The Medical Director of a combined hospital transfusion service and donor collection center reports that they recently had a husband and wife attempt to donate blood for the wife's upcoming orthopedic procedure. The husband did not report any health issues to the interviewer. However, when the wife was interviewed, she stated that her husband has "liver lesions" and she is afraid that he has hepatitis B. The wife said that she does NOT want to receive her husband's blood, but that she cannot tell him she refused to receive it because he is very controlling. She made this point several times. When the husband was asked about "liver lesions" he replied that he has liver lesions, but that they are benign and his mother has them too. He says he is not under a doctor's care nor is he supposed to have them followed up. However, his wife says that she thought he was supposed to have further work-up. The inquiring physician's dilemma was what to do with the husband, and she says the following: "On one hand, I have ethical issues with taking someone's blood knowing that we will not use it. On the other hand, I do not want to tell the husband that the wife does not want his blood because I think that is a matter between them and I do not want to put the wife in jeopardy if this is an abusive situation. In addition, I do not want to violate the privacy of the wife in relaying to her husband what she has told us. The husband insists on donating so I let him donate, but I have told our staff not to use the unit since I have questions about his honesty with the donor questionnaire. This couple is beyond childbearing age so the issue of maternal alloimmunization is not a consideration. What would others have done in this situation?"

The following responses have been received.

ADDENDA Oct. 14, 2003

1. Dr. Ronald E. Domen, Medical Director, Blood Bank and Transfusion Medicine at the Milton S. Hershey Medical Center at Penn State University College of Medicine (attribution used with permission) reports that at his facility they rely on the donor to provide honest answers to their questions. He comments "The donor history is one of the weakest links in the entire donation process but it works well most of the time. Most donor centers have policies in place for handling "hearsay" information about one of their donors. Again, fidelity and trust are important, but hearsay information is usually not acted upon until the donor can be further questioned or evaluated following this "new" information. In the case presented here, the wife's information was basically treated as hearsay information and the donor was asked further questions about his liver condition - which he answered, one assumes, with honesty. However, the complicating factor is the fact that this is a directed donation and the wife may have legitimate reasons for being concerned about the safety of her husband's blood - reasons that may even go beyond the fact of "liver lesions" that she is unwilling or unable to talk openly about. I agree that no recipient should be "forced" to receive a directed donation because of concerns they may have with the safety of the blood collected from a particular directed donor (which is often a relative known to the recipient). Recipients trust us to provide the safest blood possible, and in cases like the one presented here, we have to trust when the recipient is not comfortable receiving a directed donation and respect those concerns and wishes. So yes, discard the donated unit, and inform the donor that before any future donations will be accepted, additional information about his liver condition will need to be obtained from his physician. My guess is that this donor may have an entity called NASH (Non-Alcoholic Steato-Hepatitis) which is a non-infectious cause of fatty liver changes that causes mild elevations in the ALT and AST, and by itself, should not preclude blood donation (it has no known effective treatment other than weight loss, exercise, etc.). The wife's confidentiality does seem to have been compromised because the donor did not admit to any liver problems until after he was confronted following the donor interview.

My policy is to never draw a donor's blood unless the intent is to use that unit. Once the information is "out there" I would have insisted that the donor have his physician provide additional information about his liver condition. The donor center does not have to tell the husband that his wife does not want his blood, but simply that when a history of liver problems is received it is a matter of policy to get additional follow-up medical information before allowing donation. In this case, the donor center can provide a real service by helping to evaluate and explain the liver problem to both husband and wife, as there seems to be some confusion about what is actually going on. Finally, if there is a suspicion that the wife is in a physically abusive situation, I feel that the medical director/donor center is obligated to now explore this confidentially with the wife and do what they can to help the wife find help and resources to get out and find a safe haven."

