Vaccination of young people from 12 years of age for COVID‐19 against parents’ wishes

When a young person seeks COVID‐19 vaccination against parental wishes, should the young person’s request be respected?

Vaccination for coronavirus disease 2019 (COVID‐19) has been proven safe and effective from the age of 5 years, and is recommended by the Australian Technical Advisory Group on Immunisation (ATAGI).1 COVID‐19 vaccines provide varying degrees of protection against infection and transmission, but all give high levels of protection against severe disease and death from infection with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) — the virus that causes COVID‐19.2 While severe outcomes from SARS‐CoV‐2 infection in children are rare, leading some to question the need to vaccinate children, the risk–benefit analysis remains clearly in favour of vaccination. In Australia, the mRNA vaccines (BioNTech–Pfizer COVID‐19 vaccine [Cominarty; INN, tozinameran] and Moderna [Spikevax; INN, elasomeran; also known as mRNA‐1273]) are currently available for anyone aged 12 years and older but look certain to be offered to children from 5 years of age in 2022. The most serious but rare side effects of the mRNA vaccines requiring medical attention are myocarditis and pericarditis, occurring more frequently in males aged 12–30 years. These episodes typically occur within days of the second dose, are usually mild and self‐limiting, and respond well to anti‐inflammatory medication — occurring at a rate of about one in 20 000 vaccines in the 12–19 year age group.3

In Australia, many children and young people have suffered through protracted government lockdowns imposed to reduce SARS‐CoV‐2 spread. Many children and young people are concerned about SARS‐CoV‐2 infection and either becoming unwell or transmitting the infection to others. Government, mainstream media and social media promotion of the vaccine has been strong, so awareness of vaccination and its role in ending lockdowns is high. Vaccination is now widely available through hubs, primary care and pharmacies, with drop‐in and in‐reach services increasing access. Internationally, young people have expressed a strong desire to be vaccinated to return to school and normal life, although comparable Australian data are lacking.4 Our clinical experience has been that some young people are motivated to receive a COVID‐19 vaccine, even when their parents do not wish for them to be vaccinated. How vaccine providers should respond to this request has not been clear.

Traditionally, parents have been asked to consent for vaccination of their children, including those in high school. When this consent is withheld or not obtained, providers are usually reluctant to vaccinate, fearing legal consequences or complaints against them. Concerned about young people’s access to health care more broadly, the federal government and some state governments have developed practice frameworks that allow medical practitioners to treat mature minors without parental consent. However, vaccine providers may not be aware of these frameworks, and even if they are aware, they may not trust them to offer sufficient protection under the law, their professional indemnity insurance, or with the Australian Health Practitioner Regulation Agency (AHPRA) should parents wish to make a complaint.

In this article we examine the ethical considerations that would allow a vaccine provider to give a COVID‐19 vaccine to a person from 12 years of age (generally referred to as a “young person” in clinical practice) when this request is against the wishes of the child’s parents. This analysis is intended for young people and for health care and other providers supporting young people, including general practitioners, pharmacists, nurse immunisers, schools, youth workers and residential care workers.

Mature minor doctrine

Adults are assumed to have capacity to make medical decisions while children are not. This leads to a degree of decisional asymmetry in which children need to prove their capacity to make a medical decision that is in their best interests. When a young person requests a COVID‐19 vaccine, the first consideration is whether they have sufficient capacity to make their own decision to be vaccinated. This means considering whether the young person has the ability and maturity to weigh up the benefits and risks of vaccination. This is sometimes called the mature minor doctrine and, in common law countries, has been affirmed in the Gillick decision.5 In Australia, this principle has been considered by the High Court in Marion’s case.6 There is no minimum age for a mature minor, the critical issue is the capacity to make the specific health care decision. Assessment of decisional maturity rests with the treating clinician, with broad guidance on how capacity should be assessed.7 In practical terms, an assessment of capacity might follow from the clinician’s past knowledge of the young person (ie, from previous encounters) or may be based on the interaction discussing SARS‐CoV‐2 infection and the benefits and risks of vaccination. The Box outlines areas providers should consider when vaccinating young people without parental consent. Of note, the level of knowledge expected and the discussion of risk and benefit should not be appreciably different or more exacting than would occur with an adult patient, many of whom may have an equivalent level of health literacy to a young person.

