The blood feud: compensated versus non-compensated source plasma donations

Introduction

Plasma-derived medicinal therapies (plasma therapies) are essential, life-saving therapies for a range of conditions, including immunodeficiencies, autoimmune and neurological disorders, and rare bleeding disorders (1,2). Unlike most other pharmaceutical products, plasma therapies use a substance of human origin, plasma, as the starting material. How we collect this starting material has been and continues to be the subject of moral debate and controversy.

We seem to be pulled in two different directions. On the one hand, we seem to have good reason to make greater use of donor compensation. This is because these kinds of collection systems appear to be more efficient and economical (1). On the other hand, many have urged that we reject donor compensation because of a variety of moral concerns, as well as empirical worries.

The tension between these positions can be seen in recent literature. Monsellier [2017], for example, argues that non-compensated donation remains the gold standard for maintaining safety and quality (3). In contrast, Farrugia et al. [2010] argue that “purist” arguments against compensation often lack empirical support and that a “plurality” of collection methods is required to secure adequate supplies (4). Koch et al. [2024] and Tissot et al. [2013] highlight the conflict between defining donation as an act of solidarity versus a commercial transaction in the face of a variety of incentive tools used by blood establishments already (5,6). While these studies weigh efficacy and the general ethics of incentives, this article prioritizes the moral necessity of sufficiency. It argues that meeting patient needs is not a mere logistical goal or one consideration among others, but is the primary moral obligation of any collection system, taking priority over secondary concerns about the “nature of the donation”.

This paper offers an overview and evaluation of the traditional or historical objections, before turning to the current state of these discussions. Traditional moral concerns include the thought that people ought to donate from altruistic motivations, that our system of collection should promote solidarity, and that our system of collection ought not treat substances of human origin as mere commodities, each of which is thought to conflict with use of donor compensation. Many worry that compensation will result in vulnerable individuals and populations being wrongly taken advantage of, and raise concerns regarding coercion and undue influence. More contemporary concerns include worries that financial incentives will lead to too-frequent donations harming donor health, and that compensation for plasma for fractionation will come at the expense of non-compensated donations for transfusion.

If supporters of donor compensation are right about the greater efficiency and effectiveness of collections using donor compensation and detractors are right about their moral and empirical claims, then this represents a tragic trade-off: we will have to give up either security of supply for patients reliant on plasma therapies, or put up with harms to altruism and solidarity, the corruption of our attitudes, and wrongful exploitation of the financially vulnerable. Below I summarize, all too briefly, each of these objections beginning with the longest-standing, though I think weakest, of them before moving on to the objections to donor compensation that continue to be influential today.

The shift towards donor compensation

To begin, we should acknowledge that the case against donor compensation is much weaker today than it was in the 1980s and early 1990s. It is weaker for at least three reasons: The first is that the safety profile of plasma-derived medicinal therapies has improved dramatically compared with what it was. Modern-day therapies go through what some have called the “safety tripod” of donor selection, modern-day testing based on molecular diagnostics, and especially the many viral inactivation and removal steps, from heat treatment to nanofiltration to the use of solvents/detergents and others. These advancements have, as Farrugia [2023] put it, “…resulted in an inversion in the relative safety of the products of blood banking compared to plasma products.” (7). It is no longer true that whether a donor is compensated or not makes a relevant difference to the safety of the final therapy. What matters is pathogen removal and inactivation and, to a lesser extent, the other two legs of the safety tripod. Some still do raise safety concerns when discussing donor compensation, but this is a mistake. As the European Agency for the Evaluation of Medicinal Products said in a position paper back in 2002: “There is no evidence from clinical studies and pharmacovigilance that donor remuneration increases the risk of viral transmission via plasma-derived medicinal products, which have been subject to proper screening at donation and a validated viral inactivation/removal step.” (8).

