The Blood Economy

The United States, the country with the highest global GDP, also supplies 70% of the plasma used worldwide, in a global market projected to reach almost $80 billion by 2034.¹ Growth is driven by aging populations and a rising number of rare disease diagnoses. Plasma is specifically sought out for the treatment of rare diseases, addressing conditions such as immune system disorders and neurological conditions that lack alternative treatment options. This shortage of available substitutes means that the demand for plasma-derived medicines is highly price-inelastic, since treatment cannot be foregone regardless of increasing prices. Supply shortages of plasma directly lead to higher prices and import dependency.

Most developed nations prohibit compensation for the donation of plasma due to ethical concerns, leading to only five countries (the United States, Germany, Austria, Hungary and the Czech Republic) allowing payment for plasma donations, providing 80% of the world's supply.¹ Countries that ban payment in return for donations fail to meet their needs in blood plasma and rely on imports from the five countries that permit it. The United States dominates the supply chain by a wide margin, itself hosting more plasma collection centres than anywhere else in the world. Roughly 200,000 Americans donate plasma every day, and the country exported $6.2 billion worth of plasma products in 2024.²

A Regulatory Advantage, Not a Resource Advantage

The US market behaves like an oligopsony: a market with few buyers and many sellers. A small group of firms, including Takeda, CSL Behring and Grifols, control most plasma collection and processing in the US, yet all these companies are foreign owned: Takeda has its headquarters in Japan, CSL in Australia, and Grifols in Spain.³ These firms focus their operations in the US specifically due to its lax regulations, meaning America's advantage in plasma exportations is a regulatory one, allowing foreign multinationals to collect plasma in abundance from US donors, then process and re-export the finished product globally.

As there exists limited competition on the buyer side, these firms will offer bonuses and loyalty rewards instead of a flat rate, paying just enough to attract donors rather than competing on a single transparent price. This creates a two-tier system where new donors are lured in with large sign-up bonuses, while regular donors are retained through smaller ongoing rewards, more like a loyalty scheme than a standard wage. Because donors have different needs for money, this strategy lets firms pay less overall while still securing enough plasma, and it means there is no single standard price to compare against unpaid systems.

Since the human body replaces plasma proteins within 48 hours, donation is considered safe, and US regulations permit donors to give twice a week.⁴ The drawback lies in the unknown: the long-term health effects of donating at that frequency, sustained over years, have not been established.

The Ethics of Paying for Blood

Many consider the act of paying someone to tap their veins and extract plasma to be potentially exploitative, especially as research finds that sellers tend to be under 35, low-income, underemployed, without a college degree, and with less access to credit cards or personal loans than non-donors. Centres pay around $50 a visit, which for someone earning $15,000 a year is among the highest hourly rates available with no qualifications or experience.⁵ In the Oviedo Convention as well as the Charter of Fundamental Rights of the European Union, the principle of "dignity" is closely tied to the "prohibition on making the human body and its parts as such a source of financial gain."⁶ According to this definition, the purchasing and selling of plasma would be considered a violation of human dignity. As plasma donation disproportionately attracts people from lower socio-economic backgrounds, offering payment in return for said plasma can be viewed as a form of coercion, monetising a person's desperation and challenging the voluntariness of their consent. It poses the question, if even our blood can be commodified, where can we draw the line of what we'd give up for financial gain?

Is the Problem the Market, or Poverty?

It can be argued that poverty is the actual driver of donor vulnerability, and that it exists entirely outside the plasma market. Prohibiting payment does not reduce a donor's underlying financial need; it simply removes an option without offering a substitute.

There is evidence for that view. Gallagher and Dooley found that when a plasma centre opens nearby, local demand for payday loans falls by 6.5% and for instalment loans by 8.1%, with the effect concentrated among borrowers under 35. They estimate that Americans avoid between $180 million and $230 million in high-interest borrowing costs each year because plasma centres exist.⁵ On that reading, paid donation is not competing with a benign alternative. It is competing with payday lending.

Lithuania: A Different Way of Paying

One caveat frames everything that follows: Lithuania's paid system covered whole blood and blood components through a national blood service, not the commercial source-plasma collection described above. Lithuania paid its donors for decades and began moving away from it after joining the EU in 2004, though membership did not require the change: Germany, Austria, Hungary and the Czech Republic all pay and all remain members. What Lithuania offers is therefore not a test of payment as such, but a contrast in how payment is organised. Donation ran through a state blood service that handles more than 70% of the country's donations. Where donors were paid, the rate was a flat 12 euros, set and covered by the government and identical for everyone: a monopsony paying a regulated price, close to the opposite of the American arrangement. The paid share fell steadily, and by 2015 around 75% of donations were unpaid.⁷

Conventional economic theory would predict that paying donors increases supply. Titmuss argued, however, that financial incentives can weaken altruistic motives, reducing people's willingness to donate for the benefit of others and potentially shrinking the donor pool over time.⁸ The Lithuanian evidence is mixed but broadly consistent with this view. Most paid donors believed they deserved compensation, and 12.3% reported that they would stop donating if payment were removed.⁹ The data suggests that the paid donor pool contained a disproportionate number of people with fewer sources of income and who would thereby be more responsive to financial incentives.

This led to a secondary issue, where a study covering 2013 to 2020 found significantly higher infection rates among first-time paid donors than among unpaid donors,¹⁰ implying that donors facing financial pressure may have been more likely to withhold or under-report health risks. Overall, Lithuania's experience suggests that payment can raise supply in the short term at some cost to donor quality. It also suggests that moving away from payment is survivable: by 2020, 99.98% of Lithuanian donations were unpaid, and the system did not collapse.¹⁰

Conclusion: Beyond the Binary

Plasma donation sits at the intersection of economics and ethics. Ethical concerns about human dignity and the possible exploitation of financially vulnerable donors are significant, yet the evidence also shows that systems relying solely on voluntary donation often struggle to meet demand. Lithuania suggests a country can move away from payment without its supply collapsing, though it did so within a system it controlled directly, for a product it consumed domestically. The United States, by contrast, shows that paid donation can sustain a large and reliable global supply, although that supply is shaped by unequal bargaining power and concentrated corporate control rather than a simple competitive market. The sharper question may not be whether donors are paid, but who sets the price. Lithuania's rate was fixed by government and identical for everyone. The American market leaves it to a handful of firms with every incentive to pay each donor the least that donor will accept.