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.


The case, to be sure, did not end there. The Community Blood Bank, turning to the judicial branch of government for relief from the executive,succeeded in January, 1969, in having the 1966 ruling of the Federal Trade Commission set aside by the Eighth US Circuit Court of Appeals in St. Louis. The commercial blood bankers who might, in their next and final move, have appealed to the Supreme Court for reinstatement of the Commission’s determination, did not do so. Their success in typing up for more than a decade the efforts of the Kansas City medical community to provide for its professional needs a reliable and hygienic source of blood is striking enough to suggest that in America there is always a further chance for the truly enterprising. The gates of opportunity never finally close, even on the unqualified.

So, at least, many Americans would like to believe, and believing it is more important to them than protection from hepatitis, which, unlike failure, hardly threatens self-esteem. To be sure, compassion, justice, and generosity are counted as virtues in the ideology of Americanism, and are frequently encountered in practice. But the sense that one has been led to display these virtues tends to arouse shame rather than pride or a sense of community: shame at having been uncool, at having stuck one’s neck out; at having gotten involved, and thus having given a stranger a competitive advantage. This is the disheartening implication of an ingenious group of short experiments reported by Bibb Latané and John M. Darley,1 in which they observed the response of bystanders to simulated emergencies, in which they might have chosen to intervene to assist another person.

By staging a wide and devilishly ingenious range of situations, including epileptic fits, liquor store robberies, an attractive young woman apparently trapped under a pile of office furniture, and a mysterious fire, these investigators found that the bystander was much more likely to risk trying to help the victim if he believed himself to be the only observer than if other persons were present, and least likely to help if the other observers were, like the victim, strangers rather than acquaintances.

Latané and Darley explain their findings as what they call “diffusion of responsibility,” inferring that the solitary observer, believing himself to be the sole possible source of assistance, feels himself more strongly obliged to intervene than the observer who sees others, presumably equally responsible, who decline to do so. Each observer, knowing that others had not apparently intervened, becomes reluctant to take the risks of intervention upon himself; so that, in the event—as in the murder of Kitty Genovese, which the authors cite—thirty-eight people may be collectively less likely to help than one might be.

But it is still shocking that these observers should be so certain that non-intervention involves no comparably serious risks of social sanction or even of disapproval of their neighbors. Even grating that it is human to do what is easiest, least threatening, and most acceptable to the people we live among, we must ask how our society became one in which ignoring the misery of others—or, as at Song My, inflicting it on them—is reckoned more acceptable social behavior than intervening to prevent it. How can we all be so sure that other observers will tolerate and tacitly endorse our mutual irresponsibility?

We become sure, I think, through our simple and sometimes complex experience of what that society has come to be like; of the increasingly grim social groups that have come to dominate it; of what happens to people who help in a social system that obsessively and compulsively responds to people primarily according to whether, at the moment, they appear to be winners or losers. In such a society, not only can there be very little sense of community; there can be no effective provision for any need, however vital, that conflicts seriously with the exploitation of that need by major economic interests.

American society is not designed to respond to needs, which are what losers have. Instead, it responds to demands, which are what winners are in a position to make. Note, for example, the virtual impossibility of financing free or experimental schools which base their appeals on the unmet needs of children, compared to the extravagant provision now being made for the booming day-care center industry, which responds less to the needs of either children or parents than to the demand that welfare rolls be cut by enabling mothers with dependent children to be put to work. Like the Midwest Blood Bank and Plasma Center, these centers reopen lucrative channels for making it through child care that have been unexploited since the “baby-farming” days of Victorian England.

Titmuss’s data on Japan, moreover, suggest that a corresponding ethical climate has become established there, in response to a comparable emphasis on the expansion of economic opportunity. As already stated, virtually all blood available for transfusion in Japan comes from commercial banks. The rate of post-transfusion hepatitis ranges from 15 to 30 percent according to the area in which the study was undertaken. Japan, notoriously, has long been troubled by peculiar paradoxes attending its modernization. Many feudal social forms survived industrialization. Large industrial firms still accept responsibility for lifetime employment of workers; compared to Americans, Japanese workers enjoy much greater job security and much less economic mobility.

The unresponsive bystander syndrome, however, became institutionalized a long while ago. Ruth Benedict, I believe, in The Chrysanthemum and the Sword nearly thirty years ago mentioned that urban Japanese were usually unwilling to offer assistance to a stranger who had become the victim of an accident because, according to established custom, to do so would be to assume responsibility for the rest of his life—and this was not an appealing possibility under the conditions of modern urban life.

However, The New York Times for Sunday, March 21, in a front-page feature story from Tokyo headed “College Jam Evokes Scandal in Japan” reports that:

The annual frenzy of examination time in Japan—crams, angling for introductions to college officials, contributions to schools to assure students’ admissions—has been accompanied this year by a scandal, a murder and widespread questioning of the nation’s values.

