Discussing the intricacies of your mother’s medications is probably not what you would expect to be among the talking points during family dinner. But here we were discussing the fact that certain animal products are among the ingredients in most of her prescribed pills — and it made for interesting conversation. For the last seven generations, our family has followed a strict vegetarian diet. We also follow Hinduism (Vaishnav sect), which discourages the killing of animals and ingesting food that is derived from animals. Mother has faithfully followed her diet and her religion, and, when given the choice, will not ingest medications containing animal products. Since some meds do not have alternatives, she is sometimes left with no choice but to take those medications. Many patients who present in outpatient wound clinics across the country may be experiencing the same religious and ethical dilemmas. This article will help to educate providers and program directors on the types of medications and wound care products that include animal properties and offer guidance on how to consider alternatives for their patients given the complex field of cellular and/or tissue-based products (CTPs) and the diversity of religious beliefs.
PRESENCE OF ANIMAL-DERIVED MEDS & PRODUCTS
Animal-derived products are regularly used in all fields of medicine and surgery, which means practitioners are likely to encounter a situation in which the use of a product conflicts with a patient's religious beliefs. (See Table 1 for a few examples of related drugs, dressings, CTPs, and surgical implants.) Also, there is a popular vegan movement that is not based on the teachings of an established religion, but nevertheless could cause a patient to be ethically opposed to the use of animal-derived medical therapies. In some people’s cases, there will be a risk of nonadherence or lack of compliance if there are conflicts between religious and/or ethical beliefs and prescribed treatments.1 One study reviewed the position of religious and spiritual leaders of the six largest religions worldwide (18 branches) in 26 different countries (see Table 2) and found the following: Hindus and Sikhs did not approve of the use of bovine- or porcine-derived products; Muslims did not accept the use of porcine-derived products; and Christians (including Jehovah’s Witnesses), Jews, and Buddhists accepted the use of all animal- and human-derived products2 (with an exception among Jews who follow a kosher diet and do not eat pork or shellfish). Jehovah’s Witnesses do not approve of the use of blood-derived products. Interestingly, the same report found that all religions allowed the use of animal-derived products if there were no alternatives or an emergency situation existed.2 To learn whether a drug contains animal content, the manufacturer or a national medicines agency can be contacted.3 However, in many situations, the information related to animal-derived products is not accessible.2
Wound care clinicians utilize several products daily, so the need to discuss the sources of these products with patients is paramount. Wound care clinic providers should also regularly review the components of CTPs in use and become comfortable broaching this often-overlooked issue with patients. A study conducted in the United Kingdom found that the majority of healthcare professionals did not know the origin of animal-derived products in frequently used dressings and CTPs.4 For many patients, the use of CTPs is a welcome alternative to autologous skin grafting because it avoids anesthesia and the creation of a donor wound.5,6 A partial listing of available CTPs and their animal origins can be found in Table 3. Alternative drugs, dressings, CTPs, or implants without human or animal-derived content do exist, but not for all products.5,6 Also, collagen dressings commonly used in wound care are derived from bovine, porcine, or avian sources. In contrast, alginate dressings are derived from brown seaweed or kelp. Honey-based dressings are derived from either active Leptospermum, a genus of shrubs and small trees in the myrtle family Myrtaceae, commonly known as “tea trees,” or Manuka honey. Maggot therapy7,8 and leech therapy are also widely used as part of chronic wound management.
Wound care clinicians and clinic program directors should have a goal of fostering an environment that respects the cultural and ethical world views of patients. Nutritional/dietary screening questionnaires are effective tools to utilize during a new patient’s evaluation for various purposes, including raising awareness of religious and/ or social restrictions/preferences that impact diet and nutrition. Gathering this information early in the course of treatment alerts the clinician to potential conflicts. If patients have strong prohibitions against certain tissue types, these can be noted in the chart (just as with an allergy). Screening can be used as an educational opportunity for all parties, since the practitioner can gain a more clear understanding of the patient’s beliefs, and the patient can gain more detailed information about various products. Signed informed consent about the use of animal-based wound products is beneficial to both patients and providers, and is important to procure.9 Consider speaking in the following manner to obtain a patient’s permission to use animal products: “[Patient], in order to heal, the human body uses materials very similar to those used by animals to provide strength and support, such as collagen. Sometimes, when the body doesn’t heal the way it should, we borrow those components from animals. However, some people, for religious or personal reasons, do not want to receive products from certain animals (or any animals). Do you object to the use of products made from animals or certain types of animals in order to help your wound to heal?” Studies suggest that the majority of religions make allowances in life-saving situations. However, it is often possible to avoid conflicts entirely if the practitioner actually understands the patient’s beliefs. Most people of faith are appreciative, rather than offended, when practitioners take time to discuss their deeply held convictions. As a result, clinicians may find that engaging in this dialogue actually benefits the therapeutic relationship.
