Children as Living Solid Organ Donors: Ethical Analysis & Model Hospital Policy Statement

Abstract: Alongside donation after cardiac death, opt-out donation and synthetic organs, the transplant community is exploring strategies to increase living donation of kidneys and liver lobes to redress the critical solid organ shortage. Implicated ethical issues include medical risk and risk of coercion counterbalanced by improved medical outcomes with living versus deceased grafts and the material and psychological benefits of saving a life. Living donation is most ethically controversial if the donor is a child, given still-developing autonomy, financially and emotionally dependent status and the long-term health implications of reduced organ mass. However, there are patients on organ waitlists who stand to benefit uniquely from this donation arrangement. Here, we describe this benefit and discuss other pertinent ethical considerations, including respect for the family as a moral unit, respect for the child as a person and non-exploitation, to expand the action-guiding framework for living child organ donation published by the American Academy of Pediatrics (AAP). Key components of this framework are donation within the intimate family setting, donor assent, medical favorability, exhaustion of other donation options, detailed and independent donor social and psychological evaluation and extended follow-up. We conclude that living child organ donation is ethical when a willing, mature child donates to a close relative without other options as part of a formalized, reviewable process. To this end, we apply the outlined framework to construct an eight-point model transplant center donation policy.

Aidan Crowley, BS – Medical Student, UPenn Perelman School of Medicine; Sandra Amaral, MD, MHS – Medical Director, Kidney Transplant Program, Pediatrics - Nephrology, Children's Hospital of Philadelphia