Vol. 19, No.

2, October 2010

144

SAFE BLOOD TRANSFUSION AND ETHICAL ISSUES

IN TRANSFUSION MEDICINE
NURUNNABI ASM1, JAHAN M2, ALAM MA3, HOQUE MM4
Abstract:
Transfusion of blood and blood components, as a specialized modality of patient management,
saves millions of lives worldwide. Transfusion Medicine is an integral and indispensable part
of the healthcare system now. This topic that has been selected is intended to assist the
transfusion physician or other specialist physician in acquiring the sense of responsibility for
transfusion services. The section includes best practices in handling and administering blood
for transfusion, blood management, risks (infectious and non-infectious diseases) of blood
components. This topic has been intended to serve in a manner that this little supplement on
the state-of-the-practice will facilitate safe patient transfusions, when transfusions are indicated,
or minimize or avoid transfusions as appropriate in institutions of all sizes. The four principles
approach- autonomy, beneficence, non-maleficence, and justice- offers a common, basic moral
analytical framework and a common, basic moral language to think about ethical issues in any
field of health care services.
Key words: Transfusion medicine, blood transfusion services, safe blood transfusion,
voluntary blood donation, ethical issues.
J Dhaka Med Coll. 2010; 19(2) : 144- 149.

Introduction:
Transfusion of blood and blood components, as
a specialized modality of patient management,
saves millions of lives worldwide each year.
Recent concept of blood transfusion emphasizes
on the transfusion of component therapy
instead of transfusing whole blood1. Throughout
the world blood services aim to provide a lifesaving service by ensuring an adequate supply
of safe blood. However, across the world blood
services are at very different levels of
development. Hence, the actions taken in one
country or region would not be appropriate in
another 2 . The blood supply is usually
insufficient in some regions of the world i.e.
none of the least developed countries (LDCs)
and 9% of the developing countries (DGCs)
collect 30 units or more per 1,000 of the
population annually. Blood donor systems are
totally voluntary and non-remunerated in 15%
DGCs and 7% LDCs; 80% DGCs and 93% LDCs
1.
2.
3.

rely totally or partially on replacement donors

and 25% of both groups on paid donations. The
proportion of repeat donors is low (medians: 47%
in DGCs, 20% in LDCs), and discard rates for
collected blood are often high (up to 33%)3. The
proportion of safe donors is highest in systems
where all donors are voluntary and nonremunerated conditions that exist in 85% of
developed countries but only 15% of developing
and 7% of less developed countries3,4. Almost
90% blood comes from professional blood donors
(PBDs) for transfusion purposes in our country.
Given the lack of mandatory screening, the
safety of blood is largely dependent on the
lifestyles of the PBDs5. Routine transfusions
for
the
patients
with
anaemia,
haemoglobinopathies, elective surgeries,
trauma and burn as well as in special needs
for the neonates and geriatric patients are
provided in hospital transfusion services of all
sizes6. In Bangladesh, there are specialized

Dr. Abu Sadat Mohammad Nurunnabi, Lecturer, Department of Anatomy, Dhaka Medical College, Dhaka.
Dr. Mahmood-uz-jahan, Deputy Director, Bangladesh Medical Research Council (BMRC), Dhaka.
Dr. Mohammad Ashraful Alam, Medical Officer, Department of Transfusion Medicine, Dhaka Medical College
Hospital, Dhaka.
4. Dr. Md. Mazharul Hoque, Assistant Professor, Department of Transfusion Medicine, Dhaka Medical College
Hospital, Dhaka.
Correspondence: Dr. Abu Sadat Mohammad Nurunnabi, Lecturer, Department of Anatomy, Dhaka Medical College,
Dhaka. Cell Phone: +8801712290608, Email: [email protected]

Vol. 19, No. 2, October 2010

J Dhaka Med Coll.

