Characteristics and motivations of blood donors

 

In order to be eligible to donate blood, potential donors must meet certain criteria before they can be considered for membership by a blood bank. Firstly, in many countries they need to be older than 17 (16 years in South Africa [1]), not only to meet the legal requirement of being aware of what they are doing, but also to ensure that they have passed the main phase of adolescence, when the requirements of the body for minerals, such as iron, are greatest. With exception for some long standing donors, people who exceed an upper age limit of 60 years are also prevented from donating, as there is a risk that drawing blood from them may result in medical complications. Donors are also monitored according to their frequency of donation, with whole blood donations only being permitted every 56 days, whereas plasmapheresis is allowed to take place about every 7 days [2]. These intervals, which are imposed in order to guarantee donor safety, are minimum periods only, since prospective donors may be turned away should their haemoglobin levels be below a minimum safety level, even if they last donated blood for a much greater period of time than the stated minimum [3]. While there is no explicit discrimination according to gender, a greater proportion of donors are men, in part because many women, especially those of childbearing age, suffer from iron deficiencies that limit their haemoglobin levels, resulting in their inability to tolerate frequent donation. Finally, donors need a minimum body mass level, which varies according to the type of component donated, from 50 kg for whole blood [4] to 55kg for platelet donations. These qualifying weight limits are imposed in order to ensure that the quantity of blood extracted from their bodies, which is about 450 ml, does not have any excessively undesirable effects on the function of their bodies [5].

 

If these basic requirements are met, potential donors are then confidentially invited to review a self-exclusion questionnaire allowing them to determine whether or not they suffer from what are coyly known as “high risk” lifestyle factors. Should they (or their sexual partners) fall into one or more of these categories, there is a risk that their blood donation may be prejudicial to the welfare of recipients, and so they are prohibited from donating. While slight variations in admission criteria exist between different blood banks, the main excluding factors commonly applied to all potential blood donors are similar. Summarised in Table 3 are the factors taken into consideration by the SABTS.

 

Table 3: Exclusions commonly applied to blood donors [6]

Major excluding factors (applicable to both the donation applicant and his/her sexual partner): 1. In the past six months, the applicant has had more than one sexual partner or engaged in casual sex. 2. In the past six months, the applicant has had sex with a person whose sexual history is unknown. 3. In the past twelve months, has the applicant been a victim of a sexual assault. 4. If the applicant is male, has he had sex with another male in the past five years. [7] 5. In the past five years, has the applicant had sex with a prostitute of either gender, or engaged in sexual activities with another person in return for money, drugs or other tangible or non-tangible favours. 6. Has the applicant ever received an intravenous injection of a non-prescribed drug. 7. Has the applicant ever been accidentally exposed to blood or other bodily fluids. 8. Has the applicant ever had a sexually transmitted disease, such as syphilis and gonorrhoea. 9. Has the applicant ever had a positive test result for HIV.

Minor excluding factors [8]: 1. Has the applicant ever had, amongst others, disease of organs such as the heart, lung, liver and kidneys, tuberculosis, cancer, HTLV-1, HTLV-2, or Chagas disease [9]. 2. Has the applicant ever had hepatitis or recently been in contact with a hepatitis patient. 3. In the past twelve months, has the applicant, or sexual partner, been treated with any blood based product. 4. In the past twelve months, has the applicant had any form of ornamental piercing performed upon their bodies, tattooing, acupuncture, needlestick injury, or been scarred or stabbed with a sharp object. 5. Has the applicant received a tissue/organ transplant or been treated with human sourced products.  6. If the applicant is female, is she currently pregnant or has she given birth or miscarried very recently [10]. 7. Has the applicant or any close relative had an unexplained brain disease or CJD. [11] 8. Has the applicant ever had malaria, or, in the recent past, lived in a malaria area.

 

Once these formalities are performed, the actual drawing of blood takes place, with the entire process being a relatively simple affair that is completed within about 20 minutes for whole blood donations, although the collection of plasma and platelets can take considerably longer. After the blood has been collected, it is then refrigerated and transported to the blood bank laboratory, where it is screened for disease, typed according to blood group, and subjected to quality control tests before being processed into the end product destined for human consumption.