The second is that plasma collected using donor compensation is used in every jurisdiction that uses plasma therapies, including in those, like Australia and Italy, that prohibit domestic use of compensation but import the finished therapies. Plasma sourced using donor compensation makes up nearly 90% of the plasma used to manufacture therapies, with the United States contributing 67% of the global total (9). Donor compensated plasma therapies make up around 72% of Spain’s (10) and 38% of Italy’s (11). Even with the contribution of Germany, Austria, Hungary, and the Czech Republic [the four European Union (EU) countries that practice donor compensation and so have plasma collection surpluses], the EU is still nearly 40% reliant on plasma collected in the United States (12). This universal reliance on therapies made from the plasma of compensated donors reveals not only consensus on the safety of donor compensated plasma as a starting material, but also the apparent greater efficiency of this model. In 2018, Health Canada released an expert consensus report on the supply of immunoglobulin in Canada. As part of their investigation, they looked at the relative costs of the different models and concluded: “There is a significant premium related to the cost of collecting high volumes of plasma from volunteer source plasma donors (between 2–4 times more costly)—this is recognized by CBS [Canadian Blood Services] and was reaffirmed by discussions with other jurisdictions.” (1). It also complicates arguments against donor compensation, opening some governments up to charges of either moral insincerity or hypocrisy.

Finally, the pandemic brought the precarious situation patients reliant on plasma therapies find themselves in into sharper relief. Some said we were “steaming towards an iceberg” (2), so existential was the threat from insecurity of supply.

Perhaps because at least some of the arguments against donor compensation (and commercial participation) have weakened, the past five years have seen more governments move to allow compensation (and commercial participation) for plasma collection than we have in over two decades prior. In 2020, Ukraine started such collections (13) while Egypt formed a public/partnership with the Spanish company Grifols to collect and fractionate plasma (14). December of that year saw the province of Alberta in Canada repeal their ban on commercial compensated plasma. Just two years later, Canadian Blood Services entered into a public/private partnership similar to Egypt’s also with Grifols. The partnership allows Grifols to collect plasma as an “agent” of Canadian Blood Services everywhere outside of Quebec, including in the largest province of Ontario. The debate over the European Union Substances of Human Origin legislation resulted in a compromise document that allows countries to choose to adopt donor compensation in the form of a flat-rate expense allowance, as practiced in Germany and Austria. Greece announced their intention to allow this soon, and Uzbekistan started commercial plasma collections using donor compensation in 2025.

The moral case for donor compensation

The significance of some arguments has seen their strength wane, and other considerations, like security of supply, have risen in their relative importance. There is also, though, a strong moral case in favour of donor compensation which is very rarely explicitly made. We begin, then, with the case for compensation.

One of the better arguments has to do with the primary purpose of plasma collection. We institute collection systems in order to ensure that we collect enough so that patients served by that system are able to get the medicine they need. Collections should be dynamic so that they can adjust to changes in demand, being prepared to meet not just occurrent demand, but latent therapeutic demand as well. “Latent therapeutic demand” refers to the amount of medicine that would be used if every person who should be using it were identified by the health care system. There may be other purposes and goals that we want our system to fulfil, but meeting patient needs is at the very top of the list.

Assuming that’s right, we can look at various jurisdictions to see which collection systems meet this most important goal. If a system is meeting this goal, then we can look at other uses we might put this system to. But we should not confuse secondary goals for the primary one.

If we go around the world, we will discover that there are five collection systems with a historical record of sufficient collections to meet not only occurrent but latent therapeutic demand: Germany, Austria, Hungary, Czechia, and the United States (9,12). The United States has the highest levels of per capita immunoglobulin use, and yet is still able to not only meet their own needs but also make up for many plasma collection shortfalls elsewhere. So, we have good reason to think these collection systems are the ones we should copy, since they succeed at meeting the morally most important goal. The common elements in these five systems are that they are mixed systems, allowing the participation of commercial collectors not just non-commercial ones, and allow the practice of plasma donor compensation. Others allow only non-commercial collections, and most often ban financial compensation for plasma donation. On first blush, a simple test focused on the most important moral goal of collections will recommend donor compensation.

