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The ethics of wasting the donor’s gift of buffy coat: response to E.C. Vamvakas

Dear Editor, We are grateful for the opportunity to respond to the letter by E.C. Vamvakas. He concludes that in countries that use platelets from first-time whole-blood donors in buffy coat pools, there is a ‡ twofold difference in the risk of human immunodeficiency virus, hepatitis C virus and hepatitis B virus infections between buffy coat–derived pooled platelet concentrates and single-donor platelet concentrates. However, this is based on mathematical models. As already discussed, recently many assumptions affect the results of mathematical models and delimit their conclusions [1,2]. This risk assessment cannot be generalized because it depends on many factors, for example number of split products produced during an apheresis session from an infectious donor, number of donations in a window period, number of pooled buffy coats, strategy for selection of donors for buffy coat pooling, methods and sensitivity of infectious disease marker testing etc. We appreciate the two new aspects that are entered into this debate by the letter of Dr Vamvakas: (1) He argues that ‘the right of transfusion recipients supersede any rights of donors who have given informed consent for the procedure and are aware of its risk’. We disagree with this statement. Physicians in transfusion medicine are committed to balance the optimal treatment for patients and the safety of the donors. An informed consent by the donor does not imply a general justification of all interventions. The key point is the content of the informed consent. To give informed consent, individuals should understand the purpose, process, risk, benefits and alternatives of a proposed clinical intervention. There is a general agreement that a careful consideration of the alternatives to the planned intervention is an essential element of making an informed choice to enrol patients in a biomedical research study [3]. However, this should also apply to routine interventions and also to volunteer donors. In the context of this debate on the type of platelet concentrates, the crucial point is whether plateletpheresis donors are sufficiently informed about the alternatives, i.e. possibility to prepare platelet concentrates from available whole-blood donations? Is it general practice to inform plateletpheresis donors that at the same time other donor’s gift of buffy coat from whole blood is discarded? Would all platelet apheresis donors who give consent without hesitation would still determinately consent if they knew about the alternative (in this case: preparation of platelets from already available buffy coats)? A critical review of informed consent forms for whole-blood donations used by US blood centres revealed a substantial heterogeneity and also a lack of common essential or specific blood donation information desired [4]. Another recent study suggests that donors do not always fully comprehend the risk of donation [5]. These thought-provoking results should remind us that the ‘informed’ consent by the plateletpheresis donor is not necessarily the last point in this discussion. (2) A complete supply for all of a country’s red blood cell (RBC), platelet and plasma needs by multicomponent apheresis is a very ambitious goal. This approach should be examined carefully, and multicomponent apheresis might become the standard for collection in the future. However, despite increasing use of red cell apheresis, the number of RBC concentrates derived from whole-blood donations still outbalances the number of apheresis-derived RBC concentrates. The projection of a fundamental change how we might collect blood products in the future does not supersede the decision-making for the optimal use of the wholeblood donations we currently collect every day. Thus, as expressed earlier we recommend that for the time being both buffy coat–derived pooled platelet concentrates and apheresis platelet concentrates should be available. As long as we collect a large number of whole-blood donations, we should continue to prepare pooled platelet concentrates from buffy coat and should prefer this type of platelet concentrates unless specific conditions require apheresis platelet concentrates [1].