physician in transfusion medicine in some

tertiary hospitals, who provide hands-on
consultative services to their colleagues,
whereas in other facilities like district
hospitals, the technical specialists (including
blood bank technicians) shoulder much of the
burden of providing these services. Still there
are some drawbacks in safe blood transfusion
movement as well as maintaining the ethical
values in transfusion medicine. This article
is an effort to explore the ethical concerns as
well as the current scenario of blood
transfusion in Bangladesh and build an insight
into the physicians about ethical guideline in
day to day practice.
Ethical issues in Transfusion Medicine:
Ethics is a dynamic process in relation to the
state of scientific knowledge, public
awareness and the local laws, at any given
time and place. The practice of transfusion
medicine involves a number of ethical issues
because blood comes from human beings and
is a precious resource with a limited shelf
life7. In 1980, the International Society of
Blood Transfusion (ISBT) endorsed its first
formal code of ethics, which was adopted by
the World Health Organization (WHO) and the
League of Red Cross and Red Crescent
Societies. A revised code of ethics for donation
and transfusion was endorsed in 2000 8,9. The
first and foremost principle is that when
transfusion is required, the patient should be
advised of the current risks of receiving blood
components, based on the type of component
and its attendant risks. Both the
noninfectious and infectious risks should be
correctly and completely discussed with any
patient before administration of a blood
transfusion10. Ethical principles of autonomy,
beneficence, non-maleficence and justice
provide a rational basis for decision-making
when a new blood management programme
is instituted10,11. By proactively considering
the ethical dilemmas posed by the
juxtaposition of patient needs with clinical
judgement at the outset, institutions may
devise workable programmes that improve
patient safety and quality outcomes11.
145

145
Vol. 19, No. 2 October 2010

Ethical issues related to donors:

Donating blood should be considered as a gift.
The WHO recommends that national blood
services should be based on voluntary, nonremunerated blood donation. No one should be
forced to donate, for family or economic or any
other reason. The trade of human blood and
body parts is unethical. Though nonremunerated blood donation is considered a
gift, the blood centre has a right to accept or
defer it, if unacceptable. Donor deferral might
appear as discrimination and a violation of a
human right, but the patients right to safer
blood is more important here, as blood centres
are made to help the patients and not the
donors12.
Donor consent and confidentiality are
important issues. Personal information
disclosed by the blood donor during the course
of a pre-donation interview and information
obtained from the various tests performed on
the donated component, are expected to be held
in confidence by the blood bank authority12.
Donor screening and testing are to be simple.
Todays donors are asked intimate questions
about their lifestyles and put through a
laboratory screening. This has got a significant
repercussion for the relationships between
blood centres, blood donors, physicians and
patients7.
The donor room personnel and the donor may
have misunderstandings about confidentiality.
There is often a tension in donor centres
between the need to keep the donor
information confidential and the need to
disclose relevant information to third parties
such as family members, employers, public
health authorities and police officers7.
Blood safety depends partly on the information
provided by the donor and it is also the donors
moral duty to provide truthful information. It
is very unethical for a donor to willfully conceal
information about his/her high-risk behaviour
or medical history13.
Ethical issues related to patients:
Ethical issues related to patients include
access to risk-free safe blood, free of charge or
need of replacement, informed consent for

Vol. 19, No. 2, October 2010

Safe Blood Transfusion and Ethical Issues in Transfusion Medicine

transfusion, the right to refuse the

transfusion, and the right to be informed, if
there is any harm7.
Consent for transfusion has to be informed
consent. The patient should be informed of the
known risks and benefits of transfusion, and
alternative therapies such as autologous
transfusion or erythropoietin. Only then should
the consent be documented. If the patient is
unable to give prior informed consent, the basis
of treatment by transfusion should be in the
best interests of the patient13.
The patients right to refuse blood transfusion
should be respected14. Some religious sects
such as Jehovahs Witnesses do not accept
blood transfusions15.
If the patient has been transfused blood and
components that were not intended for him/
her, whether there was any harm or not, he/
she has the right to be informed14,16. Similarly
a patient who has inadvertently received blood
positive for a transfusion transmissible marker
has a right to be informed and given due
compensation17.
There are also some ethical principles for blood
establishments such as profit motive should
not be the basis of establishing and running
blood transfusion services18. Wastage should
be avoided to safeguard the interests of all
potential donors and recipients19.
Blood transfusion services: Bangladesh
perspective
Blood Transfusion Service (BTS) is an integral
and indispensable part of the healthcare
system now. The priority objective of BTS is to
ensure safety, adequacy, accessibility and
efficiency of blood supply at all levels2. With the
rising awareness of ethical issues in every field
of medical care and research in the world,
awareness is growing in the field of transfusion
medicine as well8. However, in Bangladesh, we
are still to adopt and maintain the code of ethics
in different fields of medical science. BTS in
Bangladesh started in 1950 at the Dhaka
Medical College Hospital. In the year 1968,
three more blood transfusion centers were
opened at Mitford Hospital, Dhaka; Chittagong
Medical College Hospital, Chittagong; and

