How Can Blood Save Your Life? (1990)
How Can Blood Save Your Life?
Source: jw.org
Contents
Title Page/Publishers’ Page
Contents
Foreword
Blood—Vital for Life
Blood Transfusions—How Safe?
Quality Alternatives to Transfusion
You Have the Right to Choose
The Blood That Really Saves Lives
Jehovah’s Witnesses—The Surgical/Ethical Challenge
Blood: Whose Choice and Whose Conscience?
Title Page/Publishers’ Page
Title Page/Publishers’ Page
How Can Blood Save Your Life?
[Picture Credit Line on page 2]
Cover Photo: Camerique/H. Armstrong Roberts
Contents
Contents
3 Blood—Vital for Life
7 Blood Transfusions—How Safe?
13 Quality Alternatives to Transfusion
17 You Have the Right to Choose
22 The Blood That Really Saves Lives
Foreword
Foreword
EACH day people face ethical decisions about health: organ transplants, abortion, the “right to die.” Hopefully, you will never face those problems.
Yet, there is one issue that demands your attention: How can blood be used to save life?
With good reason, many now ask, ‘How safe are blood transfusions?’ But this is more than a medical issue. It has made news involving Jehovah’s Witnesses. Have you wondered why these ethical people, who believe in good medicine, refuse to accept blood?
As you will see, the medical and moral aspects of using blood bear directly on how you can save your most valued possession: LIFE.
Blood—Vital for Life
Blood—Vital for Life
How can blood save your life? This no doubt is of interest to you because blood is linked to your life. Blood carries oxygen through your body, removes carbon dioxide, helps you adapt to temperature changes, and aids in your fight against disease.
The linkage of life to blood was made long before William Harvey mapped the circulatory system in 1628. The basic ethics of major religions focus on a Life-Giver, who expressed himself about life and about blood. A Judeo-Christian lawyer said of him: “He himself gives to all persons life and breath and all things. For by him we have life and move and exist.”a
People who believe in such a Life-Giver trust that his directions are for our lasting good. A Hebrew prophet described him as “the One teaching you to benefit yourself, the One causing you to tread in the way in which you should walk.”
That assurance, at Isaiah 48:17, is part of the Bible, a book respected for ethical values that can benefit all of us. What does it say about human use of blood? Does it show how lives can be saved with blood? Actually, the Bible shows clearly that blood is more than a complex biologic fluid. It mentions blood over 400 times, and some of these references involve the saving of life.
In one early reference, the Creator declared: “Everything that lives and moves will be food for you. . . . But you must not eat meat that has its lifeblood still in it.” He added: “For your lifeblood I will surely demand an accounting,” and he then condemned murder. (Genesis 9:3-6, New International Version) He said that to Noah, a common ancestor highly esteemed by Jews, Muslims, and Christians. All humanity was thus notified that in the Creator’s view, blood stands for life. This was more than a dietary regulation. Clearly a moral principle was involved. Human blood has great significance and should not be misused. The Creator later added details from which we can easily see the moral issues that he links to lifeblood.
He again referred to blood when he gave the Law code to ancient Israel. While many people respect the wisdom and ethics in that code, few are aware of its serious laws on blood. For instance: “If anyone of the house of Israel or of the strangers who reside among them partakes of any blood, I will set My face against the person who partakes of the blood, and I will cut him off from among his kin. For the life of the flesh is in the blood.” (Leviticus 17:10, 11, Tanakh) God then explained what a hunter was to do with a dead animal: “He shall pour out its blood and cover it with earth. . . . You shall not partake of the blood of any flesh, for the life of all flesh is its blood. Anyone who partakes of it shall be cut off.”—Leviticus 17:13, 14, Ta.
Scientists now know that the Jewish Law code promoted good health. It required, for example, that excrement be deposited outside the camp and covered and that people not eat meat that carried a high risk of disease. (Leviticus 11:4-8, 13; 17:15; Deuteronomy 23:12, 13) While the law about blood had health aspects, much more was involved. Blood had a symbolic meaning. It stood for life provided by the Creator. By treating blood as special, the people showed dependence on him for life. Yes, the chief reason why they were not to take in blood was, not that it was unhealthy, but that it had special meaning to God.
The Law repeatedly stated the Creator’s ban on taking in blood to sustain life. “You must not eat the blood; pour it out on the ground like water. Do not eat it, so that it may go well with you and your children after you, because you will be doing what is right.”—Deuteronomy 12:23-25, NIV; De 15:23; Leviticus 7:26, 27; Ezekiel 33:25.b
Contrary to how some today reason, God’s law on blood was not to be ignored just because an emergency arose. During a wartime crisis, some Israelite soldiers killed animals and “fell to eating along with the blood.” In view of the emergency, was it permissible for them to sustain their lives with blood? No. Their commander pointed out that their course was still a grave wrong. (1 Samuel 14:31-35) Hence, precious as life is, our Life-Giver never said that his standards could be ignored in an emergency.
BLOOD AND TRUE CHRISTIANS
Where does Christianity stand on the question of saving human life with blood?
Jesus was a man of integrity, which is why he is so highly regarded. He knew that the Creator said that taking in blood was wrong and that this law was binding. Hence, there is good reason to believe that Jesus would uphold the law about blood even if he was under pressure to do otherwise. Jesus “did no wrong, [and] no treachery was found on his lips.” (1 Peter 2:22, Knox) He thus set a pattern for his followers, including a pattern of respect for life and blood. (We will later consider how Jesus’ own blood is involved in this vital matter affecting your life.)
Note what happened when, years after Jesus’ death, a question arose about whether someone becoming a Christian had to keep all of Israel’s laws. This was discussed at a council of the Christian governing body, which included the apostles. Jesus’ half brother James referred to writings containing the commands about blood stated to Noah and to the nation of Israel. Would such be binding on Christians?—Acts 15:1-21.
That council sent their decision to all congregations: Christians need not keep the code given to Moses, but it is “necessary” for them to “keep abstaining from things sacrificed to idols and from blood and from things strangled [unbled meat] and from fornication.” (Acts 15:22-29) The apostles were not presenting a mere ritual or dietary ordinance. The decree set out fundamental ethical norms, which early Christians complied with. About a decade later they acknowledged that they should still “keep themselves from what is sacrificed to idols as well as from blood . . . and from fornication.”—Acts 21:25.