 

There are a variety of factors that motivate people to donate their blood. While almost all blood donors are said to give voluntarily, they may be recruited in very different settings, where their private incentives to donate may not be the same as those of other people. In addition, they may have different values which underlie their perceptions of altruism in general, and blood donation in particular. What follows is a modified typology of the main characteristics and motives of the various classes of blood donor as defined by Titmuss.

 

i) Paid blood donors [12]

According to the U.S. Food and Drug Administration (FDA), a paid blood donor is  “any person who receives monetary payment for a blood donation” [13]. Due to the visible, contractual exchange of money, it can be implied that such a person may regard the paid giving of blood to have about the same moral value as any other market based activity that requires the use of his time and labour [14]. In other words, to him, the drawing of blood is simply an impersonal transaction conducted for personal gain, with the price of his blood being determined by the market value for whatever he can offer (with different prices being offered for whole blood, plasma, rare blood types, etc.). As Titmuss said about the blood provided by such donors: “in no sense is it perceived by the seller or the buyer as a gift” [15]. Now, while this observation may be true, to the blood recipient, it is largely a moot point if all that he is interested in is the fact that this blood is available when he needs it to save his life, not in who gave it or how it was acquired.

 

When referring to paid donation, we must be careful to clarify what is meant by this term, as there are different categories of people who sell their blood for direct financial gain. The first type are “professional” blood donors, who may be registered with one or more collection agencies on a permanent or part-time basis, with plasma suppliers who are “milked” via plasmapheresis on a regular basis forming a key element of this group. In return for donating regularly, they may be compensated on a weekly or monthly basis where, in addition to financial payments, they may also receive medical supplements to ensure that they can continue donating. The second group are the “amateur”, or “walk-in”, donors, who donate blood on an irregular basis, primarily as a means of supplementing their income. These people are more difficult for blood banks to deal with, since their random donating pattern means that their behaviour is harder to monitor, plus they have less of an incentive to remain healthy than the professionals, for whom maintaining a reputation of having “good” blood is vital if they are to continue having a working relationship with the blood banks. Finally, we have the “paid induced voluntary donors” [16], who receive cash payments for their donations, even though they claim not to be motivated by monetary concerns when donating. While such donors may have given their blood as unpaid donors in any case, they nevertheless expect to be compensated financially for the inconvenience and incidental costs they may incur when giving, such as recouping their transportation expenses. While the distinction between this final type of paid donor and the unpaid volunteer is slight, it could be implied that such a person is only a grudging altruist who does not give his time and blood in a spontaneous manner, but instead needs to be induced to do so.

 

ii) Replacement and credit donors [17]

According to the policies of some blood banks, patients who receive a blood transfusion may be charged a “replacement” or “deposit” fee if they have not previously donated blood to it. This means that on receipt of a hefty money deposit, they are provided with a “loan” of blood by the blood bank on condition that they repay this loan at a later date. Patients then have the option of either not repaying the loan by forfeiting the deposit lodged with the blood bank, or of replacing the transfused blood with donations made either by themselves, or by friends, family members or others who have “voluntarily” agreed to assist them (in which case the deposit is reimbursed). People finding themselves paying off these replacement charges cannot really be defined as being altruistic if they are forced to provide blood, especially in cases where their replacement charges exceed the quantity of blood they may have consumed [18]. Moreover, while it could be argued that imposing a replacement policy on a blood recipient may be an acceptable policy, the situation is not so valid when applied to friends or family members, who engage in what is now known as “directed donation”. This is because in addition to having no part in the act of blood consumption, they may find themselves being drafted in to honour the debt of an acquaintance even if this is against their wishes (because, for example, they may wish to maintain the fact that they have a particular disease a secret from others).

 

To forestall the potential difficulties of having to repay blood loans, some individuals join programmes where they can pre-donate blood to a blood bank. Once a specific quantity of blood has been donated, they will be given credit indemnifying them from having to repay any blood loans, which effectively means that they have been covered by a form of insurance policy where premiums and coverage are measured in units of blood. Such donors are believed to favour what is known as an individual responsibility philosophy, which advocates that, given the opportunity and the ability, it is the responsibility of each person to provide for his or her own needs without depending on the goodwill of others. As such, these donors are not driven by a direct altruistic desire to help others when they donate their blood, since their actions are intended solely for their own personal benefit. Indirectly though, they are involved in the provision of a public good, for although their donations are intended for their own use, they may provide a benefit to others sometime in the future, as it is unlikely that they will actually use that which they have donated [19].