146
Nurunnabi ASM et al.

Rajshahi Medical College Hospital, Rajshahi20.

Later, blood transfusion departments became
operational in different medical college
hospitals and district hospitals. In 1976, the
Bangladesh Council of Blood Transfusion
Service was established to supervise and
monitor improvement of BTS in the country21.
In the year 1992, the government constituted
a committee called Blood Transfusion
Committee to offer advice on the introduction
of donor selection criteria, matters relating to
blood safety and introduction of various tests
and other technical issues. As an integral part
of the healthcare system, the objective of BTS
of Bangladesh is to ensure safety, adequacy,
accessibility and efficiency of blood supply at
all levels 22,23 . To reach this goal, the
Government of the Peoples Republic of
Bangladesh passed Safe Blood Transfusion Act,
2002 and Safe Blood Transfusion Regulations,
2008 in the Parliament. These are a regulatory
laws for setting up blood transfusion centres,
management, blood collection, blood storage,
blood testing and transfusion to prevent
unauthorized practices of human blood
transfusion. Establishment of private blood
banks, operation, licensing system, inspection
committee and punishment for violation of
rules etc. is clearly stated in the law 24 .
Moreover, The High Court gave directions for
enforcement of the Bangladesh Red Crescent
Society Order, 1973, the Safe Blood Transfusion
Act, 2002, and Safe Blood Transfusion
Regulations, 2008, to ensure the right to health,
which they argued was envisaged by the right
to life as guaranteed by Article 32 of the
Constitution25.
Lack of understanding of the issues related to
a safe blood transfusion service has led to an
emphasis on screening donor blood for
infections as a means of ensuring safe blood
transfusion. Basic licensing standards for blood
banks with regard to space, and the quality and
quantity of medical staff have remained
unchanged over the past three decades. This
compounds the problem and society pays the
price4. The importance of ensuring blood safety
as well as the inadequacy of the national blood
supply is highlighted due to the emergence of
HIV in the 1980s. The global burden of diseases
146

Vol. 19, No. 2, October 2010

J Dhaka Med Coll.

due to unsafe blood transfusion can be

eliminated or substantially reduced by adopting
an integrated strategy for blood safety 20 .
Government of the Peoples Republic of
Bangladesh with the financial assistance of the
United Nations Development Programme
(UNDP) formed a Blood transfusion subcommittee (BTSC) under the auspice of
National AIDS Committee (NAC) in 1997 with
the aim of curbing the incidence of Transfusion
Transmissible Infections (TTI) in this country.
The Safe Blood Transfusion Programme was
launched through initially establishing 98 blood
transfusion centres throughout the country
from the districts towards the national level
hospitals 22. The general objective of the
program was to provide safe blood and blood
products countrywide. There were some
specific objectives like capacity-building of
institution and service providers, ensuring
institutional facilities of screenings and
enhancing the spirit of voluntary blood donation.
The screening tests mandatorily performed in
the blood transfusion centers were HBsAg, AntiHCV, Anti-HIV ab 1 & 2, VDRL, Malarial
Parasite20,22,26. Since 2004, the programme
had been continuing in this country with the
assistance of World Health Organization (WHO)
and the World Bank. Now the programme is
being run as Health Nutrition Population
Sector Programme (HNPSP) under the Ministry
of Health and Family Welfare of Bangladesh27.
A good management structure is the key for
ensuring safe and adequate blood supply.
According to WHO guideline, inefficient and
poorly managed blood service not only misuses
scarce blood supply, but also costs more in
terms of the total national budget than a wellorganized service28.
A total of 1,687,390 donations under safe blood
transfusion programme mainly from voluntary
and directed (relatives) donors were screened
throughout the country during a period of 8
years (2001-2008). 111 donors (0.0065%) were
found to be positive for HIV ab 1 & 2. Overall
HBsAg, anti-HCV and RPR were found positive
in 0.96%, 0.15% and 0.15% donations
respectively. The important feature of the
programme is an increase in the number of
voluntary donations and thus, an increasing
147

