Ethical Issues in Pediatric Liver Transplantation

Abstract

Organ transplantation is a recognized practice since more than 30 years ago, and the largest problem it faces is the shortage of donors. This is a world phenomenon that the society at large has not yet been able to solve, which added to the accessibility and integral support of the transplanted patient represent a source of ethical conflicts. In the particular case of pediatric liver transplantation, this situation already starts with a significant numerical inferiority in the waiting list in comparison to adults. Different strategies have been devised in favor of equity such as pediatric donors for pediatric recipients, pediatric end-stage liver disease (PELD) score × 3 (the actual PELD score multiplied by 3 to be competitive on the waiting list with adults), split liver techniques, and the living donor (LD) approach, but none of these measures have shown conclusive improved results in relation to the magnitude of the waiting list times.

Two ethical assessments derive from the above mentioned situations: the first one, related to LD and the careful evaluation that it imposes since it represents a surgical intervention in a healthy individual, with potential harmful physical and psychological consequences and, secondly, equity in the distribution process with a need for a very rigorous analysis between the most compromised patient and the one with the best chance of survival, since there are two positions that at first may look as antinomic.

Pediatric liver transplantation is a high-cost practice and requires lifelong medication and follow-up. In many low resource countries, the issue of lifelong postoperative follow-up is very important, with the risk of graft malfunction with impact on quality of life, survival, and death.