You know that millions of people attend churches. Most of them would probably agree that Christian ethics involve not giving worship to idols and not sharing in gross immorality. However, it is worth our noting that the apostles put avoiding blood on the same high moral level as avoiding those wrongs. Their decree concluded: “If you carefully keep yourselves from these things, you will prosper. Good health to you!”—Acts 15:29.
The apostolic decree was long understood as binding. Eusebius tells of a young woman near the end of the second century who, before dying under torture, made the point that Christians “are not allowed to eat the blood even of irrational animals.” She was not exercising a right to die. She wanted to live, but she would not compromise her principles. Do you not respect those who put principle above personal gain?
Scientist Joseph Priestley concluded: “The prohibition to eat blood, given to Noah, seems to be obligatory on all his posterity . . . If we interpret [the] prohibition of the apostles by the practice of the primitive Christians, who can hardly be supposed not to have rightly understood the nature and extent of it, we cannot but conclude, that it was intended to be absolute and perpetual; for blood was not eaten by any Christians for many centuries.”
WHAT OF USING BLOOD AS MEDICINE?
Would the Biblical prohibition on blood cover medical uses, such as transfusions, which certainly were not known in the days of Noah, Moses, or the apostles?
While modern therapy employing blood did not exist back then, medicinal use of blood is not modern. For some 2,000 years, in Egypt and elsewhere, human “blood was regarded as the sovereign remedy for leprosy.” A physician revealed the therapy given to King Esar-haddon’s son when the nation of Assyria was on the leading edge of technology: “[The prince] is doing much better; the king, my lord, can be happy. Starting with the 22nd day I give (him) blood to drink, he will drink (it) for 3 days. For 3 more days I shall give (him blood) for internal application.” Esar-haddon had dealings with the Israelites. Yet, because the Israelites had God’s Law, they would never drink blood as medicine.
Was blood used as medicine in Roman times? The naturalist Pliny (a contemporary of the apostles) and the second-century physician Aretaeus report that human blood was a treatment for epilepsy. Tertullian later wrote: “Consider those who with greedy thirst, at a show in the arena, take the fresh blood of wicked criminals . . . and carry it off to heal their epilepsy.” He contrasted them with Christians, who “do not even have the blood of animals at [their] meals . . . At the trials of Christians you offer them sausages filled with blood. You are convinced, of course, that [it] is unlawful for them.” So, early Christians would risk death rather than take in blood.
“Blood in its more everyday form did not . . . go out of fashion as an ingredient in medicine and magic,” reports the book Flesh and Blood. “In 1483, for example, Louis XI of France was dying. ‘Every day he grew worse, and the medicines profited him nothing, though of a strange character; for he vehemently hoped to recover by the human blood which he took and swallowed from certain children.’”
What of transfusing blood? Experiments with this began near the start of the 16th century. Thomas Bartholin (1616-80), professor of anatomy at the University of Copenhagen, objected: ‘Those who drag in the use of human blood for internal remedies of diseases appear to misuse it and to sin gravely. Cannibals are condemned. Why do we not abhor those who stain their gullet with human blood? Similar is the receiving of alien blood from a cut vein, either through the mouth or by instruments of transfusion. The authors of this operation are held in terror by the divine law, by which the eating of blood is prohibited.’
Hence, thinking people in past centuries realized that the Biblical law applied to taking blood into the veins just as it did to taking it into the mouth. Bartholin concluded: “Either manner of taking [blood] accords with one and the same purpose, that by this blood a sick body be nourished or restored.”
This overview may help you to understand the nonnegotiable religious stand that Jehovah’s Witnesses take. They highly value life, and they seek good medical care. But they are determined not to violate God’s standard, which has been consistent: Those who respect life as a gift from the Creator do not try to sustain life by taking in blood.
Still, for years claims have been made that blood saves lives. Doctors can relate cases in which someone had acute blood loss but was transfused and then improved rapidly. So you may wonder, ‘How wise or unwise is this medically?’ Medical evidence is offered to support blood therapy. Thus, you owe it to yourself to get the facts in order to make an informed choice about blood.
[Footnotes]
Paul, at Acts 17:25, 28, New World Translation of the Holy Scriptures.
Similar prohibitions were later written in the Qurʼān.
[Box on page 4]
“The precepts hereby set down in a precise and methodical manner [in Acts 15] are qualified as indispensable, giving the strongest proof that in the apostles’ minds this was not a temporary arrangement, or a provisional measure.”—Professor Édouard Reuss, University of Strasbourg.
[Box/Picture on page 5]
Martin Luther pointed to the implications of the apostolic decree: “Now if we want to have a church that conforms to this council, . . . we must teach and insist that henceforth no prince, lord, burgher, or peasant eat geese, doe, stag, or pork cooked in blood . . . And burghers and peasants must abstain especially from red sausage and blood sausage.”
[Credit Line]
Woodcut by Lucas Cranach
[Box on page 6]
“God and men view things in very different lights. What appears important in our eye is very often of no account in the estimation of infinite wisdom; and what appears trifling to us is often of very great importance with God. It was so from the beginning.”—“An Enquiry Into the Lawfulness of Eating Blood,” Alexander Pirie, 1787.
[Picture on page 3]
Medicine and the Artist by Carl Zigrosser/Dover Publications
[Picture on page 4]
At a historic council, the Christian governing body confirmed that God’s law on blood is still binding
[Picture on page 7]
Whatever the consequences, the early Christians refused to violate God’s law on blood
[Credit Line]
Painting by Gérôme, 1883, courtesy of Walters Art Gallery, Baltimore
Blood Transfusions—How Safe?
Blood Transfusions—How Safe?
Before submitting to any serious medical procedure, a thinking person will learn the possible benefits and the risks. What about blood transfusions? They are now a prime tool in medicine. Many physicians who are genuinely interested in their patients may have little hesitation about giving blood. It has been called the gift of life.
Millions have donated blood or have accepted it. For 1986-87 Canada had 1.3 million donors in a population of 25 million. “[In] the most recent year for which figures are available, between 12 million and 14 million units of blood were used in transfusions in the United States alone.”—The New York Times, February 18, 1990.
“Blood has always enjoyed a ‘magical’ quality,” notes Dr. Louise J. Keating. “For its first 46 years, the blood supply was perceived as being safer than it actually was by both physicians and the public.” (Cleveland Clinic Journal of Medicine, May 1989) What was the situation then, and what is it now?