Gillick situates capacity as being specific to the treatment proposed, such that a young person may have the capacity to make straightforward decisions but not necessarily more complex ones.8 There is evidence that many young people have similar cognitive capacity to adults, which would suggest that they should be able to give informed consent for COVID‐19 vaccination.9,10,11 Conversely, neurobiology also tells us that adolescents may have a reduced appreciation of risk.12 However, given the known risks of SARS‐CoV‐2 infection outweigh the risks of an adverse event to a COVID‐19 vaccine, and that the vaccine is strongly protective, this concern against vaccinating young people does not hold ethical weight. Another feature of adolescence is developing values and planning ability, such that current decisions may be regretted later.12 Regret is not unique to adolescence and given the short term nature of vaccination, the possibility of regret also does not carry a great deal of ethical weight against vaccinating the young person. The fact a young person might choose to be vaccinated against their parents’ wishes could also be considered an endorsement of their capacity to decide — it is unlikely a decision to seek vaccination would be made simply in defiance of parental authority.

What may be important for the young person who is vaccinated against their parents’ wishes is the conflict this might generate within their family. This concern can be mitigated through a combination of privacy and pre‐vaccination counselling. There is a case for young people to tell their parents they have been vaccinated, consistent with their developing autonomy, and to promote trust in their family relationships. How the parent then responds to their vaccinated child is not primarily the responsibility of the vaccine provider, but the young person may need support if there is a fallout. Post‐vaccination support, to manage family conflict or adverse reactions to the vaccine, should be organised through the young person’s GP or community health provider.

Particular considerations for COVID‐19 vaccination

There are analogies between the Gillick determination, which related to the provision of oral contraceptive medications to young people, and the situation of young people requesting a COVID‐19 vaccine without parental consent. Key similarities are privacy, best interests, and public health. Young people can see their doctor and request treatment without their parents’ knowledge, under the usual doctor–patient confidentiality. Federal and state governments have confirmed this right to privacy for young people in a variety of ways. Even if young people are included on their parents’ Medicare card, no details of a consultation appear for children over 14 years of age. A patient aged 12–13 years can request that a consultation is made private, so it is not visible to others on the Medicare card. Similarly, the Australian Immunisation Register holds information for those aged 14 years and older in confidence. These privacy arrangements are underpinned by the bioethical principle of respect for persons.13 The young person’s decision to have a COVID‐19 vaccine is consistent with their best interests, both what the young person interprets as best for themselves through their decision to be vaccinated (self‐determined best interests) and also supported by medical recommendations. Finally, having a COVID‐19 vaccine is in line with good public health practice;14,15 therefore, the principles underpinning Gillick competence are directly applicable to young people independently seeking COVID‐19 vaccination.

Limits of parental authority

In most situations of clinical and ethical practice, parents are accepted as the natural and legal decision makers for their children. Clinicians’ work to develop a three‐way relationship with children and young people and their parents or carers, in a model of shared decision making. When a child seeks COVID‐19 vaccination against parental wishes, there is a breakdown of this three‐way relationship. How should parent authority be considered in this situation? Commentators agree that parental authority is not absolute and children are not the property of their parents.16 Parental authority is limited in three ways: the parents’ capacity to make informed decisions for their children, the parents acting in their child’s best interests (or at least making decisions that do not harm them), and the emerging autonomy of the child.

On these accounts, parents refusing COVID‐19 vaccination for their children is not in the best interests of the child based on medical recommendations and, further, could be conceived as harmful by failing to reduce the risk of disease due to SARS‐CoV‐2 infection. We accept that both best interests and harm can be contested values, with the young person and their parent’s having different views in this case. This is where the emerging autonomy of the young person becomes a central consideration. COVID‐19 vaccination seems to be precisely the sort of decision that young people should be able to make along the road to becoming independent decision makers as adults. For these reasons, parental authority is not sufficient to stop a young person having the COVID‐19 vaccine, if they so choose.

Position of governments

The federal government has indemnified clinicians and implemented a no‐fault claims process for the COVID‐19 vaccine. This applies to vaccines given at any age, including to young people aged 12–17 years. Therefore, negligence claims in the event of a vaccine adverse event should not be a reason to deter a vaccine provider from giving the vaccine. The usual practice of documenting the consent should be followed. If the vaccine provider is aware of the parents’ contrary wishes, this should also be noted, along with documentation on capacity and discussion about possible conflict with the parents.

The Australian Immunisation Handbook makes clear that common law practices such as the mature minor principle (Gillick competence) are respected, while some states have specific legislation that covers the treatment of minors (eg, Queensland also includes criteria for assessing capacity).17,18 The Handbook also makes specific reference to young people refusing vaccination and suggests that refusal should be respected, although refusal does not rely on an assessment of capacity. We agree and argue that both refusal and seeking vaccination should be respected in the case of a young person aged 12 years and older.

Conclusion

Our interpretation is that it is ethically permissible to vaccinate a young person from the age of 12 years requesting a COVID‐19 vaccine, even if their parents do not provide consent. This recommendation will have implications for other situations, including when unvaccinated young people from vaccine‐hesitant families seek catch‐up vaccines. We suggest this recommendation should be accepted as the standard of practice in Australia.