Plasma donation in the EU: compensated and uncompensated

 Here's a commentary on the EU Parliament's current efforts to ban compensation to plasma donors in the EU, published today.

 Julio J Elias, Nicola Lacetera, Mario Macis, Axel Ockenfels, Alvin E Roth, "Quality and safety for substances of human origins: scientific evidence and the new EU regulations," BMJ Global Health, Volume 9, Issue 4 (21 April, 2024) https://doi.org/10.1136/bmjgh-2024-015122

"Summary box

The new European Union (EU) ‘Regulation on standards of quality and safety for substances of human origin (SoHOs) intended for human application’ is based on a long-standing diffidence towards offering compensation to donors of SoHOs.

We point to recent, growing empirical evidence indicating that carefully designed compensation can increase the supply of SoHOs without negatively affecting quality and safety. We also elaborate arguments that address some of the moral concerns that motivate the aversion to payments.

As member states proceed to adopt the new EU regulation, our article may provide insights on how to achieve both self-sufficiency and safety"

...

"At least where plasma for fractionation is concerned, the unpaid-donor system has failed to meet demand. Table 1 indicates that in Europe, countries allowing monetary compensation for donors are the only ones achieving self-sufficiency in plasma collection for the production of immunoglobulin. The plasma sector in countries that compensate plasma donors, notably the USA, serves as supplier to many countries experiencing chronic shortages. The USA alone collects about 70% of the world’s plasma supply.10 A combination of a favourable regulatory environment, an extensive collection network and advanced technological infrastructure contributed to establishing the US position.11

Table 1

Plasma self-reliance and models of plasma collection15–19

Country	Reliance on domestic supply (% of total national need)	Monetary payments allowed	Current payment amount	Other incentives
Austria (2020)	100	Yes	€30–40	–
Czech Republic (2020)	100	Yes	€30–35	–
Germany (2020)	100	Yes	€25	–
Hungary (2020)	100	Yes	€30	–
Latvia (2018)	100	Yes	€17	–
Italy (2018)	76	No	–	Paid leave of absence from work
Slovenia (2017)	54	No	–	Paid leave of absence from work
Belgium (2019)	50	No	–	Paid leave of absence from work
France (2020)	50	No	–	–
Netherlands (2020)	45	No	–	–
Slovakia (2018)	41	No	–	–
Denmark (2018)	34	No	–	–
Spain (2020)	34	No	–	–
Portugal (2018)	22	No	–	Exemption from National Health Service user fees

• The table shows, for each country, the percentage of plasma needed for immunoglobulin (Ig) production that is collected domestically. The year in parenthesis is the one to which the data on self-reliance refer. The table then reports whether monetary payments are allowed, the current range of payments per donation and any other incentives in use in each country. In countries that allow payments, plasma collectors offer, in addition to monetary compensation for each donation, additional monetary or in-kind rewards, for example, when a donor reaches a certain number of donations (eg, 5, 10,…), or to first-time donors. The figures reported above do not include these additional rewards.

Plasma in Canada: payments and protests

 The local newspaper in Niagara on the Lake, a town in Ontario, Canada, covers the proposed opening next year of plasma collection centers that will pay for plasma.

Pay-for-plasma centre draws criticism from Health Coalition. The centre, which will pay residents to donate their blood plasma, is scheduled to open on Hespeler Road by early 2025, by Matt Betts

"The chair of the Waterloo Region Health Coalition is raising concerns about a pay-for-plasma centre slated to open on Hespeler Road in Cambridge by early 2025.

"Just as it sounds, residents can be compensated for donating their blood plasma.

"It's all part of an agreement between Spanish global healthcare company, Grifols, and the Canadian Blood Services.

"In September 2022, Canadian Blood Services announced our action plan in response to a global shortage of medications called immunoglobulins and plasma needed to make them," CBS said in an email to CambridgeToday.

"With funding from governments, Canadian Blood Services is opening 11 plasma donor centres in Canada and collecting more plasma ourselves. Our agreement with Grifols, a global healthcare company and leader in producing plasma medicines, is another part of that plan."

...

"paying for donations is banned in Ontario, Quebec and British Columbia. 

"However, CBS said its been in close discussions with the government and has an exemption.

...

"The agreement also complies with Ontario’s Voluntary Blood Donations Act, which has always contained an exemption for Canadian Blood Services, with implicit consideration of our agents, given our role as the national blood operator and supplier of blood products in Canada. Through our agreement, Grifols will operate under the Act as an agent of Canadian Blood Services."

"Per the agreement, Grifols must use plasma they collect in Canada to make immunoglobulins exclusively for patients in Canada, which reduces reliance on the global market, CBS said.

"But the whole operation doesn't sit right with Waterloo Region Health Coalition chair, Jim Stewart.

"It's a repugnant example of profit driven healthcare," Stewart said, questioning who's profiting in the end.

"What's next, paying people for their organs or embryos? This is just another example of Premier Doug Ford’s drive to privatize our healthcare system."

...

""These pay-for-donations centres really impact the homeless, people with low incomes and those with high levels of unemployment. This is going to dismantle the voluntary donor base and the sustainability of blood supply could be in jeopardy."

...

"While not confirmed by Grifols, Canadian Blood Resources and giveplasma.ca states qualified donors can earn up to $70 per donation and can donate twice in a seven day period."

