Time to Reconsider Payments to Blood Donors?

The blood transfusion system that we rely on today, where volunteers donate whole blood that is stored in a network of blood banks on behalf of patients, is less than a century old; it dates back to 1937¹. Since the earliest days of blood banking, there has been a great deal of debate over the pros and cons of paying blood donors, versus relying on altruistic donation².

Overview of donor payment debate

From the perspective of bioethics, there is no one simple answer as to whether it is better to pay or not pay donors. At the 2025 AABB meeting, Dr. Ludwig Frontier gave a talk reviewing the medical ethics of blood donation from within six different ethical frameworks: Virtue Ethics (Aristotle), Deontology (Kant), Utilitarianism (Bentham & Mill), Principalism (Beauchamp & Childress), Communitarianism (McIntyre & Etzioni), and Care Ethics (Gilligan & Held)². Each framework has a different way of looking at the trade-offs between the needs of donors versus the needs of society.

Regardless of the ethical debate, the World Health Organization (WHO) has adopted a global goal to achieve 100% Voluntary Non-Renumerated Donors (VNRD)³. This goal was adopted in 1975, but has not been achieved during the 50 years since then. In practice, international reviews have found that roughly half of the countries surveyed employ financial incentive policies for donation of whole blood^4,5. These incentives vary widely, and include cash payments, time off work, tax benefits, pension credits, healthcare services, vouchers or gift cards, and raffles^4,5.

Payment policies in the United States

Within the United States, there is currently a two-tiered system of donor compensation. Donors of whole blood do not receive financial compensation, whereas donors that give blood derivatives, like plasma or leukapheresis, are routinely paid.

Contrary to popular opinion, the US ban on paying whole blood donors is not based upon law, but upon policy. Back in 1978, the federal laws governing the FDA began requiring that any blood which is intended for transfusion to patients must be labelled as to whether the donor was a “volunteer donor” or a “paid donor”⁶.  There is no legal prohibition on “paid donor” blood, but the blood unit must be properly labelled. Subsequently, the medical community in the United States adopted the policy to not use “paid donor” blood products for patient treatment. This is a situation where the policies of professional societies can supersede the actual law. What is even more interesting about this policy, is that we could not find any medical professional society that has explicitly published the ban on paid donors on their current website⁷. Despite the policy against “paid donors”, blood centers often give “gifts” to their donors which have financial value^4,5. This creates a slippery slope of questioning when does a gift become a payment? To answer that question, the FDA periodically issues guidance on what constitutes a gift versus a payment⁸.

Meanwhile, plasma donors in the United States are paid an average of $70 for each donation, and are allowed to donate up to twice a week all year long⁹. There are currently 1,247 commercial centers for plasma donation in the United States. During 2025, the plasma industry “injected more than $4.7 billion dollars into the pockets of American households through donor compensation fees”⁹.

Another lucrative form of donation is undergoing leukapheresis to donate white blood cells that are needed to manufacture advanced cell therapies. This type of donation is only available at research centers, but the reimbursement can be $200 to $300 per session, depending on whether the patient takes a drug to mobilize their blood beforehand¹⁰.

How did the US payment policies evolve?

The different payment policies for whole blood versus blood derivatives are rooted in concerns about transmissible diseases. Bear in mind these policies were adopted at a time when transmission of blood diseases such as hepatitis or HIV was a risk¹¹. There has always been a concern that the incentive of a payment may lead some paid blood donors to withhold information about their health history.

Today, the safety of the blood supply rests more on rigorous testing of the blood products than on the honesty of donor questionnaires¹¹. When whole blood is collected at a non-profit blood center, it is tested for known diseases. Aside from this testing, whole blood donations undergo minimal manipulation before the blood or its components are given to a patient¹². By comparison, when blood plasma is collected at a for-profit donor center, it goes through a process called fractionation to manufacture pharmaceutical products¹². Some of the specialized products made from plasma, such as clotting factors for hemophiliacs, require pooling plasma from over a thousand donors. Along the way, the plasma undergoes rigorous pathogen reducing technologies and sterilization steps, so the chance of transmitting a disease is extremely low.

A frequently asked question is whether the non-profit whole blood donation centers and the for-profit plasma donation centers are in competition for donors. It turns out that in countries where both types of donor center operate, they coexist¹³. They do not compete with each other because they appeal to different demographics of donors^13-16. Indeed, there is a synergy between them due to the “Advertising Spillover Effect”: more donor center recruitment leads to more awareness of all forms of blood donation¹³.

Reasons to reconsider paying donors

Shortages of whole blood donations are becoming a chronic problem in the United States¹⁷. The Red Cross reports that someone is the U.S. needs a blood transfusion every two seconds¹⁸. But over the past 20 years, the number of people donating whole blood to the Red Cross has dropped by 40%¹⁹. This has made it necessary for blood bankers to find creative ways to manage their blood supply and demand^20,21.

The drop in voluntary blood donation is just one symptom of decreasing civic engagement in American society. The sociologist Dr. Robert Putnam coined the phrase “bowling alone” in the year 2000 to describe this phenomenon^22,23. In recent decades, a variety of shifts in American society have resulted in fewer people participating in all forms of civic and social connection to their community. These include fewer people joining clubs, attending houses of worship, volunteering for charities, or donating blood. One example of how the pool of volunteer donors is aging is that the median age of volunteer donors at the Vitalant blood center in Chicago is 59 years old²⁴.

