On its internet presence, PerthNow, The Perth Sunday Times reports that ” two men, Axel Hofmann and Shannon Farmer” have received millions by the Western Australian Health Department to create a program called Patient Blood Management (PBM). According to AABB, PBM “is an evidence-based, multidisciplinary approach to optimizing the care of patients who might need transfusion. PBM encompasses all aspects of patient evaluation and clinical management surrounding the transfusion decision-making process, including the application of appropriate indications, as well as minimization of blood loss and optimization of patient red cell mass. PBM can reduce the need for allogeneic blood transfusions and reduce health-care costs, while ensuring that blood components are available for the patients who need them.” Now, that in itself appears harmless, but money changed hands, and both happen to be Jehovah’s Witnesses, which makes the entire affair a bit more complicated than your average hospital program. But what exactly happened, what is PBM, and did their religion play a role? First, for the non-expert, some terminology. Transfusion is at this point almost a catch-all. Though experts know what they mean, the general public may assume a whole-blood transfusion procedure–the old blood-bag-IV. While that may be the case, it is important to distinguish certain procedures, whether whole blood or blood products are used, and whether the blood is taken from the patient and returned to the patient (autologous blood) or from other donor sources (allogeneic blood). As AABB points out, the point of PBM is to “reduce the need for allogeneic blood transfusions and reduce health-care cost.” Now, while these two do not need to stand in conflict–actually given the volatile nature of markets involving blood associating cost and blood is perfectly reasonable from a management perspective–a reader might think that autologous blood might then be the cheaper alternative. This case demonstrates clearly the problem with that assumption. As PerthNow explains,

● Certain patients at Fremantle Hospital, where the PBM program was piloted, are restricted to one unit of blood at a time regardless of whether their doctor recommends more than one unit. ● Literature advocating the Fremantle PBM policy states the single unit policy is in accordance with national guidelines – but no such evidence-based recommendation exists; ● As an alternative to blood, patients are sometimes given commercial drugs made by pharmaceutical companies. Some of these drugs carry significant health risk warnings. ● Mr Hofmann and Mr Farmer declared they have been paid various fees by pharmaceutical companies that make the drugs used as substitutes for blood transfusions. ● The department says that from 2009 to 2013 the WA PBM program was responsible for savings of almost $16 million in blood costs, but has failed to produce detailed costings to clarify that figure.

So not only was the cost-saving calculation not based on evidence, but the interference of the management plan with health care led to very problematic measures. If the point of the program is to cut cost, then why would incomplete care be allowed, which might well lead to complications that would add cost, not reduce them. The answer, as so often, is again money, in that Hofmann and Farmer admitted to taking money from pharmaceutical companies that offer blood transfusion substitute products. Such products are not necessarily the ‘artificial blood‘ that has been reported on over the last few years. Rather, we are looking at medication to treat anemia and coagulation problems a patient has before they go in for surgery, which would minimize the amount of transfused blood needed. Together with minimally-invasive procedures, medication involving iron or vitamin B12 can help avoid transfusion complications. Transfusion is not without risks, though these risks have been reduced dramatically in recent decades. Of course these are topics debated by the scientific community, so I don’t want to give the impression of coming down on one side of the issue. It is simply important to understand that PBM is not just a marketing scheme. For example, research indicates that an overly liberal use of transfusions in surgery of certain colon cancers can be counter-productive, and infections can never be ruled out. This is especially due to the lack of uniformity in transfusion protocols. At times the specific hospital determines the transfusion, not a general rule determined by the medical community. So, to sum up here: we have money for the procedure and actors in hospitals making decisions. We have companies interested in substituting their products to replace blood products. We have companies trying to defend the use of blood products. We have a chronic shortage of blood products and discrepancies in usage and applications across the globe as observed by  the WHO. We have individuals who for some strange reason get to implement programs like PBM, even though they have no medical degree or expertise in the topic. PerthNow quotes a former Chief Medical Officer, Dr Simon Towler, who defends his choice of the candidates by saying “We chose to engage people with substantial expertise in delivering hospital-based programs” This gets to one part of the problem. Hospital-based programs may involve many divergent and discrepant interests, and the blood transfusion that arrives in surgery thus becomes the playball that medication, equipment, and even education have been for decades. In other words: blood is still on the route to become yet another medical substance. But this case also has moments of ethical consideration of religious faith. Hofmann and Farmer are Jehovah’s Witnesses. Since the declaration of dogma that officially banned allogeneic transfusions in , JW have been in the spotlight in clashes between medicine and religion, science and faith. The ban is based on interpretations of the blood: “This is a religious issue rather than a medical one. Both the Old and New Testaments clearly command us to abstain from blood. (Genesis 9:4; Leviticus 17:10; Deuteronomy 12:23; Acts 15:28, 29) Also, God views blood as representing life. (Leviticus 17:14) So we avoid taking blood not only in obedience to God but also out of respect for him as the Giver of life.”

Just what constitutes "blood?"

Just what constitutes “blood?”

So to say that JW are “vehemently opposed to blood transfusions” like PerthNow does is not so much incorrect as glossing. In truth these are gut-wrenching decisions for JW believers. From their perspective, the ingestion prohibition extends to all incorporation. The biblical context aside, this raises fascinating questions about what blood is today and the opaqueness of many concepts surrounding blood. What IS blood? Is a part of blood still blood? Is serum blood? Can a single red cell constitute a pollutant or only the complete liquid tissue? Who has the authority to decide? Is a blood product a gift or a seductive bane? The JW point to PBM programs as evidence that their stance is actually not superstition, but a truth that may be hard to grasp but in their view comes from the highest authority. In my opinion, the religious identification of Hofmann and Farmer seem to make little difference in the case. Unless one wants to apply a Dan Brownesque logic to JW, it appears unlikely that we are facing a conspiracy against transfusion as such. However, it does seem plausible that members of different religious communities may have a different approach to blood. In this case, JW may simply be less casual about blood transfusion as such. Considering that many other Christian communities seem to have no qualms regarding the procedure (I bracket race for the moment), we observe that individuals seem to place blood in a highly individualized context. It seems pretty obvious that industrial corruption and collusion were at work here and that banknotes changed hands. Given the boom of blood product markets, I highly doubt that this will be the last case of its kind. However, beyond the sensitization of individuals to the question of transfusion or not and perhaps a greater awareness of existing alternatives, the Bible seems for once innocent.

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