Even 30 years ago, pathologists and blood-bank personnel were advised: “Blood is dynamite! It can do a great deal of good or a great deal of harm. The mortality from blood transfusion equals that from ether anesthesia or appendectomy. There is said to be approximately one death in 1,000 to 3,000 or possibly 5,000 transfusions. In the London area there has been reported one death for every 13,000 bottles of blood transfused.”—New York State Journal of Medicine, January 15, 1960.
Have the dangers since been eliminated so that transfusions are now safe? Frankly, each year hundreds of thousands have adverse reactions to blood, and many die. In view of the preceding comments, what may come to your mind are blood-borne diseases. Before examining this aspect, consider some risks that are less well-known.
BLOOD AND YOUR IMMUNITY
Early in the 20th century, scientists deepened man’s understanding of the marvelous complexity of blood. They learned that there are different blood types. Matching a donor’s blood and a patient’s blood is critical in transfusions. If someone with type A blood receives type B, he may have a severe hemolytic reaction. This can destroy many of his red cells and quickly kill him. While blood-typing and cross matching are now routine, errors do occur. Every year people die of hemolytic reactions.
The facts show that the issue of incompatibility goes far beyond the relatively few blood types that hospitals seek to match. Why? Well, in his article “Blood Transfusion: Uses, Abuses, and Hazards,” Dr. Douglas H. Posey, Jr., writes: “Nearly 30 years ago Sampson described blood transfusion as a relatively dangerous procedure . . . [Since then] at least 400 additional red cell antigens have been identified and characterized. There is no doubt the number will continue to increase because the red cell membrane is enormously complex.”—Journal of the National Medical Association, July 1989.
Scientists are now studying the effect of transfused blood on the body’s defense, or immune, system. What might that mean for you or for a relative who needs surgery?
When doctors transplant a heart, a liver, or another organ, the recipient’s immune system may sense the foreign tissue and reject it. Yet, a transfusion is a tissue transplant. Even blood that has been “properly” cross matched can suppress the immune system. At a conference of pathologists, the point was made that hundreds of medical papers “have linked blood transfusions to immunologic responses.”—“Case Builds Against Transfusions,” Medical World News, December 11, 1989.
A prime task of your immune system is detecting and destroying malignant (cancer) cells. Could suppressed immunity lead to cancer and death? Note two reports.
The journal Cancer (February 15, 1987) gave the results of a study done in the Netherlands: “In the patients with colon cancer, a significant adverse effect of transfusion on long-term survival was seen. In this group there was a cumulative 5-year overall survival of 48% for the transfused and 74% for the nontransfused patients.” Physicians at the University of Southern California followed up on a hundred patients who underwent cancer surgery. “The recurrence rate for all cancers of the larynx was 14% for those who did not receive blood and 65% for those who did. For cancer of the oral cavity, pharynx, and nose or sinus, the recurrence rate was 31% without transfusions and 71% with transfusions.”—Annals of Otology, Rhinology & Laryngology, March 1989.
What do such studies suggest regarding transfusions? In his article “Blood Transfusions and Surgery for Cancer,” Dr. John S. Spratt concluded: “The cancer surgeon may need to become a bloodless surgeon.”—The American Journal of Surgery, September 1986.
Another primary task of your immune system is to defend against infection. So it is understandable that some studies show that patients receiving blood are more prone to infection. Dr. P. I. Tartter did a study of colorectal surgery. Of patients given transfusions, 25 percent developed infections, compared with 4 percent of those who received no transfusions. He reports: “Blood transfusions were associated with infectious complications when given pre-, intra-, or postoperatively . . . The risk of postoperative infection increased progressively with the number of units of blood given.” (The British Journal of Surgery, August 1988) Those attending a 1989 meeting of the American Association of Blood Banks learned this: Whereas 23 percent of those who received donor blood during hip-replacement surgery developed infections, those given no blood had no infections at all.
Dr. John A. Collins wrote concerning this effect of blood transfusions: “It would be ironic indeed if a ‘treatment’ which has very little evidence of accomplishing anything worthwhile should subsequently be found to intensify one of the main problems faced by such patients.”—World Journal of Surgery, February 1987.
DISEASE FREE OR FRAUGHT WITH DANGER?
Blood-borne disease worries conscientious physicians and many patients. Which disease? Frankly, you cannot limit it just to one; there are indeed many.
After discussing the more well-known diseases, Techniques of Blood Transfusion (1982) addresses “other transfusion-associated infectious diseases,” such as syphilis, cytomegalovirus infection, and malaria. It then says: “Several other diseases have also been reported to be transmitted by blood transfusion, including herpes virus infections, infectious mononucleosis (Epstein-Barr virus), toxoplasmosis, trypanosomiasis [African sleeping sickness and Chagas’ disease], leishmaniasis, brucellosis [undulant fever], typhus, filariasis, measles, salmonellosis, and Colorado tick fever.”
Actually, the list of such diseases is growing. You may have read headlines such as “Lyme Disease From a Transfusion? It’s Unlikely, but Experts Are Wary.” How safe is blood from someone testing positive for Lyme disease? A panel of health officials were asked if they would accept such blood. “All of them answered no, although no one recommended discarding blood from such donors.” How should the public feel about banked blood that experts themselves would not accept?—The New York Times, July 18, 1989.
A second reason for concern is that blood collected in one land where a certain disease abounds may be used far away, where neither the public nor the physicians are alert to the danger. With today’s increase in travel, including refugees and immigrants, the risk is growing that a strange disease may be in a blood product.
Moreover, a specialist in infectious diseases warned: “The blood supply may have to be screened to prevent transmission of several disorders that were not previously considered infectious, including leukemia, lymphoma, and dementia [or Alzheimer’s disease].”—Transfusion Medicine Reviews, January 1989.
Chilling as these risks are, others have created much wider fear.
THE AIDS PANDEMIC
“AIDS has changed forever the way doctors and patients think about blood. And that’s not a bad idea, said the doctors gathered at the National Institutes of Health for a conference on blood transfusion.”—Washington Post, July 5, 1988.
The AIDS (acquired immunodeficiency syndrome) pandemic has, with a vengeance, awakened people to the danger of acquiring infectious diseases from blood. Millions are now infected. It is spreading out of control. And its death rate is virtually 100 percent.
