The Gift Relationship by Richard Titmuss: Return This Gift to Sender
The Wall Street Journal reported recently that the U.S. blood supply has dropped to “critically low levels during the pandemic (and) since March, when businesses and schools closed due to the COVID-19 outbreak, tens of thousands of blood drives have been canceled, and American Red Cross officials don’t expect a return to normal for a year or more.” Even more alarming, pre-COVID-19, the supply of blood and blood components in many hospitals was at dangerously low levels. In a recent communication, the American Association of Blood Banks (AABB) and American Red Cross stated that “prior to the COVID-19 pandemic, the blood supply was fragile due to historical trends and challenges, such as difficulties with blood donor recruitment, changing medical practices, reduced blood utilization, costs associated with implementing new safety measures, and consolidation throughout the health care system.” This confluence of factors has led us to a dangerous and unstable equilibrium, especially for platelets, which we have outlined in a white paper here. America has a precarious and inadequate blood supply whose challenges grow inexorably with time. This impacts care, drives up costs for hospitals to purchase blood components, and places patients at risk. One in ten thousand transfusion recipients are at risk of death due to sepsis from contaminated platelets; an untold number likely perish from a lack of available components. Especially since most hospitals have only one choice of blood providers (which we discuss in a recent communication), there is an urgent need for a new, diversified and viable source of supply.
The good news is that there is a long-term solution achievable today – the responsible compensation of donors. This path requires bold new thinking. Unfortunately, a dogma that dates back to the Nixon administration stands in the way – and it is irrelevant, dangerous, and most alarmingly rooted in racism that has no place in America’s society or medical care today. This dogma is based primarily on the work of Richard Titmuss, which we firmly reject. The rest of this article sets forth our case why the transfusion medicine industry should too.
Who is Richard Titmuss?
The Gift Relationship is a half century-year-old book by Richard Titmuss, a sociologist with little to no practical experience in the actual provisioning of blood to hospitals. He worked until the time of his death as a social administration professor at the London School of Economics. His book is often cited as the de facto bible by those who decry compensated donation as a strategy to improve the availability of transfusable blood components.
The book begins with a recitation of the history of the transfusion medicine industry. Titmuss goes on to describe the (then evolving) dynamics of blood component supply and demand, making clear at the time the US relied on a mix of blood sourced from commercial as well as non-profit entities (he estimates that in 1965-1967, 29% of components came from paid donors, and when counting for source plasma donors this number increases to 47%). The book then (correctly) notes the irresponsible business practices of the then commercial blood collections companies and highlights the accurate view that at the time, paid donor sources of blood were indeed more risky than volunteer sources of blood, specifically discussing the spread of viral hepatitis from blood transfusions. This is where any charitable reading of The Gift Relationship ends.
A modern-day reading of Titmuss reveals underlying racial bigotry in his arguments in support of unpaid donations. The passage cited at the outset of this post lays bare that historical (white) recipients of blood products did not want to mix their blood with transfusions from blacks. They were inappropriately worried that donors who were racially and socioeconomically different from themselves would ‘contaminate’ the blood supply they were accessing. By paying donors, the feeling at the time was that remuneration would attract “undesirable” donors. To this point, in addition to multiple references to “Negroes” and “Negroid” donors, Titmuss most directly states that black blood donors do not have the wherewithal to know the most basics of their medical history, implying that only white donors have the mental ability to understand and relate this information. He states that a blood donor program reliant on blacks means that “the risks of transmitted disease may be increased.” The fundamentals of Titmuss’ arguments on safety and need are naïve and impractical; the whole of his conjectures must be cast aside given his fundamentally racist stance and findings that are irrelevant to modern transfusion medicine. Titmuss must be relegated to the dustbin of history for his bigoted views. His book is a gift not worth receiving.
