The plasma debate: The ethics of paying for human blood
Should pharmaceutical companies pay people for their plasma? Here's why paid plasma is a hot ethical issue.
Peter Jaworski is an Associate Teaching Professor teaching ethics at Georgetown University’s McDonough School of Business. He is the co-author of “Markets without Limits” (with Jason Brennan), and has been published in Ethics, Philosophical Studies, The Canadian Journal of Law and Jurisprudence, amongst others.
PETER JAWORKSI: Let me tell you about the biggest industry you've probably never heard of. I'm talking about the blood plasma industry. The therapies made from plasma help people who suffer from primary and secondary immune deficiencies. If you ever have a serious burn you'll probably need albumin. Albumin is also used to help with a variety of cancers. And then there are people whose blood doesn't clot properly, people with Von Willebrand disease or people who have hemophilia. That's what the plasma therapies are used for. And demand for especially immune globulin. The demand for immune globulin is outstripping supply in almost every country.
Did you know that the United States supplies more than 70 percent of all of the plasma in the entire world that is used to manufacture plasma therapies? The whole world is dependent and reliant on the United States of America, on people in the United States who give their plasma twice a week on a regular basis.
Exports of plasma from the United States account for 1.6 percent of total exports by GDP according to The Economist. The New York Times said it was 1.9 percent. That's not correct. That number by the way, 1.6 percent of total exports. That's more than aluminum. It's more than steel. It's the biggest industry you've never heard of. It's about $26 billion I think annual industry. That's going to double very soon. People are anticipating it to be more than a $40 billion industry by 2040. So we're anticipating incredible growth, ten percent per year. That growth is stable. It's stable growth. There are still countries that do not realize that these plasma therapies are effective. They simply don't have the resources or the means to properly diagnose people or to give them access to these plasma therapies. But once they come online that's going to increase demand as well.
Out of all the countries in the world only the ones that pay people to make that donation are self-sufficient in plasma therapies. And even the ones that pay not all of them are, in fact, sufficient. So there are only seven countries in the world that legally permit paying people for plasma donations – Germany, Austria, Hungary, Czechia or the Czech Republic, parts of Canada. And I'll talk about Canada in a second. The United States, of course, and China. Those are the seven countries in the world that permit payment. Every other country that does not allow payment for plasma donations imports plasma therapies that make use of plasma primarily from Americans. Germans as well, but primarily Americans. That's an astonishing figure. This industry is growing so fast. In the United States alone the number of plasma centers has more than doubled. In fact, it's more than tripled since 2004. There are currently over 824 plasma centers in the United States of America.
So here's a question. We know that paying people for plasma works. We know that it's effective precisely because of what I just said. All of these countries depend on paid plasma to make the therapies and only the countries that pay have enough of them. They produce actually more than enough. They have more than enough. They're able to export to other countries and thank goodness. Imagine what the world would be like if the United States didn't pay for plasma. We wouldn't have enough plasma therapies. vAnd at the moment these plasma therapies are used for rare blood disorders and for rare diseases. Very few people are affected by it. Of course that still accounts – there's still thousands of people around the world who use these medicines on a regular basis. But imagine what would happen if it turns out that plasma is useful for something like Alzheimer's, is useful for something like heart disease. If it turns out that it is useful against an ailment, a disease, a problem that very many people are affected by then demand for these therapies is going to go through the roof. We need to be prepared for that and we need to do what works. And what works is paying people for plasma donations.
So let me talk about Canada for a second because this is where I've done the most work on this issue. So at the moment British Columbia, Alberta, Ontario and Quebec – this is where more than 80 percent of Canada's population lives. It is illegal for a commercial enterprise to come in and pay people for plasma donation. Meanwhile, Canada continues to import therapies made with American paid plasma all along. And those numbers are increasing. So why did they ban paid plasma? What kinds of arguments did people make in Ontario, in Alberta and British Columbia? I tried to remember all of those arguments and I've got like a little acronym which I call SSACE. It's Safety, Security, Altruism, Commodification and Exploitation. The first one, safety, is a nonstarter. Don't forget that Canada imports therapies made with paid plasma. So the question of whether or not it's safe to pay people for plasma donation is not a realistic question. The law doesn't ban paid plasma and it doesn't say that it's going to stop importing paid plasma.
