Blood Donation

Ethics & Law

Case 7 ILOs

To discuss the ethical complexities of blood donation

We will be covering

Blood donation – Gift or commodity?

Safety of supply and transfusion – When things go wrong

Blood refusal

Blood donation – Gift or commodity?

Blood donation – Gift or commodity

Who might need blood?

Any of us and not only that there is an expectation that it is there

when we need it.

Is it fair that if we are not prepared to donate we should have the

unreasonable expectation that we are entitled to receive?

Blood donation in the UK

UK NHS blood services

NHS Blood and Transplant

Scottish National Blood Transfusion Service

Welsh Blood Service

Northern Ireland Blood Transfusion Service

Altruistic, voluntary non-reimbursed blood donation

Approximately 5% of eligible people are regular donors

Barriers to donation

Donor & rarer types shortage

Black, Asian and minority ethnic donors and recipients

Blood donation – Gift or commodity

A gift of life?

-As a society we strongly encourage donation i.e giving.

-To donate blood is a morally good thing to do-help another

human.

Scenario 1

Mrs X is a 35 year old lady, she has 2 children aged 5 and 7.

She presents to A&E with abdominal pain and internal bleeding.

Mrs X has a ruptured ectopic pregnancy.

She requires an emergency blood transfusion. There is a

shortage of her blood type and stocks have been low. She does

not survive.

Blood donation – Gift or commodity

Given there have been shortages in blood supplies, should we

pay people?

Sales of blood

Against

Society should encourage people to be altruistic.

Moral personhood; people should not be treated as things

that can be bought/sold.

There is the risk of vulnerable/poor being exploited.

People are less likely to disclose health problems when

donating if there is a financial incentive.

Compromise own health by donating too often.

Blood should be given on basis of medical need not to

whoever can pay the most.

Sales of blood

For

False dichotomy presented-gift/sales.

Duty to rescue.

Life saving necessity-avoid the harm of human suffering.

Supply/demand issues are determining price.

Altruism is not necessarily moral.

WHO

“The safest blood donors are voluntary, non-remunerated donors

from low-risk populations.”

http://www.who.int/bloodsafety/voluntary_donation/en/

Safety of supply and transfusion –

When things go wrong

Blood transfusion – safety and risks

Relative safety of blood transfusion in the UK

Donor selection, screening, testing…

Haemovigilance - Serious Hazards of Transfusion

Better Blood Transfusion

Wrong blood

Nearly 2 million red cell units issued across UK in 2014

10 ABO incompatible transfusions, 1 major morbidity

‘Never events’

Acute transfusion reactions

Transfusion transmitted infections

Transfusion Transmitted Infections

Transfusion Transmitted Infections

Bacterial sepsis

CMV

vCJD

Serious blood-borne viruses inc Hepatitis B, Hepatitis C, HIV

Rare

Measures to avoid

Donor selection, screening, testing, deferral, exclusion

Treatment and appropriate handling of blood products

Importing blood products

NHS contaminated blood scandal

‘The worst treatment disaster in the history of the NHS’ - Lord

Robert Winston

1970s-1980s

Blood products imported from USA and some domestically sourced

Blood donations were sought from high risk populations

Contaminated with Hepatitis B, C and HIV

Pooled products to produce clotting factors were very high risk

Around 5000 people with haemophilia and others were and are affected

Scenario 2

Mr X had a laparoscopic cholecystectomy. The procedure was

surgically quite challenging and he lost a significant amount of blood.

The surgeon felt that he couldn't continue the laparoscopic procedure

and so converted to an open cholecystectomy.

In total Mr X was transfused 5 units of blood. He makes a good

recovery and is discharged home.

A year later Mr X presents to his GP with a 9 month history of general

malaise, arthritis, myalgia and abdominal pains. He is found to have a

virus contracted when he received the blood transfusion.

Scenario 2

His virus could have been picked up by a screening test. The

screening test is known to be very expensive but detects the virus.

If you were to test 10000 units of blood you would only pick up the

virus in 2 units.

Safe blood/transfusion

We have an ethical/legal responsibility to ensure that blood is safe.

Is it better to have more blood available or maintain a pool with higher

purity?

Consent

-Explain why a blood transfusion is indicated.

-What the associated risks are.

-Outline if there are alternative options available.

http://www.transfusionguidelines.org/transfusion-practice/consent-for-

blood-transfusion-1

Blood Refusal

Who might refuse blood?

Anyone

Jehovah’s Witnesses

Beliefs about blood transfusion

Talk to your patient

Scenario 3

Mrs Z was involved in a RTA. She is brought to A&E with multiple

serious injuries. She requires emergency surgery.

She is unconscious and is haemodynamically unstable as she

has lost a significant amount of blood.

Scenario 3

In an emergency situation, if a patient lacks capacity then we act

in their “best interests” and deliver “life saving treatment” if we

have no reason to believe they have registered a valid “advanced

refusal of treatment”.

Case 4

Newcastle Upon Tyne Hospitals FT v LM [2014] EWHC 454 (COP)

LM is a Jehovah's witness. She was found to have a bleeding

duodenal ulcer. She was profoundly anaemic but despite this was

adamant that she didn't want blood products and understood that she

may die without transfusion. Her discussion with the

gastroenterologist was documented in her medical records. She was

felt to have capacity.

A few days later she deteriorated and required intubation/ventilation.

She had no formal advanced refusal of treatment or lasting power of

attorney.

Case 4

Newcastle Upon Tyne Hospitals FT v LM [2014] EWHC 454 (COP)

Would it be lawful to withold transfusion?

Case went before the court of protection.

-Prior to losing capacity she had clearly indicated her wishes.

-Must respect her autonomy.

-Competent adult is permitted to make decisions even if we consider

them unwise.

-Would not have been in her best interests to be transfused against

her will.

Scenario 5

A 16 year old undergoes a tonsillectomy. Overnight post-operatively

they have a haemorrhage necessitating a blood transfusion. He

refuses a transfusion. His parents are telephoned and they also

refuse to give consent.

It's 2am and you are alone on the ward. You have called your

Consultant who is making their way into hospital.

What should you do?

Scenario 5

Re R (A Minor)(Blood transfusion) [1993]

Court ordered that child be given a blood transfusion, despite parents

refusal (jehovah's witnesses).

If parental consent cannot be obtained, further legal advice must be

sought.

Who might refuse blood?

The usual rules about consent and refusal of treatment apply

A competent adult (an adult with capacity) has a right to refuse

even life-saving treatment

Valid, applicable, Advanced Decisions to Refuse Treatment,

where there is no good reason to believe the incapacitated adult

has changed their mind, must be respected

Providing emergency treatment, that which is immediately

necessary to preserve life, taking account of the above, is the

right thing to do

Who might refuse blood?

Who can consent for a minor? A parent

A minor aged 16-18 can consent for themselves

A competent minor can consent for themselves

The courts

Case Law Re S (a minor: medical treatment)

Re E & Re L (a minor)

Blood refusal situations – Who and what might

help

Elective procedures – Planning

Seniors

Medical optimisation

Iron, B12, folate

EPO

Crystalloids & Colloids

Cell salvage

Hospital liaison committee

Hospital legal department

On call judge – specific issue orders

Defence body

Any questions?