Measles and rubella immunisation: information and consent in children
BMJ 1995; 311 doi: https://doi.org/10.1136/bmj.311.7010.923 (Published 07 October 1995) Cite this as: BMJ 1995;311:923
- George Rylance, consultant paediatriciana,
- Claire Bowen, sixth form studentb,
- Jamie Rylance, sixth form studentc
- aChildren's Hospital, Birmingham B16 8ET
- bKing Edward VI Camp Hill School for Girls, King's Health, Birmingham B14 7QJ
- cKing Edward VI Camp Hill School for Boys, King's Heath
- Correspondence to: Dr Rylance.
- Accepted 12 June 1995
Informed consent is a prerequisite for all medical actions. Before the case of Gillick v West Norfolk and Wisbech Area Health Authority,1 parents were held to be solely responsible for giving consent on behalf of their children under 16 years. Thereafter, doctors have had a responsibility to consider the child's view. This principle was enshrined in the Children Act, 1989.
Parents consider their child to be capable of making important health care decisions, and children want to have information and share in or make decisions themselves.2
The recent campaign for measles and rubella immunisation has provided a measure of the government's and health care professionals' intention to inform children and consider them as decision makers.
Subjects, methods, and results
To determine children's views on consent issues, 851 questionnaires (see table for content) were distributed to members of years 7-11 (ages 11-15) of two single sex secondary schools in Birmingham within 21 days of the national measles and rubella immunisation campaign procedure. In all, 513 (60%) were completed and returned. The table shows the responses. The proportion of children who believed they had sufficient understanding and maturity to decide about immunisation (85% for all children aged 11-15) increased with age (girls, χ2=29.12, P<0.0001; boys, χ2=7.85, P<0.01).
Questionnaire responses*. Values are numbers (percentages) of children unless stated otherwise
In all 11-15 year olds, the mean (SD) age of sufficient maturity and understanding to make a decision regarding immunisation was considered to be 12.3 (1.8) years. The age suggested increased significantly with age (girls, r=0.241, F=14.97, P=0.0001; boys, r=0.376, F=34.83, P<0.0001). There was no significant difference between girls and boys except for 14 year olds (95% confidence interval 0.13 to 1.12, t=2.51, P<0.05). The proportion of children stating that they alone made the immunisation decision increased with age (girls, χ2=6.58, P<0.02; boys, χ2=6.38, P<0.02), but most children (64%) shared decision making with their parents.
Few children (7%) were asked if they consented. Most did not believe that attending the immunisation session and cooperating implied that they consented to the procedure (65%), and most did not believe that health professionals should assume that they had consented (58%).
Comment
As Alderson found for surgical procedures,2 most children aged 11-15 believed they had sufficient maturity and understanding to make decisions about immunisation. The finding of increasing “decision making” age with increasing chronological age also supports her findings in a different area of consent. The starting point, or change in slope direction, of this relation to age has not been defined. Although the Department of Health has recognised that children can give or withhold consent, information for health professionals3 4 seems to have been directed towards parents as sole decision makers. Less than 1% of the children considered the information leaflet, which included the parent consent form,5 to be directed at children.
The benefits of immunisation to the population generally are undoubted, but children should be afforded the same freedom of choice as their parents. Professional should not assume that attendance and cooperation by a child implies consent. Most children (71%) would be immunised if their parents wished it, even if they themselves did not, suggesting that children are willing to consider and comply with other viewpoints. This response may extend to the state's influence on the benefit of immunisation to the population. Appropriate and necessary involvement of today's socially aware older children may have secondary benefit in influencing the opinions and actions of tomorrow's parents.
The difficulties of informing many children at one time and assessing their competence to give consent provide no excuse for the apparent disregard of children's rights. In not informing children directly and in not ensuring that children were asked if they consented, the Department of Health and health professionals generally seem to have acted against the spirit and principles of the Children Act, 1989. This has further shown that children's rights are little recognised, poorly respected, and inadequately supported by health professional advocacy.
Footnotes
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Funding Personal funding.
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Conflict of interest None.