We have read with interest the letter to the editor entitled “Moral complexity in the organ donation process: a prudential act”1 and felt it necessary to make a few comments on some aspects of its argumentation. Organ transplantation is a life-saving therapy, and patients on the waiting list have no alternative therapy. As intensivists, we are responsible for reducing the number of patients on the waiting list by facilitating the donation process in our units. In fact, Donation-Oriented Intensive Care (DOIC) is a common practice in our units2 and in most developed countries. Fortunately, the debate is well-resolved, and in full compliance with the principles of bioethics, the following aspects could be argued.3

Regarding the principle of beneficence: end-of-life decisions should be made primarily based on values rather than facts. For the patient, it represents an opportunity to express values such as solidarity and altruism and may be the best therapeutic option until their poor prognosis is properly assessed. For the family, it provides solace in the face of loss, and for patients on the waiting list, it offers a genuine chance of survival.

Regarding the principle of non-maleficence: DOIC requires ensuring the absence of suffering and the patient’s comfort, as outlined in existing protocols. Therefore, if deemed appropriate, DOIC should consider the possibility of having the patient accompanied by their family at the intensive care unit (ICU) setting. The option to revoke consent for DOIC is mandatory.

Regarding the principle of autonomy: All human beings aspire to live with dignity, as recognized by science, society, and law. A dignified life deserves a dignified death as an inseparable concept. Respecting dignity necessarily involves considering the option to donate each person’s organs, either directly or through representation, thus respecting the patients’ wishes and values. Providing this option is indeed a moral obligation for the health care personnel involved in patient care. Failing to offer it based on compassionate arguments would represent an undesirable paternalistic attitude.

Regarding the principle of justice: the use of ICU resources for DOIC is a matter of cost-opportunity. The moral obligation of health care providers is to allocate resources to a real—not a hypothetical—situation. Choosing a patient for DOIC vs the hypothesis that those resources could be allocated to a patient who might present represents the denial of an opportunity to stay alive in favor of a potential situation that does not exist yet.4

We agree with the authors that the donation process requires a deep understanding and analysis of each patient’s situation. Therefore, SEMICYUC considers DOICs necessary to be included in the ICU care practice and, consequently, includes this reality in both its documents and recommendations.5