HEC Forum DOI 10.1007/s10730-014-9252-6

The Gift Relationship Revisited Jeremy Frank Shearmur

 Springer Science+Business Media Dordrecht 2014

Abstract If unremunerated blood donors are willing to participate, and if the use of them is economical from the perspective of those collecting blood, I can see no objection to their use. But there seems to me no good reason, moral or practical, why they should be used. The system of paid plasmapheresis as it currently operates in the United States and in Canada would seem perfectly adequate, and while there may always be ways in which the safety and efficiency of supply could be increased, there seems no reason whatever to think that there would be an improvement if the current system changed so as to rely entirely on unpaid donors. Further, given the adequacy of paid plasmapheresis, I could see no problem if the collection of whole blood were to take place on a similar, fully-commercial, basis. Such a view is controversial. To argue for it, this paper offers just one strand in a complex argument: a critique of Richard Titmuss’s Gift Relationship, which holds an iconic position in the critical literature on the paid provision of blood. As I conclude: all told, there seems no good basis for rejecting supply of whole blood for money— let alone the supply of blood plasma. Keywords Richard Titmuss
The Gift Relationship
Blood donation
Plasmapheresis

Introduction In my personal view, if unremunerated blood donors are willing to participate, and if the use of them is economical from the perspective of those collecting blood, I can see no objection to their use. But there seems to me no good reason, moral or practical, why they should be used. The system of paid plasmapheresis as it J. F. Shearmur (&) School of Philosophy, RSSS, CASS, Australian National University, Canberra, ACT 0200, Australia e-mail: [email protected]

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currently operates in the United States and in Canada would seem perfectly adequate, and while there may always be ways in which the safety and efficiency of supply could be increased, there seems no reason whatever to think that there would be an improvement if the current system changed so as to rely entirely on unpaid donors. Further, given the adequacy of paid plasmapheresis, I could see no problem if the collection of whole blood were to take place on a similar, fully-commercial, basis. Such a view, I realize, is controversial. To argue for it systematically would require a book rather than a single paper.1 On the present occasion, I am offering just one strand in a complex argument: a critique of Richard Titmuss’s Gift Relationship (1970), which holds an iconic position in the critical literature on the paid provision of blood. The Gift Relationship casts a long shadow over the last forty-odd years of discussions of the supply of blood and blood products. Titmuss made a striking case, in part moral, in part empirical, against payment for the supply of blood. It was a powerful piece of work, and has made a lasting impact, including, I would suggest, on the recent proposals to shift away from paid plasmapheresis (and reliance also on US-supplied plasma from paid sources), in Canada. I would hope that the present essay, if successful, will play its part in chipping away at the views which underlie such proposals. In order to understand the argument against the paid provision of blood which took place in the late 1960s and 1970s, one needs to understand the historical developments which gave rise to it.2 To cut a very long story short, during the Second World War, the use of blood plasma and whole blood became common in the medical services of the Armed Forces. After the war, the American Red Cross, who had been responsible for wartime provision in the U.S., stopped providing blood. Surgeons who had found the use of blood and blood plasma invaluable wished to continue using it in civilian life. To meet their need for blood, a plethora of forms of provision developed. There was the paid collection of blood, which took various forms; the provision of blood on a volunteer basis (some of which the Red Cross organized when they re-entered the field), and also a range of forms of provision, sometimes organized by individual hospitals, sometimes by community blood banks, which often combined insurance and blood credit schemes. These typically offered insurance for the unpaid provision of blood to family members, if one family member made an annual donation. This was supplemented by a scheme in which those without blood insurance were supplied with blood, but with the requirement that multiple replacement of units was made on their behalf—a scheme being developed such that friends and family members could make such donations from anywhere in the U.S., which would be credited to the individual in question. The American Association of Blood Banks (AABB) operated a clearing-house system, modelled on that of the banks, with only net transfers being made of actual 1

See, for further discussion, Shearmur (2001, 2007a, b); see also (Shearmur 2003, 2010).

2

This paper draws on work undertaken for a larger project, over many years, including in archives at the Stanford University School of Medicine, and the NIH. I will limit the extent to which points are documented in order to keep notes to a manageable length. For a most interesting and informative guide to some of the history here, see Starr (1998).

