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 Table of Contents  
EDITORIAL
Year : 2017  |  Volume : 2  |  Issue : 1  |  Page : 1-4

Blood banker's ethical dilemma: To assure quality or contain costs


Department of Transfusion Medicine, Manipal Hospital, Bengaluru, Karnataka, India

Date of Web Publication22-Mar-2017

Correspondence Address:
Shivaram Chandrashekar
Department of Transfusion Medicine, Manipal Hospital, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/GJTM.GJTM_13_17

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How to cite this article:
Chandrashekar S. Blood banker's ethical dilemma: To assure quality or contain costs. Glob J Transfus Med 2017;2:1-4

How to cite this URL:
Chandrashekar S. Blood banker's ethical dilemma: To assure quality or contain costs. Glob J Transfus Med [serial online] 2017 [cited 2017 Jun 26];2:1-4. Available from: http://www.gjtmonline.com/text.asp?2017/2/1/1/202710


  You Can't Make a Silk Purse Out of a Sow's Ear Top


Readers of this journal will agree that one cannot deliver a good-quality blood product using substandard material be it blood bags, reagents, equipment, staff, or methodology. We know that the practice of transfusion medicine involves a number of ethical issues as blood comes from a human being and is a precious resource with limited shelf life.[1] We also understand that as per the ISBT international code of ethics,[2] blood services must be, a not for profit service.


  Customer is King Top


As professionals practicing transfusion medicine, we like to live in a utopian world where we believe “Customer (patient) is King” and willing to happily pay for the level of quality he gets. Unfortunately this does not apply to blood. A customer will happily pay more for a Mercedes, compared to a Toyota car or for that matter, a soap powder that yields better results, compared to an inferior product of another brand. Good or bad, blood must be free. For the common man blood is just a red fluid that cannot be bought or sold. Unfortunately what the society does not understand is that someone has to pay for processing and testing. By writing this I certainly run the risk of being labeled “blood seller or a doctor who frightens the patient to make money” but alas, someone has to clarify.


  Blood Bankers' Dilemma Top


Blood centers have twin objectives: (1) to ensure donor safety and (2) to ensure that no harm is done to the recipient of blood. While the former is easy, the latter is difficult. Blood bankers constantly face this dilemma: Should I use all the techniques, tests, skills available at my disposal to make blood nearly 100% safe? Should I just focus on moderate quality to keep costs low? Should I offer specialized test only for those who can afford it or should I offer the same quality blood to all patients irrespective of their paying capacity? Do my patients really know what's good for them, when it comes to blood? Am I not better qualified for the job? Why should I leave this difficult decision to the gullible patient? In the name of equality, is it right to deprive an affordable patient from reaping the benefits of advances in transfusion medicine?


  Safe Blood or Cheap Blood? Top


Thus, blood banking poses several unanswered questions. “Should blood banks, which are legally responsible for blood safety, implement a safety policy targeting the elimination of all possible risks, regardless of the costs? What should be the main priority in blood safety management? Should it be the efficient use of scarce resources, or the maximal blood safety at all costs [3]?” Should blood bank be providers of safe blood or cheap blood? There are no simple answers.

If blood banks focus on making blood very safe, blood is going to be expensive, and the blood banks are perceived as centers of profiteering, by the ill-informed community, and the voluntary blood donation movement takes a back seat. In contrast, the same community pulls up a doctor, for not offering specialized tests/processing technologies, however expensive they may be, in the event of a complication such as transfusion-transmitted infection. If the blood centers offer specialized tests and ask patients to choose the level of quality they want, then blood banks are blamed for having double standards, one for the poor and another for the rich. If blood bankers try to have a differential pricing to help the poor, then patients ask, why this difference when blood is the same?

Blood Bankers' ethical dilemma stems from the fact that each of the stakeholders in transfusion medicine, be it blood donors, patients, doctors, donor organizations, and the governments, has their own ethical, political, and social dilemmas when it comes to safe blood transfusion.


  Donor's Dilemma Top


The best things in life are free, why not blood?

