in this case, what might be termed indirect consent-namely, delegating decision-making regarding some possible course of action without explicitly consenting to the course of action itself-may be sufficient for discharging the clinician's ethical obligation to obtain consent. Identifying information has been changed or omitted to protect patient confidentiality.

There is a growing trend of refusal of blood transfusions from COVID-19 vaccinated donors. We highlight three cases where parents have refused blood transfusions from COVID-19 vaccinated donors on behalf of their children in the setting of congenital cardiac surgery. These families have also requested accommodations such as explicit identification of blood from COVID-19 vaccinated donors, directed donation from a COVID-19 unvaccinated family member, or use of a non-standard blood supplier. We address the ethical challenges posed by these issues. We describe the current screening and safety processes for standard blood donation and explore the importance of donor anonymity and challenges with directed donation and non-standard blood suppliers. We present an ethical framework using the Best Interest Standard, the Zone of Parental Discretion, and the Harm Principle when considering these refusals. Finally, we provide recommendations for how to approach these requests as they potentially become more commonplace in pediatrics.

The goal of patient blood management (PBM) is to optimize clinical outcomes for individual patients by managing their blood as a precious and unique resource to be safeguarded and managed judiciously. A corollary to successful PBM is the minimization or avoidance of blood transfusion and stewardship of donated blood. The first is achieved by a multidisciplinary approach with personalized management plans shared and decided on with the patient or their substitute. It follows that the physician-patient relationship is an integral component of medical practice and the fundamental link between patient and doctor based on trust and honest communication. Central to PBM is accurate and timely diagnosis based on sound physiology and pathophysiology as the bedrock on which scientifically based medicine is founded. PBM in all disease contexts starts with the questions, "What is the status of the patient's blood?" "If there are specific abnormalities in the blood, how should they be managed?" and "If allogeneic blood transfusion is considered, is there no reasonable alternative therapy?" There are compelling scientific reasons to implement a nontransfusion default position when there is clinical uncertainty and questionable evidence of clinical efficacy for allogeneic blood transfusion due to known potential hazards. Patients must be informed of their diagnosis, the nature, severity and prognosis of the disease, and treatment options along with risks and benefits. They should be involved in decision-making regarding their management. However, as part of this process, there are multifaceted medical, legal, ethical, and economic issues, encompassing shared decision-making, patient choice, and informed consent. Furthermore, variability in patient circumstances and preferences, the complexity of medical science, and the workings of health care systems in which consent takes place can be bewildering, not only for the patient but also for clinicians obtaining consent. Adding "patient" to the concept of blood management differentiates it from "donor" blood management to avoid confusion and the perception that PBM is a specific medical intervention. Personalized PBM is tailoring the PBM to the specific characteristics of each patient. With this approach, there should be no difficulty addressing the informed consent and ethical aspects of PBM. Patients can usually be reassured that there is nothing out of order with their blood, in which case the focus of PBM is to keep it that way. In some circumstances, a hematologist may be involved as a patient's blood advocate when abnormalities require expert involvement while the primary disease is being managed., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2022 International Anesthesia Research Society.)

Postpartum Hemorrhage is still the leading cause of maternal mortality. The management of patients who refuse allogeneic blood transfusion, like in the case of Jehovah's Witnesses, is clinically and ethically challenging. We describe the case of a woman with several risk factors for major postpartum hemorrhage, specifically the presence of a giant uterine myoma. The multidisciplinary management of this patient included an elective c-section and the use of prophylactic tranexamic acid. The perioperative and peripartum care of Jehovah's Witnesses requires specific strategies to minimize blood loss, optimize oxygen delivery and consumption, enhance hemoglobin production, correct coagulation defects and promote hemostasis. We highlight the need for a multidisciplinary approach, point-of-care testing and the use of fibrinogen concentrate and tranexamic acid, according to the patients' informed consent.

Can transfusions of blood plasma slow down ageing or even rejuvenate people? Recent preclinical studies and experimental tests inspired by the technique known as parabiosis have aroused great media attention, although for now there is no clear evidence of their effectiveness. This line of research and the interest it is triggering testify to the prominent role played by the idea of combating the "natural" ageing process in the scientific and social agenda. While seeking to increase the duration of healthy living time may be considered a duty, it also raises ethical questions about how to pursue this goal. Specifically, therapies and techniques accessible only to a fraction of the population seem destined to exponentially increase social inequality and to produce undesirable consequences. In this article we address the issue precisely in the light of the prospected use of plasma for the rejuvenation of a small elite of people.

