had received input from a wider group of scientific and medical experts, more explicit and systematic dissemination of a range of clinical options might well have been possible. In addition, the financial and other relationships between the NHF and the plasma fractionation industry created a conflict of interest that seriously compromised the perceived independence of NHF's recommendations.

No organization stepped forward to communicate widely the risks of blood transfusions to potential recipients. Many blood bank officials during this period publicly denied that AIDS posed any significant risk to blood recipients. In this context, and because many transfusions occurred on an emergency basis, patients were typically not appraised of the growing concerns about the contamination of the blood supply. For both individuals with hemophilia and recipients of blood transfusions, physician concern that their patients might refuse care deemed a "medical necessity" further contributed to failures to inform them of the risks.

CONCLUSIONS

Decisionmaking Under Uncertainty

The events and decisions that the Committee has analyzed underscore the difficulty of personal and institutional decisionmaking when the stakes are high, when knowledge is imprecise and incomplete, and when decisonmakers may have personal or institutional biases. The Committee attempted to understand the complexities of the decisionmaking process during this uncertain period and to develop lessons to protect the blood supply in the future. In retrospect, the system did not deal well with contemporaneous blood safety issues such as hepatitis, and was not prepared to deal with the far greater challenge of AIDS.

Although enough epidemiological evidence had emerged by January 1983 to strongly suggest that the agent causing AIDS was transmitted through blood and blood products and could be sexually transmitted to sexual partners, the magnitude of the risk for transfusion and blood product recipients was not known at this time. Policymakers quickly developed several clinical and public health options to reduce the risk of AIDS transmission. There was, however, substantial scientific uncertainty about the costs and benefits of the available options. The result was a pattern of responses which, while not in conflict with the available scientific information, were very cautious and exposed the decisionmakers and their organizations to a minimum of criticism.

Blood safety is a shared responsibility of many diverse organizations. They include U.S. Public Health Service agencies such as the CDC, the FDA, and the NIH, and private-sector organizations such as community blood banks and the American Red Cross, blood and plasma collection agencies, blood product manufacturers, groups like the National Hemophilia Foundation, and others. The



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