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© 2019 Medical Ethics and History of Medicine Research Center, 

Tehran University of Medical Sciences. All rights reserved. 

 

Original Article 

Volume 12     Number 1     January 2019 

*Corresponding Author 
  
Forouzan Akrami 

Department of Bioethics, Medical Ethics 

and Law Research Center, Shahid 

Beheshti University of Medical Sciences, 

1st Floor, N0. 8, Shams Alley, Tavanir 

Station, Vali-Asr Square, Tehran, Iran. 

Tel: (+98) 21 88 78 10 36  

Fax: (+98) 21 88 77 75 39 

Email: froozan_akrami@yahoo.com 

 

Received: 02 Sep 2018 

Accepted: 03 Nov 2018 

Published: 22 Jan 2019 

 

Citation to this article:  

Asghari A, Pourfathollah A, Abbasi M, 

Mohammadi T, Akrami F. Adoption of 

Iran’s code of ethics for blood donation 

and transfusion as a public health policy. 

J Med Ethics Hist Med. 2019; 12: 1. 

 

 Abolfazl Asghari1, Aliakbar Pourfathollah2, Mahmoud Abbasi3, Tooran Mohammadi1, Forouzan Akrami4* 
 

1. Researcher, Blood Transfusion Research Center, High Institute for Research and Education in Transfusion 

Medicine, Tehran, Iran. 

2. Professor, Department of Immunology, School of Medicine, Tarbiat Modares University, Tehran, Iran. 

3. Associate Professor, Medical Ethics and Law Research Center, Shahid Beheshti University of Medical Sciences, 

Tehran, Iran. 

4. Researcher, Department of Bioethics, Medical Ethics and Law Research Center, Shahid Beheshti University of 

Medical Sciences, Tehran, Iran. 

Abstract  

Blood is a public resource of human origin and its transfusion 

process is essential to individual and public health. This study 

aimed to develop a national code of ethics for blood donation 

and transfusion (BDT). 

This was a qualitative research with a multi methods approach 

in which a combination of methods including situational 

analysis, focus group discussion and expert panels were used. 

After situational analysis and orientation, the code of ethics for 

BDT was developed based on the findings of a content analysis 

within the framework of the four principles of biomedical ethics.  

The results were categorized into two sections: situational 

analysis and underpinnings measures, and the clauses of the 

code. The Iranian Blood Transfusion Organization has carried 

out three essential supportive measures over the past decades: 

approval of insurance coverage of blood recipients against 

communicable diseases; inclusion of 14 blood services in the 

book of “Relative Value Units of Health Services”; and 

formation of the National Ethics Committee of Transfusion 

Medicine. After recognition and orientation, the national code 

of ethics for BDT was adopted and imparted to blood donation 

centers. The code consists of two sections: “Blood Transfusion 

Centers: Donors and Donation” in 19 clauses, and “Hospitals: 

Patients” in 8 clauses. 

The national code of ethics for BDT establishes moral norms in 

order to protect the rights of blood donors and recipients. It 

could also serve as a basis for addressing the related ethical 

challenges and right decision-making in the area of BDT. 

Keywords: Ethics/morals; Blood transfusion; Donation; 

Public health 

  

Adoption of Iran’s code of ethics for blood donation and transfusion 
as a public health policy 



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Volume 12     Number 1     January 2019 

 

  Introduction 

Due to the functional necessity of 

establishing social relations based on 

common ethical values, most professions 

have implicitly accepted to observe a series 

of ethical guidelines as the code of 

professional ethics, which is recognized by 

members of that profession. In recent years, 

guidelines have been formulated in the form 

of codes of ethics for medicine, nursing and 

research (1). 

The code of ethics refers to a collection of 

moral norms developed in a specific 

profession based on a common value 

system. The purpose of establishing these 

codes is the identification and prioritization 

of ethical values in order to guide the right 

action and address the ethical challenges 

within the profession. The criteria can be 

used to assess professional competence and 

accountability to some extent. The 

Hippocratic Oath is one of the first pledges 

that medical graduates take and are expected 

to observe. According to this oath, 

physicians should apply their utmost effort 

and specialty to prevent harm to patients and 

promote medical preservation, and refrain 

from unfair treatment of individuals, 

assistance with euthanasia and abortion, and 

involvement in any act of abuse, especially 

sexual abuse (2). 

