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Ethics


Devon D. Mahoney, M.D.
Evelyn M. Potochny, D.O.

Last author update: 20 August 2024
Last staff update: 2 January 2025

Copyright: 2024-2025, PathologyOutlines.com, Inc.

PubMed Search: Ethics transfusion medicine

Devon D. Mahoney, M.D.
Evelyn M. Potochny, D.O.
Page views in 2024: 82
Page views in 2025 to date: 99
Table of Contents
Definition / general | Essential features | Clinical features | Blood donor screening | Donor deferral | Laboratory | Case reports | Additional references | Board review style question #1 | Board review style answer #1 | Board review style question #2 | Board review style answer #2
Cite this page: Mahoney DD, Potochny EM. Ethics. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/transfusionmedethics.html. Accessed April 1st, 2025.
Definition / general
  • Ethics describes the study of morality and seeks to provide a framework for how choices can be made in a moral manner
  • In transfusion medicine, ethics balances the goals of optimizing donor safety, maintaining an inclusive collection pool, providing safe and appropriate blood products to informed recipients and justly managing a limited blood supply
  • Ethics of apheresis and cellular therapy are beyond the scope of this outline
Essential features
  • Beauchamp and Childress' 4 principles of biomedical ethics (J Med Philos 2020;45:540)
    • Autonomy
    • Beneficence
    • Nonmaleficence
    • Justice
  • Key concerns for transfusion ethics include
    • Donor and recipient informed consent
    • Recipient's right of refusal
    • Risk - benefit ratio for blood product donors
    • Inventory management challenges
  • There is no clear cut answer to ethical problems encountered in transfusion practice and the approach to such problems should be methodical and multidisciplinary
Clinical features
  • Application of the 4 principles of biomedical ethics to blood product recipients
    • Autonomy: a patient's ability to freely make decisions about their own person
      • Consent (when possible) should be obtained prior to transfusion and should include the following elements (Council of Europe: Convention on Human Rights and Biomedicine (ETS No 164) [Accessed 14 June 2024])
        • Comprehension: explanation should be easy to understand for a layperson using language aimed at no higher than an eighth grade reading level
        • Capacity / competence: the recipient should be able to understand the consequences of their decisions
        • Disclosure: a thorough description of transfusion risks and benefits should be provided
        • Alternatives: explanation of the consequences of not proceeding with transfusion and any reasonable treatment options outside of transfusion
        • Voluntariness: while recommendations can and should be made by the clinician subject matter expert, the recipient should ultimately make the decision that is most congruent with their values and priorities
      • Any valid advance directive should be honored if consent cannot be obtained
      • Recipient has the right to refuse transfusion on their own behalf
        • While parental wishes for a child to avoid transfusion should be honored when possible, a best interests standard should be applied and transfusion given if necessary to protect the health and safety of the child (J Med Ethics 2019;45:117)
          • If time permits, agreement with a second physician about necessity and involvement of the hospital attorney is prudent before overriding parental wishes
          • Mature minor rules, where a physician can assess the capacity of an adolescent to refuse medical treatment, may apply in some jurisdictions
    • Beneficence: the performance of actions that benefit the patient's well being
      • Transfusion should be given for appropriate clinical need
    • Nonmaleficence: the performance of actions that do not cause harm to the patient
      • Transfusion should be administered by a competent and trained transfusionist
      • Patients should be informed about posttransfusion information that may become available regarding risk of harm resulting from the transfusion
      • Confidentiality should be maintained regarding the patient and their treatment
    • Justice: equitable distribution of limited resources
      • Evidence based treatment practice should be applied equally to all patients
      • Patients should receive only clinically appropriate blood products to promote effective inventory management
      • Profit motive should not be the basis for provision of transfusion
      • Transfusion should not be denied based on the patient's resources
Blood donor screening
  • Application of the 4 principles of biomedical ethics to blood product donors (Transfus Clin Biol 2023;30:347)
    • Autonomy
      • Informed consent prior to collection should be obtained as described above
        • Donors should be informed about the purposes of their donation, including if for research use
      • Blood donation should be voluntary without coercion or payment (voluntary nonremunerated blood donation) (Vox Sang 2012;103:337)
        • Blood components from voluntary donors should be labeled accordingly
        • Paid donation may inequitably target poorer, more vulnerable donors and may come at the expense of donor health
        • There is historical evidence of a lower prevalence of transfusion transmitted infection in voluntary donors than paid donors (BMJ 2007;334:879)
        • Although paid donor plasma collection for the production of plasma derived medicinal products is widely practiced in the United States and serves a critical public need for these products, WHO consensus statements advocate against this practice and for movement to all nonremunerated sources of donated plasma
      • Replacement donation, where relatives of patients are encouraged to donate to replace blood used by their relative is dubiously voluntary
      • Rare blood phenotypes: population migration and increasing globalization have led to increased incidence of mismatch between recipient red blood cell antigens and those of donors common to that population
        • Campaigns have been launched to increase donations from rarer phenotype individuals who may then feel pressured to donate
      • Directed donors may feel pressured to donate for a specific individual's medical need
        • Personal disclosures about lifestyle and behaviors that are required for safe blood donation are intimate
        • Fear that such disclosures may not be held in confidence may lead to nondisclosure of behaviors that carry risk to the recipient
    • Beneficence
      • As the donor does not benefit from donation, they should be treated with courtesy and their donation respected
      • Blood donation is ideally an act for the community good
      • Donors should be informed about the results of any positive infectious disease testing
    • Nonmaleficence
      • As much as possible, donors should not be harmed by collections
      • Administration of medication to improve collection of a specific blood component is done without benefit to the donor and can be harmful
        • This should be done with consent and demonstration of clear recipient benefit
      • Soliciting donations from repeat donors for a single patient should only be performed in cases of urgent recipient medical need
      • Donor selection criteria should be applied not only for the safety of the recipient but should also serve to safeguard the health of the donor
    • Justice
      • Wastage of collected units should be avoided whenever possible
      • Donors should only be deferred for evidence based reasons
        • Donors are less likely to return if they feel discriminated against
      • Anonymity between donor and recipient is essential
        • Labeling of blood products with extraneous donor information should not be performed
          • This prevents rejection of blood products based on nonmedical and untrue biases
          • Additional nonevidence based testing and labeling places additional unnecessary financial and administrative burden
        • Directed donation for donor preference rather than reasons of legitimate medical need should be discouraged
Donor deferral
  • There is no globally recognized right to donate blood
  • Donor deferral should not be based solely on race, gender or creed but should be evidence based for the safety of the recipient and the donor
Laboratory
  • Considerations for the blood bank for stewardship of the blood supply
    • Trends in demand for, patient needs for and clinical utilization of blood components should be routinely monitored and estimated to evaluate the level of sufficiency of blood within the health system
    • Patient blood management programs can minimize the need for blood transfusion (J Hosp Med 2014;9:60)
      • Key components include: optimization of native erythropoiesis, coagulation optimization, acceptance of physiologically tolerated anemia and minimization of surgical blood loss
      • Multidisciplinary approach to individualize treatment
    • Wastage should be avoided when possible
      • Fresher blood components should not be chosen in situations without individual medical need
    • Blood is a rare resource and conflict may arise when the transfusion needs of a single patient could prevent the availability of blood products for other individuals
      • No clear answer to the question: at what point do the requirements and or desires of a single patient become secondary to resource triage?
        • Resolution should likely involve a conversation between transfusion medicine, clinical team and if possible, patient
        • Consider patient transfer to other institutions where resources are not as depleted
    • Allocation of blood products during end of life care and in situations of medical futility (Kennedy Inst Ethics J 2007;17:247)
      • Even in scenarios where blood product availability is not immediately strained, blood is still a finite resource
      • When possible, goals of care discussions should be had with patients
      • Exceedingly scarce resources (i.e., human leukocyte antigen [HLA] matched platelets or granulocytes) should likely not be provided
      • Transfusion should be limited to the minimum required to alleviate patient distress
      • In cases of shortage, transfusions should be deferred and products allocated to other patients
Case reports
Board review style question #1
Which of the following biomedical principles is being honored in permitting a patient to refuse a life saving blood transfusion?