 

iii) Captive voluntary donors [20]

These are people who are in a subordinate position in a power relationship, who may face some form of pressure, exerted by peers or superiors, which makes them feel obliged to donate blood. If they do not do so, they fear exposure to penalties of different types that may, somehow, hamper their progress with those with whom they are associated.

 

Various groups of people fall into this particular category, including members of the armed forces, who often constitute a large, concentrated pool of young and healthy individuals. While soldiers may not be explicitly ordered to give blood, they may nonetheless feel compelled to do so if they feel that they have a particular duty not to disappoint their comrades, with whom they may have formed a strong bond. A similar attitude exists in many firms, where different branches may compete with each other to see which one can collect the most blood – here, losing groups that fail to meet their targets may feel a sense of shame at not meeting expectations. Although they may not wish to give blood, workers in these groups may feel obliged to do so if they believe that refusing to give could hamper their career prospects, while knowing that donating could have the opposite, positive effect. In this case, donation does not take place due to altruism, but because the donor believes that some private benefit can be acquired in the workplace [21].

 

Similarly, members of religious organisations may donate blood if they believe this is a charitable obligation that needs to be fulfilled. In this case, they may simply be acting according to the religious justification for altruism. While no religious body has yet been charged with arguing that any of its followers will be eternally damned to Hell if they do not donate blood, some do feel that donations sessions can be celebrated as occasions of solidarity, where members of the same faith can express fellowship with like-minded individuals. At such events, parishioners who are capable of donating, but who do not do so, may be viewed as being lacking in complete faith, and may consequently be shunned by the rest of the congregation. More generally, such social pressure can be extended to members of societies, country clubs, and other groups where people gather and are observed by peers. In order to avoid any social stigma, individuals may feel obliged to donate blood even if they do not want to, with other potential ways of expressing their altruism, such as giving monetary donations, being seen as an evasion of their duties.

 

One interesting group of captive volunteers that existed in the USA was that of prisoners, who gave blood in correctional facilities. Although most prison boards officially denied that such activities would lead to the remission of sentences, it is not inconceivable that prisoners donated if they privately believed that this would reflect favourably on their records. Thus, their donations were not truly altruistic, as they were aware that such actions could indicate to parole boards that they had been rehabilitated, and were, therefore, suitable for early release from prison [22].

 

iv) Fringe benefit donors [23]

These are volunteers who donate blood after being induced to do so by the prospect of receiving tangible, non-monetary rewards for their efforts. While such rewards are usually believed to consist of minor tokens such as caps, key rings or post-donation refreshments, they can be substantially more generous than this. For example, they can include the provision of extended holidays and better quality meals that are not medically necessary for the well being of the donor, as well as allowing employees time off work on full pay if they donate. Other benefits that have been provided, and which have been successful in drawing in donors have included the provision of vitamin and mineral supplements, as well as mini-medical examinations such as cholesterol and blood group tests [24]. When converted into their monetary equivalents, some of the perks given to these so called altruistic donors may have a value considerably greater than any cash compensation that they may have received had they simply been paid upfront for their blood. This is particularly relevant if we consider that society may not account for all the costs involved in the collection of blood from such donors – while a blood bank that collects “free” donations from the workers of a firm may not have to pay these workers anything for their generosity, the employer may incur costs in permitting workers to donate, through the provision of inducements and decreased productivity, with such costs being passed on eventually to consumers and shareholders.

 

v) Unpaid voluntary donors [25]

The definition of an unpaid donor who voluntarily donates blood due to a sense of altruism is superbly summarized by the following definition provided by the VIIIth General Assembly of the International Federation of Red Cross and Red Crescent Societies:

“Voluntary non-remunerated blood donors are persons who give blood, plasma or other blood components of their own free will and receive no payment for it, either in the form of cash, or in kind which could be considered a substitute for money. This includes time off work, other than reasonably needed for the donation and travel. Small tokens, refreshments and reimbursements of direct travel costs are compatible with voluntary, non-remunerated donation” [26].