The rapid onset and worldwide spread of the COVID-19 epidemic (caused by SARS-CoV-2 coronavirus) has been associated with a profound impact in clinical practice also in the hematologic setting. First of all, given the immunosuppressive effect of many therapies that are normally administered to patients with hematological diseases, with a consequent increased risk of contracting a more severe viral infection, it has been necessary to reconsider in each individual patient the urgency and priority of the treatments foreseen by the normal standards of care. In particular, as regards allogeneic (and to a lesser extent autologous) hematopoietic cell transplantation and CAR T-cell therapy, specific recommendations have been issued by the transplant community on the criteria to be used to decide whether or not to postpone these procedures and on the clinical management of recipients and donors exposed to COVID-19. As to cytotoxic chemotherapy and other antineoplastic therapies, criteria have been proposed to decide, in the various clinical situations, which treatments were not deferrable and which instead could be postponed or replaced by less aggressive therapies. In the outpatient clinics, various organizational solutions for telemedicine have been adopted, resorting to telephone interviews and/or Information Technology, with the aim of reducing the influx of patients while maintaining an adequate control of their clinical condition. The collection of blood by the transfusion centers has been the subject of organizational measures, in order to avoid the transmission of COVID 19 while maintaining a sufficient blood collection for clinical needs. Finally, some hematologic laboratory alterations have been identified, such as thrombocytopenia, lymphopenia and coagulation abnormalities, useful for the prognostic evaluation of infected patients., (Copyright © 2020. Published by Elsevier Ltd.)

When an incapacitated Jehovah's Witness neurologically deteriorates and requires immediate craniectomy, institutional protocols may delay surgery if the patient's refusal of blood products is ambiguous. We are among the first to describe such an ethically contentious case in emergency neurosurgery, review the morbidity of operative delays, discuss medicolegal concerns raised, and provide a detailed guide to hemostasis in patients who refuse blood products. We discuss the case of a 46-year-old woman presented with nausea, vomiting, and right-sided weakness, progressing to stupor over several hours. When an initial Computed Tomography (CT) scan showed a large, left-sided intraparenchymal hematoma with significant midline shift, she was booked for an emergency hemicraniectomy. According to the family, she was a Jehovah's Witness and would have refused blood consent, but was without the proper documentation. Despite her worsening neurological status, an indeterminate blood consent delayed surgery for more than two hours. Her neurological exam did not improve postoperatively, and she later expired. The ethical, legal, and operative concerns that arise in the emergency neurosurgical treatment of Jehovah's Witness patients pose unique management challenges. Since operative delay is a preventable cause of mortality in patients requiring urgent craniectomy, and the likelihood of requiring a transfusion from hemorrhage is minimal, an ambiguous blood consent should not postpone a potentially life-saving treatment. For the beneficence and autonomy of Jehovah's Witness patients, institutional policies should respect the family's wishes in order to expedite surgical decompression. In addition to discussing the nuances of such ethical considerations, we also provide a detailed list of commonly used, topical and parenteral hemostatic agents from the neurosurgical operating room which, depending on whether they are blood-derived, either should or should not be used when treating a Jehovah's Witness., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Purpose of Review: Jehovah's Witnesses have religious beliefs that preclude transfusion of blood products and certain medical interventions. This presents a unique dilemma and ethical challenge to healthcare providers, especially in a surgical setting., Recent Findings: The growing number of followers of this faith warrants a deeper look at the ethical, legal, and clinical implications of their beliefs. Advances in patient blood management now allow timely optimization before surgery., Summary: Anticipating the challenges associated with managing and optimizing patients who refuse blood products allows for more favorable outcomes in the preoperative period.

