E D I T O R I A L

Why “bloodless medicine” and how should we do it?

As a hematologist, I have always thought thephrase bloodless medicine to be an enigmaticway to describe an important medical ap-proach. Goethe regarded blood to be “ein ganz

besondrer Saft” (blood is a very special juice). Poets as-sociate blood with being pure and eloquent, if not alwaysroyal and blue. Hematologists are fascinated by the studyof blood. We look at it under the microscope with awe; weunderstand that the “life of the flesh is in the blood.” Wevalue it therapeutically. But, bloodless suggests lifeless,unremarkable, and perhaps valueless. However, therecan be no doubt about the value and need for advancedtransfusion practices that avoid the use of allogeneicblood transfusions.

There are many bloodless medicine programsthroughout the Americas, Asia, and Europe, and thenumber is growing. Even in remote areas of Siberia, phy-sicians and patients know about bloodless medicine. Ifone types “bloodless medicine” into an Internet searchengine, 12,000 hits are obtained, and hundreds of pro-grams are listed. This all suggests a strong interest inbloodless medicine. I do not wish to discuss the advan-tages or disadvantages of bloodless medicine. This hasalready been done by Goodnough and colleagues1 in thisissue of TRANSFUSION. My purpose is to present someideas that might be useful in establishing these servicesand to review some lessons from establishing our hospi-tal’s bloodless medicine program.

Bloodless medicine program objectives must includeproviding leadership within an institution for bloodlessmedicine and being the advocate for patients not accept-ing transfusions. Bloodless medicine programs require anadministrative structure to coordinate services across avariety of departments. The preoperative and periopera-tive management of an anemic patient who does not ac-cept transfusions for elective surgery may require coop-eration between outpatient scheduling, surgical andanesthesia physicians and their clinic personnel, operat-ing room scheduling, intensivists and hematologists toget the patient prepared, and the billing office to try todetermine reimbursement issues (far too many phonecalls for a busy surgeon or physicians in training unlessthese interactions are coordinated through a bloodlessmedicine program). In contrast, if one wants a transfu-sion, this can usually be accomplished with one phonecall. Effective cooperation between multiple hospital de-

partments is a feature of transfusion medicine programs.In many institutions, transfusion medicine specialists arealso the strongest proponents of blood conservation andare knowledgeable in transfusion alternatives. Not in-cluding transfusion medical specialists in the function ofbloodless medicine programs omits a key specialist.

In encouraging patients and physicians to embracebloodless medicine a balanced approach is needed. En-thusiasts for bloodless medicine must realize that therelative safety and efficacy of all transfusion alternativeshave not been thoroughly tested in large populations.The patient’s choice of nonblood management throughadvanced transfusion practices is medically reasonable inmany instances and legally protected for competent adultpatients. However, for some very complicated risky pro-cedures, some patients may have unrealistic expectationsthat are based on anecdotal information. For a bloodlessmedicine to thrive, vigorous testing of new treatment mo-dalities, in well-designed clinical trials, is needed. Onecannot expect bloodless medicine to be widely acceptedunless it is based upon the principles that guide otheraspects of medical discovery.

The strongest argument for having a bloodless medi-cine program is to respect the rights of patients whorefuse transfusion. The right of competent adult patientsto refuse medical treatment is well established and hasbeen upheld by several judicial decisions.2,3 This right isbased on the ethical value of autonomy or self-determination, and medical institutions have a responsi-bility to respond to this need. Jehovah’s Witnesses havedeep religious convictions against accepting primaryblood components. Members of this religion seek thebest possible medical care but believe that transfusion ofprimary blood components is forbidden for them by bib-lical passages. Working closely with the Jehovah’s Wit-nesses, especially through their hospital liaison commit-tee, is invaluable. This interaction will improve one’sunderstanding about the concerns of Jehovah’s Witnesspatients and permit treating the Jehovah’s Witness pa-tient in accordance with their beliefs.

