Last week, the Nuffield Council on Bioethics announced that it’s running a consultation into whether more people should “be expected to donate organs, eggs and sperm and, if so, how far can we ethically go in encouraging them to donate?” A lot of the questions focus on the role of incentives and giving in delivering healthcare. For example:

“Do you think that it is in any way better, morally speaking, to provide human bodily material or volunteer for a first-in-human trial for free, rather than for some form of compensation? Does the type or purpose of bodily material or medicine being tested make a difference?”

Whatever the results of this consultation, it’s clear that the nature of giving continues to prove controversial. At what point do incentives turn ‘giving’ into straightforward ‘exchange’? Perhaps, the reason for this controversy is that the issues go to the heart of our conception of the ‘common good’.

Incentives and volunteering

The incentives question is one that we’ve been wrestling with in volunteering for many years. Do incentives and obligations fundamentally alter the nature of volunteering?

For this post, I’m going to look at the research on how mixing markets and giving has influenced the development of blood and organ donation and what the implications are for our conception of volunteering.

In 2009, Michael Sandel as part of his Reith lecture series on ‘A New Citizenship’ discussed markets and morals. One of his key points was this:

Markets are not mere mechanisms. They embody certain norms. They presuppose, and also promote, certain ways of valuing the goods being exchanged. Economists often assume that markets are inert, that they do not touch or taint the goods they regulate. But this is a mistake. Markets leave their mark. Often market incentives erode or crowd out non-market incentives.

For Sandel, many aspects of our life together can be “corrupted or degraded if turned into commodities”. We need to think carefully about when to use exchange (markets) to deliver goods and services, and when to create other means to deliver necessary goods and services. Our decision can’t simply be to choose the delivery mechanism that’s most efficient, it also has to be about how we value the goods in question.

Sandel’s wider concern, as sketched out in his book Democracy’s Discontent, is how prevailing political ideology (particularly in the US) is wedded to individualism which ultimately leads to us all feeling ever more disempowered. He’s interested in how we can better recognise the interdependence of citizens and the need for civic association. This brings us back to the role of volunteering, but sets it against this ideological backdrop of how we understand the motivations behind social behaviour.

Market logic vs logic of giving

In the 1960’s, economists, particularly those in the Chicago School, such as Gary Becker, began to develop Rational Action Theory (RAT), also known as Rational Choice Theory. As the theory took hold, it began to be applied beyond simply explaining the market and monetary exchanges, to all sorts of other kinds of social behaviour. It developed out of utilitarian philosophy of the 19th century. This thinking focussed on individuals as self-interested actors who think rationally about attaining rational goals.

Elie Halevy famously described it as ‘dogmatic self-interestedness’. Many criticisms of the theory, essentially make the point that as social theory, it turns on a really hollow conception of what it means to be human. The other problem with Rational Choice Theory is that it mixes ‘what is’ (positive), that we are rational and self-interested actors, with ‘what ought to be’ (normative), that we should be rational and self-interested actors.

Alain Caille suggests gift economy theory provides an alternative to the dominance of Rational Choice Theory. He draws on the work of anthropologist Marcel Mauss (nephew of Emile Durkheim) who, almost 100 years ago, looked at the ceremonial giving practices. His work suggested that in early societies there were ceremonies that formalised the triple obligation to give, take and return. That is, obligations (a) to give a gift, (b) receive the gift (if you’re offered one), and then (c) respond in turn by giving a gift on to another (not necessarily to the original giver). This kind of early pre-modern giving had nothing to do with charity, instead it was distinctly combative. Caille explains:

Pervaded with aggression and ambivalence, it is an agonistic gift. It is not through economising but in spending and even dilapidating or in accepting to lose his most precious goods that one can make his name grow and acquire prestige.

Caille continues:

The goods which are so given, taken and returned (counter-given) generally have no utilitarian value at all. They are valued only as symbols of the social relation they allow to create and feed through activating the unending circulation of a debt, which can be inverted but never liquidated. Gifts are symbols, and they are reciprocal. Through the circulation of those gifts what is secured is the public recognition of the identity and of the value of the parteners, individual or collective engaged in the gifts circulation.