#####

HT: Frank McCormick

Earlier:

Sunday, September 18, 2022

Canadian Blood Services to start paying Canadian plasma donors

Market Design in El Mercurio--Chile's oldest newspaper

Last Tuesday, in Chile I was interviewed by Eduardo Olivares, the editor for Economics and Business of El Mercurio,  which published the interview yesterday. We talked for an hour about market design generally, about how markets work when they're working well or working badly, and we spoke about school choice (where Chile is a leader) and transplantation (where it is not). The interview is behind a paywall, but below are some extracts (retranslated back into English via Google Translate).

On markets generally:

—Many people ask that “markets be free,” as has recently happened in Argentina. Should they be free?

“That's a complicated question. Markets should be free to function well, but they need conditions that allow them to function well. Having a free market does not necessarily mean a market without rules. A wheel can spin freely because it has a well-greased axle and bearings. A wheel by itself cannot turn very well, and the same goes for the market.”

—Who puts the oil in the wheel gears?

“That's the job of market design. Part of what makes markets work well are good market rules. The government has a role in regulating markets, concerning property rights and things like that. But on another level, entrepreneurs do things. Here in Santiago I [can]... call an Uber using the same app and rules I use in California. Uber is a marketplace for passengers and drivers. The rules can be made by both private organizations and the government.”

On prices:

—Do prices matter?

"A lot. “Prices are important to help allocate scarce resources, but also to make them less scarce.”

...

—When do they not matter?

“Let me start with when they matter a lot: in commodity markets. If you want to buy commodities, price is really the only thing that's happening. But when 'El Mercurio' wants to hire journalists, it doesn't limit itself to offering a salary: it wants it to be a good job, with special reporters. Price is important, but in other markets other things are also important. When you get a new job, the first question your friends ask you is not what the salary is, but who you work for.”

On school choice:

“Most markets are not commodity markets... In some markets we don't like prices to work at all. One of the places where Chile is a leader in market design is school choice: how people are assigned to schools and Chile has done a lot of work on this, although mainly for public schools.”

—What do you know about this system in Chile?

“Not long ago, before there was centralized and widespread school choice in Chile, there were the usual problems with decentralized school choice; That is, parents had to get up early to get in line, and they had a difficult process to register their children.”

—The new system has been criticized. Some claim it caused more people to choose the private system over the public school system. Isn't it similar to what is happening in New York, for example?

“There is something to that. In New York and Boston we also have a system that we call charter schools: free access schools, but organized by private entities, even if they are municipal schools. And they also have different standards. School choice is important, but it does not solve the problems of poverty or income inequality. Now, one of the reasons we have school choice in the United States and perhaps also in Chile is because we think that, otherwise, there is a danger that the poor will be condemned to send their children to poor schools. .

—Has there been any successful case in which parents can honestly rank the order of preference for the school they want their children to go to?

“In Chile, procedures are used that [make it] what game  theorists call a dominant strategy to express true preferences. The [remaining] problem is not in creating systems that make it safe to express preferences, but in distributing the information so that people can form preferences sensibly. In the United States, the hardest families to reach are those who don't speak English at home, so it's sometimes difficult to communicate with them. And different families have different feelings about what kind of schools their children should attend.”

“The benefits of school choice come from the fact that some schools may be high quality for some children but not for others, so we would like children to attend the schools that are best quality for them.”

On kidneys:

—You are famous for the proposal that allowed the “kidney exchange.” Years after the first experience, what do you see now in this type of market?

“Kidney exchange is working quite well in the US, but it works especially well for patients who are not too difficult to match. Even in the US, a fairly large country, we have patients who are so difficult to match that we have trouble finding a kidney for them.”

—And in other countries?

“Smaller countries, with 20 million inhabitants, like Chile, would benefit if we could make national borders not so important. When we look at transplants per million inhabitants, Chile is in the middle of the world. But since it is a small country, when the total number of transplants performed is analyzed, Chile has very few. Kidneys are obtained from both deceased and living donors. In Chile, as in much of the world, the majority of transplants come from deceased donors. Kidney exchange would allow more transplants to come from living donors ... “Twenty million is not enough, so it would be very good to see in South America an exchange of kidneys that can cross between countries, which is not so easy to do.”

Equality of exchange and the role of perceptions

“One of the things that worries people when talking about transplants is that [they think it might be] a medical process that exploits the poor. Of course, the thing about kidney exchange is that each pair of people gives one kidney and receives one kidney. It is very egalitarian. I think kidney exchange is a good place to combat this notion that transplantation is like trafficking,” he notes.

—Notions, perceptions are very important. Many people think of “exchange” as the exchange of securities in the stock market.

“That's right, but not every exchange involves money. One of the discussions about money in the world that is taking place in the European Union at the moment is about payment to blood plasma donors. In the EU, only Germany, Austria, the Czech Republic and Hungary pay blood plasma donors. And those are the only EU countries that have as much blood plasma as they need. The others have to import everything, and they do it from the United States. The United States is the Saudi Arabia of blood plasma (…) The World Health Organization says that plasma must be obtained in each country, and from unpaid donors. You have to be self-sufficient... an economist finds that a little funny. Blood is a matter of life and death. “When there is a pandemic, we do not tell countries that they must be self-sufficient [in vaccines].”

—When we talk about these exchanges of blood plasma and kidneys, school choice systems, we are talking about the same idea: coincident or paired markets. But the concept of the market has been so questioned, especially by some political groups, for so long...

