Introduction
In June 2025 it was widely reported that Britain’s blood donation service desperately needed more donors. An ‘amber alert’, issued the previous year, remained in place, indicating that diminished supply was impacting on patient treatment. There was a ‘pressing need’ to avoid a ‘red alert’ which would mean that public safety was threatened by demand far exceeding capacity. One NHS Foundation Trust noted that ‘National Blood Week’ was asking people to be ‘one in a million’ and donate blood to save lives. At present, only two per cent of the population were donors but if ‘one million people in England gave blood regularly’ this would ensure a ‘safe and stable supply for patients across the country’. This was far from the first time that appeals have been made in recent times. In January 2024, for example, National Health Service Blood and Transplant (NHSBT), the responsible public body, specifically targeted ‘millennials and Gen Zs’ as donors now tended to be over forty-five years old. So how do these present concerns derive from the history of Britain’s blood transfusion services?
Blood Donation and the National Health Service
Blood transfusion services existed before 1939 but most were based in large urban centres and concerned with maintaining lists of donors. This changed dramatically during the Second World War when transfusions became a routine surgical procedure and provision was centrally co-ordinated by the Emergency Blood Transfusion Service. In 1946 the Ministry of Health, anticipating the imminent NHS, created the regionally-organised National Blood Transfusion Service. This became a national body in 1996 before merging, in 2006, with UK Transplant to become the NHSBT. Blood transfusion has thus gone from the periphery of the healthcare system to being an important component of a national institution.
The post-war era also saw unprecedented developments in medical science and in surgical techniques. Kidney transplants, for instance, became increasingly common in UK hospitals from the mid-1950s, as did heart transplants from around a decade later. Such breakthroughs were encouraged and underpinned by the availability of blood supplies, in turn enabling further innovations and stimulating demand (hence the 1996 merger of blood and transplant functions). However, the dynamic relationship between the supply of blood and the medical interventions it allows means that predicting demand is difficult, especially in the absence of constraining factors such as direct monetary charges.
Since the setting up of the NHS, supplies have come from donors who voluntarily gave their blood, and time, without material recompense (apart from the famous biscuits and sugary tea). Professional medical staff collected the blood but non-paid helpers often facilitated the running of donation centres. Essentially, this was, and remains, a system underpinned by individual altruism and operating within a framework of socialised health care, itself the apparent embodiment of social solidarity. Blood, it is worth emphasising, has a number of distinguishing features. It is produced automatically (at no ‘cost’) while having no direct synthetic substitute, is essential to human life, and is thereby literally invaluable to its owners/recipients. Blood also holds a symbolic or metaphorical significance – the very ‘stuff of life’ the voluntary/unpaid donation of which is a ‘gift’. In addition to actually saving lives, its acquisition and use is thus a particularly intimate and culturally resonant affair.
In 1961 the system, and the attitudes it embodied, was mildly spoofed by the comedian Tony Hancock in an episode – ‘The Blood Donor’ – of his popular BBC TV show. The feckless protagonist is asked, at a blood donation centre, why he has come. He replies that he wanted to do something for the country as a whole and chose giving blood over joining the Young Conservatives – a small triumph for altruism. A quarter of a century later, on 6th December 1986, The Economist, in one of its many articles on the supply blood, asked the burning question – would Hancock have done it for money? Without over-reading any of this, it nonetheless demonstrates that blood donation was at these points a recognized component of contemporary life. It is worth speculating whether such a sketch would have the same resonance today.
If judged by the volume of donations, Britain’s voluntary/unpaid system apparently worked as their number rose, in England and Wales, from just under half a million per annum in the late 1940s to around 1.5 million by the late 1960s. Possibly more concerning, however, was that although rates of donation appeared to be slowly growing the proportion of donors remained below ten per cent of its potential population. While data on blood donation is not entirely stable over time, this particular material derives from the usually reliable work of Richard Titmuss whom we shall soon meet as an important figure in our story.
