Misleading Statements About Children as Living Organ Donors Free

The American Academy of Pediatrics (AAP) policy statement¹  on pediatric organ donation and transplantation aims “to enhance comfort and increase knowledge of pediatric organ donation and transplantation to the general pediatric community.” While commendable, the statement includes misleading statements about children as living donors.

First, the authors write that “pediatric living organ donation from 2009 to 2015 was 27% lower than in 1995–2001”. While this is correct, the Organ Procurement and Transplantation Network database reports 20 living pediatric organ donations in 1995–2001 and only 14 between 2009–2015.²  So we are talking about 2–3 donations per year and a difference of 6 organs.

It is important for pediatricians to know who these minors are. Some of the minors who serve as living organ donors are domino donors. An example of a domino donor is a child with maple syrup urine disease (MSUD) who undergoes a deceased donor liver transplant to treat their enzyme deficiency. Rather than discard the explanted liver, it is transplanted into an adult who might otherwise not survive on the waitlist. Since the adult can produce the missing branched-chain amino acid enzyme in other parts of their body, the enzyme defect in the liver is tolerable. So, while the minor is a living liver donor, it is only because the liver would otherwise be discarded. Consent of the parent (and possibly the minor) to use the domino organ is essential. Second, some of the minors who serve as solid organ donors are living donors for their own children. An adolescent parent is an emancipated minor and can give her own informed consent to serve as a living organ donor, and she does not need her parent’s permission to do so. This leaves only a handful of non-emancipated healthy minors serving as living organ donors in each period.

Second, the authors cite the 2005 AAP statement “Minors as Living Organ Donors”³  (I was first author) to claim that “Specific criteria for the ethical permissibility of minors serving as solid organ donors (usually siblings) has been reviewed and supported by the AAP in exceptional circumstances and only when specific criteria are fulfilled.” Although some countries had an absolute prohibition of minors as living donors,⁴  we argued for only a relative contraindication and stringent safeguards because we acknowledged that there may be exceptional circumstances.³  We specifically rejected identical twins as a routine exception.³  Given accumulating data about the long-term health risks of living kidney donation,⁵  the AAP should take an even stricter stance.

Third, the current statement only mentions a living donor advocate (LDA) to support a child who cannot meaningfully participate in donation discussions.²  Since 2007, LDAs are required for all potential living organ donors.⁶  Thus, all children who are potential living donors must have an LDA, supplemented by professionals skilled in child development and child psychology when appropriate.³  However, children unable to meaningfully participate in donation discussions must be excluded from solid organ donation.³ 

Except in very rare circumstances, minors should not serve as living organ donors.