"It's true. Now,  kidney exchange is special because money doesn't change hands. Money changes hands to get medical care, you have to pay doctors, nurses and hospitals. But we are not talking about buying kidneys from donors, but rather that, at the patient level, each pair receives a kidney and donates a kidney. It is radically egalitarian. Many people who think about markets may not think of it as a market, but I think that's a mistake. Many markets are not just about money… we would worry much less about markets if income and wealth inequality did not exist. “What worries us about markets is that some people are poor and some people are rich, and markets seem like a way to give the rich an advantage.”

“There is no doubt that being rich is better than being poor. The real question is what do we do to alleviate poverty. Making it invisible is not the same as alleviating it. One of the reasons I think many countries don't allow blood and plasma donors to be paid is because they don't like the way that looks. It reminds them that some people would like to get some money and would donate blood for it.”

Apparently, according to the caption, I'm "affable and smiling" (although not in this picture:)

I was in Chile to participate in what turned out to be a wonderful workshop on market design at the University of Chile, organized by Itai Ashlagi, José Correa, and Juan Escobar.

Some related recent posts:

Saturday, December 23, 2023

Market design: some press accounts in Chile

Wednesday, December 20, 2023

Public lecture today at the Casa Central de la Universidad de Chile:“Quién obtiene qué y por qué: La nueva economía del diseño de mercados”

Sunday, December 17, 2023

Market Design Workshop 18 - 20 December 2023 Santiago, Chile

Saturday, November 4, 2023

The EU proposes strengthening bans on compensating donors of Substances of Human Origin (SoHOs)--op-ed in VoxEU by Ockenfels and Roth

#########

Update (Dec. 27): Here's an account of my closing public talk from the U. Chile's Center for Mathematical Modeling, one of the hosts of the market design workshop.

Alvin Roth: “Markets are human artifacts, they are tools that we build ourselves to help us”.

And here's a picture at the close, including some of those mentioned above: At my far left in the picture is José Correa,  who in addition to his other roles is Vice Rector for Information Technologies. Next to him is Alejandra Mizala, prorrector (provost) of the university.  Next to her (immediately to my left) is Rector of the University of Chile, Rosa Devés, and immediately to my right is market designer and director of the MIPP Millennium Institute, Juan Escobar. Next to him is Héctor Ramírez, director of the Center for Mathematical Modeling. And next to him (at my far right) is professor Rafael Epstein who (along with Correa, Escobar, and his daughter Natalie Epstein) has been involved with school choice in Chile, among other things.

Managing blood supplies by using blood more judiciously

Medpage has the story:

Doing More With Less Blood — Blood management programs can save money and resources  by Steven Frank, MD 

"At Johns Hopkins, since our patient blood management efforts began in 2012, we launched two distinct programs running side by side synergistically. The first program aims to reduce avoidable transfusions for the roughly 99% of patients who accept blood, while the second program provides optimal care for the remaining 1% of patients who wish to avoid transfusion for personal or religious reasons, the vast majority of whom are Jehovah's Witnesses. 

...

"treating preoperative anemia with $4 worth of iron tablets to avoid using $400 worth of blood just makes sense. Wouldn't you rather come to surgery with your own red blood cells, rather than needing a transfusion with someone else's?

""Keeping the blood in the patient" is the other major concept behind patient blood management. Simple things can reduce bleeding, such as keeping patients warm during surgery; lowering the blood pressure (controlled hypotension); tranexamic acid (an inexpensive medication that reduces bleeding by about 30%opens in a new tab or window); Cell Savers to return surgical blood loss to the patient; and using smaller phlebotomy tubes to send lab tests. All of these strategies can be bundled together to achieve this goal.

"After a decade of experience, we crunched the numbers to assess our return on investment (ROI) with our comprehensive patient blood management program, while also looking at patient outcomes. The bottom line was a 7.5-fold ROI, meaning that for every dollar spent on patient blood management, over $7 were either saved or generated in return. This calculation is based on a $3 million annual reduction in blood acquisition cost, along with a $5 million annual net margin on revenue generated by caring for patients under the Center for Bloodless Medicine and Surgery.

"At the same time, clinical outcomes were either the same or better while giving less blood. Heart attack, stroke, thrombotic events, and respiratory and kidney problems were unchanged, while the incidence of hospital-acquired infection decreased. This latter finding is very believable based on high-level evidence (meta-analysis of 18 randomized trials) that transfusions predispose patients to infections. Furthermore, by avoiding transfusions for those who do not need them, we make more blood available for those who really do -- like trauma victims and cancer patients.

"Given the ongoing blood shortages that we are facing, which has been called a "crisis" in the blood industry, patient blood management looks like a giant step towards the triple aim in medicine: improving the patient experience, clinical outcomes, and cost."

**********

See, earlier in the NEJM:

Crisis in the Sustainability of the U.S. Blood System

by Harvey G. Klein, M.D., J. Chris Hrouda, B.H.S., and Jay S. Epstein, M.D., October 12, 2017

N Engl J Med 2017; 377:1485-1488

DOI: 10.1056/NEJMsb1706496

Convalescent plasma: the picture is getting clearer

 Slowly, there is evidence accumulating that convalescent plasma is helpful in treating patients with severe Covid, if it is administered early.  There is also evidence that it doesn't help much once the disease has become well established, particularly when the primary symptoms become due to the body's own immune reaction.  These caveats help explain why early reports did not find an effect of convalescent plasma--i.e. it helped only a subset of the patients to whom it was administered. But for those it was sometimes life saving. Here is a recent paper from the New England Journal of Medicine.