Professional moralities include ethical codes 

and standards for a special profession or 

setting, and are one form of a particular 

morality (1). Thus, each country establishes 

a code of ethics in medical areas in 

accordance with the human rights charter, 

international codes, and its own politico-

moral philosophy. There is no unique model 

for appropriate responses against 

conscientious refusal that would apply to all 

beneficiaries and all cases; however, it has 

been recently emphasized that a code of 

ethics should contain ethical “musts” and 

“must nots” as well as the moral virtues in 

each professional area (1). Given the fact 

that these codes are written by experts in the 

profession, surveying beneficiaries and 

public opinions seems necessary to preserve 

the rights and needs of patients and the 

public. 

Blood is a public resource of human origin, 

and its donation and transfusion process is 

essential to protection and improvement of 

public health (3). The special nature of blood 

and its components distinguishes them from 

other medicines and therapies, and therefore 

the world medical organization (WHO) has 

categorized them as essential medicines (4). 

In 1975, WHO adopted statement number 

28.72 on “Utilization and Supply of Human 

Blood and Blood Products”, demanding that 

commercial activities in the private sector in 

the area of plasmapheresis take note of the 

prevailing health threats and ethical 

consequences, and emphasizing the 

necessity of establishing regulations to 

protect the health of donors. This statement 

asked member governments to develop 

blood transfusion (BT) on a voluntary and 

non-remunerated basis before discussing the 

issue of the code of ethics for blood donation 



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Volume 12     Number 1     January 2019 

and transfusion (BDT). There were serious 

concerns about concentrating exclusively on 

the production and provision of more blood 

and blood components and disregarding the 

threats to the health of donors and the 

quality and safety of donated blood. 

Consequently, WHO and the International 

Society of Blood Transfusion (ISBT) 

worked together to develop the code of 

ethics for BT to address these concerns and 

regulate the relationship between blood 

transfusion centers, blood donation 

volunteers and patients based on the mutual 

rights and obligations specified by ISBT. 

The above-mentioned code was adopted by 

the general assembly in 1980 (5) and 

updated in 2000 with an emphasis on the 

importance of voluntary non-remunerated 

blood donation, and was later amended by 

WHO and Red Cross associations on 

September 5, 2006 (6).  

In the years 2005 and 2010, WHO adopted 

two statements on the observation of the 

rights of blood donors and recipients: 1) 

Blood Safety: Proposal to Establish World 

Blood Donor Day (No: 58.13), and 2) 

Availability, Safety and Quality of Blood 

Products (No: 63.12) (7). Accordingly, the 

January 2017 report shows that the 

organization has established a framework in 

terms of ethical rules as well as structural 

and procedural requirements for human-

originated medical products with the aim to 

write a comprehensive and integrated 

document, which was published after a 

widespread survey (8). As a basis for the 

health of donated blood, quality assurance 

cannot bring the risks to zero (9, 10); 

however, due to the inherent risks of BT, the 

code of ethics for BT can be considered as a 

guarantee for donation and health of the 

donated blood in functional terms.  

The Iranian Blood Transfusion Organization 

(IBTO) was established in May 1974 with 

the main goal of providing safe blood and 

blood components. The safety and adequacy 

of blood supply depends on well-managed 

blood donation and distribution by the 

steward organization. The key strategy to 

provision of adequate and safe blood supply 

is recruitment and retention of voluntary and 

non-remunerated blood donors (11). 

Although blood donation in an Iranian-

Islamic context is considered as a charitable 

and ethical act, it is necessary to raise 

awareness among community members and 

encourage them to continuously donate 

blood. A 2009 study of the knowledge, 

attitudes and practices of the Iranian 

population on the subject of blood donation 

showed that 55% of the donors had donated 

blood more than once. The most common 

motivation for blood donation was altruism, 

and the most important obstacle was the 

difficulty of access to donation centers (12). 

On the other hand, the commitment of the 

steward organization to support the right to 

health care requires enhanced community 

participation and the trust of blood donors. 