We note, however troubling, that The Gift Relationship is still today being used to argue against new ways of thinking and to ignore the real regulatory and technological advances that successfully address blood safety requirements. For example, Merlyn Sayers, the CEO of Carter BloodCare, authored an editorial published recently in the journal Transfusion titled Paid donors: a contradiction in terms and contraindicated in practice. It is hard to look past the fact that this article praises and supports Titmuss and his work and specifically uses it to caution against the use of compensated donation.
Opposition to the issue of compensated donation, including recitals of The Gift Relationship, must be completely reevaluated considering: 1) considerable technological advances and the evolution of business practices since the 1970s and 2) urgent, growing blood shortages and associated patient needs. Specifically, the FDA clearance of nucleic acid testing (NAT) in 2002 and pathogen reduction (PR) in 2014 pave the way for the safe and reliable use of paid donor sources of blood components. It is noted that PR functionally eliminates the risk of bacterial and viral contaminants including, HIV and SARS-Cov2. Empirical evidence can be drawn not only from the impeccable two-decade track record of the source plasma industry (which rely almost exclusively on paid donors) but also the extensive experience of the Mayo Clinic, whose data show that blood sourced from paid donors is as safe if not safer than that of blood sourced from unpaid volunteers. STS described this thinking in a recent white paper.
Abstract philosophical discussions cannot serve as an impediment to achievable solutions. In a theoretically ideal world, many would agree that blood donation should be a fundamentally charitable act and that altruistic behavior alone should be relied upon to ensure a safe and plentiful blood supply. As Sayers himself states in his opinion piece:
The phrase “more research is needed” has been written often enough for the plea to lose any sense of relevance or urgency. That is not the case here. There are avenues to explore, particularly with regard to recruitment, before it is prematurely assumed that the only solution to the aging of the donor base is payment of donors.
While further research is welcomed into the topic of donor motivations, a safe and practical solution to persistent blood supply challenges is at hand today: the responsible compensation of donors. However, we must not conflate the desire to research with the urge to procrastinate. Millennials, Generation Z, and other younger cohorts face enormous challenges today including average student loan debt of $20-25,000 and markedly reduced home ownership rates. These well-meaning individuals do not have the time or inclination to participate in apheresis blood donations that can take three hours. It is clear that responsibly used compensation can play an important role in harnessing a disengaged cohort of potential donors. When queried about the topic of compensated donation, a 24-year-old blood donor interviewed by the Wall Street Journal in the 2020 article referenced above said that she likes knowing she is helping people and doesn’t feel less altruistic for taking money. “Why can’t I do both?” she says.
Finally, the existing system has markedly blurred the lines between purely altruistic donations and collections tied to some sort of direct benefit to the donor. As discussed in a December 2019 Guidance Document for FDA Staff, allowable donor incentives include event tickets, reduced hotel room rates, frequent flyer miles, scholarship programs, and gift cards. We note the particularly aggressive use of donation incentives in light of reduced volunteer donations around the COVID-19 pandemic, with some non-profit centers offering $20 gift cards.
Antiquated and inappropriate perspectives from a half-decade ago, including recitations of the Richard Titmuss book The Gift Relationship, must cease providing fodder for inaction or misleading information in today’s society. The responsible compensation of donors for difficult to source components in high demand must be implemented urgently to stabilize blood supplies, and this strategy can live harmoniously within the existing volunteer “non-remunerated” system.
Secure Transfusion Services (STS) is a specialty blood collection organization focused on supplying hospitals with hard to source transfusable components using the source plasma industry model of responsibly recruiting donors compensated for their time. The initial screening for STS donors differs from that of the current volunteer model. First-time donors have no transfusable product collected. Instead, donors at their first visit to an STS facility undergo health, history, and infectious disease screening in accordance with AABB standards. Components are collected from donors on a second appointment, where the collected units are used only if both the initial and subsequent infectious disease screening tests are negative. Further, STS employs 100% use of pathogen reduction allowing its customers to be fully compliant with the FDA’s Bacterial Risk Control Strategies for Blood Collection.