Because of the nerve-wracking competition to get into government or private schools and universities—and especially medical schools—entrance examinations are printed under maximum security in 48 of the country’s 66 state prisons. Six weeks ago, the police, investigating what appeared to be a gangland murder in Osaka, uncovered a syndicate that stole medical school exams from Osaka prison and sold them, mainly to wealthy doctors eager to get their children into medical school, at prices up to 10 million yen, or $28,000.

Since the scandal erupted in the press about two weeks ago, editorials and letters columns have been filled with protests over corruption in the prison system, the alleged mercenary nature of the medical profession and the “examination hell” that subjects most ambitious youngsters to a long, difficult road of competitive exams from kindergarten to university.

The Times article continues as a long, rather bizarre analysis of the economics involved in medical school entry by legal or illicit means, without really getting into “questioning the nation’s values.” But some of the more fundamental questions of value that this episode raises hardly fall within the range of the Times’s ideology. The most important of these concerns the role of medicine in a developed society. Should health care be a monopoly of the medical profession, or would larger numbers of paraprofessionals serving more of the population at a lower technical level both break this monopoly and provide a quality of service that would make medicine something more useful than the specialized prolongation of life of the moribund wealthy aged? Ivan Illich has raised precisely this issue on many occasions, sometimes in the pages of this journal. But it is apparent that there is an antecedent question: Which do those Japanese in a position to influence public policy want more: medical care or a chance to point with pride to their son, the doctor?

Yet another value question arises, even less congenial to the modern commitment to equality of opportunity as the paramount social value. Why should not the sons of physicians be given special preference in admission to medical school? Japan has a long feudal tradition. Guilds have played a prominent part in organizing the skills available in Japanese society for centuries. The mere fact that this sort of bribery goes on among the more successful members of the medical profession establishes that the culture must still provide a norm, however anachronistic, that supports it. To make this practice workable, enough influential doctors must believe that they really have a right to nominate their sons as colleagues and successors in preference to aspiring outsiders; otherwise those who got in by bribery and cheating would, in too many cases, be exposed as incompetent.

The mercenariness of the American medical profession and the commercial sale of blood, I would suggest, are tolerated because of the overriding assumption that the most important function of any social institution is to provide those who maintain it with economic opportunity. As compared to this, the institution’s manifest function, whatever it may be, is just not taken seriously in a competitive, open society. This, after all, is why medical and nursing care—most of which is routine—is maintained as a monopoly in scarce supply. This is why as astute a critic of the educational system as Miriam Wasserman finds cause in her superbly insightful book, The School Fix: NYC; USA2 to indict the schools for their success in teaching lower status children that they are destined for failure rather than, as has been customary, for their failure to develop the skills and potential of these children. But the support and maintenance of existing status distinctions are always an important part of the function of the official institutions of any society; and of schools especially.

What is ghastly is that, in a society committed to equality of opportunity, this can only be accomplished by attacking the children as unworthy and lodging their failure securely in their weakened self-esteem rather than in the dynamics of the society that oppresses them. The schools are constrained both to serve the interests of existing elites and to defend the existing status system as not merely convenient for those with relatively high status, but basically open and just as well. Schools humiliate their less privileged students by teaching them that they are inferior rather than merely, for essentially arbitrary reasons having little or nothing to do with their individual attributes, ineligible for positions of high status.

If school attendance were not compulsory, the schools could continue about their business of serving those who accepted the status system and sought preferment on its terms without having to teach lower status children the only thing many of them are really permitted to learn there: that they are supposed to be the losers in a free and open society. But modern, egalitarian industrial states are deeply and dishonestly committed to the necessity of involving everybody in games whose winners could usually have been accurately predicted in advance on the basis of perfectly ostensible—though not particularly admirable—characteristics: such as the kind of mind defined in such societies as intelligent and the kind of behavior and attitude regarded as constructive.

Consequently, a large class of angry and resentful people is created who are convinced that they have been cheated because they have done what they were supposed to do but have been denied the rewards they were led to expect, and who become increasingly aggressive as they become increasingly frustrated. Such people have come to constitute the dominant political reality in most nations of the world, regardless of their basic economic systems.

Basic improvement in the quality of life must be achieved, if it is to be achieved at all, against the quite legitimate opposition of this class—a hard fact for democratic ideologues to accept. Ecology freaks and anti-pollution campaigners, for example, insist that their programs would benefit the entire population, since everyone suffers from the destruction of the environment. But most anti-pollution measures do indeed restrict economic development—that is the whole point—and hence economic opportunity and employment.