Convalescent Plasma for Covid-19–Induced ARDS in Mechanically Ventilated Patients by Benoît Misset, M.D., Michael Piagnerelli, M.D., Ph.D., Eric Hoste, M.D., Ph.D., Nadia Dardenne, M.Sc., David Grimaldi, M.D., Ph.D., Isabelle Michaux, M.D., Ph.D., Elisabeth De Waele, M.D., Ph.D., Alexander Dumoulin, M.D., Philippe G. Jorens, M.D., Ph.D., Emmanuel van der Hauwaert, M.D., Frédéric Vallot, M.D., Stoffel Lamote, M.D., et al., October 26, 2023, N Engl J Med 2023; 389:1590-1600 DOI: 10.1056/NEJMoa2209502

"Abstract

BACKGROUND

Passive immunization with plasma collected from convalescent patients has been regularly used to treat coronavirus disease 2019 (Covid-19). Minimal data are available regarding the use of convalescent plasma in patients with Covid-19–induced acute respiratory distress syndrome (ARDS).

METHODS

In this open-label trial, we randomly assigned adult patients with Covid-19–induced ARDS who had been receiving invasive mechanical ventilation for less than 5 days in a 1:1 ratio to receive either convalescent plasma with a neutralizing antibody titer of at least 1:320 or standard care alone. Randomization was stratified according to the time from tracheal intubation to inclusion. The primary outcome was death by day 28.

RESULTS

A total of 475 patients underwent randomization from September 2020 through March 2022. Overall, 237 patients were assigned to receive convalescent plasma and 238 to receive standard care. Owing to a shortage of convalescent plasma, a neutralizing antibody titer of 1:160 was administered to 17.7% of the patients in the convalescent-plasma group. Glucocorticoids were administered to 466 patients (98.1%). At day 28, mortality was 35.4% in the convalescent-plasma group and 45.0% in the standard-care group (P=0.03). In a prespecified analysis, this effect was observed mainly in patients who underwent randomization 48 hours or less after the initiation of invasive mechanical ventilation. Serious adverse events did not differ substantially between the two groups.

CONCLUSIONS

The administration of plasma collected from convalescent donors with a neutralizing antibody titer of at least 1:160 to patients with Covid-19–induced ARDS within 5 days after the initiation of invasive mechanical ventilation significantly reduced mortality at day 28. This effect was mainly observed in patients who underwent randomization 48 hours or less after ventilation initiation."

#####

Here are my posts on convalescent plasma, and the confusing initial reports about its effects.

The EU proposes strengthening bans on compensating donors of Substances of Human Origin (SoHOs)--op-ed in VoxEU by Ockenfels and Roth

 The EU has proposed a strengthening of European prohibitions against compensating donors of "substances of human origin" (SoHOs).  Here's an op-ed in VoxEU considering how that might effect their supply.

Consequences of unpaid blood plasma donations, by Axel Ockenfels and  Alvin Roth / 4 Nov 2023

"The European Commission is considering new ways to regulate the ‘substances of human origin’ – including blood, plasma, and cells – used in medical procedures from transfusions and transplants to assisted reproduction. This column argues that such legislation jeopardises the interests of both donors and recipients. While sympathetic to the intentions behind the proposals – which aim to ensure that donations are voluntary and to protect financially disadvantaged donors – the authors believe such rules overlook the effects on donors, on the supply of such substances, and on the health of those who need them.

"Largely unnoticed by the general public, the European Commission and the European Parliament’s Health Committee have been drafting new rules to regulate the use of ‘substances of human origin’ (SoHO), such as blood, plasma, and cells (Iraola 2023, European Parliament 2023). These substances are used in life-saving medical procedures ranging from transfusions and transplants to assisted reproduction. Central to this legislative initiative is the proposal to ban financial incentives for donors and to limit compensation to covering the actual costs incurred during the donation process. The goal is to ensure that donations are voluntary and altruistic. The initiative aims to protect the financially disadvantaged from undue pressure and prevent potential misrepresentation of medical histories due to financial incentives. While the intention is noble, the proposal warrants critical analysis as it may overlook the detrimental effects on donors themselves, on the overall supply of SoHOs, and consequently on the health, wellbeing, and even the lives of those who need them. We illustrate this in the context of blood plasma donation.

"Over half a century ago, Richard Titmuss (1971) conjectured that financial incentives to donate blood could compromise the safety and overall supply. This made sense in the 1970s, when tests for pathogens in the blood supply were not yet developed. But Titmuss’ conjecture permeated policy guidelines worldwide, despite mounting evidence to the contrary. Although more evidence is needed, a review published by Science (Lacetera et al. 2013; see also Macis and Lacetera 2008, Bowles 2016), which looked at the evidence available more than 40 years after Titmuss’ conjecture, concluded that the statistically sound, field-based evidence from large, representative samples is largely inconsistent with his predictions.

