Ethics Corner: Cord Blood Banking
by Beth A. Pletcher, MD, March 1999

Lately we've been hearing a lot about stem cell transplants using cord blood. For some children (and possibly even adults) this new technology holds great promise as an alternative to standard bone marrow transplants. Many patients die while waiting for a suitable bone marrow donor to surface, and cord blood is readily available, painless to collect and carries with it no morbidity for the donor. Why not tap into this previously discarded biological resource?

The volume of blood collected from a single placental harvest is small and may contain enough stem cells to reconstitute the bone marrow in a small child but may not be enough to do so for the average adult. Until our technology permits us to expand stem cell colonies in culture, this resource may prove to be rather limiting. At present the most promising applications are for children with hematologic problems such as sickle cell anemia, Fanconi's anemia, severe combined immunodeficiency or some cases of leukemia where an HLA matched sibling happens along at the right time. One needs to consider ownership of the cord blood when harvesting this readily available resource. Over the past decade a number of companies have sprung up to address blood collection and storage issues. In order to realize the greatest financial gains, some corporations have begun to advertise their services and promote personal cord blood banking as "insurance policies against potentially life threatening conditions". What parent who has the financial resources to pay for collection and yearly storage fees would not opt to save cord blood from their newborn infant? Promotional information directed to prospective parents usually does not reveal the very slim chance that a child will ever need a stem cell transplant (estimated chance 1 in 10,000). Of even greater concern is the targeting of especially vulnerable individuals whose anxiety level about hematologic diseases is greatest. I once came across a pregnant patient who had received promotional information in the mail from a cord blood banking group because she had lost a nephew to leukemia. When this blood bank learned about her pregnancy (not from the patient herself) they sent an unsolicited letter to her outlining the following:

1. It had come to their attention that this woman was currently pregnant.

2. This woman had a close relative who had died from leukemia.

3. There is an increased risk for relatives of leukemics to also develop leukemia.

4. Cord blood is a source of autologous stem cells and could be used to save a person's life in the event of a tragic diagnosis such as this.

5. For a "moderate" collection and storage fee cord blood could be saved and stored in perpetuity for her child's own future use.

This outrageous example of fueling a pregnant couple's worst fears should not be tolerated, especially when the promoters stand to realize significant and direct financial gains. In light of the actual likelihood that any given newborn will need to have a stem cell transplant down the line, what is a more sensible approach to cord blood banking?

Cord blood banking might more reasonably be done by non-profit organizations and operate along the lines as a blood bank does today. The costs for collection, screening, and storage could be borne by the consumers and health insurance companies. There may be some value in establishing a "community cord blood bank" with collection of cord blood at all deliveries without informed consent. On the other hand, perhaps it would be more appropriate to approach all parents during the pregnancy about possible cord blood donation for the good of society and obtain written informed consent at that time.

A few ethical issues arise during the process of cord blood collection and storage that will need to be addressed. Clearly, the timing of cord clamping during delivery can significantly alter neonatal blood volume and early clamping of the cord should not be done in order to increase collection volume at the expense of the newborn. Screening of blood for infectious agents poses a dilemma when HIV or hepatitis is uncovered as it relates to informing parents. If written consent is obtained prior to delivery, this circumstance should be included in the text of the consent. If, on the other hand, no prior consent is obtained for a community bank and personal identifiers are eliminated, there may be no need for this provision since positive samples will be discarded and will be anonymous. In the unlikely situation that a prior cord blood donor actually might make use of his or her own stored sample, it would be important to track that sample which could only be done with prior consent and non-anonymous donation. There will always be a chance that the sample has already been given away unless an individual has paid for private banking.

These are but a few of the possible scenarios that might arise as cord blood banking becomes a reality and obstetricians will be at the forefront of this technological surge. How we choose to invest our monetary resources and what is in the best interest of our patients will surely drive this endeavor. The American College of Obstetrics and Gynecology published a Committee Opinion in 1997 entitled "Routine Storage of Umbilical Cord Blood for Potential Future Transplantation" and the American Academy of Pediatrics Committee on Genetics is currently working on a similar statement. There is no doubt that cord blood banking will soon become an important clinical issue rather than merely a theoretical concern. The question of how we will choose to apply this new technology for now remains unanswered.