Blood: Commodity or Gift?
For its supporters, the apparent success of voluntary/unpaid donations in a framework of socialized healthcare system encapsulated the aim of collective well-being on which the NHS had been founded. Others were less convinced. The Institute of Economic Affairs (IEA), founded in the mid-1950s, advocated ‘free’ markets and critically questioned the basis, philosophical as well as economic, of the post-war ‘welfare state’. Under its auspices the economists Michael Cooper and A.J. Culyer produced the revealingly-entitled The Price of Blood: An Economic Study of the Charitable and Commercial Principle (1968). This argued that there were, essentially, two approaches to healthcare provision. ‘Collectivists’ saw healthcare as different from other goods and as requiring centralised control and decision making. On the other hand, ‘free marketeers’ maintained that the price mechanism brought ‘order and consistency to the myriad apparently independent decisions taken by members of the community’ and was the ‘only system consistent with personal freedom and responsibility’. This fundamental disagreement had recently manifested itself, Cooper and Culyer concluded, in disputes about the efficacy of paying blood donors. But when the ‘fog of polemics’ cleared it was apparent that ‘payment for blood can be both sensible and humane’.
The most famous critique of this approach was Richard Titmuss’s The Gift Relationship: From Human Blood to Social Policy (another revealing title) first published in 1970 and since reprinted a number of times. Titmuss, professor of social policy at the London School of Economics, was already engaged in a decade-long dispute with the IEA over the market’s role in healthcare provision. His book argued that the British system of acquiring blood was morally superior to, and economically more efficient than, the predominantly commercial American system. Crucially, it also avoided any reliance on donors, often homeless, who sold their blood out of desperation. The concern here was, among other things, that such donors would be more prone to have diseases transmissible by blood – their blood was, then, potentially of ‘low quality’. Altruism, the propensity to help unknown strangers, was at the heart of Britain’s blood services but would be driven out, to the detriment of individuals and of society, by even a modest intrusion of ‘market’ principles – depicted by Titmuss and his supporters as the process of ‘crowding out’.
The book’s wider implications were immediately recognized. In the left-wing journal Tribune in mid-February 1971 Labour MP Michael Meacher claimed that at a time when ‘the National Health Service appears to be under attack’ (he was alluding to the Conservative government’s current reforms) Titmuss had produced a ‘blistering indictment of commercialized health programmes’. The latter had various drawbacks, most importantly the ‘permanent damage’ to the ‘springs of altruism’. So from blood donation as a ‘simple life life-saving process’ Titmuss sought to ‘erect an entire social philosophy’ around the conscious restructuring of social institutions ‘to foster integration rather than alienation’
Others were less impressed. Titmuss’s criticisms of American healthcare provision prompted widespread attention in that country. Free-market economists were to the fore, including Nobel Prize winners Kenneth Arrow and Robert Solow. The latter, for instance, found The Gift Relationship ‘extraordinarily interesting’ but ‘ultimately confused’. What had aroused the author’s ‘scorn and anger’ was not (as he thought) the ‘use of economic reasoning but its misuse’. Back in Britain, Cooper and Culyer did not take Titmuss’s criticism lying down. The latter told The Lancet that, fundamentally, ‘Titmuss does not understand economics’ while Cooper wrote to the British Medical Journal that in 1968 he and his co-author had sought to show that, contrary to Titmuss, blood was ‘an economic good and therefore fully amenable to economic analysis’. Titmuss was thus a ‘bad’ social scientist, a charge with ramifications beyond his own status and approach and his claims for academic credentials of social policy.
It should be stressed that most proponents of the free market did not advocate the ending of voluntary/unpaid donations and many agreed that in certain details Titmuss was right, albeit usually for the wrong reasons. In their view, paid and unpaid donations could co-exist without necessary detriment to either. This gave potential donors a choice. But whatever method they chose, it was still voluntary – an exercise of personal freedom. Furthermore, critics of a strictly unrecompensed system could (and did) legitimately ask whether unpaid donations were actually ‘free’, given that volunteers gave up their time (implicitly, time at work); and why, if the British were so altruistic, did only relatively few donate?