"Getting the facts right is important because, at least where blood plasma is concerned, the volunteer system has failed to meet demand (Slonim et al. 2014). There is a severe and growing global shortage of blood plasma. While many countries are unwilling to pay donors at home, they are willing to pay for blood plasma obtained from donors abroad. The US, which allows payment to plasma donors, is responsible for 70% of the world’s plasma supply and is also a major supplier to the EU, which must import about 40% of its total plasma needs. Together with other countries that allow some form of payment for plasma donations – including EU member states Germany, Austria, Hungary, and the Czech Republic – they account for nearly 90% of the total supply (Jaworski 2020, 2023). Based on what we know from controlled studies and from experiences with previous policy changes, a ban on paid donation in the EU will reduce the amount of plasma supplied from EU members, prompting further attempts to circumvent the regulation by importing even more plasma from countries where payment is legal. At the same time, a ban will contribute to the global shortage of plasma, further driving up the price and making it increasingly unaffordable for low-income countries (Asamoah-Akuoko et al. 2023). In the 1970s, it may have been reasonable to worry that encouraging paid donation would lead to a flow of blood plasma from poor nations to rich ones. That is not what we are in fact seeing. Instead, plasma supplies from the US and Europe save lives around the world.

"In other areas, society generally recognises the need for fair compensation for services provided, especially when they involve discomfort or risk. After all, it is no fun having someone stick a needle in your arm to extract blood. This consensus cuts across a range of services and professions – including nursing, firefighting, and mining – occupations, most people would agree, that should be well rewarded for the risk involved and value to society. To rely solely on altruism in such areas would be exploitative and would eventually lead to a collapse in provision. Indeed, to protect individuals from exploitation, labour laws around the world have introduced minimum compensation requirements rather than caps on earnings. In addition, payment bans on donors, even if they’re intended to protect against undue inducements, raise concerns about price-fixing to the benefit of non-donors in the blood plasma market. In a related case, limits on payment to egg donors have been successfully challenged in US courts. 1

"In addition, policy decisions affecting vital supplies such as blood plasma should be based on a broad discourse that includes diverse perspectives and motivations. Ethical judgements often differ, both among experts and between professionals and the general public, so communication is essential (e.g. Roth and Wang 2020, Ambuehl and Ockenfels 2017). Payment for blood plasma donations is an example. We (the authors of this article) are from the US and Germany, countries that currently allow payment for blood plasma donations while most other countries prohibit payment. On the other hand, prostitution is legal in Germany but surrogacy is not, while the opposite is true in most of the US. And while Germany currently prohibits kidney exchange on ethical grounds, other countries – including the US, the UK, and the Netherlands – operate some of the largest kidney exchanges in the world and promote kidney exchange on ethical grounds.

"The general public does not always share the sentiments that health professionals find important (e.g. Lacetera et al. 2016). This tendency is probably not due to professionals being less cognitively biased. In all areas where the question has been studied, experts such as financial advisers, CEOs, elected politicians, economists, philosophers, and doctors are just as susceptible to cognitive bias as ordinary citizens (e.g. Ambuehl et al. 2021, 2023). Recognising the similarities and differences between professional and popular judgements, and how ethical judgements are affected by geography, time, and context, allows for a more constructive and effective search for the best policy options.

"In our view, the dangers of undersupply of critical medical substances, of inequitable compensation (particularly for financially disadvantaged donors), and of circumvention of regulation by sourcing these substances from other countries (where the EU has no influence on the rules for monitoring compensation to protect donors from harm) are at least as significant as those arising from overpayment. Carefully designed transactional mechanisms may also help to respect ethical boundaries while ensuring adequate supply. Advances in medical and communication technologies, such as viral detection tests, can effectively monitor blood quality and ensure the safety and integrity of the entire donation process – including the deferral of high-risk donors and those for whom donating is a risk to their health – without prohibiting payment to donors. Even if it is ultimately decided that payments should be banned, there are innovations in the rules governing blood donation that have been proposed, implemented, and tested that would improve the balance between blood supply and demand within the constraints of volunteerism; non-price signals, for instance, can work within current social and ethical constraints.

"As the EU deliberates on this legislation, it is imperative to adopt a balanced, empirically sound, and research-backed approach that considers multiple effects and promotes policies to safeguard the interests of both donors and recipients.

References

Asamoah-Akuoko, L et al. (2023), “The status of blood supply in sub-Saharan Africa: barriers and health impact”, The Lancet 402(10398): 274–76.

Ambuehl, S and A Ockenfels (2017), “The ethics of incentivizing the uninformed: A vignette study”, American Economic Review Papers & Proceedings 107(5), 91–95.

Ambuehl, S, A Ockenfels and A E Roth (2020), “Payment in challenge studies from an economics perspective”, Journal of Medical Ethics 46(12): 831–32.

Ambuehl, S, S Blesse, P Doerrenberg, C Feldhaus and A Ockenfels (2023), “Politicians’ social welfare criteria: An experiment with German legislators”, University of Cologne, working paper.

Ambuehl, S, D Bernheim and A Ockenfels (2021), “What motivates paternalism? An experimental study”, American Economic Review 111(3): 787–830.

Bowles S (2016), “Moral sentiments and material interests: When economic incentives crowd in social preferences”, VoxEU.org, 26 May.

European Parliament (2023), “Donations and treatments: new safety rules for substances of human origin”, press release, 12 September.

Iraola, M (2023), “EU Parliament approves text on donation of substances of human origin”, Euractiv, 12 September.

Jaworski, P (2020), “Bloody well pay them. The case for Voluntary Remunerated Plasma Collections”, Niskanen Center.

Jaworski, P (2023), “The E.U. Doesn’t Want People To Sell Their Plasma, and It Doesn’t Care How Many Patients That Hurts”, Reason, 20 September.