The best things in life such as air, light, and water come free. Why then should my blood be charged? Voluntary blood donors constitute the backbone of any Blood Transfusion Service (BTS).[4] These donors who donate regularly are dedicated, socially conscious people. They firmly believe that they have donated blood free of cost and it must reach the patient free. They simply cannot comprehend that testing today is enormously expensive.

Second, to a great extent, blood safety depends on information provided by donor as no test is 100% safe. Hence, blood donors have an ethical responsibility to provide truthful information regarding their health status and blood centers have a responsibility to elicit this information, especially with reference to high-risk sexual behavior.

Donors need to realize that even a “not for profit organization” has to recover its costs with a small markup, if it has to continue to render its services. Hence, although blood is free, the bag costs money, the tests cost money, the processing of blood into components, all involve equipment worth millions which need to be bought, repaired, calibrated, and maintained.


  Patients' Dilemma Top


A rose (read blood) by any other name would smell as sweet (read safe/unsafe?)

How should a patient choose between ELISA-tested blood and Nucleic-acid Amplification Test (NAT) tested blood, especially in the developing countries where majority of patients are illiterate or semi-literate? How should a patient choose between random donor platelets derived from whole blood or single donor platelets prepared by apheresis? Can a patient understand whether leukoreduction is essential or not? Can a patient make an informed consent with respect to red cells or platelets in additive solution? All this is Greek and Latin to the patient. Blood banks would need to organize a half-a-day workshop for patients to really get an informed consent, and this would certainly drive them up the wall!

Informed consent or ill-formed consent

Even the most elite knowledgeable patient is not in a position to understand all the nuances of blood safety and give an informed consent. It is easier to explain bypass surgery to a patient than explain the testing of blood or the risks associated with transfusion. Patients may not be the right people to decide the level of quality they would like to have. If left to themselves, patients will tend to ignore expensive tests such as NAT or leukoreduction, designed to improve blood safety for short-term financial gains and they cannot be entirely blamed. In many of the developing countries where filtered water is hard to come by, can we dream of giving all our patients filtered blood which will nearly double the cost of blood? Viewed in this context, patients have their priorities right. Filtered water seems far more valuable and cost effective than filtered blood. However, one cytomegalovirus infection and this viewpoint changes. Who then should decide the kinds of bags that blood centers must use the kind of techniques they need to employ?

There is no such thing as free lunch

The bitter truth is that blood has become, and will continue to be, a very expensive product with the developments in transfusion medicine, which have no doubt made blood safer but also prohibitively expensive. No lunch comes free. One has to pay for lunch, less or more, depending on what we want to eat and where we choose to eat it, the same with blood. It costs less or more depending on the type of tests employed and the quality of bags, reagents, and services provided. Some blood centers compromise on quality and make blood cheaper while others charge more and try to maintain high quality, not to speak of the unscrupulous few who have low quality and high price and malign the entire BTS. This scenario is common in countries having a fragmented BTS. Someone has to pay for every product, and in case of health care, in this part of the world, it is always the patient.


  Government's Dilemma Top


For every government, be it in the developing countries or the developed countries, blood is an emotional issue. While everyone agrees that blood is free, blood bankers are constantly at logger heads with the government on the issue of processing charges of blood. While blood bankers would like the processing charges to be on higher side so that good quality of blood can be delivered using the best bag, best test, and the best processing technology, there is social and political pressure on the governments to keep cost of blood low. Perhaps they are morally obliged to provide free blood and in its absence contain costs. Thus, governments end up compromising on quality while appeasing patients. Delivering quality blood, at rates fixed by the government, has always been a challenge in Asian countries. Some countries like India have made earnest attempts to arrive at a reasonable price for blood, depending on the type of bag employed, type of tests done, and the type of processing technologies used, which vary from one center to another. The National Blood Transfusion Council in India is a classical example of how to deal with costing of blood by coming out with a basic cost, followed by additional costs, for additional tests. But alas, like everything else, its implementation is faulty with wide variations from state to state. I am not sure any government will ever be able to put a price on blood.

