REVIEW ARTICLE Organ donation from children: time for legal, ethical and cultural change Joe Brierley (brierj@gosh.nhs.uk), Vic Larcher Great Ormond Street Hospital for Children NHS Trust, London, UK Keywords End of life decision, Ethical issues, Intensive care, Organ donation, Organisation Correspondence Dr Joe Brierley, Paediatric and Neonatal Intensive Care Unit, Great Ormond Street Hospital for Children NHS Trust, Great Ormond St, London WC1N 3JH, UK. Tel: +442078298889 | Fax: +44 2078138206 | Email: brierj@gosh.nhs.uk Received 10 March 2011; revised 10 May 2011; accepted 7 June 2011. DOI:10.1111/j.1651-2227.2011.02380.x ABSTRACT Successful transplantation has lead to increasing need for donated organs from children; however, contemporaneously decreased brain-death rates means optimization of donation processes is crucial. Although excellent palliative care and organ donation are compatible, discrepancies exist both between and within European countries in abilities to offer families donation opportunities. Change will require address of legal, ethical and cultural barriers, and this review aims to explore such changes pertinent to both dead and living organ donation. Conclusion: We argue that across Europe it is surely time for legal, ethical and cultural change to facilitate parents, families and of course children in having the choice of donation. INTRODUCTION Organ transplantation offers children, in acute or chronic severe organ failure, similar opportunities to adults. How- ever, whilst the number who might benefit is compara- tively low, significantly fewer cadaveric donors exist for any given child compared to adults. Incompatible organ size and relatively low donation rates mean that, despite living parental donation and innovations to reduce donated organ size, children die before organs become available (1). The severity of the situation is compounded by restrictions on paediatric living donation, the applica- tion of brain-death criteria and concerns about increasing use of donation after circulatory death (DCD). In the UK, the Department of Health’s Organ Donation Task Force suggested means by which the adult donor pool might be increased, recommending that outstanding ethical and legal issues be resolved, but made no specific recommen- dations about children (2), and throughout Europe there is no consistent approach nor centralized agency to over- see organ donation from children. This review will consider organ donation from children overall including dying and dead children, as well as paedi- atric living donation. DEAD DONATION As pressure to provide organs increases, no compromise to Kant’s second formulation of the categorical imperative can be allowed: children must never be treated as a mere means, but as an end at the same time. Historically, concerns about potential conflicts between the duties involved in caring for a dying child and the need to broach the sensitive subject of Key notes • Medical and social changes mean increased require- ment for organ donation from children coexists with decreased brain-death rates. • Legal, ethical and cultural barriers to donation should be identified and addressed, although mindful of any breach in the fundamental care of the dying. Excellent palliative care and organ donation are, however, com- patible. • Living donation from competent children should remain rare, but if no other opportunity to save life exists, may be ethically acceptable. Acta Pædiatrica ISSN 0803–5253 ª2011 The Author(s)/Acta Pædiatrica ª2011 Foundation Acta Pædiatrica 2011 100, pp. 1175–1179 1175