To establish guidelines concerning patient au-tonomy and transfusion, the institutional ethics commit-tees should be involved. Consulting with other estab-lished bloodless medicine programs and representativesof the Jehovah’s Witness community is very useful. Oneparticularly important aspect of establishing a bloodlessmedicine program is careful consideration of pediatricissues of treating children of Jehovah’s Witnesses. ManyTRANSFUSION 2003;43:550-551.

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‘practioners have not been trained or have not had expe-rience in handling the ethical and legal issues involved incaring for these children It is important that bloodlessmedicine programs develop educational programs cov-ering these issues.

Some institutions market their bloodless medicineprograms by pointing out the complications and adverseeffects of allogeneic transfusion, as a way to lower hos-pital bills and expenses or an approach to reduce lengthof hospital admissions. Bloodless medicine programsshould not be started with the hope of saving money,decreasing resource utilization, or increasing the bloodsupply. This may eventually happen but careful out-comes research is needed before making this a strongargument to establish a bloodless medicine program.

If an institution wishes to offer bloodless medicine topatients, it will need to determine what the expectationsof its patients are concerning bloodless medicine. To de-termine this at our institution, we contracted with a com-pany to perform a market survey to measure the potentialuse of the service, assess awareness and attitudes towardbloodless medicine, and measure the likelihood that pa-tients would use this service.

They interviewed 100 random surgical patients whohad surgery at our hospital in the past 2 years, and 100interviews were conducted with consumers who have nothad surgery in the past 2 years. Respondents were ran-domly selected and screened to ensure that they met age,geographic, and demographic criteria. The sample size of200 was selected to provide data that were reliable withinplus or minus 7 percent at the 95 percent confidencelevel.

This survey indicated that target consumers are un-familiar with the techniques and methods that allow pa-tients to have bloodless medicine. While many respon-dents found the idea appealing, only one-third ofrespondents would prefer bloodless medicine surgeryover traditional surgery techniques. The limited appealwas primarily a result of respondent’s unfamiliarity withbloodless medicine. Twenty-five percent stated that theywould prefer not have someone else’s blood given tothem during surgery. Forty-eight percent stated that they

did not have a preference for bloodless medicine becausethey had never heard about the potential options. Manypatients felt that a discussion of comparative outcomesfor traditional versus bloodless medicine surgery isneeded. This survey suggested that once patients becomemore familiar with bloodless medicine surgery as an ap-proach, they will need more in-depth information, in-cluding likelihood for procedures to be covered by insur-ance, length of typical recovery times, and types of drugsbeing used.

A plethora of new techniques and therapies are avail-able in bloodless medicine. Proselytizing bloodless medi-cine by emphasizing the risks of allogeneic transfusion isa negative approach. Forecasting great financial returnsto an institution from bloodless medicine is an overlyoptimistic approach. The strongest argument for having abloodless medicine program is our responsibility to carefor patients who refuse transfusions on the basis of reli-gious beliefs. Networks or cooperative groups are neededto perform clinical trials to avoid treating patients in ananecdotal fashion or based on inadequate clinical trialdata. Some proponents of bloodless medicine view theblood bank as their adversary. This is self-defeating.Transfusion medicine specialists are strong advocates ofavoiding allogeneic transfusions and will embrace blood-less medicine if they are approached in a spirit of coop-eration.

Thomas S. Kickler, MDJohns Hopkins University School of Medicine

Baltimore, MDe-mail: tkickler@jhmi.edu

REFERENCES1. Goodnough LT, Shander A, Spence R. Bloodless medicine:

clinical care without allogeneic blood transfusion. Trans-

fusion 2003;43:668-76.

2. Ridley DT. Informed consent, informed refusal, informed

choice—what is it that makes a patient’s medical treat-

ment decisions informed? Med Law 2001;20:205-14.

3. Ridley DT. Jehovah’s Witnesses’ refusal of blood: obedi-

ence to scripture and religious conscience. J Med Ethics

1999;25:469-72.

EDITORIAL

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