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blood. It was also possible to avoid such replacements, by means of the payment of a hefty fee. Problems emerged in two areas. On the one side, for payment blood was typically obtained from two markets: college students, and also from people in poor areas— often from those on ‘skid row’. The latter posed a problem, because of relatively high rates of viral hepatitis which were transmitted in their donations. On the other side, there were problems because the non-paid sector developed what might be referred to as two incompatible economies of blood. The Red Cross aimed to draw on the blood of volunteers from a particular area, and then to give blood (without charge for the blood itself) to those who needed it in the areas in question. The other main form of provision—around the American Association of Blood Banks—typically operated on the basis of an assurance-insurance system of the kind that I have briefly described.3 The incompatibilities occurred in two forms. First, the operation of the AABB system required that records be kept of donations, and on whose behalf they were being made. Second, the way in which the AABB had been historically constituted, had the consequence that a few blood collection agencies which worked on a for-profit basis were members. This in turn had the consequence—which scandalized some of those associated with the Red Cross—that in principle blood which had been given by their volunteers might end up being given to for-profit blood banks, as a result of the operations of the clearing house system. This led to a campaign being undertaken against both paid provision and against what I will refer to as the AABB system. Again, the story was complex, but in the U.S. an important role was played by Joseph Garrott Allen. He had, as a surgeon, been in charge of the blood bank at the University of Chicago, and had become concerned about the high levels of hepatitis in their blood supply (which came about as a result of the changing character of the Hyde Park area, around the University of Chicago, from which they were drawing their blood). He subsequently moved to Stanford, and while there undertook intensive activities against paid blood. At the same time, the issue was taken up in the press—who were able to present lurid details of, for example, people being ‘paid’ for their blood with coupons for use in liquor stores—and in Congress, notably by Victor V. Veysey. As a result of these activities, a decision was made in 1971 to develop a National Blood Policy, one concern of which became the elimination of paid blood from the U.S. system (see Shearmur 2007b). If one looked at the U.S. blood supply at the time, it is not obvious why this should have been taken as an objective. For the problem of hepatitis in the blood supply was, essentially, not a problem of paid blood, but a problem of those from whom this blood was drawn. That is to say, the problem was that some of the poorer people from whom paid blood was drawn were carriers of hepatitis. This was not the case in respect of all paid blood. The Mayo Clinic, for example, was able to collect, from paid sources, blood of a better quality than was generally available from the Red Cross (Kessel 1974). The NIH itself collected blood, for payment, from its 3

Arrangements were, in fact, much more complex than this; not least because of the existence of a large Community Blood Bank sector (see, for an overview, Drake et al. 1982). In addition, what I am here describing as the ‘Red Cross’ and ‘AABB’ systems did not completely match membership of the Red Cross and AABB networks.

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employees. Some hospitals had moved from a volunteer system to paid panels of blood donors (drawn from former volunteers), because they found that management of people who were being paid was cheaper and more reliable (e.g., in meeting needs in holiday times).4 The discussion was settled in part because of the strongly moralistic stance taken by those opposed to paid provision and in part because those hospitals using panels of paid providers were a small minority among providers, and had no organization to speak for them. One other issue in the background, which I have been told about informally, was that part of the problem was that, in some cases, surgeons themselves owned for-profit blood-banks using paid donors, who supplied the hospitals for which they worked, and it was thought that only a complete banning of paid provision could provide a way of controlling such practises. At the time, the different forms of viral hepatitis had not been identified, and tests were not available. However, statistical information was available as to who presented the most risk as sources, and, as Ruben Kessel argued in a brilliant paper (Kessel 1974), the obvious move was simply to make hospitals—and, beyond them, collection agencies—responsible for the quality of the blood which they collected and dispensed, and as he argued, on a strict liability basis. Two points are, here, of interest. The first is that there were, in fact, two competing streams of jurisprudence relating to the liability for the provision of blood which transmitted infections. One, stemming from New Jersey, treated blood as a commodity, which made it possible for the providers of defective blood to be sued. The other, stemming from a New York decision,5 treated the provision of blood as a service and on this basis ruled out the possibility of such cases. The two streams competed for while, but the issue was in effect settled by the increasing use of uniform commercial codes, which typically took the side of the New York strand. The second issue was that the critics of commercial provision typically argued strongly against the idea that hospitals should be held liable for the quality of the blood that they transmitted. Here, Richard Titmuss—whom the next section of this paper discusses—was a notable example (Titmuss 1970, chap. 9). Titmuss merits some detailed discussion in his own right, just because he combined pioneering comparative work on the blood supply, with moralistic criticism of commercial provision, in his immensely powerful and influential The Gift Relationship. This work not only made a striking case against paid blood—and also against what I am here referring to as the AABB system—but it made it in such a way that it cast a long shadow. His work was of some influence in philosophy,6 in making a case

4

See letters from J. S. Hayhurst, Blood Bank of San Bernardino-Riverside Counties, San Bernadino, Calif., 25 March 1974 and J. Wesley Alexander and George W. Geisen, University of Cincinnati Medical Center, 30 April 1974, Folder 1.2, Box 1 of NLM MS C 393, National Library of Medicine, Bethesda, MD, USA.

5

Perlmutter v. Beth David Hospital, 308 N. Y. 100, 123 N.E. 2d 792 (1954). See, for a useful survey of these issues from the perspective of the mid-1970s (Havighurst 1976).

6

Notable, here, is his influence on the work of Singer (1973, 1977).

