Sezione Medicina

from Leadership Medica n. 3/2000

Talking about blood transfusions means dealing with a problem showing many and complex aspects. Our magazines have often dealt with this matter that in Italy - as often it happens when the concern is health - has started-off polemics and disagreement both in the political and scientific world. And if it were not enough the spread of the Hiv virus, also in other European countries, has arisen further perplexities about the reliability of the controls the blood recollected from donators must undergo.
It supervenes than another delicate aspect of the problem: the opposition to transfusions by the Jehovah's Witnesses. Some episodes have got to chronicles since magistracy has intervened for the lack of consent to blood transfusion over minor patients by parents that, precisely, professed themselves as Jehovah's Witnesses.
The core is just that: everybody knows that transfusions as a therapy free from risks need, to be carried out, the informed consent by the patient or by someone else in authority. 
Science, religion and right: a hard coexistence
It's well known that blood transfusion is required in operations when the survival of the patient is at risk. On consequence who opposes this kind of treatment often is deemed as an irresponsible that in compliance of principles, even worthy of respect, hazards the life of a relative; newspapers on their side emphasize the news, hence creating the monster.

The opinion about some behaviours concerns only the reader, while it's surely more interesting to understand the extent science is able to offer alternatives, and at the same time, which are the national and international laws ruling the informed consent matter, besides the eventual earlier achievements of the Italian jurisprudence.
First, as mentioned previously, a Ministerial Decree on 15/1/91 sets that the blood transfusion “ is a therapeutic practice involving risks...and therefore requires the receiver's informed consent”. 
Art. 1 of the “Public Services Chart” - contained in the Premier Decree 19/5/1999 - asserts furthermore: “patients have the right to be assisted and cured with care and attention in respect of the human dignity and his own philosophic and religious convictions”.
Passing to the international right, the European Council Convention (Strasbourg, November 19th 1996), sets (art. 5) that “a health treatment can be administered only if the person gives his own free and aware consent” and furthermore that “the interested person can, at any moment, withdraw freely his own consent”.
Dulcis in fundo, the Medical Deontology Code, issued on October 1998 says (art. 32): “In any case, on documented refusal by full capable person, the physician must desist from following diagnostic or curative acts, not being consented any medical treatment against the will of the person”.
As regard to the role of relatives, a decision of the Court of Messina (Preliminary Investigation Magistracy Office, July 26th 1995) has sanctioned two basic principles:
1)It is not responsible of wilful murder the physician omitting a high-risk chirurgical operation, conjecturing a disagreement expressed by the same patient or by persons representing him in the case of incapability of the patient.
2)It is not responsible of wilful murder the relative denying a high-risk chirurgical operation to be carried out to a patient in incapability condition.
Which is the range of intervention of the physician?
Till some years ago it prevailed among jurists dealing with bioethics, the trend to put the tutelage of human life over anything else. In other words the “informed consent” was only a formal “condicio sine qua non”, often disregarded by the physician wanting to adopt, in special cases, the therapies deemed the most adequate. Only lately the “right to health” about which at art. 32 of Constitution is intended in a wide meaning that is as the right not only to be cured but also to decide about the therapeutic treatments to undergo. It's not a case that it has begun to spread in the bioethics field another quite delicate concept, that of “therapeutic obstinacy”. 

The information the physician supplies beginning a certain treatment must - as the document of the Bioethics National Committee says (June 20th '92) - “a) fit the single patient, his culture and his rate of comprehension on a side and on the other side his physical condition; b) give a correct and whole information about diagnosis, therapy, risks and prognosis” 
It's evident that to perform these requirements, information must come from a qualified professional, not trying to force, by the means of his authority, the will of the patient. Really, in the sizeable cases the 'trust relationship' between physician and patient makes the latter delegating any decision to who cures him, without interfering with any kind objections. The objection “of principle” the Jehovah's Witnesses opposite to blood transfusions can be deemed, beyond the strictly religious matter, as an assertion of the patient's rights in front of the assumed omnipotence of the physician.
The alternatives to blood transfusion
Provided that, it remains to clear which are the alternatives to operation techniques and which is their reliable rate.

Within cardio surgery for example it has already been experimented the “induced hypothermia” and the “intra-operation hemodilution”.
The induced hypothermia is the lowering of body temperature and on consequence the slowing down of the cardiac function by injecting in heart a paralysing substance. The employ of these two techniques allows operating without administering transfusions at all.
Instead in the case of intra-operation hemodilution, blood is diluted with no-haematic substances. This technique is surely not the easiest one since the employed substances cannot replace the function of conveying oxygen carried out by the erythrocytes; nevertheless the fluids required for the hemodilution help blood to circulate easier favouring the release of oxygen to tissues. The chemical processes in act are of a kind that even with only the half of red blood cells working the oxygen release can get to 75% of the standard. To witness the fact that the reserves the organisms apply for in moments of extreme need are enormous and maybe yet not explored at all. 
But the chirurgical technique that is asserting the most is that basing on the Intra-operation recover (cell saver).  Summing it up at the utmost it concerns the re-employment of the blood lost by the patient during the operation by the means of a machine called “cell separator”. A crux passage of the delicate operation regards the separation of the plasma, white blood cells and platelets from red blood cells that is infused in patient once depurated. A mechanism allowing the recover of some litres of blood, lost in internal haemorrhages due to operations or accidents.
It's evident that the spread of the so-called “bloodless surgery” is due to many factors; there's no medicine advancing only in advantage of a sole social class, this case the Jehovah's Witnesses. It's out of doubt that the latter, by their behaviour, have planted to the attention of the public opinion a problem the physicians had already concentrated on. On the other side the spread of the hepatitis C throughout transfusions have always been a not-minor phenomenon, to which it has superimpose that, much more dramatic, of Aids.
The periodical publications of the Jehovah's Witnesses talk about 90.000 physicians all over the world that operate without employing blood transfusions and report the favourable opinions of famous representatives of the international academic world. Besides the religious requirements, the setting up of surgery techniques turning into outdated transfusions is at any extent a basic pace in the surgery field.
The matter is even more important for a country as Italy, where the plasma supplying has always been lacking and early also rising polemics among the several bodies dealing with its recollection and distribution. Disagreements between the Health High Institute, under the authority of the Ministry, and the Italian Red Cross that has proposed itself as a candidate to manage autonomously all the blood stock in Italy and that coming from abroad. It seems to us instead that the management of so complex problems concerns just the Health High Institute, since it's a matter requiring special training. We are dealing with this matter since time - it's enough to remember the survey by Gianni Cirone issued on “Leadership Medica” and “Leader for Chemist” in 1995 and 1996 (n. 9/95, 3/96, 5/96, 7/96) - and we have supported the proposal of the Deputy Mr. Bruno (n. 9/91). In 1991, Mr. Bruno, holding the Defence undersecretary office proposed to increase the internal stock of plasma by subjecting conscripts to blood taking, not compulsory but provided of “incentives”. The government fell and also this interesting project was set aside. Next issue of the magazine we will publish an interview deepening furthermore the aspects of therapies, chirurgical and not, that can be administered today, contrary to the past, also without carrying out blood transfusions.

La Redazione