Where Autonomy Ends: Directed Donation, COVID Myths, and the Ethics of Saying No
- caitlinraymondmdphd
- 5 minutes ago
- 5 min read
Today we had a case that many transfusion services will recognize.
A patient scheduled for surgery requested a directed blood donation. The reason given was concern about receiving blood from donors who had received a COVID-19 vaccine.
The answer was no.
She returned with a revised request: this time citing religious preference and psychological comfort.
Again, the answer was no.
Afterward, I had a long discussion with a resident — thoughtful, patient-centered, and clearly uncomfortable with refusing a request framed in ethical language. I don’t think I convinced them. And that matters, because this is exactly the kind of scenario where kindness and ethics feel deceptively close, and where “just accommodating” can feel easier than holding the line.
So let’s be explicit about why the answer was no—and why it needed to be.
What the Evidence Actually Says About COVID Vaccination and Blood Safety
The fear driving these requests is understandable—but it is not evidence-based.
There is no evidence that blood from donors who were vaccinated against COVID-19—or previously infected with SARS-CoV-2—poses increased risk to transfusion recipients.
The strongest data come from a large recipient-linked study published in Transfusion in 2025 (Roubinian et al.). Investigators examined 7,773 transfusion recipients across 8,715 hospitalizations, directly linking over 34,000 plasma and platelet units to donor vaccination and infection status. They assessed outcomes people worry about most: thrombosis, increased respiratory support, and hospital mortality.
They found no association — not with vaccinated donors, not with previously infected donors, not with recent vaccination, recent infection, or high antibody titers (Roubinian et al., Transfusion, 2025).
Concerns about transfusion-transmitted SARS-CoV-2 have likewise failed to materialize. While viral RNA can be transiently detected in blood during infection, infectious virus has not been recovered, and no cases of transfusion-transmitted COVID-19 have been documented. This is why donor vaccination status is not tracked or used in blood allocation.
So when patients request “non-vaccinated blood,” they are not asking for something safer. They are asking for something different, based on a belief that the data do not support.
What Directed Donation Is Actually For
Directed donation exists—but for narrow medical reasons, not reassurance.
Historically, it was used before modern infectious disease testing. Today, it is reserved for specific clinical indications, such as:
Patients with rare blood types or antigen profiles
Situations where compatible community donors are unavailable
Selected pediatric or immunologic scenarios where compatibility constraints are real
Outside of these circumstances, directed donation does not improve safety. In fact, it often makes things worse.
A 2025 multidisciplinary consensus analysis in Annals of Internal Medicine (Jacobs et al.) concluded that directed donation for nonmedical reasons — such as donor vaccination status or personal belief — introduces patient safety risks, operational burden, and societal harm without evidence of benefit.
Why Directed Donation Increases Risk and Cost (Even When Everyone Means Well)
The most persistent misconception about directed donation is that it is, at worst, harmless.
It is not.
Directed donation systematically increases risk, cost, and error—and it does so in predictable ways.
First, donor risk.
Directed donations disproportionately rely on first-time donors, who have consistently higher rates of infectious disease marker positivity than repeat community donors (Dorsey et al., Transfusion, 2013). In addition, directed donors are often under emotional or social pressure, which reduces the accuracy of donor health-history reporting—critical because all testing has a window period (Jacobs et al., Ann Intern Med, 2025).
Second, immunologic risk.
When directed donors are family members, additional hazards appear: HLA alloimmunization, transfusion-associated graft-versus-host disease (necessitating irradiation), TRALI risk, and complications relevant to future transplantation or pregnancy (Jacobs et al., 2025; Weaver et al., Pediatrics, 2023). Community blood is deliberately immunologically “boring.” Directed blood is not.
Third, error and logistics.
Modern transfusion safety depends on standardization. Directed units require special scheduling, labeling, tracking, storage, and coordination across multiple systems. Each deviation from routine workflow increases the risk of mislabeling, misidentification, expiration, delay, or waste. This is a human-factors problem, not a personnel problem (Jacobs et al., 2025).