Objective: To point out principles of blood sparing surgery. Medical ethical moral and legal aspects of operations on Jehovahs Witnesses., Design: Retrospective clinical study. Review of articles., Setting: Dept. of Gynecology and Obstetrics, University Hospital, Olomouc; Dept. of Health Care Sciences, Faculty of Humanities, Tomas Bata University Zlín., Materials and Methods: 72 Jehovahs Witnesses patients were operated on for various benign and malignant gynecological diseases since 2007-2017. All patiens were operated according to the rules of blood sparing surgery., Results: There were no excesive blood loss at any of the operations. The estimated blood loss was between 10 to 550 ml., Conclusions: The main principles of blood sparing surgery should be applied not only for Jehovahs Witnesses but for all patients. Even if the blood transfusion is the last resort for excessive blood loss during complicated operations it always carries some health risks. There are also the economical aspects. Blood transfusions should be therefore used only at very rare occasions. Jehovahs Witnesses refuse blood transfusions at all even if it is the only life saving resort. Our legislation deal with this problem but there are also moral and ethical aspects. The attitude of gynecological surgeons how to solve this problem differ a great deal.

Purpose of Review: Jehovah's Witness patients with critical anemia or undergoing major surgery are challenging for healthcare providers to manage, as most will decline transfusion of whole blood and its main components. Recent advances in our understanding of hemostatic agents, alternative hemoglobin-based oxygen carriers, and patient blood management have culminated in a complex array of options to manage critical anemia and bleeding in this patient population., Recent Findings: Refusal of blood products in the setting of critical anemia is associated with significant risk of morbidity and mortality. With implementation of patient blood management measures, targeted treatment of anemia and coagulopathy has reduced the need for transfusions. Likewise, increased clinical experience with hemoglobin-based oxygen carriers in Jehovah's Witnesses with critical anemia has provided new insights into their potential benefits and pitfalls., Summary: Options and alternatives to manage the Jehovah's Witness patient in the perioperative setting or in the setting of critical anemia will be reviewed.

Background and Objectives: The perception of transfusion-transmitted infections (TTIs) is sensitive to various concerns besides the probability and impact of infection, and some of these concerns may be ethically relevant. This paper aims to advance thinking about blood safety policies by exploring and explaining stakeholders' reasons to consider TTI risks tolerable or intolerable., Materials and Methods: Inspired by critical empirical ethics and phenomenological hermeneutics, we held interviews and focus group discussions to explore the moral experience of policymakers, hematologists, blood donors and recipients. Respondents were invited to discuss general concerns about the blood supply, to address the tolerability of TTI risks compared with other hazards and to comment on the costs of blood safety. Arguments for tolerance or intolerance towards TTI risks were analysed qualitatively., Results: Stakeholders' views could be clustered into seven categories: (1) clinical impact; (2) probability of infection; (3) avoidability of infection; (4) cost and health benefits; (5) other consequences of safety measures; (6) non-consequentialist ethical arguments; and (7) stakeholders' interests. Various arguments were offered that resonate with current ethical thinking about blood safety. Assuming that resources spent on inefficient blood safety measures could be applied more beneficially elsewhere, for example, responders typically expressed tolerance towards TTI risks. Some other arguments seem novel, for instance arguments for risk intolerance based on the low probability of infection and arguments for risk tolerance if patients have a poor prognosis., Conclusion: Understanding the moral experience of stakeholders enriches ethical debate about blood safety and prepares developing more widely acceptable policies., (© 2019 The Authors. Vox Sanguinis published by John Wiley & Sons Ltd on behalf of International Society of Blood Transfusion.)

MC is a 42-year-old female who was in a motor vehicle accident and suffered multiple contusions as well as a fracture of the left femur, pelvic ramus, and left orbit. Due to contusion of the brain, MC has been comatose for over a week and is on mechanical ventilation to protect her airway. There is no written declaration of surrogacy. During the admission, surgery to repair the left femoral fracture was performed and was complicated by severe blood loss. Currently, MC's hematocrit is 24% with a hemoglobin of 7.4. The trauma team asserts that a blood transfusion would be in MC's best interests. Since MC lacks capacity for decision making, she cannot consent to blood transfusion. Her parents are Jehovah's Witnesses and refuse to approve blood transfusion, stating that it is against their faith. MC's brother, however, states that MC is not a practicing Jehovah's Witness and wants the medical team to provide the blood transfusion. The parents insist that decision making is their right; MC's brother feels he should be making decisions. The trauma teams calls for an emergency consultation with the hospital ethics committee.

