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Without going into too much detail, a question has come up in a Non-Adventurer's League game that I am running where a player has asked me whether healing their character would restore blood loss from self-inflicted harm.

The difference, as I understand it, between hit points (HP) is that it is the amount of wounds or damage a person can sustain before falling to the dying state where their body works to heal themselves, as represented by the death saving throw rolls, before they die.

So if a person is purposefully bloodletting from their body, would simply healing them restore the immediate blood that they lost and allow them to reopen the wound and drain more blood as if they had never lost any to begin with?

I am pretty sure there is no definitive rules or rulings on this so I am trying to understand more of what healing represents in this context.

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    \$\begingroup\$ @zeel Even partial answers in comments are to be avoided \$\endgroup\$ – Medix2 Jan 12 at 21:52
  • \$\begingroup\$ To be clear, is the player attempting to create blood for some purpose? Or are they just hurting themselves repeatedly for some odd reason? \$\endgroup\$ – zeel Jan 12 at 22:07
  • \$\begingroup\$ @zeel For clarification it is with a purpose in mind that does not lend anything to the original question. \$\endgroup\$ – Arrowkill Jan 13 at 1:30
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    \$\begingroup\$ @Nullman Please don't answer in comments, we try to avoid that here. \$\endgroup\$ – NautArch Jan 13 at 18:02
  • \$\begingroup\$ @Arrowkill, I'm not sure I agree. If they are doing it for a non-mechanical reason, then there is no reason to have it impact the game. If they gain something from the blood-letting (like it is a spell component), then that changes things. \$\endgroup\$ – Xavon_Wrentaile Jan 15 at 2:36
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Hit points are a poor abstraction for blood loss

Here's the full description of hit points in the Basic Rules, with the most relevant phrases highlighted in bold face:

Hit points represent a combination of physical and mental durability, the will to live, and luck. Creatures with more hit points are more difficult to kill. Those with fewer hit points are more fragile.

A creature's current hit points (usually just called hit points) can be any number from the creature's hit point maximum down to 0. This number changes frequently as a creature takes damage or receives healing.

Whenever a creature takes damage, that damage is subtracted from its hit points. The loss of hit points has no effect on a creature's capabilities until the creature drops to 0 hit points.

The first highlighted phrase indicates that hit points don't just encapsulate physical durability, which makes sense, since things like psychic damage don't necessarily inflict physical harm on a target. More to the point, many damage types, such as fire, cold, lightning, poison, radiant, thunder, and (as mentioned) psychic, may not cause the kind of damage that results in any significant blood loss, despite still inflicting damage on the target.

The second highlighted phrase is potentially important, because it indicates that 0 hit points represents an important threshold: prior to that any injuries or other damage received are not sufficient to impair the creature's ability to act in combat.

With all this in mind, we can come to a conclusion: hit points are a poor abstraction for representing blood loss. Ultimately, the purpose of hit points is to track combat damage, and that doesn't match the situation of a person purposefully letting their own blood. Hence, I would not recommend using loss and gain of hit points to model loss and restoration of blood. Instead, let's look at the symptoms of anemia and try to find a D&D mechanic that comes close to modeling them.

Recommendation: Model anemia with exhaustion

Wikipedia gives the following as common symptoms of anemia (the condition that would result from excess blood loss):

Most commonly, people with anemia report feelings of weakness or fatigue, and sometimes poor concentration. They may also report shortness of breath on exertion. In very severe anemia, the body may compensate for the lack of oxygen-carrying capability of the blood by increasing cardiac output. The patient may have symptoms related to this, such as palpitations, angina (if pre-existing heart disease is present), intermittent claudication of the legs, and symptoms of heart failure.

If we take a look at the consequences of exhaustion in D&D, we'll find a pretty good match for these symptoms:

  1. Disadvantage on ability checks
  2. Speed halved
  3. Disadvantage on attack rolls and saving throws
  4. Hit point maximum halved
  5. Speed reduced to 0
  6. Death

Hence, I would recommend that if a character intentionally loses enough blood to cause adverse effects, they should start suffering progressive levels of exhaustion, which are in turn removable by the usual means, such as finishing a long rest and ingesting some food and drink or casting Greater Restoration. (Conveniently, the common means of removing exhaustion just happen to be things that could plausibly heal anemia that is caused by blood loss.)

