serious lesions in the back of the head and lack of pupil reaction and muscular response make it seem pointless for the receiving doctor to commence treatment . the point is not to restore her to a normal life but to keep her body alive long enough to figure out whether she qualifies as an organ donor . early identification of potential donors provides better transplant results , the doctor knows , and yet some element of doubt makes intubations of the dying girl difficult . the problem relates to a crucial transition characteristic of modern transplantation medicine as a person shifts positions from a patient - in - need - of - treatment to a donor - in - need - of - conservation . the story above was narrated on 9 november 2010 , when the danish center for organ donation ( dco ) brought together nurses , scientists , surgeons , and anesthesiologists to discuss the ethical quandaries in transplantation medicine . in particular , intubations and resuscitation of brain dead or near - brain dead patients gave rise to concern , and throughout the day , various cases were discussed in the search for moral guidance . the conference participants took this opportunity for reflection to try to identify key moments of moral decision making and possible principles on which to base such decisions . in fact , the conference participants seemed to proceed as if they were making an evidence - based medical decision : they searched for a decision tree with clear priorities , best evidence ( moral principles and specification of the information needed ) , and steps to follow . but what , really , is the type of decision making at stake in these instances of moral quandary ? according to classic decision - making theory , a decision is rational when based on full appreciation of available evidence and aimed at defined aims . in as early as 1959 , however , charles lindale   suggested , in what is now regarded a classic article in organization theory , that good decision making is a ' science of muddling through ' . it is never clear what constitutes the full range of evidence , and not least because of the time limits imposed on every critical choice , it is very rare that anyone ever attempts to gather that range of evidence ( by whatever standards ) . furthermore , decision trees laying out ' the ideal rational decision ' tend to neglect unexpected and , in principle , unrelated events . such unrelated events , however , were often of vital importance in the cases discussed on 9 november and will be familiar to many doctors . whether or not to resuscitate or incubate a potential donor typically needs to be decided within minutes . if intubated , donors must be kept in intensive care units , where doctors often struggle to find available beds . as a possible consequence , other patients are perhaps moved out of intensive care or scheduled operations are cancelled because the only temporary space for a potential donor is the operation theater . these complex decisions must be made at a point in time when it is unclear whether the relatives will consent to the donation or whether the donor medically qualifies . when discussing a case in the conference room , surgeons want to know whether the patient is registered in the national donor registry , but in the emergency room , there is not always time to check this information before a decision must be made . the practicalities of everyday clinical decision making involve a lot of muddling through beyond what decision trees take into consideration . but the moral problems in clinical decision making in organ donation seem to be more akin to those of organizational decision making in general , and when clinicians deal with them , it is probably useful to turn to a more pragmatic form of bioethics . instead of assuming a moral ' evidence base ' , we might be of more help to health professionals by acknowledging the lack of universal norms and standard situations . a productive dialogue about the problems people actually handle must appreciate the basic ambiguities surrounding the situations doctors and nurses face as patients become donors . health professionals dealing with new technologies in critical care units act in many instances as what anthropologist rayna rapp   calls ' moral pioneers ' : they need to create norms beyond the guidance of existing ones . when discussing decal decisions , clinicians must reflect on real - life situations such as those presented at the conference , rather than rest on presumptions about a point of total clarity at which the ' real ' ethical decision was made . we contend that the kind of dialogue that health professionals need is better facilitated by an ethics of muddling through - which does not presume clarity where there is none - than by a set of principles that they rarely get the chance to apply . consequently , we suggest rethinking more generally what we want ethics to do for us in relation to the issues raised through organ donation , in which norms are constantly negotiated and challenged in the messy and complex context of everyday clinical decision making . the authors thank the speakers and participants at the meeting in middleware , denmark , on 9 november 2010 and the danish center for organ donation ( dco ) for supporting this commentary .
organ donation offers opportunities for people in critical care units to help save the lives of other patients . 
 it is not always easy , however , to handle the transition from treating a patient to preserving a potential donor , and organ donation consistently provokes ethical questions in critical care units . 
 what do we expect ethics to deliver ? in light of a recent ethics conference in denmark , we suggest that by acknowledging that decisions made in the clinic rarely abide to rational decision trees with clear ethical priorities , we can better learn from each other 's experiences . 
 we suggest embracing an ' ethics of muddling through ' to enhance relevant reflections and stimulate a productive dialogue among health professionals .