The apparently technical/administrative issue of blood supply thus took on a range of meanings, of which three immediately stand out. First, Titmuss ‘won’ the argument in the sense that, regarding the acquisition of blood, Britain retained its voluntary/unpaid system while his book was credited with shifting federal policy in the US towards unremunerated donations. Internationally, moreover, for the last half century the World Health Organisation has promoted voluntary, unrecompensed, donation, claiming in May 2025 that an ‘adequate and reliable supply of safe blood can be assured by a stable base of regular, voluntary unpaid blood donors’. Such donors constituted the safest group, having the lowest prevalence of bloodborne infections.
Second, The Gift Relationship informed, and continues to inform, often fraught debates in areas such as medical/legal ethics (including issues around selling/purchasing body parts such as kidneys) and moral and political philosophy. On the last of these Michael Sandel, the Harvard University political scientist and public intellectual, finds The Gift Relationship a ‘classic study of blood donation’, perhaps the ‘best-known illustration of markets crowding out non-market norms’. There was, by this account, an ethical as well as economic argument against paying for blood. Once people got used to the idea of blood as a tradeable commodity, so would they be less willing to donate. Market intervention diminished the ‘spirit of altruism’ through its ‘corrosive effect on the norm of giving’ and, thereby, the ‘sense of community’ (‘crowding out’). Given his own status as a spokesperson for the liberal-left, this was clearly of concern to Sandel – hence his article’s (touchingly optimistic) call for economists to ‘re-engage’ with political philosophy.
Third, if there is, as claimed by Meacher, a ‘social philosophy’ here it is one which rejects market mechanisms and values. It is difficult to claim that this argument was ‘won’ by Titmuss. Indeed there is a strong case that the Titmuss/IEA dispute heralded an early intellectual, and subsequently policy, victory for the economic (and social and political) philosophy generally described as neoliberalism, with its stress on market mechanisms and values, not least individual responsibility and individual choice.
Crises
The NHS has been subject to various crises since its foundation in 1948 and this applies as much to blood supply and distribution as to any other part of the service. In its first decade or so the blood transfusion service, like hospitals, experienced staff shortages, potentially threatening viability. In the early 1990s, meanwhile, attempts to reduce waiting lists in line with commitments in the Patient’s Charter (an attempt by the then Conservative government to introduce a consumerist/managerialist ethos into the NHS) created blood supply problems due to an upsurge in demand, notwithstanding a recent increase in donations. And in summer 2024 a cyberattack in which a pathology services provider was among the victims led to an NHSBT amber warning and a call for more donors. In such instances, the blood services were victims of events affecting the healthcare system as a whole and over which they had little or no direct control.
More specifically, though, as the HIV/AIDS crisis took hold in the 1980s Iain McLean and Jo Poulton of Oxford University argued that Titmuss’s ‘fierce and emotional’ book had been right in its essentials, ‘although it had taken the tragedy of AIDS to underline it’. Lessons to be drawn included that both Titmuss and his critics were ‘really making normative claims behind an ill-fitting disguise of positive social science’. Britain’s blood transfusion system, including its ‘voluntary principle’, were ‘precious assets, to be tampered with only at grave danger to health’. Governments should thus ‘think twice’ before introducing the market to any service ‘provided out of altruism or moral reciprocity’, global health organisations should curtail trade in commercially produced blood products, while one particular lesson of HIV/AIDS was that blood products imported from America were to be avoided at all costs.
Sadly, this advice was not followed, one outcome being what the British Medical Journal’s legal correspondent described in 2024 as the ‘biggest treatment disaster in NHS history’. The particular victims were haemophiliacs treated with commercially-produced blood products from the US at a time when the UK was not self-sufficient. Despite increasing evidence of HIV entering Britain by way of American blood products, their use persisted. A subsequent enquiry found that the ‘disaster was not an accident’ and occurred because ‘those in authority – doctors, the blood services and successive governments – did not put patient safety first’.
