Exploring the ethical complexity of pediatric organ transplant candidates and COVID‐19 vaccination: Tensions between autonomy and beneficence, children and parents

Abstract

In January 2022, a Cyprus toddler was refused a life-saving heart transplant due to the fact that his parents were refusing COVID-19 vaccination (in the setting of requirements for legal guardians to be present and vaccinated as a condition of their child's surgery). 1 Because Cyprus lacked a pediatric heart transplant program, the child was referred to hospitals in three other countries but all refused. The dilemma was eventually solved by a Greek hospital agreeing to place the child on their heart transplant waiting list; however, this case presents many dilemmas and tensions between autonomy and beneficence in the setting of the pediatric transplant journey and COVID-19. In 2020, in USA, 1766 children received life-saving solid organ transplants, matched from 860 pediatric organ donors. 2 Currently, there are 1900 children on the USA transplant waiting list. More than 500 children waiting for a donor organ are between 1 and 5 years old. 3 Children awaiting heart transplantation experience the single highest waiting list mortality compared with all other age groups and all other solid organs. In USA, a 6-year period study found 17% (533) of children with severe heart failure died, while on the heart transplant waiting list, 63% (1943) received a transplant, 8% (252) were removed from the waiting list due to recovery, and 370 (12%) remained alive on the waiting list at the time the study had finished. 4 POT is one of the most common therapies in the

Ethical Challenges Involved in COVID-19 Vaccine Mandates for Children: A Systematic Review

“…The other articles discussed the consequences of COVID-19 vaccine refusal and methods to be followed to implement the vaccine mandate. In [ 3 , 10 , 17 ], the authors discussed COVID-19 vaccine mandates in organ transplantation, organ stewardship, and pros and cons of COVID-19 vaccine mandates for transplantation candidates. In [ 7 , 14 ], the authors spoke out against COVID-19 vaccine mandates, citing unknown side effects.…”

“…Children usually have less autonomy; they are considered to lack the capacity for decision-making [ 18 ] and depend on their parents or elders to make decisions [ 4 ]. In many medical care systems, autonomy can be reduced due to the risk to others and self-harm caused by negligence of care [ 4 , 10 , 11 ]. The mandate for the COVID-19 vaccine has created a quandary about which to prioritize; public commitment and responsibility to prevent outbreak and transmission or individual autonomy and freedom [ 16 ].…”

“…The American Society of Transplantation, the International Society for Heart and Lung Transplantation, and the American Society of Transplant Surgeons have proposed a joint statement on 13 August 2021, strongly recommending the COVID-19 vaccination in transplant candidates, recipients, and other household caregivers who are in close contact with the recipient, thereby emphasizing organ stewardship [ 10 , 13 ]. Organs are limited resources that need to be rationed and considered for the best use by maximizing the significant medical benefit to the recipient.…”

“…Parents who refuse vaccines for themselves put their children at risk, especially in transplant cases [ 10 ]. During the pre-transplantation stage, the children are expected to maintain a certain level of health in order to be eligible for the surgery [ 10 ].…”

“…This may be the reason that vaccination coverage has declined in many countries [ 8 ]. There is also a counterargument stating that voluntarily unvaccinated people are not fulfilling their obligations and could be causing harm to others, especially to the susceptible elderly and immunocompromised population [ 10 ]. The aim of this study is to discuss the pros and cons of the COVID-19 vaccine mandate for children.…”