1.Introduction

The complexity of the contemporary corporeal gift has ramifications for understanding the concept of the gift exchange mechanisms on which voluntary blood donation is thought to rest. The changing landscape of contemporary blood donation and the ensuing ‘blood economies’ which have emerged raise potential ethical concerns. Previous researchD. Latiner-Vos, The Practical Organization of Moral Transactions: Gift Giving, Market Exchange, Credit, and the Making of Diaspora Bonds (2013). has referred to the situation succinctly when saying mistaking an object intended as a gift for a commodity will lead to tensions. Blood commodification has also fallen further under the new auspices of biotechnology; becoming medicalised into a new speciality of ‘blood component therapy’ with plasma-derived medicinal products being utilised in preference to whole blood transfusions.www.who.int/mediacentre/factsheets/fs279/en/ World Health Organisation, Fact Sheet No 279, updated June 2014 (last accessed 11/2/2015). As such, the gift relationship as identified by Titmuss now falls under the lens of bioethics for scrutiny.R. Titmuss, The Gift Relationship from Human Blood to Social Policy (London: London School of Economics and Political Science, 1997).

This paper deconstructs modern day blood donation against this backdrop of commercialisation of the ‘gift’, and reveals, as a result, tensions in what was once the safe world of the easily identifiable altruistic ‘no questions asked’ donor. With little ethical debate, contemporary blood donors are becoming aware of the power and the value of their gift, and acceptance of the gift relationship has become problematic for donors where blood donated at blood donor sessions is used for a purpose unknown by the giver. Contemporary donors want to keep some moral ownership whilst giving, thus indicating that the donation of blood today is more of a covenant than an unfettered gift.M. Petrini, Between Altruism and Commercialisation: Some Ethics Aspects of Blood Donation (Ann Ist Super Sanita, 2013). This paper seeks to problematise this area for further debate and queries the nature of blood donation consent in the light of the new bio-value of blood once removed from the host.

The author re-examines social exchange theoryM. Mauss, The Gift Relationship from Human Blood to Social Policy (London: London School of Economics and Political Science 1997). and alienation theoryA.B. Weiner, Inalienable Possessions: The Paradox of Keeping While Giving (Berkley: University of California Press 1992). to argue that blood, once donated, has become inalienable from the donor in a way which changes the concept of blood given as an unfettered gift and re-examines the meanings and purpose behind the new blood donation world where donors have no notion of or say in the intended recipients of their gift, and reflects on the ethics of the contemporary giving relationship.

Demands for blood and blood products increase annually to the point where the United Kingdom uses 8,000 units per day,www.nhs.uk/Conditions/Blood-donation/Pages/Introduction.aspx/ National Health Service (last accessed 12/10/2015). meaning that society places a high value on blood.D. Starr, Blood: An Epic History of Medicine and Commerce (New York: A. Knopf 1998). The average price of blood is £ 122 per unit in the UK,www.nhsbt.nhs.uk/annualreview/blood-supply/ National Health Service Blood Transfusion Annual review 12-13 (last accessed 12/10/2015). with the WHO reporting the number of donations per annum at 108 million.www.who.int/mediacentre/factsheets/fs279/en/ World Health Organisation, Fact Sheet no. 279 (2015) (last accessed 12/10/2015). Starr (1998) argues that as blood has become a pharmaceutical product it has come to symbolise a new social system.D. Starr, Blood: An Epic History of Medicine and Commerce (New York: Harper Collins 1998/2002). Commodification of blood and its products, and the technology associated with this activity, is a fast growing business. Bio Products Laboratories (BPL) manufactures a range of products from human blood and supports markets in 45 countries.www.bpl.co.uk/ Bio Products Labortories (last accessed 2/10/2015). The Blood 2020 strategy has as its aim to provide not only blood, but blood components that are needed for stem cell testing.National Health Service Blood Transfusion, Blood 20/20.A strategy for the blood supply in England and North Wales (2014). All of these changes impact on the social system in which blood donation operates, thus affecting the traditional ambiance in which blood is given and collected. Donors potentially understand that they are giving blood and not blood products, and see their gift as inalienable. Thus this new commodified and commercialised social system of blood donation will especially impact the marketing required to retain and attract donors.

