Using Basic Ethical Principles to Evaluate Safety Efforts in Transfusion Medicine

Pursuit of pharmaceutical purity of the blood in the bag has led to a shrinking donor base and a significantly more expensive product. Decisions regarding new infectious marker testing and donor deferrals have typically been made emphasizing decreasing one specific risk without considering the effect the intervention will have on the overall safety and availability of blood transfusion. Regulations have been formulated by governmental agencies with limited input from the medical community. The decision making process has lacked risk benefit analyses and has not had the robustness associated with spirited discussions. Policies made in this manner may result in certain risks being decreased but can also have adverse unintended consequences. Being guided by the ethical principles of nonmaleficence, beneficence, autonomy, and justice, we need to evaluate our actions in the context of overall blood safety rather than narrowly focusing on any one area. 1. Introduction If automakers concentrated on perfecting the braking system in new cars while ignoring possible improvements in passenger restraint systems and steering mechanisms, consumers would likely question their wisdom and demand that they redirect their efforts to improve overall automotive safety rather than to focus narrowly on any one component of the vehicle. While most would agree that it would be great to have better, safer brakes, if the pursuit of the ideal stopping system was at the expense of improvements in safety of other parts of the vehicle, particularly if the improvements were less costly and could result in greater overall safety benefits, consumers would balk. In blood banking and transfusion medicine, we have been doing something akin to our hypothetical automobile manufacturers. We have concentrated on the pharmaceutical purity of the blood in the bag resulting in the diminished possibility of implementing other advances in blood transfusion safety. Evaluating the whole transfusion process from blood collection to care of the recipient during and immediately after the transfusion can provide significantly greater payoffs than the implementation of newer, better, but costlier measures to push the already low risk of viral transmission ever closer to the elusive rate of zero. There are other practices that may inadvertently decrease overall safety because of our obsession with the pharmaceutical purity of blood, and these will also be addressed. 2. The Zero-Sum Game A zero-sum game is one where a player can gain only at the expense of another [1]. Cutting a cake is an example. If one