By developing and enacting the code of 

ethics, the IBTO can increase the supply of 

safe blood through reassuring the public, 



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Volume 12     Number 1     January 2019 

resolving their concerns and doubts, and 

establishing good services.   

Thus, considering the politico-moral 

foundations of the country’s health care 

system, including the right to health care and 

the obligation of the state to provide it, and 

observation of distributive justice with a 

focus on vulnerable and disadvantaged 

groups (13), the present study aimed to 

develop the national code of ethics for BDT. 

 

  Method 

In this qualitative study, the multi-method 

approach was used, which is a combination 

of methods that produce data of the same 

type (14). This approach brings about 

integrity of the findings and increases the 

credibility of the research (14, 15). In the 

present study, the data obtained at different 

stages of the study were mainly of 

qualitative type. Establishment of the code 

of ethics for BDT in Iran began in December 

2015 in response to the proposal of the 

director of the IBTO to the legal department 

of the organization.  

In the first stage, analysis of the current 

situation was performed through an 

investigation of relevant publications using 

Mesh subheadings of “blood” [MeSH 

Terms] and “ethics” [MeSH Terms] in 

PubMed database; Non-Mesh subheadings 

of “ethics” and “blood donation and 

transfusion” via Google Scholar search 

engine; and the IBTO website for national 

documents. At the next stage, a focus group 

discussion was held to receive opinions 

about the themes to be considered in the 

drafting of the code as well as the main 

ethical issues in BDT. The focus group 

consisted of 14 expert specialists in the 

fields of medical ethics (2 persons), medical 

law (2 persons), medicine (2 persons), 

pharmacy (2 persons) and organizational 

management (6 persons). These people were 

selected purposefully by the supreme 

council of IBTO. After explaining the 

purpose of the study and obtaining verbal 

consent of the participants, formal invitation 

letters were sent to them. The group 

discussion was conducted and recorded by 

the first researcher and lasted 1 hour. The 

collected data were analyzed using 

deductive content analysis under the two 

main categories of Blood Transfusion 

Centers: Donors and Donation, and 

Hospitals: Patients 

Considering the international code of ethics 

for BT and the findings of the group 

discussion, the national code of ethics for 

BDT was drafted and codified within the 

framework of principlism. The primary draft 

was discussed and completed in two expert 

panels with the contribution of 12 member 

persons of the Supreme Council of IBTO, 

including experts in the fields of blood 

transfusion medicine (3 persons), medical 

ethics (2 persons), medical law (1 person), 

immunology (1 person), hematology (1 

person), pharmacy (1 person), pathology (1 

person), community medicine (1 person), 

and Food and Drug Administration (1 

person). The second draft was then sent as 

an official letter to 10 managers of the 



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Volume 12     Number 1     January 2019 

provincial bureau of blood transfusion, 3 

specialists of blood transfusion medicine, 

and 3 specialists of medical ethics who were 

not employed in the IBTO for external 

review. Simultaneously, the comments of 6 

community members who were familiar 

with blood transfusion concepts were also 

collected. After receiving the comments and 

applying them, the third draft was submitted 

to the department of quality assurance and 

control as well as the deputy of technics and 

new technologies of the IBTO in order to 

receive their approval. The last draft was 

then propounded and finalized in the 

meeting of the ethics council on transfusion 

medicine in February 2017, and was adopted 

and communicated to blood transfusion 

centers throughout the country. A number of 

the clauses in this code refer to the 

performance of hospitals regarding the 

transfusion of blood and its components, and 

the way in which patients use such services. 

Therefore, in October 2017, the national 

code of ethics was discussed and approved 

with minor revisions in a meeting with 

representatives of the main stakeholder 

organizations including the Ministry of 

Health and Medical Education, Medical 

Council, and Council of Ethics of the Iranian 

Academy of Medical Sciences. 

Selection of the participants in discussion 

sessions was based on the objectives of the 

study. All research steps were in accordance 

with the national code of ethics in 

biomedical research. Verbal consent was 

obtained from the participants to attend 

discussion sessions, and official invitation 

letters were sent to them before each session. 

 

  Results 

The results are categorized in two sections: 

the current situation and underpinning 

measures, and the code of ethics for BDT.  

