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The case for gift without gain

25 September 2020

Rod Garner celebrates the 50th anniversary of a work that has resonances today

History Collection 2016/Alamy

Richard Morris Titmuss, c.1960s

Richard Morris Titmuss, c.1960s

ON 20 May 2020, as the global pandemic remained the focus of the nation’s attention, the law on organ donation in England changed to an “opt out” model. Unless adults have recorded a decision not to donate on the NHS Organ Donor Register, or told their family, it will be assumed that they agree to donate their organs when they die.

The rationale behind the change is simple and morally compelling. Every day, people die waiting for a transplant, and more donors are required. A single donor can potentially save several lives and help desperate patients to live more fully. The voluntary bequest to another of one’s body parts — whether eyes, valves, kidneys, heart, liver, or lungs — represents a profoundly humanitarian act, prompted by a sense of obligation, and untainted by the prospect of financial gain. It raises notions of belonging and altruism: what we mean by “society”; what we owe to it; and why we freely choose to give of ourselves to others when there is no prospect of material reward.

Fifty years ago, Professor Richard Titmuss addressed such questions with the publication of his book The Gift Relationship: From human blood to social policy. He had been appointed to the newly created Chair of Social Administration at the London School of Economics, with no formal qualifications except a certificate in book-keeping. His attested intellectual rigour, other-worldliness, lean face, and compelling eyes led many to regard him as an “ascetic divine” and even a saint.

He was, more accurately, a principled agnostic, driven by the moral passion of the Old Testament prophets without sharing their religious sensibilities. Frequently referred to as “the high priest of the welfare state”, after his death at the age of 65, in 1973, he was buried in Highgate Cemetery alongside other radicals, sceptics, and freethinkers.


THE Gift Relationship represented the results of a significant study of nearly 4000 British blood donors, and the examination of the provisions made by the United States and the UK to ensure supplies of blood met medical and scientific needs. It proved a critical and unexpected commercial success: The New York Times ranked it as one of the ten most important books of the year.

Within months of its publication, the US President, Richard Nixon, had called for a comprehensive study of the deficiencies that it had exposed in the US system of blood procurement. Titmuss’s meticulously documented analysis — a tribute to his analytical intelligence and fascination with small but telling statistics — had revealed an elaborate commercial trading system in blood which, in two important respects, compared unfavourably with a UK model that depended almost entirely on voluntary donors, who gave blood as an expression of human solidarity.

In purely economic terms, the latter was more efficient in terms of purity of blood, availability, and reliability of supply, cost, and administration. Ethically, the UK practice was also superior; for it constituted a “gift relationship”: a means of relating to “the needs of the universal stranger” through the unprompted acknowledgement of a common humanity.

Blood was the essential medium of life itself: “If you cut us, do we not bleed?” Incapable of being manufactured, it represents the basic proof of what binds us together. Asked in the survey why she gave blood, a young woman who worked as a machine operator replied: “You can’t get blood from supermarkets and chain stores. People themselves must come forward. Sick people can’t get out of bed to ask you for a pint to save their life; so I came forward to help somebody who needs blood.”

Similar replies came from others questioned, ranging from bank managers to maintenance fitters.

The book proved Titmuss’s crowning achievement. It reflected the overriding concern that had characterised his work over the previous 30 years: his insistence that society, through the complex network of its government and statutory agencies, should uphold and affirm non-economic values.

In this respect, he regarded the system of voluntary blood donors as an important example of altruism. It limited the bounds of self-interest and financial gain, and “the gift relationship” acted as a necessary corrective to a market economy concerned only with supply and demand, without regard for the common good or the social practices, commitments, and mutual obligations that make human flourishing and a just society possible.

Titmuss knew about such things from personal experience. He did not belong to an élite: he came from a family who had fallen on hard times. After an education interrupted at the age of 14, working in an insurance company for 11 years had given him direct access to the social statistics that revealed the “shockingly class-determined incidence of illness and early death”. Wealth, health, and income were all unfairly distributed.

Covid-19 has exposed the same inequalities in our own day, together with the low priority and status that successive governments — and the nation — have tolerated in relation to social and nursing care and its practitioners.


ALMOST half a century after his death, Titmuss remains an influential voice. The Gift Relationship is still read, and is acknowledged as a classic. An annual lecture and a professorial chair at the LSE bear Titmuss’s name. More generally, his thinking in the field of social policy and welfare continues to generate debate and a significant body of academic literature. Not all critics share his redistributive ideals or proposals, but few deny the serious ethical purpose underpinning both.

In an age still dedicated to consumerism and competition, Titmuss reminds us that there are moral limits to markets. Not everything that matters can be bought and sold. Whether in the form of blood or organ donation, altruism constitutes an indispensable moral and civic virtue that money cannot buy.


Canon Rod Garner is an Anglican priest, writer, and theologian.

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