Pediatric Sibling Transplants, Ethics and Futility

Where the line should be drawn in medical intervention, and when treatment should be considered “futile” is under debate among medical ethicists. The majority of the medical community agrees that care is futile when it does not achieve its purpose.

But medical ethicist Dr. Norman Fost, pediatrics and bioethics professor at the University of Wisconsin, warns that as yet, there is no definitive definition of futile treatments. Will there ever be?

  • “The fact that a treatment hasn’t been tried or hasn’t been successful in the past does not mean it will not be successful in the future,” said Fost. “Some medical professionals deem any treatment that has not worked in 100 cases is not viable. Many parents argue a one in 10,000 chance still isn’t zero.”

To establish whether a treatment is “futile”, ethicists argue that we must look at whether the patient is gaining anything from the treatment. If life-saving actions are taken for a child whose quality of life will be poor, who does that serve?

Futility is Futile

Fost reminds us that these are personal value judgments and not medical judgments. This is why, in part, the medical community cannot agree on a specific definition for futility in medical treatments. The search for an ultimate definition of futility is futile, Fost argues.

For example, the father of a child with severe neurological damage asks for a treatment that the medical community agrees will not work. In fact, it may put the child at even higher risk. But the father goes to the media and the court; the court orders the hospital to give the treatment a try.

Since no U.S. court has ever refused life-sustaining treatment without parental consent, should hospitals save the court costs and just abide by whatever the parents request, for as long as they request it?” asked John J. Paris, SJ, PhD, professor of bioethics, Boston College. “Is that responsible medical care?”

The Ethics of Death

“We are all going to die,” said Rev. Paris. “So what is the best way to treat a dying child — and who decides?” Paris suggested that treatment must be in the best interest of the patient. So, if technology can prevent death, but it cannot restore well-being, what is the benefit?

Balancing the benefit and burden of medical intervention is the job of everyone involved in the care of the patient.

Pediatric Sibling Transplants

Using sibling transplants for bone marrow and other regenerative materials is well accepted in the pediatric transplant community. Most
centers will not perform solid organ transplants on underage siblings unless mandated to do so by the courts or as a last resort.

“It is assumed that having a healthy sibling is enough of a benefit to outweigh the minor discomfort and small risk of a bone marrow transplant,” says Rebecca Pentz, PhD, professor of hematology and oncology in Research Ethics, Emory University. “However, there is little or no literature to support that theory.”

Adults who donated solid tumors to unrelated patients experienced increased self-esteem, pride and higher self-worth. There are varied opinions about the benefits to underage donors. The sibling donors may experience high self-esteem and improved relationships with the family.

But, sibling donors whose transplants were unsuccessful experience guilt, shame and anger, Pentz added.

Ethical Justifications and Developmentally Impaired Children

The current ethical justifications for sibling donation are the best interest of the donor, closeness to the family and obligation to the family. The current data to support any of these assumptions is sparse, at best.

If a child is high functioning and can attend school should they be more likely to be listed for an organ transplant than a child who is profoundly developmentally impaired (with no mobility or measurable IQ)?

“It is very common for hospitals to use developmental delay as a factor in making the decision about whether to list patients for transplant,” said David Magnus, PhD, associate professor of pediatrics and medicine, Stanford University. “A few U.S.transplant programs have admitted that they exclude any patient with a delay, regardless of the severity of their case”

Some centers argue that these patients would have poor outcomes. In fact, there is little evidence that the outcomes for these children are different than those of normal, healthy children. The ethical dilemma, says Magnus, is weighing the responsibility of scarce organ resources with the physician’s obligations to treat every patient fairly. He suggests that all children should be entitled to consideration for transplant.

Adapted from a Seattle Children’s Hospital Press Release

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