Hematopoietic stem cell transplant research with pediatric donors: when can institutional review boards approve it?

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.

Interpretation of the subjects' condition requirement: a legal perspective

The U.S. Federal regulations allow institutional review boards (IRBs) to approve non-beneficial pediatric research when the risks are a minor increase over minimal, provided that the research is likely to develop generalizable knowledge about the subjects' disorder or condition. This "subjects' condition" requirement is quite controversial; commentators have argued for a variety of interpretations. Despite this considerable disagreement in the literature, there have not been any attempts to apply principles of legal interpretation to determine how the subjects' condition requirement should be understood.