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against paid provision generally, and was also an important reference-point for, for example, the work of Elizabeth Anderson.7

Richard Titmuss and The Gift Relationship Richard Titmuss was a remarkable man, who held a Chair in Social Administration at the London School of Economics without ever having attended university.8 He was influenced by Tawney and by Fabian Socialism, and became a powerful—and dogged—theorist of and spokesman for the British Welfare State. In this context, he was involved in a number of arguments with those who wrote for Britain’s marketoriented Institute of Economic Affairs,9 who were, at the time, advocating the use of market mechanisms in just those areas of health and social welfare provision within which Titmuss was strongly committed to defending state-provided universalism. Titmuss looked around for examples which would tell against the kind of case that the IEA was making, and in this context was struck by the U.S. system of blood provision. He undertook research on this, and developed a powerful case for the British (and American Red Cross) style of provision, as compared to paid provision and also the AABB model. I have described Titmuss’s argument as powerful, because he was able to combine a striking emotional case with a plethora of empirical information. At the risk of not doing full justice to what is a most interesting and rich study, Titmuss’s argument might be summed up in the following terms. (I will discuss, here, his argument against paid provision; I will discuss his separate line of argument against AABB-style arrangements, when I turn to them later in the paper.) First, Titmuss argues that the British system is superior in economic terms: it is both cheaper and involves less waste. Second, he argues that, on medical grounds, it is to be preferred. Third, it is to be preferred morally. Here his argument is, in part, that one should prefer a system which makes use of donors drawn from across the whole community rather than people who are paid; in part also, that it is to be favoured because it serves to foster community. (One might also add here, although Titmuss himself would not have put it in such terms, that it is attractive to those attached to the socialist ideal of ‘‘From each according to his ability, to each according to his needs’’.)10 Titmuss’s empirically-based case is backed up with an emotionally striking survey, in which, for example, a blind man is quoted as appreciating the opportunity to be a blood donor, because of the way in which this enables him to make a contribution to society, rather than being dependent on others. All told, Titmuss’s book advances an impressive line of argument and one which, as I have noted, has been widely influential. Unfortunately for those who favour his 7

Compare, for example, Anderson (1990); for the Titmuss connection, see especially p. 196.

8

On Titmuss see, for example, Reisman (1977, 2001), and (Oakley 1966).

9

See, for some of the story, Fontaine (2002).

10

Karl Marx, Critique of the Gotha Programme; cf. https://www.marxists.org/archive/marx/works/ download/Marx_Critque_of_the_Gotha_Programme.pdf. In Titmuss’s case, however, there is—in Fabian fashion—a backdrop of paid professionals who direct the program.

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view, it seems to be largely incorrect.11 Or, rather, while he does address our attention to important issues, they do not have the general significance that he attributes to them, and thus support the general case against the use of commerce in this field, which he and others have drawn from them. Let Me Consider his Arguments in Turn First, Titmuss argues that the U.K. blood supply is cheaper, and leads to the waste of less blood. Here, there have been questions raised about his figures (although the pioneering character of his study makes this inevitable); more to the point is that, in comparing a small and in this respect centralized country with the Federal and within that highly fragmented structure of blood provision in the U.S., he was not comparing like with like. The issue of the wastage of blood is also complex, just because there were different elements involved, which it is difficult to disaggregate. That is to say, there may be wastage in the sense of inefficiency; but also blood may be ‘wasted’ as the other side of making sure that there is adequate provision, especially in a situation in which distances make the meeting of needs from other locations difficult. As far as cost goes, it is worth noting the example to which I referred earlier, where it was found to be both more reliable and cheaper for a hospital to make use of paid donors rather than volunteers: it costs money to manage volunteers, and they were found less responsive than those who were paid on a regular basis for the donations of their blood. Second, there is the medical issue. It was clearly the case that there was a problem about the provision of blood in the U.S. But this related to the drawing of blood from people who had unacceptably high rates of hepatitis. The existing system—which involved purchase of blood from such people—was clearly problematic. But as indicated above, there would seem no reason why this could not have been dealt with by way of the introduction of strict liability for the supply of contaminated blood. In fact, in this setting, there might have been advantages to commercial provision for the following reason. The collection of blood from donors—notably by the Red Cross12—has often been by way of appeal to ideas about civic duty. But this would mean that it would be difficult to exclude people as donors, if there is a statistical case for doing so, when this might seem discriminatory.13 (Compare the ongoing controversy about the blanket exclusion from blood donation of gay male donors.) The need to avoid upsetting established donors by requiring that they answer questions about their sexual behaviour, could also be problematic. In the early years of the HIV-AIDS problems, blood banks were slower to act to exclude gay donors than was the commercial sector, just because the commercial sector typically took a much blunter view of the people 11 Important criticisms of a Titmussian approach have been made by a variety of writers over the years, but what they add up to seems seldom to be appreciated. See, for example, Alchian et al. (1973), Sapolsky and Finkelstein (1977), Sapolsky (1989), Schwartz (1999), and (Healy 2006). 12 Not least because of the way in which the Red Cross has, historically, been associated with wartime provision. 13 For example, if there is a statistically higher rate of the injection of illegal drugs among a particular racial group in a particular area.