Purpose: To determine motives and attitudes towards life-sustaining treatments (LSTs) by clinical and preclinical medical students., Methods: This was a scenario-based questionnaire that presented patients with a limited life expectancy. The survey was distributed among 455 medical students in preclinical and clinical years. Students were asked to rate their willingness to perform LSTs and rank the motives for doing so. The effect of medical education was then investigated after adjustment for age, gender, religion, religiosity, country of origin, and marital status., Results: Preclinical students had a significantly higher willingness to perform LSTs in all cases. This was observed in all treatments offered in cases of a metastatic oncologic patient and an otherwise healthy man after a traumatic brain injury (TBI). In the case of an elderly woman on long-term care, preclinical students had higher willingness to supply vasopressors but not perform an intubation, feed with a nasogastric tube, or treat with a continuous positive air-pressure ventilator. Both preclinical and clinical students had high willingness to perform resuscitation on a twelve-year-old boy with a TBI. Differences in motivation factors were also seen., Discussion: Preclinical students had a greater willingness to treat compared to clinical students in all cases and with most medical treatments offered. This is attributed mainly to changes along the medical curriculum. Changes in reasons for supplying LSTs were also documented.

Objectives: Discuss the ethical issues in the management of postoperative hemorrhage in pediatric patients whose parents are Jehovah's Witnesses (JW) and 2) Describe a framework for shared decision making in this population., Methods: A recall review of pediatric otolaryngology patients with parents of the JW faith and postoperative hemorrhage was performed over a year long period at a single institution. The literature on transfusions for JW minors was reviewed., Results: Two patients were identified. The first patient had a severe post-tonsillectomy hemorrhage requiring multiple emergency operative interventions. The child developed a hemoglobin of 5.2 g/dl and received an emergent transfusion against parents' wishes. The child subsequently did not require further intervention. The second patient hemorrhaged after a supraglottoplasty and was administered erythropoietin and iron infusion but did not require transfusion (hemoglobin nadir 7.9 g/dl). In both cases hematology was consulted, and extensive discussion with the families and the JW Hospital Liaison Committee occurred., Conclusions: The risks of hemorrhage should be discussed with JW parents of patients undergoing even routine otolaryngologic surgery. In these cases, early shared decision making with family, the JW Hospital Liaison committee, and hematology was pursued regarding mutually acceptable interventions. Aggressive non-transfusion based resuscitation was carried out to minimize the likelihood of transfusion. In the first case, danger to the patient's life eventually necessitated transfusion in accordance with the patient's best interest and previous case law. A defined framework involving all stake-holders, including Pastoral Care, in the event of postoperative hemorrhage is critical., (Copyright © 2018. Published by Elsevier B.V.)

The management of patients, such as Jehovah's Witnesses, who refuse to receive blood transfusions, is often a medical challenge, not only because of the ethical dilemma, but also because it creates a major obstacle to rapid hemorrhage control in a setting of trauma. This article explores the reasons for this conflict between the physician's duty of care and the respect for the patient's autonomy, and draws a panorama of the main understandings of the Judiciary on the subject. Finally, it is concluded that the manifestation of the patient's will, although free, is not enough to release the doctor from his (her) duty of care. In case of danger to life, the doctor must carry out a blood transfusion, regardless of the patient's consent or the permission of those responsible for the patient.

Background: Bloodless pancreatic surgery (BPS) is rarely performed and/or reported. We aim to characterize perioperative and anesthetic strategies in BPS., Materials and Methods: A literature search was performed on MEDLINE looking for case reports/case series using search terms ("Jehovah's Witness" [All Fields]) AND ("Pancreatic Surgery" [All Fields] OR "Pancreaticoduodenectomy" [All Fields] OR "Distal Pancreatectomy" [All Fields]). Data regarding categorical variables are reported as proportions and quantitative continuous variables as medians with ranges or means with standard deviation. Forty-one patients requiring BPS are reported in the literature with three additional cases from our institution (n = 44). The data analyzed included clinicopathologic factors, BPS strategies, patient complications, and in-hospital mortality., Results: The most common procedure and diagnosis were pancreaticoduodenectomy (n = 34, 77.3%) and pancreatic ductal adenocarcinoma (n = 12, 27.3%), respectively. Transfusion reduction strategies in BPS fell into three categories: preoperative, intraoperative, and postoperative. Preoperative strategies included iron supplementation (n = 24, 54.5%) and erythropoietin administration (n = 14, 41.2%). Intraoperative strategies included acute normovolemic hemodilution (n = 30, 68%) and cell saver (n = 4, 9.1%). Postoperative strategies included erythropoietin (n = 16, 48.5%) and iron supplementation (n = 16, 48.5%). Complications occurred in 21 (60%) patients. There was no in-hospital mortality among the 44 patients in this cohort., Conclusions: A broad spectrum of bloodless medicine and surgery practices were used based on patient selection, multidisciplinary practice, and preference. With careful perioperative and anesthetic management, BPS can be performed with good outcomes., (Copyright © 2018 Elsevier Inc. All rights reserved.)