This simple test is too simple. It matters if the way we collect substances of human origin violates one or another moral requirement. To give an obvious example, we can imagine a country that collects enough plasma because they threaten residents with fines or jail sentences if they do not donate. This way of collecting plasma is morally forbidden, since we think it is morally forbidden to coerce people to donate parts of themselves. This is why we insist on voluntary donations. Later, we will look at the voluntariness or autonomy objection to donor compensation as a restriction on means, but before we do, let’s first look at alternative possibilities for the most important primary goal of our collection systems.

Titmuss, altruism, solidarity, and gifts

Titmuss writing in the 1970s said that the best system of blood donation, collection and distribution should be constructed so as to be understood by the public as a kind of “gift relationship” (15). He said the UK system was just such a system, while the U.S. system was a “commercial” system, and was for that reason worse. The list of benefits of the gift system, in Titmuss’ eyes, included that it would be safer, that it would collect enough blood and plasma (and even argued that donor compensation would backfire leading to fewer donations), and that it would be more cost-effective. The evidence we now have suggests that Titmuss was wrong about each of the above. But much of his attention was on his central moral claim that donations thought of as gifts promote altruism and community solidarity.

Many within the blood and plasma collection world have been persuaded by Titmuss over the years. Shaw [2017], for example, says that “Ideals of altruism underscore public discourse, professional guidelines and social policy around virtually all body part and tissue donation…” (16). Ferguson and Lawrence [2016], citing the Nuffield Council of Bioethics, similarly say “[f]rom the perspective of policy makers, clinicians, researchers, donors, recipients, and the general non-donating public, pure altruism (i.e., helping another, at a personal cost without personal gain) is assumed to be the bedrock of blood donation.” (17). The Nuffield Council on Bioethics themselves have observed that altruism is often regarded as “the only ethical basis for donation” (18). Meanwhile, Keown [1997] wrote that “A major argument for exclusive reliance on unpaid donation is that, unlike paid donation, it promotes altruism and social solidarity.” (19). Pennings [2015] noted that the European practice is modeled on the idea that donations should be “exclusively based on charitable motives” (20). Some countries consider solidarity to be an essential component of donations, calling them “solidary donations”, rather than altruistic donations, voluntary donations, or just blood donations. One way of understanding this is that they think promoting solidarity is an essential function of blood and plasma collection systems.

In short, some believe our collection systems must promote altruism and solidarity, not just meet patient needs. So they might deny that meeting patient needs is the only primary goal, and they would deny that it has lexical priority. They might think it appropriate to weigh and balance altruism and solidarity against sufficiency of collections. It is possible that they might think that we can give up on some collections if it means greater altruism and more solidarity in our community.

But this view is unpersuasive. To see this, consider a hypothetical and an analogy. The hypothetical is this: suppose we invented or discovered perfect substitutes for blood and plasma for transfusion, and plasma for protein therapies. We already have many recombinant therapies and monoclonal antibodies that do not require donations from people, so imagine that we could do this with blood and with plasma. What would we do with our collection systems if this were possible? If the goals of promoting donor altruism and community solidarity were equally, more, or even just important enough, then we would have good reason to continue to collect blood and plasma from donors despite not needing to. But of course we would not do that. We would shut down our collection systems altogether and instead devote those resources to producing the substitutes. This would come at the expense of this way of promoting altruism and solidarity, but that would just mean we would have to promote altruism and solidarity in some other way.

And the analogy to consider is to firefighting: Imagine for a moment that we had two towns, Keinfeuer and Allesfeuer, next to each other. Imagine Keinfeuer has a career, salaried team of firefighters, and Allesfeuer has an all-volunteer firefighting team. Now imagine that each year the firefighters of Allesfeuer are able to put out about half the fires in town. They have invested in just the one fire truck, because they have just enough volunteers for the one truck, and so reasonably think they will not get enough volunteers to staff two trucks efficiently. So whenever there are two fires in different parts of town, they send out their truck to one, and call the professionals at Keinfeuer for help with the other (of course they pay the Keinfeuer firefighters when they come). In Keinfeuer, meanwhile, there is a line out the door every time the fire department is hiring fire fighters, they have plenty of trucks to fight all the fires not only in their own town but also a few extra that they send out to neighboring towns should they need help. Which town has the better fire department? The answer is not controversial: Keinfeuer’s system is clearly better, while Allesfeuer’s system is clearly worse. How much worse depends on how often they need to call Keinfeuer’s fire department for help. If it is just 10% of the time, then maybe that’s not so bad. But if it is a quarter or half the time, then that would make it pretty bad indeed. Allesfeuer is not prepared enough if there were ever a conflagration affecting both towns. Meanwhile, the explanation for why Keinfeuer’s system has so many people at-the-ready to fight fires is because they pay them a salary.