Fourth, reliability.
Directed donation assumes ideal timing: donors qualify, donate on schedule, units clear testing, surgeries proceed as planned, and blood needs match exactly. In reality, donors are deferred, units expire, surgeries change, and emergencies don’t wait. When directed units fail, patients still receive community blood — often under more urgent conditions.
Fifth, cost.
Directed donation is substantially more expensive: additional recruitment, separate processing and inventory, irradiation, staff time, and higher wastage rates. Who pays is often unclear — the patient, the hospital, the blood center, or all three. There is no evidence these costs improve outcomes (Jacobs et al., 2025).
Finally, system-level harm.
Blood is a shared resource. Normalizing directed donation diverts donors from the community supply, worsens shortages, delays care, and privileges patients with social capital and access. It also implicitly validates misinformation — suggesting that some donors’ blood is inherently safer without evidence.
Where Autonomy Applies—and Where It Does Not
This is where the ethical line must be drawn clearly.
Religious objection to blood transfusion itself is ethically valid. Competent adults may refuse blood products entirely, even if refusal carries serious risk. That is autonomy.
But autonomy does not extend to requesting blood from donors with preferred personal characteristics absent medical necessity.
Religion and moral frameworks may motivate people to donate blood altruistically to the community supply (Maghsudlu & Nasizadeh, 2011; Gillum & Masters, 2010). They do not create a right to receive blood from a chosen category of donors.
Once belief-based donor preferences are accommodated, medicine implicitly endorses them. That opens the door to discriminatory requests — vaccination status today, race or gender tomorrow — and undermines decades of ethical progress in transfusion medicine (Jacobs et al., 2025).
Respecting patients does not require validating unfounded fears or restructuring safety systems around them.
The Uncomfortable Truth
What made this case difficult wasn’t the policy—it was the discomfort.
Saying no feels unkind. Especially when requests are reframed in ethical language. Especially when anxiety is real. Especially when the temptation is to say, “Why not just this once?”
But “just this once” is never neutral.
Every exception teaches something: about evidence, about safety, about whose fears medicine will legitimize. Transfusion medicine exists precisely because we learned—often painfully—that systems protect patients better than intentions.
So yes, we said no. Twice.
Not because we dismiss religion.
Not because we don’t care about comfort.
But because our ethical obligation is to protect patients, preserve trust in the blood supply, and practice medicine grounded in evidence — not fear.
And sometimes, that means holding the line clearly, calmly, and without apology.
References
Roubinian NH, Greene J, Spencer BR, et al. Blood donor SARS-CoV-2 infection or vaccination and adverse outcomes in plasma and platelet transfusion recipients. Transfusion. 2025;65(3):485–495.doi:10.1111/trf.18159
Jacobs JW, Booth GS, Lewis-Newby M, et al. Medical, societal, and ethical considerations for directed blood donation in 2025. Annals of Internal Medicine. 2025;178:1021–1026.doi:10.7326/ANNALS-25-00815
Dorsey KA, Moritz ED, Steele WR, et al. A comparison of HIV, HCV, HBV, and HTLV marker rates for directed versus volunteer blood donations to the American Red Cross, 2005–2010. Transfusion. 2013;53:1250–1256.doi:10.1111/j.1537-2995.2012.03904.x
Weaver MS, Yee MEM, Lawrence CE, Matheny Antommaria AH, Fasano RM. Requests for directed blood donations. Pediatrics. 2023;151(3):e2022058183.doi:10.1542/peds.2022-058183
Maghsudlu M, Nasizadeh S. Iranian blood donors’ motivations and their influencing factors. Transfusion Medicine. 2011;21(4):247–255.doi:10.1111/j.1365-3148.2011.01077.x
Gillum RF, Masters KS. Religiousness and blood donation: Findings from a national survey. Journal of Health Psychology. 2010;15(2):163–172.doi:10.1177/1359105309345171
