Reflections on Ethics and Advocacy in Child Health (REACH): Creating a Forum for Ethical Dialogue

We are pleased to announce a new section of The Journal of Pediatrics entitled REACH: Reflections on Ethics and Advocacy in Child Health. REACH-themed articles will be published quarterly and feature articles that examine a pediatric ethics or child health policy issue from multiple perspectives. The first installment features 3 articles that address the ethics and policy questions about child and adolescent vaccination.

Vaccines have been controversial since their inception.¹ Although vaccines have saved millions of lives worldwide, vaccine hesitancy is a growing global phenomenon.^{2 , 3} As vaccine-preventable diseases decrease, rare vaccine adverse events, distrust in government policies, and large-scale misinformation on the web have led to vaccine refusals.⁴ Most concerning from a public health perspective is that refusals are not random, but tend to cluster, leading to the loss of herd immunity in certain communities and resulting in pockets of disease.⁵ The need to combat vaccine hesitancy and refusal has taken on greater urgency during the coronavirus disease-2019 (COVID-19) pandemic, which will require billions of people to be immunized with vaccines that have been developed and tested in a short period of time.⁶ Although pediatric testing of these vaccines for children younger than 16 years is still in early stages, once a COVID-19 vaccine is found safe and effective in children, questions will arise about whether to make these vaccines mandatory for school entry.⁷

Erin Talati Paquette discusses the ethics of mandatory vaccination for school entry in the United States, state exemption policies, and the American Academy of Pediatrics 2016 policy statement recommending the elimination of nonmedical exemptions. Paquette argues that the broad elimination of exemptions is not justified. She applies a contextualized approach to childhood vaccination that better aligns with public health law. She concludes that “Both legal and ethical (social justice) arguments also support allowing exemption based on public health ethics and public health law.”⁸ Julian Savulescu et al from Australia and the UK discuss the issue of mandatory vs voluntary vaccination of children for COVID-19 based on the actual risks and benefits that severe acute respiratory syndrome novel corona virus-2 infection poses to children and society at large. Balancing self-interest with duty to others, Savulescu et al examine the decision based upon the principles of liberty and usefulness. While awaiting pediatric safety and efficacy COVID-19 vaccine data, they consider the case for mandatory influenza vaccination in children during the pandemic, given that children are known to be a major source of influenza spread. They conclude that the case is strong for mandating influenza vaccine to decrease pressure on hospital resources: “By preventing spread to vulnerable patients who may require hospitalization for influenza, vaccination for children can free up limited resources for use by COVID-19 patients.”⁹

To round out the discussions about vaccine controversies, the article by Gregory Zimet et al discusses the ethical, legal, and practical issues related to adolescent self-consent in the US for the human papillomavirus vaccination.¹⁰ They then contextualize the issue in light of the COVID-19 pandemic, which underscores the need for vaccine policy changes to be pursued with clear communication and consistent with ethical principles.

For future REACH section articles, we are interested in both conceptual and empiric proposals, with the twin goals of providing a platform for rigorous theoretical arguments for controversies in pediatric ethics, as well as enlarging the evidence base for future policymaking. REACH themes will encompass the broad expanse of ethics controversies in pediatric health, across the domains of clinical care, research, and social determinants of health. The section will address applied ethics issues in pediatric health, such as the limits of parental authority, the evolving role of the children and adolescents in health care decision-making, healthcare disparities and racism, equity issues in the pediatric workforce, translational research ethics, child advocacy, and professionalism. We will issue calls for proposals in advance of REACH issues. See the most recent call for proposals on The Journal's website (https://www.jpeds.com/reach).