This Ethics Rounds presents a request for directed blood donation. Two parents feel helpless in the setting of their daughter’s new leukemia diagnosis and want to directly help their child by providing their own blood for a transfusion. They express hesitancy about trusting the safety of a stranger’s blood. Commentators assess this case in the setting of blood as a scarce community resource during a national blood shortage. Commentators review the child’s best interest, future risks, and harm–benefit considerations. Commentators recognize the professional integrity, humility, and courage of the physician to admit his own lack of knowledge on the subject and to seek help rather than claim directed donation is not possible without further investigation into options. Shared ideals such as altruism, trust, equity, volunteerism, and solidarity are recognized as values relevant to sustainment of a community blood supply. Pediatric hematologists, a blood bank director, transfusion medicine specialists, and an ethicist conclude that directed donation is only justified by lower risks to the recipient in particular circumstances.

Directed blood donation (DBD) poses a values tension between sense of responsibility to one’s own child versus blood as a resource to benefit the larger community. In scenarios where the medical burden or benefit to the child may be equal between receiving DBD versus community donor blood, the family’s values warrant additional thoughtful consideration.

DBDs occur when a family member or friend donates blood for an individual anticipated to need a blood transfusion in a nonurgent setting. The blood product (whether red blood cells [RBCs], platelets, or, less often, plasma) is collected, processed, and distributed by a blood donor center, stored within hospital blood banks, and then transfused to the intended recipient upon need. Other types of blood donation are allogenic (donations for unspecified others) and autologous (donations for patients’ own later use; eg, postoperatively). Current data on the rate of DBD are not available because many blood banks no longer track them. Data from a 1990 survey found that 92% of blood donations in the United States were allogenic, 5% autologous, and 3% directed.1 

In some instances, it may be medically preferred or necessary to perform DBD for hematologic or immunologic indications, such as transfusion of maternal platelets in neonatal alloimmune thrombocytopenia or providing blood from donors with rare blood types to recipients with alloimmunization to common antigens. For a child who may require multiple transfusions, there is at least theoretical benefit to limiting exposure to a small donor pool through DBD. Some transfusion reactions and complications are directly caused by donor-specific factors, including most transfusion-transmitted infections and transfusion-associated lung injury, the latter of which can be caused by donor antibodies to human leukocyte or neutrophil antigens. The very small risk of these particular transfusion-related complications does not warrant limiting a patient’s donor pool to DBD versus transfusion from the general donor population.

A 5-year-old girl, Jane, presented to her primary care provider with fatigue. She was found to be tachycardic and markedly pale, and her primary care provider referred her to the emergency department. At presentation, Jane’s white blood cell count, hemoglobin, and platelet count were low, and her lactate dehydrogenase and uric acid were high, raising the concern for leukemia. Jane’s parents were shocked and saddened by the news. When the treating physician explained the need for a blood transfusion, both parents asked about whether they could donate blood for her. He inquired into their reason for requesting directed donation. They shared they were concerned about the safety of blood from a stranger and were worried about Jane contracting an infectious disease from a transfused unit from an unknown donor. They voiced that they want to directly help their daughter. The physician recalled receiving e-mails and seeing newspaper articles about a national blood shortage. He tells Jane’s parents “I don’t know” when asked whether direct donation would be an option for Jane’s first transfusion. In the hallway, the physician tells his emergency medicine colleague that he doesn’t think directed donation is possible for children. He asks the hematologist/oncologist on call, who is coincidentally a member of the hospital’s ethics committee, for help.