The most famous illustrations of this type of giving are the potlatch of the Kwakiutl Indians (Northwestern Canadian coast) and the kula of the Trobianders. Caille believes we can link modern giving, such as blood donation, to this earlier form of giving that Mauss researched and wrote about in his 1924 book The Gift amongst other places.

Obligations and giving

Jonathan Miller in his radio series charting the rise of the National Health Service in Britain, picked up on the anthropoligical significance of the British semi-ritual of having a cup of tea and a biscuit after giving blood since the very beginnings of large scale blood donation during the Second World War. The ‘tea and biscuit’ tradition has clear parallels with the idea that there is a need to respond in turn to the gift of blood. It’s significance is social, rather than medicinal, since the medicinal benefits of drinking tea after giving blood are minimal.

It’s clear as well that an important driver at the beginning of blood donation, was a way of giving back because a friend or close relative had benefit from donated blood. This continues to be a key driver. Anecdotally, I’ve heard people describe again and again their motivation for volunteering as wanting ‘to give back to the community’.

A clear conclusion of many researching blood donation is that one specific problem of introducing market logic alongside giving blood, breaks this balance of obligations to give and give back. As the incentive to give is increased, it undermines the obligation to give. As a result, there is no net benefit. Michael Sandel again:

“Perhaps the best-known example of market norms eroding or crowding out non-market norms involves the case of blood donation. The sociologist Richard Titmuss compared the United States system, which permitted the buying and selling of blood for transfusion, with the system in the UK which banned financial incentives and relied wholly on donated blood. Titmuss found that rather than improve the quality and supply of blood, the commercialisation of blood led to shortages, inefficiencies and a greater incidence of contaminated blood. His explanation: putting a price on blood turned what had been a gift into a commodity. It changed the norms associated with blood donation. Once blood is bought and sold in the market, people are less likely to feel a moral obligation to give it out of altruism.”

Richard Titmuss’s book ‘The Gift Relationship: From Human Blood to Social Policy’, first published in 1970, is the seminal work in this area. When he wrote the book, he was writing about the NHS as much as he was blood donation: “We cannot understand the National Blood Transfusion Service without also understanding the National Health Service, its origins, development and values.” (p 60)

Modernisation of giving

In one sense, Titmuss’s work was to ensure giving survived and flourished in modern society. Indeed, one of his objectives was to study “the role of altruism in modern society. [This book] attempts to fuse the politics of welfare and the morality of individual wills.” (p 59)

“Unlike gift-exchange in traditional societies, there is in the free gift of blood to unnamed strangers no contract of custom, no legal bond, no functional determinism, no situations of discriminatory power, domination, constraint or compulsion, no sense of shame or guilt, no gratitude imperative…

“…(S)ocial gifts and actions carrying no explicit or implicit individual right to a return gift or action are forms of ‘creative altruism’…They are creative in the sense that the self is realised with the help of anonymous others.” (p 279)

“…In not asking for or expecting any payment of money, these donors signified their belief in the willingness of other men to act altruistically in the future, and join together to make a gift freely available should they have need of it.” (p 307)

“As individuals (donors were) taking part in the creation of a greater good transcending the good of self-love. To ‘love’ themselves, they recognised the need to ‘love’ strangers. By contrast, one of the functions of atomistic private market systems is to ‘free’ men from any sense of obligation to or for other men, regardless of the consequences to others who cannot reciprocate.” (p 307)

From these quotes it’s clear that Titmuss’s project was to modernise giving. What’s interesting is how these ideas can be interpreted today, given the way the web is transforming giving. Are we much more accustomed to giving to strangers via the web?

For Titmuss, a key aspect of modern giving is the idea of giving altruistically to strangers (note volunteering is typically defined as helping non-relatives, i.e. strangers). This modern kind of giving, as Philippe Steiner describes it, is “implicated in a world of radically distant relations, relations among strangers.”

