Lippincott Williams & Wilkins

Review
Author(s): Eugene Feingold
Review by: Eugene Feingold
Source: Medical Care, Vol. 11, No. 3 (May - Jun., 1973), pp. 261-263
Published by: Lippincott Williams & Wilkins
Stable URL: http://www.jstor.org/stable/3762883
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MEDICALCARE

May-June 1973, Vol. XI, No. 3

Book Reviews
The Gift Relationship:From Human Blood to
Social Policy, by Richard M. Titmuss. New
York, Pantheon Books, 1971.
THE VOICES OF CERTAIN economists are in-

creasingly being heard, arguing that social

problems should be dealt with by use of market principles, with alleged resultant gains in
efficiency and equity. Their argument is that,
if social services are financed by user charges,
then services will be provided in accordance
with the true desires of the public, rather than
being distorted by the "free" availability of
these services and goods.
In this book, Professor Titmuss makes the
contrary argument, in both specific and general terms. His specific argument is based on
an examination of the blood donation, collection, and transfusion systems in England and
the United States. Moving, as his subtitle
indicates, "from human blood to social policy,"
he discusses the implications of his findings
for social policy generally.
In England and Wales, the relationship between the blood donor and the recipient is
truly a "gift relationship": donors are virtually
all volunteers who receive no payment; recipients (even private patients) receive blood
free of charge. There is no obligation on the
patient's part or his family's to donate blood in
place of that which he has received. In the
United States, in contrast, blood flows into the
medical care system through a variety of channels, with a variety of payment mechanisms
and systems of obligation.
The common view is that most blood in the
United States is contributed voluntarily, and
we customarily use the term "donors" to refer
to those who "give" their blood. Yet Professor
Titmuss estimates that truly voluntarily given
blood-blood from donors motivated as much
as possible by "complete, disinterested, spontaneous altruism"-constitutes only 7% of the
blood used for medical purposes in this country. About half of "donated blood" is, in actual
fact, not donated but rather given in return for
a cash payment. The remainder comes pri-

marily from those who are contributingblood

to replace blood that they, members of their
families, or friends have received, or who are
contributingblood as part of a "family credit"
program,in which, in return for their contribution, theirfamiliesare assuredof being provided
with blood when necessary. Although Professor Titmuss identifies several other classes of
blood donors, and valiantly struggles with the
fragmentarydata available in an effort to estimate the proportionof the blood supply which
comes from each class, these other donors provide only a very small part of blood used for
medical purposes. Professor Titmuss's allocation of American donors to the several classes
is necessarilyspeculative,but seems reasonable.
ProfessorTitmuss then goes on to compare
the American and English systems in terms of
economic efficiency, administrative efficiency,
price and quality. His conclusion is that:
On all four criteria,the commercialized
blood
marketfails. In termsof economicefficiencyit
is highlywastefulof blood;shortages,chronic
and acute, characterizethe demandand supply positionand makeillusorythe conceptof
equilibrium;the marketalso involvesheavy
externalcosts. It is administratively
inefficient;
the so-calledmixedpluralismof the American
marketresultsin morebureaucratization,
avalanchesof paperand bills, and much greater
administrative,
accountingand computeroverheads. These wastes,disequilibriaand inefficienciesare reflectedin the pricepaid by the
patient (or consumer);the cost per unit of
blood varyingin the United States between
?10 and ?20 (at the officialrate of exchangein 1969) comparedwith ? 1 6s. ( ?2
if processingcosts are included) in Britainfive to fifteen times higher. And, finally,in
termsof quality,commercial
marketsaremuch
more likelyto distributecontaminatedblood;
in otherwords,the risksfor the patientof disease and deathin the formof serumhepatitis
are substantiallyhigher.
Perhaps the most important of these four
criteria on which the American blood market
can be criticized is that of quality. Here, the
most important problem is the possible contaminationof blood with hepatitisvirus. Blood
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Vol. XI, No. 3

