The Divine law and blood IX:Going mainstream?

Bloodless’ surgery option reveals unexpected benefits

By Sharon Kirkey, Postmedia News

When doctors at a New Jersey hospital pioneered a “bloodless” surgery program for patients who refused blood transfusions on religious grounds, they discovered something totally unexpected: Jehovah’s Witnesses, who would choose death over a transfusion, recovered just as well as transfused patients — and in many cases, even better.

They suffered fewer post-surgery complications, spent less time on mechanical breathing machines and had shorter stays in intensive care.

Recently, doctors from the Cleveland Clinic in Ohio reported that Jehovah’s Witnesses who refused blood transfusions while undergoing cardiac surgery were significantly less likely to need another operation for bleeding compared with non-Witnesses who were transfused. They were also less likely to suffer a post-op heart attack or kidney failure.

Are the Jehovah’s Witnesses onto something?

In cases of massive “bleed outs” from trauma or hemorrhage, or for patients with leukemia or other cancers, blood transfusions can be life-saving.

At the same time, experts say there is remarkably little evidence to show which patients — short of those suddenly losing large amounts of blood — actually benefit from blood transfusions.

In fact, a growing body of research links transfusions with an increased risk of post-surgery infections, cardiac arrest, heart attack, stroke, kidney failure, lung injury, multi-organ failure and death.

Transfused patients spend more time in hospital than those who don’t get blood; they spend more time in intensive care units connected to ventilators; and have a higher risk of acute respiratory distress, where the lungs become saturated with fluid, preventing enough oxygen from getting to the lungs and into the blood.

Studies suggest that up to half of all red-blood-cell transfusions may be unnecessary. Needless transfusions not only waste blood, they expose patients to risks — including potentially life-threatening human errors that are occurring at every step in the transfusion chain.

Three decades after Canada’s catastrophic tainted-blood tragedy left 2,000 people infected with HIV and another 30,000 with hepatitis C, the greatest threat to patients today isn’t the risk of contracting an infectious disease from blood, experts now say.

It’s getting blood they don’t need.

Overused medical procedure?

From ancient times to the late 19th century, sickness was treated by blood loss: using lances or leeches to bleed the body of suspected diseases that caused “bad” blood.

Today, we call blood the “gift of life.” The belief that blood is almost a magical cure is still held by many.

“In the minds of many people, blood is life, and giving people blood must help life,” says Dr. Jacques Lacroix, a professor of pediatrics at the University of Montreal and a national and international pioneer in pediatric critical care and research.

“But it does not work like that.”

In fact, transfusions have been identified by the American Medical Association as among the top five overused procedures in medicine.

In Canada, about 850,000 units of red blood cells, and 102,000 doses of platelets, were transfused into patients outside Quebec in 2011-2012, according to estimates compiled by the Canadian Blood Services for Postmedia News. (Hema-Quebec, which runs the province’s blood system, collected 252,340 units of blood from donors in 2011-2012; more than 526,000 blood products were shipped to hospitals.)

Canadian researchers have led the world in showing that patients benefit from more restrictive blood use.  But, there is no single, unified national system to determine how much of the blood distributed by the Canadian Blood Services is actually transfused, who gets it and whether it’s being given for the right reasons.

Studies suggest that, even when patients have the same underlying condition, the same surgery and the same blood loss, transfusion rates vary widely from hospital to hospital for the same operation.

For example, a review of more than 8,000 patients who underwent cardiac surgery in British Columbia between 2008 and 2010 found that the proportion of patients who received red-blood-cell transfusions ranged from 35 to 66 per cent.

A provincewide audit of Ontario hospitals published in May concluded that nearly one in three transfusions of frozen plasma — the liquid portion of blood that contains clotting factors to help control bleeding during surgery — was unnecessary.

In Calgary, knee replacement patients are being transfused at rates ranging from two per cent of patients to 25 per cent, depending on the surgeon.

Many transfusions don’t meet even minimum published guidelines, experts say. Many patients receive not one, but multiple units of blood, increasing their risk of fluid overload, where the extra blood overwhelms the heart’s ability to pump it through the body. Transfusion-related circulatory overload is one of the leading causes of transfusion-related death.

In some areas of medicine, including cardiac surgery, no clear consensus exists on when patients should be transfused.

“What we are sure of, however, is that there is a huge variation in transfusion rates across Canada for cardiac surgery patients of the same risk profile, and this is very difficult to explain,” says Dr. Fraser Rubens, a cardiac surgeon at the University of Ottawa Heart Institute.

Limiting the use of blood

As concern mounts over the dangers of unnecessary transfusions, hospitals have begun using strategies to reduce the use of blood.

For example:

• Blood draining out from under surgical wounds is being siphoned off, re-processed and then re-infused back into the patient.

• Surgeons are using drugs to prevent bleeding and improve blood clotting.

• Surgeons are operating through laparoscopes and other minimally invasive tools to reduce bleeding from large surgical wounds.

• Patients are being screened and treated for anemia with supplements or drugs that boost the bone marrow to produce red blood cells before they get into the operating room.

The variability in transfusion rates is slowly falling. But doctors have been slow to adapt. “The biggest challenge is trying to change the behaviour of physicians,” says Dr. Alan Tinmouth, a hematologist and scientist at the Ottawa Hospital Research Institute. “People are being transfused at hemoglobin levels higher than they need to be.”

Many doctors remain unconvinced of the potential dangers of transfusions. None of the studies suggesting increased risks of harm prove cause-and-effect, just an association, they point out. What’s more, patients who are transfused tend to be sicker to begin with, so it’s no surprise that they don’t recover as well as non-transfused patients, they argue.

But Dr. Paul Marik says numerous studies have shown that the more blood given, the worse the outcome.

In a widely cited study published in 2008, Marik analyzed 45 studies involving nearly 300,000 patients. In 42 of those studies, the risks of red-blood-cell transfusions outweighed the benefits. Transfused patients were twice as likely to develop infections, multi-organ failure and acute respiratory distress than the non-transfused.

Critics of his conclusions say many of the older studies were done before white cells were filtered out of whole-blood donations. White cells in the “host” body help fight disease and infection. But when they’re put into someone else, they can suppress the immune system.

More recent studies have shown that transfusion-related reactions have fallen since blood suppliers began washing white blood cells from blood. However, Dr. Aryeh Shander, clinical professor of anesthesiology, medicine and surgery at Mount Sinai School of Medicine in New York, says that while there has been an unquestionable reduction in fever rates, “the rest is debated.”

Shander helped create the bloodless medicine and surgery program at Englewood Hospital and Medical Center in Englewood, New Jersey. He says that “old habits die hard” and that too many doctors believe “something bad will happen” if patients don’t have a certain volume of blood in their system.

