A large blood center in the Northwestern United States asked how other blood centers determine eligibility for a prospective blood donor who is confined to a wheelchair and unable to transfer himself (without assistance) to a donor bed, but otherwise meets all criteria for donation. According to the inquiring center, the prospective donor has a paid attendant who can assist in moving the prospective donor into a donor bed. However, the inquiring center does not allow anyone who is not a prospective donor or a staff member to be in the drawing area or screening rooms because of the possibility of accidental exposure. In addition, the inquiring center does not allow people to donate while sitting in their wheelchairs. Finally, while the following do not apply to the donor in question, all prospective donors at the inquiring center must be able to extend their forearms 180 degrees and be able to lie comfortably on a donor bed or in a donor chair for 30 minutes.

Several replies were submitted in response to the above; most replies encouraged the inquiring donor center to accommodate the wheel chair confined donor.

1. One blood bank physician/ethicist thinks that the blood center is being too restrictive in their approach to the wheelchair-confined donor. He sees no problem with letting an individual who is confined to a wheel chair donate. He is also concerned about not allowing the donor's attendant to be in the drawing area to assist the donor. He suggests that the donor center should rethink its customer relations strategy. As far as the Americans with Disabilities Act is concerned, he thinks it might be a violation of the Act if the donor center cannot prove that there is a safety risk involved.

2. A physician blood banker in the Bethesda area thinks that the donor center needs to find a way to accept this donor. Their rule that non-donors cannot enter the donor area has no basis in science. Unless they have egregious breaks in technique, donor room personnel and certainly casual visitors are not at risk. That is why gloves are not mandated even for phlebotomists. The risk from donors to anyone, except a rare blood recipient, is negligible. The center should allow the attendant to help put the donor into the phlebotomy chair or perform the phlebotomy in the donor chair. Otherwise, this would be a blatant breach of the disabilities act for no good reason.

3. A physician blood banker from the 'valley' in Los Angeles (anyone remember the stories about Valley Girls?) reported that in his center they would draw the donor if he could lie in the donor bed for the required amount of time. They would allow an attendant to help move the donor. If a donor center did not allow attendants in the area, in his view, the donor center should make reasonable accommodations for the donor. The responding blood banker did not think it unreasonable to have the donor center staff assist the donor in getting into the donor bed (this is done frequently for autologous donors).

4. A Los Angeles physician blood banker commented that the Americans with Disabilities Act (ADA) specifically prohibits discrimination against individuals with disabilities if there can be reasonable accommodation. The responding blood banker went on to say that "As a blood banker with a disability who also serves on a board of disabilities and the health profession to improve health care access to persons with disabilities, I can say that this prospective blood donor should be allowed to donate, with the reasonable accommodation of allowing the caretaker to transfer the donor to a donor bed, under supervision for "accidental exposure". The caretaker need not be in the area during the actual drawing. I believe it is a violation of the ADA if this is not allowed, assuming the donor meets all other criteria."

5. A Texas blood bank physician said "I have found out that our large blood center in Texas does not have a policy regarding individuals in wheelchairs. Allogeneic donors would be deferred for quadriplegia or paraplegia in our system, based on recommendations from other centers that these individuals do not compensate well if they have a vasovagal reaction. The wheelchair issue comes up fairly frequently for autologous donors at our center. Although we don't have a policy, our practice is apparently to transfer the individual to a donor chair if feasible and safe, but we do on occasion draw these autologous donors in their wheelchairs if they cannot be transferred to a donor chair.

6. A dissenting opinion submitted by a Minnesota blood bank physician said the following: "While it is important to persuade more people to donate blood on a regular basis and to be frank and honest in their responses to questions, it is equally important that prospective donors, however well motivated they may be, realize that there is no constitutional, legal or God-given right to donate blood. On the other hand, blood bankers have a moral, ethical and legal responsibility to do what they can to safeguard recipients from harmful transfusions. Some donors and even some blood bankers do not understand this fact and in each case, their ignorance in this regard can be dangerous to both recipients and to the donors themselves. If donors are convinced that they do indeed "have a right to donate", they may allow this misconception to color their judgment regarding the veracity of their responses to questions pertaining to life-style or other risk factors. If blood bankers have a similar misconception, they may well be persuaded to permit a donor to donate blood in an understandable but misguided attempt to re-affirm the donor's concept of self-worth tied to his/her ability to donate. This type of reasoning may be particularly likely to occur in settings where a prospective donor with disabilities badly wants to be able to donate. If the disabilities are likely to cause the collection to be carried out in a fashion which requires the collection center to disregard some of its SOPs or to place the donor in an awkward or dangerous position, then that collection puts the donor's safety in jeopardy. That can hardly be justified and, if anything were to go wrong with the collection process (including the post-donation recovery period), the collection center would incur considerable legal risks. Common sense should tell us that a law designed to prevent discrimination against the disabled should force others to put these same disabled people in situations of increased risk compared with persons who are not disabled.