 

Voluntary donors are believed to give consciously as an act of free will, without being driven to do so by the threat of monetary, social or professional penalties. A popular opinion is that they give in a disinterested way (unlike paid donors), without regard to the racial, social, demographic or financial characteristics of the people who receive their anonymous grants. While it may be true that these donors do not receive any payment for their contributions, it would be wrong to say that they do not benefit in subtle ways that may be hard to quantify in a tangible, material sense. In particular, they may receive some psychic, or Kantian, benefit from knowing that they have done a deed that will have a significant, direct impact upon the life of an unknown stranger elsewhere in the community. Donating blood therefore helps people feel special about themselves, with one study finding that for a donor, “giving may provide emotional gratification, making one feel heroic, and thus heightening self esteem” [27] – this is hardly a sign of receiving no utility boost from the supposedly unselfish act of blood donation. Furthermore, we should question why blood banks provide donors with tokens such as T-shirts and bumper stickers that publicly identify them as donors. While such materials may admittedly have a promotional value, could they also not enable donors to gain additional psychic benefits from knowing, in their minds, that others are more likely to admire them when they notice that they give blood [28]?

 

Having examined the basic reasons that motivate donors to give blood, it would also be appropriate to consider some of the more important explanations for why most people do not donate blood. Although it may be possible to educate the public further as to the benefits of donation, there are some cases where it will be almost impossible to make individuals change their minds, unless their awareness and incentives with respect to donation are fundamentally changed. When evaluating non-donation, the most important factors to be assessed are as follows:

 

i) Religious objections and superstitious beliefs

Various religious groups believe that the drawing of blood is a sacrilegious act violating the basic tenets of their faith. While the best-known group to hold such a view is that of the Jehovah’s Witnesses, who argue that Biblical tracts rule out both the receipt and donation of blood or any other human matter [29], others who share similar objections include certain Buddhist and Islamic sects. There are also many individuals who follow a range of traditional superstitions that blood donation causes the loss of a vital life force, whose loss can cause, amongst other things, impotence, infertility, blindness, or the inability to work. Although these beliefs may appear irrational to outsiders, it is often hard to convince believers to ignore them, especially if they form a fundamental part of their convictions about the basic nature of life.

 

ii) Psychological fears

Many people avoid blood donation if they are squeamish at the sight of blood, have a phobia about medical instruments such as needles, or associate donation with physical sensations of pain and weakness. Such anxieties are not limited to non-donors though, as even actual donors express similar fears, even though they have largely managed to overcome them by donating. While these fears may seem ill-founded and exaggerated, anecdotal evidence suggests that most donors do indeed experience higher physiological levels, such as faster heartbeat rates, before rather than during a donation session, with these measures of fear and discomfort gradually decreasing as the frequency of donation rises (although they are never fully eliminated).

 

While these fears may be overcome by showing potential donors that the degree of pain is minimal and by concealing needles and blood from the donor’s line of sight (e.g. through the use of screens), of greater concern are the unsubstantiated fears that giving blood can allow donors to contract diseases, in particular HIV. In the early years following the discovery of this disease, an extensive public education programme was instituted to inform blood donors about the relevant risks of their donating activities and of the efforts that were aimed at protecting their well-being. Despite the best efforts of the authorities, it appears that while most actual donors were satisfied that their fears were unfounded, some were not convinced and have avoided calls to attend further donation sessions. Furthermore, many potential donors also seem sceptical about the assurances sent to them, and have, it seems, continued to stay away. As has always been the case with items as symbolic and emotive as blood, it appears that misconception and rumour has prevailed over clarity and fact, with blood banks not being helped by the mixed signals that are sometimes sent out on this particular issue by government and other organisations (as seen in the longstanding AIDS controversy that has continued in South Africa).

 

iii) Adverse reactions and deferrals

Many people who have actually donated blood may not return for subsequent donation sessions if they have either suffered from some adverse reaction directly attributable to the act of giving blood, or if they feel that a blood bank and its staff treated them improperly.