In addition, I would probably rule that a spell like Regenerate would literally regenerate all your blood cells and thus cure the anemia after some time. This is based on the ability of Regenerate to cure other severe forms of injury not represented by mere loss of hit points, such as those in the Lingering Injuries table of the DMG.


While I originally came up with the idea to use exhaustion to model blood loss from scratch by comparing symptoms to mechanics as described above, it turns out that there is at least one instance in the rules as written where exhaustion is explicitly used to model blood loss: the Living Armor magic item from Eberron: Rising from the Last War, pg. 278:

The armor requires fresh blood be fed to it. Immediately after you finish any long rest, you must either feed half of your remaining Hit Dice to the armor (round up) or take 1 level of exhaustion.

Of note, this item also suggests an alternative means to model blood loss: spending hit dice.

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    \$\begingroup\$ +1. Rich Burlew agrees, though OOTS is based on 3.5e rather than 5e \$\endgroup\$ – Punintended Jan 13 at 19:01
  • \$\begingroup\$ Doesn't the heal spell or the heal rules say something about not restoring loss of limb? Might be useful to find and include a reference to that for an idea of where the books draw the line on what is covered. \$\endgroup\$ – Tezra Jan 14 at 14:13
  • \$\begingroup\$ @Tezra I couldn't find anything at a glance. In any case, I think this answer already establishes sufficiently well that HP loss is a poor proxy for blood loss. \$\endgroup\$ – Ryan C. Thompson Jan 14 at 15:12
  • \$\begingroup\$ @Punintended That blood loss is via vampire bite, though, which has specific rules. (It's CON damage in 3.5e, or max HP reduction in 5e). \$\endgroup\$ – Brilliand Jan 14 at 21:07
  • \$\begingroup\$ @Brilliand Fair point. At least it's a starting point \$\endgroup\$ – Punintended Jan 15 at 17:51
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Some monsters that inflict blood loss reduce maximum HP scores.

Take, for instance, a vampire’s Bite attack:

Bite. (Bat or Vampire Form Only). Melee Weapon Attack: +9 to hit, reach 5 ft., one willing creature, or a creature that is grappled by the vampire, incapacitated, or restrained. Hit: 7 (1d6 + 4) piercing damage plus 10 (3d6) necrotic damage. The target's hit point maximum is reduced by an amount equal to the necrotic damage taken, and the vampire regains hit points equal to that amount. The reduction lasts until the target finishes a long rest. The target dies if this effect reduces its hit point maximum to 0. A humanoid slain in this way and then buried in the ground rises the following night as a vampire spawn under the vampire's control.

You could model deliberate bloodletting the same way; you can roll the damage, then reduce their maximum HP score by the same amount until their next Long Rest.

They could then heal the damage, back up to their new maximum HP score. For instance, if a character was at 50 out of 70 HP, and then took 10 points of bloodloss damage, they could heal that damage and 10 of their pre-existing damage, leaving them at 60 HP.

However, not all monsters that drain blood do this. The Stirge, for instance, does ordinary HP damage that can be healed normally.

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    \$\begingroup\$ You could argue (or decide for your game-world) that a vamp is draining your life energy, not just physical blood. Or you could decide that vamps are just physical blood-suckers and other blood-loss could work this way, too. \$\endgroup\$ – Peter Cordes Jan 13 at 18:46
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    \$\begingroup\$ @PeterCordes Normal blood draining would not have the possibility to turn someone into a vampire spawn, which I think is a point in favor of the life-energy-drain interpretation (and the necrotic damage is arguably a second point in favor). Regardless, I do think that max HP reduction is another reasonable way to handle blood loss. \$\endgroup\$ – Ryan C. Thompson Jan 14 at 14:27
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It can if you want to allow it; there are no official rules for it

D&D has no rules about losing blood. HP is an abstraction of how healthy you are, it does not have any real relation to how many injuries you have or how much blood you have lost. Somebody at 1 HP might have been hit on the head a few times with a big stick, or they might have been on fire.

As far as the game is concerned, those two cases are exactly the same, they're at 1 HP.

How you fluff that damage (blood loss, burns, etc.) is entirely up to you, the game doesn't care one way or another. If you as a DM decide that draining blood from your body deals damage, than yeah, I suppose restoring HP will also restore that blood.

If however you as a DM decide that draining blood from your body reduces your maximum HP instead, like for example a vampire's bit would do, then healing will not bring your maximum HP back up, so you could say it "didn't regenerate your blood".

You're entirely in homebrew territory, so just go with whatever fits the story best.

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