And by the way, every medical expert body around the world says that medicine made with paid plasma is just as safe as medicine made with unpaid plasma. The say it's just as safe. Not a little bit less safe. They say it's just as safe. The safety issue is simply a nonstarter. It's not a real issue. The security issue is interesting. It's an empirical question and that question is if we allow paid plasma will we get enough unpaid blood. These are two different kinds of donations. Plasma is the yellow liquid inside of our veins. It's about 55 percent of the liquid in our veins. When you donate plasma usually you do it through plasmapheresis. There's a big machine, takes all of your blood. It separates the plasma from your red and white blood cells and your platelets and then it returns the red and white blood cells and the platelets back to you and keeps just the plasma. A whole blood donation meanwhile takes less time. It takes about 30 minutes as compared to one-and-a-half to two hours. That's how long plasmapheresis takes.
It takes less time but it takes all of those things. What that means is that if you donate plasma you can do it twice a week safely. But if you donate blood you can only do that once every 56 days. Now we don't pay for blood and the concern is that if we allow both paid plasma and unpaid blood to operate side-by-side then people are going to choose the option that you get paid for rather than the option that you don't get paid for. I think that's a very serious worry. It is an empirical question. A colleague of mine and myself we have a paper forthcoming that appears to show that there is no effect on unpaid blood donations from the presence of paid plasma centers, but you'll have to look up that paper. A Health Canada expert panel said the same thing. In the United States, for example, blood donations operate side-by-side with paid plasma operations and it's not that big a deal. Same with in the Czech Republic. The same is true in Austria as well. So the security issue is another issue that was raised. I think it's the most important argument that the other side on this debate have raised. My own view on it is that it is insufficient on its own to justify banning paying people for plasma donations.
The other three are moral objections and I'll try to deal with them quickly. The first one, altruism. The argument is that people should give plasma out of the kindness of their hearts and not because what they care about is the thickness of their wallet. And so we object to paid plasma because we think that like people are doing it with the wrong motives. So the first thing to say is that if you're comparing getting enough medicine that will save lives to the motives of the people that provide the plasma it seems like the saving lives is much more important. So even if people aren't giving it out of the kindness of their hearts that doesn't matter as much as saving as many lives as we possibly can. That's the first thing to say. The second thing to say is that I think it, in fact, is a kind of prejudice. It's a kind of stigma that we associate with people who sell their plasma. Because consider none of us, I'm a professor. Guess what? I get paid to be a professor. But do I, am I a professor because that's the way that I maximize my income? No, I take seriously my obligation to let people know about things that are important, to try to bring up the next generation. And the same is true of teachers all around the world.
And we do see that teachers can both be paid and operate altruistically simultaneously. Human motivations are very complex. We think the same thing of nurses. We think nurses get paid to be nurses. Same with doctors. They get paid to be doctors. And yet we think that it's compatible with that for them to operate altruistically. In a way it's puzzling in the plasma debate in particular because everybody who has anything to do with plasma gets paid. That includes the phlebotomists, the nurses, the administrators. Everybody gets paid except for the person whose plasma it is. And we worry about altruism just when it comes to the person whose plasma it is. Why aren't we concerned about the altruistic motives of nurses, for example, or doctors. So that's why I say that argument kind of reveals a sort of prejudice. It's not a very good one. The commodification worry goes something like this. If we put a price tag on a part of a human being then it's possible that people are going to start thinking of themselves as having all of these different price tags.
So they don't think of themselves as being a person, as a whole person. They don't think of themselves as being sacred in a way. Instead they start thinking of themselves as having different price tags and they're like well what am I worth. Well actually my blood is worth this much, my plasma is worth this much and my hair is worth this much, et cetera. The worry is that if we allow a price tag on a part of us then soon we're going to think of people as commodities rather than as persons. And my response to that kind of argument is first, that's an empirical claim and I haven't seen any studies that show that, for example, in the United States people are more likely to think of themselves as commodities as compared to in Ontario or British Columbia where it's not legal to pay people for plasma. I find that argument a little bit dubious barring empirical evidence. And secondly, I don't know why anybody thinks that at all. I mean we pay for labor. Why doesn't that have the effect of commodifying persons. Why is it that if we pay for plasma then commodification will occur, but not in all of the other standard ways. Things that we constantly pay for and yet do not result in commodification.
