The logistics of altruism

Catherine Waldby, The University of Sydney

Kieran Healy Last Best Gifts: Altruism and the Market for Human Blood and Organs, Chicago, The University of Chicago Press, 2006 (200 pp). ISBN 978-0-22632-237-7 (paperback) RRP $33.95.

Human tissues today are big business. Hospitals routinely sell ‘abandoned’ tissues like placentas to cosmetics and pharmaceutical companies for the extraction of collagen and albumin. Skin procured from donated cadavers and medical circumcisions are sold to companies producing skin products, some for burns treatment but often for cosmetic surgery. With changes in intellectual property law in the early 1980s, human tissues can be patented if the applicant can demonstrate often minimal technical innovation. Since then, immortalised human cell lines and genetic sequences have become sources of substantial licensing fees and venture capital investment for the ever-growing biotechnology industry. Private corporations own patents to nearly 3000 human genes, and have filed for 20,000 more (Goldman 2007). Poverty stricken denizens of developing nations sell kidneys and ova to global brokers, who sell them on at huge mark-ups to grateful, wealthy medical tourists. Among all this feverish commercial activity, and the escalating market value of ex vivo human tissues, blood and organ donation for therapeutic purposes remains a gift relationship, at least in the advanced industrial democracies. Donors give blood and organs to cure another without material incentives, and generally without a personal relationship to the recipient.


Why do we not buy and sell blood and organs? Certainly blood and organ markets have been repeatedly mooted as ways to solve chronic shortages of therapeutic tissues, and to improve distribution mechanisms. Richard Titmuss’ celebrated polemic in favor of gratuitous blood donation, The Gift Relationship: From Human Blood to Social Policy, first published in 1970, was addressed to the pro-blood market arguments of the Institute of Economic Affairs (IEA), an early advocate of neo-liberal market rationalism. This exchange set the terms for subsequent debate and remains fascinating today because of the ways the status of blood, and by extension other human tissues, is situated within much broader considerations. Titmuss asks how does blood donation relate to the obligations of citizenship in a modern social democracy? Is blood a common good and, if so, how should it be managed? How does the distribution of blood relate to other issues of distributive justice in a welfare state?

Is blood a common good and, if so,
how should it be managed?

The IEA argued that the British National Health Service and the National Blood Service would gain in efficiency if market forces and market analysis were introduced into their administration. Titmuss, a great theorist and defender of Keynesian economic management and comprehensive welfare policy, regarded these arguments as direct attacks on the post-war social contract, and the power of the welfare state to produce egalitarian and communitarian relations between citizens. He regarded the donation of blood as a crucial aspect of citizenship in a democratic welfare state. If blood, as an intimate part of the embodied self, is not sequestered from market forces, then all kinds of social services—education, social security, child foster care, social work—would also inevitably be laid open to the market, because the sharing rather than selling of blood represents the fundamental assertion of collective values. ‘To give or not to give, to lend, repay or even buy and sell blood leads us … into the fundamentals of social and economic life’ (Titmuss 1997, p. 124). Drawing on Marcel Mauss’ earlier work on gift relation among Pacific societies, Titmuss argued that blood must be given rather than sold, because the circulation of gifts is crucial to the formation of collective social relations and mutuality among citizens. Giving and receiving blood creates a sense of impersonal mutuality and inclusion among fellow citizens, whereas to sell blood would create instrumental, non-binding commodity relations between producers and consumers, whose relationship is strictly temporary, lasting only as long as the transaction. Blood, then, is the limit case for marketisation. Once blood succumbed to market forces, Titmuss argued, all other domains of social life would be imperiled.

The brilliance of The Gift Relationship lies is the way it links together the commodification of human tissues and the neo-liberalisation of economies. It contends that a market for human tissues would open the way for a generalised application of market logics to all domains of social life. This contention has proved prophetic, as the contemporary markets for ex vivo tissues and the development of global bioeconomies attest (Organisation for Economic Co-operation and Development 2006). Published just before the oil crises, the deregulation of national economies and the dismantling of comprehensive welfare that begins in the mid-1970s, Titmuss’ book is also a profoundly poignant work read in hindsight, as the post-war social democratic order it so passionately defends dissolves around it. Ironically, however, its specific argument, therapeutic blood as the limit case for marketisation, has proved entirely robust and therapeutic tissues (blood, bone marrow, solid organs) are still, somehow, hors de commerce. This sequestering of blood and organ donation from markets is a considerable cultural accomplishment, and Kieran Healy’s new book Last Best Gifts is an attempt to account for this accomplishment in concrete terms, through empirical investigation of the gift economy for blood and organs.


