A reply.

Abstract

We would like to thank Dr Beckett for his considered response. We believe that better ethics is about making better ethical decisions and having better justifications for those decisions. The language in which these decisions are now debated, especially in the workplace, is much more sophisticated than in the past and we believe the rise in organ donation has contributed. This is good for all patients that are cared for by anaesthetists and intensivists, not just those receiving organ donation. Beckett reminds us that the clinician ‘is not an immoral being, but acts in a similar way to the vast majority of people, by acting to treat the immediate need of the patient in front of him/her, over and above that of an equally needy but more physically distant one’, but his statement highlights the seduction of basing decisions on proximity, even when the contrast is not between one equally needy patient and another, but may be between helping one non-urgent case via surgery and several serious cases via donation. It is understandable that people act in this way, but considering moral distance, even if it just provides a moment's pause, may help the clinician act in a way that enables better use of resources. Unfortunately, space constraints within the boundaries of a short editorial prevented us from fully exploring the thought experiment of the ‘trolley problem’, so Beckett is quite right to identify that there is more to this thought experiment then we discussed. Ironically, one of the reasons why people are happy to divert the train using the lever (killing one distant person to save five distant people) but not to push the large man on to the railway line (killing the large man beside you to save five distant people) is because they are all morally distant in the former case but not in the latter. This again illustrates the point that clinicians might be more inclined to facilitate organ donation if the consequences of not doing so were more readily apparent – or if they use their moral imagination to see what will happen. If our editorial simply finished after the thought experiment of the ‘trolley problem’, we would agree with Beckett that such discussions are ‘too utilitarian and simplified when describing the moral issues that clinicians face.’ However, our paper did not stop there. We explicitly acknowledged that while the trolley problem is helpful in explaining the issues of moral distance, it is not in itself enough to use as a basis for clinical decision-making, especially in a resource-starved environment. That is where we felt that distributive justice considerations, the oft forgotten fourth principle, can be helpful. The Maximin strategy – a form of triage – tells us that when we prioritise competing patient needs, we should try to maximise the interests of the worst-off first. Similarly, we are of the opinion that the cultural shift in anaesthesia and intensive care toward greater facilitation of organ donation, and donation after circulatory death in particular, has not been due to any persuasive utilitarian arguments by transplanters but because of deontological (Kantian) arguments made by anaesthetists and intensivists, who have recognised that if individuals wished to be organ donors after they die, then there is a duty on us to facilitate this if possible. Such justification is the basis for the legal guidance in the UK supporting donation after circulatory death 1-3. Beckett raises the concern that there is a moral toll on decision-makers ‘to ask for a change in moral thinking while demanding year on year ‘competitive’ improvements in organ donation rates’. Were the UK to have a donation rate amongst the best in the world or there was confidence that every family was approached when donation was a realistic opportunity, then this might be a valid concern, but such is not the case. Donation rates of 20 per million population places the UK as a middle-order donating nation, and missed opportunities for donation occur daily in the UK. However, our editorial was written in the spirit of acknowledging progress and improvement, not with any call for new action. Patients and their families, regardless of donation potential, now receive better treatment because of the ethical lessons and dilemmas with which we, as a profession and as individuals, have had to grapple over the last six years as organ donation rates have improved. This is a good thing, and something for which all anaesthetists and intensivists in the UK should be congratulated.