And then the last one which I think is the most important moral argument against paying people for plasma. It's exploitation. If you pay attention to the news in the United States and all over the world, if people are writing about paid plasma they often raise the specter of wrongful exploitation. Because here is a fact. Guess who sells their plasma? It's not professionals. It's not professors like myself. It's students and it's people who are poor. Poor people – the plasma centers are located in zip codes that have higher poverty rates and lower median and household income rates. So it is the poor that sell their plasma. And so that raises the question of whether these people are exploited or not. I don't think that they are. I think, in fact, that the amount of money that people are paid to sell their plasma is, in fact, a good deal. The global price of plasma is about $200 per liter. So the unit is a liter. It's about $200 per liter and donors or people who are paid for plasma receive about $50 for that one liter.
Typically people donate about 810 to 880 milliliters and so it takes about one-and-a-quarter donation to make a full liter of plasma. So people get paid $50 and $200 is the total price. That's a really remarkable, that's a good deal. That's not an exploitative deal. The division of the benefits is fair in my judgment. Second, there's still an open question like what good do we do – what has Ontario done? Ontario has said we're not going to pay people for plasma. That didn't result in $50 in the pockets of people who need the money. When they banned paid plasma they didn't replace that with a tree where you just grab money from that tree. No, they simply removed an option. How did that improve the lives of the people who need the money and are selling plasma maybe primarily for the money. Although footnote, don't forget I do think that most of the people that sell their plasma do it both for the money as well as out of concern for their fellow neighbors. So you don't really make people better off by removing those options.
Now if it as something that was very risky then that would be a different matter. We're not talking about paying people for kidneys. We're talking about paying people for plasma which is renewable. It's renewable and donating it is safe. It's not entirely safe. It's not 100 percent safe, but it is not risky. We are encouraging people to donate plasma. So that's my response to the exploitation argument. That's my response to all of the arguments against it. And none of those arguments overcome the fact that we can get high quality plasma for plasma therapies. We can get more of it. And countries like Canada where I'm from, we're a wealthy country. We shouldn't just be drawing on the global supply of plasma. We should be contributing to it. We are not contributing to the global supply of plasma. We are taking from it. It's just as safe as unpaid plasma. There's evidence, there's substantial proof that paying people for plasma will work. The demand for these medicines is growing significantly and we are simply not equipped to do what we need to do unless we pay donors. It should be legal to pay people for plasma.
- Human blood is made up of red blood cells, white blood cells, platelets, and plasma. Plasma is the liquid part of blood. It is used to treat rare blood conditions and has an increasing number of medical applications.
- It is a $26 billion industry, and the US is a major exporter of plasma to other nations. Most nations do not collect enough plasma to sustain therapies for their own citizens. The US has such a large supply of plasma because it pays people to donate plasma—a controversial practice.
- Is it ethical for people to be paid for their plasma? Here, Peter Jaworski, an ethics scholar, explains five key arguments people make against paying people for plasma—safety, security, altruism, commodification, and exploitation—and explains his views on them. What do you think?
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A new episode of "Your Brain on Money" illuminates the strange world of consumer behavior and explores how brands can wreak havoc on our ability to make rational decisions.
- Effective branding can not only change how you feel about a company, it can actually change how your brain is wired.
- Our new series "Your Brain on Money," created in partnership with Million Stories, recently explored the surprising ways brands can affect our behavior.
- Brands aren't going away. But you can make smarter decisions by slowing down and asking yourself why you're making a particular purchase.
How Apple and Nike have branded your brain | Your Brain on Money | Big Think youtu.be
Brands can manipulate our brains in surprisingly profound ways. They can change how we conceptualize ourselves and how we broadcast our identities out to the social world. They can make us feel emotions that have nothing to do with the functions of their products. And they can even sort us into tribes.
To grasp the power of brands, look to Apple. In the 1990s, the company was struggling to compete with Microsoft over the personal computer market. Despite flirting with bankruptcy in the mid-1990s, Apple turned itself around to eventually become the most valuable company in the world.
