Why Blood Donation Is Unpaid: A Global Perspective
By Krista Thomas, Communications Strategist
It’s not uncommon for SBC team members to receive questions as to why SBC does not pay donors who generously give their blood. Do we not value our donors? Is it too costly? Too logistically challenging?
The short answer is, if a donation is paid for, hospitals are unlikely to use it to transfuse patients due to safety to concerns, and, since 1978, the FDA has required blood centers to label any donations for transfusion as coming from either paid or volunteer donors.[1] While paying donors for transfusable products is legal in the United States, it is highly discouraged for a number of reasons that have been repeatedly touted by the World Health Organization (WHO) and are backed by scientific data. While we will get into the reasons that volunteer donors are the “gold standard” below, first, a bit of context.
Type of Donor Systems
Globally, there are three models used to provide blood to patients: volunteer, paid and family/replacement. As previously stated, voluntary blood donation is what we rely on here in the U.S. Its definition is fairly straightforward: Donors are not provided monetary compensation for their donation. And a paid system is also what you’d expect: Donors are given monetary compensation for their donated blood. The third model, family/replacement, requires that a patient in need of a transfusion provide their own donor at the time treatment is needed. This is often a family member but can also be someone who has been asked or hired by the family to donate on the patient’s behalf.[2]
Countries around the world differ on which methods are used most often (and, which are legally sanctioned). According to WHO, of 135 countries surveyed, “79 countries collect over 90% of their blood supply from voluntary unpaid blood donors; however, 56 countries collect more than 50% of their blood supply from family/replacement or paid donors.”[3] In general, voluntary donation is more prevalent among “high-income countries,” though “middle-income” and “low-income” countries have been trending towards higher rates of volunteer donors in recent years.[i]
Why Volunteer Donors?
While it may seem like simply paying donors or making donation more personal through family ties may solve blood supply issues, there are a number of factors that need to be considered when determining what is the best system for patients.
Safety
As all donors in the U.S. know, the longest part of giving blood is filling out and speaking to your medical history via the regulated Universal Donor History Questionnaire (UDHQ) that you’re required to fill out at each donation. The UDHQ asks questions that pertain directly to your medical history as well as to activities that may put you at a greater risk for contracting a disease, virus, etc. that may be transmissible via transfusion. Examples of these activities include traveling to a country with high rates of a certain disease and using non-sterile needles to inject drugs that are not prescribed by a doctor. These questions are important because, while all blood in the U.S. does undergo rigorous testing before it is transfused, these tests can have decreased sensitivity in the days following an infection (“window period”). In addition, approved donor screening tests are not available for some infectious diseases. Therefore, deferring donors who report risk factors for certain infectious diseases is an added layer of safety for the blood supply.
While donors who give blood in a volunteer-based system have little incentive to lie about their medical history and risk factors since their primary motivation is helping patients, donors in a paid system have money on the line. This can lead to donors withholding pertinent information and, potentially, making it through the screening process even when they should not be eligible to give blood due to concerns for patients’ or even their own safety.
In a family/replacement system, while hospitals/blood centers do not pay the donors, “there may be a hidden paid donation system in which money or other forms of payment are actually provided by patients’ families,” according to WHO.[4] Research has also found that donors in a family/replacement system tend to be less informed about what conditions or risk factors should preclude them from donating.[5]
Though it’s possible to have donors giving altruistically in all the systems described, the bottom line is that research has continually shown donations given voluntarily to be safer for patients than those given in a paid or family/replacement system.[6] This is the main reason that hospitals in the U.S. do not currently accept paid donations in particular and why so many health organizations advise against any method besides voluntary donation.
Availability
The other major consideration in evaluating donor systems is whether or not they support a blood supply that is both steady and voluminous enough to address patient need. While you might be inclined to think that paying for donations would be a surefire way to fill up appointments, studies have actually shown that altruism is the most dependable motivator and, accordingly, that countries that employ a volunteer-based system have the most “sufficient, sustainable blood supplies.”[7] According to WHO, “Analysis shows that countries with 100% voluntary blood donation have a higher proportion of regular blood donors and that this has been maintained over a number of years. Further, in countries where the percentage of voluntary blood donations has risen, there has also been an upward trend in the percentage of regular blood donations.”[8] Voluntary donors generally give blood more often than any other type of donors, which means that hospitals are better equipped to support patients any time they are in need.
In a paid system, the availability of blood depends on a blood centers’ ability to afford blood products when they are most needed, which could be more unreliable and potentially drive up costs for patients. And, in a family/replacement system, a patient’s ability to receive treatment depends on their connections, their ties to family or their ability to pay for a replacement donor, which can lead to great inequity in treatment and certainly does not support a stable, readily available blood supply.
Perhaps the most relevant testament to the reliability of a volunteer donor system is something we have all experienced very recently: the way in which those who are motivated by patient need, especially in times of local and national crisis, step up to give blood when the need is greatest. WHO notes that countries with a volunteer system are often able to pull together to overcome disaster and tragedy together,[9] which is something we at SBC have seen during the COVID-19 pandemic.
