An Approach to Pediatric or Mentally Deficient Donors from a Bioethical Perspective: Considerations and Recommendations on Behalf of the Donor Research Team of the Turkish Society of Hematology (DART)

To the Editor,

Donor status is an important consideration. It is possible to encounter ethical dilemmas in medical interventions that do not provide medical benefits to the donor candidate. In contemporary ethical thinking, careful evaluation of the altruistic attitude of the donor is required for human dignity. The purpose of this letter is to address bioethically appropriate approaches for pediatric or mentally deficient donor candidates.

Developing a bioethically appropriate approach to donors and striving to establish policy regulations through guidelines and other similar normative texts can alleviate the moral distress of donor candidates and transplant team professionals. While emotional distress in donor candidates is often due to practical risks, uncertainty, and family conflicts [1], for the healthcare team, it arises when it is not known how to behave morally [2]. It is important to manage emotional and moral distress when the recipient’s survival depends on the donation [3].

Children are a special group with developmental, psychological, and physiological differences compared to adults [4]. Although children 18 years or younger can be accepted as donors with the approval of their legal representatives [5], this does not mean that children are left to their sole discretion for becoming donors. It is ethically appropriate to give them age-suitable information and obtain their consent with different forms prepared considering the characteristics of different age groups.

There are limited studies on how pediatric donors are affected by transplant processes, both medically and psychologically [5]. Pain, distress, and fear should be reduced and long-term separation from the parents should be carefully evaluated. Increased self-esteem and avoidance of guilt are reported to be in the best interests of the child [6]. There are also viewpoints that find it problematic to evaluate the best interests of the child donor over the welfare of the sibling recipient. The common perspective on this issue is to focus on the self-regarding interests of the pediatric donor candidate [7]. The psychological effects of having an ill sibling on the pediatric donor are complex [7]. Accordingly, the general trend in Western countries is to provide psychological support to donor candidates [5]. However, parents may find it difficult to make decisions regarding the well-being of both the patient and the pediatric donor [8]. Therefore, a donor advocate is defined; this may be a health professional who does not treat the ill sibling, a social worker, a religious official, or a lawyer [9]. Mentally deficient donor candidates, meanwhile, should be preferred only rarely when other suitable donors cannot be found for high-risk patients. The donor candidates in this group should be given preliminary information, preferably by a psychiatrist.

It seems important to consider how to increase ethical action options without straying from the teaching of evidence-based medicine. Thus, it is necessary to recognize the ethical problems for donors and transplant teams and to develop relevant solutions. In this direction, it is recommended to organize joint workshops and panels and conduct qualitative and quantitative research with universities, specialist associations, and non-governmental organizations to determine the principles needed in practice.