The next big ethical COVID decision -vaccinating children

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The Government and JVCI are currently wrestling with the question about where to go next with our COVID-19 vaccination programme.  The jabs have been offered to all over 18s with close to a 90% take-up and in the summer this was extended to 16-18 year olds.  As of the 1st September 2021 88.5% of the 16+ population had received their first injection and 78.9% their second. 

The question now is whether to extend the programme and how.  There are three possibilities. The first is that we leave things as they are with most people sticking at two jabs.  A booster jab would however be offered to the clinically vulnerable.  The second option is to roll out booster jabs wider, at least to all over 50s and potentially to the entire adult population.  The third option is to focus on providing the vaccine to children starting with the 12-15s so that all secondary school children have been offered it.

The reason for offering booster jabs is immunity waning. The vaccines we have don’t deliver permanent immunity because the antibodies diminish over time. A recent study has suggested that after 5-6 months the efficacy of Pfizer drops from 88% to 74% and for AstraZeneca from 77% to 67% after 4-5 months.[1]  This means that those in the early priority groups who received their first jabs in January/February and their second jabs in March/April will be starting to experience some waning in immunity.  Under 50s should expect full protection to continue through to January 2022. 

But does that mean we should rush to give booster vaccines?  Well, it is worth remembering two things here. First of all, whilst immunity waning means that people are at a greater risk of suffering symptomatic infection, 67-74% protection is still significant compared to other vaccines such as the flu jab and will continue to have an impact on disease transmission. Furthermore, as things stand, it still seems that even at the 6 month mark, the vaccines continue to provide significant protection against serious illness, hospitalisation and death.  So, we are not looking at a situation where the vaccine suddenly becomes ineffective for the over 50s.

Therefore, there are some other considerations to take into account. The reason that boosters and further vaccination is being considered is that many epidemiologists expect a fourth wave during the winter months which combined with the re-emergence of other winter viruses could put significant pressure on the NHS. If that pressure comes, then there will also be pressure on the Government to bring back Non-Pharmaceutical Interventions (NPIs) which might start with the reintroduction of face masks and social distancing but could los include immunity passports (proof of either vaccination or a negative test result) and even the closure of schools and venues.  I suspect that the Government will want to do everything in its power to avoid such a scenario.

The question then  is “how do we avoid or at least mitigate against such a scenario).  We know that COVID-19 will not go away completely but the hope and expectation is that it will become endemic and a part of normal life.  However, we are not there yet. To reach such a stage we would need to have confidence that outbreaks wouldn’t lead to a healthcare crisis. Over the long term I suspect that this will happen through a mixture of anti-viral drugs, changes to medical practices and the population building up natural immunity through repeat exposure to the virus. We are not there yet.

So, in the meantime, the aim would be to attempt to reduce transmission as much as possible and that’s what we are looking for the vaccine programme to help with.  This then raises an important question.

“Will reduction in transmission be best enabled by offering booster jabs to the over 50s or by vaccinating the under 16s?”

Well, if it’s down to sheer numbers, then the former seems to be the best option.  As someone pointed out on Twitter, there are more people in the 50plus age category and potentially a greater take up rate too than in the 12-15s.  So perhaps that’s where our focus should be.

However, I don’t think that answer is as illuminating as first assumed. There are two things to consider here. First of all, given that 12-15s would prove such a small proportion of the total number of vaccines, why not do both?  Secondly,  the impact on transmission is not just about the number of people vaccinated. You see, the over 50s who have already received their two jabs will still be playing their part in reducing transmission even if it has reduced slightly. Secondly, the 12-15 year olds are more likely to be mobile, more likely to be in venues with large numbers of other people (schools) and likely to have a wider circle of social contacts.  So vaccinating them may have a far greater impact on transmission. Indeed, if you want to protect granddad from ending up in hospital with Coronavirus, it may be more effective to stop his granddaughter catching it and bringing it round when she visits than to try and protect him from picking it up from her!

So, in order to determine priorities, I would argue that the number crunchers need to look at their models and get a feel for which approach is likely to have the best result sin terms of reduced transmission in order to keep the R rate well below 1.  I suspect that this will provide a strong pragmatic argument for encouraging under 16s to get vaccinated.

This leads to ethical considerations. Vaccination of minors has proved more controversial than for adults in the case of Coronavirus.  Of course, we vaccinate children against measles, rubella, smallpox, TB etc on a routine basis. However, there has been a wariness about the COVID-19 vaccination programme. I think this links into specific perceptions about the vaccine: that the mRNA vaccines are experimental due to using new methods, that the time-frame from development through to use has been too short and that there are risky side affects that come with the vaccines.  Whilst those concerns have led to some becoming vociferously “anti-vax” this hasn’t caused too many concerns among the adult population, however I think there is slightly more hesitancy when it comes to vaccinating young people. There is probably an additional factor involved here which is whether or not it is better for children to acquire natural immunity through early and repeat exposure so that in later years the virus has no more affect than the common cold.