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from whom they were purchasing.14 In broad terms, commercial companies can simply choose with whom they will and will not deal, while for anything that looks quasi-governmental, or which has a strong community orientation, discrimination is problematic, and there is a commitment to consultation. There is, however, a more general issue here (Shearmur 2001). It is that one advantage of using donors relates to trust. At its strongest, the idea here is that one is likely, in respect of checks on the quality of blood, to have to depend on the truthfulness of one’s informants. (This is the case even when there are tests, if these depend on antibodies, as there may be ‘windows’ between the point of infection and when antibodies are produced in sufficient quantities to show up in a test.) The idea, here, is that there is an adverse selection problem: given that the sale of blood is stigmatized, those likely to be willing to sell will be the people from whom one would least wish to purchase. If, say, people are desperate for money, they might surely lie. By contrast, voluntary blood donors might seem to be paradigm cases of people whom one would trust. The situation here is not, however, as clear-cut as it might seem. For the criticism really related to the early period of paid donor recruitment. And, corresponding to it, a criticism was made of Red Cross recruitment in a similar period. It was argued— by Ross Eckert who was infected with HIV by way of Red Cross blood, and went on to write a number of critical studies of the Red Cross’s practises (see for example Eckert and Wallace 1985; Eckert 1986)—that the Red Cross were involved in what he termed the ‘promiscuous recruitment’ of donors. The issue here is that a reliance on donors for blood typically led to problems about getting enough blood, and this, in turn, led the Red Cross to make use of such things as competitions among senior school students, in which a prize was offered to the school that gave the most blood. This, in turn, led to strong informal pressures being put on potential donors (as also, say, might happen in blood drives at a person’s place of work). The underlying issue here relates to an effect which has, now, been well-documented; see (Piliavin and Callero 1991). It is that if someone can be persuaded to give blood a few times, they come to self-identify as a blood donor, to seek out opportunities to give blood, and to internalize the ethos of the blood system in which they are participating. It is, indeed, upon such people that one can then rely to comply with the rules governing giving blood. Before this happens, things might be more problematic, and—e.g., in the face of expectations of a person’s colleagues that they will give—that one may face problems not all that different to those of the paid donor. It was in response to this problem that Ross Eckert argued that the Red Cross should move to depending on a cohort of professional donors, the remuneration of whom is arranged so as to provide an incentive for regular donation and ‘good’ behaviour. On my understanding, this is the approach that has subsequently been taken, in practise, by those employing paid plasma donors, from whom, in the U.S., there seems now to be no significant risk. It should also be noted that a Titmussian approach would seem to be limited in its simple application to the case of hepatitis. In the case of HIV-AIDS, infection came into the system equally from people who were regular ‘Titmussian’ donors. It is also 14

For some interesting discussion of this, see Leveton et al. (1995).

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striking that one basis on which Titmuss argued—to which we will turn shortly— was that there is something attractive about using blood from donors who are representative of the entire population, rather than depending on relatively poor sellers of blood. But if this argument were accepted, it would, in fact, be the case that in some circumstances the blood supply would be more vulnerable to the transmission of certain diseases. Consider, in this context, the possibilities for the transmission of ‘mad cow disease’ (variant CJD) through the blood supply in the United States. Those who might be carriers of this disease would be, by and large, those who had consumed European—and, particularly, British—beef in the relevant period. But, other things being equal, a more representative sample of the population would have been more likely to have been involved in foreign travel than would a group who depended significantly on the sale of their own blood plasma. The force of Titmuss’s argument is, in fact, that the purchase of blood under certain circumstances in the U.S. happened to attract donors who carried a particular infection. It is not paid blood, as such, with which there is a problem. What of the moral argument? There is, undoubtedly, something attractive about the picture of blood donors voluntarily giving up their time to meet the needs of their fellows. We may also feel uneasy about depending on the blood of the poor. But let us look at these issues, in turn. First, it is well-known from the literature on donors in the U.S. that it is much easier to recruit and maintain a population of long-term donors in smaller towns than in large cities. The consequence is that citizens are subjected to considerable moral pressure to give. And here, as David B. Johnson argued in an (unpublished) paper,15 one needs, in assessing what is involved in policy choices, to consider the costs to individuals of opening them up to the kind of moral hectoring that is needed to produce, from volunteer sources, an adequate supply of blood and blood products. (It is striking in this context that in Australia, one consequence of the decision to supply all blood products from volunteer Australian sources, would seem to be the systematic under-supply of some plasma-based medications, in the sense of patients not being prescribed as much as would have been medically desirable.)16 Second, as Alvin Drake argued on the basis of empirical work,17 it would appear as if people’s moral preferences about the form of provision of blood are endogenous to the system with which they are familiar. In the cases which he studied, those used to an insurance/assurance system typically favoured the form of ‘individual responsibility’ which underlay that approach. While, by contrast, those who were used to the arrangements of the U.S. Red Cross, typically favoured its form of provision. If one puts this together with the work reported by Piliavin, to which I have referred before, it would seem as if people’s moral attitudes to the provision of blood are formed contextually. 15 See National Library of Health Archives, U.S. Department of Health Education and Welfare, National Blood Policy Records 1969–1981. 16