Giving to strangers

There are important echoes here of the ideas of founding sociologist Georg Simmel who identified the stranger in modern society as someone who is far away and close at the same time.

The Stranger is close to us, insofar as we feel between him and ourselves common features of a national, social, occupational, or generally human, nature. He is far from us, insofar as these common features extend beyond him or us, and connect us only because they connect a great many people. [The Stranger, 1908]

If giving is connected to the values that make us human, the challenge for Titmuss is how to drive and channel giving between strangers. In the case of blood, this means collection, rather than production. We all have access to means of production of blood, no-one has access to the means of mass production. Hence the need to collect. Philippe Steiner links this notion to Karl Polanyi’s notion of ‘fictitious commodity‘:

“In underlining the fact that blood is collected, Titmuss indicated that it is not a produced good, that it is closely tied to what makes us human, and that when commercialized, it falls into the category of “fictitious commodity” –like work, money, and land, according to Polanyi.”

Giving is becoming more exchange-like

For Titmuss, part of what makes modern giving efficient is that it overcomes the challenge of collection and recognises that we are giving to strangers. In this way of looking at it, it’s no coincidence the storage facilities for blood came to be known as blood banks (previously simply blood depots) because they act as the mode of exchange between strangers (givers and receivers). Ironically, this more modern type of giving is rather exchange-like. Steiner again:

In modern giving, anonymity is maintained in order to protect the recipient from the affective and symbolic burden of receiving the gift of life. The paradox is that this makes it hard for us to see such giving as a social tie, whereas that value – the affective and symbolic value of a social tie– has generally been the one associated with this form of commerce between human beings.

This built-in anonymity strips out the potential for giving to be combative or aggressive, as it was in pre-modern society. This use of anonymity (or at least the weakening of the social tie) seems to me to be incredibly reminiscent of much of the discussion of the web at this point. The web is excitingly social in as far as it is more efficiently connecting strangers, providing a mode of exchange for givers to give. Current debate about social media is to what extent the web can be used to strengthen social ties.

This notion of efficiently connecting strangers is one I’ll return to in a later post. Particularly interesting is the work of Jacques Godbout ‘L’esprit du don‘ (1992) who looks at how giving between strangers has been behind the growth of the voluntary sector and ‘la vie associative’ in the last few decades across the globe.

Giving is efficient

One of the reasons Titmuss’s work has stood the test of time is because he both defends an ideal social order and provides an illustration of how it works in a very concrete situation. It is both idealistic, and realistic. It’s a dual argument combining inspiring values and practical efficiency. This is something we should pay close attention to when arguing for volunteering.

Titmuss’s critics, particularly early on, included economists (Kenneth Arrow and Robert Solow) who couldn’t see why remuneration of blood donation would not result in more supply. However, in the years that have followed 1970 when Titmuss’s book ‘The Gift Relationship’ was originally published, research has generally born out Titmuss’s claim that giving is the most efficient way.

Giving and motivation theory

Rational Choice Theory sees individuals as influenced by preferences (self-interest) and constraints (e.g. money and time). Economists find preferences to be rather elusive and hard to measure independent of the behaviour in question, as a result they measure constraints to determine behaviour. Bruno Frey’s work on motivation draws out this issue of efficiency of giving. For Frey we should distinguish between two different types of motivation. There’s extrinsic motivation (e.g. a monetary incentive for giving blood), and intrinsic motivation (e.g. giver feels happier after giving blood). [Dan Pink's TED talk is a great summary of these concepts and why they matter]

Frey shows how extrinsic motivation tends to crowd out people’s intrinsic motivation. In other words, in the case of giving blood, when financial incentives are offered, some are encouraged to give blood, however others who would have given freely are put off. If the level of financial incentive is increased, there is a net increase in donors. However, there’s also an increase in undesirable donors who are no longer open about their likely risk level, for fear of not being paid.

