Last Best Gifts: Altruism and the Market for Human Blood and Organs (review)

This slim volume makes a contribution to at least three literatures: economic sociology, organizations and altruism, while building bridges between them. Most of the altruism literature assumes a social psychological or even a biological, evolutionary perspective that emphasizes individual motives and actions. In this book, as in his previous articles and chapters, Healy insists that we view altruism – exemplified by blood and organ donation – as embedded in systems of organizations. Unlike the cases of emergency intervention or mundane helping – the behaviors most studied in the altruism literature – there can be no medical donation without "procurement" by an organization that mediates between the donor and the recipient. Another major focus of the book is on the issue of economic incentives for organ donation. The gap between the demand for organs and the supply has grown so large, he argues, that there needs to be consideration of the use of some form of economic incentives.

Healy rightly credits Titmuss (1971) as the first to raise both of these issues in regard to blood donation, although he concludes that Titmuss was wrong regarding the relationship between the use of incentives and "bad blood." In a very compelling chapter on the response of blood and plasma organizations to the HIV epidemic, he makes a strong argument that it is not the form of exchange – gift or market – that leads to better or worse outcomes, but rather the relationship of the organization to its suppliers and recipients. The blood banks, dependent as they are on their altruistic donors, were loath to insult them by "refusing" their "gifts," and held off too long in eliminating high risk donors. The plasma industry that pays its "donors" responded more quickly, eliminating high-risk suppliers and developing heat and detergent treatments for the plasma.

The work that has gone into this book is truly impressive. Healy has tracked down obscure archives, has done sophisticated secondary analyses of existing statistical data, and has done a masterful review of existing published work. I recommend this book particularly to those who have not read Healy's previous articles. It would also be valuable to those who would like to get the big picture rather than delve into details of the blood and organ donation organizational structure and process. My main criticism of the book is that it is too short. I personally would have liked to see more detail in a number of places. First, in Chapter 2, he draws an analogy between life insurance and organ donation, and argues that rituals surrounding both infuse them with meaning for the bereaved. It is a provocative discussion, but I would have appreciated more information regarding the insurance case. He could also have gone into more detail regarding organ matching, the issue of timing, as well as the issues of local vs. national control of distribution. Why was Tommy Thompson so important because of his roles as Governor of Wisconsin and then as secretary of Health and Human Services?

I found Chapter 4, his comparative analysis of different blood collection regimes in the European Union unsatisfying because of a lack of texture. Yes, the three kinds of organizations – state, blood banks and Red Cross – have somewhat different profiles of donors, and are more or less effective in the amount of blood obtained, but what do they actually do that is different? In Chapter 5, on the response to the HIV epidemic, I worried about those who are not as familiar as I concerning the technical aspects of blood and plasma collection. Taking the role of these others, I would have wondered, "If the plasma industry responded so much better to the crisis than the blood industry, why did virtually all hemophiliacs become HIV positive in a very short time?" The process of pooling plasma is of course responsible, but I suspect most don't know this, and don't know why the industry uses pooling. I also wanted to know why...