AIDS is caused by the human immunodeficiency virus (HIV), which can be spread by blood. The modern plague of AIDS came to light in 1981. The very next year, health experts learned that the virus could probably be passed on in blood products. It is now admitted that the blood industry was slow to respond, even after tests were available to identify blood containing HIV antibodies. Testing of donor blood finally began in 1985,a but even then it was not applied to blood products that were already on the shelf.
Thereafter the public was assured, ‘The blood supply is now safe.’ Later, however, it was revealed that there is a dangerous “window period” for AIDS. After a person is infected, it could be months before he produces detectable antibodies. Unaware that he harbors the virus, he might donate blood that would test negative. This has happened. People have developed AIDS after being transfused with such blood!
The picture got even grimmer. The New England Journal of Medicine (June 1, 1989) reported on “Silent HIV Infections.” It was established that people can carry the AIDS virus for years without its being detectable by current indirect tests. Some would like to minimize these as rare cases, but they prove “that the risk of AIDS transmission via blood and its components cannot be totally eliminated.” (Patient Care, November 30, 1989) The disturbing conclusion: A negative test cannot be read as a clean bill of health. How many will yet get AIDS from blood?
THE NEXT SHOE? OR SHOES?
Many apartment dwellers have heard the thump of one shoe hitting the floor above them; they may then get tense awaiting the second. In the blood dilemma, no one knows how many deadly shoes may still hit.
The AIDS virus was designated HIV, but some experts now call it HIV-1. Why? Because they found another virus of the AIDS type (HIV-2). It can cause AIDS symptoms and is widespread in some areas. Moreover, it “is not consistently detected by the AIDS tests now in use here,” reports The New York Times. (June 27, 1989) “The new findings . . . make it more difficult for blood banks to be sure a donation is safe.”
Or what of distant relatives to the AIDS virus? A presidential commission (U.S.A.) said that one such virus “is believed to be the cause of adult T-cell leukemia/lymphoma and a severe neurological disease.” This virus is already in the blood donor population and can be spread in blood. People have a right to wonder, ‘How effective is the blood-bank screening for such other viruses?’
Really, only time will tell how many blood-borne viruses are lurking in the blood supply. “The unknown may be more cause for concern than the known,” writes Dr. Harold T. Meryman. “Transmissible viruses with incubation times measured in many years will be difficult to associate with transfusions and even more difficult to detect. The HTLV group is surely only the first of these to surface.” (Transfusion Medicine Reviews, July 1989) “As if the AIDS epidemic were not misery enough, . . . a number of newly proposed or described risks of transfusion have drawn attention during the 1980’s. It does not require great imagination to predict that other serious viral diseases exist and are transmitted by homologous transfusions.”—Limiting Homologous Exposure: Alternative Strategies, 1989.
So many “shoes” have already dropped that the Centers for Disease Control recommends “universal precautions.” That is, ‘health-care workers should assume that all patients are infectious for HIV and other blood-borne pathogens.’ With good reason, health-care workers and members of the public are reassessing their view of blood.
[Footnotes]
We cannot assume that all blood is yet being tested. For example, it is reported that by the start of 1989, about 80 percent of Brazil’s blood banks were not under government control, nor were they testing for AIDS.
[Box on page 8]
“Approximately 1 in 100 transfusions are accompanied by fever, chills, or urticaria [hives]. . . . Approximately 1 in 6,000 red cell transfusions results in a hemolytic transfusion reaction. This is a severe immunologic reaction that may occur acutely or in a delayed fashion some days after the transfusion; it may result in acute [kidney] failure, shock, intravascular coagulation, and even death.”—National Institutes of Health (NIH) conference, 1988.
[Box on page 9]
Danish scientist Niels Jerne shared the 1984 Nobel Prize for Medicine. When asked why he refused a blood transfusion, he said: “A person’s blood is like his fingerprints—there are no two types of blood that are exactly alike.”
[Box on page 10]
BLOOD, RUINED LIVERS, AND . . .
“Ironically, blood-borne AIDS . . . has never been as great a threat as other diseases—hepatitis, for instance,” explained the Washington Post.
Yes, vast numbers have got very sick and have died from such hepatitis, which has no specific treatment. According to U.S.News & World Report (May 1, 1989), about 5 percent of those given blood in the United States get hepatitis—175,000 people a year. About half become chronic carriers, and at least 1 in 5 develop cirrhosis or cancer of the liver. It is estimated that 4,000 die. Imagine the headlines you would read if a jumbo jet crashed, killing all aboard. But 4,000 deaths amount to a full jumbo jet crashing every month!
Physicians had long known that a milder hepatitis (type A) was spread through unclean food or water. Then they saw that a more serious form was spreading through blood, and they had no way to screen blood for it. Eventually, brilliant scientists learned how to detect “footprints” of this virus (type B). By the early 1970’s, blood was being screened in some lands. The blood supply appeared safe and the future for blood bright! Or was it?
Before long it was clear that thousands who were given screened blood still developed hepatitis. Many, after debilitating illness, learned that their livers were ruined. But if the blood had been tested, why was this happening? The blood contained another form, called non-A, non-B hepatitis (NANB). For a decade it plagued transfusions—between 8 and 17 percent of those transfused in Israel, Italy, Japan, Spain, Sweden, and the United States contracted it.
Then came headlines such as “Mysterious Hepatitis Non-A, Non-B Virus Isolated at Last”; “Breaking a Fever in the Blood.” Again, the message was, ‘The elusive agent is found!’ In April 1989, the public was told that a test was available for NANB, now being called hepatitis C.
You might wonder if this relief is premature. In fact, Italian researchers have reported another hepatitis virus, a mutant, which might be responsible for a third of the cases. “Some authorities,” the Harvard Medical School Health Letter (November 1989) observed, “worry that A, B, C, and D are not the whole alphabet of hepatitis viruses; yet others may emerge.” The New York Times (February 13, 1990) stated: “Experts strongly suspect that other viruses can cause hepatitis; if discovered, they will be designated hepatitis E and so on.”
Are blood banks faced with more long searches for tests to make blood safe? Citing the problem of cost, a director of the American Red Cross made this disturbing comment: “We can’t just keep adding test after test for each infectious agent that might be spread.”—Medical World News, May 8, 1989.
Even the test for hepatitis B is fallible; many still contract it from blood. Moreover, will people be satisfied with the announced test for hepatitis C? The Journal of the American Medical Association (January 5, 1990) showed that a year can pass before antibodies of the disease are detectable by the test. Meanwhile, people transfused with the blood may face ruined livers—and death.