Lacetera, N, M Macis and R Slonim (2013), “Economic rewards to motivate blood donation”, Science 340(6135): 927–28.

Lacetera, N, M Macis and J Elias (2016), “Understanding moral repugnance: The case of the US market for kidney transplantation”, VoxEU.org, 15 October.

Macis M and N Lacetera (2008), “Incentives for altruism? The case of blood donations”, VoxEU.org, 4 November.

Roth, A E (2007), “Repugnance as a constraint on markets”, Journal of Economic Perspectives 21(3): 37–58.

Roth A E and S W Wang (2020), “Popular repugnance contrasts with legal bans on controversial markets”, Proc Natl Acad Sci USA 117(33): 19792–8.

Slonim R, C Wang and E Garbarino (2014), “The Market for Blood”, Journal of Economic Perspectives 28(2): 177–96.

Titmuss, R M (1971), The Gift Relationship, London: Allen and Unwin.

Footnotes: 1. Kamakahi v. American Society for Reproductive Medicine, US District Court Northern District of California, Case 3:11-cv-01781-JCS, 2016.

The EU considers tightening bans on compensating donors of Substances of Human Origin (SoHO)

 Peter Jaworski considers an  EU proposal this month to harmonize across the EU bans on paying donors for Substances of Human Origin (SoHO).  Presently Germany, Austria and Chechia allow payment to plasma donors.

The E.U. Doesn't Want People To Sell Their Plasma, and It Doesn't Care How Many Patients That Hurts. The United States currently supplies about 70 percent of the plasma used to manufacture therapies for the entire world.  by PETER JAWORSKI 

"The European Union looks like it might take the foolish step of banning financial incentives for a variety of substances of human origin, including blood, blood plasma, sperm, and breast milk. The legislation on the safety and quality of Substances of Human Origin includes an approved amendment that says donors can only be compensated for "quantifiable losses" and that such donations are to be "financially neutral." This legislation is supposed to harmonize the rules across the 27 member countries, promote safety, with the ban on financial incentives intended to avoid commodification and the exploitation of the poor. 

...

"Already the E.U. is dependent on plasma collected in the United States for around 40 percent of the needs of its 300,000 rare disease patients. They're not as dependent as Canada because Germany, Austria, Hungary, and the Czech Republic allow a flat-fee donor compensation model and so are able to have surplus collections that contribute 56 percent of the E.U. total. The remaining 23 countries, each of which runs a plasma collection deficit, manage just 44 percent. 

"So what is likely to happen if the new rules make this flat-fee donor compensation model illegal? Will safety improve and commodification and exploitation be avoided? No, the E.U. will just become even more dependent on the United States."

Africa continues to suffer severe shortages of blood and plasma

 Blood and plasma are in short supply in Africa, partly due to the insistence, by the WHO and others, that  blood and plasma be supplied domestically from unpaid donors. (Much of the world buys blood plasma from the United States, where donors can be paid.)

Here's an update from the Lancet:

The status of blood supply in sub-Saharan Africa: barriers and health impact, by Lucy Asamoah-Akuoko Bernard Appiah  Meghan Delaney  Bridon M'baya  Claude Tayou Tagny  Imelda Bates Published:June 13, 2023DOI:https://doi.org/10.1016/S0140-6736(23)01164-9

"Sub-Saharan African countries continue to struggle with chronic, year-round blood shortages, limiting their ability to support patients and deliver on the health-related Sustainable Development Goals (SDGs).1 Most blood recipients in sub-Saharan African countries are children and women around the time of childbirth,2 so achieving the health-related SDGs depends on blood and blood product availability to reduce maternal mortality, end preventable deaths of newborn babies and children younger than 5 years, and achieve universal health coverage. Blood shortages in sub-Saharan Africa can have devastating consequences. An estimated 70% of 287 000 pregnancy-associated deaths in the world in 2020 occurred in sub-Saharan African countries,3 predominantly due to obstetric haemorrhage. Insufficient blood supply for transfusion contributes substantially to such maternal deaths in hospitals in sub-Saharan Africa.4 Blood transfusions are also essential for managing sub-Saharan Africa's high rates of traffic accidents5 and childhood anaemia, which is commonly due to infections such as malaria, helminthiasis, and haemoglobinopathies. Sub-Saharan Africa is home to more than 75% of the 300 000–400 000 babies born each year globally with sickle cell disease;6 blood shortages contribute to 50–90% of these children dying before their fifth birthday.7

...

"But there are several barriers to achieving an adequate and sustainable blood supply in sub-Saharan Africa. The average number of blood donations across the WHO African region is less than 6 units per 1000 population, with some countries such as Cameroon, Eritrea, and Madagascar collecting less than two units per 1000 population.8 Insufficient blood supply in sub-Saharan African countries is due to many factors, including inadequate organisation, regulation, and coordination of national blood services, and challenges with geographical distribution of blood for transfusion. There are also cultural barriers and stigma associated with knowing HIV status9 that deter some voluntary blood donors, compounded by inefficient donor recruitment programmes, and inadequate funding and sustainable financing models for blood services. Several sub-Saharan African countries including Kenya, Lesotho, Malawi, and Uganda, built their national blood transfusion services on the back of HIV funding from donor agencies such as President's Emergency Plan for AIDS Relief, The Global Fund to Fight AIDS, Tuberculosis and Malaria, and the EU, but this funding has reduced considerably.