BOOK REVIEWS

transfusion systems are dependent upon the

prospective donor's knowledge and his honesty
in reporting whether he has or has been exposed to hepatitis. Donors motivated by altruism, unlike those with commercial motivations, have no reason for concealing hepatitis.
Moreover, as those who sell their blood are
more likely to be poor, they are more likely to
have had hepatitis and, in general, less likely
to be aware of it. The risk of hepatitis from
blood transfusion in England is reported to be
negligible, whereas 2-4% of transfused patients
in the United States later developed hepatitis,
with death following for as many as 20% of
those who had it. Not surprisingly, those who
received commercial blood in the United States
were much more likely to contract hepatitis
than those who received donated blood. A
physician must always consider the risk of
hepatitis infection before transfusing blood,
and American physicians sometimes have felt
constrained to avoid blood transfusions for
even seriously anemic patients because of their
concern about the danger of contracting hepatitis. Concern about this problem has recently
resulted in regulatory action by the Food and
Drug Administration as well as several legislative proposals.
Looking at blood transfusion systems also
as systems of social redistribution, Professor
Titmuss points out that "the whole of the
United States blood donor program-and particularly the plasmapheresis program operated
commercially with paid donors-relies to a
substantial extent on supply of blood from
Negroes." Viewed as a system of social redistribution, then, the American system is one
which redistributes blood from the poor and
the black to the white and the rich. This is
true not only on a national basis, but internationally as well. The New York Times recently reported that an American firm in Haiti
is purchasing blood plasma from malnourished
Haitians and exporting five to six thousand
liters every month to the United States. In
contrast, in England, higher income people
are somewhat more likely to contribute than
lower income people, possibly because there is
no cash incentive for contribution.
Professor Titmuss goes on to discuss other
social effects of the sale of blood in the United
States, concluding that
The commercializationof blood and donor relationships repressesthe expressionof 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-[and] increases the danger
of unethical behaviour in various sectors of
medical science and practice ....
Generalizing from his comparison of British
and American blood distribution systems, Professor Titmuss attacks the economic analysis of
social problems and the effort to use the market as a means for carrying out social policy.
Such analysis, he argues, improperly ignores
the externalities (the values and disvalues
external to but created by blood distribution
systems treated as entities) and the multiplier
effects of such externalities on what we can
only call "the quality of life." At one end of
the spectrum of externalities is the individual
contaminated with hepatitis; at the other, the
market behaviour of economically rich societies seeking to import blood from other societies who are thought to be too poor and
economically decadent to pay their own blood
donors.
In Professor Titmuss' view, the market analysis of social problems not only ignores externalities, but is also simplistic in its view of
freedom, placing too much emphasis on consumer choice and material acquisitiveness.
Donors to the English National Blood Transfusion Service
were free not to give....
Yet, as this study
has shown comparatively, private market systems in the United States and other countries
not only deprive men of their freedom to
choose to give or not to give but by so doing
escalate other coercive forces in the social
system which lead to the denial of other freedoms (and maybe life itself) to other men
who biologically are in no position to choosethe young and the old, the sick, the excluded
and the inept as well as the sellers of blood.
What should individual freedom mean in organized society?
In a positive sense we believe that policy and
processes should enable men to be free to
choose to give to unnamed strangers. They
should not be coerced or constrained by the
market. In the interests of the freedom of all
men they should not, however, be free to sell
their blood or decide on the specific destination of the gift. The choice between these
claims-between different kinds of freedomhas to be a social policy decision; in other
words, it is a moral and political decision
for society.

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BOOK REVIEWS

Vol. XI, No. 3

There are other aspects of freedom . . . the
freedom of men not to be exploited in situations of ignorance, uncertainty, unpredictability and captivity; not to be excluded by market forces from society and from giving
relationships, and not to be forced in all circumstances-and particularlythe circumstances
described in this study-to choose always their
own freedom at the expense of other people's
freedom . . .
The private market in blood, in profit-making
hospitals, operating theatres, laboratories and
in other sectors of social life . . . narrows the
choices for all men-whatever freedoms it may
bestow, for a time, on some men to live as
they like. It is the responsibility of the state,
acting sometimes through the processes we
have called 'social policy,' to reduce or eliminate or control the forces of market coercions
which place men in situations in which they
have less freedom or little freedom to make
moral choices and to behave altruistically if
they so will.
In his comparison of blood collection systems, Professor Titmuss has made a substantial
contribution to our knowledge and thinking by
drawing together data from a wide variety of
sources and pointing out their significance. His
survey of British blood donors is of interest,
although it is unfortunate that there are no
comparable surveys of non-donors and of
Americans. His contribution is not limited to
his discussion of England and the United
States, as he also has brought together information about blood collection systems in a
number of other countries which are treated
more or less briefly. Although it is possible to
quibble with certain aspects of his analysis, the
basic thrust of his comments about the English and American blood collection systems
seems irrefutable.
It is when one moves on from the specific
case of blood to the more general conclusions
drawn by Professor Titmuss that the reader may
have greater disagreement. Professor Titmuss'
argument is necessarily a moral and ideological
one, although he draws upon anthropologic
literature about the significance of gifts in human society. Because of the moral and ideologic nature of his general argument, it ultimately cannot be proven (or disproven),
although he sometimes seems to feel he has
done so.
Professor Titmuss also seems sometimes to
be arguing that the commercialization of blood
in the United States has led to the commercialization of the medical care system and of
American life:

Once man begins to say, as he sees that dollars

exchange for blood supplies from Skid Row
and a poor and often coloured population of
sellers, "I need no longer experience (or suffer
from) a sense of responsibility (or sin) in not
giving to my neighbour" then the consequences are likely to be socially pervasive.
Yet it seems to this reviewer more reasonable to view the commercialization of blood as
an aspect of and the result of the primacy of
the market and classical economic thinking in
American ideology, if not in practice. Thus,
although the decline of altruism in the giving
of blood may reinforce its decline or absence
elsewhere, the main thrust of causality would
seem to be in the opposite direction.
We are left with the need to account for
the difference in American and English altruism. It cannot simply be a matter of a
market economy vs. a planned economy, of
social darwinism vs. the welfare state. Professor Titmuss' evidence about the variation in
the extent to which blood is sold throughout
the world and in different parts of the United
States indicates that the explanation is more
complex.
Whatever the cause, there is no question
that "the ways in which society organizes and
structures its social institutions-and particularly its health and welfare systems-can encourage or discourage the altruistic in man."
Professor Titmuss helps us to remember this
aspect of social policy at a time when concern
about allocating limited social resources has
led some to overemphasize other concerns.
EUGENE

FEINGOLD

Professor of Medical Care

Organization
The University of Michigan
Weinerman Memorial Volume, selected papers
and contributed articles on health services. The Yale Journal of Biology and
Medicine, Inc., 1971, $10.
MEMORIAL WRITINGS have

three

main

pur-

poses. The first is to collect and preserve ideas

in one source. The second is to preserve something of a personality. The third is to allow
for an expression of feelings and thoughts by
those who survive. This volume, a tribute to
Dr. E. Richard Weinerman whose contributions to health care in America were cut short
by a terrorist bomb in February 1970, serves
these purposes well.
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