A) The current situation and underpinning 

measures 

IBTO is a non-profit organization affiliated 

to the Ministry of Health and Medical 

Education and operated by the supreme 

council, which is composed of five expert 

members selected by the minister of health 

as the decision maker and managing director 

as the pillar of implementation. According to 

article 4 of the statute of the IBTO, adopted 

in 1984, the supply, provision and 

distribution of blood should be entirely free 

of charge. In the case of blood products and 

derivatives that require specialized and 

costly processes, according to article 7, 

clause (c) of the statute, the cost of the added 

processes can be received based on the tariff 

approved by the supreme council of IBTO. 

According to the organization’s statute, 

blood transfusion services such as the recall 

and recruitment of volunteers for donating 

blood and cellular and plasma products, the 

selection of donors from among these 

volunteers, blood sampling and screening, 

and preparation and distribution of the blood 

and blood components to the hospitals is 

exclusively the responsibility of IBTO. In 

this regard, the prescription and transfusion 



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Volume 12     Number 1     January 2019 

of blood and blood components is beyond 

the responsibility of the organization and 

falls within the expertise of responsible 

physicians. However, article 7, clause (d) of 

the organization’s statute is merely 

implemented in hospitals through the 

supervision of the IBTO according to the 

“Code of Activity of the Blood Bank and 

Blood Consuming Sectors” as one of the 

requirements for ensuring the health of the 

blood cycle. All hospitals have a structure 

called the BT section, which operates as 

blood bank and blood transfusion center and 

management. The BT department and the 

physician in charge collaborate to manage 

the blood transfusion cycle, since the need is 

announced for the blood and blood 

components until they are administered and 

the patient’s state is preserved. 

One document that is observed in the 

records of the IBTO is the “Ethics Charter”, 

in which the seventh clause and its following 

four sub-clauses refer to the ethical 

principles of blood donation. This clause 

comprises issues such as voluntary donation, 

obtaining the written consent of volunteers, 

preserving donors’ health, the necessity of 

donors’ awareness of their ethical 

responsibility toward recipients of blood and 

the possible risks of transmitting infections, 

and the confidentiality of donor information. 

The IBTO has adopted the following 

measures in the past decade, which can be 

considered as supportive actions for donors 

and recipients of blood transfusion services: 

First, based on the proposal of the IBTO and 

the approval of the Islamic Consultative 

Assembly of Iran in 2007, recipients of 

blood transfusion services were covered by 

insurance companies against the possible 

complications of blood consumption. In the 

following years, the IBTO provided 

insurance for not only recipients, but also 

blood donors against such probable events. 

Second, fourteen cases of blood transfusion 

services were mentioned in the second 

edition of the book titled “Relative Value 

Units of Health Services” since 2015 

through approval of the supreme council of 

health insurance and approval of the cabinet 

of ministers, and these services are currently 

covered by social security. Third, the “Ethics 

Committee of Blood Transfusion Medicine” 

was established with the aim of determining 

the policies and strategies related to the 

ethics of BDT and decision making about 

the ethical challenges in this area, as well as 

developing and supporting education and 

research activities in terms of the ethical 

considerations in BDT. Finally, formulation 

of a code of ethics for BDT was included in 

the IBTO agenda.  

B) Code of Ethics for Blood Donation and 

Transfusion 

Using deductive content analysis, the 

following themes emerged under two main 

categories:   

1) Blood Transfusion Centers: Donors and 

Donation  

In this category 8 themes were extracted: 

voluntary non-remunerated blood donation; 

respect for the rights of donation volunteers; 



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continuity of donation and assurance of the 

safety of blood supply; requirements for 

maintaining safety of the blood transfusion 

cycle from donation to injection; 

commitments and obligations of blood 

transfusion centers; privacy and 

confidentiality; exemptions; and education 

and research.  

2) Hospitals: Patients 

The following 4 themes emerged in this 

category: protecting the rights of blood 

recipients; responsibilities and obligations of 

blood transfusion centers; observing clinical 

standards; and managing blood 

consumption.  

The code of ethics for BDT was formulated 

and adopted based on the obtained 

subthemes and in the framework of the four 

principles of beneficence, non-maleficence, 

respect for autonomy and justice. The code 

included an introduction and the main body, 

which consisted of two parts: “Blood 

Transfusion Centers: Donors and Donation” 

in 19 clauses, and “Hospitals: Patients” in 8 

Clauses (Appendix). 