According to current surveillance, every blood donation is screened for hepatitis B and C, HIV, human T-lymphotrophic, and West Nile viruses, as well as Treponema pallidum (syphilis), and Trypanosoma cruzi (Chagas disease) at first-time donation.2  Cytomegalovirus serologic testing occurs when needed for certain recipients, and additional infectious disease screening may be instituted for donors living in endemic areas (eg, babesia testing for donor collections in the Northeastern and upper Midwestern states) or during outbreak periods (eg, Zika virus screening in 2016–2021). Because of storage conditions that make platelet products more susceptible to clinically significant bacterial contamination, platelets either undergo pathogen inactivation at collection or additional screening postcollection.3,4 

In the United States, the “estimated residual risk”5  of transfusion-transmitted infections is very low; reported at 1 in 2 million transfusions for hepatitis B and C.6  Although risk modeling has estimated the risk of HIV transmission as 1 in 1.5 to 2 million transfusions, notably, no HIV transmission via transfusion in the United States has been reported in the last 14 years, and yet we have safely given >10 million transfusions annually.2  These numbers may be considered highly conservative risk estimates. Thus, from an infectious disease and patient safety perspective, DBD does not represent a superior form of donation,7,8  including for Jane, and the family should be informed of this.

Particularly when medical benefit of using a DBD for a patient is deemed to be limited, the practical challenges of procuring DBDs must be considered. The collection, processing, and storage of blood donated for a specific recipient requires additional logistic, financial, and personnel considerations. Cost-effectiveness studies have indicated that DBD assumes higher staff time investment for product preparation and higher processing cost.810  During contingency and near-crisis measures, such as those experienced during the pandemic, blood donor centers and health care facilities face not only supply chain challenges, but also staffing shortages, which can substantially impact the ability to accommodate additional workflow processes required in DBD product collection and tracking. Whether the additional costs of DBD, if it is not clinically indicated, should be borne by the patient or distributed across the system is an unresolved issue.

For Jane, the risk of transfusion from the US community blood supply does not in itself justify pursuing DBD in this situation. The public health considerations during the pandemic at the time of this case could additionally make the growing trend of increasing DBDs an untenable strain in an increasingly stressed health care system. However, the values or beliefs of Jane’s family still warrant consideration in which accommodation of DBD may provide other benefit to this family unit (eg, relief of moral distress and feelings of helplessness). In Jane’s case, the additional time to procure a DBD would place her at increased risk of medical complications, so the clinical provider must act in the best medical interest of this minor patient by declining DBD. However, recognition of the unique personal and cultural background of this family is part of the family-centered care. The provider must make every effort to elicit Jane’s parents’ specific concerns and discuss why DBD is not in Jane’s best medical interest in the opinion of the treatment team. Careful consideration must be given to personal patient or family preference for blood source, as well as public health efforts to augment supply.11 

The harm and benefit ratio specific to Jane should take decisional priority. Jane’s parents should be given the option of DBD so long as a delay in accessing blood does not impact the clinical burden to their daughter. Directed donations are mainly used in nonurgent settings because infectious disease and ABO compatibility testing must be completed before blood component release, and therefore, this prohibits DBD use in more emergent situations.

Because of an increased risk of transfusion-associated, graft-versus-host disease because of human leukocyte antigen similarities in family members, all cellular blood products (ie, RBC, platelets) from related donors must undergo pretransfusion γ irradiation, regardless of whether a recipient is immunocompromised. Because of potassium and free hemoglobin leakage 24 hours after irradiation, RBC units should optimally be irradiated as close to administration as possible rather than stored for prolonged periods, especially for neonates or other patients who may not be able to safely tolerate a large potassium load.12,13  However, it may be logistically challenging to coordinate the timing of DBD RBC product after irradiation at the blood supplier. If Jane’s clinical condition would be harmed by waiting for DBD, then she should receive blood from a community source to foster her best interest and better clinical outcome.

Beyond the biologic, the psychosocial experience of the family warrants consideration. The family is seeking to help their child in what must feel like an overwhelming and helpless moment. Jane may experience an adverse reaction during or as a result of the transfusion. Parental guilt may ensue when the parent is the donor, which would not occur after a transfusion from an anonymous donor. Directed donations are not free from transfusion reactions, including alloimmunization and other transfusion reactions.14 