2.Reframing the Gift

This paper first focuses on the theoretical implications for reframing the process of blood donation in the UK and the issues concerned with whose blood it is and what relationship the donation has with the donor body and wider society in the spare-part blood product world. Relating classical sociological and anthropological theories of gift exchange to blood donation enables further understanding of the contemporary blood donor world, as understandings of the rationale for becoming and remaining a blood donor being a form of altruism become challenged with the notion of ‘keeping whist giving’ appearing in the narratives of donation. Appadurai has written about the social life of things and blood has entered its own sociability as a result of the new life it takes on after leaving the body of its donor.A. Appadurai, The Social Life of Things: Commodities in Cultural Perspective (Cambridge: Cambridge University Press 1998). This has relevance when reflecting the social process of donating blood and understanding it through the lens of the gift relationship. Moreover, the nature of the donation is unclear in relation to what the gift becomes as a result of the commodification blood fractionation process and whom the gift ultimately goes to.

Douglas also alludes to the ideas of exchange in society, she argues: ‘Gift cycles engage persons in permanent commitments that articulate the dominant institutions.’M. Douglas, Natural Symbols (London: Routledge 1990), xi. This can be applied to biomedicine, and for example to the institution for National Health Service Blood and Transplant (NHSBT), and may result in an ethical impasse. Douglas argues that perception of symbols and their interpretation is socially determined and that this perception can alter over time.M. Douglas, Purity and Danger (London: Routledge 2002). She goes on to underline that the social body ‘constrains’ the ways in which the physical body is perceived and that this results in continuous exchanges between the two bodies about the current meaning endowed. Blood, as a natural symbol, undergoes this continuous cycle, thus current meanings of blood need to be reinterpreted. The capacity to buy, sell and commercially fractionate blood has altered the nature of blood from what was a symbol of human kinship and life forces.

This concept of blood being a natural symbol of exchange and kinship can be re-examined in relation to aspects of recent discourse, which is reflective of the ways in which society has begun to use blood and therefore what blood represents.J. Kurtzberg, A.M. Lyerly & J. Sugarman, ‘Untying the Gordian knot: policies, practices and ethical issues related to banking of umbilical cord blood’, Science and Society (2005). Donated blood is symbolic of both bio-hazard and gift, and is a medicine in its own right. Blood being both a symbol of good and risk brings questions to the understanding of the overly simplistic interpretation of the contemporary gift relationship. Berking argues that the giving of gifts binds everything together, gifts and gifting being representative of social synthesis which irrevocably unifies economics, power and, interestingly, morality.H. Berking, The Sociology of Giving (London: Sage 1999), 32.

In furthering sociological clarification of the gift relationship, Simmel has argued that society exists where a number of individuals enter into interaction.G. Simmel, The Sociology of Georg Simmel (translated, ed. and intro K.H. Wolff, Glencoe Ill: Free Press 1950). This interaction is purposeful in achieving desired aims for the mutual benefit of that society, and it creates subsequent unity or socialisation therein. Therefore unity is derived from the sum of interactions. Simmel’s views on exchange are pertinent to this paper, in that a characteristic of pure exchange must be that the sum of value to each party must be greater afterward than before. In the case of donated blood, therefore, the pooling and reconstitution of blood into its products would constitute pure exchange rather than the donation of the blood itself. This is because in contemporary society blood has greater value when out of the body than in it; moreover the value further increases during the process of fractionation. But the donation by the donor may not be pure exchange as the sum of value to the donor after the gift has been made may not be greater, as it was in the past, due to the loss of understanding of where and to whom the gift has been given. Contemporary methods for using and repackaging donated blood change the nature and form of donated blood into a different ‘gift’ and have shifted much of the value in the gift exchange away from the donor.

Understanding, then, that the gift is altered or changed by becoming commodified, Coleman argued that such commodification would reduce the properties required for blood donation to be a gift and may dilute it.S. Coleman, ‘The Charismatic Gift’, Journal of the Royal Anthropological Institute 10 (2004), 421-442. Mauss states that the gifts are, in the final analysis, compulsory social actions, even if given in the guise of voluntary politeness; in fact strictly compulsory on pain of private or public warfare. This applies in relative contemporary terms to blood donation as a National Health Service without blood is an unthinkable prospect.