Regarding the supposed experimental nature of the drugs, it is worth remembering that all medication and treatments have by definition been “new” and “experimental” at some point. There comes a time when the treatment has to be passed to use in anger.  Furthermore, one of the reasons that the vaccines were developed so quickly is that whilst the specific coronavirus in question was new and needed an urgent response, the treatment methods have been in development for some time in response to other viruses including SARs and MERs.  We have now seen the vaccines deployed widely and have a good feel both for their efficacy and side effects.

One of the issues when determining who to give vaccines to is whether or not the side affects outweigh the benefits. There was a small risk of serious illness and death due to blood-clotting from the AZ jab and this led to it not being used amongst under 30s because the danger from the side affect was not seen to be counter-balanced by the reduction in risk of hospitalisation or death from the virus. There also appears to be a small risk of myocarditis with the Pfizer vaccine.[2]

Given that the risk of serious illness and death is much lower among the under 16 than the over 50s, some have argued that this is another example where the benefits don’t outweigh the risks to them.  They are in effect being asked to take a risk for the benefit of others.  Isn’t this then an example of utilitarian ethics?  Usually when people talk about Utilitarianism they are referring to the premise that individual rights can and should be suppressed for the greater good. Utilitarianism is about weighing up the impact or utility of a decision. 

The ethical principle is perhaps a little more complex than its popular caricature and in its favour it was behind significant public health improvements in the past. However, there are concerns about this approach (at least in simplified form) because of the fear that it will lead to authoritarianism as Governments act tyrannically and suspend rights such as freedom of speech, privacy and movement “for the greater good”.  Additionally, it can lead to discrimination against minority groups for the benefits of the majority in society. Indeed, arguably, modern Western democracy, especially First Past The Post systems may be seen as favouring such calculations.[3]

Yet, whilst we can see the ethical problem with a dictator or a majority imposing a decision on others for their benefit, it is not self-evident that it is wrong in and of itself to ask people to do something not for their benefit but for others. Indeed, this is a deeply Christian principle and the basis of Paul’s teaching in Romans 14-15 where he invites his readers to consider and follow Christ who “did not please himself, but as it is written, ‘The reproaches of those who reproached you fell on me.’”[4]

It seems to me then that it is legitimate to ask people to in effect submit to one another by putting their needs first. Indeed, for the vast majority of us, the decision to take the vaccine was not because we thought our own lives were at risk. The primary point though is that such submission is voluntary -which raises separate questions about consent and capacity (i.e. should parental consent be required?)

I say that for the majority of us, the vaccine was not to protect us but to protect others, our parents, the elderly, vulnerable friends. However, there was a little bit more to it.  We also opted for the vaccine because we saw it as enabling a resumption of normality, an end to lockdowns, social distancing and face-mask wearing (which is why we are perhaps frustrated at the time it is taking to get back to normality).  This is important because there is then potential benefit to children beyond reducing the risk of serious illness. First of all, it will reduce the risk of their education being disrupted or of a further lockdown affecting their social and emotional well-being.  It is in their interests for the NHS to run well and not be under pressure. It’s in their economic interests for the parents not to lose time at work due to the virus. It is in their interests to have their parents and grandparents around for many years to come. As a Christian I believe it to be in the interests of children for their families to be able to attend church in person for worship.  So we need to be careful about a narrow interpretation of cost v benefit here.

My personal opinion is that there is a legitimate case for vaccinating 12-15 year olds. I suspect that what will happen is that through September – October we will see this happening alongside a booster vaccination for the clinically vulnerable and perhaps the over 80s.  I expect there to be a further review in October to consider the possibility of extending the booster programme to others and that this will depend on the level of cases in the Autumn, success of other treatments and further studies into waning vaccine efficacy.

Others will take different opinions about both the ethical and practical justification for vaccinating under 16s.  However, I hope you’ve found this article helpful in raising the particular issues that need to be considered.


[1] COVID-19: Protection from coronavirus vaccines wanes within six months, study suggests | UK News | Sky News

[2] Myocarditis and pericarditis – rare adverse reactions to Comirnaty (Pfizer COVID-19 vaccine) (medsafe.govt.nz)

[3] In effect a government succeeds by identifying what will appear to benefit 40-45% of the population even if it is harmful to others.

[4] Romans 15:3.