Jayesh B. Shah is president of the American College of Hyperbaric Medicine and serves as medical director for two wound centers based in San Antonio, TX. He is also adjunct assistant professor in the department of community Medicine at UT Health, San Antonio, TX, and president of South Texas Wound Associates, San Antonio. He is also past president of the American Association of Physicians of Indian Origin and the Bexar County Medical Society.
Helpful Questions Related to Patients’ Religion & Lifestyle
Consider asking the following questions to help gain an understanding of patients’ spiritual and lifestyle preferences and to foster appropriate communication about concerns that may arise.
• Are there foods that you do not eat for religious or spiritual reasons?
• Do you have any restrictions related to receiving blood and/or blood products?
• Do you have any restrictions related to the use of products that are made from animals (or from specific animals)?
• Do you wear special items of jewelry or clothing and feel that your well-being might be affected if they are removed? If so, what are these items?
• Do you seek help from anyone other than a licensed medical provider when you are not feeling well, such as a “medicine man” or herbalist?
• What language is spoken in your home?
• Do you prefer to speak or read a language other than English?
• Will anyone other than you be participating in the decisions affecting your care?
• Do you have legal documents/information pertaining to your healthcare that we should be aware of?
AMA Adopts Policies on Animal-Derived Products
The House of Delegates for the American Medical Association (AMA) recently approved policies aimed at helping to increase the awareness of animal-derived medical products among healthcare providers. According to an AMA statement, the new policies urge manufacturers to include all ingredients and components present in medical products on the product’s label, including both active and inactive ingredients, and to denote any ingredients derived from an animal source. The new policies also encourage cultural awareness regarding patient preferences associated with medical products containing active or inactive ingredients or components derived from animal sources. The policies are enacted following a report by the AMA’s board of trustees that found that 70% of physicians were unaware that several medications contained animal-based ingredients. However, 70% of physicians also thought it was important to inform patients who might object if such medications are prescribed, the report claims. According to the AMA, manufacturers are not required to declare on labels how an ingredient is sourced, which means it is not present in drug databases and clinical decision-support systems for physicians.
1. Sattar SP, Ahmed MS, Madison J, et al. Patient and physician attitudes to using medications with religiously forbidden ingredients. Ann Pharmacother. 2004;38(11):1830-5.
2. Erickson A, Burcharth J, Rosenberg J. Animal derived products may conflict with religious patients’ beliefs. BMC Med Ethics. 2013;14:48.
3. Mynors G, Ghalamkari H, Beaumont S, Powell S, McGee P. Informed choice in medicine taking: drugs of porcine origin and their clinical alternatives: an introductory guide for patients and carers. The Muslim Council of Britain. 2015. Accessed online: http://archive. mcb.org.uk/wp-content/uploads/2015/12/ Drugs-Derived-From-Pigs-and-their-Clinical- Alternatives_Booklet.pdf
4. Enoch S, Shaaban H, Dunn KW. Informed consent should be obtained from patients to use products (skin substitutes) and dressings containing biological material. J Med Ethics. 2005:31(1):2-6.
5. Chern PL, Baum CL, Arpey CJ. Biologic dressings: current applications and limitations in dermatologic surgery. Dermatol Surg. 2009;35(6):891-906.
6.Limova M. Active wound coverings: bioengineered skin and dermal substitutes. Surg Clin North Am. 2010:90(6):1237-55.
7. Turner J. Debriding chronic wounds with larval therapy: the new answer for biosurgery in the outpatient wound clinic? TWC. 2017;7(11):20-4.
8. Gaydos J. History of wound care: maggots: an extraordinary natural phenomenon. TWC. 2016;10(4):29-31.
9. Doyal L. Good clinical practice and informed consent are inseparable. Heart. 2002;87:103-6.