Ethical and legal aspects of using an identical twin as a skin transplant donor for a severely burned minor.

I. INTRODUCTION On January 7, 2003, Sydney Cowan, a healthy six-year-old girl, underwent skin harvesting,1 specifically to be used for her badly burned identical twin sister, Jennifer.2 A day earlier, the Probate Court of Jefferson County, Alabama, after considering whether a healthy minor twin sibling could serve as a skin donor for her severely burned sister, authorized parental consent to the surgery.3 More accurately, the court addressed whether Sydney could undergo surgical procedures that provided her with no physical benefit, but, rather, resulted in harmful effects, such as acute postoperative pain, permanent residua, and potential long-term emotional and psychological dysfunction. Although the transplants were extraordinarily successful, and the newspaper article depicted Sydney's participation in heroic terms, the harvesting of Sydney's skin was ethically problematic. Specifically, I assert that the use of an incompetent minor as a skin transplant donor, even if an identical twin, is not justified unless the transplant will save the recipient's life. I develop this thesis in several foundational sections. In Part II, I present the facts of the girls' case. In Part III, I review the current treatment of burns and provide a general framework for ethical analysis of burn treatment via skin transplantation. In Part IV, I summarize the legal approach toward the use of incompetents as transplant donors. In Part V, I re-examine each of the previously discussed areas with reference to Jennifer and Sydney, specifically identifying weaknesses in the medical, ethical, and legal foundations supporting the decision to move forward with the skin harvesting procedures. Major deficiencies include the high likelihood that Jennifer would have survived her burn injuries without skin transplantation and biased ethical and judicial procedures that led to the approval of skin harvesting from Sydney. Since these deficiencies are likely to be systemic in nature and widely prevalent, in Part VI, I draw attention to the multiple pitfalls encountered in this treatment decision and offer some recommendations for hospital ethics committees faced with serious ethical treatment dilemmas. Finally, in Part VII, I offer some concluding remarks. II. THE CASE OF JENNIFER AND SYDNEY4 On December 9, 2002, Jennifer Cowan was injured when her father's attempt to light the family fireplace resulted in an explosion. As a result, Jennifer suffered third-degree burns of over 80% of her body surface area-only her head, hands, and intertriginous areas were spared. Doctors estimated that Jennifer had a 30-50% chance of survival. Following a week of stabilizing treatment, including five days on a mechanical ventilator, Jennifer's treatment focused on re-establishing a protective barrier over her burned areas.5 Her surgeon removed her dead skin and covered exposed areas with whatever unburned skin could be harvested from unburned parts of Jennifer's body (i.e., autografts). Because Jennifer did not have enough unburned skin to cover all of her burned areas, additional human skin allografts were obtained using skin harvested from cadaveric skin donors. Doctors also used porcine xenografts (i.e., pigskin) to complete the job.6 Finally, a small piece of Jennifer's normal skin was removed (i.e., biopsied) and shipped to a laboratory to grow sheets of new skin.7 Shortly after her injury, Jennifer's surgeon learned that she was an identical twin. Upon learning this information, he entertained the notion that a skin graft from her identical twin, because of its identical genetic make-up, would give Jennifer her best chance of survival. Sensing that operating on Sydney for a skin graft donation would raise ethical and legal concerns, however, the surgeon requested review by the hospital ethics committee. The ethics committee interviewed Jennifer's family, her surgeon, and a consulting psychologist who had examined both Sydney and the parents. …