The mayor and city council of Allesfeuer might complain by casting aspersions on Keinfeuer’s system: “The firefighters of Keinfeuer are selfish vendors, while ours are noble volunteers. Our firefighters promote community spirit and altruism, while theirs undermines it.” They might say that community spirit is an important part of fighting fires, and that those who do it should be moved only by charitable motives, but we would see that these complaints are confused. The point of firefighting is not the promotion of spirit, solidarity, or altruism, the point is to fight fires. The point is not to figure out which of our neighbors have charitable motives, it is, again, to fight fires. We should care much more about potential fire victims than the virtues or character traits of firefighters. The nobility of the profession comes not from the motives of those who provide firefighting services, but from the nobility of the mission itself.

Of course, all hypotheticals and analogies have their limits. Donating a part of one’s body is not the same as fighting fires, and critics may point to the distinctive nature of substances of human origin as a relevant disanalogy. However, the analogy is only meant to clarify the central point: the primary, non-negotiable purpose of our collection systems is to meet the life-saving need, and any system that reliably fails to do so is morally worse, regardless of how much it excels at meeting secondary goals.

Commodification

Let’s turn now to the most high-brow and philosophical objection to compensation. This is the concern that donor compensation is tantamount to turning something special or sacred into a mere commodity, like a nondescript “widget” in economic theory. We should not think of substances of human origin, nor the donors from which they originate, as having merely instrumental value. But this indignity, or degradation, is the result, say some, of giving donors money.

Walsh [2015] summarizes this view as follows: “The key idea is that commercializing leads us to regard the commercialized objects as mere commodities and, accordingly when applied to the case of blood products, financially compensating donors for blood plasma would lead us to regard the humans from whom the organs are obtained as mere commodities.” (21). This is why commodification is, as Walsh puts it, a “distinctive moral wrong”.

Gold [2019] offers an analysis of the possible social scientific mechanisms that could play that role for commodification arguments, and concludes that the framing effect (or the crowding out of frames) is the only one that could work (22). As a bias, the framing effect suggests we respond in different ways to the same information depending on how it is presented. I run a framing survey in my classes each year. One of the questions asks half my students what they think of a policy where 80% of the people succeed while the other half are asked about the same policy but told that 20% of the people will not succeed. The students who get the first version of the question overwhelmingly support it, while the students who get the second version oppose it. It is the same information, but people change their answer based not on the information itself, but on whether we highlight the success (or “gain”) or the failure (or “loss”).

Many have suggested that prices function as frames that lead to commodification. Cotton [2017], for example, proposes several causal mechanisms but the “cultural” one, he says, “relies on the notion that pricing symbolizes a good as a mere commodity”. While discussing Archard’s [2002] “contamination of meaning” argument (23), Cotton says: “pricing contaminates meaning. It culturally represents the relevant good as a commodity regardless of its true nature. Pricing those things that possess higher value, then, like human beings, “degrades” them” (24). Derpmann and Quante [2015] write: “An object that ought not to be for sale may yield a price, but it may nonetheless lose some of its noneconomic value when it is actually exchanged for a price. In this line of argument, ascribing a price or a monetary value to an object that is not a genuine commodity—such as life or bodily integrity, or blood—may change and impair the very object that is exchanged.” (25).