Hemoglobin transfusions can be risky

The biggest driver of red blood-cell transfusions is hemoglobin, the protein in red blood cells that ferries oxygen from the lungs to tissues and cells throughout the body. Too little hemoglobin, and the person becomes anemic.

Red blood cells are frequently transfused during cardiac surgery, prostate surgery, joint replacements and in patients bleeding from their intestinal tracts.

But, once removed from the body, red cells undergo changes in their shape and function. Their membranes deteriorate; some cells burst, releasing free hemoglobin, which mops up nitric oxide, the chemical that helps blood vessels relax. There are now growing concerns that “older” red cells stored for longer than a few weeks lose some of their ability to transport oxygen — the very reason they’re transfused. In Canada, red cells are stored for up to 42 days.

Dr. Paul Hebert, Critical Care Physician at The Ottawa Hospital on July 8, 2013, led a groundbreaking study which found that ICU patients who were transfused when they were only mildly anemic were more likely to die than patients who weren’t transfused. (Chris Roussakis / Postmedia News)

When he was in medical school, Ottawa critical care specialist Dr. Paul Hebert, whose research has transformed transfusion practices worldwide, was taught that seriously ill patients need a high level of hemoglobin to keep diseased or damaged tissues alive. So ingrained was this belief that anesthesiologists and surgeons routinely began transfusing surgery patients if their hemoglobin dipped below a certain number (100 grams per litre of blood.)

In a landmark paper published in the New England Journal of Medicine, Hebert and his team found that patients who were only mildly below that hemoglobin cutoff, but who were treated aggressively with transfused blood nonetheless, were more likely to die, and had higher rates of organ failure, than patients whose doctors held back until their hemoglobin fell to lower levels.

“We found that, if you give less blood, you do better,” Hebert said. “We think that’s because many of the patients didn’t need it in the first place.”

In a study published in January 2013, Hebert and co-authors reviewed 19 trials involving more than 6,000 patients that compared higher versus lower hemoglobin thresholds in red-blood-cell transfusions. They found that patients could be transfused at hemoglobin levels of 70 or 80 grams per litre of blood without putting them at any increased risk for major complications such as pneumonia, stroke, infection, or death.

If doctors were to use the lower thresholds, “I think you can reduce blood use in many settings by at least half,” said lead author Dr. Jeffrey Carson, chief of the division of general internal medicine at Rutgers Robert Wood Johnson Medical School in New Brunswick, New Jersey.

A recent review of blood transfusions at three Ontario hospitals found that the pre-transfusion hemoglobin levels were higher than the recommended thresholds for many patients.

Some transfusion rates have been falling since the province established a network of blood transfusion co-ordinators in 25 hospitals. A major thrust of the program is to treat patients with anemia — low hemoglobin — before surgery “so that we avoid having to transfuse them when they bleed,” said Dr. John Freedman, medical director of the program and professor emeritus at the University of Toronto.

British Columbia created the first transfusion registry in Canada in 1999; it remains one of the largest in North America. The database tracks every unit of blood that gets transfused into someone in B.C or the Yukon.

Within the year, The Ottawa Hospital hopes to have a computerized system in place to capture where blood is going, which patients are being transfused and their hemoglobin levels at transfusion.

According to the Canadian Blood Services, Canada is at the lower end of blood use worldwide, and experts say it would be dangerous to attempt to cut transfusion rates to near zero. As well, demand for blood is expected to grow as the population ages, because older people use more blood. While Jehovah’s Witnesses have taught doctors that the body can compensate for extraordinarily low levels of hemoglobin, levels that are too low mean the cells and tissues in the brain and other vital organs become starved of oxygen.

Hebert has watched Jehovah’s Witnesses die for refusing to be transfused, an experience that leaves the medical team feeling helpless. “But you can’t force your values on someone else,” he says.

Hebert says more research and education is needed to help doctors decide how long they can safely wait before ordering blood, how much blood they should give and when to hold off giving any blood at all.

“The problem is that we don’t have the data,” Hebert said. “In many cases, we just don’t know.”

By the numbers

900,000 – Average number of units of blood collected each year in Canada, outside Quebec. (Hema-Quebec, which runs the province’s blood system, collected 252,340 units of blood from donors in 2011/2012).

850,000 – Estimated units of red blood cells transfused into patients in Canada in 2011/2012.

More than 2.5 million – Number of bottles of blood collected in Canada during Second World War to help soldiers and war victims.

5 – Average number of litres of blood in a person’s body.

450 milliliters – Amount of blood that goes into a single donation. Though it is frequently referred to as a “pint,” a blood donation is 450 mL rather than the 570 mL in a pint. The human body begins replenishing the lost blood within hours, and finishes the job within 56 days.

20,000 – Number of blood clinics run by Canadian Blood Services each year.

42 days – Maximum shelf life for red blood cells collected through blood donations. Most blood is sent to hospitals within a week. Platelets have only a five-day shelf life.

One – Number of hours, on average, it takes to donate blood.

17 – Minimum legal age for donating blood in Canada.

7  – Number of times a year a healthy person can donate blood (i.e. every 56 days).

Every 60 seconds – How often, on average, someone in Canada receives blood or a blood product.

4 – Number of days after which the supply of blood products for high-demand blood groups would run out if Canadians stopped donating blood.

3 – Number of lives that can be saved with one donation of blood. Whole blood donations are separated into red cells, platelets and plasma. Each component can be given to a different person.

52 per cent – Proportion of Canadians who say they or a family member have needed blood or blood products for surgery or for medical treatment.

One in 10 – Number of people admitted to hospital who receive blood.

54 per cent – Proportion of Canadians eligible to donate blood.

3.7 per cent – Proportion of Canadians who actually give blood.

One in three – Number of Canadians who do not know their blood type.

Two – Average number of units of blood transfused for hip replacement surgery.

50 – Average units of blood transfused to save the life of a car-crash victim.

2,000 – Number of Canadians infected with HIV from donated blood.

30,000 – Number of Canadians infected with hepatitis C.

1 in 8 million donations – Estimated risk of HIV today.

1 in 6.7 million donations – Estimated risk of hepatitis C.

1 in 1.7 million donations – Estimated risk of hepatitis B,

Sources: Canadian Blood Services, American Red Cross, Hema-Quebec

A brief history of blood

400 BC – Hippocrates postulates that the body is comprised of four “humours” — blood, phlegm, black and yellow bile — and that their imbalance causes disease.

1492 – Earliest recorded transfusion: As a remedy for a stroke suffered by Pope Innocent VIII, his doctor advises a blood transfusion. The blood of four young adults is transferred to the Pope. Donors and patient later all die.

1628 – British physician William Harvey discovers the circulation of blood.

1665 – First recorded successful blood transfusion. English physician Richard Lower keeps dog alive by transfusing blood from other dogs.