[Box/Picture on page 11]
Chagas’ disease illustrates how blood carries disease to distant people. “The Medical Post” (January 16, 1990) reports that ‘10-12 million people in Latin America are chronically infected.’ It has been called “one of the most important transfusion hazards in South America.” An “assassin bug” bites a sleeping victim in the face, sucks blood, and defecates in the wound. The victim may carry Chagas’ disease for years (meanwhile possibly donating blood) before developing fatal heart complications.
Why should that concern people on distant continents? In “The New York Times” (May 23, 1989), Dr. L. K. Altman reported on patients with posttransfusion Chagas’ disease, one of whom died. Altman wrote: “Additional cases may have gone undetected because [doctors here] are not familiar with Chagas’ disease, nor do they realize that it could be spread by transfusions.” Yes, blood can be a vehicle by which diseases travel widely.
[Box on page 12]
Dr. Knud Lund-Olesen wrote: “Since . . . some persons in high-risk groups volunteer as donors because they are then automatically tested for AIDS, I feel that there is reason to be reluctant about accepting blood transfusion. Jehovah’s Witnesses have refused this for many years. Did they look into the future?”—“Ugeskrift for Læger” (Doctors’ Weekly), September 26, 1988.
[Picture on page 9]
The pope survived being shot. After leaving the hospital, he was taken back for two months, “suffering a great deal.” Why? A potentially fatal cytomegalovirus infection from the blood he received
[Credit Line]
UPI/Bettmann Newsphotos
[Picture on page 12]
AIDS virus
[Credit Line]
CDC, Atlanta, Ga.
Quality Alternatives to Transfusion
Quality Alternatives to Transfusion
You might feel, ‘Transfusions are hazardous, but are there any high-quality alternatives?’ A good question, and note the word “quality.”
Everyone, including Jehovah’s Witnesses, wants effective medical care of high quality. Dr. Grant E. Steffen noted two key elements: “Quality medical care is the capacity of the elements of that care to achieve legitimate medical and nonmedical goals.” (The Journal of the American Medical Association, July 1, 1988) “Nonmedical goals” would include not violating the ethics or Bible-based conscience of the patient.—Acts 15:28, 29.
Are there legitimate and effective ways to manage serious medical problems without using blood? Happily, the answer is yes.
Though most surgeons have claimed that they gave blood only when absolutely necessary, after the AIDS epidemic arose their use of blood dropped rapidly. An editorial in Mayo Clinic Proceedings (September 1988) said that “one of the few benefits of the epidemic” was that it “resulted in various strategies on the part of patients and physicians to avoid blood transfusion.” A blood-bank official explains: “What has changed is the intensity of the message, the receptivity of clinicians to the message (because of an increased perception of risks), and the demand for consideration of alternatives.”—Transfusion Medicine Reviews, October 1989.
Note, there are alternatives! This becomes understandable when we review why blood is transfused.
The hemoglobin in the red cells carries oxygen needed for good health and life. So if a person has lost a lot of blood, it might seem logical just to replace it. Normally you have about 14 or 15 grams of hemoglobin in every 100 cubic centimeters of blood. (Another measure of the concentration is hematocrit, which is commonly about 45 percent.) The accepted “rule” was to transfuse a patient before surgery if his hemoglobin was below 10 (or 30 percent hematocrit). The Swiss journal Vox Sanguinis (March 1987) reported that “65% of [anesthesiologists] required patients to have a preoperative hemoglobin of 10 gm/dl for elective surgery.”
But at a 1988 conference on blood transfusion, Professor Howard L. Zauder asked, “How Did We Get a ‘Magic Number’?” He stated clearly: “The etiology of the requirement that a patient have 10 grams of hemoglobin (Hgb) prior to receiving an anesthetic is cloaked in tradition, shrouded in obscurity, and unsubstantiated by clinical or experimental evidence.” Imagine the many thousands of patients whose transfusions were triggered by an ‘obscure, unsubstantiated’ requirement!
Some might wonder, ‘Why is a hemoglobin level of 14 normal if you can get by on much less?’ Well, you thus have considerable reserve oxygen-carrying capacity so that you are ready for exercise or heavy work. Studies of anemic patients even reveal that “it is difficult to detect a deficit in work capacity with hemoglobin concentrations as low as 7 g/dl. Others have found evidence of only moderately impaired function.”—Contemporary Transfusion Practice, 1987.
While adults accommodate a low hemoglobin level, what of children? Dr. James A. Stockman III says: “With few exceptions, infants born prematurely will experience a decline in hemoglobin in the first one to three months . . . The indications for transfusion in the nursery setting are not well defined. Indeed, many infants seem to tolerate remarkably low levels of hemoglobin concentration with no apparent clinical difficulties.”—Pediatric Clinics of North America, February 1986.
Such information does not mean that nothing need be done when a person loses a lot of blood in an accident or during surgery. If the loss is rapid and great, a person’s blood pressure drops, and he may go into shock. What is primarily needed is that the bleeding be stopped and the volume in his system be restored. That will serve to prevent shock and keep the remaining red cells and other components in circulation.
Volume replacement can be accomplished without using whole blood or blood plasma.a Various nonblood fluids are effective volume expanders. The simplest is saline (salt) solution, which is both inexpensive and compatible with our blood. There are also fluids with special properties, such as dextran, Haemaccel, and lactated Ringer’s solution. Hetastarch (HES) is a newer volume expander, and “it can be safely recommended for those [burn] patients who object to blood products.” (Journal of Burn Care & Rehabilitation, January/February 1989) Such fluids have definite advantages. “Crystalloid solutions [such as normal saline and lactated Ringer’s solution], Dextran and HES are relatively nontoxic and inexpensive, readily available, can be stored at room temperature, require no compatibility testing and are free of the risk of transfusion-transmitted disease.”—Blood Transfusion Therapy—A Physician’s Handbook, 1989.
You may ask, though, ‘Why do nonblood replacement fluids work well, since I need red cells to get oxygen throughout my body?’ As mentioned, you have oxygen-carrying reserves. If you lose blood, marvelous compensatory mechanisms start up. Your heart pumps more blood with each beat. Since the lost blood was replaced with a suitable fluid, the now diluted blood flows more easily, even in the small vessels. As a result of chemical changes, more oxygen is released to the tissues. These adaptations are so effective that if only half of your red cells remain, oxygen delivery may be about 75 percent of normal. A patient at rest uses only 25 percent of the oxygen available in his blood. And most general anesthetics reduce the body’s need for oxygen.