Personal recollection of discussion at a consultative meeting discussing Australian Blood Supply Policy, which had representation from patients’ groups. 17

See, on this, Drake (1976). He also contributed on this theme to Drake et al. (1982) and was also an author or co-author of related studies published internally by the Department of Operations Research at MIT; see Goodrich (1977) and Drake (1978).

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However, it might be argued, as did Titmuss: is there not something problematic about people being in a situation in which they turn their bodies into commodities, and in which we set up, or tolerate, institutions which make this possible? I would suggest that there are three aspects to this. First, we need, in this context, to bear in mind the outcome. That is to say, the consequences of the sale of blood when that took place, and currently of the sale of blood plasma, are good. Many people are alive, or are living in good circumstances, who would not have been if this had not taken place. Second, how problematic is it—or should it be—for the individuals involved in the sale? Clearly, some of those who were selling to feed a problem with alcohol or of drug addiction, or out of sheer poverty, were in a bad position. But on the face of it, it is that that calls to us for a moral response. I do not know of systematic documentation of the attitudes of those who sold blood in the U.S. who were not in difficult circumstances (e.g., university students). But there is some information about a comparable group of students who chose to sell blood plasma. Here, a fascinating study undertaken at a midwestern university suggests that the people selling their blood plasma were, in general terms, not badly off, and that they typically did so not to finance the purchase of essentials, but, rather, to support their social life in bars.18 An impartial spectator might not think much of their life choices, or of the decision to sell blood plasma in order to support it. However, this on the face of it would seem more a matter of taste than for moral condemnation. Titmuss offered another line of argument: that the freedom of the individual to give blood would be restricted if there was the option to sell. His own work suggested that there was a limited shift from donation to sale taking place in the U.S. However, three points are worth making about this. First, if the same people shift from donation to sale, there is clearly no effect on the quality of the blood supply. (The problem about paid blood was the product of who was selling, rather than that there was remuneration.) Second, there is documentation from Poland of the co-existence of both sale and donation within a single system.19 Third, one would expect that if there was a shift to a system in which only sale was possible, the effect might well be that some of the more affluent members of the population would no longer give blood. But on the face of it, one might judge that if these people are working, they could correctly judge that doing whatever they are normally paid for represents a more socially useful way of spending their time than using it to give blood. If they have a concern about the blood supply, they could, clearly, also be asked if they would make a donation towards its support. (Although why the supply of blood and blood products should be thought something which should be a matter for charity in a way in which other medical provision isn’t, is itself worth thinking about. If the answer is in terms of ‘the gift of life’, one might respond by asking the donor to think about the way in which donated blood is currently split into all kinds of components, used for all kinds of purposes, 18 See on this Anderson et al. (1999). On the sale of blood plasma see, e.g., Espeland (1984) and Kretzmann (1992). 19

An experienced researcher in this field, in a personal communication, has mentioned that: ‘‘When [the researcher] studied blood donors in Poland, they had a system in which people could give for pay or for nothing in the same facility. [The researcher] talked to donors who said they sometimes did one and sometimes the other, depending on how much they needed the money.’’

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including, in the case of plasma, for the preparation of chemicals and reagents by large commercial for-profit chemical companies.)20 The underlying issue might be simply a concern with the situation of the poor— who undertake jobs which many of us would not like, and who may be involved in the alienation of their labour in ways which we might find problematic. This is an interesting problem, but typically we have no qualms about people undertaking unpleasant and even dangerous work for money. While the partial alienation of ourselves—and for money—is part of what would seem to be an inevitable part of the kinds of economy within which most of us wish to live.21 I have indicated above that the Polish case to which I referred indicates that the simple presence of payment does not close off the possibility of donation. But clearly, commodification might affect the social meaning of the donation of blood. Changes in social meaning, however, take place all the time, and they are not, typically, things which we are willing to restrict other people’s freedom in order to control. And in this particular case, in respect of which a choice as to whether or not to allow for commodification is open to us, we would, I think, need to take into account just what is being claimed the costs and the benefits might be. I have, here, considered—and have taken issue with—Titmuss’s main lines of argument. But there was also another issue; that of ‘‘community’’. I will consider this in the next section as, in order to do so, I need also to consider an alternative form of blood provision, Titmuss’s arguments against it, and also to look at the interesting story of its disappearance in the U.S.