1667 – French physician Jean-Baptiste Denis transfuses blood from sheep into a patient. The patient survives.

1818 – British obstetrician James Blundell performs the first successful transfusion of human blood to a woman hemorrhaging after childbirth, using the woman’s husband as a donor.

1897 – Bram Stoker’s classic horror novel Dracula, about a blood-sucking being, is published.

1901 – Austrian physician Karl Landsteiner discovers the first three human blood groups – A, B and C (C later changed to O). AB, the fourth type is discovered two years later; the Rh blood group is discovered in 1939-1940.

1926 – The British Red Cross institutes the first human blood transfusion service in the world.

1945 – Canadians start giving blood to hospitals.

1947 – Canada establishes a national blood transfusion service; the first blood centre opens in Vancouver. By 1961, Canada has 16 blood centres serving every region of the country.

July 1981 – First cluster of AIDS identified in homosexuals in Los Angeles.

July 1982 – AIDS identified in hemophiliacs.

December 1982 – AIDS identified in blood transfusion recipients.

1983 – French virologist Luc Montagnier isolates the virus that causes AIDS. The Canadian Red Cross Society prohibits blood donations from men who have sex with men.

November 1985 – Red Cross starts screening all blood for HIV.

1987 – Guidelines in the U.S. and Canada encourage people who had transfusions to be tested for HIV.

October 1993 – The federal government authorizes the creation of a Commission of Inquiry on the Blood System in Canada. Justice Horace Krever is appointed as commissioner.

November 1997 – Justice Horace Krever releases his voluminous report on the tainted-blood scandal.

September 1998 – Canadian Red Cross gets out of the blood business, transferring assets to the Canadian Blood Services and Hema-Quebec.

1999 – Canadian Blood Services introduces its first deferral policy for Creutzfeldt-Jakob disease (variant CJD), the human equivalent of “mad cow” disease and announces that people can no longer donate blood if they have spent six months or more in the United Kingdom since 1980.

May 2013 – Canadian Blood Services loosens restrictions on blood donations from men who have sex with men, saying it will now accept donations from men who haven’t had sex with another man within the last five years. Before the change, men who had had sex with another man at any time since 1977 (the beginning of the AIDS epidemic in the U.S.) were turned away.

Sources: U.K. Blood Transfusion & Tissue Transplantation Services; AABB; Canadian Blood Services

Some more unsettled science.

Selection and Speciation: Why Darwinism Is False

Jonathan Wells May 15, 2009 10:00 AM

 Coyne writes that Darwin "had little direct evidence for selection acting in natural populations." Actually, Darwin had no direct evidence for natural selection; the best he could do in The Origin of Species was "give one or two imaginary illustrations." It wasn't until a century later that Bernard Kettlewell provided what he called "Darwin's missing evidence" for natural selection -- a shift in the proportion of light- and dark-colored peppered moths that Kettlewell attributed to camouflage and bird predation.⁴⁰

Since then, biologists have found lots of direct evidence for natural selection. Coyne describes some of it, including an increase in average beak depth of finches on the Galápagos Islands and a change in flowering time in wild mustard plants in Southern California -- both due to drought. Like Darwin, Coyne also compares natural selection to the artificial selection used in plant and animal breeding.

But these examples of selection -- natural as well as artificial -- involve only minor changes within existing species. Breeders were familiar with such changes before 1859, which is why Darwin did not write a book titled How Existing Species Change Over Time; he wrote a book titled The Origin of Species by Means of Natural Selection. "Darwin called his great work On the Origin of Species," wrote Harvard evolutionary biologist Ernst Mayr in 1982, "for he was fully conscious of the fact that the change from one species into another was the most fundamental problem of evolution." Yet, Mayr had written earlier, "Darwin failed to solve the problem indicated by the title of his work." In 1997, evolutionary biologist Keith Stewart Thomson wrote: "A matter of unfinished business for biologists is the identification of evolution's smoking gun," and "the smoking gun of evolution is speciation, not local adaptation and differentiation of populations." Before Darwin, the consensus was that species can vary only within certain limits; indeed, centuries of artificial selection had seemingly demonstrated such limits experimentally. "Darwin had to show that the limits could be broken," wrote Thomson, "so do we."⁴¹

In 2004, Coyne and H. Allen Orr published a detailed book titled Speciation, in which they noted that biologists have not been able to agree on a definition of "species" because no single definition fits every case. For example, a definition applicable to living, sexually reproducing organisms might make no sense when applied to fossils or bacteria. In fact, there are more than 25 definitions of "species." What definition is best? Coyne and Orr argued that, "when deciding on a species concept, one should first identify the nature of one's 'species problem,' and then choose the concept best at solving that problem." Like most other Darwinists, Coyne and Orr favor Ernst Mayr's "biological species concept" (BSC), according to which "species are groups of interbreeding natural populations that are reproductively isolated from other such groups." In Why Evolution Is True, Coyne explains that the biological species concept is "the one that evolutionists prefer when studying speciation, because it gets you to the heart of the evolutionary question. Under the BSC, if you can explain how reproductive barriers evolve, you've explained the origin of species."⁴²

Theoretically, reproductive barriers arise when geographically separated populations diverge genetically. But Coyne describes five "cases of real-time speciation" that involve a different mechanism: chromosome doubling, or "polyploidy."⁴³ This usually follows hybridization between two existing plant species. Most hybrids are sterile because their mismatched chromosomes can't separate properly to produce fertile pollen and ovaries; occasionally, however, the chromosomes in a hybrid spontaneously double, producing two perfectly matched sets and making reproduction possible. The result is a fertile plant that is reproductively isolated from the two parents -- a new species, according to the BSC.

But speciation by polyploidy ("secondary speciation") has been observed only in plants. It does not provide evidence for Darwin's theory that species originate through natural selection, nor for the neo-Darwinian theory of speciation by geographic separation and genetic divergence. Indeed, according to evolutionary biologist Douglas J. Futuyma, polyploidy "does not confer major new morphological characteristics... [and] does not cause the evolution of new genera" or higher levels in the biological hierarchy.⁴⁴

So secondary speciation does not solve Darwin's problem. Only primary speciation -- the splitting of one species into two by natural selection -- would be capable of producing the branching-tree pattern of Darwinian evolution. But no one has ever observed primary speciation. Evolution's smoking gun has never been found.⁴⁵

Or has it?

