Introduction

Adolescents present pediatrics and transplant surgery with ethically complex cases. The problems relate to the general question of the just allocation of scarce resources and how that issue is affected by two special features of adolescent development: the ambiguity about their decisional capacity and the instability of their commitments to adhere to post-transplant anti-rejection treatment regimens (Slater 1994, DeBolt et al. 1995). Combined, these concerns leave pediatricians and transplant surgeons troubled about the allocation of transplant organs to adolescents and troubled about the issue of consent. They are uncertain about when to accept adolescents' agreement to transplantation, uncertain about when to accept their refusal of transplantation, and uncertain about when to accept their decisions to become organ donors. The problems are further complicated when the adolescent is found to lack decisional capacity for making a choice about transplantation. Then the question shifts to determining whether parents should be allowed to decide and determining whether the parents are making an appropriate decision.

Assessment of decisional capacity can be an especially important issue when reasonable people see the proposed transplant as either a good or an evil and, on that basis, choose to go forward with the surgery or to refuse it. Transplantation almost always involves a lifelong commitment to immunosuppressive medications and their side effects, risk of rejection, risk of infection, and immunosuppression-related risk of neoplastic disease. There is also the ordeal of the surgery itself and the postoperative critical care hospitalization.