Titmuss, Blood and Community In an important paper published in 2002, David Archard offered a defence of Titmuss’s approach (Archard 2002). What is striking about Archard’s paper is that, in the course of it, he broadly admits the correctness of the kinds of arguments that I have discussed, above, against Titmuss’s work.22 He makes his argument, instead, on the basis of considerations—certainly to be found in Titmuss—that the kinds of arrangements that Titmuss favours are important because of their contribution to community. This is a view which may be found in the work of other writers— including the extraordinary suggestion, in the work of Peter Singer, that the moral differences on this score between London and New York are to be attributed to their differences in blood policy (Singer 1977, p. 167). Here, I wish to explore four issues. The first concerns the role of appeals to issues about community in the context of arguments about blood policy. The second relates to blood provision and the kind of community to which appeal is being made. 20

I should perhaps stress that I am all in favour of the existence and activities of such companies who on the face of it play a key role in saving lives. My point, in the text, is that it is not obvious why people should be expected to supply their raw material without payment. 21 For its unavoidability if we wish to live in an economy with the extensive advanced division of labour, see Hayek (1997). 22

He refers, in this context, to Rodriguez del Pozo (1994).

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The third relates to Titmuss’s arguments against AABB-style provision (which, I will argue, is the kind of provision which one should favour, if one thinks that community is an important issue here), and to the sad story of the demise of AABBstyle provision in the U.S., at the hands of the Red Cross and its allies. Finally, I will point to some problems about reliance on communities in anything like the traditional sense, under modern conditions. First, then, consider community and blood policy. Community is something that many of us find very attractive—especially because of the way in which it is something that, in the course of modernization, large-scale migration and the development of multiculturalism, seems to be under threat (Putnam 2007). However, not only is this issue one of long standing (To¨nnies 1957), but as Karl Popper suggested in his Open Society (Popper 1945), the attempt to restore community at a large-scale level by way of direct governmental action is all too apt to simply lead to a loss of freedom. In addition, one person’s idea of community might, for others, amount simply to the coercive imposition of values which they do not find attractive (Holmes 1988). Be all this as it may, suppose that we do, indeed, find a notion of community attractive, what should we make of the argument that blood donors are, here, significant? In some ways, the very idea seems rather odd—not least because relatively few people are involved in the giving of blood, and, in the United States, there still seems to be some confusion, among the general population, as to how blood provision takes place.23 At best, one might think that a readiness to give blood might be seen as a symptom of community: I mentioned, earlier, that it was more typical of smaller towns than of large cities. Let me now, however, move to our second topic: the kind of community with which we are, here, concerned. The point with which I am concerned here might initially seem strange. But it would seem worth exploring, even though I can deal with it here only briefly. There is a sense in which one might link a Titmussian/Red Cross approach to the collection of blood to community. But the notion of community in question seems to me a distinctive one. It is also related to the origins of the Red Cross approach: i.e., to the mobilization of a country in wartime, and to the direction—by our betters—of propaganda efforts at the rest of us to do whatever we are supposed to do to meet the functional needs of a wartime ‘community’. If people favour this in peacetime, they are, in my view, welcome to it.24 But with it may be contrasted a very different notion of community. What I have in mind, here, is a loose network of people linked variously by proximity, different kinds of shared identity, which inter alia responds to need on the basis of genuinely voluntary activity (rather than being organized by quasigovernmental agencies). This, it seems to me, was well exemplified by the kinds of community efforts which were involved in the AABB-type forms of provision. To my knowledge, there has been no systematic documentation of what was done here, so what I can best do is to convey some impressions from my reading in a very 23

I have found people who express surprise when told that blood is no longer purchased, while the ghost of the insurance/assurance arrangements still seems to live on in the basis of how people are encouraged to give blood in some areas of the U.S. 24 It is striking that, for example, David Miller favours the artificial creation by the state of such arrangements as a moral basis for a national health service; see Miller (1995).