Michael Sandel’s point, that I touched on at the start of the post, is that paying for blood where it was previously given, changes the way a society perceives the value of giving. In other words, once a payment system for blood is introduced, it can be difficult to shift a non-remunerated system. Lithuania is a fascinating case in point which is trying to move from a remunerated system of blood donation established under the previous communist government, to a non-remunerated system to meet European Union requirements. Sandel also highlights the case in the US where kids have financial incentives to read books, and the experiment in Israel where the introduction of fines for late collection of kids at a nursery led to an increase in late pick ups.

Giving is socially constructed

It is crucial to understand that blood donation is a gift economy that takes place in an industrialised context (driven by technical efficiency). As a result, giving is in many ways socially constructed. It is instructive to look at Lorentzen and Paterson’s 1992 comparative study of France, a country where kidney donation between living persons is extremely rare, and Norway, where such donation often occurs. Philippe Steiner:

Whereas in France only 41% of waiting-list patients received a transplant in 1990, there was no scarcity of organs in Norway. As the authors explain, the two countries had very different organ-collecting policies. In Norway collection is highly dependent on kidney donation from patients’ relatives and friends (49% of recipients in 1990), whereas at 2.7%, France has the lowest rate for such donation of all European countries.

It turns out that there are clear ways in which this difference between the two countries is socially constructed. It begins with the fact that French doctors are generally opposed to donation by living donors, which they see as voluntarily harming a healthy individual. This reluctance in France, means the medical establishment hardly encourages kidney donation. In addition, France is well equipped with dialysis machines, meaning there is a tendency to want to make use of existing “supply”.

Industrialisation of giving

The system for making use of gifted blood has changed dramatically as a result of industrialisation of the process. Steiner explains:

At a time when the problem of donor selection had become particularly acute [1960's], with the introduction of major new techniques for treating collected blood, included pooling (mixing the blood of several thousand donors) and breaking down blood into various stable components (albumin, fibrinogen, immunoglobin, anti-hemophiliac VIII factors), products which themselves gradually came to be categorized as medicines. Indeed, we must distinguish between blood itself, a product which cannot be kept more than a month, and the products yielded by industrial treatment of blood or plasma, which may be kept a year or more. This difference is essential. It was through technological progress and a supply of better-adapted treatments that the industrial world made its entrance into the system of blood collection and diffusion.

This industrialisation driven by technological change has meant that gift-based and market-based systems have become intertwined at the industrial level. Steiner explains:

European countries, most of whose blood collection systems are organized around the unpaid voluntary action principle (the most notable exception is Germany), are in a position to meet domestic need for blood, but not for products like plasma and stable derivatives such as Factor VIII, distributed to hemophiliacs. These products are therefore imported from countries where donors are paid for giving blood. This means that countries with unpaid action systems cannot really see this as a quality that makes them/ more virtuous than countries with paid systems. Importing plasma from the United States amounts to using blood collected in exchange for payment; meanwhile, the importing countries do not want to be responsible for deciding to set up their own paying system (Setbon, 1993, p. 124; Hermitte, 1996, pp. 177-185; Schwartz, 1999, p. 47)

Demographic differences

According to research in Lithuania, Sweden and the US, there seems to be demographic differences between donors who are remunerated and those who are for giving blood. Typically blood donors who are remunerated are majority male, while those blood donors who are non-remunerated are majority female. The non-remunerated tend also to be educated to a higher level and have a higher income.

For those donors who are remunerated, they tend to have a lower income and level of income is more evenly split. Here’s the data from the Lithuania study in more detail. This suggests that the likelihood that you’re able to access giving systems depends on how disadvantaged you are. A question is then- is there a trade off possible between incentives and accessibility of all demographics?

Motivations of blood donors

It’s striking just how many of the discussion points brought out by this research in Lithuania about blood donoring pulls out many of the issues that are typical to volunteering the world over. For example, the importance of being asked to take part, the driver of having blood donoring affect you personally in some way, and the fact that giving blood is actually almost a side effect of a more practical driver (e.g. test a health condition).