2. A colleague from South Africa reports that they have had similar problems when a designated donor came up viral positive but did not want his intended recipient to know. In this case the relationship was that of brother. They eventually told the patient that her brother's blood was 'incompatible' on further testing, and recommended the use of banked blood. They insist that patients or their next of kin, if the patient is incapacitated, sign acceptance of the intended donor prior to blood collection.This is to prevent people not acceptable to the patient rushing forward with offers to donate. In this particular case, the South African colleague does not think the blood service had any other alternative way of handling the problem.

3. A colleague from the Southern United States agrees that this is a well-defined dilemma for which there is only an optimal, not perfect, answer. He would also have collected the husband's blood, as this medical director authorized. He would not have allowed its use for anyone other than the intended recipient, for the reasons stated. If there were abnormalities detected during testing, that could suffice to address any questions the husband later might have asked regarding not using his blood. If nothing unusual was detected, it is possible that his donor center would have had a "laboratory accident" with that donation, if the greater good is not to tell the whole truth. This leaves him a little unsettled, but feeling like he has taken the wiser path in view of all the circumstances described.

4. A transfusion medicine physician in Northern California comments that the issue under discussion of a husband donating for his wife is interesting and challenging, and has this to say: "When there was no other simple way to handle something like this, and just regarding that unit, I have suggested that the phlebotomist or other staff member note that the unit was "contaminated" in the process of collections or handling so could not be used. This would not entail any kind of deferral but would just apply to that particular donation. Of course, if any of the lab results are reactive, this would take care of the problem even better."

5. A Southern California compliance officer reports having seen this situation twice before and he had no problem with the same decision that the inquiring physician made. In both cases he discussed the situation with the Medical Directors involved and their local QA Director, and it seemed to be the best solution to keep the peace, confidentiality, and safety, even if it was not totally up-front. It is not a decision to be made lightly.

ADDENDA Oct. 15, 2003

6. A colleague in Pennsylvania is of the opinion that the purported benefit of directed donation is not worth the risk described in this scenario. He shares the following opinion: "Any request for directed donation that lacks a medical indication, such as a specific immunologic problem or an attempt to significantly reduce donor exposures (single dedicated donor to supply all products likely to be needed by a patient or attempt at 10x donor exposure reduction) should be refused based on an pre-existing policy. A history of liver disease without a clear cut etiology is cause to defer any allogeneic donor. There is no constitutional right to be a allogeneic blood donor, as established in a case against Southwest Florida Blood Bank concerning transfusion transmitted nonA-nonB hepatitis is the 1960's. Donation from an unqualified donor should occur only after the donor understands that the donation will be discarded. (True story: A politician comes to provide a allogeneic blood donation in front of a film crew. The politician gives a confidential history of infectious hepatitis. The politician is allowed to donate for the camera only after stating an understanding that the donation will be discarded and that the small risk of a vasovagal faint is not balanced by the societal benefit of blood donation. Appropriate donor recognition is given and the donated unit is quietly discarded off camera. The politician's name is placed in the donor deferral registry.) A robust policy for 3rd party donor history notification may be helpful. (I hate to call it hearsay information, since the informant may have direct involvement in the donor activity.) Such a policy may follow this path: After completion of donor screening but before phlebotomy, the donor in this case may be informed that an unnamed 3rd party has provided information about liver disease in the donor. If the donor cannot provide a convincing history to address this allegation, further workup is needed prior to donation. In my opinion, collecting blood from an allogeneic donor that has a greater than 50% chance of being thrown away is not a wise use of the resources of the donor or the collection center staff. Justifying reimbursement for the directed blood donation in this scenario would be very difficult." The Pennsylvania colleague concludes with a comment about the opinion expressed by Dr. Ron Domen, also from Pennsylvania! According to this responding Pennsylvanian, Dr. Domen makes an excellent point that physicians have an ethical responsibility to evaluate allegations of abuse. Title 6 of the Pennslyvania State Code, Chapter 15, Section 21 General reporting provisions states: "A person who has reasonable cause to believe that an older adult needs protective services may report this to the local provider of protective services." The responding colleague adds that he cannot find a Pennsylvania law which requires physicians to report spouse abuse.

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Ira A. Shulman, MD
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