In The Gift Relationship, the distinguished Professor of Social Administration at the University of London, Richard M. Titmuss, examines and discusses a quite unfamiliar but most revealing index of social values. His book, subtitled “From Human Blood to Social Policy,” is a study in depth of the contrast between the British and American systems for providing human blood for transfusions, complemented by glimpses of comparable practices in the Soviet Union, South Africa, Japan, and Sweden. More accurately, one might say that Professor Titmuss contrasts the British system for supplying needed blood with the American chaos that fails to provide it, or provides instead a dubious and often fatally deficient or infectious fluid.
In both countries, the demand for blood transfusions has increased at a far more rapid rate than population, with the elaboration of techniques like open-heart surgery artificial kidneys, and organ transplants. In England, where the collection and supply of blood has been organized and controlled by the National Blood Transfusion Service since 1948, there are no paid donors, though there are some, like prison inmates and servicemen, whose participation in the program can hardly be regarded as wholly voluntary. The amount of blood available is, on the whole, adequate for the nation’s surgical needs—though this is in part merely a way of saying that the British, being less freaked out on technology than Americans, more often eschew the bloodier forms of surgical and political enterprise.
English blood is obtained under circumstances that permit careful and accurate records to be maintained of the medical histories of donors. Donors are not permitted to give blood more than twice a year. The incidence of serum hepatitis following transfusions—the most serious risk involved—is less than 1 percent, as compared with between 3 and 4 percent in the United States, causing some 10,000 deaths per year. The US rate is rising; while in Germany and Japan, hepatitis now occurs in about 15 percent of patients after transfusion.
In these high-risk countries the truly voluntary donor contributes very little to the blood supply. Half the blood collected in the United States from 1965-67 was bought outright as a commercial transaction between the donor and, usually, a commercial blood bank. Forty percent more was obtained under a contractual arrangement whereby the donor established a credit for himself and his family in anticipation of need, or discharged a debt incurred. An unknown number of these transactions were covered by commercial donors hired to substitute for the blood debtor. Only 7 percent were true volunteers. Using data from a variety of sources that, admittedly, are not fully comparable, Titmuss considers 98 percent of blood “donations” in Japan to be, in fact, purchases; estimates in Germany run up to 85 percent purchases—with the proportion being higher in East Germany than in the Federal Republic, except for West Berlin where, as in Sweden and the United Arab Republic, all “donors” are reported to be paid.
Reliance on paid donors, especially through the agency of commercial blood banks that collect blood in skid row storefronts for the convenience of the desperate, of course shifts the burden of supplying the nation’s need for blood to the poorest and sickest members of society. The frequency with which such “donors” come to be bled is also greater: five times a year is normal practice in the United States, though the actual frequency for some donors who eke out a bare existence by contributing to several blood banks, each unbeknownst to the others, is far greater. Furthermore, because of the new technique of plasmapheresis in which the red blood cells are returned to the donor after bleeding him, plasma donations may be accepted several times a week, on the usually false assumption that the donor is eating a highly nutritious diet to replace blood protein in the meanwhile.
Obviously, quite aside from the social injustice of bleeding the poor and the black to meet the nation’s sanguinary needs, the danger to the total population of collecting most of the blood available for transfusions on the skid rows of the nation is very great, particularly with respect to hepatitis, which is endemic among hard-drug addicts, many of whom give their poor blood in order to support their habit if not themselves.
Indeed, the technology of commercial blood collection makes the danger of infection far greater—for blood so collected is mixed into large pools, and then becomes infected, with no reliable record of its origins. In fact, no trustworthy record ever existed, for desperate men selling their life-blood must often falsify their medical histories.
But the baleful effects, moral and social, of the commercial blood market in the United States go much further. Whole blood is living tissue, whose cells, as in all tissues, die and are replaced. Separated from the body, red cells continue to die; the blood becomes useless, then toxic, after three weeks’ storage even under the best conditions. Moreover, such storage is itself very costly, requiring meticulous control of light and temperature. In the United States, about 30 percent of all blood collected is wasted—never used—because of administrative confusion, transportation difficulties, and panic among surgeons who habitually order more blood than they expect to use in the hope of getting enough under conditions of mounting shortage. About 2 percent of the blood collected in Britain goes unused.
