File image: African News Agency/ANA

Johannesburg - By means of this article, I wish to join the discourse which was in the main triggered by the story published in The Post in connection with the decision of the Addington hospital to apply for a court order to administer allogeneic blood transfusion on a five-year-old whose parents sought alternative treatment to the transfusion. ("Jehovah’s Witness parents refuse blood transfusion despite court order")

Although this article does not directly address the merits of the case, I thought it might be instructive to make a contribution to the general discourse around the realities of bloodless medicine and surgery. 

It was not until World War I and II that blood transfusion was first used, primarily for military casualties. Until then really, all surgeries were essentially without the use of blood. In fact, up until the 19th-century bloodletting rather than blood transfusion was the standard practice in medicine (Basics of Blood Management, 2013).

According to the book Basics of Blood Management (published in 2013), bloodless medicine is a multimodal, multidisciplinary approach to safe and effective patient care without the use of allogeneic blood products. Bloodless medicine and surgery utilise pharmacological and technological means as well as medical and surgical techniques to provide the best possible care without the use of donor blood. 

Transfusion alternatives are most effective when used in combination and as part of a comprehensive patient blood management programme. The comprehensive patient blood management programme includes the measures and strategies that the medical staff needs to adopt during the pre-operative, intra-operative, and post-operative phase of surgery.

Consider the case published in the Brazilian Journal of Cardiovascular Surgery (2012) which illustrates the benefit of a multidisciplinary approach. Antonio Alceu dos Santos (MD) and his team conducted the World’s first cardiac retransplantation in a 6-year-old child, without the use of homologous blood (blood from another person).

“The highlight of this surgery’s success was due to the importance of a multidisciplinary planning of intensive care (surgeon, clinic, anesthesiologist and intensive therapy doctors) who focused on saving the patient’s blood through a programme known as PBM (Patient Blood Management), which aims to use all the clinical and surgical strategies
to avoid the use of allogeneic blood through a transfusion.”

While the practice of blood management has gained traction since the 1960s including some developing countries. For example, in the city of Bangalore alone in India, The Bangalore Mirror dated 19 March 2014, reported that "more than 100 surgeons were performing surgeries without blood transfusion for community members and that Bangalore doctors have now become so adept at performing bloodless surgeries that they are getting Jehovah's Witnesses patients from other cities and countries." Yet, much ground still needs to be covered in terms of mainstreaming blood management into modern medicine, particularly in developing countries such as South Africa.

When children are involved

According to The International Journal of Nursing Studies (2008), there is a growing recognition internationally that children and young people have a right to participate in matters that affect their lives.

Although parents and physicians have traditionally made most medical decisions on behalf of children, the developing autonomy of children is increasingly being recognised in medical decision-making. In an article published in the BMC Medical Ethics Journal (2016) the authors argue that there is a need to "move away from a general age of consent toward more individualised, context-specific approaches in determining the maturity of a child patient to consent to medical treatment".

The article goes on to say that "where a child is able to express his or her will based on an established value system and rationality, they ought to have their views taken seriously in decisions pertaining to their medical treatment". 

Generally, this is the attitude that courts in some parts of the world have adopted, that there cannot be an arbitrary age which can be set to determine the competency of the child as they recognise that each child is different and that each case should be dealt with according to its own merits. As a result, the courts tend to be willing to overrule the refusal of specific procedures by children.

By way of concluding, Section 27 of the Constitution states that everyone has the right to have access to health care services and that the state must take reasonable measures,
within its available resources, to achieve the progressive realisation of each of these rights.

Furthermore, in terms of section 9, everyone has the right to equality, including access to health care services, which means that individuals should not be unfairly excluded in the
provision of health care. Thus, it is imperative for the State to broaden access to alternative forms of treatment, including alternatives to blood transfusion. It is important that our
public health-care system should keep up with advances in medical sciences. 

Clinicians should also not feel that the Hippocratic Oath they took should override any conscientious decision that a patient may take. Finally, while matters involving minor children present more challenges and complexities, clinicians have a legal and ethical responsibility to ensure the wellbeing of the child and should make every effort to respect the beliefs of the family and avoid the use of blood or blood products wherever possible.

* David Pooe is a member of the Hospital Liason Committee for Jehovah's Witnesses. He wrote this in his personal capacity.