HOW CAN DOCTORS HELP?
Skilled physicians can help one who has lost blood and so has fewer red cells. Once volume is restored, doctors can administer oxygen at high concentration. This makes more of it available for the body and has often had remarkable results. British doctors used this with a woman who had lost so much blood that “her haemoglobin fell to 1.8 g/dlitre. She was successfully treated . . . [with] high inspired oxygen concentrations and transfusions of large volumes of gelatin solution [Haemaccel].” (Anaesthesia, January 1987) The report also says that others with acute blood loss have been successfully treated in hyperbaric oxygen chambers.
Physicians can also help their patients to form more red cells. How? By giving them iron-containing preparations (into muscles or veins), which can aid the body in making red cells three to four times faster than normal. Recently another help has become available. Your kidneys produce a hormone called erythropoietin (EPO), which stimulates bone marrow to form red cells. Now synthetic (recombinant) EPO is available. Doctors may give this to some anemic patients, thus helping them to form replacement red cells very quickly.
Even during surgery, skilled and conscientious surgeons and anesthesiologists can help by employing advanced blood-conservation methods. Meticulous operative technique, such as electrocautery to minimize bleeding, cannot be overstressed. Sometimes blood flowing into a wound can be aspirated, filtered, and directed back into circulation.b
Patients on a heart-lung machine primed with a nonblood fluid may benefit from the resulting hemodilution, fewer red cells being lost.
And there are other ways to help. Cooling a patient to lessen his oxygen needs during surgery. Hypotensive anesthesia. Therapy to improve coagulation. Desmopressin (DDAVP) to shorten bleeding time. Laser “scalpels.” You will see the list grow as physicians and concerned patients seek to avoid blood transfusions. We hope that you never lose a great amount of blood. But if you did, it is very likely that skilled doctors could manage your care without using blood transfusions, which have so many risks.
SURGERY, YES—BUT WITHOUT TRANSFUSIONS
Many people today will not accept blood. For health reasons, they are requesting what Witnesses seek primarily on religious grounds: quality medical care employing alternative nonblood management. As we have noted, major surgery is still possible. If you have any lingering doubts, some other evidence from medical literature may dispel them.
The article “Quadruple Major Joint Replacement in Member of Jehovah’s Witnesses” (Orthopaedic Review, August 1986) told of an anemic patient with “advanced destruction in both knees and hips.” Iron dextran was employed before and after the staged surgery, which was successful. The British Journal of Anaesthesia (1982) reported on a 52-year-old Witness with a hemoglobin level under 10. With the use of hypotensive anesthesia to minimize blood loss, she had a total hip and shoulder replacement. A surgical team at the University of Arkansas (U.S.A.) also used this method in a hundred hip replacements on Witnesses, and all the patients recovered. The professor heading the department comments: “What we have learned from those (Witness) patients, we now apply to all our patients that we do total hips on.”
The conscience of some Witnesses permits them to accept organ transplants if done without blood. A report of 13 kidney transplants concluded: “The overall results suggest that renal transplantation can be safely and efficaciously applied to most Jehovah’s Witnesses.” (Transplantation, June 1988) Likewise, refusal of blood has not stood in the way even of successful heart transplants.
‘What about bloodless surgery of other types?’ you may wonder. Medical Hotline (April/May 1983) told of surgery on “Jehovah’s Witnesses who underwent major gynecological and obstetric operations [at Wayne State University, U.S.A.] without blood transfusions.” The newsletter reported: “There were no more deaths and complications than in women who had undergone similar operations with blood transfusions.” The newsletter then commented: “The results of this study may warrant a fresh look at the use of blood for all women undergoing obstetric and gynecological operations.”
At the hospital of Göttingen University (Germany), 30 patients who declined blood underwent general surgery. “No complications arose that could not also have arisen with patients who accept blood transfusions. . . . That recourse to a transfusion is not possible should not be overrated, and thus should not lead to refraining from an operation that is necessary and surgically justifiable.”—Risiko in der Chirurgie, 1987.
Even brain surgery without using blood has been done on numerous adults and children, for instance, at New York University Medical Center. In 1989 Dr. Joseph Ransohoff, head of neurosurgery, wrote: “It is very clear that in most instances avoidance of blood products can be achieved with minimal risk in patients who have religious tenets against the use of these products, particularly if surgery can be carried out expeditiously and with a relatively short operative period. Of considerable interest is the fact that I often forget that the patient is a Witness until at the time of discharge when they thank me for having respected their religious beliefs.”
Finally, can intricate heart and vascular surgery without blood be performed on adults and children? Dr. Denton A. Cooley was a pioneer in doing just that. As you can see in the medical article reprinted in the Appendix, on pages 27-9, based on an earlier analysis, Dr. Cooley’s conclusion was “that the risk of surgery in patients of the Jehovah’s Witness group has not been substantially higher than for others.” Now, after performing 1,106 of these operations, he writes: “In every instance my agreement or contract with the patient is maintained,” that is, to use no blood.
Surgeons have observed that good attitude is another factor with Jehovah’s Witnesses. “The attitude of these patients has been exemplary,” wrote Dr. Cooley in October 1989. “They do not have the fear of complications or even death that most patients have. They have a deep and abiding faith in their belief and in their God.”
This does not mean that they assert a right to die. They actively pursue quality care because they want to get well. They are convinced that obeying God’s law on blood is wise, which view has a positive influence in nonblood surgery.
Professor Dr. V. Schlosser, of the surgical hospital at the University of Freiburg (Germany), noted: “Among this group of patients, the incidence of bleeding during the perioperative period was not higher; the complications were, if anything, fewer. The special view of illness, typical of Jehovah’s Witnesses, had a positive influence in the perioperative process.”—Herz Kreislauf, August 1987.
[Footnotes]
Witnesses do not accept transfusions of whole blood, red cells, white cells, platelets, or blood plasma. As to minor fractions, such as immune globulin, see The Watchtower of June 1, 1990, pages 30-1.
The Watchtower of March 1, 1989, pages 30-1, considers Bible principles that bear on methods of blood salvage and on blood-circulating (extracorporeal) equipment.
[Box on page 13]
“We must conclude that currently there are many patients receiving blood components who have no chance for a benefit from transfusion (the blood is not needed) and yet still have a significant risk of undesired effect. No physician would knowingly expose a patient to a therapy that cannot help but might hurt, but that is exactly what occurs when blood is transfused unnecessarily.”—“Transfusion-Transmitted Viral Diseases,” 1987.
