Should Children Ever be able to
serve as Living Solid Organ Donors?
Mary Ellen Olbrisch, PhD
James L. Levenson, MD
Department of Psychiatry and
The Hume-Lee Transplant Center
Virginia Commonwealth University
Joel Newman
United Network for Organ Sharing
What We Will Cover
UNOS data regarding children as living solid
organ donors in the U.S.
Proposed guideline to make age<18 an
absolute contraindication to living solid organ
donation
Legal status of minors
Relevant developmental issues
Criteria for living solid organ donation
Ethical analysis
Recommendations
UNOS Data Regarding Children
as Living Kidney Donors 1988-2007*
Children Ages 6-10: 1 donor in 1998
Children Ages 11-17
–
–
–
–
–
45 donors total
1988-1992: 18
1993-1997: 16
1998-2002: 9 total, 5 in 1998
2003-2007: 2, including 1 in 2006
*Based on OPTN data as of November 23, 2007; Delmonico and Harmon
(2002) reported a total of 60 children as donors from the period 19872000, time periods are not identical and total numbers from either
source may not be accurate
UNOS Data Regarding Children
as Living Liver Donors
5 cases reported, 1 in 2007
UNOS Data Regarding Children
as Living Lung Donors
No case reported
Consensus Conferences
and Policies
Kansas City Conference (2000): “Although minors
(less than 18 years of age) have successfully
donated kidneys to family members in rare instances,
utilizing a minor as a live donor remains controversial
and requires careful donor consideration”
Amsterdam Forum (2004): “Minors less than 18 years
of age should not be used as living kidney donors.
CMS: recent requirement for programs to have a
written protocol for living donor evaluation, many
programs did not have one prior to this requirement
Consensus Conferences
and Policies (continued)
UNOS draft resource document, 2007:
CONTRAINDICATIONS TO LIVING DONATION
The following reasons could exclude a living donor
candidate from donating based upon scientific
data for medical risk, psychological assessment
and/or consensus on best practice.
Absolute Exclusion Criteria:
･ “Age < 18 years”
Not a policy, not intended to mandate practice
Consensus Conferences
and Policies (continued)
ASTS vocal in making changes to the document
U.S. transplant community unable to reach a
consensus regarding this issue
2008, UNOS draft resource document, still in draft
form, now reads:
THE FOLLOWING REASONS COULD EXCLUDE
A LIVING DONOR CANDIDATE FROM
DONATING:
Age < 18 years, or mentally incapable to make an
informed decision
U.S. Courts
Have sometimes permitted donation by
incompetent child via parental consent.
Typically, the court has based this on
the argument that it was in the child’s
best interests to do so.
– Questionable twist of “best interests,” i.e.
saving one’s sibling
– Who should judge the donor child’s best
interests? Note parents’ conflict of interest
How Old is Old Enough
to stay home alone without adult supervision?
to baby-sit for a younger child?
to marry?
to be held criminally responsible for one’s actions?
to drive a motor vehicle?
to die for one’s country?
to vote for local and national leaders?
to consume alcohol?
to donate blood?
to donate bone marrow?
to donate a kidney or part of a liver?
New Zealand Health Minister David Cunliffe intervened after a teenage
mother, who wanted to give part of her liver to her 10-month-old daughter,
Teyah, ill with biliary atresia,was told she was not old enough to be a
donor.
“I could join the army and go
overseas and die for my country but
I can't save my daughter's life.”
- Kataraina Pewhairangi, 18
http://www.stuff.co.nz/print/4436660a20475.html
3/12/2008
Developmental Issues
CNS development continues gradually
through adolescence
Brain maturation, including development of
executive functions, such as planning,
impulse control and weighing risks and
rewards, is not complete until the midtwenties
Adolescents typically remain dependent on
their parents, who may most want them to be
organ donors.
Developmental Issues (continued)
Youthful idealism may lead minors to be more
willing to donate than more mature individuals
with a balanced perspective on duties to self
as well as care for others
Youthful sense of invulnerability may lead
adolescents to minimize assessments of risks
to themselves
Developmental task of identity formation may
influence youth decision making and risk
taking
Ethical Issues
Do no harm
Consent/Assent
Do not exploit
Protect from exploitation by others
Autonomy
Justice
Utilitarianism vs. Deontological theories and
values
Basic criteria for living solid organ
donation
Capacity/competence
Willing and free of coercion
Medically suitable
Psychologically suitable
Fully informed of risks and benefits for
both donor and recipient
Criteria applied to minors
Capacity/competence
– Some adolescents have sufficient capacity.*
Willing and free of coercion
– Problematic, but coercion risk does not suddenly disappear
at age 18.*
Medically suitable
– Not age dependent
Psychologically suitable
– Issues of capacity and coercion; otherwise not age
dependent*
Fully informed of risks and benefits for both donor
and recipient
– Not age dependent*
* Note paucity of data regarding the above
Basic criteria for trivial risk
donation(e.g. blood, bone marrow)
Capacity/competence
– Parental consent in case of incompetent minors
Willing and free of coercion
– No longer applicable
Medically suitable
– Rarely an issue
Psychologically suitable
– No longer applicable
Fully informed of risks and benefits for both
donor and recipient
– No longer applicable
Conclusions and
Recommendations
The frequency of children becoming living
solid organ donors has decreased
considerably over the past twenty years.
All living organ donors are owed great care
to determine that they are not subject to
coercion or exploitation.
Minors are particularly vulnerable due to
dependence, incomplete brain maturation
and incomplete identity development.
Conclusions and
Recommendations (continued)
A general principle discouraging solid organ
donation by children under the age of 18
appears warranted.
Extreme caution must be observed in
considering any preadolescent child as a
living solid organ donor.
Conclusions and
Recommendations (continued)
Exceptions may be ethically permissible.
Minors should be evaluated as individuals with
special attention to developmental issues that may
impact any expressed desire to be a living organ
donor.
Thorough psychological evaluation to assess general
intelligence, reasoning and judgment, personality,
family dynamics, emotional attachment to the
recipient, the experience of coercion or manipulation,
and comprehension of risks and benefits should be
conducted.
Conclusions and
Recommendations (continued)
An independent advocate such as a
guardian ad litem should be appointed.
Particular safeguards for children who
might become living solid organ donors
protects not only children, but transplant
physicians, transplant programs, and
public support for transplantation.
Recommendations:
Delmonico and Harmon
Minors can fulfill the criteria when
– Both donor and recipient highly likely to benefit
• Esp. identical twins (no immunosuppressive Rx)
– Risk for donor extremely low
– Other options exhausted
• Cadaveric donation not timely
• No suitable adult donor
– Minor consents without coercion
• Established by independent advocate
References
The Ethics Committee of the Transplantation Society. The
Consensus Statement of the Amsterdam Forum on the Care of
the Live Kidney Donor. Transplantation, 2004, 78 (4): 491-492.
The Authors for the Live Organ Donor Consensus Group
Consensus Statement on the Live Organ Donor. JAMA.
2000;284:2919-2926.
Council on Ethical and Judicial Affairs AMA. The use of minors
as organ and tissue donors. Code Med Ethics Rep 1994; 5:229242.
Delmonico, FL and Harmon, WE. The Use of a Minor as a Live
Kidney Donor. American Journal of Transplantation 2002; 2:
333-336