All this is true, but certain ambiguities had been identified in, for example, an article in The Times on 5th November 1993. It certainly appeared to be the case, this suggested, that ‘voluntary systems are less likely to lead to the transmission of disease’ (Titmuss was duly cited). But the problem was that such systems ‘seldom produce as much blood and blood products as are needed’. America’s ‘unashamedly commercial approach’ had ‘made companies there the main producers of such products’. Five years later, on 3rd July 1998 and in a leader marking the health service’s fiftieth anniversary – ‘In Place of the State: A New Prescription for the NHS 50 Years On’ – the same newspaper claimed that since 1948 the service had been wholly dependent on the taxpayer. This had its ‘eloquent defenders’, not least Titmuss whose The Gift Relationship made a formidable case for altruism in a civilised society as embodied in the health service and ‘most noticeably in the operation of the blood transfusion service’. But the current funding mechanism was ‘crude restraint rather than a support’, with lessons to be learned from other European countries. Blood donation and market principles were thus linked.
So Where Will It Come From?
The question of ‘crowding out’, and the dynamics of the relationship between paid and unpaid donations, are still live and have strong moral overtones, acknowledged or otherwise. The philosopher Debra Satz, who has written extensively on the shortcomings of ‘markets’ as determinants of social action, recently concluded that early pro-market critiques of Titmuss were wrong, and that the latter’s ‘conjecture’ had been ‘empirically supported by numerous studies showing that financial incentives can crowd out altruism and other pro-social motivations’.
A 2013 edition of the medical journal The Lancet, meanwhile, devoted considerable attention to blood transfusion services, acknowledging that problems might be generated by, for example, overuse and that low-income countries had particular challenges in satisfying demand. Overall, though, the ‘altruism of voluntary unpaid donors, as described so eloquently in The Gift Relationship by Richard Titmuss’ should be celebrated and encouraged as the best solution to any obstacles
Sociologist Kieran Healy is more sceptical. He argues that Titmuss may have been at least partially correct in his 1970 analysis which clearly affected the behaviour of collecting bodies. Sometimes, though, this had proved counterproductive as such agencies became bound to an approach based on a belief in ‘the uniqueness and inalienability of the gift of blood’. What HIV/AIDS had shown was that altruistic and financially recompensed donation could work effectively alongside each other. Furthermore, the subsequent ‘industrialization’ of blood supply made it difficult ‘for blood donation to generate social solidarity in the way that Titmuss described’. As the market for blood and other human tissue products expanded, it was increasingly unclear whether the ‘gift relationship as presently understood’ might still provide a ‘plausible framework for the exchange of donor blood and body parts’.
On 31st August 2024, meanwhile, a leading article in The Economist (never a fan of the ‘welfare state’ or Titmuss) proposed that while the ‘trade in human blood might seem gruesome’ it was, nonetheless, ‘essential’. On the specific issue of blood plasma, there had been worldwide shortages since at least 2018, a situation exacerbated by COVID-19 and ‘especially dire in poor countries’. The solution was paid donors, a potentially more efficient method than relying on unrecompensed donations since the former tended to donate more, and more often. An article in the same edition accused countries such as Britain of ‘double standards’ and ‘hypocrisy’ given that they imported plasma from the United States (where donors were routinely paid and could donate up to 100 times per year, whereas many Europeans were restricted to around thirty annual donations) but ruled against such payments themselves. Titmuss’s claim that the British system was both economically and ethically superior was hence wrong on both counts.
