A 75-year-old man was followed for six years in our internal medicine unit for Jak2-mutated myelofibrosis. He was a former teacher, had a very supportive wife for whom he was also very supportive, and two children. He often murmured that, throughout his life, he had had to struggle against every facet of it, as if he were never satisfied with anything—a perfectionist. But that daily strife was also difficult to live with, sometimes contributing to anxiety and depressive states. At the time of diagnosis, he sighed, realizing that his combat would continue, despite his having hoped for some relief now that he was retired. He often complained that he never saw his grandchildren because of an ancient quarrel with his son. Regardless of the subject of that dispute, the consequences were hard for him and his wife to endure: he was convinced he would never see his son and grandchildren again.

We first prescribed hydroxyurea, but severe secondary anemia led to its withdrawal. He was repeatedly admitted for red blood cell transfusions and, despite adequate iron-chelation therapy (Leitch et al., Reference Leitch, Chase and Goodman2010), he eventually developed iron overload with chronic cardiac insufficiency. Interferon (Ianotto et al., Reference Ianotto, Chauveau and Boyer-Perrard2018) had too many side effects, pipobroman (Lawless et al., Reference Lawless, McMullin and Cuthbert2016) induced reversible myelodysplasia, and, finally, ruxolitinib (Verstovsek et al., Reference Verstovsek, Mesa and Gotlib2012) was tried because of his worsening clinical state with chills and markedly enlarged spleen and liver. His spleen measured 32 cm and hindered his ability to walk. Ruxolitinib initially induced spectacular improvement of his general condition, but he progressively developed anemia despite dose reduction. Splenic length continued to rise, reaching 38 cm in the sixth year. No treatment was available to alleviate his final struggle. We sat with him and his wife.

“What happens now?” he asked. To maintain his autonomy as long as possible, regular transfusions were prescribed. He received approximately 150 red blood cell units during the last year of his life. And he lived one more year, a whole year, with his 40-cm spleen making him walk in such an inimitable way, his skeletal appearance, and his lust for life. As a young doctor, I often asked myself: is it reasonable to transfuse this man with three to four units a week because he will inevitably and rapidly succumb to his disease? How could I solve the dilemma of improving his last days and optimizing blood transfusion while assuring that other patients, who could benefit from curative strategies, would receive their needed red blood cell transfusions? That question haunted me for weeks and I found no answer (Uceda Torres et al., Reference Uceda Torres, Rodríguez Rodríguez and Sánchez Ramos2014). So, we continued to transfuse him. But one final and unexpected event abolished my dilemma: reconciliation! In our patient's last days, he confided having reconciled the intergenerational bad blood, bringing his son and grandchildren back to him and his wife. Long-term palliative transfusions maintained his clinical state long enough to restore his family. What could I say? To me, it was the best resolution I could have hoped for.

Of course, I found more consensual explanations for the ethical dilemma of palliative transfusion (Sherbeck & Boss, Reference Sherbeck and Boss2016; To et al., Reference To, To and Currow2016), summarized in the friction between two principles: justice and charity. Justice? The equitable distribution of medical care and resources among individuals. In France, blood donation is free and managed by a unique blood bank called the Etablissement Français du Sang. That organization has ensured its self-sufficiency for more than 15 years in the face of huge medical demand, including our patient's. Thanks to millions of voluntary unpaid donors. Charity? Obviously. It is every doctor's duty to do all possible to relieve a patient's suffering, as much psychologically as physically, and to do so as long as the patient lives. So, at least in France, charity hopefully wins over justice in the conundrum of palliative transfusion ethics. With a third unexpected bonus: family reconciliation.