Blood Transfusion Centers: Donors and 

Donation 

The first clause of section 1 emphasizes 

voluntary, non-remunerated blood donation, 

done only for the purpose of helping one 

another and with altruism as motivation. 

Thus, volunteers donate their blood freely 

without expecting any type of 

reimbursement such as cash or cash 

alternatives. On this basis, even the granting 

of a work leave is recognized as a form of 

wage, unless it is necessary for the referral 

and conduct of the donation process. 

However, entertaining donors or 

reimbursement of transportation costs is 

acceptable when necessary.  

Clauses 2, 3 and 4 concern the informed 

consent of donors and related issues. Clause 

5 emphasizes donors’ awareness of the 

consequences and risks of donating blood 

and their ethical responsibility toward the 

recipients of donated blood. According to 

clause 6, donors must answer the questions 

that are asked of them honestly and 

accurately. Clause 7 points out that blood 

transfusion centers are obliged to inform 

donors about cases of exemption from blood 

donation as well as the reasons, and if the 

volunteer is exempted, the center should 

declare the cause, type and duration of the 

exemption. Clause 8 emphasizes that care 

and recommendations after blood donation 

should be clearly explained to volunteers/ 

donors, and this should be confirmed by 

them. Clause 9 clarifies that donors can 

cancel the blood donation process at any 

stage. Clauses 10 and 11 emphasize the 

necessity of respecting the privacy of 

volunteers/donors and the confidentiality of 

their information, and states that they should 

be aware of these considerations. Clause 12 

emphasizes that blood donors and recipients 

should not be aware of one another’s 

identity, barring exceptional cases. 

Clauses 13 and 14 point out the necessity of 

observing the national BT standards and 



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state that all BT processes should be carried 

out under supervision of a qualified 

physician. Clauses 15 and 19, respectively, 

refer to non-discrimination on the grounds of 

gender, race and socio-economic status, and 

fair access for all patients. Clause 16 states 

that blood donors and recipients should be 

aware of any complications, and clauses 17 

and 18 emphasize that the organization 

should avoid profitable incentives and 

develop executive processes to prevent the 

loss of this public resource and protect 

individual and public health. 

Hospitals: Patients 

In this section, in addition to the emphasis 

on patients’ best interests, clause 1 

highlights the right of patients to be aware of 

the risks and benefits of transfusion and 

alternative therapies. Moreover, clause 2 

states that transfusion of blood and blood 

components should only be conducted with 

the informed consent of the patients, their 

parents or legal representatives. Based on 

clause 3, the patient can cancel the process 

of receiving blood at any stage of the 

treatment. To make this decision, the patient 

should be aware of the potential 

consequences, and the decision should not 

affect the behavior and function of the 

hospitals and their staff. In clause 4, based 

on the charter of safety of blood and its 

components, all relevant processes in the 

treatment centers must be in accordance with 

national BT standards. According to clause 

5, the only basis for the administration of 

blood transfusion is the clinical condition of 

the patient, and in cases where the patient 

needs only a particular part of blood (for 

instance plasma or cell derivatives), 

prescribing the whole blood is not allowed. 

Clause 6 states that prescribing blood or 

blood components should not be based on 

financial incentives or benefits. Clause 7 

specifies that adoption of measures such as 

the use of blood substitutes, autologous 

transfusion, limited use of blood transfusion, 

and optimal blood management are the 

professional obligations of medical 

practitioners. Finally, according to clause 8, the 

administration and transfusion of blood and/or 

blood components should be carried out under 

the supervision of qualified physicians. 

 

  Discussion 

The main goal of the IBTO is to provide 

universal access to sufficient and safe blood 

and blood products and ensure their 

appropriate clinical consumption. The 

situation analysis indicates the necessity to 

establish the national ethics committee of 

transfusion medicine and develop the main 

infrastructures, including regulations on the 

provision of safe and sufficient blood 

supply, by the supreme council of IBTO 

over the past decade (16). Leadership and 

governance is one of the main domains that 

has been emphasized and assessed by the 

WHO-Eastern Mediterranean Region. The 

assessment report of blood transfusion 

services showed that among 18 respondent 

countries, 14 have a national policy, 13 have 

strategic plans, 12 have advisory 



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committees, and only 9 countries have a 

legislative mechanism (17). 

