21 January 1994
The opinion considers the peculiar aspects of organ transplants in children and adolescents. The document is divided into three parts: the most common organ transplants at paediatric age (kidney, liver and heart) and conditions of children with transplants; problems common to the different types of transplant; related ethical issues. Among the emergent problems, particular attention is paid to the criteria for the ascertaining of cerebral death, which are different for children compared to those used for adults: the ICB examines the criteria drawn up by ad hoc committees having a broad consensus in the international scientific community.
The ICB highlights the problem of the lack of organs available for transplants, which nonetheless has two important sides to it. If, on the one hand, it is necessary to promote a “donation culture” in healthcare workers and the public, on the other hand it is necessary to be rigorous and cautious in the ascertainment of cerebral death and the protection of the dying person’s dignity. In the case of anecephalous children in particular, the Committee stresses that the serious conditions of the child cannot justify persistent therapy, not even for the explant of organs.
Dealing with the juridical aspects of the issue, the Committee makes a distinction between the case in which the minor is the recipient of the donation, and therefore the subject on which the transplant is carried out, and the case in which the minor becomes the (potential) donor. The opinion pays particular attention to the question of informed consent, which in the case of transplants on minors is given by the parents or by whoever has the power to do so. It is however emphasised that the will of the mature adolescent minor must be taken into consideration, so that a clash of opinions may arise between the will of the parents and that of the minor. If the minor is the recipient of the transplant, the disagreement can be resolved by guaranteeing the realisation of his/her best interest; if the minor has the role of potential donor, his/her will is irrelevant in the case of transplant while living (insofar as it is forbidden) and is not binding in the case of a transplant from a corpse, since the relatives can oppose the explant. Hence the need for further reflection, even with regard to organ donation, which would allow the reaching of a better balance between the parents’ prerogatives and the decision-making capacity of the child.
The ICB points out how organ transplants cannot lead to definitive recovery, for which reason the side-effects of immunosuppressive therapy must be carefully assessed, above all when long term, resorting to the operation only after having analysed the cost benefits relationship. Furthermore, the patients and their families need to be constantly supported by specific multi-disciplinary services, whose approach to the problems related to the transplant is not just medical but also considers the ethical and psychological issues linked to it.