When donors receive money for plasma, this will be understood as a price for the plasma. We see a price, and we then think of other contexts where we have seen prices before, like at clothing and grocery stores, and at restaurants. Like in these other business contexts, we will come to think of the people who give plasma as “vendors” or “shopkeepers”. And since the appropriate norms within a business context include being self-regarding and treating vendors and their wares as a mere means toward our ends, so we are more likely to treat plasma and the people who give it in undignified ways, rather than in accordance with the appropriate attitudes we should have for this substance and the person who gives it.

Many seem to find this persuasive, but we should be skeptical. For example, when people act in selfish and disrespectful ways at restaurants, we do not explain this by appealing to a framing effect of sales and prices. We usually just think these people are jerks and we expect them to be respectful. That the food is priced and the waiters are paid does not matter. The norms of respect, appreciation and gratitude obtain in this context. We also often evaluate services independently of prices and payment. For example, we hold fire fighters, nurses, and lifeguards in high esteem because they provide life-saving services, not on the basis of whether they volunteer or are paid. And we appear to have little difficulty differentiating a Taco Bell, for example, from a fine dining restaurant and adjusting our attitudes toward the food and cooks according to the nature and quality of the ingredients and the skill involved in food preparation. Despite both being “business contexts” with prices and paid staff, we know that one calls for simple gratitude and basic respect, while the other calls for a deeper gratitude and more significant appreciation.

None of this is to suggest that money and prices do not colour our attitudes. What these illustrations do suggest is that we should not be credulous about the claim that “prices”, “payment”, or a “business context” will lead us to make these kinds of mistakes. Thinking a substance of human origin used to save lives is a mere “widget”, its meaning “contaminated” by prices and donor compensation, and mistreating donors as “vendors of mere widgets” are major vices. (In fact, patient organizations often directly counter this, with groups like the U.S.-based Immune Deficiency Foundation running ‘Plasma Heroes’ campaigns that celebrate compensated and non-compensated donors alike). Our skepticism should be greater since those who interact with donors—nurses, phlebotomists, and other medical staff—are professionals trained in how to treat people with dignity and respect, and this is true regardless of whether a nurse chooses to work in a commercial or non-commercial setting.

Finally, we should not overlook the fact that the form the payment takes may matter to the commodification objection as well. The Nuffield Council of Bioethics, for example, says, “We take seriously concerns that, in some circumstances, payment for bodily material may lead to people’s body parts being seen as ‘things’ that can simply be bought or sold. We do not take the view that every form of payment for donation implies this.” (18). The relevant forms payment can take in this context includes the “purchase” and so a “price” on plasma, but it also includes compensation for time and effort, acknowledgement of commitment, and/or reimbursement of expenses. In compensating we price time and effort, not the plasma itself; in reimbursing, the money is for the costs associated with donation (sometimes including opportunity costs) which are already priced; and when we give money as an acknowledgment, like an honorarium, the meaning of the money changes from a “price” to a token of gratitude.

We have many practices like this. Priests and pastors are given honoraria after performing wedding or funeral services. Professors also receive honoraria sometimes when they give a talk. It would be a recognizable mistake to think of this as a “price”. Some payments have different targets. For example, if you go to an auto mechanic, you might get charged a price for the parts, and then a separate price for the labour. A painter might charge you for paint and for labour. So even if all you want is a working car or a painted house, you cannot just pay a price for that object, you have to pay for the parts or the paint and the labour. We do not always price just the thing that we want, and sometimes we do not price the thing that we want at all.

Imagine for a moment that someone made a compelling argument that auto parts are special and should not be treated or regarded as mere commodities, and that pricing auto parts leads to this morally bad outcome. Would it follow that we could not give auto mechanics money? No, it would only follow that we could not pay a price for the parts, but we could still pay them a price for the labour. The same can be said about plasma. Even if, contrary to what I have suggested, the commodification argument is a good one, it would show that we cannot pay for and so price the plasma, but we could still pay for time, reimburse costs, or acknowledge them for doing a good thing using money. Incidentally, the companies that currently pay donors all say they are not paying donors for the plasma, but are instead compensating donors for their time, effort, inconvenience, reimbursing for costs, and sometimes they say they are acknowledging the donors.