That early-stage success wasn't due to superior products.
"People talk about technology, but Apple was a marketing company," John Sculley, a former Apple marketing executive, told The Guardian in 1997. "It was the marketing company of the decade."
So, how exactly does branding make people willing to wait hours in line to buy a $1,000 smartphone, or pay exorbitant prices for a pair of sneakers?
Branding and the brain
For more than a century, brands have capitalized on the fact that effective marketing is much more than simply touting the merits of a product. Some ads have nothing to do with the product at all. In 1871, for example, Pearl Tobacco started advertising their cigarettes through branded posters and trading cards that featured exposed women, a trend that continues to this day.
It's crude, sure. But research shows that it's also remarkably effective, even on monkeys. Why? The answer seems to center on how our brains pay special attention to information from the social world.
"In theory, ads that associate sex or status with specific brands or products activate the brain mechanisms that prioritize social information, and turning on this switch may bias us toward the product," wrote neuroscience professor Michael Platt for Scientific American.
Brands can burrow themselves deep into our subconscious. Through ad campaigns, brands can form a web of associations and memories in our brains. When these connections are robust and positive, it can change our behavior, nudging us to make "no-brainer" purchases when we encounter the brand at the store.
It's a marketing principle that's related to the work of Daniel Kahneman, a psychologist and economist who won the 2002 Nobel Memorial Prize in Economic Sciences. In his book "Thinking Fast and Slow", Kahneman separates thinking into two broad categories, or systems:
- System 1 is fast and automatic, requiring little effort or voluntary control.
- System 2 is slow and requires subjective deliberation and logic.
Brands that tap into "system 1" are likely to dominate the competition. After all, it's far easier for us as consumers to automatically reach for a familiar brand than it is to analyze all of the available information and make an informed choice. Still, the most successful brands can have an even deeper impact on our psychology, one that causes us to conceptualize them as something like a family member.
A peculiar relationship with brands
Apple has one of the most loyal customer bases in the world, with its brand loyalty hitting an all-time high earlier this year, according to a SellCell survey of more than 5,000 U.S.-based smartphone users.
Qualitatively, how does that loyalty compare to Samsung users? To find out, Platt and his team conducted a study in which functional magnetic resonance imaging scanned the brains of Samsung and Apple users as they viewed positive, negative, and neutral news about each company. The results revealed stark differences between the two groups, as Platt wrote in "The Leader's Brain":
"Apple users showed empathy for their own brand: The reward-related areas of the brain were activated by good news about Apple, and the pain and negative feeling parts of the brain were activated by bad news. They were neutral about any kind of Samsung news. This is exactly what we see when people empathize with other people—particularly their family and friends—but don't feel the joy and pain of people they don't know."
Meanwhile, Samsung users didn't show any significant pain- or pleasure-related brain activity when they saw good or bad news about the company.
"Interestingly, though, the pain areas were activated by good news about Apple, and the reward areas were activated by bad news about the rival company—some serious schadenfreude, or "reverse empathy," Platt wrote.
The results suggest a fundamental difference between the brands: Apple has formed strong emotional and social connections with consumers, Samsung has not.
Brands and the self
Does having a strong connection with a brand justify paying higher prices for their products? Maybe. You could have a strong connection with Apple or Nike and simultaneously think the quality of their products justifies the price.
But beyond product quality lies identity. People have long used objects and clothing to express themselves and signal their affiliation with groups. From prehistoric seashell jewelry to Air Jordans, the things people wear and associate with signal a lot of information about how they conceptualize themselves.
Since the 1950s, researchers have examined the relationship between self-image and brand preferences. This body of research has generally found that consumers tend to prefer brands whose products fit well with their self-image, a concept known as self-image congruity.
By choosing brands that don't disrupt their self-image, consumers are able not only to express themselves personally, but also broadcast a specific version of themselves into the social world. That might sound self-involved. But on the other hand, humans are social creatures who use information from the social world to make decisions, so it's virtually impossible for us not to make inferences about people based on how they present themselves.
