Transfusion-transmitted infections remain a public health challenge in India despite mandatory ELISA screening. Evaluate the feasibility and ethical implications of mandating Nucleic Acid Testing (NAT) in Indian blood banks.

India mandates serological screening of every donation for five transfusion-transmissible infections — HIV, HBV, HCV, syphilis and malaria [2]. Yet ELISA detects antibodies, not virus, leaving a window period of infectivity. NAT closes that gap, but mandating it is a question of feasibility, not merely of science.

Case for mandating NAT

• Scientific superiority: NAT amplifies viral RNA/DNA directly, sharply shortening the HIV and HCV window periods that ELISA cannot cover [1].
• Demonstrated Indian evidence: the Madhya Pradesh centralised hub-and-spoke PPP model screened 1,58,493 seronegative samples and found 943 (1 in 168) NAT-reactive, potentially averting 2,829 infections [1].
• Proven delivery model: centralised hubs serving satellite centres avoid equipping every licensed blood bank, making scale-up administratively tractable [1].
• WHO treats a quality-assured, universally screened blood supply as a core state obligation [4].

Feasibility constraints

• Fiscal: NAT costs several times ELISA per unit; health delivery is a State List subject (Entry 6, List II), and the Supreme Court (March 2026) declined a mandate precisely citing states' financial constraints and judicial lack of expertise [6].
• Infrastructure: molecular platforms, cold chain and trained technicians are concentrated in urban tertiary centres, not district blood banks [3].
• Legal route: a mandate requires amending blood-bank standards under the Drugs and Cosmetics Act, 1940 — an executive, expert-led act, not a judicial one [2].

Ethical implications

• Right to health under Article 21 and the precautionary principle favour maximal safety; but resource-allocation ethics demand weighing NAT against competing health needs.
• Equity: with roughly 1–1.5 lakh thalassemia-major children and 10,000–15,000 born annually [5], transfusion-dependent patients bear cumulative risk — uneven NAT access creates a two-tier blood supply.
• Higher processing charges could exclude poor patients, whereas 100% voluntary non-remunerated donation remains the cheaper first-order safety duty [3][4].

An immediate universal mandate is neither fiscally nor administratively feasible; a phased, NBTC-led centralised rollout — prioritising thalassemia day-care centres and high-volume hubs, funded through the National Health Mission and PPP hubs — is. Sequenced this way, NAT converts Article 21's promise of safe blood into a graded, funded and attainable entitlement.