147
Vol. 19, No. 2 October 2010

number of donations coming under screening

programme26.
To save people from the curse of impure blood,
different social and cultural organisations are
working across the country. The basic fact is
that in this branch of medicine, society plays
a direct role in the patients well being. The
trend should change from blood donation being
not just a gift of life but also a way of life, a
social responsibility of every healthy human
being who is eligible to donate blood. This
attitudinal shift will also take us closer to
setting up an infrastructure based on a more
systematic and collective response to illness
by society as a whole, rather than just on family
obligation29. Bangladesh Red Crescent Society
and Sandhani have been playing a leading role
in the voluntary blood donation movement
since 1973 and 1978 respectively.
Organizations like Orka, Badhon and
Quantum also conduct voluntary blood
donation activities. However, safe blood
transfusion and ethical practice in transfusion
medicine are still found to be challenging in
our country. It would help much, if government
guidelines were used to set up a procedure for
designating well-managed blood banks as
regional blood transfusion centres and setting
up multiple-tested blood storage centres to
improve the quality and increase the
accessibility of safe blood in all parts of the
country, especially the rural areas29.
Some propositions:
Some essential steps for safe blood transfusion
service are being recommended here11:
1. Formulation of a national policy for the blood
transfusion service with time-bound
programmes, which will encompass the
ethical issues;
2. A centrally coordinated, structured and
organized blood transfusion service for the
country under a defined authority;
3. A blood transfusion service based on an
organized voluntary blood donor programme.
Besides, some complementary measures can
be taken such as strict monitoring of screening
blood for transfusion-associated infections
appropriate to the countrys epidemic status,

Vol. 19, No. 2, October 2010

Safe Blood Transfusion and Ethical Issues in Transfusion Medicine

rational use of available blood, and engaging

qualified personnel to head and manage the
blood transfusion service11.
Last but not the least, the four principles
approach, developed in the United States, is
based on four common, basic prima facie moral
commitments - respect for autonomy,
beneficence, non-maleficence, and justice plus concern for their scopes of application. It
offers a common, basic moral analytical
framework and a common, basic moral
language to think about ethical issues in
health care30.
Conclusion:
The practice of transfusion medicine involves
a number of ethical issues because blood comes
from human beings and is a precious resource
with a limited shelf life. It involves a moral
responsibility of the physicians and blood bank
towards both the donors and the patients.
Decisions must be based on four principles as
mentioned earlier and of course, the
Hippocrates principle of Primum non nocere
(i.e. first do no harm).
References:
1.

Mahmud Z. Are the blood transfusions safe!

[Editorial]. JAFMC,Bangladesh 2009; 5(1): 1-2.

2.

Sullivan P. Developing an administrative plan for

transfusion medicine - a global perspective.
Transfusion 2005; 45(4 Suppl): 224-40.

3.

Gibbs WN, Corcoran P. Blood safety in developing

countries. Vox Sang 1994; 67(4): 377-81.

4.

Wake DJ, Cutting WA. Blood transfusion in

developing countries: problems, priorities and
practicalities. Trop Doct 1998; 28(1): 4-8.

5.

Bhuiya I, Hossain S, Streatfield K, Rob U. Safe

blood transfusion in Bangladesh: long way to go.
[Conference Abstract]. International Conference
on AIDS; Population Council, Bangladesh. July
7-12, 2002. Dhaka: Bangladesh.

6.

Sazama K. Transfusion medicine for the practicing

pathologist/physician with responsibilities for the
transfusion service. Arch Pathol Lab Med 2007;
131: 688-9.

7.

Elhence P. Ethical issues in transfusion

medicine. Indian J Med Ethics 2006; 3(3): 87-9.

8.