For many years, there has existed public perception that blood transfusions from family members or close family friends are safer than allogeneic transfusions from volunteer community donors. However, there is no evidence that directed donor units are safer, and in fact, higher rates of positive infectious disease markers have been shown in directed donor units compared with repeat volunteer donor units.15,16  It has also been demonstrated that first-time parental donors have significantly higher rates of positive infectious disease testing results compared with volunteer community donors.17  Truthfulness represents a core tenet in the blood donor screening process, and parents (or family friends) who are trying to help their own child (or their friend’s child) may have an additional pressure to answer screening questions in accordance with approval to donate. DBD may pose privacy risks in revealing past bloodborne illnesses or high-risk behaviors to the coparent (or family friends) because parents may wonder why their coparent or family friend is not able to donate for their child. For fairness, integrity in donor requirements, and consistency in standards, directed donors should still be selected according to institutional and federal guidelines rather than the creation of special exceptions for directed donor qualifications. Families considering DBD should be informed of the potential of reallocating the blood to another patient if it is likely to expire before its use for the intended recipient.

In the instance where the blood donor may potentially be considered to serve as a donor for a future bone marrow transplant for the recipient, exposing the child to DBD may result in HLA antibody formation that would later preclude that parent from serving as a haploidentical bone marrow transplant donor or result in graft rejection. Ethically, requests for DBD should be contextualized with consideration of whether a directed donation would restrict the child’s access to a future familial-donor transplant. Although it would be an overstatement to imply that a child who received DBD unequivocally could not later receive a bone marrow or solid organ transplant from the donor, providers should continue to try to minimize risk of HLA alloimmunization against familial donor alloantigens, particularly when haploidentical transplant may be considered in the future.

Jane’s physician presumed DBD was not possible, likely because directed donation was not a familiar process. When a family requests an unfamiliar intervention, the request presents an opportunity to admit a lack of knowledge and to commit to gathering new information to better inform the response. Medical interactions include “meetings between different epistemologies (ie, lay and expert knowledge)” with asymmetry in power dynamics.18  The physician in this case voiced the powerful phrase, I don’t know, which linguistically carries both a literal admission of knowledge void and also an important relational role of humility.19  It takes professional courage and humility to admit lack of expertise on an uncertain topic.20,21  In an era when physicians are expected to offer ready knowledge and encyclopedic answers,22  admitting I don’t know upholds professional integrity; and yet, how the phrase is wielded matters.23  Previous qualitative research surrounding phrases of uncertainty in clinical encounters reveals they either reduce space for further exploration (defer, redirect, or shut down) or they provide space for further exploration (acknowledging, clarifying, contingency planning, offering continuing dialogue).24  Curiosity remains both an ethics competency and a keen clinical commitment. “Let me look into that” offers a more dignified and partnering response than an uninformed not possible or a conclusive I don’t know.

The emergency medicine physician upheld professional integrity by asking a knowledgeable subject matter expert about options available for the family. Asking for clarity and seeking additional information requires awareness of personal cognitive bias or blind spots to fill in information gaps. The on-call hematologist/oncologist played a critical role in addressing a colleague’s medical misinformation regarding the feasibility of DBD for children. Misinformation often stems from both knowledge gaps and cognitive biases.25  Debiasing strategies include recognizing information gaps, encouraging reflection, and separating intuitive from analytic processing.26,27  Data which discredit misperceptions are best partnered with empathy and curiosity as cocontributors in collegial conversations.

Beyond just the academic or acquisition of new knowledge, curiosity also lends itself to learning more about the beliefs and values held by Jane’s parents. Learning what motivates their request for DBD would offer insight into the values guiding their preference for DBD. By inquiring into the reason for the request, the emergency department provider was able to hear more about the family’s fears, hopes, and values. Family-centered care is best informed by exploring the meaningful values which motivate a family’s request for DBD to support communication, foster trust, and partner together in the care plan.

