Blood and altruism - Richard M. Titmuss' criticism on the commercialization of blood

Public Interest, Summer, 1999 by Joel Schwartz

To what extent can we - and to what extent should we - rely on altruism to provide for the needy? That is the overarching question of a provocative book published in 1970 by British social scientist Richard M. Titmuss. Recently restored to print in a revised edition,(1) The Gift Relationship: From Human Blood to Social Policy approaches this issue through a painstaking and critical investigation of American methods of collecting blood for transfusion. Titmuss contrasted the American practice, in which recipients paid for blood, some of which was purchased from donors, with British practice, in which blood was freely given to patients and received from altruistic donors. He argued that more blood was wasted in America than in Britain, that American hospitals frequently ran short of blood, and that blood purchased from American donors was less safe and more likely to spread hepatitis among its recipients.

The book is a classic in the literature of muckraking and did much to alter the practices that it denounced. The American practice in which whole blood was sold, as opposed to freely donated, was abandoned not long after the book's publication.

But, as the book's subtitle suggests, Titmuss wrote his work less as a technical treatise on blood donation and transfusion than as a theoretical statement about social policy. This larger purpose aroused the interest of distinguished social scientists, including Kenneth J. Arrow, Nathan Glazer, and Robert M. Solow, each of whom devoted an extensive review essay to The Gift Relationship.(2) They were responding to Titmuss's warnings about the dangers of employing market mechanisms in administering social services:

If blood is morally sanctioned as something to be bought and sold, what ultimately is the justification for not promoting individualistic private markets in other component areas of medical care, and in education, social security, welfare services, child foster care.... and other "social service" institutions and processes?

Because Titmuss's polemic was pervaded by this larger concern, The Gift Relationship has rightly been described as a book about blood in the sense that Moby Dick is a book about whales. His larger concern is grasped by science journalist Douglas Starr (writing in his recently published Blood: An Epic History of Medicine and Commerce), who says that Titmuss viewed the U.S. blood system "as the symbol of everything wrong with American-style capitalism."

Titmuss's critique of markets in which blood was bought and sold reflected his wider social vision. He was a vigorous proponent of the collectivist model of providing social services and a stern critic of attempts at privatization. Titmuss articulated this vision in many of his writings and has been justly described - in the introduction to a posthumous collection of some of his essays - as "the premier philosopher and sociologist of the Welfare State."

Much has changed since Titmuss's death in 1973. His contention that the state must do more if social problems are to be solved is more controversial now than it was then. And, as I have indicated, American blood-collection practices today differ greatly from those that he described. In part, these changes derived from the emergence of new and more lethal medical risks. When Titmuss wrote, the great danger faced by those receiving transfusions was hepatitis, not HIV.

With the benefit of a generation's worth of hindsight, how well does Titmuss's analysis stand up? Are the changes in our methods of collecting blood evidence of his prescience? How plausible is Titmuss's case that altruism is preferable to economic self-interest as the basis for social policy? To answer these questions, we must examine his critique of American blood collection as practiced in 1970.

Titmuss's critique

Titmuss argued that American efforts to procure blood for transfusion were defective because they were debased by commerce:

The commercialized blood market fails. In terms of economic efficiency it is highly wasteful of blood; shortages, chronic and acute, characterize the demand and supply position.... Finally, in terms of quality, commercial markets are much more likely to distribute contaminated blood [than is a system in which blood is freely donated and transfused]; in other words, the risks for the patient of disease and death in the form of serum hepatitis are substantially higher.

But Titmuss's evidence for some of these charges was less than ironclad. (He himself repeatedly called attention to the inadequacy of available data concerning American blood collection.)

To begin with, just how commercialized was American blood collection when he wrote? In other words, what percentage of American blood donors were impelled by economic, as opposed to altruistic, considerations? In Titmuss's view, it was a "deeply held myth ... that the voluntary donor is the [American] norm." Instead, he calculated that less than 10 percent of Americans who gave blood could truly be described as voluntary donors, whereas almost a third were paid for their donations. These figures applied to donors of whole blood. If those providing only their plasma were included,(3) the figure for paid donors rose to 47 percent.