1. Prof. Samia Hurst Institut d’éthique biomédicale, UNIGE Consultante – Conseil d’éthique clinique, HUG Ethics and transfusion

2. We have more than one moral principlePLURALISM Reasonable people can disagree on their priorityDIVERSITY Unusual situations bring this out‘NEW PROBLEMS’

3. Seek good consequencesRespect persons Do goodDo right Avoid bad consequences Be fair

4. Seek good consequencesRespect persons Do good Avoid bad consequences Be fair Respect choices and the value of persons Secure blood supply Avoid harms to donors and recipients Distribute benefits and burdens equitably

5. Do good Respect choices and the value of persons Secure blood supply Avoid harms to donors and recipients Distribute benefits and burdens equitably

6. Do good Respect choices and the value of persons Secure blood supply Avoid harms to donors and recipients Distribute benefits and burdens equitably How much risk do we tolerate in blood supply?

7. Do good Respect choices and the value of persons Secure blood supply Avoid harms to donors and recipients Distribute benefits and burdens equitably And should this be the same all over the world? How much risk do we tolerate in blood supply?

8. Do good Respect choices and the value of persons Secure blood supply Avoid harms to donors and recipients Distribute benefits and burdens equitably How do we face refusal of transfusion?

9. Do good Respect choices and the value of persons Secure blood supply Avoid harms to donors and recipients Distribute benefits and burdens equitably Should we pay blood ‘donors?

11. Do good Respect choices and the value of persons Secure blood supply Avoid harms to donors and recipients Distribute benefits and burdens equitably Should we pay blood ‘donors? Classic answer N°1 No: -paying blood donors will increase risk in the blood supply. -it will have a demotivating effect on the longer term But: available data throw doubt on both Conclusion: we should reconsider paying blood donors…? Lacetera N, Macis M, Slonim R: Economic rewards to motivate blood donations. Science 2013;340:927-8

12. Do good Respect choices and the value of persons Secure blood supply Avoid harms to donors and recipients Distribute benefits and burdens equitably Should we pay blood ‘donors? Classic answer N°2 No: -paying blood donors commodifies human life and the human body -iit would greatly decrease the possibility of free informed consent and pave the way to coerced ‘donation’. Do these arguments work?

13. Coercion One definition of coercion implies the use of force. –This is clearly not the case here. Coercion, however, can also be based on a threat. –Again, however, this is not the case here. Can there be ‘coercive offers’? –At the very least, this is not obvious.

14. Commodification Concern: selling blood may express that the human body (and indirectly perhaps the owner of this body) has a specific monetary value. Glenn Cohen on a hypothetical example: “in a baby-selling market, the very fact that the seller did choose to surrender her child for $5 million expresses a relation of value equilibrium—that the $5 million was a substitute for her child… Some transactions… always express… value equilibrium, the substitutability of the things on either side of the exchange. It is this feature… that makes the transaction problematic.”

15. Commodification Concern: selling blood may express that the human body (and indirectly perhaps the owner of this body) has a specific monetary value. Response 1: a price is not the same as the value, even of things which we agree we ought to be able to buy and sell.

16. Commodification Concern: selling blood may express that the human body (and indirectly perhaps the owner of this body) has a specific monetary value. Response 2: in any case, a person is not the same as that person’s blood. Neither is it a precondition for that person’s status or dignity.

17. Commodification Concern: selling blood may express that the human body (and indirectly perhaps the owner of this body) has a specific monetary value. Response 3: if the problem were that we are saying something that is not true, that is certainly wrong. But is it wrong enough in this case to ground a ban on selling blood? Nir Eyal, unpublished to my knowledge…

18. Do good Respect choices and the value of persons Secure blood supply Avoid harms to donors and recipients Distribute benefits and burdens equitably Should we pay blood ‘donors? Classic answer N°2 No: -paying blood donors commodifies human life and the human body -iit would greatly decrease the possibility of free informed consent and pave the way to coerced ‘donation’. But: allowing the sale of blood does not constitute coercion. Neither does it commodifiy the human body or human life, at least not in a way that makes it truly wrong. Conclusion: perhaps, again, and although this will be more contentious, we should reconsider it?

19. Do good Respect choices and the value of persons Secure blood supply Avoid harms to donors and recipients Distribute benefits and burdens equitably Should we pay blood ‘donors? Answer N°3 No: -paying blood donors is unlikely to lead to fairly sourced blood supplies. -it would enhance existing stigma against vulnrable populations.

20. Do good Respect choices and the value of persons Secure blood supply Avoid harms to donors and recipients Distribute benefits and burdens equitably Should we pay blood ‘donors? Answer N°4 No: -making blood ‘monetarily available’ it would predictably lead to its formal or informal use as a collateral for debt.

21. Do good Respect choices and the value of persons Secure blood supply Avoid harms to donors and recipients Distribute benefits and burdens equitably Should we pay blood ‘donors? No, but not for the reasons we thought…

22. In conclusion Ethics deals with how and why questions. It is possible to analyse these questions with a ‘differential diagnosis’ approach that will be familiar to clinicians. As in clinical medicine, beware when a diagnosis is excluded: it does not mean the patient has no disease…