The law N° 20.584 established the informed consent. This could suggest that patients have a right to refuse a blood transfusion. However, the dominant jurisprudence in protection claims filed against Jehovah Witnesses who rejected a blood transfusion, reveals that they do not have such a right. There were two exceptions in 2008, where courts acknowledged the patient's autonomy and denied the petition to authorize a blood transfusion. Most cases precede law N° 20.584. However, those cases which were upheld by the courts after the promulgation of the law, although few, follow exactly the same doctrine as before the appearance of this act.

The refusal of blood products by Jehovah's Witness patients has provoked court proceedings, social science research, and contemporary fiction, all of which emphasize a seemingly intractable conflict between religious and secular ways of being. This article takes a different approach, focusing instead on the space that Witness patients have carved out for their accommodation in a major pediatric research hospital. Using discourse analysis and interview data, I map the way moralizing discourses surrounding Witness families have shifted over the past 70 years alongside advancements in bloodless medicine. I argue that Witnesses have helped to enable their present accommodation and recognition by marshaling particular forms of economic, human, and social capital, and consider whether their success might be attainable by other treatment-resisting patient groups. Thus, this article explores the shifting limits of multicultural accommodation and the conditions that make understanding, collaboration, and compromise possible.

Background and Objectives: Concern with the costs of blood safety is growing, which raises the question whether safety measures that reduce risk only marginally should be discontinued. Withdrawing such safety measures would allow reallocating resources to more efficient health care interventions, but it might raise moral objections., Materials and Methods: This study evaluates two ethical arguments why discontinuing blood safety measures would be more objectionable than not implementing them. The first argument is that whereas withdrawing protective measures causes harm to patients, not starting protective measures 'merely' omits to prevent harm. The second argument is that patients who benefit from protective measures are historically entitled to the continuation of those protective measures., Results: Both arguments are unconvincing. There is only a weak causal connection between removing blood safety measures and harms that transfusion recipients suffer. Moreover, patients are not entitled to the continuation of protective measures that prove very inefficient, unless applying these protective measures rectifies past injustice towards them., Conclusion: Unless stronger ethical objections can be found, blood system operators and regulators should be more willing to withdraw inefficient safety measures., (© 2017 International Society of Blood Transfusion.)

The Ebola outbreak that began in 2013 infected and killed record numbers of individuals and created unprecedented challenges, including containment and treatment of the virus in resource-strained West Africa as well as the repatriation and treatment for patients in the United States and Europe. Valuable lessons were learned, especially the important role that the laboratory and transfusion service plays in the treatment for patients with Ebola virus disease (EVD) by providing data for supportive care and fluid resuscitation as well as the generation of investigational therapies such as convalescent plasma (CP). To provide treatment support, laboratories had to evaluate and update procedures to ensure the safety of laboratory personnel. Because there is no licensed EVD-specific treatment, CP was used in more than 99 patients with only 1 possible severe adverse event reported. However, given the biologic variability inherent in CP as well as the small number of patient treated in a nonrandomized fashion, the efficacy of CP in the treatment of EVD remains unknown., (Copyright © 2016 Elsevier Inc. All rights reserved.)