In Why Evolution Is True, Coyne claims that primary speciation was observed in an experiment reported in 1998. Curiously, Coyne did not mention it in the 2004 book he co-authored with Orr, but his 2009 account of it is worth quoting in full:

We can even see the origin of a new, ecologically diverse bacterial species, all within a single laboratory flask. Paul Rainey and his colleagues at Oxford University placed a strain of the bacteria Pseudomonas fluorescens in a small vessel containing nutrient broth, and simply watched it. (It's surprising but true that such a vessel actually contains diverse environments. Oxygen concentration, for example, is highest on the top and lowest on the bottom.) Within ten days--no more than a few hundred generations--the ancestral free-floating 'smooth' bacterium had evolved into two additional forms occupying different parts of the beaker. One, called 'wrinkly spreader,' formed a mat on top of the broth. The other, called 'fuzzy spreader,' formed a carpet on the bottom. The smooth ancestral type persisted in the liquid environment in the middle. Each of the two new forms was genetically different from the ancestor, having evolved through mutation and natural selection to reproduce best in their respective environments. Here, then, is not only evolution but speciation occurring in the lab: the ancestral form produced, and coexisted with, two ecologically different descendants, and in bacteria such forms are considered distinct species. Over a very short time, natural selection in Pseudomonas yielded a small-scale 'adaptive radiation,' the equivalent of how animals or plants form species when they encounter new environments on an oceanic island.⁴⁶

But Coyne omits the fact that when the ecologically different forms were placed back into the same environment, they "suffered a rapid loss of diversity," according to Rainey. In bacteria, an ecologically distinct population (called an "ecotype") may constitute a separate species, but only if the distinction is permanent. As evolutionary microbiologist Frederick Cohan wrote in 2002, species in bacteria "are ecologically distinct from one another; and they are irreversibly separate."⁴⁷ The rapid reversal of ecological distinctions when the bacterial populations in Rainey's experiment were put back into the same environment refutes Coyne's claim that the experiment demonstrated the origin of a new species.

Exaggerating the evidence to prop up Darwinism is not new. In the Galápagos finches, average beak depth reverted to normal after the drought ended. There was no net evolution, much less speciation. Yet Coyne writes in Why Evolution Is True that "everything we require of evolution by natural selection was amply documented" by the finch studies. Since scientific theories stand or fall on the evidence, Coyne's tendency to exaggerate the evidence does not speak well for the theory he is defending. When a 1999 booklet published by The U. S. National Academy of Sciences called the change in finch beaks "a particularly compelling example of speciation," Berkeley law professor and Darwin critic Phillip E. Johnson wrote in The Wall Street Journal: "When our leading scientists have to resort to the sort of distortion that would land a stock promoter in jail, you know they are in trouble."⁴⁸

So there are observed instances of secondary speciation -- which is not what Darwinism needs -- but no observed instances of primary speciation, not even in bacteria. British bacteriologist Alan H. Linton looked for confirmed reports of primary speciation and concluded in 2001: "None exists in the literature claiming that one species has been shown to evolve into another. Bacteria, the simplest form of independent life, are ideal for this kind of study, with generation times of twenty to thirty minutes, and populations achieved after eighteen hours. But throughout 150 years of the science of bacteriology, there is no evidence that one species of bacteria has changed into another."⁴⁹

Notes

⁴⁰ Coyne, Why Evolution Is True, p. 116.

Darwin, The Origin of Species, Chapter IV (p. 70). Available online (2009) here.

H. B. D. Kettlewell, "Darwin's Missing Evidence," Scientific American 200 (March, 1959): 48-53.

⁴¹ Ernst Mayr, The Growth of Biological Thought (Cambridge, MA: Harvard University Press, 1982), p. 403.

Ernst Mayr, Populations, Species and Evolution (Cambridge, MA: Harvard University Press, 1963), p. 10.

Keith Stewart Thomson, "Natural Selection and Evolution's Smoking Gun," American Scientist 85 (1997): 516-518.

⁴² Jerry A. Coyne & H. Allen Orr, Speciation (Sunderland, MA: Sinauer Associates, 2004), p. 25-39.

Coyne, Why Evolution Is True, p. 174.

⁴³ Coyne, Why Evolution Is True, p. 188.

⁴⁴ Douglas J. Futuyma, Evolution (Sunderland, MA: Sinauer Associates, 2005), p. 398.

⁴⁵ Wells, The Politically Incorrect Guide to Darwinism and Intelligent Design, Chapter Five ("The Ultimate Missing Link"), pp. 49-59.

⁴⁶ Coyne, Why Evolution Is True, pp. 129-130.

⁴⁷ Paul B. Rainey & Michael Travisano. "Adaptive radiation in a heterogeneous environment,"Nature 394 (1998): 69-72.

Frederick M. Cohan, "What Are Bacterial Species?" Annual Review of Microbiology 56 (2002): 457-482. Available online (2009) here.

⁴⁸ Coyne, Why Evolution Is True, p. 134.

National Academy of Sciences, Science and Creationism: A View from the National Academy of Sciences, Second edition (Washington, DC: National Academy of Sciences Press, 1999), Chapter on "Evidence Supporting Biological Evolution," p. 10. Available online (2009) here.

Phillip E. Johnson, "The Church of Darwin," The Wall Street Journal (August 16, 1999): A14. Available online (2009) here.

⁴⁹ Alan H. Linton, "Scant Search for the Maker," The Times Higher Education Supplement (April 20, 2001), Book Section, p. 29.

The science is not settled;But don't take my word for it.

Welcome to the Top Ten Scientific Problems with Biological and Chemical Evolution

Casey Luskin January 2, 2015 12:00 AM 

Editor's note: This is Part 1 of a 10-part series based upon Casey Luskin's chapter, "The Top Ten Scientific Problems with Biological and Chemical Evolution," in the volume More than Myth, edited by Paul Brown and Robert Stackpole (Chartwell Press, 2014). When the series is complete, the full chapter will be posted online.

"There are no weaknesses in the theory of evolution."¹ So said Eugenie Scott, the de facto head of the Darwin lobby, while speaking to the media in response to the Texas State Board of Education's 2009 vote to require students to learn about both the scientific evidence for and against neo-Darwinian evolution.

For those who follow the debate over origins, Dr. Scott's words are as unsurprising as they are familiar. It seems that almost on a daily basis, we find the news media quoting evolutionary scientists declaring that materialist accounts of biological and chemical evolution are "fact." Students who take college-preparatory or college-level courses on evolution are warned that doubting Darwinism is tantamount to committing intellectual suicide -- you might as well proclaim the Earth is flat.² Such bullying is enough to convince many that it's much easier on your academic standing, your career, and your reputation to just buy into Darwinism. The few holdouts who remain are intimidated into silence.

But is it true that there are "no weaknesses" in evolutionary theory? Are those who express doubts about Darwinism displaying courage, or are they fools that want to take us back to the dark ages and era of the flat Earth?³ Thankfully, it's very easy to test these questions: all one must do is examine the technical scientific literature and inquire whether there are legitimate scientific challenges to chemical and biological evolution.

This chapter will review some of this literature, and show that there are numerous legitimate scientific challenges to core tenets of Darwinian theory, as well as predominant theories of chemical evolution. Those who harbor doubts about Darwinism need not be terrified by academic bullies who pretend there is no scientific debate to be had.