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scattered literature. One may find, for example, such arrangements as local hospitals operating their insurance/assurance schemes in such a way as to generate a surplus of blood which could be used to assist the isolated (who did not have relatives or friends who could give on their behalf), or those with special needs for blood (such as those suffering from haemophilia). One found Rotary and similar groups making donations for the sake of members of their local areas who were in need. One found railwaymen making donations which would be credited to the account of a member of the union, who was geographically remote from them, whose son had haemophilia, and so on. The clearing house scheme itself—devised by Bernice Hemphill, a remarkable organizer and champion of the AABB approach (see LaBerge and Curley 1998)—allowed for the mobilization of extended families which were geographically separated. In my personal view, it is community in such a sense which is valuable and worthy of being cherished by those who favour it, and much to be preferred to its ersatz collectivist competitor. Titmuss in The Gift Relationship, noted that, in fact, at the time at which he was writing, what I have here described as AABB arrangements were the most common form of provision of whole blood in the United States (Titmuss 1970, Chap. 6, Table 4, p. 94). They were something to which he took exception—although clearly not on the basis of the arguments that he had offered against payment for blood. Rather, Titmuss offered two arguments against the blood replacement aspect of AABB-style arrangements. On the one side, he was concerned that a burden was placed on those in need of blood; on the other, that there was no guarantee of provision. This, however, seems to me to be problematic. First, the entire basis of the system operated by way of individual, family and what in my view were genuine community responsibilities. This, of necessity, meant that need was experienced where it occurred. But it was, exactly, this which gave rise to the activities directed towards meeting that need. One might also add that the fact that people depended on others might, in itself, give them an incentive to participate in informal networks of the kind which might provide such support on a reciprocal basis across their lifespan. While the fact that unmet need would still occur, would be what, then, gave rise to the formation of groups to assist those in their neighbourhood who were missing out—as did the Rotary and similar groups— or the operation of informal systems such as the running of surpluses in hospitals’ blood replacement schemes (the existence of which Titmuss noted but deplored). Second, the fact that under a Red Cross system there is an entitlement to blood and blood products, does not necessarily mean that blood and blood products in adequate quantities can, in fact, be provided. (It is striking that, in the early years of the re-entry of the Red Cross into blood provision in the U.S., what they could offer was limited, so that it was hospitals who received provision from them who had sometimes to make use of commercial blood services to meet emergency need.) I have referred, earlier, to the existence of systematic under-prescription of certain blood plasma products in Australia. There are regular reports in the Press in the U.S. about shortages of blood, and about inessential surgery being suspended, but it is difficult to judge to what extent this is the product of real shortages, and to what extent it is a product of a wish to highlight problems in order to increase blood donation.

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Third, what of the ending of what I have referred to as the AABB system? For reasons of space, I can here report on this only very briefly (the full story becomes clear from materials in the NIH archives).25 One of the elements of U.S. National Blood Policy was that a statement was negotiated between various parties—including the AABB—to the effect that paid blood would be eliminated. This was accepted even by the organization representing for-payment Blood Banks. However, the National Blood Policy (cf. Shearmur 2007b)—and thus the implementation of the policy—was supervised by a panel which had a wide basis, membership of which included several people from Trades Unions (whose members represented significant numbers of blood donors). The Red Cross and those allied to it—including Garrott Allen, and some trades unionists with whom he had worked—were committed to the elimination of AABB-style arrangements, and the AABB found themselves the object of what seems almost like a guerrilla war conducted against them. The Red Cross pulled out of the clearing house system—which was vital to the operation of blood replacement arrangements. The State of California Consumer Affairs department—acting, it appears, on the basis of a long-time concern of Garrett Allen’s26—took legal action against the Blood Bank with which Hemphill was associated, on the basis of claims that they were making unfair charges for the replacement of blood. (The case came to nothing, but it led to blood banks halting cooperation with national efforts at coordination, lest they might be furnishing information which could be used against them.) The Red Cross, and its allies on the committee, chose—in flagrant breach of the obvious sense of the initial agreement (which had been agreed to by the AABB)—to interpret the policy against the paid provision of blood as ruling out ‘‘blood replacement fees’’, which played a key role in the AABB system. Finally, there is the sociological issue of the future of community in the sense which I have here discussed. I have suggested that it is, indeed, understandable that people may cherish it. Yet at the same time, it is not clear that we can expect it to be a continuing feature of modern societies. Already in his Philosophy of Right, Hegel had noted the way in which (cf. Hegel 1942, §238, p. 148): …civil society tears the individual from his family ties, estranges the members of the family from one another, and recognises them as self-subsistent persons. Further, for the paternal soil and the external inorganic resources of nature from which the individual formerly derived his livelihood, it substitutes its own soil and subjects the permanent existence of even the entire family to dependence on itself and to contingency. There would seem to me a clear sense in which, over time, this phenomenon has become more marked: consider the degree to which people are, now, mobile, and to which they typically have a variety of occupations during the course of their lives. Here, Robert Putnam’s Bowling Alone (Putnam 2000) seems to me important, in 25 See National Library of Health Archives, U.S. Department of Health Education and Welfare, National Blood Policy Records 1969–1981, MSC 393. 26

From archive materials held at the Stanford University School of Medicine, Allen—who had done a lot of work on what he thought was the misuse of blood-replacement funding by a San Francisco community blood bank – was in correspondence with the California state officers who initiated this action.

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documenting the degree to which older kinds of community, and even informal activities with neighbours and friends, have in various ways come under pressure. This is not to say that other forms of interaction may take their place—e.g., ‘virtual’ communities, and the formation of intentional communities such as Celebration, Florida which one might see as in some ways addressed at the very problems that Putnam raised (cf. Frantz and Collins 1999; Ross 1999; Shearmur 2002). But none of these would suggest how communities of the ‘network’ kind could be restored on a large scale.