Hence, ethics is more important in blood centers. To illustrate better, empty blood bags meant for blood collection are available in the market ranging from 150 to 1500. What should a government use for costing: 150 or 1500 or an average. Even if we were to take the same bag and the same brand, the cost differs significantly depending on the volume of purchase. Blood banks adopt a variety of tests such as rapid/enzyme immunoassay/chemiluminescence/electrofluorescence/NAT to suit their individual requirements, based on the type of patients they serve, and each of them have their own advantages and disadvantages. Operating costs vary widely, depending on the technology and the level of automation in testing. Should we cut down on automation given that it adds to cost, or should we promote automation in testing, given that clerical errors are a leading cause of mortality in developing countries?

Some blood banks in the government sector and some charitable institutions often sacrifice quality to meet bottom lines and ensure their existence, while private hospitals have captive patients and charge more with better testing and processing technologies to meet the demands of their rich clientele. Both understand that “People who live in glass houses should not throw stones.” Between the two there seems to be a tacit understanding that we will not speak about your quality so long as you don't speak about our price! Both are right in their own way as they are dealing with different types of clientele with differing expectations.

For blood centers to deliver good-quality service, it is important that the existing blood bankers set high standards for next generations to follow. If not, the newer generations take shortcuts, deviate from operating procedures, leading to poor-quality work. After all, we all know of the roman proverb “When in Rome, do as the Romans do!” Absence of standard protocols in many Asian countries has compounded the problem.


  Effect of Government Policies on Transfusion Medicine Top


Undoubtedly, these have a significant impact on the quality of BTS. Existence of a policy on safe blood is the first requirement. Then, there are many deterrents to safe blood transfusion practice other than cost. Outdated laws, lack of centralized BTS, lack of uniformity in awarding licenses, lack of external quality assessment schemes and accreditation programs are some of these. These are some common problems plaguing blood banking in the Indian subcontinent. As a result, we have islands of excellence amidst a sea of poor-quality blood banks. These islands of excellence need to be nurtured to enable transformation to a centralized BTS with fewer blood banks and more storage centers. Many hospital-based blood banks in India are compelled to practice replacement donations as they are denied permission to hold camps,[5] which violates the fundamental policy of collecting all blood from voluntary donors. The absence of government guidelines on safe transfusion in many countries like India, Sri Lanka, Nepal, and Bangladesh leads to inappropriate transfusions. All these countries have focused on safe donor and safe blood testing but not on developing patient transfusion guidelines.

Little knowledge is dangerous

People with little knowledge of immunohematology often feel that red cell antibody screening, leukoreduction, and antigen typing are for the rich and the famous and are not essential ingredients of quality blood. If our fore fathers lived with just a simple blood grouping, cross matching and syphilis testing, why can't we? The problem gets compounded when services of such people are utilized by the government to provide expert opinion on costing of blood. Certainly costing is not something we are taught in medical school. Until there is a change in mindset of blood bankers, government, and the patients, incremental quality upgradations will be hard to come by.

Two wrongs do not make a right

We constantly overlook what we perceive as minor mistakes during phlebotomy [6] or during patient identification. Blood centers and transfusionists gloss over minor mistakes, with the result, cumulative decrements in quality at every step lead to an incremental decrease in quality of the final product (blood product or transfusion service). Although transfusion-related acute lung injury [7] has overtaken clerical errors as the leading cause of mortality in the developed world, we still have clerical errors accounting for a significant share of adverse reactions, thanks to absence of protocols or failure to follow them.

Cleanliness is Godliness

This is a well-known adage, but we tend to forget it at the most crucial times. When we need to spend more on asepsis during phlebotomy,[8] when we need to spend more on bags with diversion pouches,[9] these are ignored, with the result we have bacterial contamination of blood and septicemia in the transfused patients. Why can't we all buy good-quality bags with basic features such as additive solutions, needle protectors, and diversion pouches, let alone bags with integral filters. We can't, because the cost of a blood bag as per government guidelines is “x” where bags with such additional features cost “2x.”

Different people have different ideas about what's valuable. While leukoreduction, NAT testing may be invaluable to a transfusion specialist in a corporate hospital, it may be a perfect no, no to a blood banker in a government hospital. Leukoreduction before alloimmunization occurs, or NAT testing to prevent window phase infections are examples for “a stitch in time saves nine.” At least affordable patients cannot be deprived of this on the pretext of equality.