...

"WHO recognises three types of blood donors: voluntary non-remunerated blood donors (VNRBD); family replacement blood donors (FRD) who donate blood for family members, friends or acquaintances; and paid donors. In high-income countries such as Denmark and the UK, the use of VNRBD ensures reliability of adequate national blood supply. In the WHO Africa region, the number of VNRBD increased from 1·89 million in 2008 to 3·42 million in 2018 (increasing total donations from 2·41 million units to 4·46 million units).11 Despite this, donations from VNRBD are unable to meet the demand for blood in many sub-Saharan African countries. For example, of 21 sub-Saharan African countries with more than 80% VNRBD, only five (Botswana, Mauritius, Namibia, South Africa, and Eswatini) have met the minimum blood requirement of 10 units per 1000 population2—a target that, although globally adopted, is not based on robust evidence.12 Paid donors have a lower safety profile as compared with VNRBD and do not contribute to achieving adequate an cd safe blood supply.13"

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And here is reference 13, a WHO pamphlet published in 2010 calling on all donations to achieve self sufficiency in unpaid blood donation

13. WHO, 2010, "Towards 100% voluntary blood donation: a global framework for action"  

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Earlier:

Monday, May 18, 2020

Plasma and plasma products (such as antibodies) are a big business (and the U.S. dominates the international market)

Blood money: plasma and ambivalence

 The Guardian has a long review of the book Blood Money, by Kathleen McLaughlin, who is dependent on blood plasma, but suggests reasons to be ambivalent about the American market for paid plasma.

‘It’s gamified’: inside America’s blood plasma donation industry. In her new book Blood Money, Kathleen McLaughlin uses a personal lens to examine an industry that rewards mass plasma donation  by David Smith

"So who is the typical blood seller and why do they do it? McLaughlin had expected to find the poorest of the poor but, it transpires, most of them are screened out because a plasma donor must have a permanent address.

“What I found instead was a lot of people who, say, 25 years ago would have been middle class, and they just don’t make enough money for that lifestyle any more. I get the sense that one of the biggest demographics is college students. We’re talking about like big public universities where there are a lot of students who don’t come from wealthy backgrounds; I’ve talked to people who use this money to buy books, to pay to go out for a night, for ‘beer money’.

“You will also find people in communities like Flint, Michigan, where I spent a lot of time, who used to be able to expect to have this very normal American middle-class lifestyle and wages and benefits no longer keep pace with that. There are people doing it to buy groceries and to pay for housing. There are also people who are selling plasma to take a vacation."

...

"And whereas donating blood for free is lauded, donating it for money is stigmatised. “If you think about blood donation, it’s something that we consider quite heroic. If you go to the Red Cross and donate blood, you’re saving a life, you’re not getting paid for it.

“But somehow this practice of donating plasma for pay comes with a pretty heavy stigma. A lot of the people I interviewed who do sell plasma had not told their families that they do it because they were afraid of what their families would think: there would be some kind of judgment or their families would be worried about their health or concerned that they don’t have enough money.

‘The stigma is entirely linked to the fact that we stigmatise poverty in the United States. We look down on it. We don’t respect people who aren’t wealthy in the same way that we respect wealthy people. It’s been interesting for me to see the way that people view selling plasma as being somehow problematic and that’s definitely contributed to the fact that this industry is kind of hidden.”

"Still, should we make a moral judgment about the blood industry? It is not, after all, pushing an addictive substance like opioids, but rather is helping the health of people in America and around the world, McLaughlin included. She replies: “We need to ask ourselves that. From my perspective as someone who depends on this substance, what people are doing is incredibly altruistic.

“I also think a lot of people are being financially coerced to do it and, the way the system is set up, you get paid more per donation for each donation you make. It’s gamified in such a way that people are encouraged to donate quite often and because it is a hidden industry, most Americans haven’t really considered if this is who we want to be.

“If you know that there are potentially millions of Americans who have sold their plasma to pay for things like groceries and vacations, are you OK with that? For me, it’s more a matter of getting people to think about it, that our economic situation is such that this is part of our fabric now and are we comfortable with being that way or do we want to think more deeply about how we can make this more feel more of a choice for people?”

"She adds: “The industry itself isn’t necessarily the problem. The problem is that we have let this industry become a part of people’s incomes. I don’t know that that’s the kind of society we want to be.”

“It’s these places where people are economically fragile, not necessarily desperately poor. The kind of fragility that we didn’t have 25 or 30 years ago when there were more social-safety protections.”

Reconsideration of covid convalescent plasma

Recently Statnews reported that Covid convalescent plasma (CCP) may in fact be useful in preventing severe illness, despite the fact that earlier clinical trials did not show success in reversing severe illness:

Covid convalescent plasma: the ‘little engine that could’  By Michael J. Joyner, Nigel Paneth and Arturo Casadevall

"Unlike monoclonal antibodies, which can be defeated by new SARS-CoV-2 variants, CCP collected from vaccinated donors after recent breakthrough infections (VaxCCP) evolves with the variants and retains the ability to neutralize them. What makes CCP an even more promising therapy is that there are now many potential donors available in the U.S. who have been vaccinated and had recent breakthrough infections.

...

"An array of data, including randomized controlled trials and careful retrospective studies, show a clear survival benefit when CCP is given to immunocompromised individuals who test positive for SARS-CoV-2. There are also impressive case reports and case series showing that Covid convalescent plasma, especially VaxCCP, is effective in patients with smoldering Covid-19.