Americus Reed II, a marketing professor at the University of Pennsylvania, told Big Think:
"When I make choices about different brands, I'm choosing to create an identity. When I put that shirt on, when I put that shirt on — those jeans, that hat — someone is going to form an impression about what I'm about. So, if I'm choosing Nike over Under Armour, I'm choosing a kind of different way to express affiliation with sport. The Nike thing is about performance. The Under Armour thing is about the underdog. I have to choose which of these different conceptual pathways is most consistent with where I am in my life."
Making smarter decisions
Brands may have some power over us when we're facing a purchasing decision. So, considering brands aren't going away, what can we do to make better choices? The best strategy might be to slow down and try to avoid making "automatic" purchasing decisions that are characteristic of Kahneman's fast "system 1" mode of thinking.
"I think it's important to always pause and think a little bit about, "Okay, why am I buying this product?" Platt said.
As for getting out of the brand game altogether? Good luck.
"I've heard lots of people push back and say, "I'm not into brands,"" Reed II said. "I take a very different view. In some senses, they're not doing anything different than what someone who affiliates with a brand is doing. They have a brand. It's just an anti-brand brand."
Powerful branding can not only change how you feel about a company, it can actually change how your brain is wired.
- Powerful branding can not only change how you feel about a company, it can actually change how your brain is wired.
- "We love to think of ourselves as rational. That's not how it works," says UPenn professor Americus Reed II about our habits (both conscious and subconscious) of paying more for items based primarily on the brand name. Effective marketing causes the consumer to link brands like Apple and Nike with their own identity, and that strong attachment goes deeper than receipts.
- Using MRI, professor and neuroscientist Michael Platt and his team were able to see this at play. When reacting to good or bad news about the brand, Samsung users didn't have positive or negative brain responses, yet they did have "reverse empathy" for bad news about Apple. Meanwhile, Apple users showed a "brain empathy response for Apple that was exactly what you'd see in the way you would respond to somebody in your family."
Scientists find routes using arches of chaos that can lead to much faster space travel.
- Researchers discovered a route through the Solar System that can allow for much faster spacecraft travel.
- The path takes advantage of "arches of chaos" within space manifolds.
- The scientists think this "celestial superhighway" can help humans get to the far reaches of the galaxy.
Humanity could be making its way through the Solar System much faster thanks to the discovery of a new superhighway network among space manifolds. Don't get your engines roaring along this "celestial autobahn" just yet, but the researchers believe the new pathways can eventually be used by spacecraft to get to the outer reaches of our Solar System with relative haste.
The celestial highway could get comets and asteroids from Jupiter to Neptune in less than a decade. Compare that to hundreds of thousands or even millions of years it might ordinarily take for space objects to traverse the Solar System. In a century of travel along the new routes, a 100 astronomical units could be covered, project the scientists. For reference, an astronomical unit is the average distance from the Earth to the Sun or about 93 million miles.
The international research team included Nataša Todorović, Di Wu, and Aaron Rosengren from the Belgrade Astronomical Observatory in Serbia, the University of Arizona, and UC San Diego. Their new paper proposes a dynamic route, going along connected series of arches within so-called space manifolds. These structures, coming into existence from gravitational effects between the Sun and the planets, stretch from the asteroid belt to past Uranus.
The most pronounced of these structures are linked to Jupiter by its strong gravitational pull, explained UC San Diego's press release. They influence the comets around the gas giant as well as smaller space objects called "centaurs," with are like asteroids in size but exhibit the composition of comets.
This animation shows space manifolds over a hundred years. Each frame of the animation shows how the arches and substructures appear over three-year increments.
Credit: Nataša Todorović, Di Wu and Aaron Rosengren/Science Advances
"Space manifolds act as the boundaries of dynamical channels enabling fast transportation into the inner- and outermost reaches of the Solar System," write the researchers. "Besides being an important element in spacecraft navigation and mission design, these manifolds can also explain the apparent erratic nature of comets and their eventual demise."
A closer image of the manifolds showing colliding and escaping objects.
Credit: Science Advances
The researchers discovered the structures by analyzing collected numerical data on the millions of orbits in the Solar System. The scientists figured out how these orbits were contained within known space manifolds. To detect the presences and structure of the space manifolds, the team employed the fast Lyapunov indicator (FLI), used to detect chaos. The scientists ran simulations to compute how the trajectories of particles approaching different planets like Jupiter, Uranus and Neptune would be affected by possible collisions and the manifolds.
