Last week Pfizer applied to the MHRA for emergency use authorisation for the vaccine roll out to children. Given we appear to be on the cusp of a paradigm shift in medical ethics there has been an alarming lack of commentary in mainstream media about this news.

It has — or perhaps, had — been a well established principle of bioethics and law that questions of child welfare should not be defined by reference to adult preferences, but instead require clear consideration of the benefits to and harms for the child. As sociologist Professor Dingwall puts it, a strong consensus appeared to have emerged that “no child should be treated as an object for the benefit of another”. 

Statements made by Government leaders had appeared until recently to be consistent with this approach: Kate Bingham of the Government Vaccine Task Force said last October that “we just need to vaccinate everyone at risk….there’s going to be no vaccination of people under 18”; CMO Chris Whitty explaining as recently as April that “one of the few good things about this epidemic … is that children are relatively unaffected – but for that reason you would want to be absolutely confident that a vaccine was highly safe”.

Leaked papers suggest a roll out to children over 12 years is planned for September

Skip forward to this month, however, and the narrative appears to have changed.  Government papers leaked a couple of weeks ago suggest a roll out to children over 12 years is planned for September; school leaders — with no medical or legal qualifications — have gone on record to back mass vaccination for children, coldly observing that the “peer pressure of seeing that your friends are lining up to do it is likely to make the overall numbers taking up the vaccine higher.”

This shift raises profound questions of safety, medical ethics and international equity. Informed debate should not only be seen as welcome, but essential — as Associate Professor Vinay Prasad at the University of California states, if unanticipated safety signals emerge — i.e. we get this wrong — we will be faced with an “existential crisis”.  Yet, debate — at least in the mainstream press — has been conspicuously absent. One must assume that fear of the dreaded “anti-vax” label and its corollary — social media censorship — fuels the silence.  This is ironic. The accusation is used under cover of the perceived advancement of a greater good but when it operates to shut down those raising important questions about an exceptionally fast roll-out of a vaccine to the world’s children, the label becomes not only unhelpful but negligent.

For obvious reasons there is, and will for some time, a lack of long term safety data about the Covid-19 vaccines, many of which use new technology.  This has led a number of expert clinicians to urge caution, and to question the use of “emergency use authorisations” under which all of the vaccine programmes worldwide currently operate.  We can fast-track approvals but we cannot condense time, so the argument goes. This lack of long term data has also generated concerns about unintended consequences — “vaccinating children might increase the frequency of large seasonal epidemics, leading to overall increases in virus induced morbidity and mortality,” states a recent BMJ editorial.

The two justifications for vaccinating children are firstly that it is for “the greater good” and secondly that it is a prerequisite for restoration of normality in schools.  The first argument relies on an argument that children, though not at risk, transmit the virus and that vaccination reduces transmission. Each of these have been questioned. Even if one accepts the scientific premise, given that vaccinated adults are themselves protected, the unspoken idea here is that we’re really vaccinating healthy children to protect unvaccinated adults.  Some will agree with this; many would not. Either way it is worthy of free and frank debate.

Informed consent is one reason why the programme has been such a success so far

The second argument is summed up by Sage member Professor John Edmunds when he says “there will continue to be major disruption in schools until we have vaccinated our children.” This comment of course assumes that school closures are an acceptable policy response in the first place.  Many would disagree; and only more so in a world where adults who wish to have a vaccine have been granted that wish.

We are in morally murky territory, but so it continues.

Condoning peer pressure might be symptomatic of this past year of “nudge” policies, but is a heavy handed approach to minors and is the antithesis of informed consent which is a key tenet of medical ethics and the bedrock of trust in the vaccination programme: informed consent is one reason why the programme has been such a success so far in the UK.  Rolling out a vaccine programme on anything other than this basis would take us back to a time before children were seen to have a developing capacity for autonomy and it risks undermining confidence in the very project which is so mission critical to this country.

There are also questions of international equity. Children are a low risk group and the WHO have urged wealthier nations to shelve plans to give children the vaccine and instead donate supplies to low-income countries.  And as Priscilla Anderson, Professor Emerita, UCL argues, the idea we would use vaccines on a large, very low risk group, instead of sharing them abroad is uncomfortable. 

Experts who have dared speak up talk about the crude and insulting comments they’ve received. The same venomous vitriol that has marked — and marred — our response to Covid appears to be at risk of stifling this next, essential discussion.  And in our silence we risk setting a terrible precedent — we risk, in the words of Professor Dingwall, creating “an expectation of vaccination for children with zero evidence of safety and efficacy, zero discussion of ethics and zero discussion of wider implications for immunity.” 

We must find the space and tolerance for the serious discussion that needs to happen. If we do not, the losers will be a generation of children.