If blood succumbed to market forces, all domains of social life would be imperiled.

Healy, a sociologist based in North America, focuses primarily on the United States, with an excursion into western European blood procurement systems, although his methodological and substantive points could be generalised to Australia and elsewhere. He has a clearly stated set of questions, which the book sets out to answer. First, how can we account for the durability of gift systems for blood and organs? Second, how can we account for the extensive variations in rates of donation between different regions in the United States and between different countries? Does this variation reflect variations in the altruistic character of different nations or are other factors at play? Healy is committed to a non-voluntarist account, one that does not rely on generalisations about national psychology or human nature. His approach is a form of economic sociology, which is critical of the resort to homo economicus, the rational, self-interested individual, as an explanatory principle within liberal economic theory. Economic sociology seeks a culturally rich account of how economies function, paying particular attention to the ways markets are embedded in broader social relationships, rather than working as anonymous, autonomous mechanisms. By extension, Healy is also critical of any resort to intrinsic human altruism to explain donation. He argues that, ‘to understand [organ and blood donation] we need to get away from the character and motives of individual donors and look instead to the cultural contexts and organisational mechanisms that provide people with reasons and opportunities to give’ (p. 2). His contention is that the gift exchange of blood and organs is the product not of spontaneous generosity, but of extensive cultural and institutional work on the part of procurement organisations and advocates which effectively produce altruism as an outcome of their operation.

Organ procurement organisations (OPOs) and blood donation centres are institutions dedicated to securing gratuitous donation, and this ethos is operationalised in their ideologies, their organisational forms, and the ways they address and mobilise potential donors. For Healy, the practical logistics of securing donation is a central consideration: ‘We can say that the donor procurement system… has industrialised altruism by treating it as a resource-extraction problem’ (p. 44). Healy works very systematically through US data on OPOs and EU data on blood donation to identify what forms of institutionalised altruism are most successful. Organ procurement is by far the more difficult task. Donation takes place in the most adverse of circumstances—a family has lost a member, usually a child, to some dreadful accident that has left them brain dead but with their vital organs intact. The victim often appears to be alive, their heart beating, their skin pink, and sometimes breathing unaided. Yet the family is faced with deciding whether to keep their precious bodies intact or giving them over for organ harvest, to help save the life of some similarly traumatised family member, waiting on the endless queue for kidneys, heart, and livers. Healy finds, unsurprisingly, that the OPOs success rates depend on fine grained operational differences in the ways hospital staff manage grieving families, gain their trust, and help them find some redeeming meaning in the senseless death of their loved one. Hospitals that employed a family support person in a separate role from the procurement nurse, for example, had more success in securing a donation.

The gift exchange
of blood and organs
is not the product
of spontaneous generosity.

Blood donation has quite a different set of conditions. Compared to the singularity and trauma of organ donation, it is both a benign and repeatable experience. Nevertheless, most people do not donate blood, and countries vary widely in the proportion of their population that does. So in the European Union only 14 per cent of the Luxembourg citizenry donate, compared to 44 per cent of the French. Healy accounts for these differences by comparing collection regimes across the EU, arguing that ‘blood can be seen not so much as something that individuals donate but as something that organisations collect’ (p. 71). Collection practices are quite diverse, ranging from the state-run national blood services in the United Kingdom, France, and Ireland through systems run by the Red Cross (Luxemburg, the Netherlands, Germany, and Belgium) and systems dominated by community or hospital blood banks, usually alongside the Red Cross (Greece, Italy, Norway, Portugal, Spain, and Denmark). Despite the European ethos of altruistic tissue donation, both Spain and Germany have paid plasma donation. Several countries have national donor organisations that assist with recruitment. So the picture is very complicated, and Healy provides a nuanced analysis of the factors which produce both the low Luxemburg figures and the high French ones. We discover that state run regimes are good at securing one-off donation but poor at holding on to donors, while Red Cross systems are good at securing repeat donation, particularly from students. Countries with volunteer donor organisations have a big recruitment advantage. The existence of paid plasma donors in Spain and Germany gives Healy a chance to test one of Titmuss’ central assertions in The Gift Relationship: that paid donors would drive out volunteers and generally suppress rather than produce altruism. The evidence seems to bear this out, and Healy finds that donation rates among the poor in both countries are comparatively low. That is, the population that is willing to sell plasma become less willing to give whole blood.