Problem 1: No Viable Mechanism to Generate a Primordial Soup

According to conventional thinking among origin of life theorists, life arose via unguided chemical reactions on the early Earth some 3 to 4 billion years ago. Most theorists believe that there were many steps involved in the origin of life, but the very first step would have involved the production of a primordial soup -- a water-based sea of simple organic molecules -- out of which life arose. While the existence of this "soup" has been accepted as unquestioned fact for decades, this first step in most origin-of-life theories faces numerous scientific difficulties.

In 1953, a graduate student at the University of Chicago named Stanley Miller, along with his faculty advisor Harold Urey, performed experiments hoping to produce the building blocks of life under natural conditions on the early Earth.⁴ These "Miller-Urey experiments" intended to simulate lightning striking the gasses in the early Earth's atmosphere. After running the experiments and letting the chemical products sit for a period of time, Miller discovered that amino acids -- the building blocks of proteins -- had been produced.

For decades, these experiments have been hailed as a demonstration that the "building blocks" of life could have arisen under natural, realistic Earthlike conditions,⁵ corroborating the primordial soup hypothesis. However, it has also been known for decades that the Earth's early atmosphere was fundamentally different from the gasses used by Miller and Urey.

The atmosphere used in the Miller-Urey experiments was primarily composed of reducing gasses like methane, ammonia, and high levels of hydrogen. Geochemists now believe that the atmosphere of the early Earth did not contain appreciable amounts of these components. (Reducing gasses are those which tend to donate electrons during chemical reactions.) UC Santa Cruz origin-of-life theorist David Deamer explains this in the journal Microbiology & Molecular Biology Reviews:

This optimistic picture began to change in the late 1970s, when it became increasingly clear that the early atmosphere was probably volcanic in origin and composition, composed largely of carbon dioxide and nitrogen rather than the mixture of reducing gases assumed by the Miller-Urey model. Carbon dioxide does not support the rich array of synthetic pathways leading to possible monomers...⁶

Likewise, an article in the journal Science stated: "Miller and Urey relied on a 'reducing' atmosphere, a condition in which molecules are fat with hydrogen atoms. As Miller showed later, he could not make organics in an 'oxidizing' atmosphere."⁷ The article put it bluntly: "the early atmosphere looked nothing like the Miller-Urey situation."⁸ Consistent with this, geological studies have not uncovered evidence that a primordial soup once existed.⁹

There are good reasons to understand why the Earth's early atmosphere did not contain high concentrations of methane, ammonia, or other reducing gasses. The earth's early atmosphere is thought to have been produced by outgassing from volcanoes, and the composition of those volcanic gasses is related to the chemical properties of the Earth's inner mantle. Geochemical studies have found that the chemical properties of the Earth's mantle would have been the same in the past as they are today.¹⁰ But today, volcanic gasses do not contain methane or ammonia, and are not reducing.

A paper in Earth and Planetary Science Letters found that the chemical properties of the Earth's interior have been essentially constant over Earth's history, leading to the conclusion that "Life may have found its origins in other environments or by other mechanisms."¹¹ So drastic is the evidence against pre-biotic synthesis of life's building blocks that in 1990 the Space Studies Board of the National Research Council recommended that origin of life investigators undertake a "reexamination of biological monomer synthesis under primitive Earthlike environments, as revealed in current models of the early Earth."¹²

Because of these difficulties, some leading theorists have abandoned the Miller-Urey experiment and the "primordial soup" theory it is claimed to support. In 2010, University College London biochemist Nick Lane stated the primordial soup theory "doesn't hold water" and is "past its expiration date."¹³ Instead, he proposes that life arose in undersea hydrothermal vents. But both the hydrothermal vent and primordial soup hypotheses face another major problem.

Chemical Evolution Is Dead in the Water

Assume for a moment that there was some way to produce simple organic molecules on the early Earth. Perhaps they did form a "primordial soup," or perhaps these molecules arose near some hydrothermal vent. Either way, origin of life theorists must then explain how amino acids or other key organic molecules linked up to form long chains (polymers) like proteins (or RNA).

Chemically speaking, however, the last place you'd want to link amino acids into chains would be a vast water-based environment like the "primordial soup" or underwater near a hydrothermal vent. As the National Academy of Sciences acknowledges, "Two amino acids do not spontaneously join in water. Rather, the opposite reaction is thermodynamically favored."¹⁴ In other words, water breaks protein chains back down into amino acids (or other constituents), making it very difficult to produce proteins (or other polymers) in the primordial soup.

Materialists lack good explanations for these first, simple steps which are necessary to the origin-of-life. Chemical evolution is literally dead in the water.

References:

[1.] Eugenie Scott, quoted in Terrence Stutz, "State Board of Education debates evolution curriculum," Dallas Morning News (January 22, 2009), also requoted in Ed Stoddard, "Evolution gets added boost in Texas schools," Reuters.com athttp://blogs.reuters.com/faithworld/2009/01/23/evolution-gets-added-boost-in-texas-schools/

[2.] Karl W. Giberson, Saving Darwin: How to be a Christian and Believe in Evolution, p. 53 (HarperOne, 2008) ("biologists today consider the common ancestry of all life a fact on par with the sphericity of the earth").

[3.] In any case, it's largely a myth that Western Civilization once believed in a flat earth. See Jeffrey Burton Russell, "The Myth of the Flat Earth," at http://www.veritas-ucsb.org/library/russell/FlatEarth.html

[4.] See Stanley L. Miller, "A Production of Amino Acids under Possible Primitive Earth Conditions," Science, 117: 528-529 (May 15, 1953).

[5.] See Jonathan Wells, Icons of Evolution: Why Much of What We Teach About Evolution Is Wrong, (Washington D.C.: Regnery, 2000); Casey Luskin, "Not Making the Grade: An Evaluation of 19 Recent Biology Textbooks and Their Use of Selected Icons of Evolution," Discovery Institute (September 26, 2011), at http://www.evolutionnews.org/DiscoveryInstitute_2011TextbookReview.pdf

[6.] David W. Deamer, "The First Living Systems: a Bioenergetic Perspective," Microbiology & Molecular Biology Reviews, 61:239 (1997).

[7.] Jon Cohen, "Novel Center Seeks to Add Spark to Origins of Life," Science, 270: 1925-1926 (December 22, 1995).

[8.] Ibid.

[9.] Antonio C. Lasaga, H. D. Holland, and Michael J. Dwyer, "Primordial Oil Slick," Science, 174: 53-55 (October 1, 1971).

