Human Papillomavirus Vaccination and Respect for Children's Developing Autonomy: Results from an European Union Wide Study

"Respect and empowerment seem to have practical as well as moral benefits."

Processes of vaccine provision vary across national vaccination programmes in Europe - from authoritarian paternalistic models, imposing a passive role on the child, to libertarian models, where mutual participation of both actors is needed. Using an expert survey within the frame of Models of Child Health Appraised (MOCHA), this article explores differences regarding expressions of respect for children's autonomy throughout all 30 European Union (EU) and European Economic Area states, using the procedure of human papillomavirus (HPV) vaccination offer as indicator.

In Europe, the HPV vaccine is commonly offered to girls in late childhood and adolescence, although boys may also benefit. Arguably, at this stage of the life course, cognitive development and decision-making competences of young people are approaching that of adulthood, and thus at least the consent of the person receiving the vaccine, as well as the consent of the legal guardians, should be requested. By this stage, young people should also be taking responsibility for their own health and health-seeking behaviour. Furthermore, the vaccine protects against an infection that can also be sexually transmitted. Issues related to the right of sexual self-determination of children and adolescents and associated conflicts in the relationship with their parents can complicate the implementation of vaccination programmes in different settings.

Participants in the study - 28 child health experts who are members of a professional network collaborating within the frame of the MOCHA project - were invited to respond between June and December 2017 to a questionnaire using vignettes regarding HPV vaccine provision. Concerning national law, the MOCHA country agents were asked to provide, wherever possible, links to the relevant pieces of legislation. They were further asked to refer to national policies or guidelines issued by a health professional or cross-sectoral body on the right of choice or refusal of treatment in childhood and adolescence and to provide the respective link if possible.

Data indicate that the HPV vaccine is offered to girls in late childhood and early adolescence in all participating countries. Although generally accepted as safe and beneficial by regulatory authorities, it is sometimes not well accepted in certain population groups, and there has been some public expression of concern, including claims of short- or long-term adverse effects. For example, in Bulgaria, the death of a teenager with a long-term systemic disorder 2 months after HPV immunisation led to public skepticism, and the programme was terminated, despite there being no causal relation between the 2 events.

The researchers present the results according to the following themes: (i) provision of informed consent; (ii) parental and medical paternalism; (iii) relevance of the child's chronological age or maturity, and (iv) vaccination programmes for boys. They also explore correlations between different practices applied throughout Europe regarding the themes (i)-(iii) and the national HPV vaccine coverage rate (VCRs). With regard to the latter, they found that average or above performing countries in terms of VCRs tend to follow less authoritative and paternalistic approaches for the vaccine provision. In fact, the country with the best VCR performance, the United Kingdom (UK), also follows most autonomy-respectful paradigms (vaccination of a consenting child, even without parental consent).

With regard to communication issues, specifically, the study found:

• Providing information to patients and parents and expecting written informed consent to provide a vaccine is not always necessary in some European states, primarily in the European south.
• Overruling a child's decision, even of one who is competent to meet a decision based on developmental criteria, is still acceptable in a large part of the EU.
• The physician may function as a negotiator in cases of disagreement between children and their parents. This may actually facilitate a solution to the problem, because the physician is required to provide valid information regarding the vaccination to both children and parents by facilitating discussions among all actors. Deriving from libertarian paternalism theories, such an approach not only respects but can also constructively boost the children's developing autonomy.

With an eye to identifying good practices, the researchers note that the United Nations Children's Fund (UNICEF), within the frame of the United Nations Convention on the Rights of the Child (UNCRC), clarifies that the right of children to access primary health care, including preventive healthcare services, is indisputable (Article 24), while educating parents and children regarding child health is essential (Article 24). Further significant ethical conditions include steering the parenting style toward more libertarian patterns (Article 14) and empowering children through offering health education (Article 17). In addition, distinctions of any kind based on sex are not acceptable (Preamble).

Providing health education regarding a vaccine to be offered to children and their parents and requesting written consent or assent are already common practices in many national vaccination programmes across Europe and could be spread throughout the EU. Other recommended approaches:

• Educate children and parents regarding the vaccine provision and involve them all in informed consent processes.
• Grant decision-making competence to children and adolescents depending on their maturity.
• In cases of refusal to treat, consider offering the vaccine to older children and adolescents, while still being sure to provide it before the individuals are sexually active.
• Do not restrict the provision of health education to children with disabilities, including diseases affecting cognition.
• Offer the vaccine to children and adolescents of both sexes.
• Involve the paediatrician as negotiator in cases of disagreement between children and parents.

In conclusion, as implied by the latter point, one implication of this proposed vision would be a paradigm change in the physician's role, evolving into an advocate for the child's autonomy development and empowerment.