The physician has an opportunity to honor the parents’ role and respect the parental desire to help their child in what feels a helpless moment. The clinical team maintains a responsibility to offer Jane’s parents additional ways in which they may help Jane. This may include equipping Jane’s parents with anticipatory guidance and strategies regarding symptoms such as pain or nausea, encouraging their role as an advocate for their child and emphasizing their opportunity to define and live into their sense of what it means to be a “good parent” specific to Jane at each moment.2830  The physician can explicitly recognize the parental intention to care for their child directly as a shared intention with the medical team’s goal to also care well for the child. This case provides opportunity to expand the parents’ sense of responsibility to the child and to also recognize altruism as a community value. In settings with a large and primarily volunteer blood donation system such as in the United States, strangers donate blood to support one another. This signifies that values such as altruism, trust, equity, volunteerism, and solidarity sustain the community blood supply.

A robust volunteer donation system expands the accessibility of this resource. In many countries, the infrastructure for blood donation systems and community blood banks does not exist and all blood donations are obtained through direct family connection. In some countries, donors are elicited from within the recipient’s genetic blood line as a practice culturally aligned with family-oriented expectations.31,32  In other countries, principles of altruism and community duty include donation of blood when need arises within a social circle, even outside of the immediate family unit.33,34  A potential inequity consequence in settings where donations must be obtained by family recruitment of others includes preferential access for children from larger healthier families of means, and decreased access for children without such advantages or social networks. The collection of blood for a child from voluntary and specifically nonremunerated community donations helps to avoid confounding motivations of duty, coercion, side payment or bribery, or personal gain that may come from reliance on social networking to obtain blood.35 

Justice means avoiding the systematic creation of separate blood access routes on the basis of privilege while still attending to the relational or safety values motivating DBD requests. The physician is uniquely positioned to honor their professional integrity in admitting lack of knowledge and willingness to obtain knowledge, to explore the family’s values, and to consider the larger community and public health values.

Jane is admitted to the hematology/oncology inpatient unit. Within the hour, Jane develops hypoxia when sleeping and needs supplemental oxygen. Now that she is symptomatic from her anemia, there is increased risk if transfusion is delayed, which shifts the harm–benefit ratio. The on-call hematologist/oncologist comes in to evaluate Jane and meets with the family to recommend transfusing available blood from the community supply because the time frame required for DBD processes would delay care. The physician shares education materials with the family regarding the safety of the community blood supply. The on-call hematologist/oncologist transparently explains to the family that, over the years of Jane’s chemotherapy course, she will likely require multiple transfusions. He also provides initial information about the process for DBD for the family. He asks them to review the materials so that they can discuss together whether they intend to limit all transfusions to DBD, explaining that this approach may not be feasible or practical during the lengthy leukemia treatment ahead. He recognizes that the family is fatigued and emotionally burdened so he offers to meet with them again to process the information together, to hear more about their concerns, to answer questions, and to remain readily available.

The child’s father asks how he can donate to the community blood bank tomorrow to “give back” for the unit of blood his daughter will receive tonight.

Requests for DBD can be based on a variety of motivations, including anxiety or helplessness. Providers who are asked about the possibility of DBD may only have a general recall of the process and its potential benefits and risks. As with other topics, it is important for provides to acknowledge when their knowledge is limited and to seek the assistance of more knowledgeable colleagues. In the United States, the risks of transfusion-transmitted infections are very low and DBDs are not free from transfusion reactions. DBD is only clinically indicated or relatively contraindicated for a small subset of patients, eg, mothers of neonates with alloimmune thrombocytopenia and parents or relatives of future bone marrow transplant recipients. A knowledgeable colleague would describe the additional burdens on the system posed by DBD and why the current blood shortage may provide sufficient justification for declining elective DBD. Having clarified the motivation, the provider may offer reassurance or other ways the potential donor can help.

Drs Weaver and Matheny Antommaria coconceptualized the paper; Drs Yee, Lawrence, and Fasano made substantial contributions to the design; and all authors drafted content for the initial manuscript, reviewed and revised the manuscript for intellectual content, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work.

The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the US Department of Veterans Affairs, the US government, or the VA National Center for Ethics in Health Care.

FUNDING: No external funding.

CONFLICT OF INTEREST DISCLAIMER: The authors have indicated they have no conflicts of interest relevant to this article to disclose.

DBD

directed blood donation

HLA

human leukocyte antigen

RBC

red blood cells

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