ADDENDUM Nov. 11, 2001

7. A blood bank physician from the Chicago area wrote that the attendant could be in the room only for the period to move the donor to the donor bed, thus not compromising privacy or leading to exposure. The rules concerning forearm extension and ability to lie on a couch would probably be considered as important for both the process and the donor safety. The ADA may well apply and particularly if a directed donor. However the degree of accomodation must be reasonable, as in this case. Having to draw a donor in a wheelchair without the ability to lower his/her head if fainting occurs might not be reasonable. Also if the nursing staff had to lift the donor, such might exceed their job requirements, and lead to other concerns.

ADDENDUM Nov. 13, 2001

8. Dr. Dan Waxman, who presented data about wheel-chair blood donors at the year 2000 AABB annual meeting has graciously provided the following information to the e-network:

"In preparing for my talk at AABB in 2000, I researched the issue of wheelchair-dependent donors. I looked in particular at spinal cord injury (SCI), as this would be a group of individuals who previously had been in good health. First, a few stats on SCI:40 cases/million population in US:

10,000 new cases/yr
Today, 183,000-230,000 persons with SCI
55% of SCIs in 16-30 yr old group
Average Age at injury=31.8%
81.7% are male

Neurologic Level and Extent of Lesion:

Tetraplegia-51.7%
Paraplegia-46.7%
Recover prior to discharge - 0.7%

60.5% employed at time of injury
91.3% discharge to home
53.5% single

So what are the issues that would affect donor eligibility? People with SCI have compromised autonomic responses and therefore have a higher risk of vaso-vagal reactions. Therefore, they should be deferred from donating for one year after initial injury. Tetraplegics are at greater risk for reaction, with paraplegics at level T6 and below at lesser risk. They should be transferred from the wheelchair to the donor bed/chair to donate.

Also, SCI predisposes a person to urinary tract infections (UTIs) due to incomplete bladder emptying and the need for many to have catheterization for urinary drainage. The statistics for this is 18.4 episodes per person-year at risk with a prevalence of UTI = 57.4%.

I was able to get much of my information for the talk from the medical staff at the University of Alabama in Birmingham. They have a SCI information network at www.spinalcord.uab.edu.

I do believe wheelchair-dependent individuals can successfully donate, but they should have the ability to move to the donor chair/bed with either no assistance or minimal assistance. Otherwise, you will need trained staff or equipment at your donor site.

I do not believe the ADA covers allogeneic donors, but undoubtedly would cover autologous donors. Donating blood in my opinion is a privilege, not a right."

ADDENDUM Nov. 14, 2001

9. A Director of Donor Operations at a community blood center in Ohio states that regarding a wheelchair-bound donor: "If the donor in question meets all of the criteria and has an attendant to transfer them from the wheelchair to the donor bed, we would accept this donor. We would allow the attendant to enter the donor drawing area to assist with the transfer to the donor bed. We see this scenario more often with autologous donors than we do with allogeneic donors. As to the question concerning a donor's inability to extend their arm 180 degrees: As long as we are able to palpate a vein within the antecubital fossa area, we would attempt to draw this donor. Realistically however, an inability to extend their arm could be quite problematic." Finally, the responding individual said that he is not aware of any ADA guidelines that would prohibit them from deferring a wheelchair-bound donor if there was no attendant to help with the transfer to a donor bed, even if the prospective donor met all of the eligibility criteria.  Because of the potential for adverse reaction, the donor would not be permitted to donate while sitting in a wheelchair.

ADDENDUM Mar. 21, 2002

 10. A British blood banker commented on UK policy. "We agree with reply number 6 from the Minnesota physician about both points raised - donor 'rights'; and not jeopardising donor safety. We advise that donors have a right to an explanation of why they are deferred - they do not need to agree with those reasons, but they are entitled to a rational explanation. They do not have an automatic right to give blood. We do not take blood from people while they are in a wheelchair mainly because were they to experience a severe adverse reaction, their care would be compromised. On the whole, if a donor can get onto and off the bleeding couch unaided, blood may then be collected (subject to some of the provisoes given such as proneness to incomplete bladder emptying, etc). We are less concerned about others 'encroaching' onto the donor area; it is not unknown for children to be accompanying their mother or father while donating. Frank Boulton (Chair of UK Standing Advisory Committee on the Care and Selection of Blood Donors)"

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Ira A. Shulman, MD
CBBS e-Network Forum Editor & Moderator