Clinicians from a leading UK children's hospital have called for European countries to change the way they tackle the shortage of organ donations from children, after a review, published in the September issue of Acta Paediatrica, found a large number of legal, ethical and cultural barriers.

Great Ormond Street Hospital's clinical lead for organ donations, consultant paediatric intensivist Dr Joe Brierley, teamed up with Dr Vic Larcher, consultant in general paediatrics and ethics, to review the discrepancies between and within European countries.

Their review, which also drew on the experiences of countries like the USA, Australia and Canada, considered the complex issues around organ donations from dead and dying children. The authors also explored the controversial option of living donations from competent children, which can sometimes be the only way to save another child's life.

"Organ transplants offer children in acute or chronic severe organ failure similar opportunities to adults" explains Dr Brierley. "However far fewer deceased donors exist for children compared to adults. Incompatible organ size and relatively low donation rates mean that, despite living parental donation and innovations to reduce donated organ size, children often die before organs become available.

"The severity of the situation is compounded by restrictions on living donations from children, the inconsistent application of brain-death criteria across Europe and concerns about the increasing use of organs after the donor has suffered circulatory death.

"In the UK, the Department of Health's Organ Donation Task Force suggested that outstanding ethical and legal issues needed to be resolved to increase the number of organs available for adult transplants. However, it made no specific recommendations about children and there is no consistent approach or centralised agency to oversee organ donations from children throughout Europe."

Key findings of the review carried out by Dr Brierley and Dr Larcher, who specialise in clinical ethics at the London-based hospital, include: Adults can decide, prior to death, whether they wish to donate their organs. But competent children cannot always do this, despite the fact that this would be consistent with the legal systems of many European countries, such as UK common law and international children's rights standards. The most viable organs are from heart-beating donors who have suffered brain death, but there are international discrepancies about how old an infant needs to be before brain death criteria can be applied. For example, the UK has an active heart transplant programme, but often has to rely on organs from Europe as very small babies cannot be donors, unlike in the USA, Australia, Canada and many European countries. There are complex clinical, ethical and emotional issues around how to maintain potential organs in the best condition for transplant, while respecting the fact that a child is dying or has just died. The techniques and organisation required for such donations need to be put in place locally and must always be balanced with a family's wishes and ethical considerations. Organ donations from anencephalic infants - born without the frontal section of their brain - have not been carried out for many years in Europe and the US programme has also ceased. Although the UK has deemed that such transplants would be legally acceptable, the practice does raise a number of complex clinical and ethical concerns that need to be explored. In the USA competent children can, on rare occasions, consent to donate their non-vital organs to close relatives if that relative would otherwise die. The European position on living donations from competent children is arguably becoming inconsistent with contemporary practices, which allow children to make decisions regarding their own healthcare in accordance with their age, maturity and understanding. However strict safeguards to prevent issues like coercion would need to be in place and living child donation should only be considered when all other options have been exhausted. "Medical and social changes mean the increased requirement for organ donations from children coexist with both improved road safety and medical advances in children's intensive care" says Dr Larcher. "These have decreased brain-death rates and reduced the number of available organs. This means that it is important to ensure that parents are always offered the chance to donate organs, if possible, if their child is sadly dying.

"Excellent palliative care and organ donation can be compatible if the legal, ethical and cultural barriers to donation are addressed in a way that is mindful of the fundamental care that dying children receive."

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