Fire departments and encroachment

Arguments for donor compensation are typically reserved to plasma collections used to manufacture medicines. Few argue for compensating whole blood donors, or plasma donors when it is used for transfusion. This means that proponents of donor compensation are often trying to defend a mixed system—compensation for plasma donations for therapies and no compensation for blood or plasma when used for transfusion. This mixed system raises questions not only about why we should have a mixed system rather than one uniform one, but also and especially about our ability to satisfy needs for both uses.

Our firefighter analogy might have something useful to say about both questions. In the United States and Canada, we have a mixed system, with volunteer and career fire fighters. The mix sometimes happens within the same jurisdiction. Fairfax County in Virginia, for example, has just such a mixed system, called a “combination” or “composite” fire department. In Fairfax County, 12 independent volunteer fire departments work in close collaboration with the career Fire and Rescue Department. The first fire department in the United States consisted entirely of volunteers, started in 1736 by Benjamin Franklin in Philadelphia, Pennsylvania. The U.S. did not have a career fire department until over 100 years later, in 1853 in Cincinnati, Ohio. Now, there are three different types of fire departments: volunteer, career, and combination fire departments. So we can ask the same questions about this system as we might for blood and plasma collection systems: why do we have such mixed systems, and what is the impact of paying some firefighters on the number of volunteers? Are there fewer volunteers because some are paid?

The answer to the former question is straightforward: it depends on the call volume. Volunteer fire departments operate where call volumes are lowest, career departments operate where call volumes are highest, and mixed systems operate when the call volume is too high for an all-volunteer team, but not high enough for an all-career team. Similarly, one answer to why most proponents of donor compensation endorse a mixed system is because the “call volume” for blood and plasma for transfusion is able to be handled by an all-volunteer system, at least in high income countries. In addition, we do not yet have universal use of pathogen inactivation and removal for blood and plasma used for transfusion, and so safety issues remain a challenge for these uses in a way that they do not for plasma therapies.

The answer to the latter question is more complicated, though there might be a lesson from the fact that career and volunteer firefighters seem to generally work well together, rather than be hostile or rivalrous with one another. Titmuss might have speculated that Cincinnati’s introduction of career firefighters would slowly but surely result in an erosion of volunteerism, along with a diminution in altruism and social solidarity. Fire fighting was a noble gift, his speculation might go, and now it will become a seedy commercial enterprise. But that does not appear to be happening. Volunteer firefighters continue to make up the significant majority, 71% of fire fighters in Canada (26) and nearly 70% in the U.S. (27).

Many influential organisations, though, do not think blood and plasma will work like fire departments. Organisations like the World Health Organization (28), the European Blood Alliance (29), and the American Red Cross (30) have said that compensated plasma collections will “compromise”, “erode”, even “cannibalize” non-compensated blood collections. Despite their confidence in these predictions and the strength of these words, none of the countries that have mixed systems have any greater difficulty collecting blood and plasma for transfusion than those that prohibit commercial compensated plasma collections. In Germany, the Bayerische Red Cross concluded that they had witnessed no “crowding out” (31). Dr. Franz Weinauer, the former medical director of the Bavarian Red Cross told The Source magazine that “Blood and plasma donors are not part of the same donor population.” (32). Plasma donors were younger, while blood donors were older. Data from the Paul Ehrlich Institute showed plasma donations increased by 12.7% from 2022 to 2023, while blood donations also increased, though by 2.6% (33).

Czechia saw the introduction of compensated plasma collections in late 2006. Between 2007 and 2010, plasma donations increased sevenfold, while whole blood donations remained steady. A 2019 Czech study that tracked individual donors in the city of Brno (which had one public blood collector and one private plasma collector) showed that while early on more people switched from the public to the commercial collector, but the trend reversed by 2012 (34). Lejdarová et al. attribute this reversal to distinct demographic and economic motivations. They found that while compensation and curiosity initially attracted students and younger donors (18-25) to the commercial center, this preference shifted as donors aged. As they entered stable employment (ages 26–40 years), they increasingly preferred the tax benefits offered by the public collection system over the immediate financial payments. Ultimately, more people switched from donating plasma to donating blood than vice versa, suggesting the two systems can co-exist.

