We have read with satisfaction and interest the 2 responses1,2 to our letter "Moral complexity in the organ donation process: a prudential act."3 As we stated in our letter, the ongoing debate in the intensive care medicine setting4,5 presents an opportunity to delve deeper into the moral aspects inherent to organ donation, fostering reflection that not only improves these programs but also helps all parties involved act justly in every decision.

Every organ donation is morally complex. Without being exhaustive, each case entails the wellbeing of the patient on the transplant waiting list; the donor's previously expressed will together with his or hers desires, beliefs and values; the interpretation that the surrogates will make of those wishes; the positive impact that donation might have on a family in mourning or the basic fact of converting a patient into a donor. To underestimate or oversimplify these factors would be, in our opinion, a mistake.

In general terms, considering a moral debate as settled is an error. In medical ethics, as Childress and Beauchamp acknowledge in the latest edition of their renowned work,6 although referring to the principles of autonomy, beneficence, non-maleficence, and justice is necessary, it is not sufficient to determine the moral goodness of a medical act. The moral character of the professional and the real, concrete circumstances are equally important elements. Real experience in the ICU setting shows that simply listing these principles does not absolve the professionals of their responsibilities towards their patients, as they cannot cease to be a moral agent.

For this reason, we continue to find the 3 recommendations in our article relevant. Let’s repeat them. First, the intensivist is not merely an executor of a system, a procedure, or someone else’s will, but a moral actor: as such, they make decisions freely. And every free decision in critical circumstances is both difficult and costly.

One might deny the existence of a moral and emotional cost in the organ donation process. It might be said that this cost is irrelevant, or even decreed that emotional wear renders the intensivist unfit to “work in a specialty where such challenges are common.” However, this does not eliminate the real experience of the medical team: the truth is that each decision tests their moral agency, and these decisions come at a cost. Unlike our kind respondents, we not only believe this wear is real; we believe it is good, as it shows that the professional is taking the moral dilemmas of the donation process seriously.

A second recommendation also seems pertinent. As a person, each patient is unique, and respecting their dignity involves recognizing them as an end in themselves. These are not empty words: the unconscious or involuntary danger of subordinating the person to the program is real and does not disappear simply by denying its possibility. The best way to avoid moral instrumentalism is not to deny its possibility but rather to make sure that the professional can recognize and acknowledge the existence of a "red line" when managing organ donation.

This is why prudence, in its deepest sense, seems to us the fundamental virtue here. In the end, neither the law, nor the clinical practice guidelines, nor procedures can provide the professional with sufficient moral certainty to do justice to the donor, the patient, the families, and the program. For this reason, we believe that the professional faced with an organ donation process must possess certain virtues,7 beginning with a solid understanding of the good, recognition of the various goods at stake, and the ability to righteously deliberate on what is good and appropriate in each specific case.

Finally, let’s move to the third recommendation, which we find particularly relevant. In ethics, there are never closed debates, and the more important and valuable the issue at stake is, the more important it is to avoid closing the discussion. Honest and open dialogue is the best guarantee for genuine improvement in donation processes. From this perspective, professionals and public authorities should be the most interested in not declaring the debate closed but rather recognizing and exploring the complexity and richness present in each case. Morally speaking, an organ donation process is, for the professional, something more than fixed, predetermined guidelines and protocols.