Mauss further tells the observer about the group relationships, in particular the role of gifting in creating and maintaining relationship between groups, arguing that blood has gone further in the medicalisation relationship and that it has indeed become a technical tool separate from, or in addition to, the body. If the body, and therefore blood, has been acknowledged as the ‘natural tool of man’, it can now also be said to be the natural ‘marketplace of man’. Increasingly, donors want to know where their blood has gone, and who has been given it, thus contesting the notion of alienation in relation to donated blood and shifting the paradigm to one of inalienation. This poses ethical issues for the concept of voluntary blood donation and the use of the raw gift for purposes unbeknown to the donor such as re-gifting or selling on.

Moody, also, argues for a rethink on serial reciprocity.M. Moody, ‘Serial Reciprocity; A Preliminary Statement’, Sociological Theory 26:2 (2008), 130-151. This has ramifications for the concept of inalienability espoused by Weiner and whether blood donors are related to the spirit of their gift after it has been not only donated, but also altered as a result of the processes used in the redeployment of blood into both the marketplace and the blood supply.A.B. Weiner, Inalienable Possessions: The Paradox of Keeping While Giving (Berkeley: University of California Press 1992).

Problems arise, then, when the donated blood is alienated from the giver by default as a result of the unidentified reuse of the gift. Therefore, as blood has become more potent as a commodity than a functioning body part following its gifting, it has developed a form of ‘sociability’A. Appadurai, The Social Life of Things: Commodities in Cultural Perspective (Cambridge: Cambridge University Press 1998). with subsequent bio-value so that blood has become a form of new bio-capital.

Donations vs. Giving: The ethical use of donated blood

Referring to the work of Weiner, blood is described as becoming inalienable, i.e. the donated blood remains in some way related to the donor in spirit after the blood has left the body. This is in contrast to the altruistic paradigm where the gift was of whole blood largely with the popular understanding that the blood became gifted in the same whole state. Weiner argues all personal possessions invoke a connection with their owner, which symbolises the personal experience and adds to their overall identity. Blood donation is an example of this. As blood is increasingly seen as a body-part, its donation or giving can inform us about the donor and what the action of giving holds for them, and about the relationship of blood to the late postmodern body.

The discourse of blood donors about what happens to their blood after donation nowadays progresses this notion that donors now want to keep whilst giving. It is the change to the understanding of the new life that blood has after donation that is entering the donor consciousness which, this paper argues, has made blood inalienable, creating further tensions and instability within the unfettered altruistic paradigm.K. Arrow, ‘Gifts and Exchange’, Philosophy & Public Affairs 1:4 (1972), 343-362.

Mauss sets out the obligations and reciprocal requirements that are needed in order for stable gift exchange mechanisms to occur. These entwined obligations, to offer, to give, to receive, to accept and to repay, are crucial to the premise of the gift exchange cycle. This is pertinent to the blood donation system in the UK, which is still regarded today in the same as it was at its inception, i.e. one based on simple altruistic gifting.

In reviewing the current status quo in the newly commercialised blood market, Coleman argues that the process of donation is not able to conform to the full theoretical application of altruism as laid out by Mauss, as the way in which contemporary societies organise and distribute the gift of blood does not cater for the visual confirmation that the gift has been received.

There has been a change in the way that donated blood is perceived as a quasi-body part in the consumer world. Being duty bound to engage in donating pieces of the body, either in life or after death, has created areas of change in the giving relationship as to how commoditisation influences the understanding of the communal identity of donated blood. This poses further ethical issues requiring reconsideration of the role of understanding donated blood as a gift rather than a more neutral commodity.

3.Ethics and the Corporeal Gift

The Nuffield Report and the Blood 2020 Strategy both look towards increasing use and re-use of a wider range of body parts and organs, which has created a growing percentage of the general population joining the ‘donor’ fraternity as a result of receiving donor body parts through the impact of rapid technological advances.Nuffield Report (2014), http://nuffieldbioethics.org/wp-content/uploads/2014/07/Public-health-ethical-issues.pdf (last accessed 23/9/2015). According to the Nuffield Report, paragraph 65, the State remains the ‘steward’ of public health in relation to the donation of bodily materials including blood. The Report states that no changes are required in the voluntary system presently in place, in which case the gift falls into the hands of this stewardship which may create tension in the future.