  What is the Solution to Problems Plaguing the Blood Transfusion Service? Top


As you sow, so shall you reap

We have failed to sow seeds of scientific temperament, scientific knowledge, honesty, integrity, confidentiality, and impartiality, in our medical or paramedical curriculum. As a result, we often see staff who are neither well conversant with technical aspects of transfusion medicine nor the nuances of good communication or soft skills.

There is no place like home

The staff of blood centers are often underpaid and overworked, as is the case in many Asian countries, leading to lack of motivation in the workplace, to establish and maintain a high-quality transfusion service. It is common knowledge that demotivated staff are dying to finish their work and go home leading to errors or compromise in quality. Practical interventions to encourage recruitment, retention, growth of staff are needed. We also need improvements in the quality and popularity of appropriately designed training programs for health professionals, especially in rural and remote regions.[10] Proper planning and resource allocation to enable a systematic overhaul of the system are essential.


  Conclusion Top


Moving away from a fragmented BTS to a centralized more organized BTS, starting more and more degree and PG programs in transfusion medicine for paramedical and nursing staff bringing clarity to donors, patients and the community on the importance of good testing will lead to more ethical practices in transfusion medicine. This coupled with employment opportunities at large centralized blood centers with career growth will foster development of staff and with them transfusion medicine in the Asian region. Centralization of transfusion services will help deliver uniform quality and will bring parity in quality across the country. In this scenario when there is parity in quality, parity in price is a possibility which will lead to more ethical transfusion practices. Further, centralization with improved economies of scale should bring down costs significantly, if well implemented. The community needs to understand that just as you cannot judge a book by its cover you cannot judge the quality of blood by its color. Finally, the author understands that “Discretion is the greater part of valor.”So let me stop before people regard me unethical.

 
  References Top

1.
Elhence P. Ethical issues in transfusion medicine. Indian J Med Ethics 2006;3:87-9.  Back to cited text no. 1
    
2.
Beal R. The International Society of Blood Transfusion and a code of ethics for blood donation and transfusion (2000). Vox Sang 2002;82:165-6.  Back to cited text no. 2
    
3.
Tsantes AE, Kyriakou E, Nikolopoulos GK, Stylos D, Sidhom M, Bonovas S, et al. Cost-effectiveness of leucoreduction for prevention of febrile non-haemolytic transfusion reactions. Blood Transfus 2014;12:232-7.  Back to cited text no. 3
    
4.
WHO: Voluntary Blood Donation. Available from: http://www.who.int/bloodsafety/voluntary_donation/en/. [Last accessed on 2017 Feb 27].  Back to cited text no. 4
    
5.
Chandrashekar S, Kantharaj A. Legal and ethical issues in safe blood transfusion. Indian J Anaesth 2014;58:558-64.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Pandey P, Chaudhary R, Tondon R, Khetan D. Predictable and avoidable human errors in phlebotomy area – An exclusive analysis from a tertiary health care system blood bank. Transfus Med 2007;17:375-8.  Back to cited text no. 6
    
7.
Álvarez P, Carrasco R, Romero-Dapueto C, Castillo RL. Transfusion-related acute lung injured (TRALI): Current concepts. Open Respir Med J 2015;9:92-6.  Back to cited text no. 7
    
8.
Buchta C, Nedorost N, Regele H, Egerbacher M, Körmöczi G, Höcker P, et al. Skin plugs in phlebotomy puncture for blood donation. Wien Klin Wochenschr 2005;117:141-4.  Back to cited text no. 8
    
9.
McDonald CP, Roy A, Mahajan P, Smith R, Charlett A, Barbara JA. Relative values of the interventions of diversion and improved donor-arm disinfection to reduce the bacterial risk from blood transfusion. Vox Sang 2004;86:178-82.  Back to cited text no. 9
    
10.
Awofeso N. Improving health workforce recruitment and retention in rural and remote regions of Nigeria. Rural Remote Health 2010;10:1319.  Back to cited text no. 10
    




 

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You Can't Ma...
Blood Bankers...
Safe Blood or Ch...
Donor's Dilemma
Patients' Di...
Government's...
Effect of Govern...
Conclusion
Customer is King
What is the Solu...
References

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