Risk reduction for small cell cancer of the ovary, hypercalcemic type in prepubertal patient: A clinical and bioethical perspective.

Loss of heterozygosity in the SMARCA4 gene is a hallmark feature of small cell carcinoma of the ovary, hypercalcemic type (SCCOHT), an aggressive ovarian cancer occurring in young adults and adolescents with an average age of 23 years and a median survival of less than fifteen months following diagnosis. Patients with germline pathogenic variants of SMARCA4 have a genetic predisposition to developing this aggressive ovarian cancer, a condition called rhabdoid tumor predisposition syndrome type 2 (RTPS2). Given the limited efficacy of surveillance imaging for ovarian neoplasm and the absence of an identified biomarker for the progression of this disease, asymptomatic patients who are found to possess pathogenic variants of the SMARCA4 gene following genetic testing are advised to consider risk-reducing bilateral salpingo-oophorectomy to eliminate the risk of SCCOHT. Given the reproductive impacts of this procedure, bioethical consultation must be considered when counseling patients with RTPS2, particularly for those who have not completed their desired course of family planning. In this report, we describe the bioethical considerations and outcomes for the case of a 6-year-old female with a pathogenic variant of SMARCA4 who underwent risk-reducing bilateral salpingo-oophorectomy (RRBSO). To our knowledge, this is the first time that this procedure has been reported in a prepubertal individual for cancer prevention in a patient with RTPS2.

Responding to offers of altruistic living unrelated kidney donation by group associations: an ethical analysis.

Members of a religious community presented to our institution and offered to be altruistic unrelated living kidney donors en masse. This situation raised a number of ethical concerns related to the situation specifically and to altruistic unrelated living kidney donation in general. Based on our ethical analysis, we made the following conclusions. Altruism is a legitimate motive for living unrelated kidney donation, and altruistic acts can be based legitimately on religious beliefs. Retrieval of kidneys from living donors is generally safe, and altruistic donors may derive benefit from donating (eg, enhanced self-esteem) assuming they are autonomous and free of coercion. Separate teams should evaluate and care for potential donors and recipients to avoid compromising the donor screening process and to ensure potential donors satisfy medical and psychosocial criteria for donation. Indeed, transplant clinicians should not assume that potential unrelated living kidney donors are not susceptible to coercion. In fact, in our situation, coercion was our biggest concern. Appointing a donor's advocate can facilitate donor understanding of the risks, benefits, and alternatives to organ donation and can help discern coercion. Furthermore, an experienced social worker should assess all potential donors and discern if coercion is present; potential donors should be referred to a psychologist or psychiatrist as appropriate. Although concerns regarding allocation were not raised by our specific situation, ethical concerns regarding allocation of kidneys donated by altruistic unrelated kidney donors exist (eg, requesting that such donations be allocated to recipients with specific characteristics).