Prior to their partnership with Grifols, Canadian Blood Services asked blood collectors in Germany, Austria, Hungary, and Czechia if blood donations decreased because of commercial plasma collections. The “Bottom line” answer was “no” (35). A 2020 study looked at the opening of commercial compensated centers in Canada and the U.S. and found that the plasma centers had no negative impact on non-compensated blood donations (36). This evidence may not yet be enough to put everyone at ease, and many countries continue to worry about this issue as their main reason for not allowing commercial compensated plasma collections.

Paternalism: autonomy and exploitation

We finally now turn to a cluster of plausible paternalistic moral arguments against donor compensation. These include two widely-cited concerns about the way compensation might lead to wrongful exploitation and potentially non-autonomous or insufficiently autonomous donation decisions. Unlike altruism and solidarity, commodification, and gift-based objections to donor compensation more broadly, worries about autonomy and exploitation are neither confused about what matters, nor do they have simple rejoinders.

At its core, the worry is that offering compensation will attract the financially vulnerable, who will donate from desperation, rather than other motives. These concerns may be grounded in worries about structural inequality; the “choice” to donate for compensation does not happen in a vacuum, but in a context where financial vulnerability is very real. These risks are more acute in low- and middle-income countries (LMICs), where weaker social insurance and regulatory frameworks can heighten the risk of not only exploitation, but harms to donors as well. As Weimer [2015] says: “…one of the main arguments against compensated donation systems is that many donors do or would come from circumstances of poverty that restrict their alternatives in a way that compromises those donors’ autonomy” (37). This compromise of autonomy represents an undue inducement. Concerns about wrongful exploitation are related to worries about autonomy. Panitch and Horne, for example, see wrongful exploitation as consisting in one, some, or all of three criteria: undue inducement, undue risk, or an unfair division of the benefits from trade (38). Most broadly, wrongful exploitation is taking unfair advantage of someone’s vulnerability.

Undue inducement can be seen as problematic for at least two reasons. The first relates to structural inequality. Here, the concern is about the background conditions within which people make choices. Young [1990], for example, sees exploitation as a systemic process where social and economic institutions create and perpetuate the vulnerability of certain groups (39). On this view, the “choice” of someone who is financially vulnerable to donate is compromised by these background conditions, with the compensated collection system taking advantage of this pre-existing vulnerability. Young’s analysis leads to a policy dilemma: banning donor compensation does nothing to address the underlying injustice, while removing a financially beneficial option to do something that saves lives. For example, the decision to take up an unpleasant or dangerous job like crab fishing or firefighting is constrained by the structure in the very same way, but we do not think this means choosing to fight fires is non-autonomous and we think this gives us reason to make these jobs more pleasant or less dangerous, not make it illegal to offer these kinds of jobs (which would counterproductively further constrain the choice set, making things worse from the perspective of autonomy).

The second more immediate reason to worry about undue inducement is the concern that financial incentives may lead donors to ignore risks to their health. Krawiec [2025] puts it like this: “An undue inducement may cause the recipient to incorrectly perceive an action as in her own best interest, when it is not. She may overweight benefits and overlook or discount costs, especially if the benefits are presently forthcoming and the costs are probabilistic or accrue only later.” (40).

Recent research on donor frequency adds some weight to this concern. A 2025 study by Haugen et al., for example, found that high-frequency (once-weekly) donations led to a drop in immunoglobulin G (IgG) levels below 6 g/liter (41). In the United States donors are deferred if their total protein level (a different but related measure) is below 6.0 g/dL. While the Haugen study’s findings are important for setting safe frequency limits, the study also noted that about a quarter of donors (26%) saw this decline. But this argument is not an argument against compensation so much as it is an argument for medical monitoring and appropriate, evidence-based frequency standards. For comparison, while the U.S. allows up to two donations in a 7-day period, other countries that allow compensation like Czechia permit donation only every 2 weeks (42,43).

