All individuals with organ failure experience related comorbidities that have a profound impact on their health. However, organ failure during critical periods of childhood development result in accrual of additional, irremediable burdens that are unique to children, with major deleterious impacts on growth¹, physical and pubertal maturation², neurocognition^3-5, mental health⁶, and emotional and psychosocial development⁷. These confer irremediable damage on the chlld as he/she transitions into adulthood. Equivalent morbidity is not experienced by adults who develop organ failure. Additional burdens accrue in the family context, with impacts on parental discord and sibling survivors, which are accentuated during care of end-stage organ failure⁸. Numerous studies have demonstrated that organ transplantation mitigates these morbidities, improving health and quality of life for pediatric transplant organ recipients across an extended period of time.^9,10 Given that developmental impacts are time-sensitive and exacerbated with more prolonged time with end-stage organ failure, delays in organ transplantation in the pediatric population generate a disproportionate degree of morbidity as compared to their adult counterparts.

Prioritizing pediatric recipients for organ allocation represents the most effective means of addressing this disproportionate morbidity, as a matter of medical urgency. Furthermore, failure to address these additional developmental burdens will prevent attainment of a child’s full potential, and lead to lasting disability and impaired participation in society as an adult.¹¹

In circumstances where a lack of health resources limits the availability of other interventions to address organ failure in the pediatric population, such as a lack of access to pediatric dialysis or pediatric cardiac function-assist devices, the prioritization of pediatric recipients for organ allocation is literally a matter of life or death.

Unfortunately, even when interventions to replace or supplement poor organ function are available, patients who have experienced organ failure requiring transplantation face a significant risk of mortality.^12-15 Therefore, in order to improve the utility of each transplanted organ, organ allocation priorities should consider the expected survival of the recipient in the context of the expected functional lifespan of the transplanted organ. By optimally matching organs and recipients, the greatest number of life-years saved can be maximized.

The likelihood of a recipient dying with a functional allograft increases as age increases across a wide variety of organs, and pediatric patients often demonstrate a greater rate of recipient survival than do their adult counterparts.^12,16-18 In this sense, the organs allocated to children can be seen to have greater utility, as they are most likely to achieve the ultimate goal of extending the life of as many recipients as possible, for as long as possible.

Attempts to expressly match organs and recipients based on expected longevity are most evident in certain kidney allocation systems, some of which place priority on younger and healthier recipients to receive what are thought to be higher quality organs for allocation. The assessment of organ quality remains in its nascency however, and the means to provide a comprehensive assessment of the potential quality of any organ being allocated is currently limited. Therefore, a purely technical and case specific method of optimally matching organs and recipients is not feasible at this time and policy that considers organ utility in allocation decisions continues to be needed.

In this argument, we acknowledge that due to the differential distribution of the causes of organ failure in adults and children, as well as variation in local resources and expertise, organ transplant in pediatric recipients cannot be presumed to yield a more efficacious outcome in all cases.

Moreover, we acknowledge that clinical constraints may preclude pediatric prioritization, including a lack of technical expertise in pediatric transplant surgery, unfamiliarity with split-liver donation procedures for liver lobe transplantation in children, or the availability of pediatric organ donor programs to enable access to size-matched allografts required for some pediatric heart and lung transplants. In these circumstances, IPTA strongly supports efforts to develop these resources sufficiently to support more effective pediatric transplantation in the future. IPTA stands ready to advise and aid in these efforts.

The fair innings argument acknowledges that while any premature death represents a tragedy, there is a particular unfairness for those who die having yet to experience what one might consider a “complete” life, including all of life’s stages from birth to old age. Within this argument, the person who dies at a young age has suffered a particular harm beyond a simple quantification of the number of life years lost, and that extension of that life provides a benefit that is qualitatively different that extending the life of an older adult. Therefore, prioritizing pediatric patients for organ allocation allow the greatest number of individuals to experience as “complete” a life as possible, independent of considerations of absolute utility.

This argument seeks to clarify and express the justification for the moral intuition that is shared across a wide variety of community surveys that demonstrate a persistent preference for prioritizing pediatric recipients for organ transplantation.¹⁹ Given that the organs available for allocation are in a sense a community resource, deference to this preference would seem appropriate.

There is a broad cultural acceptance that societies have a special obligation to their children. This is reflected in the text of the United Nations Declaration on the Rights of the Child, which notes that "the child, by reason of his physical and mental immaturity, needs special safeguards and care, including appropriate legal protection"²⁰. This document represents a broad moral acknowledgment that children are owed a degree of care by society that may exceed that which is owed to other members. This cultural norm is manifest in a variety of community structures, including programs that provide educational, financial, and healthcare support to children in need.

In contrast to many adults, the vulnerable nature of children is not only contingent on life circumstances, it is inherent to children as a group. As such, this vulnerability of childhood is additive to the other sources of vulnerability experienced by those suffering organ failure. This in turn serves as an additional justification for pediatric priority in organ allocation, whereby societies have a duty to ameliorate this disproportionate vulnerability.

1. Within countries or regions that have standardized organ allocation policies, IPTA advocates in favor of relative but explicit prioritization of pediatric recipients for organ allocation based on the arguments detailed above. This prioritization should be incorporated with acknowledgement of the needs of other stakeholders within the allocation system. However, the final allocation system should acknowledge the unique benefits experienced by pediatric recipients and their families, the medical urgency of their needs, and the broader obligations that society has to provide for their health. Within countries or regions where allocation decisions are made by individual programs, we would urge those individuals responsible for organ allocation to consider these factors as well and incorporate those considerations into the allocation process.
   
   
2. Whenever possible, IPTA supports the establishment of transparent, publically accessible and formalized allocation systems within local, regional, national and (if applicable) international health systems to minimize disparities in allocation practices that may adversely affect vulnerable groups, including children.
   
   
3. Where technical expertise exists, IPTA supports the use of technical innovations such as split liver transplantation, which will enhance availability of organs for allocation to both children and adults
   
   
4. In order to ensure that these goals are achieved, IPTA recommends the engagement of individuals with expertise in pediatric transplantation in the process of developing and regularly updating local, regional or national organ allocation policies whenever possible.