[10.] Kevin Zahnle, Laura Schaefer, and Bruce Fegley, "Earth's Earliest Atmospheres," Cold Spring Harbor Perspectives in Biology, 2(10): a004895 (October, 2010) ("Geochemical evidence in Earth's oldest igneous rocks indicates that the redox state of the Earth's mantle has not changed over the past 3.8 Gyr"); Dante Canil, "Vanadian in peridotites, mantle redox and tectonic environments: Archean to present," Earth and Planetary Science Letters, 195:75-90 (2002).

[11.] Dante Canil, "Vanadian in peridotites, mantle redox and tectonic environments: Archean to present," Earth and Planetary Science Letters, 195:75-90 (2002) (internal citations removed).

[12.] National Research Council Space Studies Board, The Search for Life's Origins (National Academy Press, 1990).

[13.] Deborah Kelley, "Is It Time To Throw Out 'Primordial Soup' Theory?," NPR (February 7, 2010).

[14.] Committee on the Limits of Organic Life in Planetary Systems, Committee on the Origins and Evolution of Life, National Research Council, The Limits of Organic Life in Planetary Systems, p. 60 (Washington D.C.: National Academy Press, 2007).

[15.] Richard Van Noorden, "RNA world easier to make," Nature news (May 13, 2009),http://www.nature.com/news/2009/090513/full/news.2009.471.html

Examining a living fossil

T'is the season to be depressed?/coping with the holiday blues.

Manifest destiny 21st Century?:Pros and cons.

On Darwinism's attempts to put words in our mouths.

Leading Evolutionary Scientists Admit We Have No Evolutionary Explanation of Human Language

Casey Luskin December 19, 2014 3:06 AM

 

 

 

Denyse O'Leary has written here about the difficulty that evolutionary psychology faces in explaining the origin of language. Indeed, back in May, a group of huge names in evolutionary biology, evolutionary anthropology, and evolutionary psychology published a peer-reviewed paper in the journal Frontiers in Psychology admitting that in fact we have no explanation for the origin of language. The abstract strikingly states:

Understanding the evolution of language requires evidence regarding origins and processes that led to change. In the last 40 years, there has been an explosion of research on this problem as well as a sense that considerable progress has been made. We argue instead that the richness of ideas is accompanied by a poverty of evidence, with essentially no explanation of how and why our linguistic computations and representations evolved. We show that, to date, (1) studies of nonhuman animals provide virtually no relevant parallels to human linguistic communication, and none to the underlying biological capacity; (2) the fossil and archaeological evidence does not inform our understanding of the computations and representations of our earliest ancestors, leaving details of origins and selective pressure unresolved; (3) our understanding of the genetics of language is so impoverished that there is little hope of connecting genes to linguistic processes anytime soon; (4) all modeling attempts have made unfounded assumptions, and have provided no empirical tests, thus leaving any insights into language's origins unverifiable. Based on the current state of evidence, we submit that the most fundamental questions about the origins and evolution of our linguistic capacity remain as mysterious as ever, with considerable uncertainty about the discovery of either relevant or conclusive evidence that can adjudicate among the many open hypotheses.
(Marc Hauser, Charles Yang, Robert Berwick, Ian Tattersall, Michael J. Ryan, Jeffrey Watumull, Noam Chomsky and Richard C. Lewontin, "The mystery of language evolution," Frontiers in Psychology, Vol 5:401 (May 7, 2014) (emphases added).)

It's difficult to imagine much stronger words from a more prestigious collection of experts. But what about all of those news stories about apes who learn how to communicate using sign language? Do they show that apes possess or can learn some primitive precursor to humanlike language? No, they say:

Talking birds and signing apes rank among the most fantastic claims in the literature on language evolution, but examination of the evidence shows fundamental differences between child language acquisition and nonhuman species' use of language and language-like systems. For instance, dogs can respond to a few hundred words, but only after thousands of hours of training; children acquire words rapidly and spontaneously generalize their usage in a wide range of contexts. Similarly, Nim Chimpsky, the chimpanzee that produced the only public corpus of data in all animal language studies, produced signs considerably below the expected degree of combinatorial diversity seen in two-year old children, and with no understanding of syntactic structure or semantic interpretation. Though these studies are of potential interest to understanding the acquisition of specialized, artificial skills -- akin to our learning a computer language -- they do not inform understanding of language evolution.

They conclude: "For now, the evidence from comparative animal behavior provides little insight into how our language phenotype evolved. The gap between us and them is simply too great to provide any understanding of evolutionary precursors or the evolutionary processes (e.g., selection) that led to change over time."

 

But what about FOXP2 -- a gene that seems to be connected to language, where humans have a couple of unique amino acid differences compared to nonhuman primates? In The Language of God, Francis Collins presented FOXP2 as something of a miracle mutation that could have caused human language to develop (see pp. 139-141). Time Magazine once claimed that our two amino acid differences in this gene could have caused "the emergence of all aspects of human speech, from a baby's first words to a Robin Williams monologue." These authors would disagree, because, as they point out, we aren't even sure exactly how FOXP2 affects language:

FOXP2 is a transcription factor that up- or down-regulates DNA in many different tissue types (brain, lung, gut lining) at different times during development as well as throughout life. This broad functional effect makes evolutionary analysis difficult. In particular, the exact mechanisms by which FOXP2 mutations disrupt speech remain uncertain, variously posited as disruptions in motor articulation/serialization in speech, vocal learning generally, or broader difficulties with procedural serialization. This is critical because FOXP2 mutations may disrupt only the input/output systems of language, sparing the more internal computations of human language syntax or semantics; or it may be that FOXP2 affects general cognitive processing, such as general serial ordering of procedures. Second, it is not clear whether the amino acid changes distinguishing FOXP2 in humans and nonhumans represent adaptations "for" language, since their functional effects remain unclear. One of the two protein-coding changes along the lineage to modern humans is also associated with the order Carnivora. Since FOXP2 also targets the gut lining, this evolutionary step may have had little to do directly with language but instead with digestion modifications driven by forest-to-savannah habit and so dietary change...

According to the paper, claims that mutations in FOXP2 explain the origin of language cannot be true because, as the authors put it, "we lack a connect-the-dots account of any gene to language phenotype."

 

Of course the authors propose various avenues of research that they think might someday lead to an understanding how language arose. But for the present, their analysis is discouraging: "Until such evidence is brought forward, understanding of language evolution will remain one of the great mysteries of our species."

But you already knew that.

Your Computer Doesn't Like You

Michael Egnor December 15, 2014 2:30 AM

 

Actually, your computer doesn't dislike you, either. Your computer has no opinion about you at all, because it has no opinions whatsoever.

This is news to Stephen Hawking and Elon Musk, who -- as Erik J. Larson has commented here -- recently have warned humanity that computers are on the verge of acquiring minds and could take over the world and end mankind.