In the United States, malpractice suits based on post-transfusion hepatitis increase in magnitude and frequency until they become insupportable even actuarially; insurance becomes unavailable. Professor Titmuss summarizes the position with understated eloquence:
From our study of the private market in blood in the United States we have concluded that the commercialization of blood and donor relationships represses the expression of altruism, erodes the sense of community, lowers scientific standards, limits both personal and professional freedoms, sanctions the making of profits in hospitals and clinical laboratories, legalizes hostility between doctor and patient, subjects critical areas of medicine to the laws of the marketplace, places immense social costs on those least able to bear them—the poor, the sick and the inept—increases the danger of unethical behavior in various sectors of medical science and practice, and results in situations in which proportionately more and more blood is supplied by the poor, the unskilled, the unemployed, Negroes, and other low income groups and categories of exploited human populations of high blood yielders. Redistribution in terms of blood and blood products from the poor to the rich appears to be one of the dominant effects of the American blood banking system.
Yes. It has been more than thirty years since Harold Lasswell defined the function of politics as eliciting blood, work, taxes, and applause for ruling elites from their subjects. And, in America, this process may be unusually painful for those from whom most is extracted. Poverty, to ordinary Americans, is not merely bad, but tabu, a violation of the folkways that makes outcasts of the poor, who are perceived as macabre and threatening more readily than as pitiful, and hence not as fit objects of compassion. No factor has contributed more to the abrasive polarization of American society than the insistence of the left on treating the poor—and especially the doubly despised black poor—with fraternal generosity and respect. In the shifting, competitive cacophony of American life real losers are represented only in the lowest and most terrifying levels of the unconscious; and efforts to make those who are more fortunate picture them as human are fiercely resisted—especially by those who are only marginally more secure and hence more easily threatened by the image of what might be.
The Poor Liberation Movement has been going on for a long while now, without meeting much popular success; though Christianity has toyed for centuries with the notion that “poor is beautiful,” it hasn’t really caught on in mainstream America. The poor are abhorred there, while, conversely, the fact that any deal or arrangement may provide a pathway to economic advancement is usually enough to justify its adoption. This principle, too, is vividly illustrated in Professor Titmuss’s account of the efforts, beginning in 1953, of a group of “doctors, pathologists, hospital administrators and local citizens” in Kansas City to form and operate a nonprofit community blood bank. “For the next two years,” Titmuss notes:
there were endless disputes among the various interests involved (which need not concern us here) about power, institutional control and finance. Then, in May 1955, a commercial blood bank (calling itself the Midwest Blood Bank and Plasma Center) started operations.
The bank was owned and operated by a man and his wife. He had completed grade school, had no medical training, and had previously worked as a banjo teacher, secondhand car salesman, and photographer. The blood bank procedures seem to have been actually directed by his wife. She called herself an R.N. but was not licensed as a nurse in either Kansas or Missouri, and did not show any evidence of experience or training in blood banking. Originally, there had been a third partner, but he had been chased out of the bank by the husband, with a gun. A medical director was appointed to comply with public health regulations. He was aged 78, a general practitioner with no training in blood banking. The bank was inspected and licensed by the Federal authority, the National Institutes of Health.
It was situated in a slum area, displayed a sign reading “Cash Paid for Blood,” drew blood from donors described as “Skid-Row derelicts,” and was said by one witness to have “worms all over the floor.” In 1958 another commercial bank, the World Blood Bank, Inc., was established in Kansas City and also began operations….
The two commercial banks then complained to the Federal Trade Commission alleging restraint of trade. In July, 1962, after an investigation lasting several years, the Commission issued a complaint against the Community Blood Bank and its officers, directors, administrative director and business manager; the Kansas City Area Hospital Association and its officers, directors, and executive director; three hospitals, individually and as representatives of the forty members of the Hospital Association; sixteen pathologists, and two hospital administrators.
The respondents appealed. After lengthy hearings…a ruling was issued in October, 1966. By a majority of three to two the Commission decided that the Community Blood Bank and the hospitals, doctors, and pathologists associated with it were illegally joined together in a conspiracy to restrain commerce in whole human blood.
The records, transcripts, and exhibits in this marathon case ran to over 20,000 pages and cost the respondents and the taxpayers something over $500,000.
To anyone primarily concerned as Professor Titmuss is here with decent medical care and the evolving power of a community to develop the institutional means to meet its own needs, this story is a scandal. But isn’t it equally a classic American success story? How like those other innovators of American banking practice, Bonnie Parker and Clyde Barrow and their associates, the founders of the Midwest Blood Bank and Plasma Center were. Yet, how much more creative, for they became, not outlaws, but enterprising citizens willing and able to operate within the existing legal system; and that system did not betray their trust. Slowly, exhaustively, sparing no expense, ever vigilant to protect the industrious small businessman from the conspiratorial machinations of large institutions and their professional staffs, the Federal Trade Commission, after hearing all sides, firmly took its stand for freedom of enterprise in Kansas City.