The not-for-profit issue has been debated in November 2016 in Paris; this issue is one of the four canonical pillars of ethical blood donation. It is intimately bound to benevolence though it is distinct, as not-for-profit calls for institutions while benevolence calls for individuals. It is indeed intended that voluntary blood donors do not benefit from their donation and are thus non-remunerated. Not-for-profit is essential since it refers to the public character of blood as a putative public resource aimed at being shared as a tribute of solidarity. A central question however is linked to the capacity- or not -of public sectors to ensure that blood components are universally available, with special mention to plasma derived drugs, without the contribution of the for profit, private sector., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Postpartum hemorrhage is a leading cause of maternal mortality. Jehovah's Witnesses (JWs) refuse allogeneic blood transfusion, and thus treatment of hemorrhagic complications in this patient population is complex. Recognition and respect for religious beliefs are essential when caring for the JW parturient and several ethical and legal considerations must be taken into account. Interdisciplinary teamwork and communication as well as active patient participation are critical in the decision-making process for JW patients. Various techniques and technologies are available to optimize red blood cell mass, minimize bleeding, increase tolerance to anemia and support multiorgan derangements derived from antepartum and postpartum hemorrhage.

Improving transfusion chain requires moral support for blood policy and ethics training of different actors. To optimize this support and ethics training, it is important to evaluate and strengthen the ethicality of the mandates of the structures involved in the transfusion chain. To help strengthen audit, this study will examine the use of anticipatory and forward slope of the principle of ethical responsibility in the blood policy in Quebec and Côte d'Ivoire. By elucidating the conditionalities of efficient use of accountability within these transfusion chain, this paper deepens the fundamentals of acting rational, sensible, prudential and therefore responsible to his blood systems and supports, at the same time the ideas of biomonitoring and preventive medicine.

Jehovah's witnesses oppose receiving blood transfusions based on religious grounds. This refusal raises complex medical, legal and ethical issues for the treating medical staff. In the past physicians attempted to force patients and children to accept transfusions when deemed medically necessary through the use of court orders. However, in recent years the threshold for blood transfusion has been gradually raised by medical experts as expressed in consensus guidelines, which means that Jehovah's witnesses' aversion to transfusion would have been partially justified medically. This article will further discuss these current trends.

Tolerance for blood transfusion risks is very low, as evidenced by the implementation of expensive blood tests and the rejection of gay men as blood donors. Is this low risk tolerance supported by the precautionary principle, as defenders of such policies claim? We discuss three constraints on applying (any version of) the precautionary principle and show that respecting these implies tolerating certain risks. Consistency means that the precautionary principle cannot prescribe precautions that it must simultaneously forbid taking, considering the harms they might cause. Avoiding counterproductivity requires rejecting precautions that cause more harm than they prevent. Proportionality forbids taking precautions that are more harmful than adequate alternatives. When applying these constraints, we argue, attention should not be restricted to harms that are human caused or that affect human health or the environment. Tolerating transfusion risks can be justified if available precautions have serious side effects, such as high social or economic costs.

John Tingle, Reader in Health Law at Nottingham Trent University, discusses an important court case on refusal of consent for a blood transfusion by a Jehovah's Witness and new guidance on caring for patients who refuse blood.

A 15-year-old was admitted to the labor and delivery unit for induction of a 41-week-gestation pregnancy. Her parents, members of Jehovah's Witnesses, and the patient, who had been studying the religion but had not yet been baptized, were adamant that no blood transfusions would be accepted even if a life-threatening hemorrhage were to occur. In our analysis, we examine the underlying ethical conflict and issues raised by this case. We considered two important ethical questions in analyzing the dilemma: first, whether adolescents are capable of providing autonomous and authentic refusals for lifesaving interventions; and second, whether parents can refuse such interventions for their adolescent children based on their religious beliefs. We provided justifications for not considering the adolescent's refusal as autonomous and for overruling the parental refusal, concluding that there was ethical support for providing potentially lifesaving transfusions should they become clinically indicated. We also suggested strategies to avoid blood loss and the need for transfusions in order to respect the stated values and preferences of the patient and her family to the greatest degree possible. In order to protect the privacy of the patient and her family, details in this case have been changed and no identifiable information has been used.

In 2012, 110 hospitals reported on consent policy against national guidelines, with 105 (95%) including a statement on blood transfusion. Of the 103 hospitals (1788 transfusion episodes) that participated in the consent practice component, 89 specified the method of consent used; 46 (52%) had a specific transfusion consent form and achieved compliance of 90% compared to 43-69% for most other methods. The consent audit shows that a specific blood consent form achieved a high rate of medical record documentation compliance., (© 2016 Royal Australasian College of Physicians.)