Computers, of course, cannot "take over the world and end mankind," because computers have no intelligent agency at all. Intelligence, as denoted in "artificial intelligence," corresponds roughly to what Aristotle meant by intellect and will. Intellect and will are the rational capabilities of human beings -- the ability to reason, to contemplate universals such as good and evil and right and wrong, to love and hate, to judge and intend and carry out decisions arrived at through reason. These are capabilities of human beings, and only of human beings.

Inanimate devices have agency too, but they have unintelligent agency. Computers can store electrons, move electrons about, light up a screen, boot up, crash, freeze, and so on. Computers can of course be a tool by which human beings express their own human intelligent agency. When a person commits bank fraud via a computer, the person, not the computer, goes to jail. Computers have no intelligent agency of their own, and never will, any more than the paperweight on your desk has intelligent agency.

The only way a computer can hurt you, on its own, is if it falls on your foot.

Computers are electromechanical devices that we use as tools. They differ only in complexity from other tools like books, which we use to store and retrieve representations of knowledge. We make tools, and we use tools, and they serve our ends. We put representations of our intentions and knowledge and desires and memories and conceptual insights and errors into computers, and the software that we have written maps our inputs to outputs, and then we analyze and ponder the outputs. Nowhere in this process is there the slightest bit of thinking on the part of the computer. Computers can't think because things like tools -- even tools made in Silicon Valley -- can't think. Computers are devices we use for our own purposes, and like all devices, sometimes the consequences aren't what we expected. Sometimes the book really changes the way we think about things, and sometimes we drop the book on our foot. But the consequences of using tools -- and the consequences can on occasion be transformative for humanity -- are consequences entirely of human purposes and mistakes.  

We've been through this before. After the invention of writing in Sumer, parchment didn't acquire a mind and inflict evil on humanity. But writing did change civilization. After the invention of the printing press, books didn't acquire a mind and inflict evil upon humanity. But the printing press did change civilization. Nor will computers in the 21st century acquire a mind and inflict evil on humanity, because computers can't think any more than parchment or books can think.

But the information age will change civilization.

The salient harm that the silly "artificial intelligence" trope will do to humanity, aside from the general stupidity the concept fosters, is that it will distract us from the astonishingly potent transformation of our civilization that we will bring about in the information revolution. The transformation will be much more radical and rapid than the transformation in the 15th century caused by the printing press. Within a century or two after Gutenberg, millions of people had read things they had never read before, and thought of things they had never thought of before, and doubted and believed new things and found new ways to change their lives and their cultures. The Renaissance flowered, the Reformation raged, the Enlightenment (however misnamed) bloomed, and modernity dawned.

By 1648 northern and central Europe was bled white and a third of the population of Germany was dead from famine and war. By 1789 Napoleon was studying his schoolbooks.  By 1867 Marx had a publisher for Das Kapital, and by 1925 Hitler published volume one of Mein Kampf.

Parchment and books and computers are the tools -- merely the tools -- by which humanity transforms itself.

The information revolution will leverage human intentions and mistakes in ways we can only begin to imagine. None of the transformation will have anything to do with science fiction stories about malevolent robots. It's the malevolent humans -- and even the well-intentioned humans -- who will fashion our ends

Artificial intelligence is an oxymoron. Only human beings have intelligence. We use tools to bring about our ends, and the human information revolution made possible by our tools will transform our civilization, for better or worse and probably both. But the only real threat "artificial intelligence" poses is that it disposes us to dread HAL when we should be contemplating the transformation -- a transformation far more fundamental and astonishing than writing or the printing press -- that humanity will bring upon itself via the information revolution.

René Girard has a few thoughts about what we do to ourselves.

 

The divine law and bloodVIII:swimming against the flow.

From the spring 2013 edition of "stanford Medicine"

 

AGAINST THE FLOW
WHAT’S BEHIND THE DECLINE IN BLOOD TRANSFUSIONS?

by Sarah C.P. Williams
Illustration by Jonathon Rosen

One day in 2011, an ambulance pulled up to the Stanford emergency room and paramedics unloaded a man in his 30s who had crashed his motorcycle. He was in critical condition: Tests showed dangerously low blood pressure, indicating that around 40 percent of his blood was lost. And an ultrasound revealed that the blood was collecting in his belly, suggesting that one or more of his abdominal organs was the source of the blood loss.

Paul Maggio, MD, a trauma surgeon and co-director of critical care medicine at Stanford Hospital & Clinics, sped the patient into the operating room. But he made sure that the technicians prepping his operating room took the time to set up one key piece of equipment, called an intraoperative cell salvage device, which is now commonly used in trauma cases. As the patient lay on the operating table and Maggio made the first cuts into his abdomen, suction devices slurped up the loose blood, directing it away from the surgery site through tubes. But instead of leading to a container bound for disposal, the tubes led to the salvage device.

The ATM-sized machine spun the blood to separate its components, cleaned it of any debris that had been suctioned up from the abdomen and sent it back out into fresh bags. From there, the blood was shunted right back to the patient’s body, through intravenous tubes poking into his veins. The cell salvage device has been around for decades, but only recently has evidence emerged that autotransfusion — giving patients their own blood instead of blood from donors — leads to better surgery outcomes. As a result, the use of the machines has gone from extremely rare to commonplace. Today, hospitals that have the machines use them in many scheduled abdominal and heart surgeries and routinely in trauma cases involving massive bleeding.

“Autotransfusing this patient spared him from getting more banked donor blood and from all the risks associated with it,” says Maggio of the motorcycle crash victim. He turned out to have an injury to his spleen, which Maggio repaired. In all, around 2 liters of blood were collected from the patient’s abdomen, processed through the salvage device, and transfused back into his body.

Blood transfusions involve routing a needle into one of a patient’s veins — most often in an arm — and attaching a thin tube to the needle. Blood flows through the tube directly into the patient’s blood vessels. Ten years ago, a patient like Maggio’s would most likely have had a transfusion of blood donated by volunteers at the Stanford Blood Center. But over the past decade, a growing body of research has revealed that in hospitals around the world, donated blood is used more often, and in larger quantities, than is needed to help patients — both in operating rooms and hospital wards.

Some of the research has been conducted by physicians working with patients who refuse donated blood on religious grounds; other findings have come from the front lines of the war in Afghanistan, where blood is hard to transport; and some studies have been inspired simply by the rising cost of blood and a desire to save resources. Some findings are new, and others, like studies by Stanford’s Tim Goodnough, MD, a hematologist and the director of transfusion services, are years old but only recently being noticed. The takeaway message from all is the same: While blood is precious and continues to save lives, its use can be minimized and fine-tuned to optimize patients’ health and reduce costs.

The American Medical Association brought attention to the subject last fall at its national summit on the overuse of five medical treatments. Blood transfusions were on the list (along with heart stents, ear tubes, antibiotics and inducing birth in pregnant women).

