A Laboratory of Behavioural Interventions by Nicola Lacetera and Mario Macis

Blood transfusions allow medical professionals to address a wide variety of emergencies, from trauma-induced blood loss to blood replacement during surgeries. Population aging and the increase in surgical procedures such as organ transplants are further increasing the demand for blood. The question is, What will influence human behaviour more: appealing to altruistic motives to the request or providing an economic incentive? We decided to find out.

Interventions targeting altruistic motives. According to the guidelines of the World Health Organization, the objective of national blood procurement and allocation systems is “to obtain all blood supplies from voluntary non-remunerated donors.” There are several ethical and behavioural foundations at the origin of this stance. The first is a strong reliance on the power of altruism as a motivator: People might want to help others because of a genuine desire to increase the other’s wellbeing, even at the expense of their own. In his 1759 book The Theory of Moral Sentiments, Adam Smith claims that this “virtue of beneficence” derives from natural human sympathy. Behavioural scientists call this tendency ‘warm glow’ or ‘impure altruism.’ Another strong underlying source of altruistic behaviour is the desire to signal to others — or to oneself — that one is ‘a good person,’ and to improve one’s reputation in a community. Yet another source of altruism derives from reciprocal feelings, whereby a person behaves altruistically with the expectation that the recipient will reciprocate in the future, should the need arise.

Interventions applying economic incentives. The second key behavioural claim at the root of promoting purely altruistic donations is that material rewards or compensation might actually have perverse effects that do not correspond with the ‘rational agent’ view. According to this view, the higher the reward for an activity, the more an individual will make an effort in that task. In his 1970 book The Gift Relationship, British scholar Richard

Titmuss claimed that material rewards might change a donor’s perception of the nature of their act from being altruistic to resembling a market exchange. This could reduce altruistic drive without a counterbalancing increase in material incentives — especially if the amount of the reward is small. Titmuss also argued that monetary incentives would attract donors with a higher risk of carrying infectious diseases. According to Titmuss’s hypothesis, rewards are especially appealing to low-income individuals who are, in turn, more likely to be affected by blood-transmissible diseases due to unhealthy lifestyles and risky behaviours.

The strong objections to providing any form of compensation to blood donors derive from multiple concerns. At the same time, both in the Western world and even more so in low- and middle-income countries, guaranteeing the availability of blood for transfusions is critical and has proven difficult. The seasonality of the blood supply compared to the constant need, moreover, adds to the difficulty of keeping an adequate inventory level. Even in contexts where the organization of procurement and allocation is advanced, relying on altruism is often insufficient to cover the demand for blood.

This conundrum has stimulated efforts to devise incentive programs that would minimize potential ‘crowding out’ effects as well as addressing ethical concerns. In Italy, for example, employees have the right to a paid day-off work on the day they donate. In our own research we investigated the effectiveness of this policy and found that those who benefit from it do indeed donate blood more frequently. This implicit economic incentive, however, is expensive: We estimated that each additional unit of blood collected due to the ‘day-off incentive’ would cost about 400 Euros.

In the U.S., American Red Cross (ARC) blood drives sometimes offer rewards such as T-shirts and gift cards to people who donate. In research we did in collaboration with the ARC, we found that these rewards did increase donations, with rewards of higher economic value resulting in more additional donations than rewards of smaller value. However, we also found that part of the increase in donations at blood drives offering rewards came from a reduction in turnout at neighbouring blood drives that were not offering incentives. On the one hand, our findings highlight the importance of carefully distributing rewards across geographic areas to avoid competition between blood drives, and on the other, they imply that the use of rewards in periods with lower seasonal supply can be effective.

Our research indicates that even small economic rewards can increase donations in a cost-effective way. For example, the cost of one extra unit of blood collected using a $5 gift card as an incentive was $22. In recent years, the ARC has offered gift cards during periods of low supply — for example, in the winter. In an intervention conducted in collaboration with an Argentine blood bank, we found again that gift cards motivated additional donations, whereas ‘social-image stimuli’ (e.g. T-shirts with designs indicating the wearer was a blood donor) were not as effective.

Overall, the evidence demonstrates that certain economic incentives have positive consequences in terms of the quantity of blood collected. People respond in a rather standard way: higher-value rewards have bigger effects than lower-value rewards — even in the case of an archetypically altruistic activity like blood donation. The fact that several organizations allow and make broad use of (appropriately framed) economic incentive programs suggests that there are further opportunities out there to leverage motives beyond altruism — so long as it is done in a way that is socially and ethically acceptable.

Nicola Lacetera is Chief Scientist at the Behavioural Economics in Action Research institute (BEAR) at the Rotman School of Management and a Professor of Strategic Management in the Department of Management, University of Toronto Mississauga with a cross-appointment to the Rotman School. Mario Macis is a Professor of Economics at the Johns Hopkins Carey Business School and Affiliate Faculty at the Hopkins Berman Institute of Bioethics. This is an excerpt from their chapter in Behavioural Science in the Wild (Rotman-utp Publishing, 2022.)