Gold offers some ethical commentary on both body and blood. He argues that the body has authentic good conferred upon it by society and this is manifest in diverse ways as well as in intensely personal ways.E.R. Gold, Body Parts: Property Rights and the Ownership of Human Biological Materials

(Washington DC: Georgetown University Press), 12. It is a representation of who we are, and for some the body is the expression of a higher order, such as God. Therefore society values the body as a whole, but also increasingly in and for its contingent parts. Whilst these parts are not autonomous, the body is being broken down into both visible and microscopic parts such as DNA. Gold further highlights that this inherent ‘goodness’ of the body can be used in aiding human health. He cites blood as an example of being symbolically representative of life as well as becoming valuable as a ‘health preserving product’ once it has been broken into its therapeutic parts (Factor VIII, plasma, etc.) This is an important ethical development in the way societal and individual blood is regarded. While blood parts do not carry the same value as does blood as a whole, it is argued by Gold that we do value blood parts for what they represent in being a ‘symbol of community’, and thereby strengthening the growing link between body components and health.

Gold postulates that, rather than blood as a symbol of life losing its power via its transformation from whole blood to blood parts, in the doing of this the value society places on blood must increase, as blood therefore confers life to the recipient on behalf of society and not the donor. Ethical issues surround the concepts concerning whose blood it is in the first place and who this manifold body part belongs to. The property discourse was embedded in the solid body part donation debate, but it is argued here that the transformation of donated blood increases the original fluid’s value more than the volunteer donors understand. The debate concerning ethics of blood parts is not evident in the UK, perhaps because of the voluntary nature of the blood market. Weiss’s concept of ‘intercorporeality’ can be applied to the relationships created by the donating and distribution of the specialist components of blood.G. Weiss, Body Images Embodiment as Intercorporeality (London: Routledge 1999). Weiss is correct when she argues that no one is discrete in their identity, as the new person or ‘I’ is becoming mediated by the interdependence of what Waldby has called ‘biotechnical fragmentation’.C. Waldby, ‘Stem Cells, Tissue Cultures and the Production of Biovalue Health’, An Interdisciplinary Journal for the Social Study of Health, Illness and Medicine 6:3 (2003), 239. The NHSBT should therefore make more widely known what happens to the whole blood that is collected, and to ascertain whether donors know what happened to their blood after its donation, to allow for informed consent concerning the gift of blood as one entity and recipients being gifted or charged for a refashioned product of the gift.

Cohen also argues that there has been a development of an ‘ethics of parts’ in relation to the new divisible, commoditised late modern body.L. Cohen, ‘Where it Hurts: Indian Material for an Ethics of Organ Transplantation’, Daedalus 128:4 (1999), 135-65, cited in: Scheper-Hughes & Waquant, Commodifying Bodies (London: Sage 2006), 1. By this he means that ethics and ethical stances that used to apply to whole bodies are now applied part by part, thus allowing market forces to dictate the value of individual parts. These ethics are now being applied to blood parts within the Nuffield Report.

Lock argues that market forces make blood donating particularly vulnerable to exploitation due to the fact that donors are made to feel that blood is both a renewable resource from the body and easy to donate.M. Lock, ‘The Alienation of Body Tissue and the Biopolitics of Immortalised CellLines’, Body & Society 7:2-3 (2001), 63-91. This allows both objectification and fetishism for those whose blood is rare, for example. Busby argues that traditional blood services are built on the understanding that everyone is dependent on transfusion and/or transplant medicine.H. Busby, ‘The Meanings of Consent to the Donation of Cord Blood Stem Cells: Perspectives from an Interview Based Study of a Public Cord Blood Bank in England’, Clinical Ethics 5 (2010), 22:27.

Waldby and Mitchell postulate that tissue economies, which increasingly include emergent blood-related economies, are about the tense intersection of biological capacities and political systems of power.C. Waldby & R. Mitchell, Tissue Economy: Blood Organs and Cell Lines in Late Capitalism (London: Duke University Press 2007). This in itself resonates with the need to rethink the ethical issues with regard to the collection of blood in an altruistic fashion and then alienating the donor from its subsequent re-use. The donated blood, when circulating outside the body, becomes in fact more important, it treats deficient bodies which are in need of its hidden powers. Blood is separated out in order to produce more power parts in the form of fractions of itself, e.g. Factor VIII or white cells. Some of the current donors may understand the developing capacity of their donated blood, understanding that the donation would be separated into parts and used for people with different problems. Although donors may understand blood donation being seen packaged into a new form, however other donors may not know fractionation occurred, for whom there are potential future ethical issues.

