One frequent challenge in treating cancer patients, including those with osteosarcoma, arises when patients refuse blood transfusions due to religious beliefs (such as Jehovah's Witnesses). Just a decade or so ago, I promptly and immediately refused to treat such patients when I encountered them. Even now, I do not consider it right to refuse transfusions when life is at stake. But what can one do? Religious beliefs are not something that can be understood by the common sense of ordinary people.

Since 2012, I have advocated for minimal transfusion. This is based on a scientific perspective, not a religious one. Specifically, it is based on two key facts: the theory that excessive transfusions negatively impact patient outcomes, known as Patient Blood Management, and the recognition that past transfusion practices were excessive. I have therefore implemented treatment using minimal transfusions for my patients.

Now, I have gained the confidence that most surgeries can be performed without the need for transfusions. Consequently, without any intentional effort on my part, Jehovah's Witness patients began seeking me out.

For osteosarcoma cases, I have been performing transfusion-free procedures since 2013. The surgical approach itself hasn't changed much. Although the patient numbers aren't large enough for statistically significant results, we previously used an average of six pints (six units of blood) before and after surgery. Now, we perform procedures without any transfusions whatsoever. Perhaps because of this, there hasn't been a single case of the once common surgical site infections, and patients' recovery times seem significantly faster.

As mentioned earlier, transfusions are directly linked to postoperative infection. I find this approach satisfying and take pride in it. The problem is the helplessness I feel when encountering patients who are simply too difficult to manage without transfusions, even for someone like me.

There was a male patient in his 40s with chondrosarcoma in the pelvic bone. The tumor was so large that we had to perform surgery to resect half of the pelvic bone. Orthopedic textbooks typically do not specify blood loss volumes for specific surgeries; however, this particular procedure does, noting a staggering 3,000 cc. The textbook's 3,000 cc is likely based on a master surgeon's standards; for a specialist like me, it would be more, not less.

At the time, the patient's hemoglobin level was barely above 10.0 g/dL (the normal range is 13-14 g/dL). If bleeding exceeded 3,000 cc, death was inevitable. Yet the patient insisted on no blood transfusion. One might as well ask why I transfused blood and said I didn’t. No, that’s absolutely not permissible in this case. Death due to refusing a transfusion might be acceptable, but saving a life through transfusion is not, becoming a bigger problem. After agonizing over it, I came up with a creative idea and managed to complete the surgery. The patient even talked with me in the ICU, but ultimately passed away that evening.

Despite the successful surgery, the patient's death left me deeply distressed and guilt-ridden. I called the family to express my sincere apologies, but they responded by thanking me for helping their loved one uphold his beliefs. They also requested that I never give up and always strive to treat patients with religious convictions.

Most doctors criticize Jehovah's Witnesses for refusing blood transfusions. Having treated them for over a decade, I now focus on providing the best possible care, rather than criticizing or persuading them. I understand that religious beliefs are not about right or wrong, but exist beyond life itself.