The Gift Relationship: : From Human Blood to Social Policy

Citation

Buurman, G.B. (1999), "The Gift Relationship: : From Human Blood to Social Policy", International Journal of Social Economics, Vol. 26 No. 6, pp. 224-228. https://doi.org/10.1108/ijse.1999.26.6.224.3

The new edition of Richard Titmuss′ notable work, The Gift Relationship (The Gift), is timely. It is of interest to sociologists, economists (particularly health economists), and others interested in public policy.

The Gift was first published in 1970, just three years before Titmuss died. The book was a comparative study of blood donation in the United Kingdom (UK) and in the United States (USA). In the UK in the late 1960s, the supply of blood for transfusion came primarily from voluntary donations. The system in the USA, which often included payment for blood, resulted in higher cost blood and greater waste.

Titmuss′ main argument was that altruism can be efficient. He saw blood donation as the purest form of altruism, where people give without expecting blood to be given in return. The editors claim that his arguments may be more pertinent now than they were in the early 1970s. I would agree. Not only have significant health reforms taken place in many countries since the first edition; there are also medical advances requiring a greater supply of blood as well as recent developments to which Titmuss′ analysis can be applied.

The new edition includes five new chapters and is divided into three parts. Part I includes Oakley and Ashton′s introduction and two chapters updating the AIDS virus and summarizing advances in transfusion techniques. These are written by V. Berridge and V. Martlew respectively. Part II reproduces the main text of the original version of The Gift. In part III, G. Weaver and A. S. Williams draw parallels between the donation of breastmilk and blood. There is also an excellent “Afterword” by J. Le Grand covering (among other things) inefficient markets, morality, Titmuss′ contribution to the theory of adverse selection, and markets for used cars and blood. While some of the new chapters might be viewed as geared to the specialist, they contain a wealth of material.

Titmuss was interested in how the “social” could be separated from the “economic” in public policy. Why do people not just opt out of the “social” and act on their own advantage? He contended that if blood could be bought and sold, all policy would become economic policy, and only values measurable in money would count. This and a few other passages in the book (mentioned below) show that Titmuss had a somewhat distorted view of economics. First year texts in economics in that era explained the concept of opportunity cost and stressed that not only monetary values are important to the economist. Further, in economics, individuals are assumed to maximize utility, not amass money. Thus donating to a charity may be acting rationally in economic terms.

In chapters 6 and 7 (of the new edition), Titmuss commented on demand and supply. We find that the demand for blood was growing faster than population and he noted a problem similar to one we now recognize concerning health care: that we cannot really measure demand, only how much blood has been used. Because quantity demanded must be associated with price, there are problems for economists in this area. Many other current concerns in health economics are touched on by Titmuss. He linked the increase in the demand for blood to new medical techniques, aging populations, and greater reliance on general surgery.

On the supply of blood, the situation in the USA was especially obscure because there was no centralized data gathering agency. In England and Wales there was an increase in the supply of blood, the number of donors also increased and Titmuss claimed there was no evidence of a general shortage of blood. For the USA, Titmuss cited material showing wastage, acute shortages, incentive systems, voluntary donations not keeping pace with demand, and paid donors comprising 33 per cent of donors.

Titmuss then discussed blood as a gift. Donors must be healthy to protect the recipient (a great amount of trust is required) and even the medical profession does not know the quality of the gift until after it is given. In its altruistic extreme, a blood donation is impersonal and anonymous. If it were not, it may not be given or accepted.

He also classified eight different types of blood donor. These ranged from the extremes of the paid and the professional donor (types A and B) to the voluntary community donor (type H). Space precludes listing all of the intermediate types, but type F is the captive volunteer donor, who is in a subordinate position and expected to donate. Examples of this type are people in the army, prisoners, union members, etc. Type G is the fringe benefit donor, who is attracted by tangible rewards. Examples of this type are people who donate blood in return for days off work, longer holidays or free baseball tickets.

Titmuss then attempted to classify US donors into these eight types. Given his initial argument, he wanted to show a large proportion of paid or induced, versus voluntary, donors in the US. His initial calculations were conservative, but showed that about one‐third of donations were paid for and over one‐half were “tied” by various contracts. Only about 9 per cent of donations could be considered as free gifts contributed by voluntary community donors. This put paid to what Titmuss claimed was a deeply held myth in the USA: that most blood donations are contributed by volunteers.