[Box on page 14]
“Some authors have stated that hemoglobin values as low as 2 to 2.5 gm./100ml. may be acceptable. . . . A healthy person may tolerate a 50 percent loss of red blood cell mass and be almost entirely asymptomatic if blood loss occurs over a period of time.”—“Techniques of Blood Transfusion,” 1982.
[Box on page 15]
“Older concepts about oxygen transport to tissues, wound healing, and ‘nutritional value’ of blood are being abandoned. Experience with patients who are Jehovah’s Witnesses demonstrates that severe anemia is well tolerated.”—“The Annals of Thoracic Surgery,” March 1989.
[Box on page 16]
Little children too? “Forty-eight pediatric open heart surgical procedures were performed with bloodless techniques regardless of surgical complexity.” The children were as small as 10.3 pounds (4.7 kg). “Because of consistent success in Jehovah’s Witnesses and the fact that blood transfusion carries a risk of serious complications, we are currently performing most of our pediatric cardiac operations without transfusion.”—“Circulation,” September 1984.
[Picture on page 15]
The heart-lung machine has been a great help in heart surgery on patients who do not want blood
You Have the Right to Choose
You Have the Right to Choose
A current medical approach (called risk/benefit analysis) is making it easier for doctors and patients to cooperate in avoiding blood therapy. Doctors weigh factors such as the risks of a certain drug or surgery and the probable benefits. Patients too can share in such an analysis.
Let us use one example that people in many places can relate to—chronic tonsillitis. If you had this problem, likely you would go to a doctor. In fact, you might consult two, since health experts often recommend getting a second opinion. One might recommend surgery. He outlines what that means: length of hospital stay, amount of pain, and cost. As to risks, he says that severe bleeding is not common and death from such an operation is very rare. But the doctor giving a second opinion urges you to try antibiotic therapy. He explains the type of drug, likelihood of success, and expense. As to risk, he says that very few patients have life-threatening reactions to the drug.
Each competent physician likely considered risks and benefits, but now you have to weigh the risks and possible benefits, as well as other factors that you best know. (You are in the best position to consider such aspects as your emotional or spiritual strength, family finances, effect on the family, and your own ethics.) Then you make a choice. Possibly you give informed consent for one therapy but decline the other.
This would also be so if it was your child that had the chronic tonsillitis. The risks, benefits, and therapies would be outlined for you, the loving parents who are most directly affected and who will be responsible to cope with the results. After considering all aspects, you can make an informed choice on this matter involving your child’s health and even his or her life. Perhaps you consent to the surgery, with its risks. Other parents might choose the antibiotics, with their risks. As physicians differ in their advice, so patients or parents differ as to what they feel is best. Such is an understood feature of making informed (risk/benefit) choices.
What about use of blood? No one who objectively examines the facts can deny that blood transfusions involve great risk. Dr. Charles Huggins, who is the director of transfusion service at the large Massachusetts General Hospital, made this very clear: “Blood has never been safer. But it must be considered unavoidably non-safe. It is the most dangerous substance we use in medicine.”—The Boston Globe Magazine, February 4, 1990.
With good reason, medical personnel have been advised: “It is necessary to reevaluate as well the risk part of the benefit/risk relationship for blood transfusion and to seek alternatives.” (Italics ours.)—Perioperative Red Cell Transfusion, National Institutes of Health conference, June 27-29, 1988.
Physicians may disagree as to the benefits or risks in using blood. One may give many transfusions and be convinced that they are worth the risk. Another may feel the risks are unjustified, for he has had good results with nonblood management. Ultimately, however, you, the patient or the parent, must decide. Why you? Because your (or your child’s) body, life, ethics, and profoundly important relationship with God are involved.
YOUR RIGHT IS RECOGNIZED
In many places today, the patient has an inviolable right to decide what treatment he will accept. “The law of informed consent has been based on two premises: first, that a patient has the right to receive sufficient information to make an informed choice about the treatment recommended; and second, that the patient may choose to accept or to decline the physician’s recommendation. . . . Unless patients are viewed as having the right to say no, as well as yes, and even yes with conditions, much of the rationale for informed consent evaporates.”—Informed Consent—Legal Theory and Clinical Practice, 1987.a
Some patients have encountered resistance when they have tried to exercise their right. It might have been from a friend having strong feelings about a tonsillectomy or about antibiotics. Or a physician might have been convinced of the rightness of his advice. A hospital official might even have disagreed, based on legal or financial interests.
“Many orthopaedists elect not to operate on [Witness] patients,” says Dr. Carl L. Nelson. “It is our belief that the patient has the right to refuse any type of medical therapy. If it is technically possible to provide surgery safely while excluding a particular treatment, such as transfusion, then it should exist as an option.”—The Journal of Bone and Joint Surgery, March 1986.
A considerate patient will not pressure a physician to use a therapy at which the doctor is unskilled. As Dr. Nelson noted, though, many dedicated physicians can accommodate the patient’s beliefs. A German official advised: “The doctor cannot refuse to render aid . . . reasoning that with a Jehovah’s Witness not all medical alternatives are at his disposal. He still has a duty to render assistance even when the avenues open to him are reduced.” (Der Frauenarzt, May-June 1983) Similarly, hospitals exist not merely to make money but to serve all people without discrimination. Catholic theologian Richard J. Devine states: “Although the hospital must make every other medical effort to preserve the patient’s life and health, it must ensure that medical care does not violate [his] conscience. Moreover, it must avoid all forms of coercion, from cajoling the patient to obtaining a court order to force a blood transfusion.”—Health Progress, June 1989.
RATHER THAN THE COURTS
Many people agree that a court is no place for personal medical issues. How would you feel if you chose antibiotic therapy but someone went to court to force a tonsillectomy on you? A doctor may want to provide what he thinks is the best care, but he has no duty to seek legal justification to trample on your basic rights. And since the Bible puts abstaining from blood on the same moral level as avoiding fornication, to force blood on a Christian would be the equivalent of forcible sex—rape.—Acts 15:28, 29.
Yet, Informed Consent for Blood Transfusion (1989) reports that some courts are so distressed when a patient is willing to accept a certain risk because of his religious rights “that they make up some legal exceptions—legal fictions, if you will—to allow a transfusion to occur.” They might try to excuse it by saying that a pregnancy is involved or that there are children to be supported. “Those are legal fictions,” the book says. “Competent adults are entitled to refuse treatment.”
