The Code of Ethics of the International Society of Blood Transfusion.

Dear Sir, We appreciate the importance given to our recent paper "Some reflections on the Code of Ethics of the International Society of Blood Transfusion"1 (ISBT) as reflected in the commissioning of Flanagan's editorial2. However, Flanagan asserts that our position, which has been carefully put together from our different backgrounds in transfusion (AF) and philosophy (CDB), arises from "Farrugia's close association with the commercial plasma industry"2. Flanagan's assertion may appear logical but is in fact, incorrect. It seems to be rather a case of making an observation on the basis of information that, since the Authors' profiles are clearly stated in the "Conflict of Interests" declaration, is irrelevant to the argument put forward. Other works by Farrugia are referred to in reference3 (see references 13, 21, 48 within), which we are unable to cite in their entirety due to the space restrictions here. These clearly resonate with the concepts regarding voluntary non-remunerated donation (VNRD) set out in our paper. These papers were published during Farrugia's tenure as a senior public health official in Australia charged with the oversight of a plasma product supply system underpinned by a vigorously defended domestic monopoly, now fortunately defunct, which was ideologically justified by the kind of VNRD principles espoused by Flanagan. This led to Australia trailing behind other developed health systems in the adequate provision of essential plasma products to patients. So much for the historical record. Like Flanagan, we support the concept of the Nuffield Council around the "Ladder of Altru sm", believing that, in human affairs, absolutes are rarely constructive, and we have, indeed, embedded within it our concept of "supplier". We contend that paid plasma donors make an undeniable contribution to the supply of sufficient safe plasma products globally and that this is crucial for the wellbeing of vulnerable patients (Figure 1). As the supply of plasma recovered from blood from VNRDs continues its inexorable decline, both through the decreased use of red cells resulting from Patient Blood Management and from the demographic imbalance between the donors and the users of blood, this is, if anything, increasing in importance. The reality is that, despite the best efforts of heavily subsidised blood systems such as those in Australia and the Netherlands where, despite