There are, however, greater risks associated with being a firefighter than there are with even high-frequency plasma donation. It is plausible to think that if people can autonomously choose to become firefighters, they can autonomously choose to be high-frequency donors. One possibly relevant difference is that unlike firefighting, compensated plasma donation is stigmatized. White [2015] argues that this stigma makes it difficult to autonomously choose to donate plasma (44). But, she says, this shows we should either prohibit donor compensation, or destigmatize compensated plasma donation. And since these donations save lives, it looks like the morally best thing to do is to work towards destigmatization, rather than prohibition.

While the risks associated with plasma donation are generally small, undue inducement nevertheless remains controversial, and so it may plausibly underwrite a concern about wrongful exploitation. Claims about an unfair division of the benefits of trade, however, are much less plausible. Currently, the price of a liter of plasma is around U.S.$200. Donors receive around 20–30% of that in donor fees. But if this division is deemed unfair, the solution is not prohibition, which drives the donor’s share to $0 and eliminates all benefit to them. As Panitch and Horne [2019] note, “Whether 30% represents a fair share... it is clearly a lot fairer than 0%” (38). A more just solution would be to increase the proportion donors receive through a regulated system, not to ban the practice, which only harms patients and removes a financial option from donors.

Many arguments against donor compensation should now be regarded as dated, especially those around blood being a “gift”. It is morally better to make sales and meet patient needs than it is to give gifts at the expense of meeting patient needs. It is better to put out fires with paid firefighters, than to watch some houses burn so that we might promote altruism and community solidarity through volunteers.

Paternalistic arguments involving undue inducement and wrongful exploitation remain unresolved, though there are now plausible rejoinders to each of these arguments (see Table 1). Recalling again one of the reasons why donor compensation has become more persuasive over time, we need to construct undue inducement and exploitation arguments in such a way that it does not undermine both donor compensation and import of therapies made from the plasma of compensated donors. If we think any payment is undue inducement or wrongfully exploitative, then it would be equally bad whether we directly pay donors ourselves, or do it indirectly by offshoring the practice to the United States. Although there is still the question of what we should do about this. Banning payment does not seem to do anything about the underlying problem, which is poverty. As Buyx [2009] puts it: “Banning payment for donation without at the same time improving the situation of those for whom it would be attractive does not make this particular injustice disappear. It just makes it less visible.” (45).

Limitations and future research

This review has several limitations. The analysis and evidence presented is drawn primarily from the context of high-income countries in North America, Europe, and Australasia. The ethical landscape and risk-benefit analysis may differ significantly in LMICs, where risks of exploitation and structural coercion could be more pronounced. Future research could address this gap. Additionally, while this paper discusses Titmuss’s “gift relationship”, it does not fully engage with all contemporary communitarian or relational accounts of solidarity that go beyond simple altruism. A deeper engagement with these positions, as well as with empirical longitudinal studies on long-term donor health and well-being, would be valuable avenues for future research.

Conclusions

The primary moral goal of our collection systems is to meet the life-saving needs of patients, a goal that non-compensated systems consistently fail to achieve all on their own. So a call to action is for policymakers to focus on designing collection systems that ensure sufficiency, including by allowing donor compensation for plasma donation, while simultaneously protecting those donors from harm. Such a framework would include fair compensation models, strict donor health protections based on medical evidence, and public health efforts to destigmatize compensated plasma donation, recognizing it as the life-saving contribution it is. Patients deserve at least this.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Jan Hartmann) for the series “Source Plasma” published in Annals of Blood. The article has undergone external peer review.

Peer Review File: Available at https://aob.amegroups.com/article/view/10.21037/aob-25-39/prf

Funding: None.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://aob.amegroups.com/article/view/10.21037/aob-25-39/coif). The series “Source Plasma” was commissioned by the editorial office without any funding or sponsorship. P.M.J. reports consulting fees from CSL Behring, Factor IX Capital, and support from Grifols for the trip to see hemophilia centers and plasma collection centers in Cairo, Egypt. The author has no other conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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