Discussion - Blood Donation

During times of crisis such as mass casualty events, one of the first medical supply resources to be exhausted is blood and blood products. Normally given generously by willing donors, the products themselves only go so far with regards to their utility in treatment with many patients often requiring multiple infusions to obtain the desired therapeutic effect. Additionally these products have a set shelf life meaning that stockpiling them during normal times is not possible. During times of significantly increased demand blood collection services will often make a call to the public to consider donation to aid in alleviating the shortage. This often comes at a financial cost to the services as the call to aid can involve buying advertising space in major media outlets, as well as social media networks. This begs the questions, should a piece of legislation be introduced which requires capable persons be forced by law to give their blood to blood banks during times of crisis?

The donation of blood and blood products in Australia refers to three different procedures. All three involve the insertion of a large bore butterfly needle into a superficial large vein in either the donor’s right or left antecubital fossa region. The collection of packed red blood cells is the shortest of the three with the collection of around 250-300ml of blood in a direct blood draw, lasting approximately fifteen minutes for most donors. The second procedure is a blood plasma donation that involves the draw of blood, which is centrifuged to separate the plasma, which is collected, from the red blood cells which are returned to the donor with the addition of some normal saline to make up the lost volume. This procedure lasts approximately 45 minutes to one hour. The final procedure is the donation of platelets which is similar to the donation of plasma, but lasts approximately one and a half to two hours.

There are some obvious allures to introducing a policy that will legally require people to give their blood during times of crisis. Physically speaking, the procedure generally has no lasting harm to those who give blood. Most healthy people are able to reproduce the products given within a week, with only some slight fatigue in the first one to two days post blood draw being the most common side effects. These side effects, whilst very real and recognised in the medical literature are, from a utilitarian perspective greatly outweighed by the potential benefit from giving the blood and blood products.

Blood and blood products are often crucial in saving the life of medically unwell people. Some general groups of people that may receive blood and blood products include victims of major trauma and women who have given birth where there has been a catastrophic haemorrhage, and cancer patients with haematological derangements only cured by replacement of blood and blood products. During times of crisis, blood and blood product stores can be rapidly depleted as the crisis places additional burden on a resource that is at a baseline often stretched. If everyone who was capable gave their blood, the burden of time and risk associated by continued frequent donation by the few would not be required.

As tempting as some of these positives of such a piece of legislation are, the counterarguments must also be considered. Firstly, the phrase ‘time of crisis’ is one which is very poorly defined. There is some intention to this as any government introducing new legislation is understandably unable to predict all future events which may require enacting the policy, thus its inclusion criteria must remain vague. Consider however one situation in which a mass casualty event in a particular city immediately overwhelms local medical resources requiring enactment of the policy. Now consider an ongoing medical crisis such as a global pandemic where demand for blood and blood products steadily rises until such a point where medical resources are overwhelmed. The first situation has a very clearly defined point at which the policy should be enacted, but second less so. Both however are still considered crises. This opens up the problem of the government enacting the policy as a public health measure in anticipation of increased demand before it actually happens.

Preempting demand for an increased medical resource by no means constitutes poor public health policy. Contrary to the point, it is almost the whole point of having public health policy in the first place. In recent months, the Australian government has spent millions of dollars purchasing personal protective equipment, renovating health campuses and debating policy in anticipation of widespread community transmission of covid-19 that never happened. Whilst similar, this is not really analogous to preemptively enacting policy to forcibly collect blood and blood products.

The collection of blood and blood products is an invasive medical procedure that has, like any procedure, associated risks. Infection at the site of blood draw from poor aseptic technique can cause local inflammation and damage, as well as potentially progress to systemic illness which itself carries considerable mortality. ‘Missing the vein’ during the physical insertion of the large needle can damage local veins, tendons, nerves and potentially even pierce the brachial artery which can cause significant bleeding and is a medical emergency. A considerable percentage of the population has a recognised phobia of needle insertion, the extent of which sits on a spectrum from a minor aversion to needles on one end to the very site of needle precipitation a vasovagal response with syncope which can lead to other medical complications.

Another more recent consideration of enacting any sort of widely encapsulating policy involves bringing large numbers of people together in a blood collection facility in the context of the 2020 global pandemic. Forcing people to gather and interact with others who typically would otherwise sit outside of their normal circle of interaction can increase the risk of exposure to viral respiratory illnesses. This can result in contributing to a positive feedback loop as more blood draws being required causing more widespread infection leading to more blood being required and so on.

Finally, certain religious denominations prevent donation under their belief system, the most commonly recognised of which being those of the Jehovah’s Witness faith. Introduction of such a policy that forces blood collection blatantly discriminates against those of this faith and would lead to significant ongoing trauma to this subgroup of the population.

Ultimately, in terms of a hard yes or no as to whether such a policy as described should be introduced, the most appropriate answer is no. Whilst considered a relatively minor procedure that is undergone tens of thousands of times a day over the world normally without complication, that does not completely negate the fact that donating blood is a medical procedure, and does come with an element of risk to the donor. An opt out system without being questioned or having to provide explanation in times of crisis is probably a more reasonable end point to reach with regards to this policy. Opting out without having to provide an explanation will avoid the potential for profiling and discrimination toward those choosing not to give their blood during times of crisis.

During normal times and times of crisis most people are likely benevolent enough to undergo short lived harm if they know it will result in healing another person. This is assuming that the reasons for why the procedure is required and who it benefits are adequately and intentionally explained. Additionally, those undergoing the procedure should be made aware of the risks of the procedure and given the chance to make an informed decision about remaining in. Moreover, there needs to be considerable thought given to exactly which situations this policy can be enacted, ensuring that the safety of the population is ultimately not grossly compromised at any time.