4.Commoditisation of the gift

Sahlins stated, prophetically, that ‘one man’s gift should not be another man’s capital.’M. Sahlins, Stone Age Economic (New York: Aldine de Gruyter, 1972) 14, Intro. This can be applied to current controversies over blood donation, the argument being particularly pertinent to the themes identified in this paper, as in relation to blood this is precisely what has occurred. Donors have had very little idea what value others put on their gift, and more importantly, if the end product of the gift was not something that would be recognisable to the majority of donors, then it cannot be the gift as given. Farrell has asked whether blood now is really a gift or a commodity.A.M. Farrell, Political Scandal and Contaminated Blood in Ireland in Scandals in Past and Contemporary Politics (J. Garrard & J. Newell (eds.), Manchester: Manchester University Press 2005), 163-176. The innocuous donation of blood has turned into an unrecognisable product, and the convention of a voluntary supply of blood does not mean that there is no selling of blood here in the UK, as identified within the Archer Report.The Archer Inquiry, Independent Public Inquiry Report on NHS Supplied contaminated blood and blood products (2009).

In looking at ways in which contemporary societies manage blood it is possible to say that donated blood has become ‘McDonaldised’.G. Ritzer, McDonaldisation: The Reader (London: Pine Forge Press 2006). Blood is processed and packed in an identical way across the globe, with principles of McDonaldisation applied to the blood service in that the work is related to targets and strict policy.Joint United Kingdom (UK) Blood Transfusion and Tissue Transplantation Services Professional Advisory Committee, www.transfusionguidelines.org.uk/red-book/(last accessed 12/10/2015). The final aspect of the McDonaldisation thesis is that of control being passed from human to non-human. The laboratory-based component services are in the process of becoming non-human operated. The BPL is the embodiment of this aspect. All these processes alienate the giver from their gift, so that the need for re-evaluation of the concept of the gift of blood needs to be acknowledged. How can the donated blood remain in any way related to the giver after these processes?

5.Discussion

Some blood donors may understand this prerequisite relationship between the State and their gift, but not all donors. The body part generation seem to understand that blood is a substance for donating without emotions attached to it, but we still need to reframe the actions from being altruistic or those of citizenship to a half-way house of a covenant relationship. Ethically, there is an issue over the use of donated blood in relation to the spirit of the rationale for giving, thus echoing Titmuss, who predicted that the alienation of the giver from the destination of the product would be problematic in relation to blood donation. This leads contemporary blood donation to become defined as a form of covenanted altruism.

If the NHSBT were to become a non-voluntary institution, there would be serious ramifications for the ways in which the small part of the population who give their blood for free would regard the product of their gift. We can relate this issue to the work of Howson who argues that a key characteristic of the contemporary society is not only the emphasis placed on consumption, but also the sense of ‘self’ which derives from, for example, gifting of donated blood. Therefore damaging the gift relationship could have profound implications for people’s sense of self from their lack of knowledge of the true current market value of their donated blood.A. Howson, The Body in Society (Cambridge: Polity Press 2004). This argument has relevance for how donors see themselves in relation to the highly commoditised blood donation system. Beck further argues that we have become ‘agents of the self’, creating a partnership between the new technologies and the self.U. Beck, The Risk Society: Towards A New Modernity (London: Sage 1992).

Further, the cultural value of differing parts of the body for sale or ‘donation’ informs us of the hierarchical regard for relevant parts of the body that different cultures hold, which is well documented.B. Turner, Medical Power and Social Knowledge (2nd edn, London: Sage 2001). It invites investigation concerning the relationship between the body and the self in relation to the cyborg culture as well as the concept of bio-value or body capital in the consumerist society.

6.Conclusion

This paper extends the scope of understanding changes in blood donation and the gift relationship on which it depends, in relation to ethics and the gift exchange model. It aims at addressing the impact of developments in biomedicine and consumerism with regard to the self and blood donation and blood products, reflecting on the ethical issues involved in this new type of giving and receiving. Hidden behind a mask of quasi-altruism, donors are shown to be purposeful in their donation behaviour, and as Mauss has argued, there is no such thing as a ‘free gift’. Thus this paper reveals a dichotomy in the interpretation of the action of blood donation – is it an unfettered gift or a covenanted donation? An ethical rethink is required in order to fully understand the new gift relationships that exist in the contemporary world of blood donation.