A few months later, and shortly after the summer 2025 call for more donors, the Labour government issued its ten-year plan for England’s NHS. Notwithstanding the recent donation crisis, no direct mention is made of transfusion services (although the contaminated blood scandal is noted). In broad terms, though, the service stood at an ‘existential brink’ (whatever that means). Although starting from the NHS’s ‘founding principles’ the government nonetheless proposed to ‘entirely reimagine’ its working. Not to do so would almost certainly lead to the erosion of ‘the principle of solidarity that has sustained the NHS’ resulting in a ‘poor service for poor people’ (probably unintentionally, an expression historically associated with Titmuss and like-minded commentators). This protests rather too loudly, and it is difficult not to see further marketisation of the NHS on the government’s agenda.
Conclusion
In such circumstances, where does blood donation stand? On one level, since donations remain monetarily unrecompensed and the present administration is grappling with challenging public finances, it is difficult to see any form of payment being introduced any time soon. But on both the supply and the demand side actual or potential problems remain. On the demand side, medical innovations will undoubtedly continue and require support from adequate blood supplies. And with an ageing population it is simultaneously encouraging that older age cohorts are the most committed donors but more problematic given that it is the elderly who require disproportionately more medical attention.
So where it the blood to come from? For some this is easily answered – commercial suppliers (at present mostly based in America) and financially-rewarded donors. Free-marketeers claim that this would be more efficient, allow individuals to exercise free choice, address the issue of low donor numbers, and cut through the current British system’s moralistic fog (or hypocrisy, cant, and double standards). In support, they could point to a 2022 YouGov poll which found that nearly half of 18-24 year olds would donate blood if paid to do so (presently, around 10% do in some sort of way)
On the other hand, if the unpaid/voluntary system is to persist, why might donors continue to donate without financial recompense? By definition, individuals cannot be compelled to be altruistic. It is interesting to speculate, then, whether the slow but discernible growth in blood donations the post-war era reflected an altruistic commitment by the wartime generation and ‘baby-boomers’ to the recently-created ‘welfare state’. Is unpaid blood donation another aspect of the Beveridge/Keynes consensus now conceivably (and, for free-market critics, belatedly) on the way out, supplanted by neoliberal hegemony?
Nonetheless, appeals to altruistic conduct are still made, if only implicitly or in a roundabout way. The recent call to GenZs/millennials, referenced earlier, quoted one nineteen-year-old urging her peer group to ‘think about who you may be helping. It’s a small act but one that can make a big difference to someone’s life’. Interestingly, the same call also highlighted the personal satisfaction donors could derive from their gifts. So does the future of blood donation involve altruism, possibly coupled with self-fulfilment, financial incentives, or some combination thereof? On the issue of self-fulfilment, it should be noted, The Gift Relationship made the striking claim that in order to love oneself, one must first love strangers – the essence of altruistic blood donation.
This suggests that perhaps economic questions focused on supply and demand miss a more fundamental point. We have seen that pro-marketeers belittled Titmuss’s purported knowledge of economics. Similarly, we have noted too that their arguments thus rested on the superiority of market mechanisms and values (they were often shy about articulating the latter, but were as prone to normative judgements as any other social scientist). If these drove out, for example, unpaid blood donation, so be it. There was no reason why this should happen, but even if it did it was a price worth paying to enable the price mechanism and individual freedom of choice.
But what Titmuss and those who have since subscribed wholly or partly to his analysis (Satz and Sandel, for instance; also Farrell) promoted, and continue to promote, was a particular vision of society based on certain moral premises such as social solidarity and altruism and a rejection of that version of individualism underpinned by market values. So while it is true that, for example, altruism cannot be enforced, it could equally certainly be encouraged and enabled. And if desirable ethical behaviour was ‘crowded out’ (although this continues to be debated), then this was a collective failure on society’s part. In the last resort, then, debates around blood supply (and to a lesser extent demand) have been proxies for fundamental disagreements about the place of the market and market values, and so about the sort of society we seek. At the very least, engaging with them requires rigorous thinking about economic approaches, often presented as immutable laws, such as ‘the Treasury View’ and ‘fiscal rules’.