Virtually all donors in the UK were type H, but Titmuss used survey data to compare their characteristics with the eight donor types in the USA. In the USA, the majority of donors were men (from 78 to 94 per cent depending on the study) and many were under age 30; professional and middle classes were underrepresented and unemployed men were heavily represented. In the UK, approximately 60 per cent of donors were men and while donors were somewhat younger than the general population, 10 per cent of blood came from those over age 65. Also men and women in social classes earning higher incomes appeared as a higher proportion of donors than in the general population.

Concerning the quality of blood, the problem in Titmuss′ era was the transmission of hepatitis. A key point for Titmuss was that the type of collection system can influence the amount of truthfulness of donors. Economists would agree. In summary, if we assume a system of paid donors, an unequal distribution of income in the society, and that the poor have a higher incidence of hepatitis, then there is an incentive for donors to lie in order to obtain income from blood. Titmuss cited statistics to show a high incidence of hepatitis occurring after a transfusion in the USA as compared to the UK. He concluded that Government systems of licensing are helpless in controlling private markets (this point has been questioned by critics).

Many of the issues just raised are linked to payment for blood when Titmuss summarized the “famous” Kansas City case of 1962. In the late 1950s, two commercial blood banks were competing with a non‐profit bank, organized by a group of medical professionals. Local hospitals refused to accept blood from the commercial banks because of its poor quality. The commercial banks then lodged a complaint with the Federal Trade Commission and, after appeals, it was ruled that the non‐profit bank and the hospitals had conspired to restrain trade in blood.

According to Titmuss, the main ramification was a legal one. If blood is viewed as a saleable commodity, lawsuits are possible for faulty blood. This can be extended (and has been in the USA) to other areas in medicine. Hence, insurance becomes necessary for medical professionals. Under the topic of moral hazard, health economists comment on the rising costs of insurance and the likelihood of these costs being passed on to the consumer of health care. This makes insurance a more attractive option for potential patients, but rising costs may put insurance out of reach for others.

Titmuss blamed the Kansas City fracas on the market system. Yet it could be argued that the market in blood was working efficiently since hospitals recognized that blood was not a homogeneous commodity and preferred non‐commercially obtained blood. Blame might be better placed on the legal system.

Chapter 15 is on economic and social man. Along the way to this chapter Titmuss took some shots at economists in general: claiming, among other things, that some act as if they have a “hotline to God” and ignore ethical values. He summarized an economic study by Culyer and Cooper which recommended payment for blood donors in the UK. Titmuss argued that the authors concluded that blood is an economic good, that we can attach an economic meaning to wastage, and that payment for blood would increase its supply. However Titmuss refused to comment on these conclusions, but again resorted to comparison of the blood distribution systems of the USA and UK. Since there are different cultural and value systems, why should a market in blood in the UK result in the same outcome as in the USA?

Noteworthy sociological points from the last chapters of The Gift include the kind of actions that mankind should perform in society. Titmuss argued that those who donate blood cause more good to exist in the universe than would exist if they did not act in this way. He also maintained that a study which included values for social and economic data might show (for some systems) large flows of total redistribution from the poor to the rich. That is, social gifts from the poor may outweigh the combined effects of progressive taxation and transfers. However, here Titmuss may have overlooked the benefit that actual cash payments for blood confer on the “poorer” donors.

The conclusion to The Gift was that mankind should be free to give and not be constrained by the market. In the interests of freedom for all, we should not be free to sell blood. Of course this, along with comparison of the USA and UK, implicitly presumes that adopting the UK system would alleviate shortages of blood in other societies. Given the different value systems of countries noted by Titmuss, there is no guarantee that an unpaid supply would be forthcoming elsewhere.

Of course there is a different twist to the arguments in The Gift. Throughout the literature in health economics, health care problems in the USA have been blamed on the use of market forces. D. Green has noted that these problems may actually be due to constraints preventing efficient markets. One example is the American Medical Association′s monopoly on the licensing of doctors which restricts supply and raises fees. Thus it could follow that constraints on competition was the cause of the problems.

Those who are skeptical that The Gift raised issues that are current today might consider the following points. First, Titmuss was worried that, ultimately, organs for donation may be bought and sold. Currently there are rumors that prisoners are shot to order for organ transplants in at least one country. Second, his analysis can also be applied to surrogacy. We have sperm and womb donors as well as markets for these services. Titmuss′ warning would have concerned legal implications, in this case potentially over ownership of the output. Third, hepatitis C infections due to tainted blood products were widespread in the late 1980s. To what extent should governments (operating a national health system) be liable for compensation to victims given that antibody screening tests were not used?