Ethical dilemmas in pediatric organ donation: psychological, medical, and family considerations

Ethical Considerations of Children as Organ Donors

Ethical dilemmas are defined as a situation that "…involves the need to choose from among two or more morally acceptable courses of action, when one choice prevents selecting the other; or, the need to choose between equally unacceptable alternatives (Hamric, Spross, and Hanson, 2000 cited in: A Framework for Resolving Ethical Dilemmas in Healthcare, 2003) Chasson writes that values and ethics have a relationship that is clear and that the mixture of these two can serve to create complications for the nurse and specifically that moral values "are evaluated in terms of positive or negative effects. If the choice between good or bad results is very clear, no confusion or ethical dilemma will ensue…" (nd, p.13) However, when the choice is not clear the moral choices are fraught with great difficulty. Recent studies have demonstrated that living donors are an increasingly important organ transplantation source however, there is a great deal of concern relating to the ethics concerning children as donors of those organs. Involved are various factors that include developmental factors. It is reported in the work of Ross and Thistlethwaite (2008) in the work entitled "Minors and Living Solid-Organ Donors" that solid-organ transplantation "has become standard treatment for a variety of diseases in children and adults." (p.1) The participation of minors as living organ donors is stated to raise ethical issues that are of a serious nature.

Emotional and Psychological Risks

Ethical issues include "potential psychological and emotional benefits" that may be experienced by the donor/child including the development of "greater self-esteem" however, the psychological risk involved must be considered as well. Stated for example is that children may fail to understand "the meaning of the lost body pat or the reason for any scars." (Ross and Thistlethwaite, 2008, p. 1) In addition, it is reported that the child/donor "may experience guilt and blame if the transplant fails and/or the recipient dies." (Ross and Thistlethwaite, 2008, p. 1) Another risk is stated to be that of the "potential coercive nature of the request: how can children refuse when their parents are asking them to donate?" (Ross and Thistlethwaite, 2008, p. 1) However, there are also potential emotional and psychological risks when a child is barred from organ donation including blame by self or by others for the death of the family member if the child is not allowed to donate the organ.

Medical Risks

Ross and Thistlethwaite (2008) state that there are inherent medical risks involved in organ donation which include the risks of surgery and anesthesia and in fact, the calculated risk of mortality from donating a kidney is stated as "approximately 2 in 10000" and "up to 10-fold greater for a left lateral segment living liver donation." (Ross and Thistlethwaite, 2008, p.1) In fact, all donors are noted to experience acute pain with some developing chronic pain. (Ross and Thistlethwaite, 2008, p.1)

Conditions for Minor Organ Donation

There is reported to be a lack of stringent criteria for minor participation as organ donors. For example the Amsterdam Consensus Panel holds that minor children under the age of 18 years should never be allowed o donate an organ while the U.S. Live Organ Donor Consensus Group, holds that minors under the age of 18 years could ethically donate however, only in circumstances that are "rare and exceptional." (Ross and Thistlethwaite, 2008, p. 1) The AAP holds that a minor may participate as an organ donor but only if specific and stringent criteria are met. The conditions that the AAP states as a requirement for minor organ donation are those as follows: (1) The first condition makes a requirement that both the potential organ donor and the potential recipient will benefit highly from the organ donation; (2) the surgical risk to the donor must be extremely low; (3) the third condition states that "all other opportunities for transplantation have been exhausted, no potential adult living donor is available, and timely and/or effective transplantation from a cadaver donor is unlikely; (4) the minor is required to "freely agree to donate without coercion and should only be allowed to donate within the immediate family; (5) there is a requirement that the emotional and psychological risks to the child donor be minimized. (Ross and Thistlethwaite, 2008, p. 1) The work of Olbrisch, Levenson, and Newman (2010) report that developmental factors that are important for consideration of children as organ donors includes "brain maturation affecting decision making, executive function and impulse control…" and "youthful idealism" along with the minor's sense of being invulnerable. (p. 1)

Summary and Conclusion

There are various ethical considerations to children becoming donors or organs for transplant and these have been reviewed in this brief study. Included in those ethical considerations are such as developmental issues and the medical, emotional and psychological risks associated with organ donation by children. Guidelines have been stated and reported by various organizations however, as noted in this study lacking are clear and stringent guidelines concerning children as organ donors. There is a need for the development of guidelines that clearly address the issue of children as donors of organs and it is necessary that these guidelines be clear and that the guidelines state stringent requirements for organ donation by minor children.