Intended for healthcare professionals

Views And Reviews

Consent for covid-19 vaccination in children

BMJ 2021; 374 doi: https://doi.org/10.1136/bmj.n2356 (Published 28 September 2021) Cite this as: BMJ 2021;374:n2356

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  1. Azeem Majeed, professor of primary care and public health1,
  2. Simon Hodes, GP partner2,
  3. Stephen Marks, consultant paediatric nephrologist3
  1. 1Imperial College London, London, UK
  2. 2Watford, UK
  3. 3Great Ormond Street Hospital, London, UK
  1. Follow Azeem Majeed on Twitter @Azeem_Majeed Follow Simon Hodes on Twitter @DrSimonHodes

Now that covid-19 vaccination of children in the UK is starting, it is essential that the legal basis of consent is well understood

A Court of Appeal, on 17 September 2021, overturned a previous High Court ruling and decided that parental consent is not needed for children under 16 to take puberty blockers.1 This reaffirms, again, that the responsibility to consent to treatment depends on the ability of medical staff to decide on the capacity of those who are under 16.

The timing is auspicious. Just a few days before, the four UK chief medical officers recommended that all healthy children aged 12-15 should be offered a single covid-19 vaccine, with a booster likely in spring 2022. Until now, the only children in this age group offered a vaccine have been those with certain medical conditions or those living in a household with a clinically vulnerable adult.2 With a mass vaccine campaign for children now starting, the matter of consent for this group has been headline news.

Reaching the decision about vaccinating 12-15 year olds in the UK has been an interesting process. The Joint Committee on Vaccination and Immunisation have deliberated, awaiting evolving evidence, and have scrutinised the data available on a risk-benefit basis. The chief medical officers also looked into the wider effects on society and ultimately recommended vaccination to the government, leaving the final decision to politicians.

It is essential that the legal basis of consent for a medical intervention in this group is well understood by parents, carers, health professionals, and, most importantly, by children. Teenagers aged 16 or 17 are deemed under English law to be able to give their consent for vaccination. But what about 12-15 year olds?

Ideally, for these children, covid-19 vaccination would be given with the approval and support of their parents. This is likely to improve children’s confidence in vaccines and help ensure a high and rapid take-up. With the vaccine programme scheduled to start in schools before the end of September, parents are currently being sent consent forms along with NHS information leaflets. Explaining such a decision in child friendly terms will be challenging, however. A survey by the UK Office for National Statistics reported that around 90% of parents were in favour of vaccinating children. Surveys also show confidence in covid-19 vaccines among children and young adults (but usually at a lower level than older people).

Despite high overall support for covid-19 vaccination, there will be families where children and parents have differing opinions about its risks and benefits. In such circumstances, the NHS and the responsible clinicians must decide if the child is competent to make their own decision about vaccination. This is known as Gillick competence, following a court case in the 1980s. The case eventually made its way to the House of Lords, which ruled that, “As a matter of law, the parental right to determine whether or not their child below the age of sixteen will have medical treatment terminates if and when the child achieves sufficient understanding and intelligence to understand fully what is proposed.” The ruling is valid in England and Wales.

Whether a child is Gillick competent is assessed using criteria such as the age of the child, their understanding of the treatment (benefits and risks), and their ability to explain their views about the treatment. If deemed to be Gillick competent, the child can make their own decision about medical intervention.

There may also be situations in which two parents disagree about vaccination. If the child is not Gillick competent, then a decision needs to be made about which parent’s views take priority. In a court case in 2020 where parents disagreed about vaccination for their children, the judge ruled that vaccination was in the best interests of the child because this is what evidence suggests. The judge deferred deciding about any future covid-19 vaccination because of the “early stage reached with respect to that vaccination programme.” Now that vaccination has been approved by the UK government and is supported by bodies such as Public Health England, it is likely that a court would rule in favour of covid-19 vaccination where two parents had opposing views.

None of these matters are new; however, the scale and speed of the covid-19 vaccination programme may make it more contentious—particularly given the finely balanced risk-benefit profile, the small risks of myocarditis, and the vaccine hesitancy already noted in younger people.34

It is important that parents, teachers, and healthcare professionals understand the risks and benefits of covid-19 vaccination for children, so that we can support them in reaching an informed decision. We need to respect the ability of our children, whose lives and education have been so greatly affected by the pandemic, to reach their own conclusions given the evidence available. Where there is a disagreement between a child and their parents regarding any medical treatment, healthcare professionals must feel confident in judging Gillick competence and the matters surrounding capacity to give consent.

Acknowledgments

AM is supported by the NIHR Applied Research Collaboration NW London. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care.

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