Concluding Comments There was, in the U.S., a problem posed for the blood supply system by the drawing of blood from members of the population who had relatively high rates of infection with hepatitis. It is clear that action needed to be taken to avoid this. It is also clear that there was nothing wrong with paid blood, as such; for, clearly, blood that was identical in its character could be drawn from the same people, whether or not they were paid for it. Titmuss was, indeed, concerned about a shift of people from volunteer to paid provision. To be sure, those who sold blood (or plasma) were not of the same sociological composition as were volunteers. Indeed, this formed the basis of one of Titmuss’s arguments for the form of provision that he favoured. But it is not clear that this posed a general problem for the quality of the blood supply, as opposed to something that was specific to the transmission of hepatitis at that time. While on the face of it, the obvious course of action would then have been to have enforced strict liability on hospitals and blood-collection agencies for the transmission of blood which gave rise to infections—a course of action which was strongly opposed by Titmuss. That there is no insuperable problem with regard to a system of paid blood is clear from the fact that in the U.S., blood plasma is successfully drawn from among poor people, using a system of financial incentives for good behaviour. Those with a sense of irony might appreciate the fact that in the light of problems in the UK with VCJD, the UK—and thus the system of which Titmuss was the champion—is currently supplied with blood products from this very source. Titmuss was correct in stressing that the transmission of hepatitis was a problem. But, as I have argued in this paper, his moralized diagnosis of the character of the problem seems largely incorrect. Indeed, the simple message which has been drawn from this work: ‘paid, bad; Red Cross-style donations, good’ has, as far as I can see, no cogent factual basis to it. It is certainly the case that we may have various qualms about aspects of the commodification of the person. The issues, here, however, are complex, and relate to all forms of employment and remuneration. In this context, we need to consider both the wider utilitarian benefits of arrangements, and also to make sure that we do not prevent people from doing things which, all things considered, they wish to do, just because we find the idea of people doing such things unsettling. As with many other such cases, simply to prevent people from doing things which concern us because we do not like them, but which serve to better people’s situations, is to

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make them worse off.27 If we are concerned about the situation of people who are disadvantaged, then it is that situation that we need to address, rather than trying to prevent people’s efforts to make the best of it. (Clearly, it is a different issue if people are being coerced into the behaviour in question.) In the case of blood and blood products, remuneration looks like a good way to go. As was argued at the outset of the U.S. Blood Policy, there would be considerable difficulties in meeting the need for blood products, if one were to depend on voluntary donations (see Shearmur 2007b). In addition, as what is involved, here, is the provision of an ingredient for commercial chemical companies, the case for voluntary donation looks very odd (as, clearly, is increasingly the case with regard to the donation of whole blood, too). Further, as the case of VCJD should suggest, we can never tell when established sources of blood may prove problematic, and a commercial system here has the advantage of being flexible. While the AABB-style of individual responsibility and community support seemed to me to have advantages, it is not clear that it could be re-introduced—not least because of the increasing role played by cities and high mobility.28 At the same time, an idea which was suggested some years ago by some U.S. blood bankers might seem useful, especially if one values volunteering and community, or was worried about Titmuss’s concerns about the blood supply depending just on the poor.29 It was that one might allow for paid blood donation made on behalf of charities, religious groups, and so on. That is to say, such groups might appeal to their members for blood, as a form of fund-raising for their community, church, mosque and so on. It would be up to commercial companies involved in the collection of blood as to whether they wished to deal with such groups, and on what basis (e.g., in the light of what would best meet issues of blood safety). All told, there seems no good basis for rejecting supply of whole blood for money – let alone the supply of blood plasma.

References Alchian, A., et al. (1973). The economics of charity. London: Institute of Economic Affairs. Anderson, E. (1990). The ethical limitations of the market. Economics and Philosophy, 6, 179–205. Anderson, L., et al. (1999). ‘‘Selling blood’’: Characteristics and motivations of student plasma donors, Sociological Spectrum, April–June (19, no. 2), pp. 137–162.

27

Radin (1996) is useful on this point.

28

In addition, it is not clear that moral pressure on family members is a good basis on which to collect blood. (For example, people who have good reasons not to donate may be reluctant to have to explain these to members of their immediate family). 29 See George W. Geisen and Eve Gorman, ‘Let’s Get on the Target’, delivered to the AABB Annual Meeting, Bar Harbour, Miami Beach, Florida, November 14th 1973, and also submitted as part of a response to the National Blood Policy Implementation Plan, MSC 393, Box 1, 1–5, No. 218; see National Library of Health Archives, U.S. Department of Health Education and Welfare, National Blood Policy Records 1969–1981.

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