Sazama K. Practical issues in informed consent

for transfusion. Am J Clin Pathol 1997; 107(4
suppl.1): 72-4.

148
Nurunnabi ASM et al.

9.

Sazama K. The ethics of blood management. Vox

Sang 2007; 92(2): 95-102.

10.

Kolins J, Kolins MD. Informed consent, risk, and

blood transfusion. J Thorac Cardiovasc Surg 1990;
100(1): 88-91.

11.

Nanu A. Blood transfusion services: organization

is integral to safety. Natl Med J India 2001; 14(4):
237-40.

12.

Macpherson CR, Domen RE, Perlin TM. eds.

Ethical issues in transfusion medicine. Bethesda:
AABB Press; 2001.

13.

Stowell C, editor. Informed consent for blood

transfusion. Bethesda: American Association of
Blood Banks Press; 1997.

14.

Macpherson JL, Mansfield EM. Medicolegal

aspects of blood transfusion. In: Simon TL, Dzik
WH, Snyder EL, Stowell CP, Strauss RG. eds.
Rossis principles of transfusion medicine. 3 rd ed.
Philadelphia: Lippincott Williams & Wilkins;
2002.

15.

Muramato O. Bioethical aspects of recent changes

in the policy of refusal of blood by Jehovahs
witnesses. BMJ 2001; 322: 37-9.

16.

Mann JM. Medicine and public health, ethics and

human rights. Hastings Cent Rep 1997; 27(3): 613.

17.

McCullough J. Transfusion medicine. 2nd ed. New

York: McGraw-Hill; 2005.

18.

Harmening DM. ed. Modern blood banking and

transfusion practices. 5 th ed. Philadelphia: FA
Davis Co; 2005.

19.

Hillyer CD, Hillyer KL, Strobl FJ, Jefferies LC,

Silberstein LE, eds. Handbook of transfusion
medicine. San Diego: Academic Press; 2001.

20.

Directorate General of Health Services. Safe Blood

Transfusion. Safe Blood Transfusion Programme,
Ministry of Health and Family Welfare,
Government of the Peoples republic of Bangladesh
and UNDP; Dhaka: Bangladesh; 1997.

21.

Islam MB. Blood transfusion services in

Bangladesh. Asian J Transfus Sci 2009; 3(2): 10810.

22.

Blood Transfusion Sub-Committee (BTSC). Plan

of action on safe blood transfusion. National AIDS
Committee, Dhaka: Bangladesh; February, 1997.

23.

Ministry of Health and Family Welfare. Country

Progress Report. National AIDS/STD Programme
(NASP); Dhaka: Bangladesh; 2008.

24.

Directorate General of Health Search (DGHS).

Review of the capacity of regulated and
unregulated blood bank in Bangladesh. Ministry
of Health and Family Welfare, Government of the

148

Vol. 19, No. 2, October 2010

J Dhaka Med Coll.

Vol. 19, No. 2 October 2010

access to treatment for HIV/AIDS for all who need
it. Available from: http://www.undg-policynet
.org/ext/MDG-GoodPractices/mdg6/ MDG6A_
Bangladesh_Safe_Blood_Transfusion.pdf
[Accessed on 11.09.2010].

Peoples Republic of Bangladesh and WHO

Country Office, Bangladesh. 2008.
25.

26.

27.

149

Anisur Rashid, ASK and BLAST vs. Bangladesh

and others [Safe Blood Transfusion Case]. Writ
Petition No. 1360 of 2010. High Court Division
of the Supreme Court of Bangladesh. Dhaka:
Bangladesh; 2010.
Safe Blood Transfusion Centre. Annual reports
of donor screening. Dhaka Medical College;
Dhaka: Bangladesh; 2009.
United Nations Development Program (UNDP).
MDG target 6.A: Achieve, by 2010, universal

149

28.

World Health Organization (WHO). Strategies for

safe blood transfusion. Available from: http://
www.searo.who.int/en/Section260/Section600/
Section605_2709.htm [Accessed on 10.09.2010].

29.

Viswanath V. Strengthening blood ties. Indian J

Med Ethics 2010; 7(3); 177.

30.

Gillon R. Medical ethics: four principles plus

attention to scope. BMJ 1994; 309: 184-8.