According to some researchers [see notes below 1,2,3], the main motivating factor that mobilizes prospective donors is their awareness of the patients’ need for blood in combination to one’s presumption that one day they may also find themselves in need of blood transfusion. Other research findings support the claim that altruism and awareness of the need are not strong enough motivation factors [see notes 4,5]. The present research shows that people donate their blood if they receive a call to do it, are informed of somebody’s vital need for their blood, wish to test their health condition or get some earnings.

Retention of blood donors

It would be interesting to look for more research about what makes people repeat donors and what accounts for the high rate of one off donors. Anecdotally there are changes in how people are donoring blood in the UK, i.e. there are less, regular donors. This seems to chime with the issue generally that patterns of volunteering are changing, becoming more episodic. The research in Lithuania found:

Not all persons who have once donated their blood become repeat donors. Findings of earlier research show that 40 per cent do it as a one-time act [See note 3]. In the Lithuanian case, the greater part of non-remunerated donors comprises persons who did it for the first time. Thus it is really crucial to focus donor recruitment strategies on the transformation of the first timers’ into the repeat ones as well as the retention of the latter [See note 6].

Retention of donors is also largely dependent on donor satisfaction with blood collection services [See note 7]. So it is vital to help them feel at home at blood centres. Another crucial aspect is making donors feel that their blood donations are useful for the community and appreciated by it.

Communication of volunteering and donation

Finally, there’s surely opportunities for working together to continue to develop and build a positive image of volunteering that includes blood donation along with many other kinds of giving and volunteering today. The research in Lithuania noted:

To promote non-remunerated donation, it is essential to build a positive image of the donor in the public and further develop donation as an act of charity. Thus good public relations is a crucial promotional means in blood donor recruitment and retention management. Community participation and involvement in blood donation could also be encouraged by paying public honour to the most active donors and charity events. Another possibility would be to employ mass media in providing information on blood donation and its positive effect on human health as well as the national supplies of blood and its components at national blood collecting centres.

Footnotes

1. Olaiya MA, Alakija A, Ajala A, Olatunji O. Knowledge, attitudes, beliefs and motivations towards blood donations among blood donors in Lagos, Nigeria. Transfusion Medicine. 2004;14:13–17. doi: 10.1111/j.0958-7578.2004.00474.x.

2. Androulaki Z, Merkouris A, Tsouras C, Androulakis M. Knowledge and Attitude Towards Voluntary Blood Donation Among A Sample of Students In TEI Of Crete, Greece. Nurs Web J. 2005. p. 23.

3. Godin G, Sheeran P, Conner M, Germain M, Blondeau D, Gagné , et al. Factors explaining the intention to give blood among the general population. Vox Sanguinis. 2005;89:140. doi: 10.1111/j.1423-0410.2005.00674.x.

4. Nilsson BS. The blood – donation experience: perceived physical, psychological and social impact of blood donation on the donor. Vox Sanguinis. 2003;84:120–128. doi: 10.1046/j.1423-0410.2003.00271.x.

5. Fernandez Montoya A, de Dios Luna del Castillo J, Lopez Berrio A, Rodriguez Fernandez A. Attitudes, beliefs, and motivations in blood donors and non-donors. Sandre . 1996;41:427–40.

6. World Blood Donor Day. http://www.ifrc.org/what/health/blood/index.asp

7. Politis C. Blood donation systems as an integral part of the health system. Arch Hellen Med. 2000;17:354–357.

Further thinking

James Neuberger, Chris Rudge and AC Grayling discuss the reasons why we give and how we can influence altruistic behaviour.

I was listening to this discussion at the RSA ‘Living by giving: Donation and the benefits of altruism’. There’s a point in the discussion where a mother of child saved by donated organs explains how important it was for her to know she had the consent of the giver – before her child received those organs. It’s an important point that explains the difference between giving with and without consent, that’s discussed in the debate about whether we should opt in or opt out of organ donation.

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