Though we are still having more difficulty meeting patient need than we did before the pandemic due to logistical challenges (Read the “How COVID-19 May Have Permanently Changed Donor Recruitment” article in this issue of PULSE!), even when a shelter-in-place was in effect, we never had to turn a patient away due to insufficient blood. You may even recall that when need was at its height last summer and we weren’t sure if we would get by, SBC and many other blood centers around the U.S. began running media and noting the serious criticality of the situation more publicly. As soon as our community was made aware of the situation, we had so many donors, both new and existing, sign up to give blood that we were nearly 100% booked up with appointments for over a month! The desire to do good for others — your desire to go good for others — really is powerful.
Ethics
The third and least often addressed consideration is what can only be described in terms of ethics or respect and care for individuals’ wellbeing. WHO notes that systems in which donors are paid can turn exploitative, particularly for those who’re struggling financially and turn to selling blood, even when it may not be safe for them to do so, as a means of supporting themselves. On the flip side, in family/replacement systems, families may face significant financial hurdles in paying for volunteer donors outside of a regulated healthcare system (potentially creating a black market for donated blood) and may avoid seeking care or not being able to provide for care to their family members because of it.
Donors in family/replacement systems also may feel pressured to donate more than they should to support their family member for fear that they will not get the blood they need otherwise, which in turn puts pressure on doctors to take as much blood as possible (or, if donors aren’t available, to transfuse as little blood as possible) to accommodate the family’s situation.[10] In a family/replacement system, donors who may be ostracized by their family or not have living relatives are particularly disadvantaged and face even more stress in finding a donor at a time when they should really be focusing their efforts on healing.
While cost of treatment can still be a challenge in all three of these systems, ultimately volunteer systems provide the most ethical circumstances for donation and go the extra mile by making patients feel cared for by their generous donors and making donors feel rewarded for doing a selfless good deed.
But What About…
Paid Plasma?
To make this situation a bit more complicated, those of us in the U.S. are likely familiar with the concept of paid plasma donations. Plasma collected at a plasma center from paid plasma donors is referred to as “source plasma.” While we don’t want to focus too much on this topic in this article, there are a few distinctions worth mentioning that help clarify why dedicated plasma centers can more openly pay for plasma donations:
- Paid plasma donations are mostly associated with for-profit companies, and source plasma is primarily used for the creation of other drugs and therapies or for research.[11]
- Because source plasma is being used as a component for another drug/therapy rather than directly transfused, it undergoes extensive processing including further purification and sterilization than would not be appropriate for plasma that is directly transfused — all of which helps reduce concerns of transmitting diseases through plasma. There are challenges to implementing this type of processing for plasma that is directly transfused[12], [13] There are challenges to implementing this type of processing for plasma that is directly transfused.
- Additional donor testing criteria is required for source plasma donations which is not in place for plasma collected directly for transfusion.
- In general, nonprofit blood centers like SBC that collect plasma for direct transfusions to patients do not offer payment for plasma for all the reasons previously mentioned in this article, though there is still a need for and appreciation of donations!
Gift Cards and Other Donation Incentives?
Because we are discussing compensation for donations, and because you have likely received some sort of promotional item or thank-you for donating at SBC in the past, it seems only natural to wonder how this fits into the idea of a volunteer system. Ultimately, while our donors are primarily motivated by the desire to help patients, we know that sometimes having that extra incentive of a gift card or a t-shirt or even a raffle entry (Check out our Spring Raffle article in this issue of PULSE!) can push donors that extra step to make an appointment sooner rather than later, which can be particularly important for us in times of high patient need. Plus, it really is a great opportunity for us to say thank-you for your time and generosity!
It’s important to note that receiving the types of thank-yous you get from donating at SBC do not categorize you as a paid donor. This is because the FDA has regulations about what does and does not qualify as “payment” in the context of donation, and each promotional item offered at SBC goes through a rigorous review process to ensure it still meets the qualifications to uphold its recipients as volunteer donors.
You may have noticed on any redemption cards you get from SBC or even on your old coupons and Cinemark tickets that there is a small sticker with our heart mark logo on it, and around that sticker are the words “non-refundable, non-transferrable and non-redeemable for cash.” These are the main points all blood centers must take into consideration in selecting their thank-you items and why we have to be selective in the types and amounts of gift cards we offer to ensure they cannot simply be traded in with the vendor for money directly.
In Conclusion
Ultimately, a volunteer donor system is the safest, most reliable and most ethical donation system of the three systems used internationally. But, it’s important to point out that the reason it is so reliable, the reason it works for patients, is because of how incredible and giving blood donors are. We at SBC say all the time we are thankful for your generosity, and this is why! We know that we can count on donors to show up when patients need them most and to do so out of the goodness of their hearts. If we didn’t have donors like you, the system would not be possible. So, to anyone who has donated blood with us or with any other blood center, thank you for your selflessness and for making the work we do possible.
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