While the results are encouraging, the next step is to figure out how these arches can be used by spacecraft for much speedier travel. It's also not clear how similar manifolds work near Earth. Also unclear is how they impact our planet's run-ins with asteroids and meteorites or any of the man-made objects floating up in space near us.
Check out the new paper "The arches of chaos in the Solar System" in Science Advances.
Evolution proves to be just about as ingenious as Nikola Tesla
- For the first time, scientists developed 3D scans of shark intestines to learn how they digest what they eat.
- The scans reveal an intestinal structure that looks awfully familiar — it looks like a Tesla valve.
- The structure may allow sharks to better survive long breaks between feasts.
Considering how much sharks are feared by humans, it is a bit of a surprise that scientists don't know much about the predators. For example, until recently, sharks were thought to be solitary creatures searching the seas for food on their own. Now it appears that some sharks are quite social.
Another mystery is how these prehistoric swimming and eating machines digest food. Although scientists have made 2D sketches of captured sharks' digestive systems based on dissections, there is a limit to what can be learned in this way. Professor Adam Summers at University of Washington's Friday Harbor Labs says:
"Intestines are so complex, with so many overlapping layers, that dissection destroys the context and connectivity of the tissue. It would be like trying to understand what was reported in a newspaper by taking scissors to a rolled-up copy. The story just won't hang together."
Summers is co-author of a new study that has produced the first 3D scans of a shark's intestines, which turns out to have a strange, corkscrew structure. What's even more bizarre is that it resembles the amazing one-way valve designed by inventor Nikola Tesla in 1920. The research is published in the journal Proceedings of the Royal Society B.
What a 3D model reveals
Video: Pacific spiny dogfish intestine youtu.be
According to the study's lead author Samantha Leigh, "It's high time that some modern technology was used to look at these really amazing spiral intestines of sharks. We developed a new method to digitally scan these tissues and now can look at the soft tissues in such great detail without having to slice into them."
"CT scanning is one of the only ways to understand the shape of shark intestines in three dimensions," adds Summers. The researchers scanned the intestines of nearly three dozen different shark species.
It is believed that sharks go for extended periods — days or even weeks — between big meals. The scans reveal that food passes slowly through the intestine, affording sharks' digestive system the time to fully extract its nutrient value. The researchers hypothesize that such a slow digestive process may also require less energy.
It could be that this slow digestion is more susceptible to back flow given that the momentum of digested food through the tract must be minimal. Perhaps that is why sharks evolved something so similar to a Tesla valve.
What is Tesla's valve doing there?
Above, a Tesla valve. Below, a shark intestine.Credit: Samantha Leigh / California State University, Domi
Tesla's "valvular conduit," or what the world now calls a "Tesla valve," is a one-way valve with no moving parts. Its brilliance is based in fluid dynamics and only now coming to be fully appreciated. Essentially, a series of teardrop-shaped loops arranged along the length of the valve allow water to flow easily in one direction but not in the other. Modern tests reveal that at low flow rates, water can travel through the valve either way, but at high flow rates, the design kicks in. According to mathematician Leif Ristroph:
"Crucially, this turn-on comes with the generation of turbulent flows in the reverse direction, which 'plug' the pipe with vortices and disrupting currents. Moreover, the turbulence appears at far lower flow rates than have ever previously been observed for pipes of more standard shapes — up to 20 times lower speed than conventional turbulence in a cylindrical pipe or tube. This shows the power it has to control flows, which could be used in many applications."
A deeper dive
Summers suggests the scans are just the beginning. "The vast majority of shark species, and the majority of their physiology, are completely unknown," says Summers, adding that "every single natural history observation, internal visualization, and anatomical investigation shows us things we could not have guessed at."
To this end, the researchers plan to use 3D printing to produce models through which they can observe the behavior of different substances passing through them — after all, sharks typically eat fish, invertebrates, mammals, and seagrass. They also plan to explore with engineers ways in which the shark intestine design could be used industrially, perhaps for the treatment of wastewater or for filtering microplastics.
It could fairly be said, though, that Nikola Tesla was 100 years ahead of them.