The medical ethics of bone marrow transplantation in childhood

Children as hematopoietic stem cell donors

In the past half-century, hematopoietic stem cell transplantation has become standard treatment for a variety of diseases in children and adults, including selected hematologic malignancies, immunodeficiencies, hemoglobinopathies, bone marrow failure syndromes, and congenital metabolic disorders. There are 3 sources of allogeneic hematopoietic stem cells: bone marrow, peripheral blood, and umbilical cord blood; each has its own benefits and risks. Children often serve as hematopoietic stem cell donors, most commonly for their siblings. HLA-matched biological siblings are generally preferred as donors because of reduced risks of transplant-related complications as compared with unrelated donors. This statement includes a discussion of the ethical considerations regarding minors serving as stem cell donors, using the traditional benefit/burden calculation from the perspectives of both the donor and the recipient. The statement also includes an examination of the circumstances under which a minor may ethically participate as a hematopoietic stem cell donor, how the risks can be minimized, what the informed-consent process should entail, the role for a donor advocate (or some similar mechanism), and other ethical concerns. The American Academy of Pediatrics holds that minors can ethically serve as stem cell donors when specific criteria are fulfilled.

Use of minors as bone marrow donors: current attitude and management. A survey of 56 pediatric transplantation centers

OBJECTIVE

To determine the current attitude about the use of minors as bone marrow donors in pediatric bone marrow transplantation (BMT) centers in North America.

STUDY DESIGN

A questionnaire was mailed to 70 North American BMT centers. The questionnaire asked for opinions on a number of ethical and clinical issues pertaining to the use of minors as marrow donors. A case history was included and respondents were asked to check all appropriate answers listed in the survey.

RESULTS

Fifty-six (80%) of 70 centers responded. There was general consensus on many issues. Pediatricians endorse the validity of parental consent, even in potentially controversial situations. Most are prepared to extract marrow from young (about 6 months of age) infants and are willing to use the same donor more than once. There is general approval of performing BMT with experimental protocols, and the projected outcome of BMT does not affect the decision to use a minor as a marrow donor. There is less consensus regarding the optimal management of minors donating a large volume of bone marrow.

CONCLUSION

This survey shows a fairly consistent attitude among pediatric BMT centers about the use of minors as marrow donors. The actual management of such donors was not evaluated in detail and requires further study.

Psychiatric and psychosocial aspects of bone marrow transplantation

Bone marrow transplantation (BMT) is being increasingly used to treat children and adults with a variety of life-threatening diseases. Although BMT is a life-saving intervention in many instances, it is a high-technology procedure--both aggressive and life-threatening--associated with an array of physical and psychological stressors. Therefore, psychiatric and psychosocial research and intervention can greatly contribute to the understanding and management of BMT recipients, donors, and their families. Seven major areas of psychiatric and psychosocial concern in BMT are identified and the literature relevant to each area is reviewed.

Cosmetic surgery for a fatally ill infant

The ethical and clinical dimensions of strabismus surgery in a case of an infant with mucolipidosis type II are discussed. Three sets of considerations are relevant to the decision of performing such surgery: professional obligations to protect patients from futile or contraindicated treatment; parental authority to assess the risks and benefits for elective pediatric care; and the role of the family as patient. We argue that, when weighed together in the context of this case, these considerations can support a decision to perform the surgery upon parental request, despite the patient's poor prognosis.

Marrow transplantation in treatment of children with aplastic anaemia or acute leukaemia

Seventy-six patients, aged 2 to 17 years, were treated with bone marrow transplantation for severe aplastic anaemia or acute leukaemia refractory to conventional therapy. 16 of the 22 patients (73%) who received marrow transplantations for aplastic anaemia are surviving, 12 of these for over one year. In acute leukaemia, using preparation with cyclophosphamide and total body irradiation, 8 of 33 patients (24%) receiving allogeneic and 5 of 8 (63%) receiving syngeneic transplantations are continuing in remission from 3 months to beyond 2 years. The longest continuing remission off therapy is now over 4 1/2 years after preparation with total body irradiation. The major causes of failure remain graft-versus-host disease, infection, graft rejection (aplastic anaemia), and leukaemic relapse.