Based on the “framework for action for 

blood safety and availability 2016 - 2025” 

(17), the second phase of the present study 

was performed to develop and implement a 

legislative system for supervising the blood 

donation and transfusion services. 

Accordingly, the national code of ethics for 

BDT was formulated and codified based on 

scientific standards and the four principles of 

biomedical ethics and its derivatives, 

including: consideration of the benefits and 

burdens of patients and donors; respect for 

autonomy and the rights of donors and 

patients; emphasis on respect for privacy and 

confidentiality of information; and equity in 

two sections: “Blood Transfusion Centers: 

Donors and Donations” and “Hospitals: 

Patients”. Due to the nature of blood and 

blood donation as a public resource, the first 

section of the national code was mostly 

formulated based on the principles of public 

health ethics (18, 19). The second section, 

however, was mainly focused on the 

principles of clinical ethics due to its patient-

centered nature (20). For this reason, in the 

second section of the national code, all the 

terms of the international code have been 

addressed and the obligations of health 

professionals according to clinical and para-

clinical guidelines have been emphasized. 

The code of ethics of ISBT has also been 

divided into two sections: “Blood 

Transfusion Centers: Donors and Donations” 

in 11 clauses, and “Hospitals: Patients” in 7 

clauses. The pillars of this code are the 

following ethical elements (21): the 

principle of voluntary non-remunerated 

blood donation without material incentives 

as the basis for blood transfusion services, 

and universal access to blood as a public 

resource. A review of the 2017 version of 

the international code indicates that the 

revision has been based on human dignity 

and the four principles of biomedical ethics, 

which is similar to the national code 

developed in this study. The difference in 

the number of clauses in the first section is 

due to the emphasis on instances of 

informed consent and the ethical 

responsibility of volunteers for public health 

in the national code.  

Access to blood mainly relies upon 

voluntary and non-remunerated contribution 

of a human donor (22). Thus, the first clause 

of section 1 emphasizes voluntary and non-

remunerated blood donation with the motive 

of altruism. A survey conducted in Shiraz 

Blood Transfusion Center on motivations for 

blood donation showed altruistic causes to 

be the main motive at 65.3%, while other 

common motivations included controlling 

individual health status, earning money, 

treating illnesses and curiosity in that order 

(23). According to the regional strategic 

framework for blood safety and availability 

(2016 - 2025), the volunteers/donors and 

their actions must be respected, and all 

necessary measures should be taken to 

protect their health and safety, and to ensure 

that blood products are equitably and 



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appropriately distributed (17). Therefore, 

given the importance of protecting donors as 

the main source of blood supply in 

continuous voluntary non-remunerated 

blood donation, the next clauses mainly 

focuse on respecting the rights of the 

volunteers/donors.  

One of the 10 basic functions of public 

health is mobilizing the community to 

contribute to solving health problems (24). 

A sense of social responsibility will lead to 

participation in public health activities to 

achieve public good. According to Weed 

and McKeown et al. responsibility is a 

profound concept that is linked to 

commitment to someone or something. 

Therefore, being responsible entails 

commitment to a positive action, or the 

attempt to achieve a high value such as 

social or public good (25).  

In public health, social responsibility has 

been considered as a moral norm, which, in 

addition to promoting participation, helps to 

protect and promote public health (26). In 

this area, people are responsible for what 

will happen if preventive measures are not 

applied, which is referred to as 

consequentialist responsibility (27). With 

regard to blood donation for check-up 

purposes, especially by donors with high-

risk behaviors, clauses 5 and 6 emphasize 

the moral agency of the donors and 

confidential self-exclusion strategy to ensure 

the health of both donors and recipients (28). 

In terms of accountability (17), the focus of 

these clauses is on the proper governance 

and management of the blood transfusion 

cycle. As previously mentioned above, the 

second section of the code is mainly patient-

centered; clauses 1, 2 and 3 of this section 

pertain to respecting the rights of recipients 

and patients, while the succeeding clauses 

are about observing professional standards 

and patient blood management. Promotion 

of the clinical use of blood and blood 

products (17) and patient blood management 

are priority interventions to optimize the 

care and improve patient safety and clinical 

outcomes (29, 30).  