...

"the early “major” RCTs that tested the efficacy of CCP on survival in hospitalized patients tested the wrong use case. These studies treated patients who were too sick for too long to benefit from antibody therapy. But the major “negative” trials all showed evidence of effectiveness among people who received CCP earlier, who were not already desperately ill, who were immunocompromised, or who received the most antibodies. Unfortunately, these positive signals, which were consistent with impressive real-world data on Covid-19 and CCP, were buried under the top-line results."

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Earlier posts on convalescent plasma

Moral certainties versus moral tradeoffs

 An article and a commentary in PNAS raise the possibility that  economists and psychologists and moral philosophers concerned with morally contested transactions may be able to engage in more useful discussions. A problem is that economists mostly think about tradeoffs while many moral philosophers (or at least those who write about medical ethics) often think of morality as involving absolutes. (This is clearly illustrated in discussions about repugnant transactions, such as those involving compensation of donors of blood plasma or kidneys, for example.)

The PNAS article is   

Guzmán, Ricardo Andrés, María Teresa Barbato, Daniel Sznycer, and Leda Cosmides. "A moral trade-off system produces intuitive judgments that are rational and coherent and strike a balance between conflicting moral values." Proceedings of the National Academy of Sciences 119, no. 42 (2022): e2214005119. https://doi.org/10.1073/pnas.2214005119

"Significance: Intuitions about right and wrong clash in moral dilemmas. We report evidence that dilemmas activate a moral trade-off system: a cognitive system that is well designed for making trade-offs between conflicting moral values. When asked which option for resolving a dilemma is morally right, many people made compromise judgments, which strike a balance between conflicting moral values by partially satisfying both. Furthermore, their moral judgments satisfied a demanding standard of rational choice: the Generalized Axiom of Revealed Preferences. Deliberative reasoning cannot explain these results, nor can a tug-of-war between emotion and reason. The results are the signature of a cognitive system that weighs competing moral considerations and chooses the solution that maximizes rightness.

"Abstract: How does the mind make moral judgments when the only way to satisfy one moral value is to neglect another? Moral dilemmas posed a recurrent adaptive problem for ancestral hominins, whose cooperative social life created multiple responsibilities to others. For many dilemmas, striking a balance between two conflicting values (a compromise judgment) would have promoted fitness better than neglecting one value to fully satisfy the other (an extreme judgment). We propose that natural selection favored the evolution of a cognitive system designed for making trade-offs between conflicting moral values. Its nonconscious computations respond to dilemmas by constructing “rightness functions”: temporary representations specific to the situation at hand. A rightness function represents, in compact form, an ordering of all the solutions that the mind can conceive of (whether feasible or not) in terms of moral rightness. An optimizing algorithm selects, among the feasible solutions, one with the highest level of rightness. The moral trade-off system hypothesis makes various novel predictions: People make compromise judgments, judgments respond to incentives, judgments respect the axioms of rational choice, and judgments respond coherently to morally relevant variables (such as willingness, fairness, and reciprocity). We successfully tested these predictions using a new trolley-like dilemma. This dilemma has two original features: It admits both extreme and compromise judgments, and it allows incentives—in this case, the human cost of saving lives—to be varied systematically. No other existing model predicts the experimental results, which contradict an influential dual-process model."

Here is their first example:

"Two countries, A and B, have been at war for years (you are not a citizen of either country). The war was initiated by the rulers of B, against the will of the civilian population. Recently, the military equilibrium has broken, and it is certain that A will win. The question is how, when, and at what cost.

"Country A has two strategies available: attacking the opposing army with conventional weapons and bombing the civilian population. They could use one, the other, or a combination of both. Bombing would demoralize country B: The more civilians are killed, the sooner B will surrender, and the fewer soldiers will die—about half from both sides, all forcibly drafted. Conventional fighting will minimize civilian casualties but maximize lives lost (all soldiers).

"More precisely: If country A chooses not to bomb country B, then 6 million soldiers will die, but almost no civilians. If 4 million civilians are sacrificed in the bombings, B will surrender immediately, and almost no soldiers will die. And, if A chooses an intermediate solution, for every four civilians sacrificed, approximately six fewer soldiers will die.

"How should country A end the war? What do you feel is morally right?"

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Here is the followup commentary:

Lieberman, Debra, and Steven Shenouda. "The superior explanatory power of models that admit trade-offs in moral judgment and decision-making." Proceedings of the National Academy of Sciences 119, no. 51 (2022): e2216447119.

"We make “moral” decisions each day (should I stay and help my graduate student with her thesis thereby delaying dinner for my children? And if I do stay, how long is acceptable until the trade-off tips in favor of my children—30 min? An hour? Longer?). There are costs associated with every act, and part of the human condition is that we seek to balance our duties to everyone in our social network.

"Moral judgments, as the above example illustrates, lead to intermediate, compromise solutions. For this reason, the value of moral dilemmas like the trolley problem that yield only binary outcomes is limited to the superficial exploration of normative theories within philosophy—not the underlying mental software driving moral cognition

...

"As a philosophical tool, the trolley problem playfully probes certain (limited) contours of moral decision-making. But, as a methodology imported from philosophy into cognitive science to illuminate moral cognition, the translation is impoverished because it yields only binary, extreme solutions and prevents moral trade-offs or compromise judgments. "