Purpose of the Study: The goal of this study is to assess the physician's management of patients who refuse blood transfusion., Material and Methods: A questionnaire to assess the experience, the acceptance or refusal and the operating methods in case of vital risk has been realized and circulated at a national scale., Results: A total of 793 questionnaires were sent back and analysed according to 3 different categories: anesthesiologists, physicians and surgeons. Seventy-nine percent of total respondents and 90% of anesthesiologists had had to take care of a Jehovah's Witness. In 51% of all cases, it appears to be associated with mainly relational problems with the patient or his family. Nevertheless, 83% accept to take care a Jehovah witness, the most reluctant of them being anesthesiologists. A written confirmation of blood transfusion refusal even at vital risk and a piece of written evidence of belonging to Jehovah's Witnesses are not systematically required. For them, the impossibility to foresee with certainty the need for blood transfusion represents the main barrier to the medical care of a Jehovah's Witness. In case of imminent vital risk and if there are no available alternative procedures, 67% of respondents administer blood products (89% if the patient is unconscious)., Conclusion: This situation has nothing exceptional but the medical community does not seem to know all the regulatory requirements. Generally speaking, they do not oppose the medical care of a Jehovah's Witness, but remain committed to their primary focus: to save the patient, as long as it is not an end-of-life situation., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

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.

Indications for transcatheter valve implantation have been extended to treat native valve aortic regurgitation in case of disproportionate risk for open surgery. Transcatheter aortic valves are also an attractive alternative in patients who refuse blood transfusions. We report the successful off-label implantation of a self-expandable transcatheter valve in a Jehovah's Witness with prior replacement of the ascending aorta for Type A dissection, residual severe aortic regurgitation and refractory heart failure., (© The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Ethics is on the cross road of off values that are present along the ways of transfusion medicine. This is an important tool to afford opinions as well as debates that always emerge when discussing transfusion medicine. The wording is particularly important; this was one among several others that characterized the soul of Jean-Jacques Lefrère when he opened the doors of the ethical issues of transfusion medicine., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Since the context of the contaminated blood affair in 1983, the homosexual male were excluded from the blood donation in France. This exclusion is often called into question in several countries and is an actual lively debate. In France, reform process is ongoing for a practical change. Three issues make up the discussion: the infectious risk bound to sexual behavior, the feasibility of the powerful biological tests but having a silent window and the protection of the blood recipient. The infectious risk in the homosexual male is higher for the human immunodeficiency virus (HIV) than in the rest of the population. Even if every person has his/her own individual risk depending on his/her habits, everyone is confronted to the same law. The challenge is to build a consensus, along with the precautionary principle, the non-discrimination policy, and the individual and collective responsibilities., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

In France, men who have sex with men (MSM) were "permanently deferred" of blood donation. This measure reflected the fact that according to scientific research data, MSM have a higher risk to be infected notably by the human immunodeficiency virus. This "permanent postponement" was the subject of much debate as discrimination criterion. Can ethics be the basis for the reexamination of conditions of access of MSM to blood donation? It seems that ethics can and should in fact be reconvened in the reflections. The donor selection criteria should be regularly reviewed in the light of emerging risks. The exclusion must be reexamined, questioned again, remembering the reality and not enclosing blood transfusion in a secure dynamic unsuited to the reality of the risk. Also, it appears capital to keep the debate in mind, far exceeding that of blood donation to involve more that a legitimate search for equality and justice in a society. The debate must take account of these elements of reality, without leave to fascinate at the risk of providing an unadjusted answer to the original problem. Ethics seems to invite us in these discussions as they show the axes of reflection or problematization channels. Far from closing the debate, it opens the latter to new areas and participates in the advance of ideas, thus constituting a main actor., (Copyright © 2016. Published by Elsevier SAS.)

Nowadays, in France, anonymity, gratuity, volunteering, non-profit are recognized as ethical principles in blood transfusion. Can we add responsibility to this list? Can a logo named "Responsiblood" efficiently encourage blood donation? This article explores Hans Jonas's reform of the responsibility concept in order to measure its applicabilities and limits in the field of blood transfusion. Indeed, this concept - rethought by Jonas - seems to be a good encouragement which avoids the pitfalls of the concept of duty and of the idea of payment for blood donation. But can't we also see in this reform a threat to blood transfusion because of technophobia and the heuristics of fear that it involves?, (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)