AABB2025: Examining the Future of Volunteer Blood Donation

The principle that blood donation should remain an altruistic and voluntary act is facing challenges as increasing risks amidst blood shortages worldwide. In some cases, countries are reconsidering their current systems. In an interactive Sunday session, “Ethical Dilemmas in Compensating Blood Donors: Navigating Global Health Perspectives,” Richard R. Gammon, MD, Moffitt Cancer Center; and Ludwig R. Frontier, MD, MSc, MBA, DHSc, Macropharma and Universidad Anáhuac México, discussed the implications and complex ethical considerations of paid donation systems versus voluntary non-remunerated blood donation (VNRD).

VNRD is defined as blood donation given freely without payment in cash or in-kind compensation that could substitute for money. In the United States, most whole blood donations are not paid, although there is widespread use of gift cards, refreshments, raffles, loyalty programs and complimentary items such t-shirts. These small tokens remain compatible with VNRD principles.

The World Health Organization (WHO) is aiming for 100% voluntary donation by 2030, yet currently only 64 countries have 100% (or more than 99%) of their blood supply provided by voluntary unpaid blood donors. In 54 countries, more than 50% of the blood supply is dependent on family/replacement and paid blood donors.

Even amidst the drive to reach 100% VNRD, many countries are dependent on the U.S.’s paid plasma system. The U.S. supplies 75% of the world’s plasma through donors who are compensated for their time.

While the U.S. blood supply shows continued stabilization, a major concern is that the donor base is aging significantly, with the average age of blood donors jumping 16 years between 2001 and 2017. The “Civic Generation,” born between 1910 and 1945, has largely aged out of donation and younger Americans are not showing strong interest in replacing them. This aging trend threatens long-term sustainability of the blood supply and has brought increased attention to the issue of using paid donation as a way to increase donations from younger generations.

Critics worry that paying donors exploits the economically disadvantaged. Proponents argue that advanced testing has made paid blood dramatically safer than in the 1960s, when the connection between payment and disease transmission led to today’s volunteer-only policies.

Frontier discussed six bioethical frameworks that offer different perspectives on paid donation. These frameworks often conflict when applied to donor payment. The principle of double effect suggests that actions producing both good and bad outcomes may be permissible if the intention is good, harm is unintended, and benefits outweigh risks.

Ultimately, ethical decisions in all areas of transfusion medicine require balancing moral ideals with life-saving pragmatism.