Alternatives to paying donors

At the 2025 AABB meeting, Dr. Ruchika Goel gave a talk about the importance of tailoring donation recruitment strategies to the motivations of different generations²⁵. “For example, local blood drives and faith-based outreach are typically more successful in recruiting Baby Boomer donors. But for Millennial donors, social media and corporate giving programs were more likely to be effective.”

In order to counter declining numbers of platelet donors, one blood center in Illinois ran a pilot program of paying platelet donors²⁴. They reported in a poster at the 2025 AABB meeting that they recruited over two thousand new donors, with a median age of 39 years old, and had minimal conversion of their volunteer donors that give whole blood.

It is not a foregone conclusion that we will run out of blood donations if we don’t start paying donors. America’s Blood Centers calculates that if we can increase the fraction of the population that donates whole blood from 3% to 4%, it will alleviate the shortages²⁶. However, it would also help if transfusion medicine specialists would consider dropping the taboo against compensation for donors of whole blood. The examples in other countries show that there are many creative ways to offer incentives that have value but are not cash payments^4,5. Dr. Frontier closed his talk at the 2025 AABB meeting with these two points²⁷:

• How do we reconcile ideals with life-saving pragmatism?
• Perhaps, by redefining what “ethical sustainability” means in transfusion medicine?

References

1. American Red Cross. History of Blood Transfusions. Blood Services. Accessed 2026-01-01
2. Association for the Advancement of Blood and Biotherapies (AABB). AABB2025: Examining the Future of Volunteer Blood Donation. AABB News Center. Published 2025-10-27
3. World Health Organization. Health products policy and standards. Voluntary donation. Accessed 2026-01-01
4. Chell K, Davison TE, Masser B, Jensen K. A systematic review of incentives in blood donation. Transfusion. 2018; 58:242-254.
5. Graf C, Oteng-Attakora K, Ferguson E, Vassallo R, Merz EM. Blood Donor Incentives across 63 Countries: The BEST Collaborative Study. Transfusion Medicine Reviews. 2024; 38(2):150809.
6. Code of Federal Regulations. 21 CFR 606.121(c)(8)(v) Additional labeling standard for blood and blood components. 
7. American Medical Association. Voluntary Donations of Blood and Blood Banking H-50.995. Policy Finder. Last updated 2021
8. FDA Guidance Document. Blood Donor Classification Statement, Paid or Volunteer Donor. Issued 2002-05-07, Last updated 2019-12-06
9. Jaworski P. America’s Plasma Contribution to the World: 2025. Blood Plasma Quarterly. Published 2026-01-02
10. Red Cross. Support Cutting Edge Advancements To Help Save Lives. Specialized Donor Program. Accessed 2026-01-01
11. Shaz BH, Domen RE, France CR. Remunerating donors to ensure a safe and available blood supply. Transfusion. 2020; 60:S134-S137.
12. Verter F. Tariff Impacts on the Blood Supply. Parent's Guide to Cord Blood Foundation. Newsletter. Published 2025-11 
13. Jaworski P. Blood Feud. Blood Plasma Quarterly. Published 2025-06-30
14. Ochoa A, Shaefer HL, Grogan-Kaylor A. The Interlinkage between Blood Plasma Donation and Poverty: An Examination of the Location of Plasma Centers in the United States. J. Soc. & Soc. Welfare. 2021; 56(2) 
15. Dooley JM, and Gallagher E. Blood Money: Selling Plasma to Avoid High-Interest Loans. Review of Financial Studies. 2024; 37(9):2779–2816. 
16. McConnell B, Zapryanova M, Kang S. Financial Incentives and Public Safety: The Role of Blood Plasma Donation Centers in Crime Reduction. Social Science Research Network. 2025; 2025:5259763.
17. Sellinger T. Blood Donation Crisis: Only 3% of Americans Donate Despite 15M Annual Transfusions. Physicians Weekly. Last updated 2025-01-17
18. American Red Cross. US Blood Supply Facts. Accessed 2026-01-01
19. Bowen E. The U.S. Blood Shortage: Why This Crisis Matters. Athens Science Observer. Published 2025-03-10
20. Gammon R, Becker J, Cameron T, ... Tanhehco YC. How do I manage a blood product shortage? Transfusion. 2023; 63(12):2205-2213.
21. Brigmon EP, Cirone J, Harrell K, ... Jenkins DH. Walking blood bank: a plan to ensure self-sufficiency in an era of blood shortage. BMJ Trauma Surgery & Acute Care. 2024;9:e001151.
22. Putnam RD. Bowling alone: the collapse and revival of American community. New York: Simon & Schuster, 2000.
23. Kolins J, Herron Jr. R. On bowling alone and donor recruitment: lessons to be learned. Transfusion. 2003; 43(11):1634.-1638
24. Crane JE, Papari M, Bravo M, Charbonneaux J, Hopkins C. A National Blood Supplier Starting a Paid Donor Model: Our Experience. Transfusion. 2025; 65(S2):79A
25. Association for the Advancement of Blood and Biotherapies (AABB). AABB2025: Adjusting Donor Recruitment Strategies For Different Generations May Offer Key to Expanding Donor Pool. AABB News Center. Published 2025-10-27
26. America’s Blood Centers (ABC). Verified Statistics on the Blood Supply and Donor Demographics. Publications. Accessed 2026-01-01
27. Frontier L. Paying Blood Donors in the 21st Century: Ethics, Policy and the Global Reality of Recruitment. AABB News Magazine. Published 2026-01-14