Some who insist on transfusing blood ignore the fact that Witnesses do not decline all therapies. They reject just one therapy, which even experts say is fraught with danger. Usually a medical problem can be managed in a variety of ways. One has this risk, another that risk. Can a court or a doctor paternalistically know which risk is “in your best interests”? You are the one to judge that. Jehovah’s Witnesses are firm that they do not want someone else to decide for them; it is their personal responsibility before God.
If a court forced an abhorrent treatment on you, how might this affect your conscience and the vital element of your will to live? Dr. Konrad Drebinger wrote: “It would certainly be a misguided form of medical ambition that would lead one to force a patient to accept a given therapy, overruling his conscience, so as to treat him physically but dealing his psyche a mortal blow.”—Der Praktische Arzt, July 1978.
LOVING CARE FOR CHILDREN
Court cases regarding blood mainly involve children. On occasion, when loving parents have respectfully asked that nonblood management be used, some medical personnel have sought court backing to give blood. Of course, Christians agree with laws or court action to prevent child abuse or neglect. Perhaps you have read of cases in which some parent brutalized a child or denied it all medical care. How tragic! Clearly, the State can and should step in to protect a neglected child. Still, it is easy to see how very different it is when a caring parent requests high-quality nonblood medical therapy.
These court cases usually focus on a child in a hospital. How did the youngster get there, and why? Almost always the concerned parents brought their child to get quality care. Even as Jesus was interested in children, Christian parents care for their children. The Bible speaks of ‘a nursing mother cherishing her own children.’ Jehovah’s Witnesses have such deep love for their children.—1 Thessalonians 2:7; Matthew 7:11; 19:13-15.
Naturally, all parents make decisions affecting their children’s safety and life: Will the family use gas or oil to heat the home? Will they take a child on a long-distance drive? May he go swimming? Such matters involve risks, even life-and-death ones. But society recognizes parental discretion, so parents are granted the major voice in nearly all decisions affecting their children.
In 1979 the U.S. Supreme Court stated clearly: “The law’s concept of the family rests on a presumption that parents possess what a child lacks in maturity, experience, and capacity for judgment required for making life’s difficult decisions. . . . Simply because the decision of a parent [on a medical matter] involves risks does not automatically transfer the power to make that decision from the parents to some agency or officer of the state.”—Parham v. J.R.
That same year the New York Court of Appeals ruled: “The most significant factor in determining whether a child is being deprived of adequate medical care . . . is whether the parents have provided an acceptable course of medical treatment for their child in light of all the surrounding circumstances. This inquiry cannot be posed in terms of whether the parent has made a ‘right’ or a ‘wrong’ decision, for the present state of the practice of medicine, despite its vast advances, very seldom permits such definitive conclusions. Nor can a court assume the role of a surrogate parent.”—In re Hofbauer.
Recall the example of parents choosing between surgery and antibiotics. Each therapy would have its own risks. Loving parents are responsible to weigh risks, benefits, and other factors and then to make a choice. In this connection, Dr. Jon Samuels (Anesthesiology News, October 1989) suggested a review of Guides to the Judge in Medical Orders Affecting Children, which took this position:
“Medical knowledge is not sufficiently advanced to enable a physician to predict with reasonable certainty that his patient will live or die . . . If there is a choice of procedures—if, for example, the doctor recommends a procedure which has an 80 per cent chance of success but which the parents disapprove, and the parents have no objection to a procedure which has only a 40 per cent chance of success—the doctor must take the medically riskier but parentally unobjectionable course.”
In view of the many lethal hazards in medical use of blood that have surfaced and because there are effective alternative ways of management, might not avoiding blood even carry the lower risk?
Naturally, Christians weigh many factors if their child needs surgery. Every operation, with or without the use of blood, has risks. What surgeon gives guarantees? The parents may know that skilled physicians have had fine success with bloodless surgery on Witness children. So even if a physician or a hospital official has another preference, rather than cause a stressful and time-consuming legal battle, is it not reasonable for them to work with the loving parents? Or parents may transfer their child to another hospital where the staff is experienced in handling such cases and willing to do so. In fact, nonblood management will more likely be quality care, for it can help the family “to achieve legitimate medical and nonmedical goals,” as we noted earlier.
[Footnotes]
See the medical article “Blood: Whose Choice and Whose Conscience?” reprinted in the Appendix, on pages 30-1.
[Box on page 18]
RELIEVING LEGAL CONCERNS
You may wonder, ‘Why are some doctors and hospitals quick to get a court order to give blood?’ In some places a common reason is fear of liability.
There is no basis for such concern when Jehovah’s Witnesses choose nonblood management. A doctor at Albert Einstein College of Medicine (U.S.A.) writes: “Most [Witnesses] readily sign the American Medical Association form relieving physicians and hospitals of liability, and many carry a Medical Alert [card]. A properly signed and dated ‘Refusal to Accept Blood Products’ form is a contractual agreement and is legally binding.”—Anesthesiology News, October 1989.
Yes, Jehovah’s Witnesses cooperatively offer legal assurance that a physician or hospital will not incur liability in providing requested nonblood therapy. As recommended by medical experts, each Witness carries a Medical Document card. This is renewed annually and is signed by the person and by witnesses, often his next of kin.
In March 1990, the Supreme Court of Ontario, Canada, upheld a decision that commented approvingly on such a document: “The card is a written declaration of a valid position which the card carrier may legitimately take in imposing a written restriction on [the] contract with the doctor.” In Medicinsk Etik (1985), Professor Daniel Andersen wrote: “If there is an unambiguous written statement from the patient saying that he is one of Jehovah’s Witnesses and does not want blood under any circumstances, respect for the patient’s autonomy requires that this wish be respected, just as if it had been expressed orally.”
Witnesses will also sign hospital consent forms. One used at a hospital in Freiburg, Germany, has space where the physician can describe the information he gave the patient about the treatment. Then, above the signatures of the physician and the patient, this form adds: “As a member of the religious body of Jehovah’s Witnesses, I categorically refuse the use of foreign blood or blood components during my surgery. I am aware that the planned and needed procedure thus has a higher risk due to bleeding complications. After receiving thorough explanation particularly about that, I request that the needed surgery be performed without using foreign blood or blood components.”—Herz Kreislauf, August 1987.
…