  1. Autonomy
  2. Beneficence
  3. Justice
  4. Nonmaleficence
Board review style answer #1
A. Autonomy. This principle states that a recipient with capacity may make decisions regarding their own body and medical care without coercion. Answers B and D are incorrect because refusing a life saving transfusion would result in physical harm to the patient. Answer C is incorrect because medication refusal does not relate to the common good or equitability.

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Reference: Transfusion medicine - Ethics
Board review style question #2
Voluntary nonremunerated blood donors are preferred over paid donors for which of the following reasons?

  1. Collections from volunteer donors are processed and available more quickly after collection
  2. Higher rates of repeat donation among volunteer donors
  3. Paid donation may disproportionately and inequitably be provided by female donors
  4. Potentially higher rates of transfusion transmitted illnesses in paid donations
Board review style answer #2
D. Potentially higher rates of transfusion transmitted illnesses in paid donations. While recent evidence is mixed on the risk of transfusion transmitted infection in paid donors, historical evidence favored a lower prevalence in voluntary (unpaid / nonremunerated) donors. Answers A and C are incorrect because there is no evidence of differences in processing speed or disproportionate donation by women in paid versus voluntary blood donation. Answer B is incorrect because some studies have suggested higher rates of repeat donations in paid donors rather than in volunteer donors.

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Reference: Transfusion medicine - Ethics
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