And what of the various procurement scandals over the last twenty years? The global blood supply was contaminated with HIV during the 1980s, while at the Alder Hey Hospital in the United Kingdom a huge stash of dead children’s organs had accumulated, retained without the parents’ knowledge and stored in a neglected state for some unspecified future use. Healy uses these scandals to argue, contra Titmuss, that neither gift nor market systems for the exchange of human tissues can guarantee probity, safety, and ethical conduct. In the case of the blood contamination scandals, the commitment to the gift relationship actually prevented blood banks adopting early screening procedures for their precious donors, so that France, the country with the greatest respect for the gift of blood, ended up with the highest rates of transfusion-related infection. In the case of Alder Hay, the public disgrace related neither to marketisation nor to an abuse of a gift relation (as parents were never asked about the retention of their children’s organs) but to the fact that human tissues, so singular in their human origin, are routinised, processed, and industrialised after procurement. Once the material leaves the organisations dedicated to altruistic procurement and to honouring the gift, it often ends up in the hands of organisations that have much more bureaucratic or corporate aims.


Gift and market systems, according
to Healy, have no
intrinsic ethics.

Gift and market systems, according to Healy, have no intrinsic ethics. Everything depends on the social relations that embed different systems of exchange. The kidney vendor in rural India sells his precious organ to a broker not because a transnational market exists, but because of the asymmetries of power between vendor and purchaser. Healy concludes that this sad state of affairs ‘involves questions of social justice that go well beyond any particular sale of blood and organs’ (p. 125), and a little further one he states that ‘social solidarity is not the goal of exchange in human goods: the system only exists in order that illness can be cured and lives saved’ (p. 126). Here we can see the limits of the logistic approach. While Last Best Gifts is in an implicit dialogue with The Gift Relationship, it refuses the much broader philosophical investigation Titmuss undertakes between blood donation and social order. Because of this, Titmuss’s book, with all its technical and social anachronisms, still provides a better conceptual framework for understanding how tissue economies bear on broader questions of political economy and human rights, and how health and illness intersect with these issues. So, for example, we could consider how kidney selling is inextricable from the debt peonage that structure relations between the losers and winners in the new world order. What Titmuss understood, albeit implicitly, and what Healy fails to acknowledge, is that systems of human rights and citizenship are very much concerned with the mitigation of bodily risks and the protection of vulnerable life from rapacious expropriation. This protection is not currently afforded to the poor and powerless in developing countries, who have no access to the benefits of the global economy. Rather than conclude, as Healy does, that the global organ trade is beyond any realpolitik solution, the spirit and conceptual richness of Titmuss’ work might help us to formulate human rights and protections for those who are forced to exploit their only asset, their bodies.


Goldman, B. 2007, ‘HER2 testing: The patent “genee” is out of the bottle’, Canadian Medical Association Journal, May 8, vol. 176, no. 10, pp. 1443–1444.

Organisation for Economic Co-operation and Development 2006, The Bioeconomy to 2030: Designing a Policy Agenda, OECD, Paris.

Titmuss, R. 1997 (1970), The Gift Relationship: From Human Blood to Social Policy, ed. A. Oakley & J. Ashton, LSE Books, London.

Catherine Waldby is Associate Professor and International Research Fellow in the Department of Sociology and Social Policy at The University of Sydney. She is the author, with Robert Mitchell, of Tissue Economies: Blood, Organs and Cell Lines in Late Capitalism (Duke University Press 2006), and many other works on social aspects of biomedicine. Her current research focuses on the social relations of stem cell research and pharmacogenetics.