“From the clinical standpoint, I’m not really thinking about resources or cost,” says Maggio, who’s also an assistant professor of surgery. “I’m thinking about giving the patient the best care.” Donated blood carries risks, albeit very slight, of infection and setting off an immune reaction. But research is also showing that even when these drastic outcomes are avoided, there’s something else about donated blood — which scientists don’t fully understand — that could slow recovery time or increase complications.

While autotransfusion for trauma patients is growing, and guidelines for blood transfusions are changing in response to this new research, altering the protocols that doctors have been using for so many years is a slow process.

 

Changing the routine

At Stanford, it took an innovative new program that used alerts on doctors’ computer systems to enforce fewer blood transfusions

But the push paid off: Blood use in the operating rooms, emergency rooms and hospital wards of both Stanford and the Lucile Packard Children’s Hospital has declined by 10 percent in just a few years. At Packard Children’s alone, 460 transfusions and $165,000 were saved in one year, according to a pilot study conducted Feb. 1, 2009, through Jan. 31, 2010.

‘There’s this idea ingrained in the culture of medicine that people will die if they don’t have a certain level of blood, that blood is the ultimate lifesaver.’
– Patricia Ford, MD, Founder and Director of Pennsylvannia Hospital’s Center for Bloodless Medicine and Surgery at Penn Medicine

“I think we’re probably still giving too much blood in some of these situations,” says Maggio. “But we hope that physicians are becoming better informed about when to give blood.”
People most often need blood transfusions when they’re in one of three situations: They lose blood from a major surgery that’s been scheduled for weeks or months; they lose blood in a way that their body won’t be able to replace, such as a blood cancer that shuts down the body’s ability to make blood cells; or they lose blood during a more sudden trauma — either an external wound or internal bleeding.
“For that first group of patients, scheduled for elective surgery, if you can plan ahead, you should be able to avoid using blood,” says Goodnough, a professor of pathology and of medicine. In those patients, drugs can boost a patient’s own blood production ahead of surgery, blood can be collected from a patient ahead of time to re-infuse later, precautions can be taken to prevent sudden blood loss, or autotransfusion machines like the cell salvage device can be set up. “Where we still need a national blood inventory is for patients who can’t plan ahead,” says Goodnough.
In the cases where physicians continue to give blood when it might not be needed, it’s often because they can’t imagine not doing everything they can to help a patient — and blood has always been viewed as having far more benefits than risks in almost any population of patients. But now, that risk-benefit analysis is changing.
“There’s this idea ingrained in the culture of medicine that people will die if they don’t have a certain level of blood, that blood is the ultimate lifesaver,” says Patricia Ford, MD, founder and director of Pennsylvania Hospital’s Center for Bloodless Medicine and Surgery at Penn Medicine. “And that’s true in some specific situations, but for most patients in most situations it’s just not true.” Ford’s center is one of the oldest and largest in the country that specializes in treating patients without donated blood; dozens of others have been created over the past decades but mostly at a smaller scale.

Going bloodless

 

Every year, Ford treats or operates on around 700 Jehovah’s Witnesses, whose religion prohibits transfusions of blood that is not one’s own. Since 1996, she has been fine-tuning ways to give these patients the best care as well as ways to apply these techniques to the broader population.

“Many physicians I talked to at the beginning had this misperception that a lot of patients just can’t survive without receiving blood,” says Ford. “I may have even thought that myself to some degree. But what I rapidly learned was you can care for these patients by just applying some easy strategies.”

In fact, a study published in August 2012 by researchers at the Cleveland Clinic concluded that Jehovah’s Witness patients recovered better from heart surgery than patients who received blood transfusions. It’s the longest study conducted on such patients — the researchers followed them for up to 20 years. The Jehovah’s Witness patients had higher five-year survival rates, fewer heart attacks following the surgery and fewer complications including sepsis and renal failure. The better outcomes might not have been due to the absence of transfusions but to differences in care received — the patients were more likely to be treated for low blood levels before surgery by receiving iron supplements and vitamins, and every patient’s surgery included use of an intraoperative cell salvage device. The findings suggest that these methods employed for bloodless surgeries could help patients beyond the Jehovah’s Witness community.

At Pennsylvania Hospital, Ford has discovered that, for scheduled surgeries, one of the best ways to avoid the need for blood transfusions is to test patients’ levels of hemoglobin — the protein in red blood cells that carries oxygen — well before their surgery. If the levels are low, then the patient can take vitamin K and iron supplements, which help the body produce more blood cells and help red blood cells more efficiently carry oxygen throughout the body. The practice of testing for low red blood cell levels, or anemia, is now beginning to spread from specialized clinics like Ford’s to other hospitals around the country.

“Testing for anemia was just not on people’s radar screens, because they knew that they could always give the patient blood,” says Ford. Now, many doctors consider testing a patient’s blood cell levels just as important as testing their heart and lung health before surgery. This shift is supported by studies such as an October 2012 analysis in the Annals of Thoracic Surgery of the outcomes of more than 17,000 heart surgeries, which found an increase in stroke, death during surgery and death after surgery when patients were anemic before surgery.

At Stanford, standard pre-surgery tests include blood counts for patients who are expected to lose large amounts of blood, says Goodnough. If anemia is suggested by the results, clinicians aim to manage the condition before surgery.

At Penn, Ford also emphasizes the conservation of blood during surgery, often by using an intraoperative cell salvage device. Patients can also donate blood in the weeks leading up to a scheduled surgery and their own saved blood — called an autologous donation — can be used for a transfusion if necessary. In the 1980s, Goodnough studied the usefulness of autologous donations in different patient population groups and pushed for its broader usage. It’s now considered a mainstream way of reducing the need for donated blood. “It sounds like a mundane concept now, but it was quite progressive when we first started looking at it,” says Goodnough.

Among Ford’s lessons with the Jehovah’s Witnesses, she says that perhaps her most important has been that there’s no magic hemoglobin number that tells doctors when a patient will start exhibiting signs of anemia. Typically, doctors consider hemoglobin above 12 to be normal, and hemoglobin below 7 or 8 to indicate the need for a blood transfusion. But Ford and a growing number of other doctors think those numbers could be pushed down further, a change that would require new studies for many to adapt.

“It’s not unusual for me to see a patient who has a hemoglobin of 5 and they look as healthy as anyone walking down the street,” says Ford. Of course, there also can be patients who become sick with much higher hemoglobin levels, but Ford would like to see more doctors treating blood levels based on symptoms, not a number. Goodnough agrees: “It’s really hard to demonstrate at what level of hemoglobin a transfusion will help a patient,” he says. “And we’re increasingly seeing that for most patients, hemoglobin has to be exceptionally low to have effects.” But it depends more on the patient’s health and risk factors, he says. There’s no one-size-fits-all solution.