In the next phase of the study, the revision of 

the code will be considered 3 years after 

adoption. For this purpose, the new national 

evidences and recommendations of the main 

stakeholders will be investigated with more 

focus on the moral norms in public health 

policy and the stewardship role of the IBTO.  

 

  Conclusion  

The developed national code of ethics for 

BDT adopts moral norms for protecting the 

rights of blood donors and patients alike. It 

uses human rights literature and the values 

of the Iranian health care system and 

transnational documents within the 

framework of citizenship laws. These norms, 

along with cultural beliefs and values, 

develop a common ethical framework in the 

relationships among volunteers/donors, 

blood transfusion centers, health centers and 

hospitals, medical doctors and other health 

professionals, and the patients; at the same 

time, they provide a basis for addressing 



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ethical challenges and making the right 

decisions in the area of BDT. Since these 

moral norms have been formulated based on 

respect for the rights of volunteers and 

donors, they can encourage volunteers to 

continue donation and can be effective in 

supplying adequate and safe blood supplies. 

The internalization of these moral norms as 

well as their observation as an organizational 

behavior by medical professionals and blood 

donors can ensure the implementation of the 

code.  

  Acknowledgments 

Financial support was provided by IBTO 

and the Research Deputy of SBMU. Authors 

appreciate the academic board and experts 

who contributed to this national study.  

 

  Conflict of Interests 

The authors declare that they have no 

conflict of interests. 

 

 

 

  



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Appendix 

Iran’s Code of Ethics for Blood 
Donation and Transfusion 

 

Purpose  

The purpose of the code is to establish 

ethical and professional principles that 

should be observed in all activities in the 

field of blood donation and transfusion 

according to the Iranian Blood Transfusion 

Organization (IBTO).  

 

Introduction 

The code of ethics for blood transfusion and 

donation puts forward a set of moral norms 

to protect the rights of blood donors and 

patients. These norms, along with cultural 

beliefs and values, establish a common 

moral system for blood donors, blood 

transfusion centers, medical centers, medical 

practitioners and patients, while establishing 

a basis for addressing ethical challenges and 

making related decisions and solutions. The 

main foundations for developing the code 

included: observing scientific and ethical 

principles, considering donors’ and patients’ 

interests as well as harms that they may 

suffer, emphasizing the privacy and 

confidentiality of donors’ information, 

respecting the dignity and rights of patients 

and donors, and obtaining informed consent. 

 

Definitions 

“Blood Donation” is the voluntarily 

donation of blood, which is collected either 

for direct transfusion or preparation of a 

medicinal product for human use.  

“Blood Transfusion Center” refers to an 

entity that is responsible for any aspect of 

the recruitment of donors, collection and 

screening of blood, and also blood 

processing, storage, and distribution, when 

intended for transfusion.  

“Screening” refers to a laboratory process 

that determines the safety of donated blood 

by performing tests to detect certain 

infectious agents transmitted through the 

bloodstream. 

“Qualified Physician” is a person who holds 

a valid medical professional license and has 

passed related training courses and received 

a certificate. 

“Autologous Transfusion” is a condition in 

which donated blood is used exclusively for 

self-administration by the donor. 

“Restrictive Transfusion Strategy” is blood 

transfusion that is performed only if the 

patient has a hemoglobin level of less than 7 

g/dl and is considered in stable condition.  

“Patient Blood Management” is an 

evidence-based, patient-centered and 

multidisciplinary approach that is adopted to 

manage anemia, minimize iatrogenic blood 

loss, and harness tolerance of anemia in an 

effort to improve patient outcome. 

 

Blood Transfusion Centers: Donors 
and Donation 

1. Blood donation must be voluntary and 
non-remunerated under all circumstances 

and performed solely for the purpose of 

altruism. Volunteers donate their blood 

without any compensation, whether cash or 

cash alternatives. Thus, even a work time 

off, other than for the purpose of conducting 

the donation process, is recognized as a form 

of wage. However, refreshments and 

reimbursement of direct travel costs are not 

contrary to voluntary, non-remunerated 

donation. 