Proposals for de-schooling society and reducing its dependency on formal credentials would indeed, if implemented, liberate children from the humiliating imposition of a constrictive and often foreign style of life, and make it harder to label those who rebelled or resisted as losers. But they would also deny parents who wanted to submit their children to such indoctrination, or children who wanted it for themselves, in the interests of “getting somewhere,” from using education as a means of social mobility—which is why working-class parents are so frequently impatient with liberal upper-middle-class teachers who “don’t make their kids work” or “don’t teach them anything.”

This does not mean that the preservation of the environment and the elimination of compulsory school attendance are not goals to be zealously sought. It means merely that there are real conflicts of interest in society, and that the better course of action may sometimes be distinguished and supported even though by doing so one advances the interests of a relatively privileged class at the expense of the already disadvantaged. It is by no means obvious, and may not even be true, that more Americans will profit from the availability of clean blood without cost than from the opportunity to participate, without penalty, in shady business transactions involving their or other persons’ blood.

Those, like Titmuss and probably most of his readers—in view of the way serious reading is related to social class in America—who would prefer to stop this traffic in bad blood must then surely learn to tolerate the existence of bad blood between them and their ambitious adversaries, and to accept the probability that a society that treated blood as a humane resource would probably also provide substantially less opportunity for economic mobility than the United States now does, or than they, as conscientious liberals, might wish.

Indeed, one issue that must haunt any radical reader of Titmuss is the very success of the British system of collecting and distributing transfusible blood, which Titmuss never tries to explain. He does make it clear that, in direct contrast to American practice, upper status Englishmen give at least their proportional share of blood through the National Blood Transfusion Service, though they also withdraw rather more than their share, since even under the National Health Service physicians apparently attribute more extensive surgical needs to their higher status patients. It seems likely, therefore, that the British system works at least partly because British society remains more personal and clublike, and less economically dynamic, than American, and that it would become less dependable as it grew more impersonal, competitive, and open. More Englishmen, perhaps, will give their heart’s blood to keep that banjo teacher, used car salesman, and photographer from achieving real economic and political power—an action both noble and prudent.

Titmuss likewise leaves unexplained his curious datum that half the transfusible blood collected in the Soviet Union is purchased from donors. This does not, of course, go into a commercial bank for resale and cannot, therefore, bring in its suite the invidious moral effects Titmuss attributes to the commercial sale of blood. But it would not be necessary or even tolerable if egalitarian state socialism brought with it, in addition to its manifold economic advantages, a greatly enhanced sense of human brotherhood.

The sense of human brotherhood, however, is not an unmixed good; among its consequences is a refusal to face serious moral issues like those related to the sale of blood, if those issues turn out to be seriously devisive. At the present moment in America, this is especially the case: The argument for “the cooling of America” resounds through the land. Those who advance it take comfort from the fact that the wave of protest has died down, that the dissenting young, especially, seem to be coming reluctantly to terms with the system. They concede that this may be a response to repression rather than reconciliation, and that it may be regrettable that the moral fervor so movingly displayed by a segment of American youth should have been lost with no corresponding indication that trust has been restored. But, on the whole, the change is seen for the better, in the interests of preserving American society from destruction by fatal polarization; it grants a respite in which conflict may be worked through to a position of mutual accommodation.

The preservation of America from polarization hardly seems desirable, however, if it must be accomplished on terms that leave dominant in America the side of the polarization that is willing to destroy as much of the rest of the world as may be necessary to preserve American hegemony, or at least the illusion of it. It is hard to see how, with any consistency, even Middle Americans can deny the justice of a sentence of life imprisonment for pushers of the American flag—a dangerous drugget if ever there was one, whose influence has been, and is, responsible for millions of bad trips and countless uncontrollable homicidal fantasies with tragic results—though that penalty may be excessively severe for simple possession, even by such devils as the Joint Chiefs.

These people, common as they are, are truly enemies of life; and I believe that the argument that the resistance is now ready to negotiate with them is based on a false premise about what is happening. Dissenting American youth, having ripped into the body politic with a genuinely therapeutic purpose—though often crudely and without the anesthetic of civility—seems to have concluded that the condition revealed by their incisive intervention was so much more desperate than expected as to make further surgery futile—especially in a society in which a good supply of transfusible blood cannot be counted on.

They have dismissed their operation, as surgeons sometimes must, as an exploratory laparotomy. After one of those, the sickroom is usually quieter and less tense; physicians cease to hassle the patient and concentrate, instead, on making him as comfortable as possible and saving his energy so that he might take advantage of a miracle, if there should be one. Things settle down. If the surgeon has reason to believe that his own life is linked to that of the patient the atmosphere is unlikely to become really cheerful; but there is still nothing to be gained by being unpleasant to others.

This Issue

May 20, 1971