 

While blood banks do everything possible to ensure that the incidence of donation induced reactions such as cold chills and toxic exposure are minimised, these are sometimes unavoidable, with their incidence being greater with some procedures than with others. For example, while whole blood donors rarely suffer significant discomfort, up to 10% of platelet donors will face some problem after donating, due largely to exposure to the chemical solutions that enable apheresis to take place [30]. In such events, where donors do suffer pain, it is likely that they may reconsider donating in future, with the likelihood of such a decision being greater if the reactions experienced were particularly intense or if the donors were relatively inexperienced.

 

A fundamental point that may be overlooked, especially by blood banks, is that while people may voluntarily enter into a blood donation programme, there are limits to the way in which they may agree to be treated. While not everyone can be pleased at the same time, this is a point worth noting, because when policies emphasising the safety of recipients are introduced, they may work only at the expense of long-term donor loyalty [31]. As the number of risk categories and screening tests for disease has risen, so the number of donors (both actual and potential) who are now disqualified from donating by the newly imposed criteria increases. While some of those newly excluded donors may undoubtedly pose bad risks, many others may be healthy and have, at worst, suffered only from repeated false positives on tests that are not always absolutely reliable. In such a situation, even if the screening tests are proven to be faulty and are changed, a large percentage of these rejected donors are likely to be so distressed at their treatment that they may no longer feel like reapplying to donate in future because of the implicit doubts expressed as to their worthiness as blood donors. While this statement may appear to be exaggerated, we should note that in the USA, a defectively designed hepatitis test that excluded tens of thousands of healthy individuals from donating might have led to the permanent loss of a large potential donor pool who felt guilty about their results [32]. Even after the fault was identified and rectified, many of these people were unlikely to contemplate returning for a re-evaluation of their suitability as donors due to the initial doubts expressed about their fitness.

 

iv) Apathy and inconvenience

Many people undoubtedly do not donate blood because they simply do not feel inclined to do so, as they may receive no utility whatsoever from such an act, even if they were to be paid to give their blood. This should not be unexpected, as the very essence of gift-giving is that it is the right of every individual to determine whether or not a gift is to be given, and, if it is to be given, the particular form in which it is to be composed. Thus, such behaviour should not be interpreted as meaning that a non-donor is always apathetic and not an altruist, as he or she may indeed have a desire to help a blood bank, except in a way which does not entail the drawing of blood (such as donating money).

 

Other people do not give blood due to a lack of opportunity, either because the times or location within which they are requested to donate are inconvenient to them. This is especially common during the week, when many people are at their places of employment or study, which may either be located some distance away from their nearest donation centre, or which may only operate during business hours, when personal freedom is limited. While blood banks have succeeded in opening some fixed centres over the weekends, and in sending mobile clinics to suitable venues, such as factories and schools at specified times, these measures are obviously not perfect. This is since not only may some potential donors be mentally or physically unprepared to donate at the specific times when these mobile clinics appear, but efficiency measures dictate that mobile clinics and their required staff can go only to where sufficiently large numbers of donors are available, leaving the blood resources of smaller, dispersed organisations largely untapped. Furthermore, economic trends such as corporate downsizing and home based work may have also had some effect on blood collection, since many workers who could previously be “captured” with relative ease have now been dispersed, with only truly dedicated donors making any effort to continue giving blood. Thus, as the pace of modern life has become more hectic, so people have had to readjust their schedules in order to accommodate the changing priorities in their lives, with blood banks having only limited success in promoting what is essentially a time consuming activity in a world that is increasingly centred on fast paced activities providing instant gratification.

 

Finally, while much time, money and effort has been spent on advertising the fact that blood is an important substance that is always in demand, it is likely that there may still be many people who remain ignorant of the pressing needs of blood banks. This is most likely to arise with people residing in rural areas, with possible reasons including a greater prevalence of illiteracy, a less comprehensive degree of media exposure relative to people living in highly concentrated urban areas, and an inappropriate manner of putting the message across (such as not using the local vernacular or understandable terms in media campaigns). Even when rural people are aware about blood donation, they may have difficulties in reaching a donation centre, since the low population density and significant distances involved mean that setting up collection points in minor towns may not be justifiable relative to the quantity of blood collected. 

 

Link to:  <Contents>  <Previous Section>  <Following Section>