Spain is a global leader in organ donation and transplantation. In 2019 it reached a proportion of 48.9 donors per million inhabitants, with a target of 50 donors per million inhabitants for 2022. Among the measures taken to achieve this target are strategies to promote paediatric donation. However, the number of paediatric donors has been decreasing sharply since 2002, despite a historical reduction to the lowest levels of family refusal to donation.

The document presenting the “National recommendations on paediatric donation”1 discusses new alternatives to obtain organs, some of which may pose an ethical dilemma. This is the case of controlled donation after circulatory death, in which, beyond its conflict with the Dead Donor Rule,2 which is the foundation of any transplantation programme, antemortem interventions may be performed to facilitate the donation process, including the establishment of central vascular access and other measures taken solely to improve the viability of the organs. Handling prior to the death of the donor can be a form of instrumentalization that goes against the dignity of the patient, as it involves interventions that do not provide any direct benefit to the patient and are not justified by the clinical situation.3

The document also includes a section on donation in special situations, using donation in anencephalic newborns as an example. The term “severe nervous system malformation incompatible with life” is inaccurate, as these infants are born alive and it would be more appropriate to refer to these malformations as having a poor prognosis with a very short life expectancy. The established clinical approach in conformity with the lex artis in these patients is to provide care to improve comfort and, to the extent possible, management by a neonatal palliative care team. The use of invasive interventions on the newborn (intubation, insertion of central access lines) that are not beneficial to the patient are not justified from an ethical standpoint. In consequence, we consider that the recommendations of the Canadian Paediatric Society not to use medical treatment or mechanical ventilation in anencephalic infants to support organ donation continue to apply.4

The interpretation of the ethical principles in paediatric organ donation offered by the authors1 does not suffice to justify these interventions, despite the potential benefits for future recipients.