2. Blood donation must be voluntary and 
done with the donors’ informed consent. 

Donors have the right to be clearly informed 

about the conditions for donating blood, the 

stages, and any actions and expenditures 

related to blood and blood components, and 

their consent should also be obtained to use 

the blood and blood components. 



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3. Donors have the right to be fully 
informed about the blood donation 

conditions and processes. 

4. Donors have the right to be informed 
about the potential risks of blood donation. 

In all cases, the priority is to protect the 

health and safety of the donor. 

5. Donors should be aware of the hazards 
and consequences of donating infected 

blood, and of their moral responsibility 

toward potential recipients.   

6. Donors should answer the questions 
honestly and clearly. 

7. Blood transfusion centers must inform 
donors about cases of exemption from blood 

donation and the reasons. In the event of a 

voluntary exemption from donation or 

detection of infections during the screening 

process, the centers should inform donors 

about the type, cause and duration of 

exemption.  

8. Post-donation care should be clearly 
communicated and it must be established 

that the donor has fully understood it. 

9. Donors can cancel the blood donation at 
any stage.  

10. The privacy of donors must be respected 
during the medical interview and the 

screening process. 

11. The information of donors must not be 
disclosed, and they must be ensured about 

the confidentiality of their information and 

medical records. 

12. Blood donors and recipients should not 
be aware of one another’s identity, barring 

exceptional cases. Blood transfusion centers 

and hospitals must take all the necessary 

measures in this respect. 

13. All the processes related to blood 
donation must be performed in accordance 

with the standards of the National Blood 

Transfusion Organization, and under the 

supervision of a qualified physician. 

14. The only criterion for accepting or 
exempting donors is the standards of the 

National Blood Transfusion Organization. 

Physical examinations and interviews must 

be conducted under the supervision of a 

qualified physician. 

15. Any discrimination based on gender, 
religion, ethnicity or nationality is 

prohibited. Blood donation centers and their 

staff should not make discriminatory 

requests from donors and recipients. 

16. Blood donors and recipients must be 
informed about any possible complications. 

17. Establishing blood transfusion centers 
and providing blood services must not be 

done for commercial motives and profitable 

purposes. 

18.  All measures from donation up to blood 
transfusion should be implemented in such a 

way as to prevent the loss of blood and 

blood components.  

19.  All patients must have access to blood 
and blood components when necessary. 

 

Hospitals: Patients 

1. Patients have the right to be clearly 
informed about the risks and benefits of 

blood transfusion as well as alternative 

therapeutic procedures by the physician. 

2. The transfusion of blood and its 
components must only be performed after 

obtaining the written informed consent of 

the patient or her/his legal representative; if 

this is not possible, the decision for 

transfusion of blood and blood components 

should be based on the “best interests of the 

patient”. 

3. The patient has the right to refrain from 
receiving blood or blood components at any 

stage of the treatment. In this case, he/she 

should be notified of the possible 

consequences of the decision, and the final 

decision should be documented and 

approved by him/her. However, such a 

decision should not adversely affect the 

behavior of physicians and medical 

practitioners in providing the best alternative 



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treatment and reducing the consequences of 

the patient’s decision. 

4. To ensure the safety of the blood and 
blood components, all relevant processes 

must be done in accordance with the 

standards of the National Blood Transfusion 

Organization. 

5. The blood transfusion must be done only 
based on the patient’s clinical condition; 

therefore, in cases where the patient only 

needs a specific component of the blood 

(plasma or cell derivatives), administration 

of the whole blood is not permitted. 

6. The administration of blood or blood 
components must not be due to financial 

incentives. 

7. Adoption of measures such as the use of 
blood substitutes, autologous transfusion, 

restrictive transfusion strategy and patient 

blood management fall within the domain of 

professional ethics, and must be supervised 

by responsible physicians.  

8. The prescription and administration of 
blood and blood components must be done 

by a qualified physician. 

 Blood transfusion centers, hospitals, and 

other related centers are required to 

comply with this code of ethics and take 

it into account when compiling or 

revising their guidelines. 

 The ethics committee of the Supreme 

Council of IBTO is responsible for the 

supervision and revision of the code.